If someone has mentioned "apraxia" in connection with your child's speech, you probably have a lot of questions. Childhood apraxia of speech (CAS) is less common than many other speech difficulties, and it can be confusing to understand how it differs from a child who is simply hard to understand. This overview summarizes what leading organizations say about CAS: what it is, the signs that are commonly described, and how it's diagnosed.
What is childhood apraxia of speech?
The American Speech-Language-Hearing Association (ASHA) defines CAS as "a pediatric neurological speech sound disorder." With CAS, ASHA explains, "the precision and consistency of movements during speech production are impaired, but reflexes are intact and muscle tone is typical."[1] The difficulty lies in planning and programming the movements for speech: their timing, direction, force, and sequence.[1]
The National Institute on Deafness and Other Communication Disorders (NIDCD) puts it simply: "The brain knows what it wants to say, but cannot properly plan and sequence the required speech sound movements."[2] NIDCD also notes that apraxia of speech "is not caused by weakness or paralysis of the speech muscles." Weakness or paralysis of the speech muscles causes a different disorder called dysarthria.[2]
Apraxia Kids describes CAS as "a motor speech disorder that first becomes apparent as a young child is learning speech."[3] NIDCD's parent guide to milestones describes apraxia as a speech disorder "that makes it difficult to put sounds and syllables together in the correct order to form words."[6]
How common is childhood apraxia of speech?
ASHA reports that the population estimate for CAS in children 4 to 8 years old is about 1 in 1,000. Among children in that age range with speech delay of no known cause, the estimate is around 2.4%.[1] ASHA also lists conditions in which CAS is reported more often, including certain genetic conditions, and notes that more than 30 genes together account for approximately one third of CAS cases.[1] NIDCD notes that children with apraxia of speech "often have family members who have a history of a communication disorder or a learning disability," and that childhood apraxia "appears to affect more boys than girls."[2]
What are the signs of childhood apraxia of speech?
ASHA is careful to note that "there are no validated diagnostic features that differentiate childhood apraxia of speech (CAS) from other childhood speech sound disorders." However, three core features "have gained some consensus among researchers":[1]
- Inconsistent errors on consonants and vowels when the same syllables or words are repeated
- Lengthened and disrupted transitions between sounds and syllables, including pauses that break up the flow of speech
- Unusual prosody, meaning differences in the rhythm and stress of words and phrases
ASHA adds that "these features are not proposed to be the necessary and sufficient signs of CAS."[1]
The Apraxia Kids parent portal describes what these can sound like: a new word "does not always sound the same in repeated productions," speech that may "sound choppy," and prosody that can sound "flat or monotone."[4] Other characteristics that organizations describe include:
- Trouble with vowels, which Apraxia Kids notes most other speech sound disorders don't typically involve[4]
- More difficulty with longer words or sentences than with short, simple ones[2, 4]
- Groping or "trial and error" movements of the mouth before a word comes out[2, 4]
- Difficulty copying non-speech movements, like sticking out the tongue or blowing a kiss[4]
- Less babbling in infancy, starting to talk late, or losing words that were learned[4]
- Understanding that is well ahead of expression; Apraxia Kids states that "receptive ability far exceeds expressive ability"[3]
Apraxia Kids notes that professionals "do not all agree on the characteristics that define apraxia" and that some of these characteristics "may also be present in children with other severe speech sound disorders."[3] That's why no single sign on this list means a child has CAS.
How is CAS different from other speech sound disorders?
Many young children have trouble with speech sounds for other reasons, such as the articulation and phonological disorders that ASHA groups as speech sound disorders with no known cause.[5] ASHA describes consistent phonological error patterns as "characterized by predictable errors," and notes that some children who produce words differently each time do so "in the absence of motor speech difficulties."[5] In CAS, the core difficulty is the motor planning of speech.[1]
ASHA also cautions that "the diagnosis of CAS cannot be based solely on the severity of a child's SSD, as this may result in overdiagnosis."[1] In other words, being very hard to understand doesn't by itself mean a child has apraxia. For more on those other disorders, see our post on articulation vs. phonological disorders.
How is childhood apraxia of speech diagnosed?
According to ASHA, speech-language pathologists (SLPs) play a central role in the assessment and diagnosis of CAS.[1] ASHA recommends that children suspected of having CAS receive "a comprehensive motor speech assessment by an SLP with experience in pediatric motor speech disorders."[1] According to ASHA and NIDCD, an evaluation may include tasks such as:[1, 2]
- Saying single words that include all the sounds of the child's language or languages
- Saying longer, multisyllabic words, and words of increasing length (NIDCD gives the example "love, loving, lovingly")
- Repeating the same word several times to look for consistency
- A sample of connected, everyday speech
- An oral motor assessment, including non-speech movements like "smile" and "kiss"
NIDCD notes that to diagnose CAS, "parents and professionals may need to observe a child's speech over a period of time."[2] For toddlers, ASHA explains that diagnosis is especially challenging because of limited speech and rapid changes in the first 3 years. Clinicians may use provisional wording, such as "CAS cannot be ruled out" or "suspected to have CAS."[1] ASHA also states that families should be referred for a screening or evaluation when they have concerns, "even if the child is younger than 3 years of age."[1] ASHA adds that children younger than 3 can qualify for early intervention services if they have, or are at risk for, a developmental delay, disability, or health condition.[1] Our early intervention page has more background.
Do children outgrow childhood apraxia of speech?
NIDCD states that "children with AOS will not outgrow the problem on their own," and that they "do not acquire the basics of speech just by being around other children, such as in a classroom."[2] ASHA similarly notes that people with CAS "do not 'grow out' of it but can improve their communication with speech and language services."[1]
On treatment, NIDCD reports that "frequent, intensive, one-on-one speech-language therapy sessions are needed," and that "no single approach has been proven to be the most effective."[2] ASHA describes several motor-based treatment approaches and notes that "intensive and individualized treatment of childhood apraxia is often necessary."[1] ASHA also mentions that CAS services can be delivered by telepractice, while noting that the research is limited.[1] Some children also use other ways to communicate, such as sign language, pictures, or an electronic communication device; NIDCD lists these as options in severe cases.[2] You can learn more about our speech therapy services.
From Apraxia Kids: "If you are a parent and are worried about your child's severely unclear or absent speech, we recommend you schedule a comprehensive speech and language evaluation by a qualified speech and language pathologist."[3]
The bottom line
Childhood apraxia of speech is a motor planning difference: the child knows what they want to say, but coordinating the movements to say it is hard. It shares features with other speech sound disorders, so careful evaluation matters. If your child's speech is very hard to understand, inconsistent from one try to the next, or much further behind than their understanding, talking with a speech-language pathologist experienced in motor speech disorders is a reasonable next step.
Sources
- American Speech-Language-Hearing Association (n.d.). Childhood Apraxia of Speech (Practice Portal). ASHA.
- National Institute on Deafness and Other Communication Disorders (n.d.). What Is Apraxia of Speech?. NIDCD, National Institutes of Health.
- Apraxia Kids (n.d.). What is Childhood Apraxia of Speech?.
- Apraxia Kids (n.d.). Characteristics of Childhood Apraxia of Speech. Apraxia Kids Parent Portal.
- American Speech-Language-Hearing Association (n.d.). Speech Sound Disorders: Articulation and Phonology (Practice Portal). ASHA.
- National Institute on Deafness and Other Communication Disorders (n.d.). Speech and Language Developmental Milestones. NIDCD, National Institutes of Health.
Articles from Speech Me Therapy, a pediatric speech-language therapy practice in North Phoenix serving Scottsdale, Paradise Valley, and families across Arizona by telehealth. Our posts summarize published guidance from professional and public health organizations; sources are listed at the end of every article.