Childhood apraxia of speech

Overview

Childhood apraxia of speech (CAS) is a rare speech disorder. Children with this disorder have trouble controlling their lips, jaws and tongues when speaking.

In CAS, the brain has trouble planning for speech movement. The brain isn't able to properly direct the movements needed for speech. The speech muscles aren't weak, but the muscles don't form words the right way.

To speak correctly, the brain has to make plans that tell the speech muscles how to move the lips, jaw and tongue. The movements usually result in accurate sounds and words spoken at the proper speed and rhythm. CAS affects this process.

CAS is often treated with speech therapy. During speech therapy, a speech-language pathologist teaches the child to practice the correct way to say words, syllables and phrases.

Symptoms

Children with childhood apraxia of speech (CAS) may have a variety of speech symptoms. Symptoms vary depending on a child's age and the severity of the speech problems.

CAS can result in:

• Babbling less or making fewer vocal sounds than is typical between the ages of 7 to 12 months.
• Speaking first words late, typically after ages 12 to 18 months old.
• Using a limited number of consonants and vowels.
• Often leaving out sounds when speaking.
• Using speech that is hard to understand.

These symptoms are usually noticed between ages 18 months and 2 years. Symptoms at this age may indicate suspected CAS. Suspected CAS means a child may potentially have this speech disorder. The child's speech development should be watched to determine if therapy should begin.

Children usually produce more speech between ages 2 and 4. Signs that may indicate CAS include:

• Vowel and consonant distortions.
• Pauses between syllables or words.
• Voicing errors, such as "pie" sounding like "bye."

Many children with CAS have trouble getting their jaws, lips and tongues to the correct positions to make a sound. They also may have a hard time moving smoothly to the next sound.

Many children with CAS also have language problems, such as reduced vocabulary or trouble with word order.

Some symptoms may be unique to children with CAS, which helps to make a diagnosis. However, some symptoms of CAS are also symptoms of other types of speech or language disorders. It's hard to diagnose CAS if a child has only symptoms that are found both in CAS and in other disorders.

Some characteristics, sometimes called markers, help distinguish CAS from other types of speech disorders. Those associated with CAS include:

• Trouble moving smoothly from one sound, syllable or word to another.
• Groping movements with the jaw, lips or tongue to try to make the correct movement for speech sounds.
• Vowel distortions, such as trying to use the correct vowel but saying it incorrectly.
• Using the wrong stress in a word, such as pronouncing "banana" as "BUH-nan-uh" instead of "buh-NAN-uh."
• Using equal emphasis on all syllables, such as saying "BUH-NAN-UH."
• Separation of syllables, such as putting a pause or gap between syllables.
• Inconsistency, such as making different errors when trying to say the same word a second time.
• Having a hard time imitating simple words.
• Voicing errors, such as saying "down" instead of "town."

Other speech disorders sometimes confused with CAS

Some speech sound disorders often get confused with CAS because some of the symptoms may overlap. These speech sound disorders include articulation disorders, phonological disorders and dysarthria.

A child with an articulation or phonological disorder has trouble learning how to make and use specific sounds. Unlike in CAS, the child doesn't have trouble planning or coordinating the movements to speak. Articulation and phonological disorders are more common than CAS.

Articulation or phonological speech errors may include:

• Substituting sounds. The child might say "fum" instead of "thumb," "wabbit" instead of "rabbit" or "tup" instead of "cup."
• Leaving out final consonants. A child with CAS might say "duh" instead of "duck" or "uh" instead of "up."
• Stopping the airstream. The child might say "tun" instead of "sun" or "doo" instead of "zoo."
• Simplifying sound combinations. The child might say "ting" instead of "string" or "fog" instead of "frog."

Dysarthria is a speech disorder that occurs because the speech muscles are weak. Making speech sounds is hard because the speech muscles can't move as far, as quickly or as strongly as they do during typical speech. People with dysarthria may also have a hoarse, soft or even strained voice. Or they may have slurred or slow speech.

Dysarthria is often easier to identify than CAS. However, when dysarthria is caused by damage to areas of the brain that affect coordination, it can be hard to determine the differences between CAS and dysarthria.

Causes

Childhood apraxia of speech (CAS) has a number of possible causes. But often a cause can't be determined. There usually isn't an observable problem in the brain of a child with CAS.

However, CAS can be the result of brain conditions or injury. These may include a stroke, infections or traumatic brain injury.

CAS also may occur as a symptom of a genetic disorder, syndrome or metabolic condition.

CAS is sometimes referred to as developmental apraxia. But children with CAS don't make typical developmental sound errors and they don't grow out of CAS. This is unlike children with delayed speech or developmental disorders who typically follow patterns in speech and sounds development but at a slower pace than usual.

Risk factors

Changes in the FOXP2 gene appear to increase the risk of childhood apraxia of speech (CAS) and other speech and language disorders. The FOXP2 gene may be involved in how certain nerves and pathways in the brain develop. Researchers continue to study how changes in the FOXP2 gene may affect motor coordination and speech and language processing in the brain. Other genes also may impact motor speech development.

Complications

Many children with childhood apraxia of speech (CAS) have other problems that affect their ability to communicate. These problems aren't due to CAS, but they may be seen along with CAS.

Symptoms or problems that are often present along with CAS include:

• Delayed language. This may include trouble understanding speech, reduced vocabulary, or not using correct grammar when putting words together in a phrase or sentence.
• Delays in intellectual and motor development and problems with reading, spelling and writing.
• Trouble with gross and fine motor movement skills or coordination.
• Trouble using communication in social interactions.

Prevention

Diagnosing and treating childhood apraxia of speech at an early stage may reduce the risk of long-term persistence of the problem. If your child experiences speech problems, have a speech-language pathologist evaluate your child as soon as you notice any speech problems.

Diagnosis

To evaluate your child's condition, a speech-language pathologist reviews your child's symptoms and medical history. The speech-language pathologist also conducts an exam of the muscles used for speech, and looks at how your child produces speech sounds, words and phrases.

Your child's speech-language pathologist also may assess your child's language skills, including vocabulary, sentence structure and ability to understand speech.

Diagnosis of CAS isn't based on a single test or observation. A diagnosis is made based on the pattern of problems that are seen. The specific tests conducted during the evaluation depend on your child's age, ability to cooperate and the severity of the speech problem.

It can sometimes be hard to diagnose CAS, especially when a child speaks very little or has trouble interacting with the speech-language pathologist.

Still, it's important to identify whether your child shows symptoms of CAS because CAS is treated differently from other speech disorders. Your child's speech-language pathologist may be able to determine the best treatment approach for your child even if the diagnosis is not certain at first.

Tests may include:

• Hearing tests. Your doctor may order hearing tests to determine if hearing problems could be contributing to your child's speech problems.

• Oral-motor assessment. Your child's speech-language pathologist will examine your child's lips, tongue, jaw and palate for structural problems, such as tongue-tie or a cleft palate. The speech-language pathologist also will look for other problems such as low muscle tone. Low muscle tone usually isn't associated with CAS, but it may be a sign of other conditions.

  Your child's speech-language pathologist will watch how your child moves his or her lips, tongue and jaw in activities such as blowing, smiling and kissing.

• Speech evaluation. Your child's ability to make sounds, words and sentences may be observed during play or other activities.

  Your child may be asked to name pictures. This allows the speech-language pathologist to check to see if your child has trouble making specific sounds or speaking certain words or syllables.

  Your child's speech-language pathologist also may evaluate your child's coordination and smoothness of movement in speech. Your child may be asked to repeat syllables such as "pa-ta-ka" or say words such as "buttercup."

  If your child can speak sentences, the speech-language pathologist observes your child's melody and rhythm of speech. Melody and rhythm are heard in the way your child puts stress on syllables and words.

  Your child's speech-language pathologist may help your child by providing cues, such as saying the word or sound more slowly or providing touch cues to the face.

A trial of speech therapy to observe how your child responds to CAS treatment can help the speech-language pathologist confirm CAS.

Treatment

Children don't outgrow childhood apraxia of speech (CAS), but speech therapy can help them make the most progress. Speech-language pathologists may treat CAS with many therapies.

Speech therapy

Your child's speech-language pathologist usually provides therapy that focuses on practicing syllables, words and phrases.

Depending on the extent of the speech problems, your child may need speech therapy 3 to 5 times a week. As your child improves, the number of weekly speech therapy sessions may be reduced.

Children with CAS generally benefit from individual therapy. One-on-one therapy allows your child to have more time to practice speech during each session.

It's important that children with CAS get a lot of practice saying words and phrases during each speech therapy session. It takes time and practice to learn how to say words and phrases the right way.

Because children with CAS have trouble planning movements for speech, speech therapy often focuses your child's attention to the sound and feel of speech movements.

Speech-language pathologists may use different types of cues in speech therapy. For example, your child's speech-language pathologist may ask your child to listen carefully. Your child also may be asked to watch the speech-language pathologist's mouth form the word or phrase.

Your child's speech-language pathologist also may touch your child's face as your child makes certain sounds or syllables. For example, a speech-language pathologist may help round your child's lips to say "oo."

No single speech therapy approach has been shown to be most effective for treating CAS. But some important principles of speech therapy for CAS include:

• Speech drills. Your child's speech-language therapist may ask your child to say words or phrases many times during a therapy session.
• Sound and movement exercises. Your child may be asked to listen to the speech-language pathologist and to watch the speech-language pathologist's mouth while speaking a word or phrase. By watching the speech-language pathologist's mouth, your child sees the movements that go along with the sounds.
• Speaking practice. Your child will likely practice syllables, words or phrases, rather than isolated sounds. Children with CAS need practice making the movements from one sound to another.
• Vowel practice. Children with CAS tend to distort vowel sounds. The speech-language pathologist may choose words for your child to practice that contain vowels in different types of syllables. For example, your child may be asked to say "hi," "mine" and "bite." Or your child may be asked to say "out," "down" and "house."
• Paced learning. Depending on the severity of your child's speech disorder, the speech-language pathologist may use a small set of practice words at first. The number of words for practice will likely be gradually increased as your child improves.

Speech practice at home

Speech practice is very important. Your child's speech-language pathologist may encourage you to be involved in your child's speech practice at home.

The speech-language pathologist may give you words and phrases to practice with your child at home. Each home practice session can be short, such as five minutes in length. You might practice with your child twice a day.

Children also need to practice words and phrases in real-life situations. Create situations for your child to say the word or phrase. For example, ask your child to say "Hi, Mom" each time mom enters a room. This makes it easier for your child to say the practice words automatically.

Alternative communication methods

If your child can't effectively communicate through speech, other communication methods can be helpful.

Other methods may include sign language or natural gestures, such as pointing or pretending to eat or drink. For example, your child could use signs to ask for a cookie. Sometimes electronic devices such as tablets can be helpful in communication.

It's often important to use alternative communication methods early. It may help your child become less frustrated when trying to communicate. It also may help your child develop language skills such as vocabulary and the ability to put words together in sentences.

Therapies for coexisting problems

Many children with CAS also have delays in their language development. They may need therapy to address language issues.

Children with CAS who have trouble with fine and gross motor movement in their arms or legs may need physical or occupational therapy.

If a child with CAS has another medical condition, treatment for that condition may be important to improving the child's speech.

Treatments that aren't helpful for CAS

Some treatments aren't helpful in improving the speech of children with CAS. For example, there is no evidence that exercises to strengthen speech muscles will help improve speech in children with CAS.

Lifestyle and home remedies

You and your family can work with your child at home. Home practice, in addition to your child's speech therapy sessions, may help your child's progress.

Encourage and support your child as your child practices speech and language skills. Your child is likely to feel good about making improvements in speech with your support.

Be mindful of giving your child rests from therapy, as well. If your child has physical or occupational therapy along with speech therapy, schedule the sessions so that your child doesn't become too tired.

Coping and support

It can be hard to have a child who has problems communicating. There are a number of support groups available for parents of children with childhood apraxia of speech. Support groups may offer a place for you to find people who understand what you're going through and who can share similar experiences.

To learn about support groups in your area, see the Apraxia Kids website.

Preparing for an appointment

Your child is likely to start by seeing a doctor trained in the general care and treatment of children, known as a pediatrician. Or your child might see a doctor trained in treating children with neurological conditions, known as a pediatric neurologist, or a doctor specializing in developmental disorders experienced by children, known as a developmental pediatrician. Your child will likely be referred to a specialist in speech and language conditions, known as a speech-language pathologist.

Because appointments have limited time and there's a lot to talk about, it's a good idea to be well prepared for your child's appointment. Here's some information to help you and your child get ready and to get an idea of what to expect.

What you can do

• Write down any symptoms your child is experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Bring a list of all medicines, vitamins or supplements that your child is taking.
• Write down questions to ask your child's health care team and speech-language pathologist.
• Bring a copy of a recent progress report. If your child has already been seen by a speech-language pathologist, bring your child's individual education plan if you have one.

Your time during the appointment is limited. Prepare a list of questions ahead of time to help make the most of your time. For childhood apraxia of speech (CAS), some basic questions to ask the speech-language pathologist include:

• Does my child have CAS, or any other speech or language problems?
• How is CAS different from other types of speech disorders?
• Is my child's condition going to improve?
• What treatments are available, and which do you recommend?
• What can I do at home to help my child?
• Are there any brochures or other printed material that I can take home with me? What websites do you recommend?

In addition to the questions that you've prepared, ask questions during your appointment at any time that you don't understand something.

What to expect from your child's speech-language pathologist

Your child's speech-language pathologist is likely to ask you a number of questions. Being ready to answer them may allow more time to talk about your child's diagnosis and recommended treatment. Your child's speech-language pathologist may ask:

• When did you first have concerns about your child's speech development?
• Did your child babble? For example, did your child produce cooing sounds and then produce syllables, such as "ba-ba-ba" or "da-da-da"? If so, when did that start?
• At what age was your child's first word?
• At what age did your child's vocabulary include five words that were used frequently?
• How many words does your child currently have in his or her vocabulary that would be understandable to most people?
• In what other ways does your child communicate? For example, does your child point, make gestures, make signs or act things out?
• Has anyone in your family had speech or language problems?
• Has your child had ear infections? About how many ear infections has your child had?
• When was your child's hearing tested? Was any hearing loss detected?