What is Childhood Apraxia of Speech?

As a pediatric speech-language pathologist who has been working in early intervention for more than 5 years, I have come across few children with true isolated, childhood apraxia of speech (CAS).  There’s a reason for this, and a reason to be wary when you hear this diagnosis thrown at you as an explanation for child’s speech delay.  Not all children who are late talkers have CAS.

CAS is a tricky condition because in order to accurately diagnose it, a child needs to have some speech--- but a speech delay/limited sound repertoire is usually a characteristic of children with CAS.  Huh?!  You can see how this is confusing to parents, and less experienced therapists alike.  Many professionals are mis-diagnosing and over-diagnosing, and the purpose of this post is to clarify some things about Childhood Apraxia of speech.  I will start with the definition as provided by the guru of CAS, Nancy Kaufman:

“Childhood Apraxia of Speech (CAS) is a motor-speech programming disorder resulting in difficultly producing and sequencing the oral motor movements necessary to produce and combine speech sounds to form syllables, words, phrases and sentences on a voluntary (rather than only reflexive) control.”

When you are working with children younger than 3-4 years of age, it is considered best practice to diagnose as suspected Childhood Apraxia of Speech (sCAS).

Children with CAS know what they want to say, understand what they hear, have the words, phrases, and even sentences inside of their head, but when they go to speak, something in their motor plan goes wrong and sounds cannot be sequenced appropriately, preventing accurate (or any) sound production.  How frustrating is that?!

Clinically, the children I have treated with isolated sCAS have also presented with extremely challenging interfering behaviors.  It sort of makes sense, doesn’t it?  Imagine understanding everything in the world around you, knowing what you want to say, but either unintelligible jargon comes out or even worse – nothing.  Of course this may result in challenging behavior until an SLP comes around and knows how to help the child communicate!

To reiterate, CAS is a motor planning disorder, completely independent of any oral-motor weaknesses, cognitive delays, and receptive language delays.

Let’s look at an example:

Joey loves playing farm.  He knows all the animals by name and all of the sounds they make.  During play, Joey can often be heard producing “moo” and “neigh!” while engaging in pretend play.  When Mom joins the activity and in an attempt to make it interactive, asks “Joey, what does a cow say?” Joey may produce “oo”  “doo” “boo” or he may not produce any audible sound.  Mom may think that Joey does not know his animals and their sounds, and can you imagine how frustrating this is to Joey?  Mom may then break down the “moo” into  “mmm” and have Joey imitate it, which he does.  Then ask him to copy the “oo” sound, which he does. Then, when asked to sequence the sounds (m…ooo), Joey produces “da!”  Imagine how difficult and frustrating this must be for our children with CAS!  This example is often what CAS looks like in a child who has emerging speech.

The specific population of children I work with mostly fall on the Autism Spectrum.  Children with Autism Spectrum Disorder (ASD) can also present with CAS, just like they can also have a hearing loss or brown hair (read: not related).  This is important for an SLP to recognize when planning appropriate treatment methods.  Some of the current “hot” therapies for CAS (e.g. PROMPT) are sold as the gold standard of CAS therapies, based on their ability to effectively treat children with CAS (which they can do), but in my experience these therapies do not account for children on the Autism Spectrum with sensory processing differences, or any child with receptive language delays.  Children with ASD or receptive language delays are potentially missing necessary skills to participate in this type of therapy.  A general word of advice is never buy in to the “buzz word” therapy and that therapy alone. Parents love to ask “Are you PROMPT trained?” and I thankfully can answer “yes” but I would like to stress that a good SLP is educated and trained in all relevant and effective methods particular to a disorder, not just the latest buzz!

Check out Nancy Kaufman’s website for early signs and symptoms as I simply could not come up with a list as comprehensive and accurate as she has compiled on her website: www.kidspeech.com

If the signs and symptoms read a little too clinical or too technical, feel free to shoot us an email and we will be happy to further explain!

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Speech vs. Language

Speech and language are two terms which are often used interchangeably in error! Though related, the two terms are clinically separate entities.  As they are both areas of potential delay in your child’s development, let’s get some clarification on the differences between them!

Speech is the sound system produced as a result of vocal fold vibration in coordination with respiratory support and shaping of the articulators (cheeks, lips, tongue, oral cavity).  Speech is what we hear.  More technically and specifically, speech is comprised of phonemes (sounds) that are labeled as consonants and vowels. Speech production becomes more complex as speakers combine consonants and vowels to form more complex syllable shapes

Take a moment and sound the following words out and you’ll become aware of just how many different actions your articulators are making in “elephant” compared to a more simple word “me.”  

In typical speech development, there are certain sounds that a child produces earlier vs later. The more visual sounds (bilabial) are those that are made with our lips such as “b” “p” “m” are our earlier sounds.  The more complex sounds that are produced inside the oral cavity using specific tongue placements come later in speech development, such as “r” “s” “l.” Parents can expect children to mispronounce words that are more difficult or have later developing sounds for a period of time, while they are honing their speaking skills.

Language is the way we exchange information.  “Exchange” implies the presence of two individuals, or communicative partners, because language requires a listener and a speaker.   Language can be verbal (speech) and non-verbal (gestural/graphic). Language is further broken down into receptive language (understanding gestures, eye contact, spoken and written words) and expressive language (using gestures, eye contact speech, and written words to communicate a message).

Common gestures that children use include pointing, waving, and shaking their heads “no” and “yes.” If the child is using words, is she starting to combine them? This typically happens when a child is approximately 2 years of age. Is the child using their words for different communicative functions? The main areas of communicative functions that I look for as an Speech Language Pathologist (SLP) include the following: labeling, commenting, calling attention, greeting, exiting, refusing, requesting objects, answering yes/no questions, requesting actions, and requesting information (e.g. asking wh-questions).  A huge component of language development is the function of language. A child may be able to name every animal while reading his favorite book, but can he use that same word to request an animal during play?

Some questions to ask about your child’s language development include:

Receptively, does my child …

Respond to his name with eye contact?

Following familiar commands?

Follow new commands?

Answer questions?

Locate familiar people and objects?

Identify his body parts?


Expressively, does my child…

Use gestures such as pointing and waving?

Look at the person he is communicating with?

Continue to add to his growing vocabulary?

Put words together to express his wants?

Ask questions about his environment?


As with all early childhood development, it’s important to understand that each child develops a little differently, some at slower paces than others.  In the early years, I always stress to parents to worry less about the articulation (speech) because to a certain degree, unintelligibility is typical! You really want to make sure that even if your child’s speech is not quite there yet, are they still communicating effectively through other routes of language?

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