Catherine H. Earnhardt, MCD, CCC-SLP
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Financial: Catherine H. Earnhardt does not
have any relevant financial information to
disclose.
Non-Financial: Catherine H. Earnhardt has a
son with childhood apraxia of speech, she is
the VP of Clinical and Professional Affairs on
the SCSHA Executive Board, is the ASHA CE
Administrator for SCSHA, and is the SCSHA
convention co-chair.
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Definition and Terminology
Characteristics of Childhood Apraxia of
Speech
Evaluation Challenges
Differential Diagnosis
Treatment Approaches
Multi-Cultural Issues
The Importance AAC with CAS
Case Study
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“Childhood apraxia of speech (CAS) is a neurological
childhood speech sound disorder in which the
precision and consistency of movements underlying
speech are impaired in the absence of neuromuscular
deficits (e.g. abnormal reflexes, abnormal tone). CAS
may occur as a result of known neurological
impairments in association with complex
neurobehavioral disorders of known and unknown
origin, or as an idiopathic neurogenic speech sound
disorder. The core impairment in planning and/or
programming spatiotemporal parameters of movement
sequences results in errors in speech sound production
and prosody” (ASHA, 2007a, Definitions of CAS
section, para. 1).
Source: http://www.asha.org/Practice-Portal/Clinical-Topics/Childhood-Apraxia-of-Speech/
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Childhood Apraxia of Speech (CAS)
Dyspraxia
Verbal Dyspraxia
Developmental Apraxia of Speech
Developmental Verbal Apraxia
According to ASHA.org, the term Childhood
Apraxia of Speech is preferred term.
Source: http://www.asha.org/Practice-Portal/Clinical-Topics/Childhood-Apraxia-of-Speech/
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The term “Developmental” is seen by many
professionals and payor sources as a “delay” in
development.
Prefix “A” implies Absence and the Prefix “Dys”
implies Partial. This is usually used as a personal
preference, based on a geographic area, or based on the
educational institution.
The term “Apraxia” is widely used to describe the
adult form of Apraxia.
ASHA.org states that the term Childhood Apraxia of
Speech is used as a “unifying cover term for all
presentations of apraxia of speech in childhood,
whether congenital or acquired or associated with a
specific etiology”.
Source: http://www.asha.org/Practice-Portal/Clinical-Topics/Childhood-Apraxia-of-Speech/
Source: http://www.apraxia-kids.org/guides/slp-start-guide/the=terminology/
Suspected Childhood Apraxia of Speech:
It is considered best practice to diagnose any
child under the age of 3 with Suspected
Childhood Apraxia of Speech Vs. Childhood
Apraxia of Speech.
Once the child turns three years of age a reevaluation is completed and the diagnosis of
Childhood Apraxia of Speech can be given at that
time.
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Automatic Speech vs. Volitional Speech
Automatic Speech: Speech activities that have
become rote and does not require motor planning
(i.e. 1-10, DOW, MOY).
Volitional Speech: Involves motor planning and
sequencing of sound segments for correct
articulator movement and speech production
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1-2 children per 1,000
3.4% to 4.3% of all children referred for
evaluation of speech disorder
Boy to girl Ratio: 2 or 3:1 (more boys than
girls)
Increase Prevalence Rate with certain comorbidities (i.e. galactosemia and fragile
x syndrome).
Source: http://www.asha.org/Practice-Portal/Clinical-Topics/Childhood-Apraxia-of-Speech/
ASHA’s Ad Hoc Committee on Childhood Apraxia of
Speech Cites and Increase prevalence in CAS cases
with Complex Neurobehavioral Disorders to include:
 Autism
 Epilepsy
 Fragile X Syndrome
 Galactosemia
 Rett Syndrome
 Chromosome Translocations Involving Deletions
and Duplications
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In most cases there is no known cause
Considered to be a Neurological Deficit
Higher prevalence with certain Genetic
Disorders/Syndromes
Damage to areas of the brain controlling motor
planning (i.e. Brain Injury/Stroke)
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Not every child with CAS present the same
Inconsistent errors are a key characteristic
Not all characteristics are present. This a major reason why
not every child with CAS will present the same.
It is not a disorder that can be “out grown” and there is no
cure (This is a major reason why we must be careful with
diagnosing a child as having CAS).
Typically once something is learned, it is difficult to correct
if it is incorrect (example: daycare calling a child “Hunter E”
if there are two Hunters and the child starting to say their
name as “Hunter E”. It can be very difficult to reteach a
child with CAS to say “Hunter”.
There is frustration because the child understands what is
going on around them but they can’t express their wants
and needs.
“There is something wrong with my mouth.”
“Everything I say is wrong.”
“Why won’t my mouth work?”
“Why don’t you understand me?”
“There is something wrong with me.”
A person’s perception is their reality.
Imagine if this was your reality.
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Motor Planning Disorder
Difficulty with sequencing sound segments
Not related to muscle weakness or paralysis
Inconsistency with errors
Provided that there is not a cognitive deficit
present, the child knows what they want to say
but the muscles will not move in the correct
sequence to make the correct sounds.
Source: http://www.asha.org/public/speech/disorders/childhoodApraxia
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Inconsistent errors with Sound Segments
Inappropriate Prosody
Groping
High incidence of vowel distortions
Frequent sound distortions and distorted consonant substitutions
Initial Consonant Deletion
Voicing Errors
Schwa additions/insertions to consonant clusters
Greater ease with use of frequently used phrases that become much like
automatic speech phrases: “I love you”
Difficulty with accurate movement of speech musculature when trying to
imitate words not previously mastered
Inconsistent suprasegmental characteristics (rate, pitch, loudness)
Increased errors with increased MLU and longer/more complex syllables
and words.
Atypical Regression
Sequencing Errors
Source: http://www.asha.org/Practice-Portal/Clinical-Topics/Childhood-Apraxia-of-Speech/
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Limited vowel repertoire; less differentiation between vowel distoritions
Idiosyncratic error patterns (Many times these errors are impossible to
transcribe)
Errors increase with MLU and complexity of words and sound segments
Prosody disturbances including overall slow rate
The child may be able to say the target sound correct in one utterance but
will produce the same target sound incorrectly in another utterance.
Impaired diodochokinetic tasks (unable to maintain consistent rate of
sequences such as /pa/ /pa/ /pa/ and/or accuracy with sequencing
such as /pa/ /ta/ /ka/
“Choppy” monotone speech
Groping or observable physical struggle with muscle movement to
produce a target sound
Impairment with non-speech movements may be present if the child also
has oral apraxia
Source: www.apraxia-kids.org/guides/slp-start-guide/key-charactoristics-of-cas/
http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAYQjB1qFQoTCMCn0rf8i8kCFYlZJgodmD
YPCQ&url=http%3A%2F%2Fwww.thedcladies.com%2F2014%2F07%2F15%2Fwhat-is-childhood-apraxia-ofspeech%2F&psig=AFQjCNEZj1ZONTZVORBhpOgFnWbABrDKiw&ust=1447455058756580
ASHA Position Statement
Childhood Apraxia of Speech
Ad Hoc Committee on Childhood Apraxia of
Speech
http://www.asha.org/policy/PS2007-00277/
“Review of the research literature indicates that,
at present, there is no validated list of diagnostic
features of CAS that differentiates this symptom
complex from other types of childhood speech
sound disorders, including those primarily due to
phonological-level delay or neuromuscular
disorder (dysarthria).”
Source: http://www.asha.org/policy?PS2007-00277/
“Three segmental and suprasegmental features
that are consistent with a deficit in the planning
and programming of movements for speech
have gained some consensus among
investigators in apraxia of speech in children:
(a) Inconsistent errors on consonants and vowels
in repeated productions of syllables or words.
(b) Lengthened and disrupted coarticulatory
transitions between sounds and syllables
(c) Inappropriate prosody, especially in the
realization of lexical or phrasal stress.”
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Source: http://www.asha.org/policy?PS2007-00277/
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Inconsistencies with voice, prosody, rate,
articulation, and errors.
Cat
Target Production 1: mat
 Target Production 2: bet
 Target Production 2: moj
 Etc.
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Groping and uncoordinated muscle
movements can be misdiagnosed as a stutter
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CAS is a motor speech disorder that effects the
ability to sequence sound segments at the
word, phrase, and sentence level.
Therefore, the child has difficulty learning to
put the sounds together to say the word.
The typical child acquires speech sounds in the
initial, final and then middle position of the
words.
The child with CAS must learn each word.
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Typical Prosody: Intonation rises at the
beginning of the phrase or utterance and then
falls at the end of the phrase or utterance. This
rising and falling of intonation are markers that
identify the phrase or utterance boundaries.
Prosody with CAS: Trouble with natural
inflection and natural stress to mark phrase
and utterance boundaries. There is often also
inconsistency with prolonged pauses making a
smooth transition difficult.
“Importantly, these three features are not
proposed to be the necessary and sufficient signs
of CAS. These and other reported signs change in
their relative frequencies of occurrence with task
complexity, severity of involvement, and age.”
Source: http://www.asha.org/policy?PS2007-00277/
ASHA.org
Childhood Apraxia of Speech
http://www.asha.org/public/speech/disorders/
ChildhoodApraxia/
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Delayed Language Development
Difficulty with fine motor
movements/coordination (writing, buttoning
clothes, etc.)
Difficulty with sequencing other motor
movements (riding a bike, karate, swimming, etc)
Word order difficulty
Hypersensitivity and/or Hyposensitivity in their
mouths (may not like certain textures in the mouth
– toothbrush, mixed consistencies, crunchy
consistencies, etc)
Difficulty learning to spell, read and write
Source: www.asha.org/public/speech/disorders/ChildhoodApraxia/
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Children with CAS present differently
Not all characteristics of CAS are present
No validated list of characteristics for
differential diagnosis at this time.
Limited Speech Samples
Must rule out:
Auditory deficits
 Severe Phonological Disorder
 In some cases you may need to rule out
velopharyngeal Insufficiency (VPI)
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ASHA’s Practice Portal Cites that there are a variety of reasons that it is
difficult to diagnose CAS under the age of 3:
“the potential presence of developmental disabilities and/or comorbid
conditions”
“The lack of a single validated list of diagnostic features that
differentiates CAS from other types of childhood speech sound
disorders (e.g., those due to phonological-level deficits or
neuromuscular disorders)”
The fact that some primary characteristics of CAS (e.g., word
inconsistency, a predominant error pattern of omission, etc.) are
characteristics of emerging speech in typically developing children
under the age of 3 years”
“The lack of a sufficient speech sample size for making a more definite
diagnosis”
“The challenge of sorting out inability versus unwillingness to provide a
speech sample or to attempt a speech target”
“The possibility that changes occurring prior to age 3 (e.g.,
developmental maturation, social and linguistic peer exposure, and
beneficial effects of therapy) may alter the diagnostic label”
Source: http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935338&section=Assessment/
ASHA’s Practice Portal Cites:
“Diagnosis below age 3 is best categorized under
a provisional diagnostic classification, such as
“CAS cannot be ruled out,” “Signs are consistent
with problems in planning the movement
required for speech,” or “suspected to have CAS.”
Source: http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935338&section=Assessment/
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Case History
Hearing Screening
Oral-Motor Evaluation
Articulation/Speech Production
Prosody
Voice
Language
ASHA Practice Portal Also Cites the Use of Additional Tasks
for Differential Diagnosis to Include:
 “nonspeech articulatory postures (e.g., smile) and
sequencing (e.g., kiss-smile) versus speech sounds and
words”
 “Well practice/automatic versus volitional speech (for
children who are older and/or have some speech)”
 “Speaking tasks that require single postures versus
sequences of postures (e.g., single sounds such as /a/ vs.
words such as /mama/”
 “Speech production at the syllable, single-word, bisyllable,
multisyllable, phrase and sentence levels”
 “sequential/alternating movement repetitions (e.g.,
/papapapa/ versus /pataka/, formerly called
diadochokinesis)”
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Limited early sound play
Sound inventory restrictions
Expressive language deficits in contrast to
receptive language
Imitation superior to Volitional Skills
Sequencing/Movement difficulties
Word/Sentence complexity breakdown
Prosodic deviances
Inconsistencies
Source: Hammer, David, M.A., CCC-SLP Childhood Apraxia of Speech: New Perspectives on Assessment and Treatment: Spnonsored by CASANA; 2008
9. Voiced/Voiceless sound errors
10. “Groping” behaviors
11. Vowel Distortions
12. Sound Omissions
Source: Hammer, David, M.A., CCC-SLP Childhood Apraxia of Speech: New Perspectives on Assessment and Treatment: Spnonsored by CASANA; 2008
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Multi-sensory Input Approach: Input that is visual, proprioceptive, tactile
and auditory to teach sequencing of motor movements for speech
production (CASANA)
Motor Programming Approaches: sequencing of articulator movements
for speech production (asha.org/policy)
Combined Linguistic-Motor Programming Approaches: uses tactile cues
along with descriptive phrases/cues for sound production
(asha.org/policy)
Sensory and Gestural Cueing Approaches: Electropalatography of tongue
movement to provide visual feedback (asha.org/policy)
Integral Stimulation Approach (modified for the use with children as
Dynamic Temporal and Tactile Cueing): Most commonly used method in
treating speech disorders; involves the child imitating target utterances
produced by the clinician “listen to me, watch me, do what I do”
(CASANA)
Prosodic Cueing Approach: Incorporates rhythm, stress and melody to
produce speech production; example: Melodic Intonation Therapy (MIT);
usually used with less severe deficits or later in therapy (CASANA)
CASANA
“Treatment Approaches for Children with
Childhood Apraxia of Speech (CAS)”
http://www.apraxia-kids.org/apraxiainformation-downloads/
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Developed by Nancy R. Kaufman, who is the owner of
Kaufman Children's Center for Speech, Language,
Sensory-Motor, and Social Connections, Inc.
Breaks the target into smaller units and builds back up
to the larger speech target using cues, fading cues and
cueing before failure. (ASHA – Portal)
Video 3 Year Old Male with CAS
https://www.youtube.com/watch?v=pCw3Jn7NW_s
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Build on current expression
Use starter positions
Label sounds, but try to incorporate
placement/manner cues
Make a core vocabulary book
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Benefits:
Organizes a starting vocabulary for facilitation of a mutal focus
between therapist, parents, other caregivers and communication
partners in the child’s life
 Enables the child a sense of success
 Allows parents/caregivers to immediately feel a part of the “team”
 Provides a foundation for AAC device if necessary. Also allows
for low tech AAC vocabulary and expanding on current core
vocabulary
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Procedures:
Use photographs containing pictures of people, toys, objects, and
verbs important in the child's life, as well as target words for
therapy.
 Photographs placed in a “Grandma’s Brag Book” with written
words at the top (when you point at the picture do not cover the
word).
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Prompts for Restructuring Oral Muscular Phonetic
Targets
Providing tactile-kinesthetic-proprioceptive input
for speech production
Apraxia motor planning/sequencing deficits
secondary to decrease independent articulator
movement. Therefore, patient can learn sequence
for one word instead of for specific sound to be
carried over to other words.
Must gain independent movement between
lingual, labial and jaw movements
Independent movement of labial and lingual
movement is not possible without jaw stability
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Appropriate Referrals May Include:
Audiological/ENT Evaluation
VPI Evaluation
Physical Therapy: gross motor skills are a concern
Occupational Therapy: fine motor skills are a
concern
Speech Language Pathology Referral: Skilled and
experienced Clinicians in motor speech disorders
should assess CAS cases or be under the
supervision of a Speech Language Pathologist with
specific training/experience in motor speech
disorders (ASHA Ad Hoc Committee on
Childhood Apraxia of Speech).
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Key to allowing a child with CAS a successful
means of communication.
Can be low tech or high tech based on the child’s
abilities and needs
Key to expanding the core vocabulary
Key to expanding expression
Reduces aggressive behavior and frustration due
to inability to express thoughts, ideas, wants and
needs
Increases progress towards verbal expression
Lay down foundation for language (pre-linguistic
skills not mastered due to limited early sound
play)
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Bilingual/Multilingual Populations
Factors to Consider Per ASHA’s Practice Portal:
“Bilingual treatment may facilitate greater improvement than
English-only treatment in a child with CAS”
“Beginning treatment by first targeting phonemes that are shared
between the languages spoken by a child may yield the greatest
improvement in intelligibility across languages in the shortest
amount of time.”
“Cross-linguistic transfer is also most successful when stimuli are
chosen that are shared between the two languages. Additionally,
cross-linguistic transfer can be used to target goals in one
language while targeting properties of a second language. For
example, treatment addressing multisyllabic words in Spanish
may facilitate transfer to the phrase level in English.”
Source: http://www.asha.org/PRPSpecific Topic.aspx?folderid=8589935338&section=Treatment
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Bilingual/Multilingual Populations
Factors to Consider Per ASHA’s Practice Portal:
“Errors that are only present in one language are unlikely to improve
intelligibility in the other language when addressed in treatment. For
example, if final consonants are targeted in English to improve
intelligibility, but occur rarely in the child’s primary language,
intelligibility in that language will not be positively influenced by
addressing accurate final consonant productions in English.”
“Clinicians consider the context in which a child uses each language
identify vocabulary words that are likely to facilitate carryover, functional
use, and repeated practice and exposure in each language.”
“Treatment incorporates activities that facilitate cross-linguistic transfer
of skills and improved intelligibility, including providing activities for
home practice in the language used by the family.”
“Goals and Targets in each language are chosen based on the properties
and word shapes of each language. English has more monosyllabic
words with consonant clusters and, thus, targets in English should be
representative of the word shape.”
Source: http://www.asha.org/PRPSpecific Topic.aspx?folderid=8589935338&section=Treatment
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1:9 Male
History of:
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oral, pharyngeal dysphagia with multiple hospitalizations for aspiration
pneumonia. In speech therapy since 4 weeks of age but was moved to
another speech therapist at 8 weeks of age because the mother felt the
treatment was increasing risk of aspiration.
malignant hypothermia
visual field delay – resolved,
Severe torticollis (neck angled to one side) resulting in torso weakness,
right-sided weakness. Torticollis was resolved but was followed by
hypersensitivity to the right side.
Initial ENT diagnosis of conductive hearing loss. However, upon
inspection of the tympanogram the mother determined that the results
were not consistent with a conductive hearing loss and sought a second
opinion that concurred with the mothers findings of a sensorineural
hearing loss.
ENT diagnosis of Laryngeal collapse and mild bilateral sensorineural
hearing loss for all frequencies. Tubes were placed at 14 months – hearing
loss resolved.
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Patient did not begin walking until 13 months
due to torticollis
Not yet toilet training at 1:9
Reported periods of gain followed by loss of
acquired skill.
Diagnosed by Occupational therapy as having
hand and finger apraxia
Physical therapy since 4 weeks of age and
occupational therapy since 6 months of age.
Recently discharged from physical therapy but
continued with occupational therapy
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No babbling or playing with speech sounds
Has a good /m/ and says /mama/ for all purposes
Vowel distortions
Inconsistent errors
Use of simple signs (i.e. more, etc)
Able to nod for yes/no
Will use intonation with grunts
Jaw pumping and “groping” with verbalization attempts,
especially when attempting to initiate.
Can follow 4-5 step directions and was tested as being cognitively
2 years above his chronological age
Extreme frustrations with attempts to verbalize to the point that
the pediatrician wanted to label the child autistic. The mother
disagreed with this diagnosis, refused the referral for autism
testing and sought another pediatrician.
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Continues to have significant drooling at 1:9
Interacts only with younger children that are
nonverbal
Likes playing with ‘Thomas the Train’ and
things with faces.
Severe separation anxiety if mother or
grandmother is not present.
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What are your impressions about the child
based on the information provided by the
parent?
What are your impressions about the parent
based on the information provided by the
parent?
What are your impressions related to
differential diagnosis?
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“There is something wrong with my mouth.”
“Everything I say is wrong.”
“Why won’t my mouth work?”
“Why don’t you understand me?”
“There is something wrong with me.”
A person’s perception is their reality.
Imagine if this was your reality.
“Why can’t I fix this for my child? I failed him.”
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7.
Kaufman Speech Praxis Test for Children (KPST) was given.
Clinical Impressions and Diagnosis: Key characteristics for CAS
noted:
“Limited repertoire of vowels; less differentiation between vowel
productions; and vowel errors, especially distortions”
“variability of errors”
“Unusual, idiosyncratic error patterns”
“able to produce accurately the target utterance in one context
but is unable to produce the same target accurately in a different
context”
More difficulty with volitional, self-initiated uttereances as
compared to over-learned, automatic, or modeled utterances”
At some point in time, groping or observable physical struggle
for articulatory position”
Impaired volitional nonspeech movements”
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The following Characteristics were noted that
may describe children with CAS
“Delayed onset of speech”
“Limited babbling as an infant”
“Restricted sound inventory”
“Loss of apparently previously spoken words”
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Recommendations
It is recommended that Hunter be enrolled in a
treatment program with goals consistent with
those addressed in treatment with CAS, including
a primary focus of increasing functional
communication through signs and gestures while
building on sounds in his phonemic repertoire to
increase verbal output.
It is recommended that, if at all possible, Hunter’s
treatment be administered in short, frequent
sessions (20-30 minutes sessions 2-3 times per
week).
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KPST results indicated a Severe speech praxis
disorder.
Due to his age, the mother asked, and the
evaluating therapist agreed to place Hunter under
a “Working Diagnosis of Childhood Apraxia of
Speech”.
One year later, he was re-tested with the KPST, by
the same evaluating therapist, and was diagnosed
as having Severe Childhood Apraxia of Speech.
Hunter’s hand apraxia had improved with
occupational therapy and hunter was starting on a
low tech picture AAC with a core vocabulary.
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Between 2:9 and 3:9, he saw significant increase
with expressive language due to:
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3.
Implementation of key components of the Kaufman
and Hammer treatment modalities.
AAC use for successful communication in
restaurants, home, etc to increase independence
and ability to express specific wants/needs.
Although the severity of his CAS should have
resulted in the use of ACC in the 4K, he entered 4k
with the ability to successfully communicate
expressively in 60% of attempts. No AAC was
necessary in the school setting.
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He saw significant rates of progression with verbal
expression and accuracy with the addition of
PROMPT therapy modalities, although Kaufman
and Hammer continued to be used as well.
He also so significant increase in overall motor
planning with activities that utilized
proprioceptive input with gross motor
movements.
Swimming
 Riding Bike
 Soccer
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“Position Statement: Childhood Apraxia of Speech: Ad Hoc
Committee on Childhood Apraxia of Speech”, ASHA 2007:
http://www.asha.org/policy/PS2007-00277/
“Childhood Apraxia of Speech” ASHA
http://www.asha.org/public/speech/disorders/ChildhoodApra
xia/
“If I Could Only Tell You, I would Say …” CASANA
http://www.apraxia-kids.org/apraxia-information-downloads/
“Treatment Approaches of Children with Childhood Apraxia of
Speech (CAS): Fact Sheet”, CASANA http://www.apraxiakids.org/apraxia-information-downloads/
“About Childhood Apraxia of Speech” CASANA,
http://www.apraxia-kids.org/apraxia-information-downloads/
Please Note: The presenter will not be providing printed copies of
the session resources to ensure that there is no perception of
copyright infringement. The presenter requests that you print a
copy for your individual use.
CASANA Video
Hope Speaks: An Introduction to Childhood
Apraxia of Speech
https://secure2.convio.net/caosa/site/Ecommerce/1590065402?VIEW_PRODUCT=true&product_id=1121
&store_id=1241/
CASANA Video
Treatment Strategies For Childhood Apraxia of
Speech with David W. Hammer, M.A., CCC-SLP
https://secure2.convio.net/caosa/site/Ecommerce/1590065402?VIEW_PRODUCT=true&product_id=1141
&store_id=1241/
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“Technical Report: Childhood Apraxia of Speech: Ad Hoc
Committee on Apraxia of Speech in Children”, ASHA 2007:
http://www.asha.org/policy/TR2007-00278/
“Childhood Apraxia of Speech”, ASHA Practice Portal:
http://www.asha.org/Practice-Portal/ClinicalTopics/Childhood-Apraxia-of-Speech/
“Speech-Language Pathologist Start Guide” CASANA:
http://www.apraxia-kids.org/guides/slp-statrt-guide/
“PROMPS for Restructuring Oral Musculature Phonetic
Targets” Introduction to Technique: Manual, The PROMPT
Institute; Revised January 2012.
“Childhood Apraxia of Speech: Resource Guide” Dr. Shelley
L. Velleman