Childhood apraxia of speech

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

In CAS, the brain isn't able to direct the lips, jaw, and tongue to create speech sounds clearly or at the proper speed. The speech muscles aren't weak, but they are not able to form words the right way.

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

Children with childhood apraxia of speech, also called CAS, may have various speech symptoms. Symptoms vary depending on a child's age and whether their speech problems are severe.

Children usually talk more between the ages of 2 and 4. Signs that may indicate CAS include:

• Unclear vowels and consonants.
• Pauses between syllables or words.
• Voicing errors, such as the word "pie" sounding like the word "bye."

Symptoms that are unique to the speech of children with CAS help make a diagnosis. Some characteristics, called markers, help distinguish CAS from other types of speech disorders. Those markers may include:

• Trouble moving smoothly from one sound, syllable or word to another.
• Off-target movements of the jaw, lips or tongue as they search for the correct movements for speech sounds. This is called groping.
• Saying vowel sounds incorrectly.
• Using the wrong stress in a word, such as pronouncing the word "banana" as BUH-na-nuh instead of buh-NA-nuh.
• Using equal emphasis on all syllables, such as saying BUH-NA-NUH.
• Putting a pause or gap between syllables.
• Saying the same word differently when using it more than once.
• Having a hard time imitating simple words.
• Voicing errors, such as saying the word "down" instead of the word "town."

However, some CAS symptoms also are symptoms of other speech or language disorders. CAS may be hard to diagnose if a child has symptoms found in both CAS and other disorders.

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

CAS can result in:

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

These symptoms are usually noticed between the ages of 18 months and 2 years. Symptoms at this age may suggest a condition called suspected CAS. Suspected CAS means a child may develop CAS. The child should receive ongoing exams in addition to speech therapy.

Other speech disorders sometimes confused with CAS

Other speech sound disorders are often confused with CAS because some symptoms are similar, such as voicing errors and leaving out certain sounds. These other 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 movements to speak. Articulation and phonological disorders are more common than CAS.

Articulation or phonological speech disorder symptoms 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. For example, the child might say "ting" instead of string or fog instead of frog.

Dysarthria is a speech disorder that may be confused with CAS.  It happens because the speech muscles are weak. Making speech sounds is hard because the speech muscles can't move as far, as fast or as strongly as they need to for clear speech. People with dysarthria also may 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 may be hard to determine the differences between CAS and dysarthria.

Childhood apraxia of speech, also called CAS, has many possible causes. But often a cause can't be found. There usually isn't an obvious change in a child's brain with CAS. However, CAS can be the result of brain conditions or injuries. These may include stroke, infections or traumatic brain injury.

CAS also may be a symptom of a genetic condition or syndrome or a metabolic condition.

CAS is sometimes referred to as developmental apraxia. But children with CAS don't make typical developmental sound errors. CAS also does not go away as a child grows older. This is unlike what happens in children with delayed speech or developmental conditions who follow typical speech and sound development patterns but at a slower pace.

Childhood apraxia of speech, also called CAS, is linked to gene differences in about one-third of children with the condition. Sometimes, it's caused by a change in a single gene. For example, risk may increase due to a change in the FOXP2 gene. This gene helps the brain control muscles needed for talking, especially for planning how to move the mouth.

Other times, CAS is related to larger changes in chromosomes, such as parts being missing or repeated. These changes can affect many genes. For example, missing part of chromosome 22q11.2 can raise the risk of speech sound disorders, including CAS.

CAS also can be part of certain genetic syndromes that affect the whole body. One example is galactosemia, a condition that affects how the body breaks down certain sugars in the blood. Children with galactosemia have a higher chance of having CAS.

Many children with childhood apraxia of speech, also called CAS, have other conditions that affect their ability to communicate. These conditions aren't due to CAS but may happen along with CAS.

Symptoms 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 trouble with reading, spelling and writing.
• Trouble with motor movement skills or coordination.
• Trouble using communication in social interactions.

You can't prevent childhood apraxia of speech, also called CAS. But early diagnosis and treatment of CAS may reduce the risk of long-term complications. If your child has trouble with speech, have a specialist, called a speech-language pathologist, evaluate your child as soon as you notice any issues.

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

Your child's speech-language pathologist also may test 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 symptoms. The specific tests your child has during evaluation depend on your child's age, ability to cooperate and whether speech issues are severe.

Diagnosing CAS can sometimes be hard, especially when a child speaks very little or has trouble engaging with the speech-language pathologist during the exam.

Still, it's important to identify whether your child shows symptoms of CAS because the condition 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 child's healthcare professional may order hearing tests to determine if trouble with hearing could be contributing to concerns with your child's speech.
• Oral-motor assessment
• Your child's speech-language pathologist examines your child's lips, tongue, jaw and palate for structural changes, such as tongue-tie or a cleft palate. The speech-language pathologist also looks for other symptoms, 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 watches how your child moves the lips, tongue and jaw in activities such as blowing, smiling and kissing.
• Speech exam
• Your child's ability to make sounds, words and sentences may be watched during play or other activities.
• Your child may be asked to name pictures. This allows the speech-language pathologist to check whether your child has trouble making specific sounds or speaking certain words or syllables.
• Your child's speech-language pathologist also may look at 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 watches 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 slower or providing touch cues to the face.

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

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

Speech therapy

Speech therapy focuses on practicing syllables, words and phrases.

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

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

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

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.

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 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 has been shown to be the 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 the words "hi," "mine" and "bite." Or your child may be asked to say the words "out," "down" and "house."
• Paced learning. Depending on the severity of your child's speech disorder, the speech-language pathologist may first use a small set of practice words. The number of words for practice may slowly increase as your child improves.
• Focus on correct movement, stress patterns and smoothness. While children with other speech sound disorders may need to focus only on making sounds correctly, children with CAS also need to pay attention to where they are putting stress on words and how smoothly their movements make sounds.

Speech practice at home

Speech practice is very important. Home practice, in addition to your child's speech therapy sessions, may help your child's progress. Your child's speech-language pathologist may encourage you and your family 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. For example, you might practice with your child for five minutes twice a day.

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

Other communication methods

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

These 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.

If you want to use these other communication methods, it is best to start using them early. This 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 conditions

Many children with CAS also have delays in 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.

Be mindful of giving your child rest breaks from therapy. If your child has physical or occupational therapy and speech therapy, schedule the sessions so that your child doesn't become too tired.

Treatments that aren't helpful for CAS

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

At times, it may be challenging when your child has trouble 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.

Visit the Apraxia Kids website to learn about support groups in your area.

Having CAS also can be difficult for your child. Encourage and support your child as your child practices speech and language skills. Your child will likely feel good about improving their speech with your support.

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 in 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 is 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 having, including any that may not seem related to the reason you scheduled the appointment. Bring this list to your child's appointment.
• Bring a list of all medicines, vitamins and supplements that your child is taking.
• Write down questions to ask your child's healthcare team and speech-language pathologist.
• Bring a copy of a recent progress report. If your child has already seen a speech-language pathologist, bring your child's individual education plan, also called an IEP, if you have one.

Prepare a list of questions ahead of time to help make the most of your time. For childhood apraxia of speech, also called CAS, some basic questions to ask the speech-language pathologist include:

• Does my child have CAS or any other speech or language disorders?
• How is CAS different from other 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 materials that I can take home with me? What websites do you recommend?

In addition to the questions you've prepared, ask questions during your appointment whenever you don't understand something.

What to expect from your doctor

Your child's speech-language pathologist will likely ask you several 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 they often used?
• How many words does your child now use that most people would understand?
• 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 a speech or language disorder?
• Has your child had ear infections? About how many ear infections has your child had?
• Has your child's hearing been tested? When was your child's hearing tested? Was any hearing loss detected?