When I receive a consultation request from a parent that says ‘my child isn’t talking’, the first thing I always explain is that there are many reasons why a child may be experiencing a speech and/or language delay. The brain is a complex structure, where development may take a detour in one or several specific areas. This is why differential diagnosis is so important. It is not appropriate to simply label the child as having a ‘language delay’; we must investigate and determine the nature of the problem, so that appropriate treatment can be recommended.

Parents should be aware that speech therapy approaches to address a language disorder are very different from approaches for a severe speech sound disorder, like apraxia. I always tell parents early on, that even if we are only ‘suspecting’ apraxia, we want to monitor closely and provide the right kind of therapy from the beginning, so that we don’t waste the child’s time and lose out on the critical developmental period.

I like to think of childhood apraxia of speech (CAS) as an extra special speech disorder that requires an extra special touch. Not all speech-language pathologists have developed the ear for tuning into CAS early on. I feel that early diagnosis is very important, because it dictates the path for treatment. Using differential diagnosis, I take a careful look at everything the child IS doing, and compare it to what they are struggling with. There are many red flags that can be found if you understand what you are looking for.

Let’s look at an example here. Child-A is 2.5years old, appears to be understanding most of what is said to him, is following directions, and has good joint-attention and clear communication intent. They are trying to communicate, and seem to know what they want to say, but they rarely say words that anyone can actually understand. But then they have about 10-15 words that they say clearly and consistently with no problems. Parents wonder, why can he say ‘apple’ clearly, but when he tries to say his name (Paul), which has similar sounds, we can’t understand him?
Many times the child speaks in long strings of ‘gibberish’ (the official speech term in jargon) that sounds like real speech, but you can’t understand any of it. And when family members try to get him to repeat words sitting face to face with exaggerated models, he produces a different combination of sounds each time (Say Paul: ‘aba’. Say Paul: ‘ala’. Say Paul: ‘papa’).

Child-B is also 2.5y old, not talking much, and using only a few words to communicate. They have trouble following directions, don’t seem to understand what is said to them, don’t follow along with story reading time very well, and are easily frustrated. This child also says about 10-15 words clearly, but when you ask them to repeat words, they can imitate words pretty well. When you point to something and say the word without them seeing your face, even on a noisy city street, they immediately repeat what you say clearly (Look a bus! ‘bus’).

We would say that Child-A is suspected of a speech sound disorder and Child-B is suspected of a language disorder. We would approach therapy differently for these two children. If Child-A does indeed have a motor planning disorder, and therapy does not provide approaches in line with motor planning research, then they may
lose valuable time where they could begin to make progress.

This is why I believe that differential diagnosis is so important, and why I spend the time to take a close look at every individual client that comes in for an evaluation, so I can recommend the right treatment approaches and maximize their opportunity for progress.