Because Childhood Apraxia of Speech is a communication disorder, the most qualified professional to provide assessment, evaluation, and diagnosis is a licensed speech-language pathologist (SLP).  Other professionals can be helpful and necessary at some point in time for children with CAS; however, they have not typically undergone the extensive and concentrated study and certification to fully evaluate speech and/or language disorders.  Professionals such as pediatric neurologists or developmental pediatricians sometimes make the diagnosis but more often, and more appropriately, they refer to the speech-language pathologist on their team who has the skill and extensive training to distinguish between CAS and other types of speech sound disorders.

The Evaluation

An SLP will take a very careful history of the child’s development history and note any known medical issues or other problems.  The evaluation most likely will include the following:

• A complete inventory of the sounds, syllable shapes (consonant and vowel combinations that make up syllables), and words a child can make or attempts to make will be noted, as well as any “mistakes” the child makes when doing so.  Errors and/or distortions of sounds will be compared with what is known about normal speech development to determine if the child’s speech performance is normal or not.
• The SLP will try to interact with your child and try to get them to use their speech in order to see what happens when they are asked to repeat syllables, words, or phrases a number of times.  Observations will be made about how your child combines sounds together and whether the length or difficulty level of words or phrases makes a difference in the accuracy with which the child says words.
• A child’s ability to both use and understand words, phrases, word endings, grammar, etc. will be evaluated and compared to what is typical for their age range.
• The child’s oral structures and the oral cavity (inside the mouth) will be examined to determine that they appear normal and are in good working order for speech.  Some young children do not like strangers peering in their mouths, thus this part might be a challenge!  Some children also might be sensitive to touch around the mouth and this will be noted.
• Observations will be made about the child’s respiratory system and if they seem to have enough airflow to sustain speech; how they hold their bodies; if they appear to have enough muscle strength and muscle tone for speech; if the quality of their voice seems appropriate; if their face appears symmetrical and if they seem able to move the lips, tongue, jaw and soft palate normally.
• The SLP will make note of the child’s intentions to communicate and interact; engage in social interaction; listen; and respond.  They will observe what other forms of communication the child uses such as pointing and gesturing.
• Especially if an SLP suspects apraxia of speech, she/he will observe what effect certain types of “help” have for the child’s speech accuracy.  For example, the SLP may slow down their own speech and ask the child to try a word or phrase with them  at the same time (simultaneously).  Or the SLP may use words of other types of “cues” to help the child figure out how to form the mouth or how to place the tongue and/or lips in order to produce the desired target word.
• If CAS is suspected, the SLP will attempt to do a “motor speech exam.”  This means that the SLP will try to get the child to repeat increasingly difficult and challenging syllables, words, and phrases and will observe how length and complexity impacts the child’s speech intelligibility.  Typically, at the same time, the SLP will use the “cueing” mentioned above to observe the impact.

Once the SLP has collected enough information, they will attempt to determine if the child’s speech and language is developing normally or not.  If they determine that the child’s speech is developing normally, however it is at a slower rate than most other children are, the child may be said to have a speech and/or language delay.

If the SLP has observed characteristics that do not fit with normal speech/language development, they will try to determine a “differential diagnosis.”  Some children may get a diagnosis of suspected CAS (sCAS).  A differential diagnosis is when there is enough information to state that the child’s skills “fit” with a specific speech/language disorder.  When a child is diagnosed with Childhood Apraxia of Speech, the SLP has made a differential diagnosis.  She/he has determined that after thorough evaluation, the child demonstrates characteristics of CAS that helps the SLP distinguish it from other possible speech problems.

Top Three Characteristics of Childhood Apraxia of Speech

The top three characteristics of Childhood Apraxia of Speech, as reported by the American Speech-Language-Hearing Association (ASHA) Technical Report on Childhood Apraxia of Speech, that can help the SLP make a differential diagnosis are:

• Inconsistent errors with consonants and vowels on repeated productions of syllables and words (your child says the same word in different ways when asked to repeat it several times.  This might be more apparent in new words or longer more complex words.)
• Difficulty moving from sound to sound or syllable to syllable, resulting in lengthened pauses between sounds and/or syllables
• Inappropriate stress on syllables or words (such as all syllables are said with equal stress on each one causing the “melody” of speech to sound odd)

Other Possible Symptoms of Childhood Apraxia of Speech

Other possible signs of apraxia of speech are:

• Increased mistakes in longer or more difficult and complex syllables and words.
• Reduced vowel inventory (the number and assortment of vowel sounds that your child can produce), or errors when producing vowels, and
• Possible “groping” behaviors in which your child appears to struggle to achieve the correct oral posture to start or produce the syllable or word.  (Not all children exhibit this at all times or situations.  If your child does not demonstrate groping of their speech musculature, that alone is not enough to rule out apraxia of speech.)

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CAS is considered to be a “low” prevalence speech disorder in children.  In fact, researchers and professionals believe CAS is a rare speech disorder. That means that out of all children with speech problems, few have CAS.  It also means that other types of speech problems are much more likely in children than is CAS.  Research in this area has been limited, but there are estimates that on a “typical” SLPs caseload of preschool children with speech sound disorders, only 3 – 5% of them would likely have apraxia of speech.  Highly experienced SLPs, that gain a reputation for providing excellent evaluation and treatment, would obviously have a larger proportion of children on their caseload with CAS than is typical.  Because it is so important to match a speech therapy approach to the nature of the child’s speech difficulty, misdiagnosis can prevent children from receiving the help that they really need.

Unfortunately, research has determined that childhood apraxia of speech can be over diagnosed.  Children – some of them extremely young – are given the diagnosis even though a thorough speech evaluation has not yet been possible.  Sometimes, due to a lack of experience with CAS, the professional may not fully grasp what should be involved in assessment and in distinguishing apraxia from other speech problems.  Misdiagnosis causes parents to have unnecessary worry, fear, and stress.  Firm diagnosis should not be made in extremely young children or children who are unable to give an adequate speech sample or cooperate and understand the tasks being asked of them in an evaluation.  In recent years, the term suspected CAS is used to identify a child who potentially has this speech problem and should be carefully watched and so helpful therapy can begin.

Some research also indicates that the apraxia of speech diagnosis is often “missed” in children who really do have it!  This is also not a good situation.  The speech therapy treatment for childhood apraxia of speech is different than it is for most other speech disorders or speech delay.  In addition to the speech therapy methods being different, children with apraxia of speech, at least for some period of time, require more speech therapy than children with other speech problems in order to improve their speaking ability.  Without proper diagnosis, children are at risk of not receiving adequate and appropriate help.

Parents who are concerned with their child’s speech and language development should first try to seek help from the child’s pediatrician.  Keeping a written record of concerns that can be discussed at an office visit can be very helpful.  Parents can request that the child be referred for a comprehensive speech and language evaluation.  At times, parents may have to be assertive about getting a referral to speech and language evaluation by a qualified speech-language pathologist.  Be persistent and do not give up!  Your child’s pediatrician has a responsibility to monitor and supervise your child’s development in all areas, including speech and language.  A good pediatrician will also listen and respond to a parent’s concern for their child’s development.  If your child is not developing as expected, your pediatrician should assist you in arranging for or referring to an appropriate professional or specialist.

By Lawrence Shriberg, Ph.D., CCC-SLP

Let me begin by noting that my clinical and research experience convinces me that the core problem in this disorder is appropriately described by the diagnostic term childhood apraxia of speech. The controversy, as I see it, is that there currently are no research findings that provide unequivocal support for the core problem or its diagnostic label. To answer those who take issue with this diagnostic classification, with its important implications for prognosis and treatment planning, a compelling study or program of research would have to provide at least one of three types of evidence.

The most convincing research evidence for the validity of childhood apraxia of speech as a diagnostic classification would be a clear biological finding. Although researchers have many leads to follow, the relatively small research literature on childhood apraxia to date has failed to identify a biological locus or processing correlate of the disorder. Unlike acquired apraxia in adults, in which neurological loci and neurolinguistic processing correlates are readily documented, there are no studies indicating that children with this suspected disorder share a common neurological challenge. Worldwide, research using molecular genetics and imaging techniques has only recently begun.

A less convincing, but still useful source of evidence would be a set of behavioral assessment findings that discriminate children with this disorder from children with severe phonological disorder or with dysarthria. Currently, each clinician and researcher must rely on a weighted checklist that yields individual profiles believed to be consistent with the disorder. Note the circularity here: a biological correlate of childhood apraxia will eventually be needed to determine which behavioral assessment findings are the markers for the disorder.

The third type of research finding providing support for this diagnostic classification would be tied to treatment outcomes for children with suspected childhood apraxia. As in other areas of medicine, a treatment regimen documented to be both necessary and sufficient to normalize a disorder provides some measure of support for the validity of a diagnostic category-particularly to the degree that the treatment differs significantly from treatments used with one or more other disorders that closely resemble the target disorder. Such findings from controlled treatment studies can often be the only way to begin to understand the processes that eventually define the disorder.

(Dr. Shriberg is Professor of Communication Disorders at the University of Wisconsin – Madison. Additionally, he is co-director of The Phonology Clinic and principal investigator on the Phonology Project at the Waisman Center. He is also a member of the Apraxia Kids Advisory Committee. Dr. Shriberg’s principal research interests focus on the nature and origin of childhood speech disorders, including studies to identify diagnostic markers for clinical subtypes and studies to develop subtype-specific treatment technologies, one such disorder being childhood apraxia of speech. Dr. Shriberg is the chairperson of the ASHA AdHoc Committee on Childhood Apraxia of Speech.)

Updated 11-1-19