What is Apraxia?

Apraxia is an oral motor speech disorder that makes it harder for children to speak. Officially known as childhood apraxia of speech or CAS, this disorder occurs when the brain and nervous system have trouble coordinating plans for speech movements.

It is important to note that children with apraxia usually understand language and know what they would like to say. Moreover, the oral-motor and speech muscles are not weak in and of themselves. Rather, the brain and nervous system have a hard time directing the oral motions needed to turn sounds into syllables, words into sentences, and so on.

What Causes Childhood Apraxia of Speech?

Childhood apraxia of speech can have a number of possible causes. Doctors and researchers have not yet identified one possible cause or difference in brain structure that results in apraxia. Instead, CAS primarily occurs when there is a problem when the brain sending signals to mouth muscles in order to produce speech and communication directly. Because of this, a child cannot simply “outgrow” CAS and would need speech therapy to overcome challenges associated with the disorder.

In addition, childhood apraxia often co-occurs with a larger disorder or condition, including

• Galactosemia
• Cerebral palsy
• Autism
• Epilepsy
• Mitochondrial disorders
• Neuromuscular disorders
• Traumatic brain injury
• Genetic (“runs in the family”)

Other possible risk factors include differences in the FOXP2 gene or children with family members who also have communication disorders.

What are some of the Signs or Symptoms of Childhood Apraxia of Speech?

Childhood apraxia of speech symptoms may vary based on age and concurrent conditions. Possible signs that are noticeable when a child is 18 months and two years include the following:

• Delayed onset of first word (and less than frequent babbling in the months leading up to the average onset of first word)
• Unusually few spoken words or vocalizations
• Child is only able to make a few consonant or vowel sounds
• Lack of variety in sound inventory
• Excessive mouth movements (such as the jaw, tongue, or lips while attempting to make the right sounds)

As a child’s overall language development progresses, signs and symptoms of CAS can become more pronounced. Signs that indicate apraxia between ages two and four include the following:

• Multiple or unusual errors in sound production
• Frequent regression in formerly spoken words
• Problems saying multi-syllable words and phrases
• Inconsistency in using the same words at different times (for example, child says the same word a different way each time she attempts to express it)
• Problems in stress in syllables in words (for example, saying BAH-nan-ah or BAH-NAN-AH instead of the standard rhythmic flow of bah-NAN-uh)
• Long pauses between words or phrases (as child attempts to formulate speech)
• Problems putting sounds, syllables, or words together in the right order (for example, omitting, switching, or even adding in extra syllables)
• Issues with prosody (intonations that convey the emotional context of speech)
• Ability to understand language (such as follow commands) but inability to respond with verbal answers. In other words, parents and teachers may notice a gap between receptive and expressive language.

Children with childhood apraxia of speech may demonstrate signs sometimes associated with other disorders, such as:

• Fine-motor difficulties and delays
• Sensory processing issues
• Problems writing or reading
• Chewing, swallowing, or other oral-motor problems

How Does Childhood Apraxia of Speech Different From a Speech Delay or Speech Sound Disorder?

Since characteristics of communication disorders can overlap, it is easy to confuse CAS with a speech delay or other speech sound disorder. However, there is key differences between CAS and a true developmental delay of speech. There is also a difference between CAS and speech disorders such as (articulation disorders, phonological disorders, dysarthria, or aphasia).

• A developmental delay of speech occurs child when follows the typical or standard path of speech development, but at a slower rate than average. Children with CAS are not on the typical or standard speech development path, so the brain has difficulty planning or processing speech accordingly.
• Articulation disorders involve problems making clear and distinct syllables and words. Phonological disorders involve sound errors. Articulation and phonological disorders are far more common than apraxia. Examples might include substitutions, airstream problems, and simplifications (such as “wabbit” instead of “rabbit,” “tee” instead of “three,” or “doo” instead of “zoo”). In contrast, CAS has less to do with articulation and phonology, and more to do how the brain coordinates oral-motor function.
• Dysarthria is a condition associated with muscle weakness of spasticity that results in hoarse, strained, or slurred speech. In contrast, CAS has nothing to do with muscle weakness. Instead, CAS has to do with the brain’s coordination of these muscles.
• Aphasia refers to an inability to understand or express speech. Although aphasia may occur with apraxia in instances of brain injury, children with CAS do not automatically have aphasia. Most children with CAS understand speech but have problems making responses due to coordination issues between muscles and the brain.

Since it is far too easy to confuse childhood apraxia of speech (CAS) with other disorders, parents or caregivers should contact a licensed speech-language pathologist (SLP) for the appropriate diagnosis of symptoms. Treatment for CAS may differ from other disorders, so a misdiagnosis can, unfortunately, result in reduced therapy gains.

What is the Treatment for Childhood Apraxia of Speech?

Treatment for CAS is intensive and focuses largely on speech-motor planning and programming. This may include sound-sequence drills, sound-motor exercises, and adapted cueing. In addition to paced learning, the SLP might request that the parent or caregiver engage in co-production (saying the word at the same time). Depending on severity, a professional might also suggest orofacial myofunctional therapy and visual prompts for restructuring oral muscular phonetic targets therapy (known as the PROMPT system). As you might imagine, a therapy program can take years to complete, so accurate diagnosis is critical for best results.

Although childhood apraxia of speech differs from more commonly understood speech disorders, parents and caregivers should not feel discourage. Studies have found that while researchers do not know the single cause of CAS, most children with CAS can achieve verbal communication after undergoing intensive therapy. If you have any questions about childhood apraxia of speech, contact The Warren Center for more information.