Editor’s Note:    This article was written for us back in 2009 by Sharon Gretz.  We hope you enjoy this encore publication

By: Sharon Gretz, M.Ed.

What are the characteristics of Childhood Apraxia of Speech?
Unfortunately there is not complete agreement among researchers. However, currently it is generally held that, regardless of other features, the hallmark of CAS is an inability or disruption in the planning and programming of speech movements. While there is still not complete agreement among researchers, the 2007 ASHA Technical Report on CAS identified 3 features that appear to have the most agreement. These include:

1. inconsistent errors on consonants and vowels in repeated productions of syllables or words,
2. lengthened and disrupted coarticulatory transitions between sounds and syllables, and
3. inappropriate prosody, especially in the realization of lexical or phrasal stress.” (ASHA Technical Report on CAS, 2007)

Other characteristics that appear often in the literature and may be observed clinically are limited vowels and/or vowel distortions; difficulty achieving and maintaining articulatory configurations; unusual, idiosyncratic error patterns; increased errors with length or phonetic complexity of utterances; depending on level of severity, the child may be able to achieve accuracy for the target utterance/movement gesture in one context but is unable to produce the same target accurately in a different context; more difficulty with volitional, self-initiated utterances as compared to over-learned, automatic, or modeled utterances.

Is the incidence of Childhood Apraxia of Speech rising?
There is little data available to answer this question; however, unpublished data appears to suggest that more cases are being identified. It is unclear if this is due to increased awareness of core characteristics, thus there is better identification or if there are actually more children with CAS or if the identified cases are “true” cases and are not misdiagnosed. In our organization, unfortunately, we receive many contacts from parents of children who are most likely “inappropriately” diagnosed with CAS simply because they say little and have better receptive than expressive language. These characteristics are insufficient for an apraxia of speech diagnosis, yet we see this all the time. It is interesting that childhood apraxia of speech is missed in children who probably really have it (false negatives) and misdiagnosed in children who probably don’t have it (false positives)! This is a very complex speech disorder!

What are best practices for assessment for CAS?
First of all, in order to provide a differential diagnosis it is important that a comprehensive speech/language evaluation occur. As a special note, please know that a cursory administration of a “developmental scale” is insufficient. This means, that in order to be comprehensive, the SLP will still collect data on core aspects such as a child’s history; social interactions; expressive and receptive language; their phonemic and phonetic inventory; and an analysis of errors, substitutions, distortions, etc. The SLP will still perform an oral mechanism exam. The SLP will need to evaluate the child’s prosody in regards to rate, stress, and intonation. In addition to all of this, the SLP needs to examine speech motor processes. He/she can do this through investigating the child’s ability to sequence speech movements using stimuli of increasing length and phonetic complexity. So, for example, if the child can say “me”, the next stimuli could be “meet”, then “meeting”. The SLP can start with vowels; moving to monosyllables (CV, VC), then, for example, to CVC with same initial and final consonant, then CVC with different initial/final consonants; then to more complex word shapes; and for those children who are capable, multisyllabic words and even sentences of increasing length. All along, various levels of support, feedback, and cueing can be implemented to see the effect that this has on the child’s accuracy. Finally, all the data needs examined to determine if CAS is the diagnosis and if other potential diagnoses can be ruled out.

What speech therapy method is appropriate for CAS?
There is no “one” method that is the most effective. Much research is still needed on treatment efficacy for CAS. SLPs need to consider the child’s entire communication profile when planning a treatment program. However, if one understands CAS as a problem at the speech motor planning/programming level in the speech processing system, then a number of core features become important in the treatment approach. The overarching principles needed for improving speech motor planning and programming are called the “principles of motor learning.” When these principles for speech motor learning are applied in speech therapy, the children appear to benefit, regardless of the particular “name” for the method. The principles of motor learning include at least the following:

Frequency and intensity of practice opportunities. From research into human movement we know that skilled motor activity is acquired through repetitive practice. For children with CAS, SLPs need to maximize the number of appropriate practice trials in each therapy session. Additionally, children with CAS will benefit from the intensity of individual speech therapy vs. group therapy. It is unlikely that the child with significant speech apraxia can receive adequate intensity of practice and therapist input when sharing session time with groups of other children. Sessions should be frequent. The ASHA Technical Report on CAS suggests that for children with significant apraxia of speech the frequency of sessions should be in the range of 3 – 5 times per week. Incorporating parents as therapy extenders is also ideal so that the child is practicing throughout their day and thus receiving additional frequency. Parents need direct mentoring in order to understand how and when to elicit practice. They will not have adequate information by simply hearing a summary of what happened in therapy. They should observe therapy as frequently as possible and receive direct instruction from clinicians.

Task Specificity. The motor learning literature indicates that one must practice the actual motor task that one is trying to learn. Thus, in order to improve motor planning for speech, one must actually work on speech production.

Type of practice. Most children with severe apraxia of speech would start with a small set of core functional words. When they practice one word over and over, then another word over and over that is considered massed practice and this may be helpful to achieve early success. When the child practices their set of words, randomly, over and over, this is called distributed practice and overall this is felt to lead to the best generalization of motor skill. Also, when practice opportunities are spread out over the course of the week and throughout the day, this would be more akin to distributed practice.

Type, amount, and schedule of feedback. Early in the therapy process, the SLP who applies the principles of motor learning is likely to provide immediate frequent feedback to the child about the accuracy of their performance, For example, “Yes, that’s right, puff your cheeks out.” or “No, you need to keep lips tight.” However, as the child’s speech motor system improves the SLP will use less immediate and direct feedback on performance so that the child begins to use his/her own intrinsic feedback system to guide their performance. Visual, tactile, and verbal cues provide additional feedback and appear to greatly benefit children with CAS. Yet, equally important is careful cue fading, when appropriate, so that children do not become cue-dependent.

All along in therapy, the SLP will need to provide enough support, feedback and cueing so that the child’s speech movements are being shaped as close as possible to accurate productions. The end result that we seek is effortless, self-generated, creative, accurate, intelligible continuous speech. Improvement of individual sounds/phonemes is not the ultimate goal for the apraxia component of a child’s communication difficulty, though, they may need directly taught some of the phonemes. SLPs need to consider the movements underlying speech that are required for moving smoothly from sound to sound, syllable to syllable, word to word. Speech therapy for children with CAS needs to be considered a dynamic process.

Some of the methods, which incorporate principles of motor learning at least in part, include Dynamic Tactile Temporal Cueing (a variation of what some may know as Integral Stimulation); the Kaufman Method (a variant and expansion of Successive Approximations); the PROMPT Method and the Multi-sensory Method.

A final very important point about therapy is that most children with CAS will have needs in addition to the direct speech production practice to improve speech motor planning and programming. Research indicates that language goals are also likely to be needed. Children may have difficulty in syntax, morphology, narrative and other aspects of language. Additionally, children with CAS are at high risk for literacy related difficulties and should be continually monitored for this with appropriate goals incorporated into therapy.

What advice do you have for clinicians?
First of all, it is so very important to engage the parent in the therapy process. For these children, in particular, home practice is going to be incredibly important to their overall success. Secondly, there are resources to help you. Our organization (Childhood Apraxia of Speech Association of North America – CASANA) has a wealth of information on our acclaimed website, Apraxia-KIDS (Apraxia-KIDS.org). In addition, each year we provide numerous educational workshops around North America and a summer conference in order to teach clinicians the various approaches and methods to effective assessment and therapy. Finally, please understand that this is very difficult business. There is no way around that fact. The severity and degree of speech impairment in these children can feel overwhelming to the children, their families, and to you. You will be called to be their advocates. If anyone on your caseload could benefit from more frequent, direct and targeted speech therapy, it is children with CAS. Simply providing a cursory or insignificant amount of treatment/therapy time or intensity is not an option if your goal is to help the child develop the capacity for intelligible speech.

Again, you will be called to be an advocate for these children to receive the frequency and intensity of services they need. The good news is that with appropriate speech therapy to target the speech motor planning issues and enough of it (frequency), children with CAS can make incredible gains in their speech, many to the degree that no one would guess that they had, at one time, a serious speech disorder. The challenges are great and the rewards are many in providing help to these wonderful children and their families. CASANA stands ready to help you. Please visit our website for further information and for ongoing learning opportunities – http://www.apraxia-kids.org/.

This Month’s Featured Author: Sharon Gretz, M.Ed CASANA

Our thanks to Sharon Gretz of CASANA for providing this months Q&A article.

Sharon Gretz, M.Ed., is the founder and current Executive Director of CASANA. In 2001, Sharon was awarded the National Distinguished Service Award at the Kennedy Center in Washington, DC, presented to her by the National Council on Communicative Disorders. Sharon has nearly 25 years experience in nonprofit services for people with disabilities, disability rights advocacy, and program management. She is also the parent of a child diagnosed with apraxia of speech and has completed all coursework towards a Ph.D in the Dept. of Communication Disorders and Sciences at the University of Pittsburgh.

Apraxia-KIDS is the Internet’s largest, most comprehensive and trusted website for information on childhood apraxia of speech (verbal dyspraxia, developmental apraxia of speech) and children’s speech and language topics, including evaluation, speech therapy, research and other childhood communication topics. Invaluable for parents, speech-language pathologists, teachers and all those who care about a child with apraxia. For more information about this organization please visit CASANA.