Childhood Apraxia of Speech

Overview

The scope of this page is Childhood Apraxia of Speech in preschool and school-age children from 3 to 21 years of age.

See the Apraxia of Speech (Childhood) Evidence Map for summaries of the available research on this topic.

Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g. abnormal reflexes, abnormal tone). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known and unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody. (ASHA, 2007b, Definitions of CAS section, para. 1).

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (American Psychiatric Association [APA], 2013) uses the term verbal dyspraxia to describe this disorder. It is discussed within the Speech Sound Disorders category, under the subheading, "Associated Features Supporting Diagnosis." Verbal dyspraxia is described in the DSM-5 as a disorder in which "other areas of motor coordination may be impaired as in developmental coordination disorder" (p. 44).

The term childhood apraxia of speech (CAS) is used in this ASHA Practice Portal page as a cover term for all presentations of apraxia of speech in childhood, whether congenital or acquired and whether or not associated with a specific etiology.

ASHA prefers CAS over other terms used for this disorder—including "developmental apraxia of speech" and "developmental verbal dyspraxia"—which typically refer to idiopathic presentations and not to acquired neurological etiologies. In addition, the inclusion of "developmental" in reference to childhood apraxia might be incorrectly interpreted as indicating that children can "grow out of" this disorder. Unlike speech delay, the characteristics of CAS are likely to persist past the developmental period (Lewis, Freebairn, Hansen, Iyengar, & Taylor, 2004).

See the Apraxia of Speech (Childhood) Evidence Map for summaries of the available research on this topic.

Incidence and Prevalence

Incidence of childhood apraxia of speech (CAS) refers to the number of new cases identified in a specified time period. Prevalence of CAS refers to the number of people who are living with the condition in a given time period.

Prevalence estimates of CAS are unreliable due to the inconsistency of diagnostic guidelines (Shriberg, Aram, & Kwiatkowski, 1997), lack of adequately validated diagnostic tools (McCauley & Strand, 2008), and small sample sizes in relevant studies. These same factors may also play a role in the frequent overidentification of CAS by clinicians (Davis, Jakielski, & Marquardt, 1998; Shriberg & McSweeney, 2002).

CAS was estimated to occur in 1 to 2 children per 1,000 (0.1%–0.2%; Shriberg et al., 1997). It was estimated to be higher in male children than in female children with a 2–3:1 ratio (Hall, Jordan, & Robin, 1993; Lewis et al., 2004). Children with CAS were reported to have a higher likelihood of concomitant language, reading, and/or spelling disorders (Lewis et al., 2004; Lewis & Ekelman, 2007).

CAS, or its characteristics, were reported to have greater prevalence in various syndromes such as galactosemia (Shriberg, Potter, & Strand, 2011), fragile X syndrome (Spinelli, Rocha, Giacheti, & Richieri-Costa, 1995), and velocardiofacial syndrome (Kummer, Lee, Stutz, Maroney, & Brandt, 2007). Although autism spectrum disorder (ASD) has a higher prevalence of concomitant speech delay and speech errors, research indicates that children with ASD do not have a higher prevalence of CAS (Shriberg, Paul, Black, & van Santen, 2011).

Signs and Symptoms

Currently, there are no validated diagnostic features that differentiate CAS from other childhood speech sound disorders. However, three segmental and suprasegmental features consistent with a deficit in the planning and programming of movements for speech have gained some consensus among those investigating CAS:

Inconsistent errors on consonants and vowels in repeated productions of syllables or words.
Lengthened and disrupted coarticulatory transitions between sounds and syllables.
Inappropriate prosody, especially in the realization of lexical or phrasal stress.

(ASHA, 2007b)

"Importantly, these features are not proposed to be the necessary and sufficient signs of CAS" (ASHA, 2007b, Definitions of CAS section, para. 1). The frequency of these and other signs may change depending on task complexity, age of the child, and severity of symptoms (Lewis et al., 2004).

Other Reported Characteristics

Other characteristics that have been reported in children diagnosed with CAS and that represent difficulty with the planning and programming movement gestures for speech include

articulatory groping—articulatory searching prior to phonating;
consonant distortions;
difficulty with smooth, accurate movement transitions from one sound to the next;
increasing difficulty with longer or more complex syllable and word shapes;
schwa additions/insertions—insertion of schwa between consonants or at the end of words;
slower than typical rate of speech
syllable segregation—pauses between sounds, syllables, or words that affect smooth transitions;
voicing errors—voiceless sounds produced as their voiced cognates; and
vowel errors—vowel distortions or substitutions.

See Iuzzini-Seigel (2017) and Strand (2017) for summaries of CAS characteristics that help discriminate CAS from other speech sound disorders and that represent expert consensus.

The presence of error patterns in the child's speech does not necessarily indicate a phonological problem rather than a motoric problem. Many patterns can have either linguistic or motoric bases. For example, a child may consistently reduce consonant clusters either because of lack of understanding of the phonological rule or because of a motoric inability to sequence consonants.

Co-Occurring Characteristics/Symptoms

The behavioral features reportedly associated with CAS place a child at increased risk for problems in expressive language and weakness in the phonological foundations for literacy (Lewis et al., 2004; McNeill, Gillon, & Dodd; 2009b).

As in children with other speech disorders, co-occurring language and literacy problems can be present, including

delayed language development;
expressive language problems, such as word order confusion and grammatical errors;
problems learning to read, spell, and write; and
problems with social language/pragmatics.

Co-occurring nonspeech sensory and motor problems can also be present (Crary & Anderson, 1991; Davis et al., 1998; Dewey, Roy, Square-Storer, & Hayden, 1988; McCabe, Rosenthal, & McLeod, 1998; Shriberg et al., 1997). These include

gross and fine motor delays;
motor clumsiness;
oral apraxia;
limb apraxia;
feeding difficulties; and
abnormal orosensory perception (hyper- or hyposensitivity in the oral area).

Causes

CAS can be congenital, or it can be acquired during speech development. Both congenital and acquired CAS can occur

as an idiopathic neurogenic speech sound disorder (i.e., in children with no observable neurological abnormalities or neurobehavioral disorders or conditions);
as primary or secondary signs within complex neurobehavioral disorders (e.g., autism, epilepsy, and syndromes, such as fragile X, Rett syndrome, and Prader–Willi syndrome; Bashina, Simashkova, Grachev, & Gorbachevskaya, 2002; Boyar et al., 2001; Scheffer et al., 1995; Spinelli et al., 1995); or
in association with known neurological events (e.g., intrauterine or early childhood stroke, infection, trauma, brain cancer/tumor resection; see, e.g., Brown et al., 2000).

The neurological deficits underlying CAS are different from those that underlie dysarthria.

A number of researchers have investigated possible genetic bases for CAS. Of particular interest are findings from studies of a four-generation London family—the KE family—many of whom have apraxia of speech. Findings suggest that deficits in the FOXP2 gene may negatively affect the development of neural networks involved in the learning and/or planning and execution of speech motor sequences (Lai et al., 2000; Lai, Fisher, Hurst, Vargha-Khadem, & Monaco, 2001; Liégeois, Baldeweg, Connelly, Gadian, & Vargha-Khadem, 2003; Marcus & Fisher, 2003; Shriberg et al., 2006; Tomblin et al., 2009; Zeesman et al., 2006).

Recent research continues to find a link between the FOXP2 gene and apraxia of speech, although it is likely that more than one gene is responsible (Adegbola et al., 2015; Laffin et al., 2012; Reuter et al., 2017).

Roles and Responsibilities

Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of persons with CAS. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016). See also ASHA's Position Statement on Childhood Apraxia of Speech (ASHA, 2007a).

Appropriate roles for SLPs include, but are not limited to, the following:

As indicated in the Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so. SLPs who diagnose and treat CAS must possess skills in differential diagnosis of childhood motor speech disorders, specialized knowledge in motor learning theory, and experience with appropriate intervention techniques that may include augmentative and alternative communication (AAC) and assistive technology.

Assessment

See the Assessment section of the Apraxia of Speech (Childhood) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Screening

Screening is conducted by an SLP whenever a speech sound disorder is suspected or as part of a comprehensive speech and language evaluation for a child with communication concerns. The purpose of the screening is to identify those who require further speech-language assessment or referral to other professional services. For a more detailed list of screening components, see the Screening section of ASHA's Practice Portal page on Speech Sound Disorders: Articulation and Phonology.

To date, there are no available CAS-specific standardized screening tools. In addition, CAS may not be identified during screening because the diagnosis sometimes results from observations made over the course of treatment.

Comprehensive Assessment

Children who are suspected of having CAS on the basis of screening results should be referred to an SLP for a comprehensive assessment.

Consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2023; WHO, 2001), a comprehensive assessment is conducted to identify and describe

impairments in body structure and function, including underlying strengths and weaknesses in speech sound production and verbal/nonverbal communication;
co-morbid deficits or conditions, such as developmental disabilities, medical conditions, or syndromes;
limitations in activity and participation, including functional communication, interpersonal interactions with family and peers, and learning;
contextual (environmental and personal) factors that serve as barriers to or facilitators of successful communication and life participation; and
the impact of communication impairments on quality of life of the child and family.

See ASHA's International Classification of Functioning, Disability, and Health (ICF) for examples of assessment data consistent with ICF for various clinical disorders.

Assessment is accomplished using a variety of standardized and nonstandardized measures and activities. See ASHA's resource on assessment tools, techniques, and data sources. Keep in mind that standard scores cannot be reported for assessments that are not normed on a group representative of the individual being assessed.

SLPs take into account cultural and linguistic speech differences across communities. They select assessments that are culturally and linguistically sensitive, taking into consideration current research and best practice in assessing speech sound disorders in the languages and/or dialect used by the individual (see, e.g., McLeod, Verdon, & The International Expert Panel on Multilingual Children's Speech, 2017). See ASHA's Practice Portal page on Cultural Responsiveness.

Comprehensive assessment for speech sound disorders typically includes a case history, oral mechanism examination, speech sound assessment, and language assessments, if indicated. For details, see the Comprehensive Assessment section of ASHA's Practice Portal page on Speech Sound Disorders: Articulation and Phonology. See also ASHA's Practice Portal pages on Spoken Language Disorders and Written Language Disorders.

A comprehensive oral mechanism examination includes a motor speech assessment. This is critical for differentiating CAS from childhood dysarthria and other speech sound disorders and for identifying both oral apraxia and apraxia of speech—either of which may occur in the absence of the other. See McCauley and Strand (2008) for a discussion of nonverbal oral and speech motor performance assessment tools.

A key consideration in the motor speech assessment is an evaluation of movement accuracy. Using a variety of tasks, the SLP looks for the presence of consensus features and other clinical characteristics of CAS to help identify the presence of motor-based planning and speech difficulties (see the Signs and Symptoms section of this page).

Examples of tasks include

nonspeech articulatory postures (e.g., smile) and sequences (e.g., kiss–smile) versus speech sounds and words;
well-practiced/automatic versus volitional speech (for children who are older and/or have some speech);
speaking tasks that require single postures versus sequences of postures (e.g., single sounds such as [a] vs. words, such as [mama]);
speech production at the single syllable, bisyllable, multisyllable, phrase, and sentence levels; and
sequential and alternating movement repetitions (e.g., [papapa] and [pataka]; Thoonen, Maassen, Gabreëls, & Schreuder, 1999; Thoonen, Maassen, Wit, Gabreëls, & Schreuder, 1996).

Sequencing errors may consist of inaccuracies, inconsistency (i.e., not producing the same sound or syllable in each repetition—whether correct or not), or mis-ordering sounds (Velleman, Huffman, & Mervis, 2012). In preschool children, consistency and accuracy of repetitions are likely to be more useful performance indicators than repetition rate (Williams & Stackhouse, 1998, 2000).

Assessment should include performance across multiple contexts (e.g., spontaneous vs. elicited vs. imitated utterances), as results can vary by context. Fluidity (smoothness), rate, consistency, lexical stress, and accuracy should be monitored, as there may be trade-offs among these variables (e.g., the child's productions might be smoother when speaking rate is slow vs. rapid).

Dynamic assessment is important for differential diagnosis of CAS and for determining severity and prognosis (Strand, McCauley, Weigand, Stoeckel, & Baas, 2013; Strand & McCauley, 2019). Using dynamic assessment procedures, the clinician can provide cues (e.g., gestural or tactile cues) to better judge the child's speech production and to determine how much cueing is necessary to facilitate performance.

Assessment may result in

diagnosis or provisional diagnosis of CAS or diagnosis of other speech sound disorder (e.g., articulation and/or phonological disorder);
description of the characteristics and severity of the disorder;
identification of factors that might contribute to the speech disorder;
recommendations for intervention that relates to overall communication adequacy, including AAC measures, as needed;
diagnosis of a spoken language (listening and speaking) disorder;
identification of literacy (reading and writing) problems;
monitoring of literacy learning progress in students with identified speech sound disorder by SLPs and other professionals within the school setting;
recommendations for a multi-tiered system of support (e.g., response to intervention [RTI]) in the child's school to support speech and language development; and
referral to other professionals as needed, including
- an occupational therapist for nonspeech, sensory-motor, or fine-motor issues;
- a physical therapist if gross motor skills or overall muscle tone are of concern;
- a pediatric neurologist if neurological indicators (e.g., potential seizure activity, tremors, or imbalance) are present; an
- a geneticist if the child's medical or family history suggests the possibility of a neurobehavioral disorder of genetic origin (e.g., fragile X syndrome, Rett syndrome, dysmorphology).

Cultural and Linguistic Considerations

In children who speak more than one language, CAS will influence production across all languages; however, errors may be manifested differently in each language.

SLPs consider the variation in vowel systems across languages and the number of vowels within a language when evaluating error patterns. Some languages have a greater number of vowel phonemes than other languages, and this may influence intelligibility and/or the overall frequency of errors.

In languages where multisyllabic word productions are common early in development, CAS may manifest as metathesis, coalescence, syllable deletion, and other word-level errors due to the longer motor plan required to produce these words. In languages with a higher frequency of single-syllable words, CAS may be more likely to manifest in vowel errors and inconsistent consonant production in the early stages of speech development.

Word and syllable structure (e.g., frequency of consonant clusters) in a language may also influence errors. For example, English has many one-syllable words with final consonants and consonant clusters. In children with CAS, this may result in more frequent cluster reduction, final consonant deletion, and unstressed syllable deletion.

In tonal languages, which rely on changes in intonation to change the meaning of a word, CAS may have an increased impact on intelligibility and error frequency.

The following may be observed in children with CAS who speak more than one language:

They may rely on earlier mastered sounds across all languages spoken.
They may appear to favor or use one language over another, but the difference may be due to the relative ease of the phonemic inventory and word structure in that language rather than an indication of language choice or dominance.

See Considerations When Working With a Bilingual Child With CAS (Portland State University, n.d.). See also ASHA's Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology and Cultural Responsiveness.

Diagnosing CAS

Diagnosis Under 3 Years Of Age

Diagnosis of CAS in children under 3 years of age is challenging for a variety of reasons, including

the potential presence of developmental disabilities and/or comorbid conditions;
the lack of a single, validated list of diagnostic features that differentiates CAS from other types of childhood speech sound disorders (e.g., those due to phonological-level deficits or neuromuscular disorder);
the fact that some primary characteristics of CAS (e.g., word inconsistency, a predominant error pattern of omission, etc.) are characteristic of emerging speech in typically developing children under the age of 3 years;
the lack of a sufficient speech sample size for making a more definitive diagnosis;
the challenge of sorting out inability versus unwillingness to provide a speech sample or to attempt a speech target; and
the possibility that changes in speech occurring during the first 3 years (e.g., due to developmental maturation, social and linguistic peer exposure, and/or the beneficial effects of treatment) may alter the diagnostic label.

Retrospective analyses of home videos suggest some early indicators of CAS below the age of 3 years (Overby & Caspari, 2015). More recent data suggest that consonant development of children between birth and age 3 years who were later diagnosed with CAS may be different than that of children with other types of speech sound disorders and children who are typically developing. Differences include less vocalizations overall, fewer consonants, a less diverse phonetic repertoire, and later consonant acquisition (Overby, Caspari, & Schreiber, in review). However, given the preliminary nature of these data and the need for more research (e.g., longitudinal studies from infancy), diagnosis below age 3 years is best categorized under a provisional diagnostic classification, such as "CAS cannot be ruled out," "signs are consistent with problems in planning the movements required for speech," or "suspected to have CAS."

Differential Diagnosis

A number of instruments have been proposed for use in assessing the speech motor planning and programming skills considered to represent the core deficits in CAS; however, the rigor of their psychometric characteristics has been called into question (see, e.g., McCauley & Strand, 2008). Dynamic assessment can be used as a method for examining both the question of differential diagnosis and the value of particular types of cues (Strand et al., 2013; Strand & McCauley, 2019).

CAS Versus Speech Delay or Other Speech Sound Disorders

Many of the behaviors and signs associated with CAS are also found in children with more broadly defined speech sound disorders (McCabe et al., 1998; Shriberg et al., 2017). In addition, it is important that the diagnosis of CAS not be based solely on the severity of a child's speech sound disorder, as this may result in overdiagnosis.

Differentiating CAS from some types of dysarthria presents a significant challenge because these disorders can share several speech, prosody, and voice features (e.g., imprecise consonant, inconsistent pitch or loudness, inappropriate or aberrant stress patterns). For example, vowel distortions can be a result of oral hypotonicity or dysarthria, especially if the error is made in isolation and not influenced by connected speech. Polysyllabic production accuracy, along with an assessment of diadochokinetic rates, may be sufficient to identify CAS and rule out dysarthria (Murray, McCabe, Heard, & Ballard, 2015). Several maximum-performance tasks may also help differentiate CAS from (spastic) dysarthria or establish the presence of both (Thoonen et al., 1996, 1999).

Less commonly, but on occasion, there is a need to differentiate between apraxia and dysfluency (stuttering, cluttering), given that there can be some overlap in symptoms (Byrd & Cooper, 1989). Also, similar to children without motor speech disorders, children who are suspected of having CAS may go through periods of disfluency (Byrd & Cooper, 1989). See ASHA's Practice Portal page on Childhood Fluency Disorders for more information about fluency.

In rare cases, CAS can co-occur with dysarthria or fluency disorders; therefore, it may not be an "either-or" diagnosis. Further, the child's limited speech sound system may mask these other diagnoses.

CAS Versus Speech Characteristics Typical of Dual or Second Language Learners or Speakers of Dialects of English That Are Unfamiliar to the Clinician

It is important to differentiate potential features of CAS from differences noted in typical dual or second language acquisition, as well as those noted in dialectal variants of English. A child's complete language system must be considered in order to appropriately distinguish differences from disorders.

In bilingual children, normal processes of second or dual language acquisition may be confused with features of CAS. For example, syllable reduction or deletion in specific word positions may vary by dialect or language. Expected prosody and stress patterns may not be present due to these differences. Children may also demonstrate inconsistent error patterns for phonemes in a new language that are not present in their primary language or are allophones in their primary language. For example, /l/ and /r/ are allophones in some languages, and children may have difficulty accurately and distinctly producing these phonemes in English.

See ASHA's Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology and Cultural Responsiveness.

Response to Treatment

Disorders with similar symptoms (e.g., CAS vs. severe phonological disorder vs. severe articulation delay) may not be distinguishable from one another without treatment. During treatment, the clinician has the opportunity to document the rate and amount of progress that a child has made before making a definitive diagnosis (Davis & Velleman, 2000; Strand, Shriberg, & Campbell, 2003).

In these cases, a provisional diagnostic classification (e.g., "suspected of having CAS") can serve as a working diagnosis during the period of treatment. The working diagnosis can be used until a definitive diagnosis can be made.

Treatment

See the Treatment section of the Apraxia of Speech (Childhood) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Reduced intelligibility (i.e., the degree to which the listener understands the individual's speech) and comprehensibility(i.e., the degree to which the listener understands the individual's speech within a communicative context; Yorkston, Strand, & Kennedy, 1996) can be especially debilitating for many children with CAS (see, e.g., Hall, 2000a, 2000b).

Treatment goals for children with CAS focus on facilitating overall communication and language skills by

increasing speech production and intelligibility or, when indicated,
using AAC, such as gestures, manual signs, voice output devices, and context-specific communication boards.

See ASHA's International Classification of Functioning, Disability, and Health (ICF) for examples of functional goals consistent with ICF for various clinical disorders.

Motor speech disorders require repetitive planning, programming, and production practice; therefore, intensive and individualized treatment of childhood apraxia is often necessary (see, e.g., Maas, Gildersleeve-Neumann, Jakielski, & Stoeckel, 2014; Namasivayam et al., 2015; Skinder-Meredith, 2001).

To the extent possible, treatment takes place in naturalistic environments, is provided in a culturally appropriate manner, and involves as many important people in the child's life as possible to facilitate carryover and generalization of skills. Involving caregivers in treatment helps them understand and practice goals with the child outside the treatment setting.

Many children with CAS also have phonological impairment and language impairment. The relative contribution of motoric and linguistic deficits is considered when planning treatment (see treatment approaches below). If a child has mild motoric deficits and significant phonological deficits, then linguistic approaches may need to be prioritized while also bringing in some principles of motor learning to facilitate movement accuracy (Maas et al., 2008; Maas, et al., 2014. Macdonald-D'Silva, van Rees, Ballard, & Arciuli, 2014; McCauley & Strand, 1999).

Treatment Approaches

Treatment approaches that focus directly on improving speech production can be classified as follows:

Motor programming approaches—use motor learning principles, including the need for many repetitions of speech movements to help the child acquire skills to accurately, consistently, and automatically make sounds and sequences of sounds.
Linguistic approaches—focus on CAS as a language learning disorder; these approaches teach children how to make speech sounds and the rules for when speech sounds and sound sequences are used in a language.
Combination approaches—use both motor programming and linguistic approaches.
Rhythmic (prosodic) approaches, such as melodic intonation therapy (MIT; Albert, Sparks, & Helm, 1973; Helfrich-Miller, 1984, 1994)—use intonation patterns (melody, rhythm, and stress) to improve functional speech production.

Treatment approaches that target speech production focus on helping the child achieve the best intelligibility and comprehensibility possible. However, when there are concerns that oral communication is not adequate, AAC may also be used to provide functional communication while at the same time supporting and enhancing verbal speech production (Bornman, Alant, & Meiring, 2001; Cumley & Swanson, 1999; Yorkston, Beukelman, Strand, & Hakel, 2010). In addition to increasing communication success, AAC approaches may stimulate the development of language skills that cannot be practiced orally (Cumley & Swanson, 1999; Murray, McCabe, & Ballard, 2014). See ASHA's Practice Portal page on Augmentative and Alternative Communication.

See ASHA's International Classification of Functioning, Disability and Health (ICF) web page for examples of treatment goals consistent with ICF for various clinical disorders.

Treatment Options

Below are brief descriptions of both general and specific treatments for addressing CAS. This list is not exhaustive, and the inclusion of any specific treatment approach does not imply endorsement from ASHA. See Murray et al. (2014) and Maas et al. (2014) for recent reviews of the evidence base.

The majority of treatment approaches for CAS emphasize movement patterns versus sound patterns. Many of those listed below incorporate the following techniques:

Shaping the best/most accurate productions possible.
Sensory cueing approaches that involve using the child's senses (e.g., visual, auditory, proprioceptive, and/or tactile cues) to teach the movement sequences for speech. Sensory cues can be used separately or in combination (i.e., multisensory approach). These approaches may facilitate speech production by providing additional feedback to the child if they cannot benefit from, or does not receive, sufficient intrinsic sensory feedback. Many treatments for CAS incorporate sensory cueing (e.g., motor programming approaches; Hall, 2000b).
- Visual cueing methods provide visual "cues" as to the shape, placement, or movement of the articulators. Visual cues can be gestural (e.g., simple hand signs) or more technologically advanced methods such as electropalatography readouts, ultrasound images (see, e.g., Preston, Brick, & Landi, 2013; Preston, Leece, & Maas, 2016; Preston, Leece, McNamara, & Maas, 2017; Preston, Maas, Whittle, Leece, & McCabe, 2016), computerized speech viewing programs, and other forms of biofeedback that provide visual cues about speech movement performance.
- Verbal/auditory cues provide instruction on how to move the articulators during production attempts (“spread your lips wide”) in order to assist the child in making more accurate movement gestures for speech.
- Tactile facilitation methods are those that provide direct tactile input for correct speech production. Using these methods, the SLP applies pressure or otherwise touches the child's face, neck, and head to provide a tactile cue for correct production or speech movement gesture. PROMPT© (Prompts for Restructuring Oral Muscular Phonetic Targets) is one tactile method of treatment that is based on touch, pressure, kinesthetic, and proprioceptive cues (Dale & Hayden, 2013; Hayden, Eigen, Walker, & Olsen, 2010). The Touch-Cue Method is another tactile approach in which touch cues are given simultaneously with auditory and visual cues during the initial stages of therapy (Bashir, Grahamjones, & Bostwick, 1984).

A core set of child-specific functional stimuli (e.g., words or phrases) is often incorporated into various treatment approaches (Iuzzini & Forrest, 2010; Strand, Stoeckel, & Baas, 2006).

Treatment selection depends on factors such as the severity of the disorder and the communication needs of the child. Because symptoms typically vary both from child to child and within the same child with age (Lewis et al., 2004; Shriberg et al., 2003), multiple approaches may be appropriate at a given time or over time.

Apraxia in other systems may also play an important role in treatment. For example, the presence of limb apraxia may make it difficult for the child to use manual signs for functional communication. The presence of oral apraxia may support the need for either more aggressive or alternative approaches to the use of phonetic placement cues in speech treatment.

Motor Programming Approaches

Motor programming approaches are based on motor programming/planning principles. These approaches

provide frequent and intensive practice of speech targets;
focus on accurate speech movement;
include external sensory input for speech production (e.g., auditory, visual, tactile, and cognitive cues);
carefully consider the conditions of practice (e.g., random vs. blocked practice of targets); and
provide appropriate types and schedules of feedback regarding performance (Maas et al., 2008).

For a discussion of the principles of motor learning as they apply to CAS and a review of motor-based treatment approaches for CAS, see Maas et al. (2014).

Examples of motor programming approaches include the following:

Dynamic Temporal and Tactile Cueing (DTTC) is an integral stimulation ("look, listen, do what I do") method that uses a cueing hierarchy (auditory, visual, and tactile) and systematically decreases supports as the child achieves success at each level of the cueing hierarchy (Strand & Debertine, 2000; Strand et al., 2006). Movement gestures are shaped, beginning with direct imitation, moving to simultaneous production with tactile or gestural cues if direct imitation was unsuccessful, and then fading the simultaneous cue and again moving to direct imitation. The key element of this approach is that the clinician is constantly adding or fading auditory, visual, and tactile cues as needed after each practice trial. It is suggested for very young children with severe CAS.

Nuffield Dyspraxia Program( NDP3®) is a motor skills learning approach that emphasizes motor programming skills and focuses on speech output. It is described as a "bottom-up" approach in which the aim is to "build" accurate speech from core units of single speech sounds (phonemes) and simple syllables. New motor programs are established using cues and feedback and through frequent practice and repetitive sequencing exercises. Phonological skills are incorporated into the treatment approach through the use of minimal word pairs (Williams & Stephens, 2010).

Rapid Syllable Transitions (ReST) is a method that involves repetition of varied sequences of real or nonsense syllables to train motor planning flexibility (Velleman, 2003; Velleman & Strand, 1994). It uses intensive practice in producing multisyllabic, phonotactically permissible pseudo-words to improve accuracy of speech sound production, rapid and fluent transitioning from one sound or syllable to the next, and control of syllable stress within words. Pseudo-words are used to allow the development and practice of new speech patterns without interference from existing error speech patterns (McCabe et al., 2014; McCabe, Murray, Thomas, & Evans, 2017; Murray, McCabe, & Ballard, 2015; Thomas, McCabe, & Ballard, 2014; Thomas, McCabe, Ballard, & Lincoln, 2016).

Linguistic Approaches

Linguistic approaches for treating CAS emphasize linguistic and phonological components of speech as well as flexible, functional communication (Velleman, 2003). These approaches focus on speech function. They target speech sounds and groups of sounds with similar patterns of error in an effort to help the child internalize phonological rules. It is important to note that linguistic approaches to CAS are intended as a complement to motoric approaches, not as a replacement for them.

Examples of linguistic approaches include the following:

The Cycles approach (Hodson, 1989) is a linguistic approach that targets phonological pattern errors. It is designed for children whose speech is highly unintelligible and who have extensive omissions, some substitutions, and a restricted use of consonants. The goal is to increase intelligibility within a short period of time. Treatment is scheduled in cycles ranging from 5 to 16 weeks. During each cycle, the SLP targets one or more phonological patterns. After each cycle is completed, another cycle begins that targets one or more different phonological patterns. Recycling of phonological patterns continues until the targeted patterns are present in the child's spontaneous speech (Hodson, 2010; Prezas & Hodson, 2010). The goal is to approximate the gradual typical phonological development process. There is no predetermined level of mastery of phonemes or phoneme patterns within each cycle; cycles are used to stimulate the emergence of a specific sound or pattern, not produce mastery of it.

Integrated Phonological Awareness (IPA) is designed to simultaneously facilitate phonological awareness, letter–sound knowledge, and speech production in preschool and young school-age children with speech and language impairment. Specific approaches to facilitate the development of phonological awareness include (a) developing knowledge that positively influences phonological awareness development (e.g., teaching nursery rhymes and focusing on sound properties of spoken language) and (b) integrating phonological awareness activities into treatment sessions (e.g., phoneme awareness and letter game activities; McNeill, Gillon, & Dodd, 2009a, 2010; Moriarty & Gillon, 2006).

Prosodic Facilitation

Prosodic facilitation treatment methods use intonation patterns (melody, rhythm, and stress) to improve functional speech production. Melodic intonation therapy (MIT; Albert et al., 1973) is a prosodic facilitation approach that uses singing, rhythmic speech, and rhythmic hand tapping to train functional phrases and sentences. Using these techniques, the clinician guides the individual through a gradual progression of steps that increase the length of utterances, decrease dependence on the clinician, and decrease reliance on intonation (Martin, Kubitz, & Maher, 2001).

Augmentative and Alternative Communication (AAC)

Augmentative and augmentative communication (AAC) involves supplementing or replacing natural speech or writing with aided symbols (e.g., picture communication, line drawings, Blissymbols, speech-generating devices, and tangible objects) or unaided symbols (e.g., manual signs, gestures, and finger spelling). Whereas aided symbols require some type of transmission device, production of unaided symbols requires only body movements. See ASHA's Practice Portal page on Augmentative and Alternative Communication.

Considerations For Bilingual and Multilingual Populations

The following information and treatment considerations are summarized below (Gildersleeve-Neumann et al., 2023):

For general information about treating a bilingual or multilingual child with a speech sound disorder, see the Treatment section of ASHA's Practice Portal page on Speech Sound Disorders: Articulation and Phonology. See also ASHA's Practice Portal page on Multilingual Service Delivery in Audiology and Speech-Language Pathology.

Considerations in Schools

Criteria for determining eligibility for services in a school setting are detailed in the Individuals with Disabilities Education Improvement Act (IDEA; 2004). For information about eligibility and dismissal from speech-language pathology services in the schools, see the Considerations for Treatment in Schools section of ASHA's Practice Portal page on Speech Sound Disorders: Articulation and Phonology. See also ASHA's resources on eligibility and dismissal in schools, IDEA Part B Issue Brief: Individualized Education Programs and Eligibility for Services, and 2011 IDEA Part C Final Regulations.

Children With Persisting Speech Difficulties

For some children, speech difficulties persist throughout their school years and sometimes into adulthood. Pascoe, Stackhouse, and Wells (2006) define persisting speech difficulties (PSD) as "difficulties in the normal development of speech that do not resolve as the child matures or even after they receive specific help for these problems" (p. 2).

Anecdotal evidence from clinical observations suggests that, for children with CAS, persisting difficulties can include residual prosody issues, persistent speech sound distortions, and ongoing struggles handling unfamiliar multisyllable words.

For more detailed information about treatment options for children with persisting speech difficulties, see the Children With Persisting Speech Difficulties section of ASHA's Practice Portal page on Speech Sound Disorders: Articulation and Phonology.

Transition Planning

Children with persisting speech difficulties may continue to have problems with oral communication, literacy, and social aspects of life as they transition to postsecondary education and vocational settings. The potential impact of persisting speech difficulties highlights the need for continued support to facilitate a successful transition to young adulthood. See ASHA's resource on Postsecondary Transition Planning.

Service Delivery

See the Service Delivery section of the Apraxia of Speech (Childhood) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

In addition to determining the type of speech and language treatment that is optimal for children with CAS, consider other service delivery variables that may have an impact on treatment outcomes. These include dosage, format, provider, timing, and setting.

Dosage

Dosage refers to the frequency, intensity, and duration of service and the culmination of those three variables (Warren, Fey, & Yoder, 2007).

A high treatment dosage (total amount of treatment) for CAS is consistent with principles of motor learning (Maas et al., 2008, 2014; McNeil, Robin, & Schmidt, 1997). Given the need for repetitive production practice in motor speech disorders like CAS, intensive and individualized treatment is often stressed (Hall et al., 1993; Namasivayam et al., 2015; Skinder-Meredith, 2001; Strand & Skinder, 1999). It is unknown whether the critical variable is the number of sessions per week or the overall amount of treatment (total number of sessions).

For younger children, the frequency and length of sessions may need to be adjusted (e.g., shorter, more frequent sessions are often recommended; Skinder-Meredith, 2001). Given the potential for fatigue, treatment activities may need to be varied accordingly.

Format

Format refers to the structure of the treatment session (e.g., group and/or individual). The appropriateness of treatment format (individual vs. group vs. both) depends on the primary goal for the child at a particular point in the treatment process. For example, if the primary goal is to improve the motor aspects of speech, individual sessions that emphasize motor practice might be the preferred approach. However, once the child has made progress on goals targeting motor speech production, goals might then include language and the enhancement of pragmatic skills. At that point, a combination of individual and group treatment may be appropriate.

Provider

Provider refers to the person providing the treatment (e.g., SLP, trained volunteer, caregiver). SLPs treat the speech-motor and linguistic aspects of the child's speech sound disorder. Other professionals (e.g., physical therapist or occupational therapist) may also be involved in the treatment of children with apraxia. It is important for SLPs to collaborate with other professionals about treatment alternatives and to participate in co-treatment when appropriate (Davis & Velleman, 2000; Velleman & Strand, 1994).

See ASHA's resource on IPE/IPP.

Timing

Timing refers to timing of intervention relative to diagnosis. When a child is diagnosed with CAS, they are likely to present with a significant speech disorder that warrants immediate intervention. Early treatment is also indicated for children suspected of having CAS or with a provisional diagnosis of CAS, given that progress in treatment can help in making a definitive diagnosis.

Setting

Setting refers to the location of treatment (e.g., home, community-based). A naturalistic treatment environment is important for facilitating generalization and carryover of skills, and home practice is essential for helping the child make optimal progress.

Resources

ASHA Resources

Other Resources

This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.

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About This Content

Acknowledgements

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Childhood Apraxia of Speech page.

In addition, ASHA thanks the members of the Ad Hoc Committee on Childhood Apraxia of Speech whose work was foundational to the development of this content. Members of the committee included Lawrence Shriberg (chair), Christina Gildersleeve-Neumann, David Hammer, Rebecca McCauley, Shelley Velleman, and Roseanne Clausen (ex officio). Celia Hooper, vice president for professional practices in speech-language pathology (2003–2005), and Brian Shulman, vice president for professional practices in speech-language pathology (2006–2008), served as the monitoring officers.

ASHA seeks input from subject matter experts representing differing perspectives and backgrounds. At times a subject matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association (n.d.). Childhood Apraxia of Speech (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Childhood-Apraxia-of-Speech/.

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.