Childhood

Apraxia Of
Speech
Rahaf Shihadeh
Marah Talat
Eman Samara
Mariam Omran
Majd Al-Anati
Overview
 Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder that
reflects an impaired capacity to plan or program sensorimotor commands necessary for directing
movements that result in phonetically and prosodically normal speech, in the absence of neuromuscular
deficits.

Motor speech
Cognitive
planning, Neuromuscular
linguistic
programming execution
process
and control

 The core impairment in planning and/or programming spatiotemporal parameters of movement

sequences results in errors in speech sound production and prosody. 
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).
 In association with known neurological events (e.g., early childhood stroke, infection,
trauma, brain cancer/tumor resection).
 Prevalence

 Childhood apraxia of speech (CAS) is an

uncommon speech disorder.

 It was estimated to occur in 1 to 2 children

per 1,000 (0.1%–0.2).

 It was estimated to be higher in male

children than in female children with a 2–3:1
ratio.
Childhood apraxia of Speech: Demographics

 More than 80% of children with CAS have at least one family member with reported speech
and/or language disorders (Velleman, 2003).

 CAS demonstrates higher rates of family history than other speech sound disorders, which
suggests a genetic basis in at least some cases (Lewis et al., 2003).

 Up to 3% to 4% of children with speech delay are given the diagnosis of CAS (Delaney & Kent,
2004).

 CAS symptoms are common among children with Down syndrome (Kumin & Adams, 2000).

 Approximately 60% of children with autism spectrum disorder have speech problems;
about 13% report primarily symptoms of apraxia of speech (Marili, Andri- anopoulos, Velleman, &
Foreman, 2004).
 The term childhood apraxia of speech implies a shared core of features (both speech
and prosodic) regardless of the time of onset and whether it is congenital or acquired
or has a specific etiology.

 Early reports delineating the symptoms were based on acquired apraxia of speech in
adults.

• Similarities and differences between the specific articulatory problems noted in adults
with acquired apraxia of speech and children with childhood apraxia of speech were
compared.

• The most important similarity between these two groups of clients pertains to the lack
of sequential volitional control of the oral mechanism.
 There remains a clinical necessity to
delineate the speech characteristics of CAS
children from those evidenced by children
with developmental speech sound
disorders.

 Both groups of children have certain

characteristics in common:

 The onset is early in the developmental

period.
 The course is long term, often extending into
adulthood.
 Speech
Characteristi
cs
 Complaints nearly always center on articulation
and rate and rarely on breathing, phonation, or
resonance.
Patient
Many patients recognize errors and attempt to
Perceptions correct them.

and Many say that the problem worsens under

conditions of stress or fatigue.
Complaints
Patients deny difficulties with verbal
comprehension, reading comprehension, and
the linguistic aspects of writing.
Speech Findings
Articulation:
I. Consonant and vowel distortions (imprecise articulation)
II. Distorted substitutions
III. Distorted additions
IV. Distorted sound prolongations
V. Distorted voicing distinctions “blurring of voiced-voiceless boundaries”

Apraxic speakers produce more consonant distortions than substitutions and that
half of their perceived substitutions are also perceived as distorted.
Rate and prosody

I. Slow overall rate regardless of phonemic accuracy, especially for utterances more than
one syllable in length.
II. Prolonged but variable vowel durations in multisyllabic words or words in sentences.
III. Prolonged but variable interword intervals regardless of phonemic accuracy.
IV. Syllable segregation.
V. Errors in stress assignment with a tendency to equalize stress across syllables and
words.
VI. Decreased phonetic accuracy as rate increases, sometimes crossing phonemic
boundaries.
VII. Altered stress occasionally leads to perception of foreign accent.

No prosodic abnormalities in mild AOS, but very evident in moderate and severe AOS
Fluency:

I. Successful or unsuccessful
attempts to self-correct
articulatory errors that cross
phonemic boundaries.
II. False articulatory starts and
restarts.
III. Effortful visible and audible trial-
and-error groping for articulatory
postures.
IV. Sound and syllable repetitions.
Influential task variables:

I. Syllabicity effects: increased error rates for low frequency syllables, syllables
with more phonemes.
II. Error rates higher for volitional vs. automatic/reactive utterances.
III. Error rates higher for nonsense syllables than meaningful words of comparable
length and complexity
IV. Imitation of utterances particularly difficult
Characteristics of Severe Apraxia of Speech
1. Limited repertoire of speech sounds.
2. Speech may be limited to a few meaningful or unintelligible utterances.
3. Imitation of isolated sounds may be in error.
4. Errors may be limited in variety and highly predictable.
5. Automatic speech may not be better than volitional speech.
6. Usually accompanied by significant aphasia but can occur in the absence
of aphasia.
7. Usually accompanied by nonverbal oral apraxia.
Multidisciplinary Team
 Professionals to collaborate with
when working with CAS

•Since CAS is a speech sound disorder, the

most appropriate professional to diagnose
and treat it is a speech-language
pathologist (SLP).

• Is SLP enough?
Depending on your child’s needs, other
professionals may also be part of your
team.
 What other Professionals
May Be Involved?

1- DEVELOPMENTAL PEDIATRICIAN

• is a pediatrician with advanced training in

neuro-developmental disorders and “atypical”,
out of the ordinary child development. 
• This type of professional can help recommend
specialists and coordinate and advocate for
services that the child may need. 
2. PEDIATRIC NEUROLOGIST

A Pediatric Neurologist may be helpful if

there are overall neurological concerns
in addition to speech. If you are
concerned about whether there is:
• a problem of brain structure
• seizures
• other brain related activities

Some medical tests that can be done

include MRIs to examine brain structure
and extended EEGs to investigate the
electrical system of the brain.
3. CLINICAL GENETICIST

•A Clinical Geneticist may become involved if there is

suspicion of an underlying genetic condition.

•If there are extended family members who also have

histories of speech and/or language problems or if there
are medical concerns about your child, parents should
speak to their pediatrician about referral to a geneticist. 
4. OCCUPATIONAL THERAPIST
An OT can evaluate your child’s overall ability to
function in many aspects of life, including fine
motor control.

Often, children with apraxia of speech have:

• difficulty in managing the fine motor
movements and coordination with their
hands that are necessary for skills such as
printing and writing, dressing, manipulating
toys or objects and other self-help skills.

• Additionally, some occupational therapists

are great resources for evaluating children
with difficulty eating.

• Sensory processing difficulties are often

reported by parents of children with CAS,
such as difficulty with noises or in touching
various textures and more. A highly trained
occupational therapist can help evaluate
and treat sensory difficulties.
5. PHYSICAL THERAPIST
A PT can evaluate overall physical
functioning, body coordination and
motor control of larger muscles of
the body (gross motor control) and
how the child is able to function in
their environment. 

6. A DEVELOPMENTAL SPECIALIST OR
PSYCHOLOGIST
A Psychologist or Developmental
Specialist can help to examine a child’s
cognitive abilities and whether they are
developing as expected. 
 Gather Your Team

Each member of your child’s team has their

own area of expertise and strengths. Your
child’s team will depend on their needs and the
resources available. If you have concerns about
your child’s development in addition to their
speech, other professionals may be called on to
get involved in helping your child. 
1-Parents/Caregivers

•You are the expert on your child and know

your child the best

•You provide invaluable information about

your child's motivations, moods, and
challenges.

•You're the one who knows everything that

is going on for your child and can help fill-in
that information for other team members.
 2-SLP(s)

Your child might be working with more than one

SLP. One SLP might be an expert on CAS and
another might have more experience with AAC
(augmentative and alternative communication) or
language.
3-Teacher(s)

If the child is in school, their

teacher(s) are likely to also be a
critical part of the team. Since
many children with CAS also
experience academic challenges.
4- Other Therapists
• Audiologist – PT – OT …
Assessment
 Assessment is accomplished using a variety of standardized and nonstandardized
measures and activities.

 Comprehensive assessment typically includes:

General
observations Speech Stimulability
Oral
Case history of production and response
examination
neurological and analysis to cueing
signs
Case History
Prior speech and
Early vocal
Family history language
behaviours
treatment

Feeding problems
Hearing status (currently or Other treatment
Previously)

Medical or other
Ear infections diagnosis
(Reports)
General observation of neurological signs

It is important to make differential diagnosis between CAS and dysarthria.

We should observe and note neurological signs such as significant muscle tone
abnormalities, asymmetry, extraneous limb movements, abnormal gait
patterns, exist of pathological reflexes. As these signs consist with the diagnosis
of Dysarthria.
Oro-motor examination
Assessing Structure:
Structure refers to the anatomy (e.g., the mouth, teeth, lip,
tongue, pharynx, and larynx).

CAS is associated with intact oral structures for speech (ASHA,

2007).

Body structure deficits may be present if a child has a comorbid

diagnosis such as cleft palate or dysarthria (Murray et al., 2015).

Oral structures need to be assessed using an oral-motor

assessment, such as the Oral and Motor Speech Protocol
(Robbins & Klee, 1987).
Assessing Function:
Function refers to the physiology of the body.

The CAS diagnosis is associated with functional deficits rather than structural deficits
(Iuzzini-Seigel, J., & Murray, E. 2017). Examination of the function of oral peripheral
mechanism.

Imitation of signal and combined nonspeech oral movements, note:

Groping (may indicate CAS)

Inability to imitate single oral/facial movements (may indicate oral apraxia)

Incoordination or lack of rhythmicity of movement sequences slow, clumsy or

inaccurate (may indicate CAS) (Fish, 2016)
Speech production and analysis
Diadochokinetic rates and coordination.
Articulation test.
Syllable testing.
Speech sample.
Prosody and suprasegmental features of speech.
Diadochokinetic rates and coordination

Ask the child to produce the syllables /pa/, /ta/, /ka/ 5-10 times each at first slowly, then
naturally, and then as fast as they can.

The child then produces /pa.ta.ka/ 5 times at first slowly, then naturally, and then as fast as
they can.

Note the following:

Reduced misarticulate sounds
Reduced accuracy with increase rates
Reduced rhythmicity of the syllable sequences
Articulation test

Consonant repertoire:
List each consonant that the child produces (even if distorted, substituted incorrectly, or
ordered incorrectly).
Vowel repertoire:
List each vowel (pure vowels, diphthongs) the child produces (even if distorted,
substituted incorrectly, or ordered incorrectly).
 Phonetic accuracy
Consonant accuracy:
Consonant accuracy was assessed by computing the percentage of consonants produced correctly
compared to the number of consonants attempted during each session to get the percent
consonants correct (PCC).
PCC is calculated by = number of correct consonants (excluding distortions) / total number of
consonants * 100.
• Rating system according to Shriberg and Kwiatkowski (1982):
Mild: 85-100%
Mild-moderate: 65-85%
Moderate-Severe: 50-65%
Severe: Below 50%

Vowel accuracy:
This tests the child’s ability to produce the targeted vowels and calculate the percentage of
correctly produced vowels per totally examined vowels (i.e. Percent Vowels Correct PVC).
PVC is calculated by = number of correct vowels / total number of vowels * 100.
Place, manner and voicing errors

SODA (substitution, omission, distortions and addition)

Have children produce test words both
spontaneously and imitatively:

Some children with CAS are able to produce the

word or utterance spontaneously, but not imitate
the same utterance after a model.

Other children can imitate words when provided

with enough cueing but cannot produce the same
words without a model.

This gives indication that the child is

demonstrating a challenge in planning of speech
movement sequence (Fish,2016).
Consistency of consonant and vowel errors

This is observed by asking the child to repeat test items more than once.
Inconsistency is a common finding in children with CAS. So, asking the child to
produce a word only once doesn’t provide enough information if the child
demonstrate ‘inconsistent errors’ or not.
If the formal test you are using doesn’t require the child to produce the test
items more than once. You can add this informally. Only repeat the words that
exhibit motor planning challenges as a starting point (Fish, 2016).
Syllable testing
Syllabic accuracy
 Syllabic accuracy measures the participant ability to produce accurate syllable number, shape and
sequencing.

 For the analysis of syllable number and structure accuracy, a study that was preformed in Egypt
(2010), they used a specially designed syllable accuracy task ‘‘The Arabic Syllable Accuracy Word
Task’’ (ASAWT).

 Participants were asked to repeat 32 different consonant vowel (CV) structures with increasing
task demands.
 Task levels were arranged into 8 categories guided by the hierarchy of phonotactic difficulty.

 (1) Simple open monosyllable (CV) as in /ba/, /ti/, /me/, /do/.

 (2) Reduplicated open syllables (CVCV—same syllable repeated) as in /mama/, /baba/, /nunu/, /titi/.

 (3) Harmonized non-reduplicated disyllabic open syllable forms CVCV as in /teta/, /duda/, /keka/,
/bobi/

 (4) Non-harmonized non-reduplicated disyllabic open syllable forms /toka/, /futa/, /tani/, /hati/.

 (5) Harmonized closed monosyllable CVC /bab/, /dad/, /tut/, /bib/.

 (6) Non-harmonized closed monosyllable CVC /kan/, /gab/, /bet/, /hat/

 (7) CVCVC polysyllable words (non-reduplicated, non-harmonized) /dulab/, /ketab/, /Rarab/,

/mezan/

 (8) Words with initial, medial, and/or final close-to-clusters (using short vowels /gebna, /benti/,
/wedni/, /kofta/
The following scores were then calculated:

(a) Syllable number accuracy

Syllable number accuracy is the proportion of words in which the correct number of syllables is
maintained regardless of the correctness of consonants. For example, if 5 words should have been
produced with 2 syllables and only 4 were produced with 2 syllables, then syllable number
accuracy for disyllables is 4/5 = 80%.

(b) Syllable shape accuracy

Syllable shape accuracy is the proportion of words produced in which the syllable shape is
maintained regardless of the correctness of consonants.

For example, if the target word / ketab/ is produced as /tetab/, the syllable shape is accurate even
though the substitution of the posterior velar /k/ by the anterior alveodental /t/ stop is an error.

The percent of correct syllable shape to the totally produced syllable was calculated to get the
syllable shape accuracy.
Prosody and suprasegmental features of speech

Some of the suprasegmental characteristics that can be impacted in children with

CAS include ( stress, intonation, rhythm, resonance and rate).

 Note whether the child is using excessive equal stress, placing stress on an
incorrect syllable or using flat intonation (Fish,2016).

 Syllable stress inventory: list the syllable stress patterns produced by the child,
even if they are produced incorrectly.
Speech sample
Obtain speech sample to analyse the child’s speech through connected speech.

Consonant and vowel repertoire.

Consonant and vowel accuracy.
Place, manner and voicing errors.
SODA (substitution, omission, distortions and addition).
Phonological patterns.
Rate of speech: Children who are suspected of CAS, may have slow rate as they
struggle to connect phonemes smoothly and efficiently.
Intelligibility of speech: This is measured by comparing the total number of
intelligible words in a speech sample by the total number of words in in the
speech sample.
Stimulability
To assess dynamic motor speech, let the child repeat words after the clinician and
cueing such as simultaneous imitation and touch cues are used to determine
what a child can do with support (Strand, McCauley, Weigand, Stoeckel, &Baas,
2013)
Intervention
Foundation to treat childhood apraxia of speech P.R.I.S.M:

• Phoneme Sequencing

• Repetitive Practice

• Intensity of Treatment

• Selection of Target Utterances

• Multisensory Cues and Feedback

Phoneme Sequencing
Syllable Shapes
 Syllable shape: refers to the
ordering of consonants (C)
and vowels (V) within a
syllable.

 Word shape : refers to the

ordering of Cs and Vs within a
word.
Repetitive Practice
Enhancing Motivation

1. know they are successful.

2. understand the power of language.

3. Understand how motor skills will affect their ability to communicate.

4. having fun.
Intensity of Services
Considerations Related to Treatment Intensity

 Severity of the child’s speech praxis challenges

 Age of the child
 Attention capacities of the child
 Physical stamina of the child
 Types of goals being addressed in speech and language treatment
 Coexisting needs that may require other types of treatment (motor, cognitive,
learning, medical, social, emotional)
Selecting Target Utterances
When choosing target utterances for therapy, there are five main speech-related
areas to consider:

1. Syllable Shapes

2. Phonemes

3. Prosody

4. Flexibility and contextual limitations and Facilitating contexts

Multisensory Cueing
 Sensory cueing approaches that involve using the child's
senses;
- Visual cues
- Auditory cues
- Proprioceptive cues
- Tactile cues
to teach the movement sequences for speech.
https://youtu.be/u4DNZYHOeCI
Evidence-Based
Treatment Programs
for Children with CAS
 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.

 In addition to increasing communication success, AAC approaches may stimulate the

development of language skills that cannot be practiced orally.

 These approaches use multisensory cues within the context of treatment to facilitate
the accurate production of new motor speech plans.
 Motor
programming
approaches

Rhythmic Treatment Linguistic

(prosodic)
Approaches approaches
approaches

Combination
approaches
 Dynamic Temporal and
Tactile Cueing (DTTC)

Motor Nuffield Dyspraxia

programming Program(NDP3®)
approaches
Rapid Syllable Transitions
(ReST)
 Motor programming approaches are based on motor programming/planning
principles. These approaches:

1. Provide frequent and intensive practice of speech targets.

2. Focus on accurate speech movement.
3. Include external sensory input for speech production (e.g., auditory, visual, tactile).
4. Carefully consider the conditions of practice (e.g., random vs. blocked practice of
targets).
5. Provide appropriate types and schedules of feedback regarding performance.
 Cycles approach

Linguistic
Approaches
Integrated Phonological
Awareness
 Linguistic Approaches
 Linguistic approaches for treating CAS emphasize linguistic and phonological
components of speech as well as flexible, functional communication.

 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.
Prosodic Facilitation
 Prosodic facilitation treatment methods use intonation
patterns (melody, rhythm, and stress) to improve
functional speech production.

 Melodic intonation therapy 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.
Prompts for Restructuring Oral Muscular Phonetic Targets
 A PROMPT : clinician uses tactile/proprioceptive input to the speech subsystems (e.g.,
phonation, mandible, labial-facial, lingual) to facilitate production of phonemes, words,
and phrases.

 Prompts are provided externally to:

 The jaw (to facilitate the accurate degree of jaw opening, provide jaw stability, and
reduce extraneous jaw excursions).

 The muscles of the face, including the cheeks and lips (to facilitate independent lip
closure, rounding, and retraction).

 The mylohyoid tissue under the chin (to facilitate placement, width, and timing of
contraction in the tongue musculature).

https://youtu.be/yXtNYsfNXO4
 This case study is used to illustrate the changing
nature of treatment over time for a child with CAS.

 At each stage of development, the child’s present

level of performance will be described, along with
recommendations for treatment that are priorities
for the child at that moment in time.

 Basic treatment goals and possible methods for

treatment are listed; these change depending on
the child’s age and performance levels.

 The treatment goals listed in this case study are

basic goal areas that will be addressed for this
child.
Marissa, Age: 2 Years, 5 Months
Marissa, Age: 2 Years, 9 Months
Marissa, Age: 3 Years, 3 Months
Marissa, Age: 4 Years, 4 Months
Thank You!
Any Questions?
 References
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2. Childhood apraxia of speech. American Speech-Language-Hearing Association. https://www.asha.org/practice-

portal/clinical-topics/childhood-apraxia-of-speech/. Accessed April 2, 2021.

3. Bauman-Wrangler, J. (2016). Articulatory and phonological impairments: A clinical focus 3d Ed. Boston: Pearson,
Allyn& Bacon.

4. Luzzini-Seigel, J., & Murray, E. (2017). Speech Assessment in Children With Childhood Apraxia of Speech. Perspectives
of the ASHA Special Interest Groups, 2(2),

5. Aziz, A. A., Shohdi, S., Osman, D. M., & Habib, E. I. (2010). Childhood apraxia of speech and multiple phonological
disorders in Cairo-Egyptian Arabic speaking children: Language, speech, and oro-motor differences. International
Journal of Pediatric Otorhinolaryngology, 74(6), 578–585.

6. Fish, Margaret A,. (2016), Second edition. Here's how to treat childhood apraxia of speech.

7. Feldman, H. (2019, November 7). What other Professionals May Be Involved? Apraxia Kids.

8. Waldrup, B. (2020). Team Approach for Children with Childhood Apraxia of Speech. Child Apraxia Treatment.

9. Mayo Foundation for Medical Education and Research. (2019, May 10). Childhood apraxia of speech. Mayo Clinic.