CHILDHOOD APRAXIA

OF SPEECH
Submitted to : Dr. Ravalli Mathur
Submitted by : Fatema Siawala
 INTRODUCTION
● In order for speech to occur, messages need to go from your brain to your
mouth. These messages tell the muscles how and when to move to make
sounds. When a child has apraxia of speech, the messages do not get
through correctly. The child might not be able to move their lips or tongue
in the right ways, even though their muscles are not weak. Sometimes, the
child might not be able to say much at all.
● A child with CAS knows what they want to say. The problem is not how
the child thinks but how the brain tells the mouth muscles to move.
● CAS is sometimes called verbal dyspraxia or developmental apraxia. Even
though the word “developmental" is used, CAS is not a problem that
children outgrow. A child with CAS will not learn speech sounds in typical
order and will not make progress without treatment. It can take a lot of
work, but the child’s speech can improve.
 DEFINING THE DISORDER
● 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 or unknown origin, or as
an idiopathic neurogenic SSD.
● The core impairment in planning and/or programming spatiotemporal
parameters of movement sequences results in errors in speech sound
production and prosody. (ASHA,2007a)
 CAUSES
The ASHA definition also emphasizes that although CAS is seen as a
neurological problem, it may arise in one of at least three general ways.
● First, it may be a reflection of a known neurological condition such
as cerebral palsy.
● Second, it may also be comorbid with “known neurobehavioral
disorders” such as fragile X syndrome, galactosemia, or Rett
syndrome. [Note that at one point, autism was included in the list of
neurobehavioral disorders, but some recent analyses suggest that the
speech errors seen in that population are qualitatively and
quantitatively different from those seen in CAS (Shriberg, Paul,
Black, and van Santen, 2011)].
● Finally, the third and most common origin of CAS is unknown
 THE CORE PROBLEM
As the definition indicates, the primary problem in CAS appears to be one of
planning and/or programming for speech. Such planning and programming
(or what Shriberg, Lohmeier, Strand, and Jakielski [2012] have called
transcoding), is part of how many clinicians and researchers would describe
the process of generating speech, which may be outlined as follows:

Transcoding
Encoding
(Planning/
Ideation (language Articulation
Programming
formulation)
)
1. IDEATION - the speaker starts by deciding what idea or ideas he or she wants to
express; totally conceptual.

2. ENCODING- then the speaker selects the sentence structure and specific words
to use; includes determining the phonemes and allophones to express the words.

3. TRANSCODING- involves translating the linguistic message into the details of

which particular muscles are to be moved, including their sequence and timing, in
order to express the message. This is what is meant in the CAS definition above by
“the spatiotemporal parameters of movement sequence.” For many in the field,
transcoding is referred to as motor planning.

4. ARTICULATION- once the plan is created, it is sent via the nerves to the speech
musculature, and the physical movements(i.e., articulation) is carried out.

Relative to ASHA definition, the core problem in CAS is in the motor planning
step. The speaker has difficulty either creating the motor plan or accessing an
● Shriberg and colleagues (2012) tried to determine whether children
with CAS also had problems with either their representations or
memory. They used a nonword syllable repetition task to compare
40 children with CAS against 119 typically developing children, and
210 children with non-CAS speech delay (70 of whom also had
coexisting language impairments).
● They concluded that, in addition to problems with transcoding
(motor planning), the children with CAS also had deficits in their
underlying representations and problems with memory.
 DIAGNOSTIC MARKERS
Possible diagnostic features lists for CAS
RECOMMENDED ASSESSMENT BATTERY FOR CAS
1. Case History (including review of feeding history)
2. Hearing Screening / Testing
3. Screening of voice and fluency characteristics
4. Speech Mechanism Examination
a. Structure and function
b. Strength, tone, stability
c. DDK tasks
5. Connected Speech Samples
a. Segmental Productions
b. Syllable and word shape productions
c. Phonological Patterns present
d. Intonation, vocal loudness, resonance
e. Analysis of consistencies (words occurring more than once)
6. Segmental Productions (single word analysis; independent analysis for those
with a limited phonological repertoire)
 a. Consonants, vowels, diphthongs used
b. Syllable shapes used
7. Intelligibility - how well the acoustic signal is understood with and without
context
8. Stimulability testing (including multiple opportunities)
c. Segments
d. Syllables
e. Words with increasing number of syllables
9. Phonological awareness assessment
10. Interpersonal skills
f. Social interaction
g. Behavioral interaction
h. Academic/community interactions
11. Language Evaluation
i. Comprehension and production
j. Sound productions at various semantic and syntactic levels
 TREATMENT FOR CAS
Assuming that the core problem in CAS is difficulty with motor planning (transcoding) for
speech, one might assume that neither traditional motor approaches nor linguistic
approaches would likely work well for these children. Interestingly, the review by Murray
and colleagues (2014) concluded that there was sufficient evidence available to suggest that
at least two different motor approaches and one linguistic approach may be effective for
treating CAS. These are highlighted below.

1. Dynamic Temporal and Tactile Cueing (DTTC):

● Historically called integral stimulation;
● Strand and Skinder(1999) described it as: a hierarchically organised sequence of
stimuli for practice of specific movement gestures of speech production...first
with maximal support, then with gradually faded cues, so that the child takes
increasing responsibility for the processing.
● It uses the principle of motor learning and is heavily built around the child
watching, listening to and imitating the clinician.
2. Rapid Syllable Transition Element(ReST):
● A motor based approach; includes a focus on motor planning by using
random presentation of multisyllabic targets.
● In addition, it targets the prosodic deficits in CAS by focusing on the
appropriate use of stress at the syllable level.
● It combines strings of nonwords (e.g.,/batigu/) to avoid the emergence of
previously stored linguistic and motor representations, with variations in
syllable stress(e.g., BAtigu vs. baTIgu vs. batiGU).

3. Prompts for Restructuring Oral Muscular Phonetic Targets(PROMPT):

● A subject of limited formal study; is the motor approach known as PROMPT.
● It draws on several theoretical perspectives, including dynamic system theory,
neuronal group selection theory and motor learning theories.
● Detailed elaboration is beyond the scope of the current text. The PROMPT
approach was originally developed by Chumpelik (1984) and is quite unique in
its focus on jaw height, facial-labial contraction, tongue height and
advancement, muscular tension, duration of contractions, and airstream
4. Integral Phonological Awareness Intervention(IPAI):
● The main focus of this approach is phoneme-level phonological awareness
activities (e.g., segmentation and blending, letter naming).
● There is also a simultaneous focus on production, as the specific words used in
treatment are selected to represent one or more of a client’s speech production
error patterns.
● When production errors occur during the awareness activities, Moriarty and
Gillon (2006) reported that: ....the researcher aided the child to identify the error
and then used the coloured block or letter block as a prompt for speech
production. For example, if Katie said “top” instead of “stop”, it would be cued
via the following method. “You said ‘top’ but I can see a /s/ sound at the start of
the word (pointing to the s letter block). Try the word again with a /s/ sound at
the start”. The children did not receive any articulatory prompts regarding place
or manner of production of the target sounds.
● The most unique aspect of IPAI is the linkage between the language system and
the speech motor system by combining phonological awareness with child-
specific production targets. Thus, the child is learning about the phonological
functions of the sounds in the language while at the same time practicing and
5. Augmentative and Alternative Communication(AAC) and CAS:

The use of AAC systems has long been suggested as a temporary bridge to speech for
children with CAS. Cumley and Swanson (1999) noted that AAC: . . . provided them
with greater opportunities for communicative success and flexibility for initiating,
participating in, and repairing their communication breakdowns . . . [and] afforded
greater opportunities for supporting and facilitating the language development,
communicative interaction, and academic success of these children.

6. Traditional Articulation Therapy CAS:

● The study involved “concurrent task sequencing” where the treatment continuum
was presented in random order. Skelton and Hagopian studied three children with
CAS aged 4 to 6 years, with treatment for one child beginning while treatment was
delayed for the other two for several sessions.
● The researchers then introduced treatment for the second child while continuing to
delay it for the third.
● Treatment was later introduced for the third child. Findings
showed that change (improvement) for each child started only
once treatment began, not before. This suggested that the
study had provided some degree of control over extraneous
effects (i.e., it was the treatment that was causing the change).
 TREATMENT RECOMMENDATIONS FOR
CAS
With a still emerging literature, it is perhaps premature to make definitive
treatment recommendations for children with CAS. This is especially so because
direct comparison studies of different treatments are not yet available. However,
preliminary suggestions are possible. The above discussion suggests that some of
the available approaches may be more appropriate for particular subsets of the
CAS population. For example, perhaps highly structured approaches such as
DTTC or PROMPT may be better suited to younger children and/or those with
the most severe CAS involvement (i.e., those with the most limited production
abilities). Approaches such as ReST or IPAI may then be more appropriate for
older children and/or milder cases of CAS. Various types of AAC might be at
least considered as a short-term bridge to communication for any child with
 REFERENCES
● Articulation and Phonological Disorders(Speech
Sound Disorders in Children):- John E. Bernthal,
Nicholas W. Bankson, Peter Flipsen JR.
● https://www.asha.org >childhood apraxia of speech