Childhood apraxia of speech (CAS) is difficult to accurately diagnose and should be evaluated by a speech-language pathologist (SLP) who is trained and has experience assessing and treating children with CAS. An SLP will look at how well the child understands language (receptive language), how the child uses language (verbal and non-verbal) for communication (expressive language), and the child’s oral motor skills (how the mouth moves in general), motor speech skills (how the mouth moves for speech production), and speech melody or intonational patterns (prosody). They should also look for areas of strengths and weaknesses in all developmental areas. Sometimes it may take the speech therapist working with a child over a period of weeks or months to determine an accurate diagnosis. In this case, treatment should be geared towards improving motor planning skills.

At What Age Can A Child Be Diagnosed with CAS?

This is the wrong question to ask as there is not a minimum age at which a trained speech-language pathologist (SLP) can diagnose CAS! The question should be: “What skills does a child need to have in order for characteristics of CAS to be seen?” SLPs have specific tasks that they do with a child they suspect has CAS and if the child is not able to participate in them, they cannot confirm a CAS diagnosis. The child will need to be able to:

• Say some words or word attempts on their own
• Be willing to try to imitate sounds and words
• Attend to the SLP’s face and other cues to improve their production of words
• Follow simple instructions
• Be able to attend for several minutes at a time

Some children can do these things at 2 years of age and others, not til they are older. If your child is not able to do all of these things and you are concerned about their speech and language, you should by all means have your child tested by a SLP as soon as possible. Even if a firm diagnosis is not confirmed, the SLP can look for signs that might indicate CAS is a possibility and perhaps use the diagnosis of suspected CAS. Then as the therapist works with your child and more skills develop over time, a diagnosis can be confirmed of CAS or perhaps another type of speech sound disorder. Regardless, it is important that children with slower than typical development of speech and language be seen as early as possible so that any needed intervention can begin to improve the long term outcomes for the child.

How is CAS Diagnosed?

Because childhood apraxia of speech is a communication disorder, the most qualified professional to provide assessment, evaluation, and diagnosis is a licensed speech-language pathologist (SLP). Other professionals can be helpful and necessary at some point in time for children with CAS; however, they have not typically undergone the extensive and concentrated study and certification to fully evaluate speech and/or language disorders. Professionals such as pediatric neurologists or developmental pediatricians sometimes make the diagnosis but more often, and more appropriately, they refer to the speech-language pathologist on their team who has the skill and extensive training to distinguish between CAS and other types of speech sound disorders.

A thorough speech and language evaluation by a speech-language pathologist consists of several parts:

• Exploration of the child’s history of the pregnancy, birth history and developmental milestones met across all areas of development.
• The possibility of a hearing loss needs to be ruled out.
• How does your child communicate with others? How well do others understand your child?
• How much does your child understand from others in their environment?
• What speech sounds (consonants (C) and vowels (V)) and/or words is your child able to say and imitate? What type of errors are made? What type of syllable structures is your child able to produce? (CV like ma, CVCV like mama, CVC like dog…)
• What types of cues and strategies help your child improve their speech production?
• Are there any structural or muscular differences/weaknesses in your child’s mouth (tongue, jaw, lips…) and how it moves for both speech and non-speech movements that could be a cause for speech difficulties?
• What does your child’s spontaneous speech sound like as far as intonation patterns, smoothness, loudness, rate of speech and overall intelligibility? How does it compare to imitated speech?

The SLP will do a variety of different tasks geared towards your child’s age level and skill level in order to gather the above information. The SLP should be able to give you both strengths and weaknesses that will be important for providing appropriate therapy. Click here to read more detailed information about these different areas.

Why is CAS Difficult to Accurately Diagnose?

Childhood apraxia of speech is difficult to diagnose for a number of reasons.

• There is not a standardized evaluation tool to use that adequately diagnoses CAS.
• There is not a list of characteristics that are agreed upon that are necessary for giving a diagnosis. There are multiple characteristics and we are finding that children do not necessarily have all of the characteristics.
• Many of the characteristics of CAS overlap other speech sound disorders so differential diagnosis is complex.
• Many SLPs do not have appropriate training in order to differentially diagnose CAS causing misdiagnosis in young children which leads to inappropriate intervention.
• Current research is suggesting that there may be different underlying causes for motor planning issues such as CAS.

Parents/caregivers who are concerned about their child’s speech and language should seek out an evaluation with a SLP, who is trained and experienced in CAS, through their pediatrician, early childhood intervention services or school based services in their area. SLPs who have some training, knowledge, and experience in CAS are listed on our SLP directory.

What are Additional Areas to Consider an Evaluation for?

Often children with motor planning difficulties such as CAS have other comorbid disorders. Parent/caregivers should watch their children carefully for signs that there are additional struggles in these areas:

• Gross and fine motor skills – this can include general difficulties with overall coordination – falls a lot or is more clumsy than typical children, or delayed skill development in gross motor skills such as crawling, walking, running, jumping, stair climbing, throwing/catching a ball, and riding a bike; or fine motor skills such as using eating utensils, picking up small items with thumb and index finger, holding a crayon/pencil for coloring and writing, zipping and buttoning clothes, stacking small blocks, and doing puzzles. A physical therapist (PT) can evaluate gross motor skills and an occupational therapist (OT) can evaluate fine motor skills.
• A sensory processing disorder (SPD) is where incoming sensory stimuli from how things feel, smell, taste, look, sound and where our body is in space are not processed the same as other people. Lights can be too bright and stimulating, everyday sounds can seem too loud, light touch on the skin can be painful, too much sensory input is overwhelming, or there could be a low reaction to stimuli – hot water doesn’t burn. An Occupational Therapist can diagnose SPD.
• Children with CAS are at high risk for developing later literacy and reading difficulties in school. Early on, children should be monitored for their early literacy skills such as rhyming, sound identification, and sound manipulation so that these type of skills can be incorporated into speech practice activities by the SLP. When a child is school age, they should be tested by school based personnel to be sure they are acquiring reading skills appropriately with their age peers.
• Overall receptive and expressive language skills should be tested regularly to ensure there are not any underlying difficulties with what the child understands of language and what he/she is able to express. Children who do not have a functional way to communicate with the world around them should be evaluated by a trained SLP for the appropriateness of an augmentative or alternative communication system such as signs, pictures, or a speech tablet.
• Socio-emotional well-being should be considered as an area to monitor to be sure the child is appropriately dealing with stress and growing in their ability to interact with adults and children in their environment. For a child with CAS, talking can be extremely difficult and speech therapy is very hard work. This has an emotional toll on not only the child, but the family as well. Parents and caregivers can talk with their doctors, social workers or counselors about any concerns in this area.

If a parent/caregiver has concerns about any of these above areas, they should bring their concerns to their child’s speech therapist, pediatrician or other health professional to get an appropriate referral for an evaluation.

By Laura L Moorer
November 2021