It can be difficult to distinguish between childhood apraxia of speech (CAS) and autism spectrum disorder, especially when children are not yet talking very much. Below are three real-life examples of cases in which both autism spectrum disorder and CAS were suspected. Since autism and CAS require specialized treatment approaches, it is important to get accurate diagnoses to plan the most effect treatment.
Note that there are many reasons why children may have difficulty talking, and all children will look differently. If your child sounds like one of the examples described below, talk to a speech-language pathologist with experience in autism and CAS, as well as your pediatrician. Your child’s pediatrician may refer you to a specialist for further testing.
Child 1: Mia
Mia is a four-year-old girl, who was diagnosed with autism at two years old. She consistently uses a few words, including “ou” (for “outside”), “ma” (for “mom”), “wa” (for “water”), “no,” and “mmhm” (for “yes”), and she uses signs for “more” and “all done.” She sometimes repeats words when asked to do so, but most often she does not respond. Mia’s parents describe her as generally happy, easily excitable, and gentle. They also noted that she is sensitive to loud sounds and often fixates on bright lights. When excited or overstimulated, she might flap her arms, yell, or cover her ears. Mia tends to use her body to communicate more than her words—if she wants something she will find a way to get it! She likes to do certain play routines by herself (e.g., stacking blocks and knocking them over) and does not usually look at someone or interact in a back-and-forth way unless she needs them (e.g., getting a push on the swing). Mia’s parents are concerned that although she receives daily speech and language therapy, she does not seem to be making much progress with her verbal development. Could she have CAS?
Mia’s parents are absolutely right to question if there could be potentially overlooked reasons as to why her language is developing slowly. They worked with a speech-language pathologist with expertise in autism and CAS to plan a comprehensive speech assessment. The assessment was completed over several short sessions to give Mia many different opportunities to produce words without overwhelming her. Across sessions, Mia said 20 different words and repeated most at least twice. She repeated the words largely the same way each time and while she always shortened longer words, she produced almost all vowels correctly. However, she was only able to correctly use a few consonant sounds and was not able to produce enough longer words for the clinician to be able to judge her ability to use correct word stress. In the end, the speech-language pathologist determined that it was possible but unlikely that Mia had CAS. She recommended re-evaluation for a possible speech production disorder after Mia developed more speech and consistent ability to repeat words. The family and clinician also determined that changes were needed to Mia’s communication treatment plan given her recent lack of progress. The clinician recommended that therapy focus on strengthening her foundational communication skills, such as joint attention and engagement, rather than “drilling” words. The clinician also recommended practicing more signs and introducing a picture-based communication system to help her develop more language. They agreed to revisit the plan after three months to make sure Mia was making progress with the adjusted approach and to make further adjustments as needed.
Child 2: Craig
Craig is an 8-year-old boy, who was diagnosed with autism at age four. He was late to start talking, but with several years of intensive therapy, his language really took off. His parents have always had difficulty understanding his speech when he launches into a story or tries to say complex words, but they currently describe him as a “chatterbox.” Although Craig has gotten very good at acting things out or using gestures when people do not understand him, he also gets very frustrated when he is misunderstood. His previous therapist tried to work on articulation but stopped doing so because he would burst into tears, turn over furniture, and rip up papers when he was asked to repeat words or was given corrections. Should Craig be re-evaluated for CAS?
The speech-language pathologist and Craig’s family agreed that a speech evaluation would be a good idea. Up until now, the focus of Craig’s therapy was on developing his language skills. Now that his language has improved, the difficulty he is having with articulation is more apparent and it is causing him frustration. In the evaluation, the clinician used strategies to take some of the pressure off Craig and reduce his frustration (e.g., had him “teach” puppets how to say words, asked him to repeat made up words instead of real words, included lots of breaks, completed the evaluation over many short sessions). She also consulted with a behavioral therapist to find more ways for him to participate without becoming frustrated. The speech-language pathologist determined that there was clear evidence of CAS and devised a plan to work on speech while minimizing distress. The clinician decided to focus on practicing a small set of made-up words in short, play-based sessions. This way, Craig could still work on producing accurate speech movement gestures and imitating different word stress patterns, but without the frustration of being corrected on words he already “knew” how to say. The clinician worked with Craig’s teacher to find time to pop into the classroom to work on his speech goals for ten minutes per day, rather than pulling him out of the classroom for longer, potentially frustrating sessions. The team decided to monitor frustration levels and to re-evaluate his progress in a few months to make sure improvements were carrying over into his everyday speech.
Child 3: Andres
Andres is three-year-old boy who has difficulty talking. He did not say his first word until age 2 and his parents note that even as a 1-year-old, his babbling was more like the “ooo’s” and “ahhh’s” of a younger child. At three, his speech is always difficult to understand even for those who interact with him daily. He uses a few simple words (e.g., “da” for dad, “oh” for “no,” and “ee” for “eat”) and attempts to say other things but his sounds “get jumbled up.” He is very expressive and has clear intent to communicate. His parents describe him as a “busy guy;” it can be difficult to get him to sit still and follow directions. Andres was diagnosed with a “developmental delay” has been receiving speech therapy to help with his communication skills. His pediatrician suspects autism and refers him to a specialist.
It is always a good idea to consider all possible reasons why a child is having difficulty talking. Andres was late to begin talking and is still difficult to understand, but he does not show other warning signs that might indicate autism. Still, he saw a developmental pediatrician who ruled out autism after performing an evaluation. The doctor used tests like the Checklist for Autism Spectrum Disorder, which has been shown not to overdiagnosis autism among children who also have speech disorders (Tierney et al., 2015). Andres already receives therapy from a speech-language pathologist, but it is unclear if the therapist has experience with CAS. It would be a good idea to also complete a speech evaluation with a speech-language pathologist who has expertise in CAS to determine if a more specific diagnosis is appropriate. It is possible that when Andres started therapy, he was not talking enough for the therapist to evaluate him for a specific speech sound disorder. Now, Andres uses a few words without being prompted and tries to repeat words when asked. Although Andres has a high activity level, with the right approach, enough information should be able to be gathered from an evaluation to diagnose or rule out CAS.
As shown by the case examples, it is important for children to receive the correct diagnoses to receive appropriate, effective treatment. Treatment for both autism and speech disorders such as CAS work best when delivered early. However, children are never “too old” to receive an evaluation or a different type of treatment.
Mia’s case shows that it is normal for even highly experienced speech-language pathologists to recommend follow-up evaluation if there is not currently enough information to make a confident diagnosis. It is important to continue to work on these foundational communication skills and re-evaluate frequently.
On the other hand, Andres’s example highlights that even young children are able to be diagnosed with CAS if they can engage in assessment tasks and repeat words. Autism and speech and language disorders can present similarly in young children who are not yet talking very much. However, there are signs that qualified professionals can use to effectively tell them apart.
As seen in the case of Craig, autistic children can display the full range of speech disorder severity, just as children without autism. Although Craig had relatively mild CAS, it impacted his communication, caused frustration, and needed to be addressed in treatment. Few children respond to CAS treatment in the same ways, and clinicians may need to modify research-based treatment approaches given a child’s strengths and needs. Since there is very little research about how to treat CAS among children with autism, clinicians and families should pay close attention to whether improvements are being made and adjust the treatment plan as needed.