Psychosocial Effects of CAS in Adolescents and Adults

We know from a 2018 study by Rusiewicz et al, that parents of children with childhood apraxia of speech (CAS) are also concerned about areas other than speech including peer relationships, the need of the parent to be a voice for their children, the effects of CAS on daily activities, and the level of frustration they see in their child due to communication difficulties. These parental concerns continue as the child becomes older and their speech intelligibility improves, however, new comorbid concerns may become evident such as a language disorder or difficulties in skills such as reading, writing, or other academic areas. Psychosocial issues in children, teens, and adolescents in the areas of social withdrawal, behavior, mood, attention, anxiety, and depression due to persisting speech and language difficulties are reported in the literature (Cassar et al 2022; Lewis et al, 2021).

There are two recent studies looking at the psychosocial comorbidities in older children through adults who were diagnosed as a young child with severe speech and language disorders and childhood apraxia of speech. In one of the studies by Lewis et al, (2021), four groups of children were examined in their teens for psychosocial difficulties and the results were compared. The four groups included (1) adolescents diagnosed as a young child with CAS with or without a comorbid language disorder, (2) adolescents diagnosed as a young child with other types of speech sound disorders (SSD), (3) adolescents diagnosed as a young child with other SSD and a language impairment, and (4) adolescents without any speech or language diagnosis. The adolescents were administered several psychosocial tests that included self-ratings and parental ratings of inattention, hyperactivity, anxiety, depression, behavior, and mood, as well as tests of receptive and expressive language.

A higher number of adolescents with CAS displayed residual errors compared to the SSD group which was felt to impact the psychosocial scores. The issues that were self-reported or parent reported included depression, anxiety, social problems, thought problems, externalizing (aggressive behavior), internalizing problems, and inattention/ADHD. Although most teens with CAS did not score in the borderline/clinical range on the measures, their scores indicated a higher prevalence of psychosocial issues and ADHD than the SSD only and no speech and language diagnosis groups. There was little difference between the CAS group and the SSD plus a language impairment group. The authors found that within the CAS group, those with concurrent language impairment reported more psychosocial and attention issues. Having a receptive language disorder is hypothesized to impact social and pragmatic language which hinders social skill development. In addition, having poor communication skills as a young child interferes with the development of crucial social skills due to limited interaction and play with others. The literature has also reported higher incidences of depression and anxiety in adolescents when there is a concurrent language disorder.

The effects of CAS on the psychosocial disorders was found to change depending on the environment – at home, in school, with peers, with family, or in unfamiliar places. In addition, factors such as feelings of hope and positive supportive relationships with family members, school staff, and friends help lessen the effects on their psychosocial skills. The study recommends that the benefits of counseling for children impacted by severe and persistent SSD such as CAS and their families should be considered (Lewis et al, 2021).

The second study by Cassar et al (2022), conducted a survey of adults who self-reported a diagnosis of CAS as a child. The survey consisted of 4 parts: (1) demographic information and questions regarding their speech, therapy, and education, (2) completion of the Brief Fear of Negative Evaluation Scale – Revised (BFNE-R), (3) completion of The State-Trait Anxiety Inventory (STAI), and (4) collection of a single word and connected speech sample. 16 participants completed parts 1, 2, and 3 and six participants completed all four parts. When looking at the data collected, all but one participant reported they still had some issues with speech errors and 82% reported they avoided some speaking tasks such as talking on the phone, public speaking, reading out loud, and use of longer or more difficult words. Participants also reported that their speech difficulties impacted other parts of their life in the past and/or currently including social aspects, confidence, career path, and anxiety.

Results from the STAI indicated that individually, most (14 out of 16) participants reported elevated levels of state and trait anxiety compared to normative samples. On the BFNE-R, 11 out of 16 participants showed clinically significant fear of negative evaluation. Analysis of the speech samples that were collected from all six participants confirmed that there were speech errors consistent with a diagnosis of CAS including segmentation and stress errors as well as speech sound errors in production of single words and conversational speech. There were moderate to very strong negative correlations between the speech measures and the anxiety measures (STAI) meaning that as speech errors increased, so did levels of anxiety which would be expected based on reports of other speech disorders in adults such as stuttering.

Conclusions from this study indicate that while we need more research regarding the effects of CAS on the mental health of young children, adolescents, and adults, there is evidence that speech errors do often persist into adulthood and that there are often long term psychosocial effects. These authors have several recommendations. With the recent evidence supporting specific assessment and treatment protocols for CAS and more are currently underway, training needs to made available to graduate students and practicing speech-language pathologists (SLPs) so that children can be diagnosed earlier and receive appropriate treatment to reduce the persisting errors seen in adolescents and adults. Treatment needs to focus on connected speech to reduce the stress and segmentation errors seen in the current sample of adults. These recommendations will hopefully reduce the psychosocial effects. Most importantly, SLPs and parents will need to take a multidisciplinary approach to support the mental health of young children.

The takeaways from these recent articles are that children with CAS often continue to have lingering errors in their speech beyond elementary school. Severe CAS also impacts young children’s ability to interact with others in their environment which affects their development of social skills. These speech deficits can lead to psychosocial problems in older children and adolescents and even into adulthood. If there are comorbid issues such as language or literacy difficulties, the effect can be compounded. For parents, recommendations include:

1. Obtaining appropriate intervention as early as possible once CAS is suspected.
2. Talk to your child about their speech difficulties and mental health early on.
3. Instill confidence and hope by having supportive family members, friends, and school staff around them to reduce other negative emotions.
4. Consider counseling or therapy to help deal with any anxiety, depression, or social withdrawal to support their development.
5. Help increase awareness and understanding of your child’s struggles within their school/environment.
6. Make sure your child’s SLP has information and training on appropriate assessment and treatment of CAS.

Cassar, C., McCabe, P., & Cumming, S. (2022) “I still have issues with pronunciation of words”: A mixed methods investigation of the psychosocial and speech effects of childhood apraxia of speech in adults. International Journal of speech-Language Pathology. DOI: 10.1080/17549507.2021.2018496

Lewis, B.A., Benchek, P., Tag, J., Miller, G., Freebairn, L., Taylor, H.G., Iyengar, S.K., & Stein, C.M. (2021). Psychosocial Comorbidities in Adolescents with Histories of Childhood Apraxia of Speech. American Journal of speech-Language Pathology. 30, 2572-2588.

Rusiewicz, H.L., Maize, K., & Ptakowski, T. (2018) Parental experiences and perceptions related to childhood apraxia of speech: Focus on functional implications. International Journal of Speech-Language Pathology, 20:5, 569-580, DOI: 10.1080/17549507.2017.1359333