Early signs of Childhood Apraxia of Speech Under 3 years

This blog will focus on the early signs of Childhood Apraxia of Speech (CAS) to help parents and caregivers identify potential speech development concerns. Previously, we have covered the prevalence, causes, assessment, diagnosis, treatment, and the important role of Speech Therapists in managing CAS.

What to look for?

Understanding the early signs of Childhood Apraxia of Speech (CAS) is crucial for early diagnosis and treatment. Although no definitive diagnostic features distinguish Childhood Apraxia of Speech (CAS) from other speech sound disorders, professionals have reached a consensus on certain characteristics that indicate a problem with planning and executing speech movements.

• Inconsistent errors on vowels and consonants in repeated productions of syllables or words. For example, a child who says “ba” correctly the first time, then says “da” the second time, and then says “ba” again the third time. This inconsistency in producing the correct sound for the same syllable or word could suggest a deficit in the planning and execution of speech movements.
• Disrupted and lengthened coarticulatory transitions between syllables and sounds. For example, a child who is trying to say the word “spoon” but instead produces something like “s-puh…oo-n” with a noticeable pause between the “s” and “p” sounds and the vowel sound in the middle elongated. The disruption in the smooth transition between sounds can indicate difficulty with the motor planning and programming of the speech movements needed to produce the word correctly.
• Inappropriate prosody. An example of inappropriate prosody in a child with CAS could be a difficulty using the appropriate pitch, stress, or intonation patterns in their speech. For instance, a child with CAS may speak in a monotone voice or may emphasize the wrong words or syllables in a sentence.

It is important to note that these features are not necessarily exclusive to CAS but may also be present in other speech sounds or developmental language disorders.

Other Signs

Other characteristics reported in children with CAS include:

• Articulatory groping. For example, a child with CAS may repeatedly move their tongue around the mouth or make multiple attempts to produce a sound before finally achieving the intended sound. This groping behavior may be accompanied by visible effort, frustration, or tension in the face and neck muscles.
• Consonant distortions – refer to mispronunciation or errors in producing specific consonant sounds, such as substituting one consonant for another or altering the manner or place of articulation of a consonant sound. For example, a child with CAS may substitute a “t” sound for a “k” sound or produce a “b” sound with the lips instead of the vocal cords.
• Difficulty with smooth movement transitions. For example, a child with this difficulty may have trouble producing the sound /s/ and transitioning smoothly to the sound /t/ in a word like “stop,” resulting in a choppy or separated pronunciation of the two sounds.
• Increasing difficulty with longer or more complex syllables and word shapes. An example of increasing difficulty with longer or more complex syllables and word shapes in a child with CAS could be that they struggle to say “spaghetti” or “hippopotamus” correctly but can say simpler words like “cat” or “dog” without difficulty.
• Schwa additions/insertions- refer to the addition of a neutral vowel sound, called a schwa, between two consonants in a word. For example, a child with CAS might say “suh-puh-lie” instead of “supply,” inserting the schwa sound in between the “p” and “l” sounds.
• Slower than typical rate of speech
• Syllable segregation. For example, a child may say “ap-ple” instead of “apple,” or “but-ter-fly” instead of “butterfly.” This can make their speech sound choppy and difficult to understand.
• Voicing errors. Vowel errors in CAS may include:
  • Voicing errors are errors in which the voice is either turned on or off at the wrong time, producing an incorrect sound. An example of a voicing error is producing the voiceless “p” sound instead of the voiced “b” sound or vice versa.
  • Vowel errors. Vowel distortions: where the sound of the vowel is not produced correctly, such as producing an “uh” sound instead of “ah.”
  • Vowel substitutions: where one vowel is substituted for another, such as saying “bet” instead of “bat.”
  • Vowel omissions: where the vowel sound is left out of a word, such as saying “bt” instead of “bat.”
  • Vowel prolongations: where the vowel sound is held for too long, such as saying “baaaaaat” instead of “bat.”
  • Vowel repetitions: where the vowel sound is repeated, such as saying “ba-a-at” instead of “bat.”

However, it’s important to note that the existence of error patterns in a child’s speech doesn’t always point to a phonological issue; it could also indicate a motoric problem.

Co-occuring Problems

Children with CAS have a higher risk for problems in expressive language and phonological foundations for literacy. Co-occurring language and literacy problems may include:

• Delayed language development
• Expressive language problems
• Difficulty learning to read, spell and write
• Problems with social language/pragmatics

Co-occurring nonspeech sensory and motor problems may include:

• Limb apraxia
• Gross and fine motor delays
• Abnormal orosensory perception
• Motor clumsiness, oral apraxia
• Feeding difficulties

By recognizing the early signs of CAS, speech therapists can provide early intervention to improve outcomes for children with this disorder.

Identifying childhood apraxia of speech

Early signs of Childhood Apraxia of Speech (CAS) can be difficult to diagnose in children under three years of age due to various reasons. Firstly, developmental disabilities or comorbid conditions may be present, making identifying CAS as the primary diagnosis challenging. 

Additionally, a validated list of diagnostic features that differentiate CAS from other speech sound disorders does not exist. Some primary characteristics of CAS, such as word inconsistency and omission, may be characteristic of emerging speech in typically developing children under the age of 3 years. 

Furthermore, there may be a lack of sufficient speech sample size for making a definitive diagnosis, and it may be challenging to differentiate the inability from the unwillingness to provide a speech sample or attempt a speech target.

However, home video analyses have suggested that certain early indicators of CAS can be identified in children under the age of 3. These indicators may include reduced overall vocalizations, lower use of consonants, a less varied range of speech sounds, and delayed acquisition of consonants. Recent data also suggest that consonant development of children between birth and three years old who were diagnosed with CAS may differ from that of patients with other types of speech sound dysfunctions and those typically developing.

Here is an example video of patients with CAS

Despite these early indicators, SLP and physicians diagnose patients under three years old of age under a provisional diagnostic classification, for example, “CAS cannot totally rule out,” “signs are consistent with CAS condition,” or “suspicious to have CAS.” Therefore, it is essential to monitor a child’s speech development closely and seek professional help if there are concerns about their speech and language skills. Early intervention is crucial to support children with CAS in developing their speech and language skills and improving their overall quality of life.