What is childhood apraxia of speech

Childhood apraxia of speech is an uncommon motor speech disorder in which a child has difficulty making accurate movements when speaking ¹. Childhood apraxia of speech occurs in children and is present from birth. Childhood apraxia of speech is a neurological disorder that affects the brain pathways involved in planning the sequence of movements involved in producing speech. The brain knows what it wants to say, but cannot properly plan and sequence the required speech sound movements. In childhood apraxia of speech, the brain struggles to develop plans for speech movement. With this disorder, the speech muscles (the muscles of the jaw, tongue, or lips) aren’t weak, but they don’t perform normally because the brain has difficulty directing or coordinating the movements. [Note: Weakness or paralysis of the speech muscles results in a separate speech disorder, known as dysarthria.]

Apraxia of speech is sometimes called verbal apraxia, developmental apraxia of speech, or verbal dyspraxia. No matter what name is used, the most important concept is the root word “praxis.” Praxis means planned movement. To some degree or another, a child with the diagnosis of apraxia of speech has difficulty programming and planning speech movements. Apraxia of speech is a specific speech disorder. This difficulty in planning speech movements is the hallmark or “signature” of childhood apraxia of speech.

To speak correctly, your child’s brain has to learn how to make plans that tell his or her speech muscles how to move the lips, jaw and tongue in ways that result in accurate sounds and words spoken with normal speed and rhythm. For reasons not yet fully understood, children with apraxia of speech have great difficulty planning and producing the precise, highly refined and specific series of movements of the tongue, lips, jaw and palate that are necessary for intelligible speech.

Top Three Characteristics of Childhood Apraxia of Speech

The top three characteristics of Childhood Apraxia of Speech, as reported by the American Speech-Language-Hearing Association Technical Report ² on Childhood Apraxia of Speech, that can help the speech-language pathologist make a differential diagnosis are:

1. Inconsistent errors with consonants and vowels on repeated productions of syllables and words (your child says the same word in different ways when asked to repeat it several times. This might be more apparent in new words or longer more complex words.)
2. Difficulty moving from sound to sound or syllable to syllable, resulting in lengthened pauses between sounds and/or syllables
3. Inappropriate stress on syllables or words (such as all syllables are said with equal stress on each one causing the “melody” of speech to sound odd)

Other Possible Symptoms of Childhood Apraxia of Speech

Other possible signs of apraxia of speech are:

• Increased mistakes in longer or more difficult and complex syllables and words.
• Reduced vowel inventory (the number and assortment of vowel sounds that your child can produce), or errors when producing vowels, and
• Possible “groping” behaviors in which your child appears to struggle to achieve the correct oral posture to start or produce the syllable or word. (Not all children exhibit this at all times or situations. If your child does not demonstrate groping of their speech musculature, that alone is not enough to rule out apraxia of speech.)

Childhood apraxia of speech appears to be more common in boys than girls ³. Children with this condition have difficulty planning and producing the precise, refined, and specific movements of the tongue, lips, jaw, and palate that are necessary for intelligible speech ⁴. In many cases, the underlying cause of childhood apraxia of speech is unknown (idiopathic) ⁵. Some cases are associated with a known neurological cause (such as intrauterine or early childhood stroke, infection, trauma, brain cancer or tumor resection, traumatic brain injury, etc.), and other cases occur as part of a complex neurobehavioral disorder (such as autism, epilepsy, fragile X syndrome, galactosemia, Rett syndrome, Prader-Willi syndrome or certain types of chromosome abnormalities) ³. In some cases, researchers have found alterations (mutations) in the FOXP2 gene or loss of genetic material involving this gene ⁶.

Incidence of childhood apraxia of speech refers to the number of new cases identified in a specified time period. Prevalence of childhood apraxia of speech refers to the number of people who are living with the condition in a given time period. Efforts to determine epidemiologically sound estimates of the incidence and prevalence of childhood apraxia of speech have been hindered by a number of factors, including a lack of clear and consistent diagnostic guidelines (Shriberg, Aram, & Kwiatkowski, 1997) and adequately validated diagnostic tools (McCauley & Strand, 2008). These same factors may also play a role in the frequent overidentification of childhood apraxia of speech by clinicians (Davis, Jakielski, & Marquardt, 1998; Shriberg & McSweeney, 2002).

A population estimate based on clinical referral data suggests that childhood apraxia of speech occurs in 1-2 children per 1,000 ⁷ and is found in 3.4%-4.3% of the children referred for speech disorders ⁸. On average, idiopathic childhood apraxia of speech affects more boys than girls by a ratio of 2 or 3:1 ⁹. Higher prevalence rates have also been reported with certain medical conditions, such as galactosemia and fragile X syndrome ¹⁰.

Treatment of childhood apraxia of speech involves speech therapy with a speech-language pathologist. Those with more severe cases will require more therapy than those with mild cases ¹¹. The goal of therapy is to increase speech production and intelligibility. In some cases, augmentative and alternative forms of communication may be needed ¹².

What Kind of Help Will My Child Need?

Children who receive an apraxia of speech diagnosis should begin speech therapy with a speech-language pathologist, preferably one that has had previous experience and success in treating apraxia. Exactly how often the child should have speech therapy will vary according to the individual needs of each child. Children with speech-language pathologist who have severely unclear or little speech and are more severely affected will require more therapy than those who have milder apraxia.

How Does Speech Happen?

The act of speech begins with an intention to communicate. Next, an idea forms, outlining what the speaker wants to say. The words for the desired message are put in the correct order, using the correct grammar. Each word contains a specific sequence of sounds (also called phonemes) and syllables that must be correctly ordered together. All of this information is translated from an idea and information about order of sounds and syllables into a series of highly coordinated motor movements of the lips, tongue, jaw, and soft palate.

The brain must tell the muscles of these “articulators” the exact order and timing of movements so that the words in the message are properly pronounced. Finally, the muscles themselves must work properly with enough strength and muscle tone to perform the movements needed for speech. Amazingly, all of this happens in the blink of an eye.

When speech is developing in a normal way, children make word attempts and get feedback from people around them and from their own internal sensory systems regarding how “well” the words they produced matched the ones that they wanted to produce. Children use this information the next time they attempt the words and essentially are able to “learn from experience.” Usually once syllables and words are spoken repeatedly, the speech motor act becomes automatic and less effortful. The child doesn’t have to think about how to say the word or phrase they want to say. At this point, speech motor plans and programs are stored in the brain and can be quickly accessed and put together effortlessly when they are needed. Children with apraxia of speech have the most difficulty in this aspect of speech. It is believed that children with childhood apraxia of speech may not be able to form or reliably access speech motor plans and programs or that these plans and programs are faulty for some reason. Unlike children developing typical speech, speech motor plans and programs for children with childhood apraxia of speech fail to become automatic and easily accessed when they wish to speak.

Recent research also suggests that, to some degree or another, the sensory feedback loops needed for learning and acquiring accurate speech may not work well in children with apraxia of speech. There are several forms of feedback children use to learn speech and the complex series of movements underlying it. First, children use auditory information (through their hearing system) to judge whether their word attempt was correct. Researchers believe that the child’s speech processing system “couples” (or ties together) an auditory event – what they hear themselves say – with the movements of the oral structures needed to produce an utterance. Secondly, sensory feedback called proprioception is used so that the child knows where speech structures like lips, jaw, tongue, palate are physically located and how they relate spatially to one another during speech movement. So, for example, during speech attempts the child may not be aware of where their tongue is within the oral cavity or how its position relates to other structures like the lips. Sensory feedback is especially important during the learning of motor plans such as in early speech learning or speech acquisition. If these two feedback mechanisms are not working properly, speech intelligibility is affected.

How Is childhood apraxia of speech Different Than A Speech Delay?

A true developmental delay of speech is when the child is following the “typical” path of childhood speech development, although at a rate slower than normal. Usually this rate is also in pace with the child’s cognitive skills. In typical speech/language development, the child’s receptive and expressive skills increase together to a large extent. What is often seen in a child with apraxia of speech is a wide gap between their receptive language abilities and expressive abilities. In other words, the child’s ability to understand language (receptive ability) is broadly within normal limits, but his or her ability to use expressive language through speech is seriously deficient, absent, or severely unclear. This is an important factor and one indicator that the child may be experiencing more than “delayed” speech. In the case of such a mismatch in skills, the child should be evaluated for the presence of a specific speech disorder such as apraxia. However, certain language disorders may also cause a similar pattern in a child. A gap between a child’s expressive and receptive language ability is not sufficient to diagnose apraxia, in and of itself. And to complicate matters further, some children with apraxia of speech do have both reduced expressive language AND reduced receptive language.

At What Age Can A Child Be Diagnosed With childhood apraxia of speech?

It is not often possible for speech-language pathologist’s to provide a differential diagnosis for a child under two years old. That is because most children under age two do not have the ability to understand specific directions for tasks that would be critical to making the diagnosis. Or the child may be unable to cooperate or pay attention to the extent that they would need to do so in order for a differential diagnosis. Children between ages 2 – 3 may also be difficult to firmly diagnose with childhood apraxia of speech. Some can and some cannot. There is no strict age as to when a child can be diagnosed with childhood apraxia of speech. The most important thing is that the child is able to fully participate in the tasks required by the speech-language pathologist who is evaluating them. Equally important is that the speech-language pathologist understands appropriate diagnosis techniques and the core characteristics that differentiate childhood apraxia of speech from other types of speech problems. Regardless, the disorder can be “suspected” and early help can and should begin. Often, a few months of “diagnostic therapy” can help to determine if childhood apraxia of speech is the main issue that is causing a child to have difficulty speaking.

Overall, while it is possible to determine that a child’s speech is not developing in the same way or at the same rate as other children and to suspect childhood apraxia of speech, in very young children it is often not possible to clearly state that the reason is due to an apraxia of speech, excluding other speech disorders or causes. However, it is possible to institute speech therapy when a problem is suspected. Early intervention is very important to children with speech and language disorders.

Childhood apraxia of speech prognosis

The question of how one’s child will do over time and if he or she will speak normally is perhaps the biggest question of all for parents of children with childhood apraxia of speech. While there are no hard and fast statistics, professional articles and experienced speech-language pathologists report that most children with childhood apraxia of speech, with appropriate help, eventually learn to speak clearly. Some children may have some minor differences in their speech patterns, such as less than crisp /r/ sounds or slightly “off” vowels. In some children, their intonation may not be perfect or others may perceive some sort of accent. However, most children will speak in a way that others understand. Some children progress to the point that no one would be able to tell that at one time they had a significant speech problem. A few children, despite the best efforts of all, may not develop into primarily verbal communicators. These children will also make progress but may need augmentative or alternative methods for the long term to help them communicate.

There are a number of factors that are likely to influence progress for children with childhood apraxia of speech. Some of these factors are:

• The severity of the problem
• The existence or co-occurrence of other disorders or problems, such as other speech or language diagnoses, poor health, attention issues, and cognitive problems
• The age at which the child began appropriate intervention
• The child’s ability or opportunity to practice speech outside of direct therapy time
• The child’s intent to communicate and willingness to make speech attempts

Each child is different in his or her communication strengths and weaknesses and so it is not possible to predict for sure the extent or degree of language related problems. Anecdotally and in some published research, very few children with childhood apraxia of speech have “pure” apraxia of speech with no other language or communication difficulties. Talented speech-language pathologists can often weave goals together so that your child with apraxia is receiving intensive speech practice while also building other expressive and receptive language skills.

Although research is needed, it may be that childhood apraxia of speech which is associated with genetic, metabolic, or neurological conditions may be more challenging than for children that have childhood apraxia of speech for unknown reasons (idiopathic childhood apraxia of speech). It does appear that each issue, in addition to childhood apraxia of speech, and which is layered over top of it contributes to more uncertain progress and long-term outcome. There is much to learn and research is needed to identify children who are most in need of help and those who are likely to need long term communication support.

No one can totally predict the child’s ultimate success at becoming a verbal communicator. Thus, be wary if you are told that your child will never learn to speak or conversely that it won’t be long until your child is speaking perfectly. The act of learning to speak clearly is typically long and challenging for children with truly do have apraxia of speech, but they can and do make great strides and much progress with speech therapy appropriate to their needs. With appropriate help, there are many reasons to be hopeful!

It is important for parents to understand and support their child with apraxia in all of the speech and language areas in which there may be weakness. Even though what you may notice most is that your child with apraxia struggles so much just to get a thought or idea across or even to utter a single word, it is important to fully embrace that the child may also need speech therapy help for other aspects of the process of effective communication.

Childhood apraxia of speech complications

Many children with childhood apraxia of speech have other problems that affect their ability to communicate. These problems aren’t due to childhood apraxia of speech, but they may be seen along with childhood apraxia of speech.

Symptoms or problems that are often present along with childhood apraxia of speech include:

• Delayed language, such as difficulty understanding speech, reduced vocabulary, or difficulty using correct grammar when putting words together in a phrase or sentence
• Delays in intellectual and motor development and problems with reading, spelling and writing
• Difficulties with gross and fine motor movement skills or coordination
• Hypersensitivity, in which the child may not like some textures in clothing or the texture of certain foods, or the child may not like tooth brushing.

Childhood apraxia of speech causes

Childhood apraxia of speech has a number of possible causes, but in many cases a cause can’t be determined. Doctors often don’t observe a problem in the brain of a child with childhood apraxia of speech.

Childhood apraxia of speech can be congenital (present at birth) or it can be acquired during speech development. Both congenital and acquired onsets can be idiopathic (unknown cause) or can occur in the context of complex neurodevelopmental disorders or in association with a neurological event ⁷. The neurologic deficits underlying childhood apraxia of speech are different from those that underlie dysarthria.

Childhood apraxia of speech may be the result of brain (neurological) conditions or injury, such as a stroke, infections or traumatic brain injury.

Childhood apraxia of speech may also occur as a symptom of a genetic disorder, syndrome or metabolic condition. For example, childhood apraxia of speech occurs more frequently in children with galactosemia.

Childhood apraxia of speech is sometimes referred to as developmental apraxia. However, children with childhood apraxia of speech don’t necessarily grow out of childhood apraxia of speech as they develop. In many children with delayed speech or developmental disorders, children follow usual patterns in development of speech and sounds, but they develop more slowly than usual.

Children with childhood apraxia of speech don’t make typical developmental sound errors. They need speech therapy to make maximum progress.

Childhood apraxia of speech, as defined in American Speech-Language-Hearing Association can occur ¹³:

• in association with known neurological causes (e.g., intrauterine or early childhood stroke, infection, trauma, brain cancer/tumor resection) ¹⁴;
• as primary or secondary signs within complex neurobehavioral disorders (e.g., autism, epilepsy, and syndromes, such as fragile X, Rett syndrome, and Prader-Willi syndrome) ¹⁵;
• as an idiopathic neurogenic speech sound disorder (i.e., children with no observable neurologic abnormalities or neurobehavioral disorders or conditions).

A number of researchers have investigated possible genetic bases for childhood apraxia of speech. Of particular interest are findings from studies of the KE family, many of whose members have apraxia of speech. These findings suggest that deficits in the FOXP2 gene may negatively affect the development of neural networks involved in the learning and/or planning and execution of speech motor sequences ¹⁶, ¹⁷.

Risk factors for childhood apraxia of speech

Abnormalities in the FOXP2 gene appear to increase the risk of childhood apraxia of speech (childhood apraxia of speech) and other speech and language disorders. The FOXP2 gene may be involved in how certain nerves and pathways in the brain develop.

Researchers continue to study how abnormalities in the FOXP2 gene may affect motor coordination and speech and language processing in the brain.

Childhood apraxia of speech prevention

Diagnosing and treating childhood apraxia of speech at an early stage may reduce the risk of long-term persistence of the problem. If your child experiences speech problems, it’s a good idea to have a speech-language pathologist evaluate your child as soon as you notice any speech problems.

Childhood apraxia of speech symptoms

Currently, there is no validated list of diagnostic features differentiating childhood apraxia of speech from other childhood speech sound disorders, including those due to phonological-level delay or neuromuscular disorder (dysarthria).

Children with childhood apraxia of speech may have many speech symptoms or characteristics that vary depending on their age and the severity of their speech problems.

Childhood apraxia of speech can be associated with delayed onset of first words, a limited number of spoken words, or the ability to form only a few consonant or vowel sounds. These symptoms usually may be noticed between ages 18 months and 2 years, and may indicate suspected childhood apraxia of speech.

As children produce more speech, usually between ages 2 and 4, characteristics that likely indicate childhood apraxia of speech include vowel and consonant distortions; separation of syllables in or between words; and voicing errors, such as “pie” sounding like “bye.”

Many children with childhood apraxia of speech have difficulty getting their jaws, lips and tongues to the correct position to make a sound, and they may have difficulty moving smoothly to the next sound.

Many children with childhood apraxia of speech also have language problems, such as reduced vocabulary or difficulty with word order.

Some symptoms may primarily be seen in children with childhood apraxia of speech and can be helpful to diagnose the problem.

However, some symptoms of childhood apraxia of speech are also symptoms of other types of speech or language disorders. It’s difficult to diagnose childhood apraxia of speech if a child has only symptoms that are found in both childhood apraxia of speech and in other types of speech or language disorders.

The current knowledge that scientists have about childhood apraxia of speech is this.

Childhood Apraxia of Speech may occur in the following 3 conditions:

• Neurological impairment caused by infection, illness or injury, before, during or after birth. This category includes children with positive findings on MRI’s (scans) of the brain, or those with brain injury or trauma, etc.
• Complex Neurodevelopmental Disorders – We know that childhood apraxia of speech can occur as a secondary characteristic of other conditions such as genetic, metabolic, and/or mitochondrial disorders. In this category would be Childhood Apraxia of Speech that occurs with Autism, Fragile X, Galactosemia, some forms of Epilepsy, and some types of chromosome translocations, duplications and/or deletions (genetic conditions). There are quite a few disorders in which childhood apraxia of speech can arise, but that does not mean that all children with these disorders also have childhood apraxia of speech. For example, many children with Galactosemia have a speech problem, and out of those children, only some of them have childhood apraxia of speech. Only some children with autism also have childhood apraxia of speech. Only some children with epilepsy have childhood apraxia of speech and so forth.
• Idiopathic Speech Disorder (a disorder of “unknown” origin) – with this condition, we currently don’t know “why” the child has apraxia of speech. Children do not have observable neurological abnormalities or easily detected neurodevelopmental conditions.

Some speculate that childhood apraxia of speech and other childhood conditions may be a result, in part, of environmental conditions such as exposure to pollutants and toxins before or after birth. Others speculate that nutritional deficits or malabsorbtions cause childhood apraxia of speech. While toxins and nutritional deficits do cause some developmental problems, to date these theories, as they relate specifically to childhood apraxia of speech, are only speculations with no research evidence to support them.

That said, a child’s positive health will contribute to their ability to benefit from their learning exposures every day and from therapy designed to help them. A child who is healthy is more fully capable of taking advantage of opportunities to learn. Children who are sick frequently with ear and sinus infections, enlarged tonsils and adenoids, asthma, allergies or have sleep disturbances, attention and behavioral difficulties are going to find it much more difficult to benefit from the help provided. Helping your child be healthy and thus more “present” and available to the learning opportunities around them is one important way parents can help.

Most likely in the future scientists will learn that childhood apraxia of speech is caused by multiple factors and conditions, not one. To the extent that research evidence becomes available that childhood apraxia of speech is caused by some factor that can be manipulated to reduce or eliminate it, will determine whether or not it is preventable. Until then, scientists do know one very critical thing – that appropriate speech therapy, tailored to the difficulty of speech motor planning and provided frequently, is the single most important opportunity for children with childhood apraxia of speech to improve their speech capacity. Children who are able to maintain optimum health will most likely directly benefit the most from appropriate help.

More recently, three segmental and suprasegmental features consistent with a deficit in the planning and programming of movements for speech have gained some consensus among those investigating childhood apraxia of speech ¹⁸:

• Inconsistent errors on consonants and vowels in repeated productions of syllables or words,
• Lengthened and disrupted coarticulatory transitions between sounds and syllables,
• Inappropriate prosody, especially in the realization of lexical or phrasal stress.

Importantly, these features are not proposed to be the necessary and sufficient signs of childhood apraxia of speech ¹³. The frequency of these and other signs may change depending on task complexity, the age of the child, and the severity of symptoms ¹⁹.

Some characteristics, sometimes called markers, help distinguish childhood apraxia of speech from other types of speech disorders. Those particularly associated with childhood apraxia of speech include:

• Difficulty moving smoothly from one sound, syllable or word to another;
• Groping movements with the jaw, lips or tongue to make the correct movement for speech sounds;
• Vowel distortions, such as attempting to use the correct vowel, but saying it incorrectly;
• Using the wrong stress in a word, such as pronouncing “banana” as “BUH-nan-uh” instead of “buh-NAN-uh”;
• Using equal emphasis on all syllables, such as saying “BUH-NAN-UH”;
• Separation of syllables, such as putting a pause or gap between syllables;
• Inconsistency, such as making different errors when trying to say the same word a second time;
• Difficulty imitating simple words;
• Inconsistent voicing errors, such as saying “down” instead of “town,” or “zoo” instead of “Sue”;
• Limited consonant and vowel phonetic inventory in young children;
• Frequent sound distortions and distorted consonant substitutions;
• Initial consonant deletions;
• Voicing errors;
• Schwa additions/insertions to consonant clusters, within words and on the ends of words;
• Predominant use of simple syllable shapes;
• Greater ease in producing automatic (e.g., frequently used phrases, such as “I love you”) versus volitional utterances (e.g., novel phrase or sentence);
• Difficulty with smooth, accurate movement gestures;
• Better performance on speaking tasks that require single postures versus sequences of postures (e.g., single sounds such as [a] vs. words such as [mama]);
• Difficulty achieving accurate articulatory movement gestures when trying to imitate words not yet mastered;
• Presence of groping behaviors when attempting to produce speech sounds or coordinate articulators for purposeful movement;
• Altered and/or inconsistent suprasegmental characteristics (rate, pitch, loudness);
• Increased difficulty with longer or more complex syllable and word shapes (often resulting in omissions, including word-initial consonant deletion);
• Predominant errors of consonant, vowel, syllable, and/or word omissions;
• Atypical levels of regression (e.g., words or sounds mastered, then lost);
• Sequencing errors affecting sounds (e.g., metathesis, migration), syllables, morphemes, or words.

The presence of error patterns in the child’s speech does not indicate a phonological rather than motoric problem. Many patterns can have either linguistic or motoric bases. For example, a child may consistently reduce consonant clusters either because of lack of understanding of the phonological rule or because of a motoric inability to sequence consonants.

Other characteristics are seen in most children with speech or language problems and aren’t helpful in distinguishing childhood apraxia of speech. Characteristics seen in both children with childhood apraxia of speech and in children with other types of speech or language disorders include:

• Reduced amount of babbling or vocal sounds from ages 7 to 12 months old
• Speaking first words late (after ages 12 to 18 months old)
• Using a limited number of consonants and vowels
• Frequently leaving out (omitting) sounds
• Difficult to understand speech

Co-Occurring Characteristics/Symptoms

The behavioral features reportedly associated with childhood apraxia of speech place a child at increased risk for problems in expressive language and weakness in the phonological foundations for literacy ²⁰. These problems may reflect the consequences of childhood apraxia of speech, nonrelated co-occurring problems (e.g., learning disabilities and attentional difficulties), or even the effects of compensatory strategy use and include:

• delayed language development;
• expressive language problems, like word order confusion and grammatical errors;
• problems when learning to read, spell, and write (literacy);
• problems with social language/pragmatics.

Nonspeech sensory and motor problems include:

• gross and fine motor delays;
• motor clumsiness, oral apraxia;
• limb apraxia;
• feeding difficulties;
• abnormal orosensory perception (hyper- or hyposensitivity in the oral area).

Other speech disorders sometimes confused with childhood apraxia of speech

Some speech sound disorders often get confused with childhood apraxia of speech because some of the characteristics may overlap. These speech sound disorders include articulation disorders, phonologic disorders and dysarthria.

A child who has trouble learning how to make specific sounds, but doesn’t have trouble planning or coordinating the movements to speak, may have an articulation or phonologic disorder. Articulation and phonologic disorders are more common than childhood apraxia of speech.

Articulation or phonologic speech errors may include:

• Substituting sounds, such as saying “fum” instead of “thumb,” “wabbit” instead of “rabbit” or “tup” instead of “cup”
• Leaving out (omitting) final consonants, such as saying “duh” instead of “duck” or “uh” instead of “up”
• Stopping the airstream, such as saying “tun” instead of “sun” or “doo” instead of “zoo”
• Simplifying sound combinations, such as saying “ting” instead of “string” or “fog” instead of “frog”

Dysarthria is a motor speech disorder that is due to weakness, spasticity or inability to control the speech muscles. Making speech sounds is difficult because the speech muscles can’t move as far, as quickly or as strongly as normal. People with dysarthria may also have a hoarse, soft or even strained voice, or slurred or slow speech.

Dysarthria is often easier to identify than childhood apraxia of speech. However, when dysarthria is caused by damage to certain areas of the brain that affect coordination, it can be difficult to determine the differences between childhood apraxia of speech and dysarthria.

Childhood apraxia of speech diagnosis

To evaluate your child’s condition, your child’s speech-language pathologist will review your child’s symptoms and medical history, conduct an examination of the muscles used for speech, and examine how your child produces speech sounds, words and phrases.

Your child’s speech-language pathologist will also assess your child’s language skills, such as his or her vocabulary, sentence structure and ability to understand speech.

Diagnosis of childhood apraxia of speech isn’t based on any single test or observation. It depends on the pattern of problems that are seen. The specific tests conducted during the evaluation will depend on your child’s age, ability to cooperate and the severity of the speech problem.

It can sometimes be difficult to diagnose childhood apraxia of speech, especially when a child speaks very little or has difficulty interacting with the speech-language pathologist.

It’s important to identify whether your child shows symptoms of childhood apraxia of speech, because childhood apraxia of speech is treated differently from other speech disorders. Your child’s speech-language pathologist often may be able to determine an appropriate treatment approach for your child, even if the diagnosis is initially uncertain.

Tests may include:

• Hearing tests. Your doctor may order hearing tests to determine if hearing problems could be contributing to your child’s speech problems.
• Oral-motor assessment. Your child’s speech-language pathologist will examine your child’s lips, tongue, jaw and palate for structural problems, such as tongue-tie or a cleft palate, or other problems, such as low muscle tone. Low muscle tone usually isn’t associated with childhood apraxia of speech, but it may be a sign of other conditions. Your child’s speech-language pathologist will observe how your child moves his or her lips, tongue and jaw in activities such as blowing, smiling, and kissing.
• Speech evaluation. Your child’s ability to say sounds, words and sentences will be observed during play or other activities. Your child may be asked to name pictures to see if he or she has difficulty making specific sounds or speaking certain words or syllables. Your child’s speech-language pathologist may evaluate your child’s coordination and smoothness of movement in speech during speech tasks. To evaluate your child’s coordination of movement in speech, your child may be asked to repeat syllables such as “pa-ta-ka” or say words such as “buttercup.” If your child can produce sentences, your child’s speech-language pathologist will observe your child’s melody and rhythm of speech, such as how he or she stresses syllables and words. Your child’s speech-language pathologist may help your child be more accurate by providing cues, such as saying the word or sound more slowly or providing touch cues to his or her face.

Why is accurate childhood apraxia of speech diagnosis important?

childhood apraxia of speech is considered to be a “low” prevalence speech disorder in children. In fact, researchers and professionals believe childhood apraxia of speech is a rare speech disorder. That means that out of all children with speech problems, few have childhood apraxia of speech. It also means that other types of speech problems are much more likely in children than is childhood apraxia of speech. Research in this area has been limited, but there are estimates that on a “typical” speech-language pathologists caseload of preschool children with speech sound disorders, only 3 – 5% of them would likely have apraxia of speech. Highly experienced speech-language pathologists, that gain a reputation for providing excellent evaluation and treatment, would obviously have a larger proportion of children on their caseload with childhood apraxia of speech than is typical. Because it is so important to match a speech therapy approach to the nature of the child’s speech difficulty, misdiagnosis can prevent children from receiving the help that they really need.

Unfortunately, research has determined that childhood apraxia of speech can be over diagnosed. Children – some of them extremely young – are given the diagnosis even though a thorough speech evaluation has not yet been possible. Sometimes, due to a lack of experience with childhood apraxia of speech, the professional may not fully grasp what should be involved in assessment and in distinguishing apraxia from other speech problems. Misdiagnosis causes parents to have unnecessary worry, fear, and stress. Firm diagnosis should not be made in extremely young children or children who are unable to give an adequate speech sample or cooperate and understand the tasks being asked of them in an evaluation. In recent years, the term suspected childhood apraxia of speech is used to identify a child who potentially has this speech problem and should be carefully watched and so helpful therapy can begin.

Some research also indicates that the apraxia of speech diagnosis is often “missed” in children who really do have it! This is also not a good situation. The speech therapy treatment for childhood apraxia of speech is different than it is for most other speech disorders or speech delay. In addition to the speech therapy methods being different, children with apraxia of speech, at least for some period of time, require more speech therapy than children with other speech problems in order to improve their speaking ability. Without proper diagnosis, children are at risk of not receiving adequate and appropriate help.

Parents who are concerned with their child’s speech and language development should first try to seek help from the child’s pediatrician. Keeping a written record of concerns that can be discussed at an office visit can be very helpful. Parents can request that the child be referred for a comprehensive speech and language evaluation. At times, parents may have to be assertive about getting a referral to speech and language evaluation by a qualified speech-language pathologist. Be persistent and do not give up! Your child’s pediatrician has a responsibility to monitor and supervise your child’s development in all areas, including speech and language. A good pediatrician will also listen and respond to a parent’s concern for their child’s development. If your child is not developing as expected, your pediatrician should assist you in arranging for or referring to an appropriate professional or specialist.

Childhood apraxia of speech treatment

Speech-language pathologists may treat childhood apraxia of speech (childhood apraxia of speech) with many therapies.

Childhood apraxia of speech is a motor speech disorder, which involves a difficulty or inability to plan and program the rapid sequence and timing of movements needed to produce speech that can be understood by others. Facial and oral structures such as the lips, tongue, soft palate, jaw and vocal folds – and the muscles that move these structures – need to be activated and move at just the right time, in just the right order, and with just the right force so that the words your child intends to say are produced accurately.

Because the main problem of childhood apraxia of speech is speech motor planning and programming, a speech therapy approach needs to focus on the actual movement of speech structures and muscles during speech attempts (Note: the important words here are movement during speech attempts). The approach used by the therapist should aid the child in producing clearer and more accurate words, phrases, and sentences.

Because speech is a series of movements, we can use ideas in speech therapy that, more generally, help people to acquire skill in learning movement! How do people best learn to shoot a basketball and score? How do people learn to hit a golf ball with a golf club and have the ball go in the hole? How to people learn to ride a bike? How do all of these motor skills become automatic so one doesn’t have to even think much about doing them well? How does “motor learning” occur?

There is a complete and large body of research evidence on how motor learning occurs in people. The principles and theories from this research have been applied to speech motor learning, too, and form the base of ideas that are incorporated into appropriate speech therapy for children with childhood apraxia of speech. More research is needed specifically in childhood apraxia of speech, but experts have used “Principles of Motor Learning” as a common understanding of how to treat Childhood Apraxia of Speech. Thus, there are a number of features of speech therapy that appear to be most successful for children with apraxia of speech, regardless of the name of a particular method. These features include:

Speech therapy

Your child’s speech-language pathologist will usually provide therapy that focuses on practicing syllables, words and phrases. When childhood apraxia of speech is relatively severe, your child may need frequent speech therapy, three to five times a week. As your child improves, the frequency of speech therapy may be reduced.

Children with childhood apraxia of speech generally benefit from individual therapy. Individual therapy allows your child to have more time to practice speech during each session.

Typically, experienced speech-language pathologists will suggest that a child with moderate to severe apraxia of speech have 3 – 5 times a week of individual speech therapy. The American Speech Language Hearing Association ²¹, the professional organization representing speech, language and hearing professionals, has agreed with this in its position paper on childhood apraxia of speech.

However, there ARE other considerations for the amount and frequency of speech therapy for a child with childhood apraxia of speech:

• The extent to which the child will practice at home with their parents or caregivers;
• How much the child can individually tolerate;
• How frequently the parents can bring their child to speech therapy, etc.
• The presence of other speech and/or language difficulties

It’s important that children with childhood apraxia of speech get a significant amount of practice saying words and phrases during each speech therapy session. Learning to say words or phrases takes children with childhood apraxia of speech time and practice.

Because children with childhood apraxia of speech have difficulties planning movements for speech, speech therapy often focuses your child’s attention to the sound and feel of speech movements.

As a child begins to make progress in their ability to produce speech that is understood by others, the amount and frequency of therapy can be adjusted accordingly. As speech gets clearer and more abundant, therapy time can be gradually reduced. As a child’s speech moves from severely affected to moderately affected to mildly affected, the amount of speech therapy time targeting the apraxia can be gradually reduced.

Speech-language pathologists may use different types of cues in speech therapy. For example, your child’s speech-language pathologist may ask your child to listen carefully and watch him or her form the target word or phrase with his or her mouth.

Your child’s speech-language pathologist also may touch your child’s face as he or she makes certain sounds or syllables. For example, your child’s speech-language pathologist may use his or her hands to help your child round his or her lips to say “oo.”

No single speech therapy approach has been shown to be most effective for treating childhood apraxia of speech, but some important general principles of speech therapy for childhood apraxia of speech include:

• Your child’s speech-language therapist will focus on speech drills, such as asking your child to say words or phrases many times during a therapy session.
• Your child will be asked to listen to the speech-language pathologist and to watch his or her mouth as he or she says the target word or phrase. By watching the speech-language pathologist’s mouth, your child also sees the movements that go along with the sounds.
• Your child will most likely practice syllables, words or phrases, rather than isolated sounds, during speech therapy. Children with childhood apraxia of speech need practice making the movements from one sound to another.
• Because many children with childhood apraxia of speech distort vowel sounds, your child’s speech-language pathologist may choose words for your child to practice that contain vowels in different types of syllables. For example, your child may be asked to say “hi,” “mine” and “bite,” or “out,” “down” and “house.”
• If your child has severe childhood apraxia of speech, your child’s speech-language pathologist may use a small set of practice words at first, and gradually increase the number of words for practice as your child improves.

Practice and repetition – with speech.

Speech therapy for children with apraxia will include a high degree of practice and repetition. Research shows that therapy for children with apraxia of speech is more effective when the speech targets (words, phrases) are practiced with a greater degree of frequency and intensity. Children in appropriate speech therapy will be attempting syllables, words and phrases many, many times during each session while the speech-language pathologist works to shape their speech attempts, and the movements underlying them, into speech that is more accurate.

Parents and caregivers will be asked to help the child practice in real life, outside of speech therapy. Intensity (practicing a lot) and frequency (practicing often) are key concepts in speech motor learning. It is for this reason, especially in the early phases of therapy, that children with apraxia should have individual speech therapy. While group speech therapy may be appropriate in addition to frequent individual therapy, children with childhood apraxia of speech that have little speech or significantly unclear speech are not likely to make the gains they are capable of making with just group therapy.

[Special note: According to current research, spending valuable therapy time on non-speech movements (for example, blowing bubbles, licking peanut butter, tongue exercises, etc.) is not supported as effective in improving speech production. Such practices have been under scrutiny in the field of speech-language pathology for some time now. While there is no research to support the use of such procedures, some professionals do believe that such activities can lead to better speech or should happen before a child tries to practice speech and thus use the non-speech activities even without published data to support their use.]

Use of Cueing

Appropriate therapy for children with apraxia usually includes increased sensory information to help in the control of speech movement sequences. Thus, visual, verbal, tactile or touch cueing are used in appropriate speech therapy for children with childhood apraxia of speech. Cues from the therapist are different types of “reminders” about what your child should do when attempting a word or phrase. For example, a speech therapist points to his throat when the first sound of the word which the child is going to attempt is a sound that is made in the back of the throat (/k/ or /g/ sound). The child sees where the therapist is pointing and it triggers her memory of the position of her tongue in the back of the throat. The child is receiving a “visual cue” about where to start in producing the speech target. Seeing the therapist point to his throat helps to remind the child of how to get started with movement for the particular word. Here’s another example. The speech therapist gently uses her fingers to press the child’s lips together when he needs to make a “lip” sound as part of the target word (lips sounds are called bilabial sounds and include /m/, /b/, and /p/). Feeling the touch and his lips together, helps the child to know how to start a lip sound. This is an example of a “touch” or tactile cue. There are many examples of cues and they take advantage of sight, touch, or understanding in order to aid the child in achieving the speech movement necessary.

While experienced speech-language pathologists use cueing in speech therapy for children with apraxia, they also keep in mind that over time cueing should be reduced and then eliminated as soon as possible. A child who is only capable of their best speech when someone cues them is not developing independence. The speech-language pathologist will not want your child to overly rely on cues. The therapist will want to see that the child’s own speech processing system is beginning to take on the work rather than relying on others to help. The cue “fading” process is also individualized and occurs over time.

Feedback

Your child’s speech-language pathologist will place thought and emphasis on how to alert or tell your child whether their speech attempts have been correct or not correct. The speech-language pathologist will also be carefully weighing how much help they will give to guide your child’s speech attempts and also when they will give feedback to your child about their speech attempt. For example, the speech-language pathologist could say something like, “You need to get your lips tight together when you start. Show me ‘tight lips’.” That type of information, about the specifics of how your child is forming sounds and syllables and how to specifically correct is called “knowledge of performance.” Another type of feedback is called, “knowledge of results.” With knowledge of results feedback, the speech-language pathologist will say something like, “Good!” or “Almost” after your child has attempted a speech target. Feedback of results focuses on general information about whether or not your child was successful with their target word or phrase. speech-language pathologists that have experience working with children with childhood apraxia of speech are going to be carefully thinking about:

• How much feedback?
• What kind of feedback?
• When should feedback be given?

Generally speaking, children who are just starting out in speech therapy and are severely impacted by childhood apraxia of speech may need more immediate feedback about the specifics of their speech movements than will children who have grown in their ability to produce intelligible speech. Some research has begun so that we better understand the role of feedback in speech therapy treatment for children with childhood apraxia of speech.

Use of rhythm

Use of rhythm may help pace speech and help with naturalness of intonation, syllable and word stress patterns – a particular problem for children with apraxia of speech. The rate, intonation, and stress in speech are called prosody. Examples of the use of rhythm in speech therapy for children with apraxia may be clapping or tapping for each syllable or clapping harder when saying the syllable that should be stressed in a word.

Focus on speech sequences

While some children with apraxia of speech may need help to expand the number of individual sounds they are capable of saying, the main “work” and practice the children need is in moving from sound to sound, syllable to syllable, and/or word to word. Remember that speech is a series of rapid, highly refined movements and children with childhood apraxia of speech have difficulty planning and programming those specific movements that underlie speech. Professionals who have a great deal of experience with childhood apraxia of speech advocate that speech targets (words, phrases) should be functional to the child. That means that the words should be useful, practical, and something that the child might actually want to say! For example, the words “hi” and “bye” are very useful (i.e.: functional) for children who are significantly affected by childhood apraxia of speech. In daily living, every child is urged to, “Say hi!” or “Say bye-bye.” The words are one-syllable words without end consonants and so that makes producing them more simpler than words with more than one syllable or words with ending consonants.

Your child’s speech-language pathologist should put a lot of thought into what speech practice targets are appropriate for your child. He or she will carefully think about all consonant and vowel sounds that your child can produce (even those which are not yet perfect but are produced somewhat well). The speech-language pathologist will also give consideration to what types of “syllable shapes” your child can produce (Syllable shapes are various combinations of vowels and consonants that get combined to make a syllable, for example: Consonant-Vowel (CV), Vowel-Consonant (VC), Consonant Vowel Consonant (CVC), and so on). The speech-language pathologist will think about words and ask you for words that your child might enjoy trying to say or that he or she may want or need to say frequently. Then the speech-language pathologist will construct a short list of useful (aka: functional) words that your child might reasonably, given his level of apraxia and his current “inventory” of sounds and syllable shapes, be able to practice with help.

While some children will need taught individual sounds, experienced speech-language pathologists do not focus exclusively at the single sound level for children who have apraxia of speech nor do they make single sound practice the majority of the child’s therapy. Instead, they incorporate the sound being taught into short, functional words that become the child’s speech practice targets in therapy and at home. speech-language pathologists experienced in apraxia, do not “wait” for a child’s various sounds to be perfect before moving on to words and new sounds! Speech therapy is like an art form. The therapist will carefully help your child build larger and more complex syllables, words and phrases, practice them relentlessly; guide and shape them into closer and closer accurate words and phrases; and will “back up” to teach new sounds or sharpen existing sounds in the process.

Need for success

Many children with apraxia of speech have felt defeated by the difficulty they experience at trying to talk. A great many more children have experienced speech therapy that may not have actually helped them speak or communicate. Many parents and therapists anecdotally report that children with childhood apraxia of speech are keenly aware of how difficult “talking” is for them. And, indeed, some children communicate without words that, “mouth broken” or “mouth not work.”

It is important that speech-language pathologists who are working with your child have an immediate focus on how they can help your child experience quick success in therapy. A child with apraxia may have withdrawn from taking risks with their speech, anticipating the difficulty and the failure that they have had in previous attempts or in previous therapy. By carefully planning speech practice targets and structuring therapy for success, children with apraxia can come to trust the speech-language therapist, the therapy process, grow in confidence and begin the important and hard work that is ahead.

Equally, it is important for your child to also experience success with speech attempts at home. Parents are often eager to just do something! They frequently ask, “What can we do at home?” Parents and other caregivers are definitely an important part of the journey to their child’s speech! Especially for children with apraxia, parent involvement is crucial. That said, an speech-language pathologist experienced and successful with children who have apraxia of speech will serve as the guide and coach as to how to best help at home. They want to make certain, to the best that they can, that nothing “sours” your child to the idea of speech practice. Success breeds success. The more confidence your child gains at taking risks with making speech attempts, the more he will benefit from speech therapy.

Speech practice at home

Because speech practice is very important, your child’s speech-language pathologist may encourage you to be involved in your child’s speech practice at home.

Your child’s speech-language pathologist may give you words and phrases to practice with your child at home that he or she has learned in speech therapy. Each home practice session can be short, such as five minutes in length, and you may practice with your child twice a day.

Children also need to practice words and phrases in real-life situations. Create situations where it will be appropriate for your child to say the word or phrase spontaneously. For example, ask your child to say “Hi, Mom” each time mom enters a room. Practicing words or phrases in real-life situations will make it easier for your child to say the practice words automatically.

Sign Language, iPads, and Other Communication Forms

If your child has a severe speech disorder and can’t effectively communicate, alternative communication methods can be very helpful.

In addition to direct speech therapy, many therapists recommend the use of sign language, picture books, communication devices and other means to augment speech in the child who is not clearly understood. This approach may be called “total communication.” Having the child pair a vocal word attempt with a sign enhances the chance that the listener will be able to “catch” the communication (if the spoken word isn’t understood, perhaps the sign will be). Having others understand the communication can offer the child motivation and the feeling of success in using their voice to communicate.

Alternative communication methods may include sign language or natural gestures, such as pointing or pretending to eat or drink. For example, your child could use signs to communicate he or she wants a cookie.

It’s often important to use alternative communication methods early. Using these methods may help your child become less frustrated when trying to communicate. It may also help your child to develop language skills such as vocabulary and the ability to put words together in sentences.

Today, newer technology is coming into play in a big way. Electronic tablets such as the iPad and special communication “apps” are being used more and more as support for communication in children with all kinds of speech problems. These devices are catching on because they are relatively inexpensive compared to dedicated augmentative communication devices; parents and children can catch on quickly at home; and speech therapists are able to use apps and tables in their practice for multiple children.

Many children with apraxia of speech, even at young ages, have some awareness of their difficulty. Parents should not fear using other forms of communication, even if temporarily, in order to support successful communication. Providing successful communication experiences only encourages the child.

Special Notes

Of particular usefulness for children with apraxia of speech, signs can become important visual cues to help them know how to place their mouths, etc. in order to produce the desired word. When pairing of spoken word and sign is consistent, the child may come to associate the visual image of the sign with the placement of their articulators and thus, the sign alone may become a “cue” for the speech attempt. In a few children, sign may not be appropriate. For example, for some children signing might be too distracting or their ability to consistently form a sign may be impaired.

Also, parents should never see iPad apps as “the answer” for their child’s speech improvement.

• Nothing – nothing – can replace direct person to person interaction and support to teach and help our children with apraxia of speech. Young children should not be using the iPad speech therapy apps by themselves. Rather, parents should be with the child to enable the most appropriate and successful practice opportunities and provide direct human interaction at the same time.

As speech improves, these strategies and devices may no longer be necessary.

Therapies for coexisting problems

Many children with childhood apraxia of speech also have delays in their language development, and they may need therapy to address their language difficulties.

Children with childhood apraxia of speech who have fine and gross motor movement difficulties in their arms or legs may need physical or occupational therapy.

If a child with childhood apraxia of speech has another medical condition, then effective treatment for that condition may be important to improving the child’s speech.

Service Delivery

In addition to determining the type of speech and language treatment that is optimal for children with speech sound disorders, speech-language pathologists consider other service delivery variables that may have an impact on treatment outcomes, such as:

• Dosage: the frequency, intensity and duration of service
• Format: whether a person is seen for treatment one-on-one (i.e., individual) or as part of a group.
• Provider: the person providing the treatment (e.g., speech-language pathologist, trained volunteer, caregiver)
• Setting: the location of treatment (e.g. home, community-based, school)
• Timing: the timing of intervention relative to the diagnosis.

The combination of service delivery factors is important to consider, so that children receive optimal intervention intensity to ensure that efficient and effective change occurs ²².

Treatments that aren’t helpful for childhood apraxia of speech

Some treatments aren’t helpful in improving the speech of children with childhood apraxia of speech. For example, there is no evidence to show that exercises to strengthen speech muscles will help improve speech in children with childhood apraxia of speech.

Children With Persisting Speech Difficulties

For some children, speech difficulties persist throughout their school years and into adulthood. Pascoe, Stackhouse, and Wells ²³ define persisting speech difficulties as “… difficulties in the normal development of speech that do not resolve as the child matures or even after they receive specific help for these problems.” The population of children with persisting speech difficulties is heterogeneous, varying in etiology, severity, and the nature of their difficulties ²³ and includes children with:

• speech sound disorders of unknown etiology (i.e., typical articulation and phonological disorders),
• motor-based speech disorders (e.g., childhood apraxia of speech, dysarthria),
• medical conditions and sensory-based problems (e.g., chronic otitis media, hearing loss),
• structure-based speech disorders (e.g., cleft lip/palate, other craniofacial anomalies).

A child with persisting speech difficulties may be at risk for:

• difficulty communicating effectively when speaking,
• difficulty acquiring literacy skills,
• psychosocial problems (e.g., low self-esteem, at increased risk of bullying).

Intervention approaches will vary and may depend on the child’s diagnosis (e.g., structural vs. condition-related) and his/her area(s) of difficulty (e.g., speaking, literacy, and/or psychosocial issues). In designing an effective treatment protocol, the speech-language pathologist considers:

• a psycholinguistic approach to identify the level at which speech processing is disrupted, including:
  • input/perception (auditory discrimination of sounds and words),
  • storage (underlying lexical representation),
  • speech output (planning and production of sounds needed for speech);
  • phonological (linguistic) approaches to treat the level or levels of identified disruption, using specific interventions and stimuli (e.g., minimal pairs,
  • maximal pairs, metaphon approaches);
• medical and surgical intervention (e.g., for children with cleft lip/palate or other physical conditions);
• collaboration with teachers and other school personnel to support the child and to facilitate his/her access to academic curriculum;
• management of psychosocial factors, including self-esteem issues and bullying (Pascoe et al., 2006).

Transition Planning

Children with persisting speech difficulties may continue to have problems with oral communication, literacy, and social aspects of life as they transition to post-secondary education and vocational settings. The potential impact of persisting speech difficulties highlights the need for continued support to facilitate a successful transition to young adulthood.

These supports include:

• Transition Planning—the development of a formal transition plan in middle or high school that includes discussion of the need for continued therapy, if appropriate, and supports that might be needed in postsecondary educational and/or vocational settings ²⁴.
• Disability Support Services—individualized support for postsecondary students that may include accommodations, such as extended time for tests, the use of assistive technology (e.g., to help with reading and writing tasks), accommodations for oral speaking assignments, and methods/devices to augment oral communication, if necessary. The Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act provide protections for students with disabilities transitioning to postsecondary education to ensure that programs are accessible to these students and to provide aids and services necessary for effective communication (U.S. Department of Education, Office of Civil Rights, 2011).

Lifestyle and home remedies

You and your family can work with your child at home to improve his or her speech and language skills. Home practice, in addition to your child’s speech therapy sessions, may help your child’s progress.

Encourage and support your child as he or she practices speech and language skills. Your support can help your child feel that he or she is doing well and improving.

If your child is participating in physical or occupational therapy, as well as speech therapy, schedule different types of therapy at various times so that your child doesn’t become too tired from therapy.

Coping and support

No doubt if you are the parent of a child recently diagnosed with apraxia of speech, you are having many feelings and emotions in reaction to the news. You may be feeling quite fearful about the future. Perhaps you are wondering how this happened to your child or even if you did something to cause your child to have apraxia. You may feel sad that your child is going to have to work harder than other children to do something that seems as natural as learning to speak. Confusion may rule as you attempt to figure out what your child needs and how you will insure that he or she will receive what he needs. Perhaps you lie awake at night wondering what your child will be like as an adult, will he/she be “ok”.

First, it is okay to have these feelings! Your experience and feelings are normal and natural. This diagnosis has thrown a real twist in to how you anticipated life for your child would go. Allow yourself to have these emotions. Take some time to adjust without being harshly judgmental of yourself! However, you will need to move from emotions to action. Learning about apraxia is the first step in helping your child and you are already doing that by reading this book. Regardless of a childhood apraxia of speech diagnosis, your child is still the wonderful child that he or she was before a diagnosis. Your child is brimming with potential and is counting on your help so he or she can unfold the many gifts that lie inside of them.

There are a number of support groups available for parents of children with childhood apraxia of speech. Support groups may offer a place for you to find people who understand your situation and who can share similar experiences.

• To learn about support groups in your area, see the Apraxia-KIDS website: https://www.apraxia-kids.org/

Many parents find it helpful to connect with other parents who have traveled the road ahead of them. Apraxia-KIDS online discussion and support groups are wonderful places to gain information and support from other parents and the professionals who care about children with apraxia. Additionally, there may be local parent groups available in your community. Finally, be sure to ask your child’s speech-language pathologist if he/she may know other parents of children with apraxia in your community whom you can meet and with whom you could share concerns.

1. What is Childhood Apraxia of Speech? https://www.apraxia-kids.org/guides/family-start-guide/what-is-childhood-apraxia-of-speech/[↩]
2. American Speech-Language-Hearing Association. Childhood apraxia of speech [Technical report]. http://www.asha.org/policy/[↩]
3. Apraxia of Speech. National Institute on Deafness and Other Communication Disorders (NIDCD). https://www.nidcd.nih.gov/health/apraxia-speech[↩][↩]
4. A Beginner’s Start Guide to Childhood Apraxia of Speech (CAS). The Childhood Apraxia of Speech Association of North America. https://www.apraxia-kids.org/guides/family-start-guide/[↩]
5. Childhood Apraxia of Speech. American Speech-Language-Hearing Association. http://www.asha.org/Practice-Portal/Clinical-Topics/Childhood-Apraxia-of-Speech/[↩]
6. Morgan A, Fisher SE, Scheffer I, et al. FOXP2-Related Speech and Language Disorders. 2016 Jun 23 [Updated 2017 Feb 2]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2018. Available from: https://www.ncbi.nlm.nih.gov/books/NBK368474/[↩]
7. Shriberg L. D. (2010). A neurodevelopmental framework for research in childhood apraxia of speech. In B. Maassen & P. van Lieshout (Eds.), Speech motor control: New developments in basic and applied research (pp. 259-270). Oxford, UK: Oxford University Press.[↩][↩]
8. Delaney, A. L., & Kent, R. D. (2004, November). Developmental profiles of children diagnosed with apraxia of speech. Poster session presented at the Annual Convention of the American-Speech-Language-Hearing Association, Philadelphia, PA.[↩]
9. Taylor-Goh, S. (Ed.). (2005). Royal College of Speech and Language Therapists clinical guidelines: 5.3 School-aged children with speech, language & communication difficulties . Bicester, UK: Speechmark.[↩]
10. Shriberg, L. D., Potter, N., & Strand, E. A. (2011). Prevalence and phenotype of childhood apraxia of speech in youth with galactosemia. Journal of Speech, Language, and Hearing Research, 54, 487-519.[↩]
11. A Beginner’s Start Guide to Childhood Apraxia of Speech (CAS). The Childhood Apraxia of Speech Association of North America. http://www.apraxia-kids.org/guides/family-start-guide[↩]
12. Childhood Apraxia of Speech. American Speech-Language-Hearing Association. http://www.asha.org/Practice-Portal/Clinical-Topics/Childhood-Apraxia-of-Speech[↩]
13. American Speech-Language-Hearing Association. (2007a). Childhood apraxia of speech [Technical report]. http://www.asha.org/policy/[↩][↩]
14. Brown, T., Cupido, C., Scarfone, H., Pape, K., Galea, V., & McComas, A. (2000). Developmental apraxia arising from neonatal brachial plexus palsy. Neurology, 55(1), 24-30.[↩]
15. Bashina, V. M., Simashkova, N. V., Grachev, V. V., & Gorbachevskaya, N. L. (2002). Speech and motor disturbances in Rett syndrome. Neuroscience and Behavioral Physiology, 32, 323-327.[↩]
16. Lai, C. S. L., Fisher, S. E., Hurst, J. A., Levy, E. R., Hodgson, S., Fox, M., … Monaco, A. P. (2000). The SPCH1 region on human 7q31: Genomic characterization of the critical interval and localization of translocations associated with speech and language disorder. American Journal of Human Genetics, 67, 357-368.[↩]
17. Liégeois, F., Baldeweg, T., Connelly, A., Gadian, D. G., & Vargha-Khadem, F. (2003). Language fMRI abnormalities associated with FOXP2 gene mutation. Nature Neuroscience, 6, 1230-1237.[↩]
18. Childhood Apraxia of Speech. American Speech-Language-Hearing Association. http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935338&section=Signs_and_Symptoms[↩]
19. Lewis, B. A., Freebairn, L. A., Hansen, A. J., Iyengar, S. K., & Taylor, H. G. (2004). School-age follow-up of children with childhood apraxia of speech. Language, Speech, and Hearing Services in Schools, 35, 122-140.[↩]
20. McNeill, B. C., Gillon, G. T., & Dodd, B. (2009a). Phonological awareness and early reading development in childhood apraxia of speech (CAS). International Journal of Language and Communication Disorders, 44(2), 175-192.[↩]
21. American Speech Language Hearing Association. http://www.asha.org/[↩]
22. Williams, P., & Stephens, H. (2010). The Nuffield Center Dyspraxia Programme. In A. L. Williams, S. McLeod, & R. J. McCauley (Eds.), Interventions for speech sound disorders in children (pp. 159-178). Baltimore, MD: Brookes.[↩]
23. Pascoe, M., Stackhouse, J., & Wells, B. (2006). Persisting speech difficulties in children’s speech and literacy difficulties: Book 3. West Sussex, England: Whurr.[↩][↩]
24. Individuals with Disabilities Education Improvement Act (IDEA). (2004). https://sites.ed.gov/idea/[↩]