When First Words Don’t Come Easily

Somewhere between twelve to eighteen months of age, a child should begin to speak his
or her first words. Parents eagerly anticipate those first words to come. As the months
pass by without the emergence of words, the excitement of anticipation evolves into
concern and anxiety that their child is not speaking.

Family and friends may try to offer words of comfort by saying things like, “he’s just
a late talker”, or “boys just develop more slowly than girls.” Even your spouse may be
telling you, “you’re overreacting.” Your motherly instincts still tell you something is not
right.

With all the media attention and increased awareness of Autism Spectrum Disorder
(ASD) in the past decade, your first concerning thought could be that your child may be
autistic. You pursue diagnostic testing for ASD, and are relieved to find out that your
child is not autistic; he just has a “speech delay.” This global, almost generic, diagnosis
provides some immediate relief. It implies that your child may grow out of it and even
suggests a “wait and see” approach. You are still left questioning why your child has a
speech delay, and you remain uncertain if your child really will grow out of it. What if it
is something more?

Your child may have a rare motor speech disorder called Childhood Apraxia of Speech
(CAS). Moving the articulators of the mouth for speech is a neurological process in
which the brain orchestrates motor actions by planning, organizing, initiating, and
sequencing movement patterns. Childhood Apraxia of Speech is a neurological pediatric
speech sound disorder in which the precision and consistency of movements underlying
speech are impaired. The core problem is believed by many experts to be with the
planning and programming of movement gestures and sequences underlying speech
production. While it is possible to have a comorbid diagnosis such as dysarthria (a
weakness or dysfunction of the muscles), children with CAS typically do not have
difficulty with the oral muscles themselves. CAS is a motor planning disorder in the
absence of muscle weakness. It is a disorder of movement and planning; it is not a
disorder of strength.

Proposed characteristics that are more likely to be found in children with CAS compared
to children with nonapraxic speech sound disorders include:

• Difficulty putting sounds and words together
• Difficulty sequencing and ordering articulatory movements for speech
• Increased errors in longer, more complex words
• Vowel errors
• Reduced vowel inventory
• Inconsistency of errors across repeated productions
• Unusual and atypical speech error patterns
• Speech regression

Children with apraxia typically have normal intelligence, good receptive language
(comprehension) skills, but delayed expressive language skills. Apraxia can also be part
of a more global primary diagnosis such as cerebral palsy, autism, intellectual disability,
Down syndrome, or other genetic factors. It is not uncommon for children with apraxia
to have sensory processing problems as well. In one study examining the prevalence of
CAS in children with Down syndrome, researchers found at least 15% of individuals
with Down syndrome had a confirm diagnosis of CAS, but at least 60% of the 1600
individuals with Down syndrome involved in the study likely had CAS; however, it was
never diagnosed.

There are many reasons why a child might be speech delayed. In order to obtain a
differential diagnosis, it is highly recommended to use a multidisciplinary evaluation
approach including a Speech-Language Pathologist, Neuropsychologist or Psychologist,
Developmental Pediatrician, and possibly an Occupational Therapist.

An accurate diagnosis is imperative, as the treatment techniques are very specific
to addressing motor planning for speech, and different from how Speech-Language
Pathologists treat other speech disorders. Early and intensive intervention is also critical
for the most favorable outcomes. A child who has apraxia of speech will not simply grow
out of it.

By Lynn Carahaly, M.A., CCC-SLP

Resources to learn more about Childhood Apraxia of Speech:

National organizations:

www.apraxia-kids.org (The Childhood Apraxia of Speech Association of North America:CASANA)

www.cherab.org (Communication Help, Education, Research, Apraxia-Base: CHERAB)

www.asha.org (The American Speech and Hearing Association)

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