• Doesn’t smile or interact with others (birth-3 months)

• Doesn’t babble (4-7 months)

• Makes few sounds (7-12 months)

• Does not use gestures such as waving and pointing (7-12 months)

• Doesn’t understand what others say (7 months-2 years)

• Says only a few words (12-18 months)

• Doesn’t put words together to make sentences (1 ½-3 years)

• Has trouble playing and talking with other children (2-3 years)

• Has problems with early reading and writing skills – for example, may not show an interest in books or drawing (2 ½-3 years)

Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (abnormal reflexes, abnormal tone). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.

The following are symptoms of CAS:

• Limited or little babbling as an infant (void of many consonants). First words may not appear at all, pointing and “grunting” may be all that is heard.

• The child is able to open and close mouth, lick lips, protrude, retract and lateralize tongue while eating, but may not be able to when directed to do so.

• First word approximations occurring beyond the age of 18 months, without developing into understandable simple vocabulary words by age two.

• Continuous grunting and pointing beyond age two.

• Lack of a significant consonant repertoire: child may only use /b, m, p, t, d, h/

• All phonemes (consonants and vowels) may be imitated well in isolation, but any attempts to combine phonemes are unsuccessful.

• Prosody is unusual, there is equal stress or lengthy pauses between or within syllables or words, and sometimes a monotone quality.

• Speech may change or disintegrate with many repetitions.

• Words may be simplified by deleting consonants or vowels, and/or replacing difficult phonemes (consonants and vowels) with easier ones.

• Single words may be articulated well, but attempts at further sentence length become unintelligible.

• Receptive language (comprehension) appears to be better than attempts at expressive language (verbal output).

• One syllable or word is favored and used to convey all or many words beyond age two.

• The child speaks mostly in vowels.

• Verbal perseveration: getting “stuck” on a previously uttered word, or bringing oral motor elements from a previous word into the next word uttered.

• Oral groping may occur when attempting oral motor movements or consonant/vowel production.

• Struggle behavior may occur when attempting to imitate or to speak (without dysfluency or stuttering).

• Deletions or replacements of consonants, vowels or syllables may occur at the end of a word, phrase or connected word levels.

• Vowel distortions or replacements occur which are not due to oral motor weakness.

• The ability to blurt out clear whole words, phrases or sentences may occur though there is difficulty imitating these same words “on command” or upon imitation.

• Difficulty with maintaining clarity with extended word length or complexity.

• Many phonological processes are employed to simplify motor speech output.

• Late talking with above characteristics or errors may be present.

• Other fine motor challenges may be present.

• Echolalic utterances (the automatic repetition of words, phrases or sentences often without comprehension) might be perfectly articulated but novel attempts at words or combinations might be more effortful.

The following articulation errors are typical of preschoolers and are usually not cause for concern. If they persist past age five, an evaluation is necessary.Frontal and lateral lisps

• Weak articulation of /r/

• Substituting /j/ (the “y” sound) for /l/
• Difficulty with blends /r, l, s/ (brake, clown, slow)

Dysarthria (flaccid) is a speech disorder caused by dysfunctional or damaged innervation to the speech musculature (tongue, lips, soft palate, facial muscles, larynx).  Generally, oral musculature is weak.  Some children may have a functional dysarthria, due to inappropriate carriage of the tongue at rest.

The following are signs of dysarthria:

• Marked difficulties with strength, speech and accuracy of articulatory movement.

• Imprecise or weakly targeted consonants.

• Imprecise or weakly targeted vowels, especially those which involve spreading intrinsic tongue muscles, such as /i/, /ai/, /ei/, oi/.

• Weak vocal quality (lack of respiratory support).

• Hypo or hypernasality.

• Weak articulatory contacts.

• Rapid or slow speaking rate.

• Speech clarity disintegrates with lengthy utterances (this may be due to lack of breath support or muscle fatigue and may resemble apraxia of speech).

• Weak targets, especially for / r, s, l / and vowels.

• Generally weak, mushy, garbled, imprecise speech.

Many children with apraxia of speech have an accompanying oral-motor weakness. Usually, working on the apraxia inadvertently helps to strengthen weak articulatory contacts.

Severe dysarthria can be such a significant obstacle to motor-speech skill development in that the average listener may not be able to decode their speech. Children with severe dysarthria will require an augmentative communication system.

Children with expressive language disorder have difficulty with verbal expression (putting words together to formulate thoughts).

The following are symptoms of expressive language disorder:

• Word retrieval difficulties.

• Difficulty naming objects or “talking in circles” around subjects with lack of the appropriate vocabulary.

• Dysnomia (misnaming items).

• Difficulty acquiring syntax (the rules of grammar).

• Difficulties with morphology (changes in verb tense).

• Difficulty with semantics (word meaning).

Receptive language disorders include central auditory processing disorders (CAPD), aphasia, comprehension deficit, “delayed language,” and “delayed speech.” Receptive language disorders also refer to difficulties in the ability to attend to, process, comprehend, retain, or integrate spoken language.

The following are symptoms of a receptive language disorder:

• Echolalia (repeating back words or phrases either immediately or at a later time).

• Inability to follow directions (following of routine, repetitive directions may be OK).

• Inappropriate, off-target responses to “wh” questions.

• Re-auditorization (repeating back a question first and then responding to it).

• Difficulty responding appropriately to yes/no questions, either/or questions, who/what/where questions, and when/why/how questions.

• Not attending to spoken language

• High activity level and not attending to spoken language

• Jargon (sounds like unintelligible speech)

• Using memorized phrases and sentences.

Please note: Children with autism spectrum disorders often have difficulty decoding spoken language and may tend to memorize rather than have a true understanding of novel language.

Social pragmatic language disorder may also be known as semantic/pragmatic language disorder, nonverbal learning disability (NLD), or even autism/Asperger's syndrome.

The following are symptoms of social pragmatic language disorder:

• Excessive questioning.

• Lack of eye contact.

• Aggressive language.

• Excessive talk about specific subjects in too much detail

• Only talking about him/herself.

• Disinterested in other children.

• Unable to engage in conversational exchange.

• Literal/concrete understanding of language.

• Unable to answer open-ended questions such as “what happened?”

• Difficulty with abstract language such as verbal problem solving (why, when, how do you know?), double meanings, innuendos, and jokes.

• Difficulty taking the listener’s perspective.

• Difficulty reading or interpreting body language, facial expressions.

• Unable to express feelings.

Unintelligible speech is a descriptive term used subjectively by the listener.  It can be due to a few minor consonant or vowel errors, oral-structural differences, oral-motor weakness, dysarthria or apraxia of speech.

However, another casual factor to unintelligible speech, which even many professionals miss, is that of the faulty perception of language.  Children who have difficulty processing and comprehending spoken language, particularly children who exhibit autism spectrum disorders, may exhibit jargon (sometime called “gibberish,” or unintelligible speech).

It is important to uncover whether a child has an unusual capacity to memorize dialogue, which doesn’t necessarily hold any meaning for them and are reiterating it the way they perceive it, without attaching meaning.  In this case, the more emphasis there is upon improving processing and comprehension skills, the more improvement will be seen in increased intelligibility.  Whereas, unintelligible speech rooted in the fine-motor coordination aspect of talking would require motor-speech or verbal motor work.

Children may have both perceptual and motor-speech difficulties.  If there are any questions regarding whether the child comprehends spoken language, attention should be given to comprehension and not necessarily motor-speech output.

• Limited repertoire of vowels; less differentiation between vowel productions; and vowel errors, especially distortions.
• Variability of errors.
• Unusual, idiosyncratic error patterns (sometimes defying transcription).
• Errors increase with length or complexity of utterances, such as in multi-syllabic or phonetically challenging words.
• Depending on level of severity, a child may be able to produce accurately the target utterance in one context but is unable to produce the same target accurately in a different context.
• More difficulty with volitional, self-initiated utterances as compared to over-learned, automatic, or modeled utterances.
• Impaired rate/accuracy on diodochokinetic tasks (alternating movement accuracy or maximum repetition rate of same sequences such as /pa/, /pa/, /pa/ and multiple phoneme sequences such as /pa/ /ta/ /ka/)
• Disturbances of prosody including overall slow rate; timing deficit in duration of sounds and pauses between and within syllables contributing to the perception of excess and/or equal stress, “choppy” and monotone speech.
• At some point in time, groping or observable physical struggle for articulatory position may be observed (possibly not present on evaluation, but observable at some point in treatment).
• May also demonstrate impaired volitional nonspeech movements (oral apraxia).
• Verbal perseveration: getting “stuck” on a previously uttered word or bringing oral motor elements from a previous word into the next word uttered (Nancy Kaufman’s observation).

Other characteristics that may describe children with CAS, but are less likely to contribute to a differential diagnosis include:

• Poor speech intelligibility
• Delayed onset of speech
• Limited babbling as an infant
• Restricted sound inventory
• Loss of previously spoken words

Note: A speech and language pathologist must be involved to rule out other possibilities as primary reasons for the above-mentioned signs and symptoms. Simple "late talkers" can have similar characteristics.

Childhood apraxia of speech can and often does coexist with other speech and language challenges. It requires proper diagnosis and treatment by an experienced speech-language pathologist.

Apraxia of speech is usually treatable with the appropriate techniques. Children must be seen one-on-one, at least in the early stages of treatment, even as early as age 2.

Kaufman Speech to Language Protocol is a highly effective program with young children. It is currently the #1 tool used to treat childhood apraxia of speech in the US (source) and is used by speech-language pathologists in many other countries. The approach is also now being accepted and implemented into applied behavior analysis (ABA) and applied verbal behavior (AVB) programs for children on the autism spectrum.

K-SLP materials, including Kaufman Speech Praxis Test for Children, Kaufman Speech to Language Treatment Kits, Kaufman Speech to Language Workout Book, and K&K Sign/Select to Talk, are helpful tools to diagnose apraxia, determine treatment goals, and provide effective therapy.

It is imperative that children with childhood apraxia of speech gain as much practice as possible, and that is not limited to official speech session. Involvement from parents and caregivers in the child's natural environment (home, school, community) is essential for the practice needed.

With quality therapy specific to childhood apraxia of speech and support from their community, many children can make progress becoming successful vocal communicators!

TRUTH: The K-SLP is not just a drill-oriented method. It is not just about the picture cards in Kits 1 and 2. Play is incorporated into every session. Picture cards are initially implemented, as it is too difficult to contrive the specific targets for the child to be able to practice the specific vowels, consonants, and syllable shapes with enough repetition necessary for success.

If the SLP is only using the Kit pictures within a session, they are not implementing the K-SLP the way it was intended! Sessions can and eventually should be conducted without any pictures at all. For very young children, pictures are not introduced until the task of imitation is understood, and there are always targeted goals through play.

Practicing new skills through play and the natural environment is essential to the K-SLP methods. The K-SLP is implemented with high levels of motivating toys and activities in a warm, encouraging manner. Many responses are necessary for success. Therefore, you will see a great deal of repetition in a K-SLP session.

If the K-SLP is done the way in which it was intended, the children will be willing, cooperative and successful learners.

TRUTH: It's a misconception that kids with CAS should only be taught the full, adult forms of words. The K-SLP effectively involves teaching word approximations toward target words, phrases and sentences, and not simply just accepting the child’s approximation. Word approximations are continuously shaped toward the full target words to perfection.

Once the child learns a closer approximation of a target word, the old approximation is extinguished and only the closer approximation is reinforced. Full correct words and phrases are always modeled for the child. If the child is not stimulable to produce a vowel or consonant accurately, they would be taught a compensatory placement, while continuing to gain stimulability for articulatory accuracy.

There is a great deal of research supporting teaching a new behavior (in this instance, the behavior of producing and combining vowels and consonants to form words, and combining words to formulate language) through shaping successive approximations. (See the list of evidence-based practice).

Every child Nancy Kaufman or any SLP at the Kaufman Children’s Center has ever taught to develop effective vocal communication was taught via successive word approximations and compensatory articulatory placements. The K-SLP methods have been implemented successfully since 1979.

TRUTH: Due to the nature of the K-SLP, it is difficult to systematize the process so each clinician is using the exact same intervention strategies. The protocol depends upon a wide range of variables including:

• The individual clinician
• How cues are chosen
• How motivation and reinforcement is implemented
• How to simplify the motor plans of words temporarily based upon the child’s repertoire

However, a great deal of evidence and peer-reviewed research has been completed. You can find a list of resources HERE.

TRUTH: There are many controversies surrounding “oral-motor therapy.” The research has taught us that oral-motor exercises do not help children to be more successful vocal communicators if they are exhibiting only characteristics of CAS. We do not implement oral-motor exercises at all for this population of children.

Specific tools established and offered through TalkTools and Apraxia Shapes have been instrumental for those who have very few vowels or consonants within their repertoire and who struggle with the underlying oral placement to sustain the accuracy of a vowel or consonant. When appropriate, a tool will be implemented inside the oral cavity to assist the child as a cue (much like how PROMPT cues are used outside of the oral cavity) for initial success, then the tool is faded out as the child is able to produce the underlying movement to sustain the new vowel or consonant independently.

TalkTools and Apraxia Shapes are also implemented here at the KCC to assist with the quality of feeding for those children who struggle with sucking, chewing and swallowing, and who also struggle to speak. Horns and/or straws are only introduced to gain the necessary skills for improved feeding or as a tool to gain a vowel or consonant as above. Sometimes, horns are introduced to help the child to practice sustaining respiratory support that would be needed to support sentence length or as a tool to be paired directly with a consonant that requires sustaining and grading air flow such as for /s, f, sh/.

TRUTH: K-SLP materials are not essential for successful K-SLP methods. They were produced by Nancy as she needed/wanted them for stimuli and assumed that other SLPs might also find them to be useful.

If SLPs understand the K-SLP methods, all that is needed are pictures, objects, toys, and other highly preferred items or activities for each child. Each SLP will also require knowledge about how to simplify the motor plans of words by implementing natural phonological processes and understanding shaping methods.

Visit Northern Speech Services for a 6-hour course on the full K-SLP method (ASHA credits available).