OMNIE - Ohio Masters Network Initiatives in Education

Childhood Apraxia of Speech
Submitted by
Erin Redle - erin.redle@cchmc.org
Barb Conrad - Manager - conrad@esclc.org
Peer Reviewed: Dawn Betts & Kim Smola
Updated: November, 2011

Childhood Apraxia of Speech Guidelines
Overview and Definition	Speech Motor Control	Assessment and Diagnosis
Available Assessments	Therapy Overview Frequency of Production	Motor Learning
Literacy and CAS	CAS vs Phonology Diagnosing Treatment	Alternative Approaches
Links/Websites	ASHA Convention Handouts	References

Overview and Definition of Childhood Apraxia of Speech (CAS)

In the past, a variety of terms were used to describe suspected motor planning problems in children, including (but not limited to): Dyspraxia, childhood verbal apraxia, developmental apraxia of speech, developmental dyspraxia of speech, developmental verbal dyspraxia, childhood apraxia of speech
In 2007, the consensus from an ASHA workgroup was the term should be "childhood apraxia of speech"
Prior to the ASHA position statement and technical report, there was NO consistent definition of CAS in the literature.
This lack of consistent definition impacted capacity to generalize the results of any research study for both diagnosis and treatment

In response to the need for a consistent definition, ASHA (2007) developed the following:

Key components of the definition

Neurological childhood speech sound disorder: believe the speech deficit is caused by a deficit in the neurological system but not caused by a neuromuscular deficit, such as in the dysarthrias
CAS can co-occur with other known neuromuscular deficits, such as hypotonia, dysarthria, cerebral palsy, etc. To further differentially diagnose CAS, the observed deficits in speech production must reflect motor planning deficits above and beyond the expected deficits of the known neuromuscular deficits
CAS can co-occur with other neurobiological disorders, such as galactosemia and epilepsy
CAS can occur in the absence of any known medical or neurological condition; this is known as the idiopathic or "pure" form of CAS
Speech deficit is due to inaccurate precision and inconsistency of movements, these deficits effect speech sound production and prosody
Caused by deficits in planning and or programming movements of the articulators for speech
CAS can persist beyond childhood but may still be referred to as "childhood apraxia of speech" to differentiate it from the acquired apraxia of speech that results after a stroke or other type of brain lesion

Prevalence

Preliminary population estimate 1-2 in 1,000 (Shriberg, Aram, & Kitowski, 1997)
Children with speech and language disorders 3.4%-4.3% (Delany & Kent, 2004)
Incidence is reported to be increasing, unknown if this is due to a true increase in the incidence, better identification, or incorrect, overdiagnosis

Suggested Etiologies Include

Neurological deficits (Weistuch et al., 1996)
Genetics (Lewis et al., 2004)
Difficulties prenatally and/or at birth (Hall et al., 1990)
Right lobe dominance
Currently research focused on genetics and neurological systems, starting to use imaging studies to look at specific regions and areas of the brain

Speech Motor Control

Both the diagnosis and treatment of CAS should be firmly grounded in an understanding of the mechanisms of speech motor control
Overview of Speech Motor Control

The human capacity for speech is special and unique to humans
Researchers study not only how we develop control, but how this control changes and matures over time (see discussion at below)
Development of Speech Motor Control

The differentiation of speech motor control from general oral motor skills and the refinement of the accuracy of speech motor control are well established in the literature
Speech motor control continues to refine into middle to later childhood (Smith & Goffman, 2004; Green, Moore, Higasjikawa & Steeve, 2000)

Anatomy Review

Important points about muscles

As SLPs, muscles are not something we usually really think of or worry about but it is very important to understand how the muscles we use for speech are different than other muscles because how you incorporate this information into potential treatment approaches is very important.
The speech mechanism is made up of approximately 100 different paired muscles, all of which are important for speech (Kent, 2004)
These different muscle types include (Kent, 2004):

Joint related muscles, such as the muscles for jaw movement
Sphincter related muscles used for valving, such as muscles of lips
Tongue muscles
Muscles for vibration, including muscles of the larynx for voicing
Muscles in the respiratory process

Different types of muscles respond to interventions in different ways; (e.g. medication can fatigue, strength training)
Muscles in speech mechanism have a high degree of specificity to support

Rapid movement, at a rate unlike that for any other activity that humans perform
Highly precise coordination, both for placement and timing

Remember that in CAS, the problem is not with the STRENGTH of the muscles but rather the coordination of the muscles

The various different types of muscles are all active in the speech mechanism, rapid coordination of the muscles can be difficult
Treatment needs to activate all types of muscles to achieve their intended activation patterns and activate in a coordinated manner that replicates speech activation patterns.

Specificity of movement training (Clark, 2003)

Two types of fibers exist in all muscles
Type I (slow-twitch): analogous to the muscles used to run a marathon, recruited first
Type II (fast-twitch)

Fast resistant: intermediate types of fibers, analogous to the muscles for running a 400 meter race, usually recruited second
Fast fatigable: classic fast twitch, analogous to the muscles for a true sprint, recruited last

Very, very important to point out that the recruitment of muscles and muscle fibers in activations needs to as closely as possible replicate what is needed for the desired task

This is well established in motor literature
This is a very important point WHY oral motor treatments are NOT effective in treating CAS; they cannot replicate the muscle fiber activations needed for speech production

Neuroanatomy and physiology review (Guenther, 2006; Bohland, Bullock, & Guenther, 2009 )

This model assumes ability to select words appropriately
In this model, not exactly sure where breakdown occurs in CAS, most likely deficits in mapping and/or initiating speech sounds, represented in red print
This model, although complex, represents what a child needs to be able to replicate to accurately produce speech
Very important for treatment that you are addressing the multiple levels of planning that must take place to execute speech
Therapy activities need to, as closely as possible, replicate this model

Diagnosis of CAS

Currently, there is not a validated or consistent list of characteristics or markers to diagnose CAS (ASHA, 2007).
The most promising and consistent identified by ASHA include: 1) inconsistent consonant and vowel errors in repeated productions, 2) disrupted and/or lengthened transitions in coarticulation between sounds and syllables, and 3) altered or inappropriate prosody
Forrest (2003) surveyed 75 speech language pathologists to determine what criteria they were using to diagnose CAS; results were highly variable. Six factors were consistently identified to account for approximately 50% of the responses, including: inconsistent productions, general oral-motor difficulties, groping, inability to imitate sounds, increasing difficulty with increased utterance length, and poor sequencing of sounds.

In addressing the difficulty in differentiating CAS from other speech sound disorders, ASHA (2007) addressed six major areas, described in more detail below

Non-speech motor skills

Non-speech oral motor skills

Some discussion of difficulty coordinating oral-motor movements, such as sequencing non-speech oral movements, slowness or oral movements, and some general weakness of the oral musculature
These signs may represent an oral CAS or dysarthria and independently cannot be used to differentiate CAS, although they may be a co-existing component of CAS
Deficits in sequencing these types of movements may represent a general motor planning problem that may or may not include the speech mechanism

General non-speech motor skills

Children with CAS are often in the literature described as being clumsy, uncoordinated, etc. in the past

Newmeyer et al. (2007) found poor oral imitation skills were correlated with poor fine motor skills in a group of children with speech sound disorders, as well as an overall deficit in fine motor skills in this group
Important to consider if a general praxis is present, how does this affect ability to coordinate non-speech praxis, such as in sign language?

Speech Motor Production

Two of the most commonly reported diagnostic markers in both research and clinical practice are 1) difficulty with the repetition of syllables and 2) difficulty with the production of alternating syllables

Can ask the child to repeat syllables as fast as they can (straight repetition)
Can ask the child to alternate syllables (such as in diadokoineses activities)
Children with CAS can have deficits with either of these tasks; these are frequently reported in the literature

Qualitative differences in speech sound production is frequently, and commonly reported

Lewis identified the following as reliable markers that differentiated children with CAS from OTHER CHILDREN with speech sound and language disorders (a very important consideration): differences in syllable structures, sound sequencing, vowel errors, voicing errors, unusual errors, persistence of development patterns
As previously mentioned, no agreed upon set of characteristics, Lewis model is one of the most clinically relevant

Other reported characteristics include:

reduced vowel inventory
vowel errors
inconsistency of errors, including vowels
increased errors in longer or more complex syllable and word shapes (especially omissions, particularly in initial position)
articulatory groping
unusual errors, errors that do not follow developmental processes
sound production regression
differences in performance of automatic (overlearned) versus volitional (spontaneous or elicited) activities, volitional activities more affected
order errors for sounds, syllables, morphemes, and words

Prosodic differences

This is the most consistent finding in the literature
Prosodic differences include rate changes, syllable prolongations, lengthened pauses in speech at syllable, word, sentence level
Often described as having staccato speech
Pitch range can be limited, can have reduced volume
May also note differences in nasality; can be inconsistently hyper- or hypo-nasal, or may fluctuate between the two

If you note CONSISTENT hyper- or hypo-nasality, refer for a resonance evaluation

Speech perceptions differences

Some preliminary data to support this population may have difficulty with speech perception and awareness, needs further investigation

Language differences

Research to support language deficits are present and persist in children with CAS (Lewis, 2004), more severe persistence than children with general speech sound disorders
May also present with specific language impairment deficits as well

Metalinguitic differences/literacy

May have difficulty with phonological awareness
Lewis et al. (2004) found persistent literacy deficits
Not to be unexpected given the difficulty in producing sounds and correlating to symbols

As stated above, there is no clear diagnostic criteria for CAS at this time
Diagnostic battery for research is the most accepted

In a recent study to isolate children with CAS, the authors (Lewis et al., 2004) started with children referred from community therapists for suspected childhood CAS of speech (n=42)
Ages were initially 3-0 to 10-0, although everyone over 6 was eventually eliminated
Goldman-Fristoe and Kahn Lewis
For inclusion in the study as a child with CAS they required:

Scores below the fifth percentile
Presence of at least 3 phonological processing errors in the moderate to severe range
Kahn Lewis severity rating of at least 4
This eliminated 11 children

Next test was the Oral Speech Motor Control Protocol
Reduced DDK according to the Total Function Score (TFS); had to be at least 2 SD below the norm
Also looked for errors in sequencing of syllables for real and nonsense words on the OSMCP

This test eliminated 7

Also stated errors needed to be "unusual" including:

Non-developmental processes
Metathetic errors
Prolongations
Addition errors
This eliminated 3
LEFT WITH 21 CHILDREN

This is not practical in a clinical setting, but the careful testing allows the researchers to reduce the sample and include children more likely to have true, pure, CAS
Clinically, the diagnosis is based on a cluster of signs gathered from:

Receptive and expressive language skills
Based on current research, you should NOT diagnose CAS in children who are completely non-verbal or have very minimal verbal output
Receptive language should be (but not always) age appropriate or at least superior to expressive language for idiopathic CAS

Case history

Are there any other signs in their history that may indicate an overall motor planning or neurological condition?
Especially in the area of motor development (fine and gross)

Treatment history

Series of articles by Shrieberg & Aram indicates resistance to traditional treatment is a criterion for the diagnosis of CAS
Should treat the child to determine how they respond to treatment prior to labeling with CAS

Clinical indicators from a spontaneous speech sample, connected speech

Vowel errors
Inconsistent errors
Difficulty with sequences
Syllable omissions
Sound omissions
Difficulty with multisyllabic words
Expressive language deficits

THE DIAGNOSIS IS MADE AT THE DISCRETION OF THE TREATING THERAPIST AND MAY OR MAY NOT INCLUDE A COMMERCIALLY AVAILABLE ASSESSMENT TOOL (SEE AVAILABLE ASSESSMENTS)
ASHA TECHNICAL REPORT (2007) ALSO REPORTED TWO CONSISTENT FINDINGS IN RESEARCH DIAGNOSITICS: DIFFICULTY WITH MULTI-SYLLABLE UTTERANCES AND PROSODIC DIFFERENCES
SPEECH-LANGUAGE PATHOLOGISTS, REGARDLESS OF THE EMPLOYMENT SETTING, ARE UNIQUELY QUALIFIED TO MAKE THE DIAGNOSIS OF CAS

SLPs can, and when appropriate, should diagnose CAS, including in an educational setting

Available Assessments

Four sub-tests

Part 1: Oral Movement Level
Part 2: Simple Phonemic/Syllabic Level
Part 3: Complex Phonemic/Syllabic Level
Part 4: Spontaneous Length and Complexity

Each of the 4 parts is norm-referenced with separate standardization; standard scores are compared to either typical children or children with other speech sound disorders
Normed for children 24-72 months

Pros:

Do not need photos or a book for administration (all imitation)
Very helpful for planning therapy; assists with determining level of breakdown
Yields a standard score, may be necessary to qualify a child

Cons:

The standardization is not psychometrically supported; the sample is small, minimal psychometric properties (reliability, validity) assessed or reported
Scoring can be difficult
Administration can be lengthy for a child with more expressive language (e.g. can produce sentences)
There are no pictures, books, etc. to keep the child interested

A screening checklist, can be used with children 3 years (3-5 years preschool form) up to 13 years of age (6-13 years use school-age form)
Administered in 25-35 minutes, takes 10-15 minutes to score
Summary page is helpful for organization
No standardized scores

Pros

Word repetition increases in difficulty
Prosody and rhythm examined
Contains a checklist to assist with quantification of other observations

Cons

Not normed or validated; minimal psychometric information for scale development and standardization process
Scoring is confusing

Intended for children ages 3 to 10
The starting point and initial targets for therapy are based directly off of the results of the assessment; the levels of assessment and progression of assessment mirror the treatment approach
Assessment
For children under 4, assessment focuses on syllable progression (one, two, three)
For children over 4, assessment focuses on movement sequences at the multi-syllabic word level
For both ages assesses by placement
Score based on level of cueing
There are levels of cueing

Pros

Provides complete information regarding level of breakdown and information for treatment planning
Correlates directly with the accompanying treatment program

Cons

Scoring is very difficult and not norm-referenced

Treatment Overview for CAS

In general, the best course of therapy will incorporate the following characteristics:

Frequent: the more frequent the better, smaller periods of time over more sessions/days better than one large period of time
Focused: focused on speech production (unless focusing on AAC)
Functional: provide the child with functional communication

Functional therapy goals may include

Functional vocabulary
Alternative communication

Very consistent, strong support in motor learning literature (not specific to speech) that to learn a movement you must practice the full, functional movement sequence, not just the specific components

For example, in teaching a child to walk you would not just work on the isolated movement of one leg or the motions while laying on your back
This is why it is CRUCIAL that the child practices actual speech production

Treatment should focus on building syllabic structures; building on syllable shapes and phonemes (consonants and vowels) the child has in repertoire
Treatment should follow principles of motor learning (see Motor Learning and CAS)
Treatment should also facilitate correct, accurate productions; use maximum levels of cueing to achieve correct productions

Cueing can be:

visual (modeled and/or with a mirror; may be helpful to sit behind child with both therapist and child looking in same mirror)
tactile (touch cues specific to CAS and/or tactile/kinesthetic cues)
verbal (placement cues for articulators)

Targets and goals should be simple and achievable to facilitate success, especially early in treatment to minimize frustration
Specific therapy approaches with a strong theoretical model

Touch Cues (Bashir et al., 1984)

Originally introduced by Bashir et al., this approach pairs individual phonemes or cognates together with an associated gesture, usually a hand movement or "touch" to the face
When producing words, these movements are sequenced together
Theoretically, the idea is that the broader motor movements are associated with the phonemes and facilitate better access to the motor patterns for sound production
Touch cues/gestures are also a component of other commercial treatment programs, such as Easy Does It Apraxia-Preschool (Strode & Chamberlain, 1994)
Easy-Does It Apraxia Preschool also has movements for vowels that can be incorporated into the movement sequences for syllables and words
The touch cues should be consistent between therapists and the family for each individual child

Motoric Syllable Shape Development

Kaufman approach (Kaufman, 2001)

Breaks words down to simplest productions the child is able to produce and then builds syllable shape and complexity
For example 'people' would follow this progression for a child with only CVCV shapes and minimal vowels and consonants

Puh-puh
Puh-po
Pee-o
Peep-o
Peep-po
People

From a linguistic standpoint this is counter-intuitive as you are modeling an incorrect word and/or production
Children with well developed language skills may not have difficulty with this, children who are simultaneously learning language and speech may have difficulty assigning multiple representations to the same object or word
Basic and advanced level cards available, as well as a workbook
No documented efficacy of this specific treatment

Easy Does It (Strode & Chamberlain, 1994; Chamberlain & Strode, 1993)

Also focuses on development of syllable shapes
The pre-school version included age-appropriate pictures and hand gestures similar to touch cues
Preschool version specifically targets vowels as well
No documented efficacy of this specific treatment

Moving Across Syllables

Focuses on development of syllable shapes and movement patterns between place of articulation
Sold as complete manual with assessment and black and white reproducible sheets that can be cut into card
No documented efficacy of this specific treatment

Integral Stimulation Therapy/ Dynamic Tactile and Temporal Cueing (Strand & Debertine, 2000; Strand & Skinder, 1999; Strand 2009)

Facilitate motor performance and motor learning for speech patterns
Well described treatment approach for CAS
Strong theoretical basis and encompasses principles of motor learning (see Motor Learning and CAS)
Target 3-10 targets at a time
Use max cues to achieve correct productions and fade out
One published case study regarding the effectiveness of this treatment, found to be effective, evidence is weak but at least has evidence
See further description and comparison with phonological treatment in Treatment of CAS vs. Phonology

Therapy for Prosody

Pacing board: For children who cannot yet read, can put pictures of words and follow with their finger, they add in stress every nth word

If the child can follow with 1:1 correspondence can also use colored dots and add in stress every certain colored dot.
In this example, would add stress every red square

For children who can read, can mark words or syllables using a highlighter, every word that is marked receives extra emphasis.

For example: My mom went to the store to get a pumpkin

Suggested Treatment Goals Suggested from the Literature and Clinical Practice

Verbal Goal Hierarchy for Non-Verbal Child

To increase functional signs to express wants/needs
To establish a core vocabulary for child
To imitate or spontaneously produce motor sounds or animal sound
To imitate or spontaneously produce a variety of vowels
To imitate or spontaneously produce a variety of vowels with other vowels (i.e. /i/-/o/)
To imitate or spontaneously produce a variety of consonants
To imitate or spontaneously produce a variety of vowels and consonants in combination

Verbal Goal Hierarchy for Verbal Child

To produce CV and VC syllable structures
To produce VCV syllable structures
To produce CVCV syllable structures
To produce VCVC syllable structures
To produce CVCV syllable structures with alternating vowels
To produce CVCV syllable structures with alternating consonants
To produce CVCV syllable structures with alternating vowels and consonants
To produce CVCVCV syllable structures with alternating vowels and consonants
To produce CVC syllable structures
To produce CVCV syllable structures with assimilation of posterior and anterior positions example

Goal example for a child who is producing /m, p/ with cues

To produce CV and VC syllable structures (my, pie, mo/Elmo), bye, up, moo, ba)
To produce VCV syllable structures (obo, emo/Elmo)
To produce CVCV syllable structures (moo-moo, ba-ba)
To produce VCVC syllable structures
To produce CVCV syllable structures with alternating vowels (baby, mommy, puppy)
To produce CVCV syllable structures with alternating consonants (moo-boo?)
To produce CVCV syllable structures with alternating vowels and consonants (maybe, boppy)
To produce CVCVCV syllable structures with alternating vowels and consonants
To produce CVC syllable structures (mop, bop, bam, beam)
To produce CVCV syllable structures with assimilation of posterior and anterior positions (go ma)

PROMPT Approach

PROMT is an acronym for "Prompts for Restructuring Oral Muscular Phonetic Targets"

Involves touch and pressure (kinestietic and tactile cues) achieved by the therapist placing her hands onto the articulators of the patient
This touch and pressure is hypothesized to provide greater input the motor system for both feedback and feed forward mechanisms

Must be certified in the PROMT approach to provide this type of treatment

This is an intensive (3 days) and expensive ($650 per person) program; the institute itself is non-profit
It requires follow-up with videos sent to the PROMPT trainers to ensure techniques applied correctly

The website for the PROMPT institute lists and describes research studies documenting efficacy, there are no peer-reviewed studies of efficacy
Some children may not tolerate the therapist placing his/her hands on the child's face or articulators
Overview of PROMPT hierarchy (Hayden, 1994)

Level I: postural support for speech, emphasizes the attainment of trunk, neck, and head control, and the suppression of abnormal oral-motor reflexes
Level II: phonatory control (ability to voice) for at least 2 to 3 seconds
Level III: jaw movements in speech; different degrees of opening for different vowels. There is establishment of control over vertical jaw movements, while inhibiting horizontal and anterior-posterior movements. Maximal jaw opening for normalized speech is established, i.e., the degree of opening of the jaw should not exceed that of the position required for / a / in connected speech. Control over the degree of jaw opening is then established using age appropriate words that contain vowels of varying heights
Level IV: adequate jaw control, lip rounding and retraction are practiced at this level
Level V: Anterior and posterior tongue action, raising-lowering movements, and contraction along the tongue body
Level VI: Retain control of the above for longer lengths of speech production
Level VII: Retain control of the above while normalizing rate and intonation

Augmentative and Alternative Communication (AAC)

AAC should be considered any time expressive language skills are not consistent with receptive skills (Grether, personal communication)

Need to provide the child with a way to communicate
Reduces pressure on speech motor mechanism which will be beneficial
May also improve later literacy skills, important for children with CAS

Be careful with dependency on sign language
Newmeyer et al. (2007) documented a subtle fine motor delay in children with speech sound disorders, may have difficulty with rapid coordination of movements for sign
American sign language may not facilitate literacy as well as AAC may

Oral Motor Exercises

A word about the use of oral motor exercises in children with CAS

Children with CAS do not generally need to improve strength; if dysarthria is present may improve strength but even dysarthria treatment includes speech gestures as soon as possible
There is very good, very solid evidence that the neural mechanisms mediating speech production vs. other oral motor gestures are DIFFERENT. Focusing treatment on non-speech gestures, even the coordination of non-speech gestures or movements WILL NOT facilitate production
Very limited tactile input to help the child understand placement cues may be appropriate (e.g. this is your alveolar ridge), but it should be immediately paired with speech production
This is the one area we have evidence in CAS, not for what is helpful but for what is NOT helpful

Frequency of Production

In a recent study, Edeal and Gildersleeve-Neumann (2011) reported the results of a small study investigating the importance of the frequency of target production in therapy. This article is summarized well on the CASANA website (http://apraxia-kids.blogspot.com/2011/05/what-research-says-importance-of.html). Although there are certainly limitations in this article, it serves as an important reminder that SLPs need to make maximal use of the time in therapy with children to elicit a maximal number of productions. Although no specific frequency has been identified as the most effective, Edeal and Gildersleeve-Neumann found over 100 to be more effective. Additional research is needed to identify the most effective number of productions.

Suggestions for improving frequency of production include:

Setting a goal and using a counter during therapy to measure progress towards goals. Electronic counters are now available and do not make the same clicking noise as the mechanical versions. There are also counter apps for smart phones that are free.).
Use a metronome to determine the pace of your treatment, adjust as needed. For example, you could start at a very slow setting (17 beats per minute) to determine if you elicit a production for every beat. If you are not on target to meet the goal you set, use this feedback to increase the pace. Some children even find producing targets with the metronome beats to be motivating. On-line software is available for your computer and there are several free apps for metronomes. Additionally, if you have the program Garage Band on your computer, a metronome is built in to that program.
Set a timer for a specific time during therapy (I usually do 5-10 minutes) and during that time, both you and the child know the goal is productions. Chose a reinforcing activity that does not require much turn taking to minimize time lost to play. After the timer goes off, a less production focused approach can be used during therapy.
Alter your reinforcement schedule to increase productions. If you are used to requiring 3 productions prior to a reinforcement activity (a turn, a crayon, etc.) determine if the child can go to 5 productions. This tends to work better for older children.

The complete reference for the Edeal and Gildersleeve-Neumann (2011) is: Edeal, D.M. & Gildersleeve-Neumann, C.E. (2011). The importance of production frequency in speech therapy for childhood apraxia of speech. American Journal of Speech-Language Pathology. 20(2), 95 – 110. The abstract can be accessed by the public and the full text for ASHA members at:

http://ajslp.asha.org/cgi/content/abstract/20/2/95.

Literacy and CAS

Emerging line of research indicating children with CAS may be at risk for literacy deficits during school-age years,
In a follow up study of school-age children diagnosed with CAS during the preschool years, Lewis et al. (2004) found the following differences:

Decoding
Reading comprehension
Spelling
Performance IQ scores

Implications for treatment

May also want to include phonological awareness, pre-reading, spelling, non-phonics approach to reading, for children with CAS

At a minimum must monitor and be aware children with CAS are at-risk for these deficits

Work with the educational team to identify deficits early maximize performance

Diagnosing: CAS vs. Phonology

Differentially diagnosing CAS from phonology can be very challenging
Phonology is defined as "the science of speech sounds and sound patterns" (Sloat et al. 1978)

"Phonological process analysis is a common method for identifying error patterns" (Bernthal et al., 1998); error patterns are also present in apraxia which makes differentially diagnosing the two conditions challenging

Examples of phonological processes identified include "Whole word processes include final consonant deletion, unstressed syllable deletion, reduplication, consonant cluster simplification, epenthesis, metathesis, coalescence, and assimilatory (harmony) processes" and "Segment substitution processes include velar fronting, backing, stopping, gliding of liquids, affrication, vocalization, denasalization, deaffrication, glottal replacement, prevocalic voicing, and devoicing of final consonants" (Bernthal et al., 1998)

When children present with severe speech production problems, the question is- IS THIS LINGUISTICALLY OR MOTORICLY BASED?

The problem is, it is NOT that simple, especially in younger children and children still acquiring language

Do children with CAS also present with phonological disorders?

They can! Phonological systems are rule-based systems, they are built on the rules established by the child's linguistic system
When a child has CAS, there is a lack of consistent productions, therefore a lack of a consistent system on which to build rules

Can children have both CAS and a phonological disorder?

Yes, they can; although CAS is presumed to be a motor planning disorder, this variance in motor planning is likely to affect phonological development

One of the biggest reasons to differentially diagnose is to implement the appropriate treatment approach. At the most basic level, the treatment approaches for phonology and apraxia have some similarities

See the chart on phonological treatment approaches vs. CAS treatment approaches

Alternative and Supplemental Treatments

This is not an endorsement of any type of alternative treatment. Rather it is a compilation of treatments about which parents may inquire
These therapies may be primary or supplemental
The type of treatment and resources for accessing additional information are listed below

Nutritional supplements

Believed to replace or supplement missing elements impacting the nervous system
Among the proposed interventions are fish oils, a variety of omega oils, gluten-free diets, and Vitamin E
No peer-reviewed evidence
Anecdotal evidence can be found on the web
Appear to be gaining popularity
Recommending this is outside the scope of speech pathology; encourage families to talk to the pediatrician, dietician, or other sub-specialist (e.g. developmental pediatrician, neurologist)
http://www.apraxia-kids.org/site/c.chKMI0PIIsE/b.980831/apps/s/content.asp?ct=464239
http://www.apraxiaspeaks.com/new-research-apraxia.html
http://www.zimmerscope.com/apraxia.html

Craniosacral therapy

What is it?
Should be certified in this approach prior to attempting, generally physical and occupational therapists, massage therapists implement this approach
Through manipulation of the cranioscaral system (skull, spine, fascia) believed to modify and improve flow of cerebrospinal fluid which will improve skills
No evidence related to improvement in speech; controversial evidence for other disorders
http://www.craniosacraltherapy.org/Whatis.htm
http://en.wikipedia.org/wiki/Craniosacral_therapy
http://www.quackwatch.org/01QuackeryRelatedTopics/cranial.html

Music therapy

Music used to improve all aspects of patient, including physical and emotional
Popular intervention, does not specifically focus on speech production
No peer-reviewed evidence for speech
http://www.musictherapy.org/
http://www.musictherapy.org/faqs.html

Melodic intonation therapy

Originally intended for patient with brain damage
Based on theory can re-train right hemisphere to compensate and aid in speech production
Frequently used for treatment of aphasia
No peer-reviewed evidence for CAS
http://en.wikipedia.org/wiki/Melodic_intonation_therapy
http://aphasiology.pitt.edu/archive/00000680/01/07-11.pdf (adult study)
http://www.ncbi.nlm.nih.gov/pubmed/7994292 (ABSTRACT ONLY; clinical perspective, no experimental evidence in CAS)

Tomatis method

Program designed to improve listening and increase right hemisphere activation
More frequently used in ADD, ADHD
No evidence specific to CAS
http://www.tomatis.com/
http://www.vanderbilt.edu/AnS/psychology/health_psychology/TOMATIS.html#INTRODUCTION
http://www.apraxiaspeaks.com/sound-therapy.html

ASHA Convention Handouts (08-10)

http://www.asha.org/Events/convention/handouts/2008/2358_Vossbeck_Kelli.htm

http://www.asha.org/Events/convention/handouts/2010/1259-Shriberg-Lawrence.htm

http://www.asha.org/Events/convention/handouts/2010/2323-Pukonen-Margit.htm

http://www.asha.org/Events/convention/handouts/2008/2359_Lewis_Barbara.htm

http://www.asha.org/Events/convention/handouts/2010/1850-Skelton-Steven.htm

http://www.asha.org/Events/convention/handouts/2009/1972_Bauman-Waengler_Jackie.htm

http://www.asha.org/Events/convention/handouts/2010/1851-Lyons-Kristin.htm

http://www.asha.org/Events/convention/handouts/2008/2360_King_Jaime.htm

http://www.asha.org/Events/convention/handouts/2008/2361_Moore_Jill.htm

http://www.asha.org/Events/convention/handouts/2008/2402_Edeal_Denice.htm

http://www.asha.org/Events/convention/handouts/2009/1372_Flipsen_Jr_Peter.htm