(Updated by the author November 2003)
- What resources are available on Childhood CAS of Speech (CAS)?
- At what age is it appropriate to diagnose CAS?
- What factors do you use in basing recommendations for intensity of direct speech therapy services for children with CAS?
- How much overlap is there between CAS and aphasia?
- Is CAS a red flag for other possible neurological disorders?
- Is CAS a red flag for up and coming disorders, such as Pervasive Developmental Disorder (PDD), OCD, Attention Deficit Hyperactivity Disorder (ADHD), etc.?
- What are “limb apraxia” and “global apraxia”?
Q. What resources for parents and/or therapists are available on CAS?
A. Since I first wrote this column 6 years ago, the internet has become a much more reliable resource for parents and professionals searching for information on CAS. The CASANA/Hendrix Foundation website has wonderful information. Shelley Velleman has written the Childhood Apraxia of Speech Resource Guide, available through Amazon.com. A google.com or yahoo.com search will result in multiple sites and resources.
That said, some of what you come across on the internet isnt necessarily factual, current, or research-based. Be a careful consumer is the web-site through a university? Does the organization have a list of advisors on their website? If so, are they speech-language pathologists? Does the web-site make claims of cures? If in doubt, come back to CASANA and see if they have knowledge.
Check out bookstores and libraries for books written for parents. Check out www.asha.org for reputable links.For professionals, the ComDis Dome is a great resource for finding books, papers, and articles.
Go to conferences, talk to speech-language pathologists, and talk to other parents. Most of what I know about treating motor speech disorders has come from attending advanced level seminars and by learning from other therapists.
Useful THERAPY PROGRAMS
- Easy Does it For CAS and Motor Planning, LinguiSystems, 1993
- Easy Does for CAS — Preschool, LinguiSystems, 1994
- Moving Across Syllables, Communication Skills Builders, 1990
- The Kaufman Speech Praxis Kit, Wayne State Press
Q. At what age is it appropriate to diagnose CAS?
A.Basically, a diagnosis of CAS cant be confirmed until a child has enough of a speech repertoire to determine that there is a deficit.So, you could have a very talkative 2-year-old who is 100% unintelligible that could be diagnosed, but if you have a completely non-verbal 4-year-old, it might be more difficult. However, a working diagnosis can be made, and therapy initiated as young as 2 or 3 if there are significant concerns.As with other disabilities, early intervention is crucial.
Q. What factors do you use in basing recommendations for intensity of direct speech therapy services for children with CAS?
A. The decision about frequency and duration of therapy, as well as the age of onset for therapy, must take into account a number of factors. It must always be a decision made based on the individual needs of the child. The first factor, and most important to me, is the readiness of the child. Is the child able to sit for a reasonable period of time? Can she sustain attention long enough to respond to the therapist? Does she have the ability to follow oral directions? Can she respond to an adult other than a parent? Also, children will benefit from more or less therapy at different times in their lives. Sometimes, a child will be making great strides in their reading skills, and need a break from speech. At other times, motor skills will be regressing, and the decision will be made to concentrate on physical or occupational therapy.
The second factor is the severity of the disorder. The more severe the child is, the more intense therapy will need to be. When therapy is just beginning, I will never recommend group treatment for CAS. As children progress in therapy, and when they are older (maybe 2nd or 3rd grade) adding another child can be beneficial, as long as some sessions are still individual.
A third factor is the commitment level of the parents. Will the parents be able to get the child to therapy twice a week? three times a week? Are they able to follow through on recommendations and home practice assignments? Another factor is whether or not the child is getting other services. Is she enrolled in a preschool class? Is she getting group therapy? Once these factors are weighed, there are factors relating to the setting. Some clinics/hospitals provide one-hour sessions, others provide half-hours. Schools are going to offer primarily group therapy; if you feel that your child needs individual therapy, you will have to push. While I feel that group therapy can be effective for phonology and articulation skills, I have seen moderately and severely apraxic kids make limited progress until they receive individual therapy.
Then the question remains, how many sessions per week? If your child is receiving therapy from a qualified therapist who knows her stuff, two or three individual sessions should be sufficient to see progress. The rate of progress will depend on the individual child, the appropriateness of the exercises, and the parents’ follow-through on home practice assignments. I am a firm believer that “more is not necessarily better”. Some parents want to enroll their children in multiple programs, and give them the MOST therapy. This can, in fact, be counterproductive. Children who are over-scheduled may end up rebelling, and then no therapy will help. I believe that no matter what the special needs are of the particular child, we must remember that above all, they are children. Children need time to play without therapists, teachers, counselors, and other well-meaning adults. It is essential to balance the special needs of a child with the ordinary needs of all children. There is no “formula” for deciding how much, how often. The decision should take into account all of the above factors, as well as the parents’ desires and needs. Like all decisions, sometimes the wrong choice will be made, and then you will make adjustments, as needed. Flexibility and a good sense of humor can always be effective tools as you navigate the maze of special services.
Q. How much overlap is there between CAS and aphasia?
A. Aphasia is impairment of comprehension, formulation, and expression of language. Aphasia is most often the result of brain damage, like a stroke, epileptic aphasia, etc. CAS is a disorder of the motor planning required to formulate given words. The child or adult with apraxia knows what they want to say – they just can’t coordinate all of the motor movements. In stroke patients, there is a large co-incidence of apraxia and aphasia. From what I have read and in my experience with children with CAS there does not appear to be an overlap. These children may have some co-occurring expressive language problems, but these appear to be due to the general delay in talking and the reduced intelligibility rather than an underlying “aphasia” or language disorder. The kids I see who appear to have an “aphasia” in addition to CAS also have a significant neurological history.
Q. Is CAS a red flag for other possible neurological disorders?
A. The children whom I have seen with isolated CAS do not have associated neurological disorders. Some of them have accompanying sensory-motor or fine-motor difficulties. In general, though, in the absence of a significant medical history of seizures, lack of oxygen at birth, etc., CAS by itself does not raise the red flag.
Q. Is CAS a red flag for up and coming disorders, such as Pervasive Developmental Disorder (PDD), OCD, Attention Deficit Hyperactivity Disorder (ADHD), etc.?
A. The therapist says to this one “Don’t borrow trouble”. Really, it’s hard to say. My initial thought is that there are certainly kids with PDD, OCD, ADHD who also exhibit signs of CAS, but this would be coincidental and not cause-effect. Similarly, some children with CAS may also have ADHD, etc., but again, this is coincidental. Not all children with CAS have other symptoms, and not all kids with PDD, etc. have CAS. How’s that for a non-answer?
Q. What are “limb apraxia” and “global apraxia”?
A. “Oral apraxia” and “verbal apraxia” are terms which describe a difficulty coordinating mouth and speech movements, “limb apraxia” would refer to motor planning deficits relating to arms, legs, fingers, etc. and “global apraxia” would be all of the above. The globally apraxic child would very likely be a mild cerebral palsy or “sub-clinical” cerebral palsy.