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Differential Diagnosis In Childhood Apraxia of Speech

Lori Hickman, M.A., CCC-SLP

There are many disorders which can cause a delay in a child’s verbal communication skills. Among them are apraxia, dysarthria, autism spectrum disorders, cognitive delay, hearing impairment, visual impairment, functional speech impairments, genetic disorders (i.e., Down Syndrome, Fragile-X, Angelman Syndrome), social/emotional disorders, and central auditory processing disorders. In order to make the best treatment plan, a Speech-Language Pathologist (SLP) must make what is called a “differential diagnosis .” This means that he/she must evaluate your child and review his/her records regarding pregnancy, birth and development in order to figure out which of the many possibilities may be causing your child’s communication delay. This task is made even more difficult by the fact that for most children, more than one of the disorders listed above may be contributing to the delay.

A diagnostic work-up then, must “rule out” some of the disorders so that only a few are left. In this way, treatment can be focused in the most meaningful and effectual way. When you take your child to be evaluated by an SLP, he/she will need to know many things in order to make appropriate diagnostic and prognostic statements. These statements are essentially explanations that provide information for you regarding the cause of your child’s delay, what the SLP recommends be done to treat your child, and how long he/she thinks your child will need to receive professional treatment.

A complete diagnostic work-up is the only way to make a differential diagnosis. This is because so many disorders have symptoms that are similar. For many children that the SLP will evaluate, the primary concern is lack of or limited verbalizations. To “rule out” many of the disorders listed above (and those not listed as well), your SLP will need as much information as you can provide to add to the information he/she will obtain during the evaluation.

The information gathering and assessment of your child will probably include the following:

Your Child’s Development:

  1. Hearing – The very first consideration when attempting to determine the cause or etiology of a child’s communication delay is that child’s hearing status. Whenever a child exhibits delays, an audiologist should perform an audiological evaluation to ensure that hearing loss is not a factor in the child’s delay. Vision should also be assessed.
  2. Pregnancy and Birth History – the SLP will want to know about any illnesses or accidents you may have had during your pregnancy with this child; also, any labor and/or birth information that may pertain to your child’s communication delay.
  3. Developmental Milestones – the SLP will want to know when your child rolled over, sat, crawled, walked, etc. Comparison of your child’s development to other children’s will assist the SLP in evaluating your child’s overall development and in identifying other areas which may be of concern.


Communication With Others – The SLP will want to know all the ways that your child communicates with others:

  • verbalizations/words
  • nonverbal communication such as:
    • pointing
    • eye gaze (toward the desired object)
    • eye contact
    • bringing object to another person for help
    • bringing/dragging another person to a desired object
    • shaking head yes/no
    • shared attention (when a child engages another person in their activity or play through eye contact, body language, giving objects, etc.)
    • tantrums (yes, these can be a form of communication!)
    • shyness/passivity especially with strangers, etc.

The SLP will also be looking for these communication strategies/skills during his/her assessment of your child:

Receptive/Expressive Language:

The SLP will want to know what words, phrases, instructions, etc. your child understands (his/her receptive language ability). He/she will also evaluate the verbalizations your child is using and your child’s ability to name/label objects and pictures (his/her expressive language ability). He/she will use standardized tests (tasks that have been designed to be completed in the same way with each child so that the child’s skills can be compared to other children of that chronological age) to measure this.

Articulation/Oral Motor Skills

The SLP will look inside your child’s mouth to complete an oral motor exam. He/she will look at your child’s oral structures (hard and soft palate, tongue, teeth, uvula) to see if there are differences/abnormalities in these structures that may be interfering with your child’s ability to
produce phonemes (sounds). He/she will observe your child to determine if your child drools (and if so, under what circumstances), what position your child’s oral structures are at rest (when they are relaxed, i.e., is the tongue protruding or sticking out of the child’s mouth?), etc.

The clinician will look at the following in terms of your child’s articulators (tongue, jaw, lips, soft palate-the parts of his/her mouth that your child uses to articulate or talk):

  1. Automatic Control of the Oral Structures – the SLP will want to know how your child moves his/her articulators when he/she is making movements that are familiar, often-used, and so, automatic to the child (i.e., biting, chewing, swallowing a cracker; kissing; blowing bubbles, etc.). Children with apraxia generally can complete often-used and familiar movements such as these spontaneously. Children who exhibit difficulty with these automatic oral movements may be exhibiting a dysarthria, a motor disorder characterized by abnormal oral reflexes, vegetative functions (sucking, swallowing, etc.), and weakness of the oral muscles. It is important for the SLP to determine if dysarthria is contributing to your child’s intelligibility deficits.
  2. Volitional, Nonverbal Movements – the SLP will want to know how your child moves his/her articulators when he/she is attempting to imitate or produce nonautomatic movements and sequences of movements with his/her articulators. These are movements that are novel to the child. The child will watch the SLP make a movement or several movements with her articulators and then attempt to imitate the movements. The SLP will observe to see how easily the child is able to do this. Children with apraxia often have difficulty with activities that require them to imitate the clinician’s oral movements. In effect, they have to use the SLP’s face like a mirror. Even small babies will do this (i.e., if you stick your tongue out at an infant, he/she will often do the same back at you). Children with apraxia may not be able to do this consistently, or may have to pause and/or “grope” (this is where the child responds to the SLP’s visual model by positioning his/her articulators in the wrong position and then moving to the correct position) for the position they should take with their articulators.
  3. Volitional Verbal Oral Movements – as stated in #2, but combined with verbalizations.
  4. Altering Motion Rates of the Articulators – the SLP will want to see if the child can repeat a sequence of movements, with and with out verbalizations, and at different rates. Children with apraxia have difficulty not only in repeating sequences of oral movements, but in altering the rate (slow, medium, fast) that they produce the sequence(s).
  5. Diadochokinetic Rate – the SLP will want to see how quickly the child is able to produce sounds using different parts of his/her mouth (front of the mouth “puh,” middle of the mouth “tuh,” back of the mouth “kuh,” and all three together “puhtuhkuh” over and over). Children with apraxia have difficulty repeating syllables as quickly as other children their age would. They are often unable to repeat the multiple-syllable task of “puhtuhkuh.”
  6. Ability to Articulate Phonemes, Syllables and Words – the SLP will want to see how the child is able to imitate phonemes (sounds) at all of these levels of production. This is important in order to determine where in the process this particular child’s coarticulation skills disintegrate (at the sound level,the syllable level, the word level, the phrase level, in conversation, etc.) This enables the SLP to determine the severity of the child’s apraxia, the sounds and sound sequences that are effected, and which types of error the child exhibits for these motor sequences (an omission, distortion, substitution, or addition of sound(s)). Additions of phonemes are particularly indicative of apraxia.
  7. Production of Vowels During Coarticulation – the SLP will want to determine if the child has difficulty with the vowels in a word or just the consonants. Vowel distortions are often heard in children with apraxia.
  8. Ability to Articulate Multiphonemic Patterns – the SLP will want to see if the child has more difficulty with production of phonemes as words become longer, or as utterances become longer. Children with apraxia become more difficult to understand as their words and/or phrases become longer.
  9. Phoneme Production In Spontaneous, Contextual Speech – the SLP will want to hear how the child’s spontaneous (non-imitated) speech sounds. How much (what percent) is understandable (intelligible)? How long are the utterances? What types of language (vocabulary) and sentence structures is the child using? Is the intelligibility, utterance length and complexity typical for a child this age? If not, in what ways is it different? Children with apraxia are more difficult to understand in their spontaneous conversation than other children their age. They also use shorter, less complex, sentences than their age-mates.
  10. Prosody– the SLP will want to determine if the child is able to imitate changes in the rate, intonational pattern, and/or intensity(loudness) of their utterances. Does the child’s spontaneous speech sound like that of his/her peers? If not, in what ways are these features different for the child? Does the child’s speech sound more or less nasal than other children’s? Children with apraxia often use what is called “equalized stress” when they speak. That means that they place equal emphasis on each word, sometimes seeming to pronounce/say each word as a separate unit instead of coarticulating (connecting) the words. They also have difficulty varying the loudness of their verbalizations or the rate at which they speak.
  11. Error Patterns – what articulatory (movement) sequences does the child produce successfully? Which ones are difficult for your child? Do those that are in error involve primarily tongue movements? Lip movements? Both? Are the errors an omission, a distortion, a substitution or an addition of the phoneme (sound)? Are all these types of errors present? Are they consistent or inconsistent? Under what circumstances (consistent/inconsistent)?
  12. Communicative Impact -How much does the child’s difficulty in communicating impact his/her life? What is the child’s response to a listener’s inability to understand his/her verbalizations? (frustration,tantrums, withdrawal, passivity, etc.)

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (CASANA)