Recently, I have been getting an influx of children with the diagnosis of Childhood Apraxia of Speech (CAS). Sometimes the child actually has Childhood Apraxia of Speech. However, most often they are wrongly diagnosed.
There have been several studies over the past few years that have shown that when evaluated by an expert in Childhood Apraxia of Speech roughly 75% of children with the diagnosis are found not to have the disorder. One study even reported that 7 out of 53 children previously diagnosed or suspected of having Childhood Apraxia of Speech, a full 87%, did not actually have the severe speech disorder.
Neurologists Should Not Diagnose Apraxia
It feels as if every time I turn around there is another non-verbal 2 year old getting this diagnosis from a well meaning Neurologist. There seems to be many Neurologists who will diagnose any child who has a normal neurological exam at age 2 and is not talking with Childhood Apraxia of Speech.
I am not blaming the Neurologists for this. Most of the time, they are put in this position by Speech Language Pathologists who don’t feel comfortable giving the diagnosis themselves.
Unfortunately diagnosing this severe speech disorder is not easy. In fact there is no one agreed upon assessment tool within the field to make the diagnosis. Because of this many Speech Language Pathologists do not feel as if it is their role to make this call when in fact it is.
Expertise Matters
Of course the Speech Language Pathologist should have extensive knowledge of childhood motor speech disorders to properly diagnose and to treat Childhood Apraxia of Speech. If they don’t, a referral to Speech Language Pathologist who does is the more appropriate next step.
While the person who makes the diagnosis may seem unimportant, it really is extremely important.
A neurologist can rule out any other neurological causes for a severe speech disorder; however they should not be asked to make the diagnosis of Childhood Apraxia of Speech. They are not experts in speech and language disorders, only Speech Language Pathologists are. Neurologists have plenty of other areas in which they are the experts; this is not one of them.
This scenario is contributing to the over-diagnosis of this disorder.
Age Of Diagnosis Also A Factor
Another factor contributing to this problem is the age of diagnosis. A child should be at least 3 before they can be accurately diagnosed. Prior to age 3 the disorder may be suspected, but it should not be diagnosed. A lot can change between the ages of two and three.
Childhood Apraxia of Speech is a speech disorder which involves motor planning deficits of volitional speech. Until a child makes an attempt to speak we have no idea what is going on. We can suspect motor planning is an issue due to some red flags we look for, however a diagnosis should not be made too early.
Important Red Flags
Some red flags in infants and toddlers include; little or no babbling, drooling and feeding difficulties, limited intonation, and words used and then lost.
While these characteristics are not enough to make a diagnosis they are reason to be concerned and take action. A child suspected to have Childhood Apraxia of Speech should be treated as though they have the disorder even without a diagnosis.
Just because there is over-diagnosis does not mean that therapy should be avoided. With any speech disorder the sooner therapy starts the better the outcome.
When a child has Childhood Apraxia of Speech he or she may need 3000 productions of a sound combination or word to learn a muscle memory for that combination. So I am a strong believer that the more therapy a child is able to get, and the sooner they get it, the better. I would add to that, that therapy must be fun and doable for everyone. If someone in the equation is miserable something must change.
Stop Searching and Take Action
So if you are a parent of a young child who is diagnosed with Childhood Apraxia of Speech and you are searching and searching for answers and opinions, stop now. Find yourself an excellent Speech Language Pathologist with the proper experience and start therapy immediately.
While finding answers is important, getting the right therapy for your child is a better use of your time.
Sources noting over-diagnosis of Childhood Apraxia of Speech:
Stoeckel R., (2008). Childhood Apraxia of Speech (CAS) Differential Diagnosis and Practical Treatment Strategies, 8-9. Rye, NY
Jakielski, K J., (2006) Childhood Apraxia of Speech (CAS) Assessment and Intervention, 12-13. White Plains, NY.
Shriberg L.D, Campbell T.F., (2002). Proceedings of the 2002 Childhood Apraxia of Speech Research Symposium, 38. Tucson, Arizona: The Hendrix Foundation
Davis, B.L., Jakielski, K J., & Marquqrdt, T.M. (1998). Deveopmental Apraxia of Speech: Determiners of Differential Diagnosis. Clinical Linguistics and Phonetics, 12, 25-45.
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{ 2 comments }
You say, “A child suspected to have Childhood Apraxia of Speech should be treated as though they have the disorder even without a diagnosis.” However, as a mom who has logged hundreds of hours fighting with her insurance company, I can tell you that without a diagnosis, the insurers will not approve speech therapy at all. In addition, some State EI programs are ill equipped to handle the needs of these children. My son was diagnosed by an SLP in my State’s EI program as having suspected apraxia at age 21 months. He then languished for months without progress under the care of a traditionally trained SLP who claimed to have experience treating children with apraxia. Luckily, we found a developmental pediatrician who was willing to diagnose him with apraxia because the insurance company would not accept the diagnosis from an SLP, it had to be from a medical professional. So I realize that you believe that an MD cannot diagnose apraxia, but most insurance companies will not accept any diagnoses from non-MDs. We also located the *ONLY* SLP under EI in our area who was trained in Kaufman (none were trained or certified in PROMPT) and, amazingly, my son began to show progress under her care! With the diagnosis of apraxia from our MD, the insurance company approved PROMPT therapy which he has in addition to Kaufman from the EI SLP. What little “speech” he has is still largely unintelligible at 2.5 yrs old, but how wonderful it is to hear him try at last! I can sympathize that you think the condition is being over diagnosed, but you also say that childern with suspected apraxia should be given the same treatment tools as those with confirmed apraxia. You should know that without someone (typically an MD) who is willing to diagnose “apraxia” children with suspected apraxia will NOT receive the proper treatment. Yes, some will be just fine over time, but some won’t and frankly I don’t want to bet that my child will be just fine. I’d rather get treatment early as you recommended in your article. I just thought you might benefit from hearing why a diagnosis of apraxia is SOOO important from a parent who has fought the good fight with insurance and the EI system.
-les
Hi Les,
Thank you very much for your comments. I agree with what you said and deal with reimbursement issues just about every day in my practice. Regardless of the diagnosis insurance companies always want documentation from an MD. I will most often make the specific diagnosis or recommendation and then refer the child to their doctor or neurologist to get a letter of medical necessity with a diagnosis code.
While the code and letter are needed for reimbursement a Speech Language Pathologist is the one with expertise in sound speech disorders and should make the original diagnosis. When I speak of proper diagnosis I am looking at the diagnosis of the disorder separate from the funding issue. It’s disappointing that your original EI Speech Language Pathologist did not have the expertise to treat speech sound disorders.
Happy to hear you found the right therapist now and your son is making progress!
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