Seventy Five Percent Of Apraxia Cases Wrongly Diagnosed

by Isa Marrs

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.

{ 154 comments… read them below or add one }

Tania March 31, 2014 at 6:48 am

My son just turned 2. He receives 2 Sessions for speech and 3 sessions of PT per week. He pretty much has 4 words and some animal sounds. He has been receiving Early Intervention therapies since 7 months of age due to gross motor delays and torticolis. My question is why is it so difficult for him to imitate speech sounds? Why are the vowels such a challenge for him? He can’t say oo, oh, ee, ai… Pretty much his only vowels are ah and eh. He has not been diagnosed with CAS yet. He did have feeding problems but that has improved considerably and he has a gross motor delay and wears orthotics. My third and last question: when should I ask for a CAS evaluation? Thanks in advance.

Deepak April 2, 2014 at 4:18 am

My son 2.5 yrs old. A month ago I was surfing internet to find out the reasons of speech delay and I stumbled across Autism. It was quite new to me. Then, I started following the symtoms and started matching them with my son. He had most of them. Probably, because we let him grew that way. We threw him in front of TV, laptops and mobiles with loud music, rhymes. and given him lots of blocks to play with. But, never sat with him for an hour.

The moment we understood what autism is, we changed the routine completely and in a week we noticed that he was not much interested in lining those blocks or play alone. It was us who probably forced him.

We now get his diagnose done and doctor says he is in mild to moderate spectrum. We took lot of videos to explain how he behaves and to suggest us accordingly but in India no doctor really cares.

Symptoms why we think he may be a late talker or not much autistic: he can read easily (He learnt A-Z and 1-20 in 3 days), loves music, can stay 2-3 hours at dj, he does mix up with other kids (but tendency remain to be alone because he doesn’t understand the social rules), Memorize all the ways to our home, park, temple (I mean he knows where is he going and will give expression accordingly, he is very much attentive to surroundings ), he can say ‘water” when he is thirsty, he can say ‘juice’when he wants juice. he has good eye contact with everybody. He laughs, smile and cry. If he is in need of something he can go to anybody in crowd of 100s of people and ask for the help (Non verbal though, he will pick someones hand and will take to somewhere he needs the help). He has no problem if other kids are playing where he is playing.

Symptoms which suggests he may have mild autism, he doesn’t pay attention to what we are saying. Doesn’t react to his name always (2 times out of 10). He is very selective to what he wants to respond, for example if we say ‘take juice’, he will immediately turn back with smile and expanding his hands. but, if we tell him ‘look dog’ he would never look, not even if we say alound 20 time. Has 6-7 words so far which he uses to communicate. But, can sing 20 songs, 30 rhymes and play drum. Music draws his attention immediately (because music is all he has listen to b/w 15-30 months of age).

Just 2 days ago he was found extreme deficient in Vitamin D (6.49 ng/ml). We are very confused what should we do. We don’t want to wait and watch. We want to act to provide what is the best for him. Any suggestions…

Isa Marrs April 10, 2014 at 9:22 am

Your son is a too young to give a firm diagnosis of CAS however a therapist can say it is “suspected” if he is displaying some of the signs. With all the other motor deficits he has it is likely that his speech delays are motor based. PROMPT therapy could be a beneficial therapy for your son if there are motor speech impairments. You might also want to increase his therapy to 3x a week. If you are working with a qualified Speech Language Pathologist she will make a diagnosis when feels confident.

Isa Marrs April 10, 2014 at 9:36 am

I definitely would put his nutrition first. This can make a huge difference in his development. find a good nutritionist who works with children who have special needs and make sure he is getting what he needs. Next I agree with what you have done. For a young child who is diagnosed with an autism Spectrum Disorder I recommend no screen time. Try to interact with him as much as possible. Establishing shared emotion and joint attention is crucial. It is also extremely important to get him high quality therapy. Some of therapies that could be beneficial are speech therapy, behavioral therapy, and occupational therapy. Be very proactive, now is the time!

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