It can be difficult to know exactly how to help children with childhood apraxia of speech during speech therapy sessions.  That’s why I’ve broken the communication skills out into categories and created a hierarchy of skills for each level.  Download the PDF using the button below and then keep reading to learn more about the different levels and how you can use this to figure out what to target during speech therapy sessions.

Click Here to Download the CAS Levels PDF

What is Childhood Apraxia of Speech (CAS)?

CAS is a rare, neurologically-based speech disorder where the child knows what he wants to say but the message gets mixed up in the motor planning and execution phase so the sounds come out all wrong.

Imagine it’s like you’re driving your car and you know you’re going to turn right so you turn on your right turn indicator (or blinker).  But then, for some reason, your clock starts flashing instead of your turn indicator light (true story, I once had a car that did this).  So you think, “Well that wasn’t what I wanted to happen” and you try again.  This time, your trunk pops open!  Imagine how frustrating that would be!

That’s exactly how it is for our kiddos with CAS.  They know what they want to say and they tell their mouth to say it but it just comes out all wrong.

How Do We Diagnose CAS?

Since CAS is still a relatively new diagnosis, there are no standard diagnostic criteria for determining if a child has it or not.  That can make it very difficult to know for sure if this is the right diagnosis.  From what we can tell, though, most clinicians agree that these three common features should be present for the diagnosis:

  1. Inconsistent errors on consonants and vowels in repeated productions of syllables or words (meaning that if the child says the same word many times, it may sound differently each time).
  2. Lengthened and disrupted coarticulatory transitions (meaning that the child’s speech sounds choppy or disconnected due to trouble transitioning between sounds or between words in older children).
  3. Inappropriate prosody, especially in the realization of lexical or phrasal stress between sounds and syllables (meaning that the rhythm, intonation, and stress of speech may sound off, the child may sound robotic, have incorrect phrasing, or stress the wrong words or syllables).

Other Characteristics of CAS (Less Commonly Agreed Upon)

These other symptoms have often been noted in children with CAS but don’t HAVE to be present for the diagnosis to be made:

  • Reduced vowel inventory
  • Vowel errors
  • Increased errors in longer or more complex syllable and word shapes (especially omissions, particularly in word-initial position)
  • Groping
  • Unusual errors that “defy process analysis”
  • Persistent or frequent regression (e.g., loss of words or sounds that were previously mastered)
  • Differences in performance of automatic (overlearned) versus volitional (spontaneous or elicited) activities, with volitional activities more affected
  • Errors in the ordering of sounds (migration and metathesis), syllables, morphemes, or even words

Speech Therapy for Children with CAS

Although therapy for each child will be individual to that child’s particular needs, we must consider and include these 4 components in their treatment (along with any other problems the child may be having):

  1. Speech Sound Production
  2. Language Development
  3. Augmentative-Alternative Communication (AAC)
  4. Prosody


Including the 4 Components in Therapy:

Think of each of those areas as a hierarchy of skills that the child needs to communicate.  Figure out where on the hierarchy the child is for each area and provide therapy that is appropriate to that need.  You should include all four areas as possible but for younger children you may need to prioritize two areas at first.  This method can also be used for children with suspected CAS or those who aren’t making progress with typical speech therapy.


Download My Skills Charts

I have outlined skill charts for each of the 4 components.  This is a basic framework to work from, but some children will need to do the steps out of order and some will be working on multiple steps at the same time.  Start with this framework and modify as needed for each individual child.

Click Here to Download the CAS Levels PDF

The 4 Areas:

1. Speech Language Production:

This is the first component of therapy for children with CAS and often the first one that we think of.  For this skill area, you will work on improving the child’s ability to speak speech sounds clearly and in increasingly long utterances.  Here is an example of the order that you might work on speech sound skills for a child with CAS (for more detailed info, download the PDF using the button above).

  1. Imitating Actions: Start by having the child imitate simple whole-body actions and move toward being able to imitate actions and sounds with the mouth.
  2. Functional Sounds, Sound Effects, Vocalizations: Encourage the child to make sounds with his mouth using sound effects and basic vocalizations, like making animal and vehicle noises or saying “mmmm” for a yummy sound.
  3. Sound Combinations (CV, VC): Have the child say some simple consonant + vowel (CV) and vowel + consonant (VC) words. These would be words like “me”, “no”, “hey”, “hi”, “bye”, etc.
  4. Repeated Strings of CV or VC: The next step is having the child repeat the same CV or VC structure twice. They could say things like “mama” or “dada” or “no no”.
  5. Add a Structure, Add a Sound: At this point, your goal is simply to add more structures and more sounds. Try to teach the child a new sound in a word structure they already know (like CV or VC).  Or, try to teach the child to say new word structures (like CVC or CVCV) with sounds that they’ve already mastered in CV or VC structures.
  6. Sound Accuracy in Phrases and Sentences: Work on increasing a child’s ability to say sounds correctly in phrases and sentences.
  7. Sound Accuracy in Connected Speech: Have the child practice saying speech sounds correctly during conversational speech.
  8. High-Demands Context: Once the child has mastered all of these other steps, he may still have trouble when he’s in high-pressure situations (like giving a presentation) or when encountering new, multi-syllabic words. Teach him strategies to help in those situations.

2. Spoken Language Skills:

The goal of this skill set is to improve a child’s willingness and ability to use speech functionally in the natural environment.  Speech sound accuracy is not the primary goal for this hierarchy (though it is encouraged), so close approximations of words are accepted and encouraged.  For more detailed information, download the PDFs using the button above.

  1. Increasing Vocalizations: Draw attention to mouth movements and sounds, encourage vocalizations while communicating with gestures or signs, teach parents on how to respond to and encourage vocalizations at home.
  2. Functional Vocabulary, First Words: Start with just a few highly motivating words and teach the child to say his best approximation of that word in functional activities. Provide many opportunities to say the words repeatedly and cue with sign language signs or other cueing.  Add more words as the child is ready.
  3. Functional Phrases and Carrier Phrases: Start putting together a few words at a time as soon as the child has some in his vocabulary. Spend some of your time teaching new single words and some of your time putting existing words together.  Use carrier phrases like “I want…” or “I see…”.  Continue to use these phrases and words functionally throughout the child’s day and provide many targeted practices of the words and phrases.  Exact pronunciation is not the key, functional speech is the target.
  4. Spontaneous Sentences: Encourage the child to put words together in new ways to form novel, spontaneous sentences. Start with targeted practice that will allow a child to practice a sentence structure repeatedly and move toward more varied productions.
  5. Grammatical Markers and Linguistic Components: Analyze which grammatical markers and linguistic structures are missing and systematically teach each one. Start with single words and gradually build up the sentence complexity in which the child is able to use the structure or component.
  6. Using Complete Sentences in Connected Speech: Provide targeted practice to use one grammatical marker or linguistic component in connected speech. Target 1-2 structures at a time until mastery or rotate through in a cycles-like approach.

** Introduce other language concepts as necessary for success or after achieving complete sentences.  Other skills may include following directions, increasing vocabulary, asking and answering questions, etc.  Not all children with CAS will struggle with other language concepts so they are not included here.

3. Alternative/Augmentative Communication (AAC):

The goal of this skill set is to provide a child an alternative means of communicating to relieve frustration and communicative pressure if speech is not adequate to do this.  If a child’s speech is functional to communicate everything that he wants and needs to communicate in his natural environment, this hierarchy can be skipped.  Or, this hierarchy can be abandoned once functional speech becomes adequate.

  1. Non-Standardized Communication/Engagement: Encourage the child to communicate intentionally with others using gestures, pointing, eye contact, joint attention, proximity, leading an adult by the hand, non-standard signs, acting out what one wants, etc.
  2. Choosing an AAC System: Choose an AAC system that meets the needs of the child, the family, the educational environment, etc. All members of a child’s family and educational team should be included in the decision-making process.
  3. Training for AAC System: All family members, educators, therapists, and the child should be trained on how to use the system.  If the system involves a device, this training should include basics of how to operate the device and how the child will use it.  If sign language is used, all participants should be shown how to learn new signs.
  4. Using AAC System for Functional Needs : Use of the AAC system is modeled by all communication partners. The child is encouraged to play with the system and is taught how to use the system to communicate with others using a single message (such as one sign or one button push).
  5. Combining Words Using AAC: Child is taught how to use the AAC system to combine words to create short phrases or simple sentences. Targeted practice provides many opportunities for the child to practice new combinations and sentence structures.
  6. Teaching Grammatical Markers and Linguistic Components using AAC: Child is taught how to include grammatical markers and other linguistic components to create full, complex sentences to communicate with those around him.  This allows the child to practice complex language structures before his speech mechanism is able to practice them.
  7. Using AAC for School and Learning: Child is shown how to use AAC to participate in classroom activities and practice language skills learned in the school environment. Additional vocabulary words are added to the system as needed to allow the child opportunities to practice and use the language that is being taught at school.

4. Prosody:

The goal of this skill set is to improve prosody skills in children with CAS, including rate, pitch, and volume.

  1. Attending to Variations in pitch, rate, and volume: Expose the child to variations in pitch, rate, and volume and pair these variations with words to describe them. Opposites such as fast/slow, high/low, and loud/quiet should be introduced.
  2. Demonstrating Prosody Variations in Non-Speech: Help the child demonstrate variations in pitch, rate, and volume with non-speech (sound effects or noises). Demonstrations should start with opposites for contrast (high/low, etc) and move to more subtle variations.
  3. Demonstrating Prosody Variations in Speech: Have the child demonstrate variations in pitch, rate, and volume with single words or nonsense syllables. Start with opposites for contrast and move to more subtle variations.
  4. Using Appropriate Prosody in Single Words: Help the child understand how to speak single words with correct prosody. Talk about which syllable gets stress (loudness), the rate at which certain sounds or syllables are spoken (rate), and how pitch variations can make the word sound more like a question, statement or exclamation.
  5. Using Appropriate Prosody in Phrases and Sentences: Help the child understand how to use appropriate rate and pausing, intonation, and stress in phrases and sentences. Talk about how changes in pausing, intonation, and stress can change the meaning of a sentence.
  6. Using Appropriate Prosody in Connected Speech: Help the child understand how to use the prosody strategies from previous levels in connected speech.

Where to Start:

I know this can seem overwhelming when you’re first starting out so keep in mind that you only need to work on one level from each of these four areas and you can even prioritize it down so that you’re just working on one or two areas at a time.

Also, keep in mind that this should be used as a framework for speech therapy and not a prescribed program or system.  This method has not been tested by research and is just my interpretation of one way that these skills may be broken down.  I have decided on this order based on my clinical experience and what I’ve read in the current CAS literature, but it is not backed by specific research.  This is just an idea to get you started, but you should tweak it and modify it for each individual child.

If you need additional help, please feel free to download the free PDF that breaks these skill sets out into charts that will help you decide where to start on each one.

Click Here to Download the CAS Levels PDF

More Resources for Speech-Language Pathologists:

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