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Imitating Speech: What is Childhood Apraxia of Speech(CAS) and How Might It Affect My Child?

By Carly Davis M.Ed. CCC-SLP

Early intervention (for everything!) has exploded in the past 10-15 years regarding getting additional help for our little ones in whatever they may need. That being said, you have probably been at your child’s checkup where the pediatrician went through the checklist of developmental milestones. One milestone that sticks out to most parents with toddlers is whether or not their child is using enough words. At the 18 month check-up, the question is, “Is my 18 month old using about 20 words including different types of words such as nouns (baby, cookie), verbs (eat, go), prepositions (up, down), and social words (hi, bye)?”

If the answer to that question is NO, your doctor will mostly likely give you a referral for a “speech evaluation” and deem your child as having a “possible speech delay”.

As a Speech-Language Pathologist (SLP), I personally do not get alarmed seeing an 18-month-old with less than 20 words. The #1 thing I want to know is, “Is your child imitating sounds you make or words you say?” — that answer is most likely ‘No, they don’t’. If it’s the parents 2nd or 3rd child, I remind them to think back to their older son or daughter and remember that stage of “parrot talk” where you have to watch everything you say because the kids mimic or repeat everything they hear. A lot of times parents will respond that they babble all the time during play and have a few words they use consistently on their own. However, when asked to repeat a word, they refuse. “That’s because they have a stubborn personality, right?” My response is always partly yes, and partly no.

The YES and the NO:

The next step is to figure out WHY your child is ‘stubborn’ about reproducing words. Of course, every 2-year-old wants to be independent, like big brother and daddy— that’s the how the term was coined years ago calling this age ‘the terrible twos’. However, the reason your 2-year-old isn’t talking is a little bit different. Why can they say ‘bubble’ when they want to play, but can’t say ‘bye bye’ or ‘baby’? Seems about the same, right? There are 2 /b/’s and then some vowels in the middle, shouldn’t it be simple? Our children who are not ‘imitating’ sounds and words are not doing it because they are stubborn or trying to be difficult— they literally just can’t manage it, simple as that.

But WHY Can’t They Imitate?

According to the American Speech-Language-Hearing Association, “Childhood apraxia of speech (CAS) is a neurological pediatric speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.”

In a nut shell, all that means   is  …. ‘unable to imitate on command’.

What does ‘imitate on command mean’?

To imitate on command is to have a direct reduplication of something after initiated by someone. You can call it Simon Says if you want. For example, if I stomp my foot, then you will stomp your foot and that is an imitation on command. If I say, ‘uh’, then you say ‘uh’ and there is a direct imitation.

That point takes me into the ‘motor’ aspect of speech. Just like walking requires ‘gross motor skills’ to pick up our feet and put one in front of the other, and writing requires ‘fine motor skills’ to hold a pencil and move it delicately, our mouth is full of our ‘motor speech’ sensors that all coordinate to produce intelligible speech.

HOW do you produce intelligible speech?

Every time you speak you probably don’t think of all the steps that actually take place before you even say a word. You probably don’t realize pressure from your lungs builds up and vibrates at your vocal folds to produce your ‘voice’ and then is individualized in to specific consonants and vowels within the vocal tract by moving the oral cavity, tongue, teeth, and lips different ways. Pretty cool, huh! Oh yeah, and on top of that, your brain is what tells you what to say and sends the signal to get that whole process started.

So now what?

Now that we know your child has difficulty imitating sounds or words on command, it is our job to figure out where the breakdown is and how we can help.

During the evaluation, we will assess where your child’s ‘receptive language (what they understand), expressive language (words, phrases and sentences they use) and their articulation (or the sounds they can produce). Most children who have CAS have a big difference in score between their receptive language (average or above) and their expressive language. They recognize the word and understand what the word means, but have trouble recreating the sound of the word on their own.

During therapy, your therapist will figure out the starting point for your child to learn how to ‘imitate’ sounds. We will see which word structures your child is already using which may consist of Vowel-Consonant (VC) as in ‘up’ or CVC (‘pop’), CVCV (‘mama’), and what we can do to expand their utterances into phrases. Maybe they can produce sounds that stay the same such as ‘bubble’, but cannot coordinate when consonants or vowels change as in ‘buddy.’ That is still considered a part of ‘motor speech.’ Maybe your child walks around the house all day saying ‘uh-oh’, but when you prompt them to say /uh/ for ‘up’ or /o/ for ‘go’ you get no response. That is because they have mastered the ‘motor plan’ for ‘uh-oh’ and it can only be produced in that specific sequence. It takes many, many repetitions to master a motor plan in order to be able to produce the same ‘word’ on command. You also might see your child open their mouth just like you when you ask them to say /ah/, but nothing happens. This is a breakdown in the coordination of ‘turning the voice box on’ to produce phonation (voice).

Motor speech/apraxia treatment is built up syllable by syllable starting at 1 syllable and so on. For example, 1- Mo (‘more’), 2- Mo ba (‘more ball’), 3- Mo ba peas (‘more ball please’), 4- Mo bubbo peas (‘more bubble please’), 5- Mo ba peas mama (‘more ball please mama’) and so on…

Some of the questions parents ask me…

  • Why does my daughter have to be able to imitate if she is already picking up and using words on her own?
    • In order to learn vocabulary and increase expressive language, your child will have to be able to hear a word and produce that word again to add it to their ‘word bank’ (which is imitating 😊). Imitating requires watching the mouth move, listening to the production of sound, and coordinating all of the things required to produce speech you learned above. There is research that shows that spontaneously using words is done by a different part of the brain than imitating. Many kids with CAS who have ‘words’ may actually lose those spontaneous words once they learn to imitate and re-learn them during the process described above.
  • My son has no problem using a single word for requesting what he wants, but he is 2 and a half years old now, shouldn’t he be putting words together now?
    • Yes, at 2 years children should be emerging on using 2-word phrases. To me personally, emerging means using at least 2-3 phrases/day spontaneously, and if not, having the ability to imitate 2-words together (ie. ‘hi mommy’, ‘eat cheese’, ‘bye baby’, etc.)
  • My daughter babbles all the time while she is playing with her brother and ‘has her own little language’. Is she talking and do we still need therapy?
    • It is GREAT to hear that children are babbling different consonants, vowels, and intonations during play. However, unless there is someone to transcribe this language to the world, then yes, your child will most likely still need to come to therapy so your child can learn ‘meaningful’ language to use in everyday life to express their wants and needs.
  • My child is 4 now, will he always present with ‘apraxia’?
    • In typical developing children without any other underlying diagnoses, by the age of 4 children will be primarily intelligible at the phrase, sentence or even conversational level.
      • As apraxia continues to develop, a child may now ONLY present with some ‘speech sound errors’ (uses a /w/ for an /l/ or uses /t/ for /k/) and a different approach may be used as the motor planning approach is weaned out.
      • A 4 year old may be working on more complex word structures in longer sentences embedded with 2-3 syllable words such as, “Panda eat tuna”, or “Moppy take out bubbles”.
        • It is very typical for a child with previous motor speech difficulty to drop medial /t/, /d/, /n/, or /p/, /b/, /m/ wounds within 2-3 syllable words.

There are other factors related to Childhood Apraxia of Speech when it is associated with other diagnoses such as cerebral palsy, down syndrome, autism spectrum disorder, sensory processing disorder, and other genetic disorders—in these cases some of the above would differ. However, in regards to treatment there is always one thing that stays the same and that is gaining the ability to imitate on command which gives us the ability to make meaningful language at whatever level your child may be.

If you have more questions or would like more information on how we can help your child, please contact our office!