Ages and Stages, Assistive Technology, Speech & Language, Therapy Tools

Ask an Apraxia Specialist: Children with DS and CAS

As promised! I am so grateful to my friend and former colleague Shelley Myers, MS, CCC-SLP for allowing me to pick her brain shelleyregarding childhood apraxia of speech (CAS) in children with Down syndrome (DS). Shelley is a speech-language pathologist for Banner Children’s at Banner Thunderbird Medical Center in Phoenix, Arizona. Her professional interests include Speech Sound Disorders, Childhood Apraxia of Speech, Augmentative Communication, and developmental disabilities. Shelley has specialty training in PROMPT, the Kaufman Speech to Language Protocol, and the DTTC (Dynamic, Temporal, & Tactile Cueing) Approach. For seven years, Shelley worked in the Jane and Richard Thomas Center for Down Syndrome in the Division of Developmental and Behavioral Pediatrics at Cincinnati Children’s Hospital Medical Center. While at Cincinnati Children’s, Shelley was also a member of the Apraxia Special Interest Team and lead speech therapist for the multidisciplinary apraxia clinic.

So, let’s get started! Shelley, thank you so much for agreeing to talk with me about CAS and children with Down syndrome. Let’s discuss the characteristics of CAS in children with DS. What are some of the key features you observed during your clinical experience?

The key features of CAS in a child with Down syndrome are the same features you would see in a child with CAS who does not have DS.  The most prominent features of CAS include:

  • Inconsistent speech sound error patterns
  • Frequent omissions and substitutions of sounds
  • Difficulty with transitions between sounds/syllables/words/phrases (as the utterance length increases, so does the number of errors)
  • Errors in prosody (the child may sound choppy, monotonous, or stress the wrong syllable or word)

Walk me through the process of evaluating children with DS for CAS.

Evaluating a child with DS for CAS is not a quick nor easy task. The SLP needs to consider many things, including the child’s age, current ability level, previous exposure to therapy, and amount of progress. Also to be considered are family history of speech disorders and any neurological involvement the child may have.

When a kiddo with DS comes to see me for a question of CAS, I always start with building rapport (as you would with any child).  Once rapport is gained, I would then look at spontaneous and imitative speech capabilities.

  • Does the child seem to physically struggle when trying to speak?
  • Do they use only vowels?
  • Are their errors consistent or inconsistent?
  • Can the child imitate oral-motor movements with no vocalization? [like opening and closing his mouth]
  • How understandable is their overall speech?
  • What is the child’s primary mode of communication? [How do they communicate every day?]
  • Can the child understand language significantly better than they can produce it?

I would NEVER diagnose CAS on a single visit.  I believe that CAS should not be diagnosed in a child with DS until the child has been in therapy for several months or longer. The reason for this is that what may look like CAS on day one, may turn out to be an entirely different speech sound disorder. A lot can happen when a child is provided with the right approach to treatment.

I have many families who come in and give me this scenario, “Beth is 3 ½ years old and her preschool SLP thinks she may be apraxic. What do you think?” I know Beth uses very simple word approximations and is very communicative. She’s able to imitate many developmentally appropriate sounds, but has difficulty as those same sounds are combined into words. Is there an age or stage when you feel comfortable giving a CAS diagnosis in children with DS?

It is important to remember is the CAS is rarely an easy disorder to diagnose, especially in a child with DS (bearing in mind that speech-language disorders are typically present). When consulting on the above situation and keeping in mind the aforementioned about speech disorders in kiddos with DS, I would not feel comfortable endorsing a diagnosis of CAS for Beth at this time and here’s why:

  • Her age. Beth is only 3 ½ years old.  While a typical peer would be expected to be speaking in sentences at this age, the same does not hold true for a child with DS.  Children with DS acquire speech and language at a slower rate.  Significant growth will still occur after the age of 3 ½ with respect to language and speech sound production.
  • Her ability level.  Beth is able to imitate many developmental appropriate sounds.  This is a great jumping off point.  I understand that she has more difficulty with the same sounds when they are combined into words…but what about the syllable level?  Start small and build up. Everyone does this…even typical peers.
  • Exposure to therapy. At age 3 ½, Beth likely has not been in preschool that long.  How much time has her school SLP spent in direct therapy with her?  It is my professional opinion that CAS should not be diagnosed in a child with DS until they have been in regular therapy for at least several months, and in some cases, even a year or longer.
  • Understanding of DS.  While some speech-language pathologists may not even consider the diagnosis of CAS for a kiddo with DS, others may be too quick to give the diagnosis. I have seen the latter happen many times. It could happen for a number of reasons, but I believe the most prominent reason is due to the pace of progress that is seen in children with DS.  Unfortunately, children with DS usually progress significantly slower than a typical peer. Remember, progress in a child with CAS is slower than in a child with a phonological disorder, which is slower than a child with an articulation disorder.  If the child has DS in addition to one of these speech sound disorders, expect progress to move even slower yet.  I cannot stress this enough…Slow does not mean nonexistentt!!!!  Some therapists fail to recognize this and it can subsequently result in dismissal from therapy.  For a child with DS and a speech sound disorder, that would be detrimental.

There are a number of different treatment programs developed for children with CAS such as Kaufman, PROMPT, etc. What have you seen work for children with DS?

All children respond differently to different treatment approaches.  I do not have one specific “marketed” approach that I use for children with CAS.  I believe in using what works for the child.  If that means mixing a couple of different approaches, then I will do that (GASP!).  It is not uncommon for me to use more than one approach with the same child in the same session or even simultaneously.  However, in order to do so, I have to keep up to date on what the different treatment approaches are and make sure I receive the appropriate training. All of the marketed approaches have pros and cons (a discussion for another day).

What I can say is that kiddos with DS are typically visual learners. I have not seen one child with DS that has not benefitted from the use of simple touch cues (aka: gestural cues, hand signals).  These are simply visual/tactile cues made with the hands that help a child see how to produce a sound in addition to hearing the sounds (ie. pulling your index in front of your mouth when making a “m” sound).


Shelley, thank you so much for taking the time to answer my questions. This has been a hot topic around the blogosphere and I know many will appreciate your candid answers! Jenn

7 thoughts on “Ask an Apraxia Specialist: Children with DS and CAS”

  1. Hi what about kids who don’t speak at all? I keep hearing that with apraxia, there are errors in speech however my son is 4 this week and is Totally non verbal except he did have dadada for a while..seems to have lost this tho and he can whisper pear..he has had slt for a year as his 1-1 is an ex slp. He can say the sound b consistantly and with practice but no more. He seems to look intently at what she is doing but has no idea what to do himself. Could this b CAS? He is a very active an inquisitive boy. Seems to be functioning at about 24 mth level.

    1. Tara, Does your little one communicate with you in other ways? Signs, pointing, pulling your hand to things he wants, showing you toys?
      Instead of focusing on the diagnosis (which is important), I’d get started on trying to establish an alternative form of communication for him. However, he communicates in the future (speech or alternative) he needs those foundational skills. You’re question is excellent and I will write a more in-depth post about it soon.
      Kind regards, Jennifer

  2. Awesome entry. Thanks! When I read your last entry that kids with DS shouldn’t be diagnosed before 5, I was puzzled. I get where you are coming from now. Also, I’m really enjoying your blog overall. Well written and very informative. There needs to be more information in regard to speech/language therapy with this population.

    1. Thanks Laura! There does need to be more information and techniques to use with kids with DS. Look for more posts on this very thing to come!

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