As a speech-language pathologist (SLP) that has specialized in diagnosing and treating children with childhood apraxia of speech (CAS) for more than 14 years, I have evaluated hundreds of children for a speech sound disorder. Most of the children I have evaluated have been referred by the treating SLP who suspects or has diagnosed CAS or by parents seeking an expert opinion after their child’s SLP has mentioned or diagnosed apraxia. My own evaluation process has changed substantially since I first started evaluating for CAS in 2012, as research has continued to progress and our standards for diagnosis have evolved. It is a near-constant process to stay up-to-date on the latest research and best practice for evaluating for CAS. Here are some of the most common mistakes that I see when evaluating for childhood apraxia of speech.
Mistake #1: Ruling Out CAS Because of Phonological Patterns
It is sometimes thought that if a child is using phonological patterns (either atypical ones or at an age when we expect the pattern to have been suppressed), that the child has a phonological disorder. This thought is reinforced by the ICD-10 code for childhood apraxia of speech (R48.2), which states that the use of this code excludes the code for articulation/phonological disorder (F80.0).
The truth is, phonological patterns are a way to simplify speech production and make it easier. Young children with developing motor speech systems use phonological patterns for this reason. For example, children first learning to talk omit final consonants in CVC words to make CVs, since CVs are more motorically stable (Namasivayam et al, 2020) and easier to produce. The discussion of whether this pattern is more linguistic, motor or a combination is beyond the scope of this blog, but we can agree that there is a feedback loop that is typically present, in which children continue to progress with their motor skills, which allows more advanced sequencing, and the use of phonological patterns declines or is suppressed as motor skills progress.
Children with CAS are trying to produce speech with inefficient systems that are struggling to accurately motor plan and program speech. Using phonological patterns makes talking easier, because these are simplified motor sequences. As the motor speech skills of children with CAS are not developing in a typical way, their feedback loop is interrupted and/or they do not have the necessary motor skills to produce the sequence and thus “suppress” the pattern (Namasivayam et al, 2025).
Most children with CAS use phonological patterns, at least early in their speech journey. At first glance, when you see and hear the use of phonological patterns, you might assume the child has a phonological disorder. However, it is digging deeper and assessing across speech tasks of varying motoric complexity that helps inform us as to if there are other speech errors present, that may be indicative of CAS.
For billing purposes, we can not use the diagnostic codes for apraxia and phonological disorder simultaneously. However, clinically, we can note the use of phonological patterns in addition to discriminative characteristics of CAS and keep these patterns in mind as we design treatment.
Mistake #2: Basing the Diagnosis on Non-Speech Movements
The definition of CAS is difficulty motor planning and/or programming the movements for speech production (ASHA, 2007). This is sometimes confused with difficulty motor planning and/or programming non-speech movements, which is a separate diagnostic label (non-verbal oral apraxia or NVOA). While CAS and NVOA frequently co-occur, along with other motor difficulties, the presence of one disorder does not mean the other disorder is present. Due to the frequent rate of co-occurrence, screening and/or assessing for NVOA is part of a differential motor speech exam. However, we can not assume that because a child has NVOA that they have CAS. In order to diagnose CAS, we must assess for the presence of CAS-specific speech features across speech tasks. Clinically, I have treated a number of children with CAS whose non-verbal oral motor skills were within normal limits. Moreover, I have seen difficulties with non-speech oral movements that are a result of issues with execution, rather than motor planning and programming. In these cases, the non-speech oral movement difficulties have been due to dysarthria, rather than NVOA. This is part of the reason why it is imperative to include a thorough oral mechanism exam when evaluating for a motor speech disorder.
Mistake #3: Diagnosing Non-Speaking Children with CAS
As discussed above, the diagnosis of CAS is dependent on a child demonstrating discriminative features of CAS across speech tasks. If a child is not yet speaking enough to complete multiple speech tasks, it is not possible to conclusively diagnose CAS.
However, an important point to consider here is that we do not want to withhold appropriate intervention if a child is demonstrating indicators of motor speech difficulties, even if we can not conclusively diagnose. For example, I have evaluated a child who was only able to produce a few CV and CVCV words in a dynamic motor speech exam with maximum cueing but demonstrated multiple features of CAS within those tasks. While that was not enough information to conclusively diagnose CAS, it was enough to recommend that a trial of motor speech therapy be implemented with a working diagnosis of suspected CAS. Over time, as the child produced more speech, I observed more features of CAS across additional speech tasks of varying complexity and reached a conclusive diagnosis. I have also frequently seen young children demonstrate some features of CAS but over time, in response to motor speech therapy, these features resolved and additional characteristics did not emerge. At times, I have felt the diagnosis of speech motor delay was more appropriate than CAS for these children, although motor speech therapy based on the Principles of Motor Learning was still the treatment recommendation.
Mistake #4: Using Outdated or Inaccurate Features
One of the most common mistakes that I see when diagnosing CAS is the use of outdated or inaccurate features. Typically the inaccurate features are ones that are non-discriminating between CAS and other speech sound disorders. For example, I’ll see a limited sound repertoire and/or the use of simple syllable shapes used as support of a CAS diagnosis. While it is true that many children with CAS display these features, so do children with a severe phonological disorder, thus making these characteristics non-discriminative. While we still use the ASHA 3 (ASHA, 2007) core features of disrupted coarticulation, inappropriate prosody and inconsistency in repeated productions, we now have a lot more detailed information about features. For example, we know that disrupted coarticulation may be segmentation or difficulty with transitionary movement gestures. Inappropriate prosody may be even and equal stress and/or inappropriate stress. The best way to measure inconsistency seems to depend on the age of the child, with phonemic inconsistency being best for preschoolers and token-to-token inconsistency using an appropriate stimulus more robust for children over age five (Iuzzini-Seigel et al, 2017).
Mistake #5: Using Tasks that are Too Motorically or Linguistically Difficult
Research on the production of multisyllabic words in preschoolers has indicated that children developing speech typically still struggle to produce multisyllabic words accurately, with some research indicating that children with typical speech development aren’t completely accurate with multisyllabic words until between 7:0 and 10:11 years (Masso et al, 2018). Young toddlers with typically developing speech produce many errors on multisyllabic words, including on stressed syllables, while older toddlers and preschoolers may make segmental and timing errors (Masso et al, 2018). Thus we want to be careful when assessing preschoolers on whom we have placed a demand that is too motorically difficult and are labeling the result of what is typical development as features of CAS.
Similarly, we want to be careful with the stimuli that we use for children. In Iuzzini-Seigel et al’s study on inconsistency (2017), they found that children with language impairment also showed inconsistencies when repeating the same phrase multiple times, especially with more linguistically difficult tasks.
Another example is the use of tongue twisters. The entire point of tongue twisters is that these phrases are motorically difficult, even for individuals with typical motor speech skills. If you make the task difficult enough, even individuals with typical motor speech skills will display features of CAS.
Summary
When we are evaluating for childhood apraxia of speech, we must be careful to make sure that we are assessing for discriminative characteristics of CAS across speech tasks. This means that we can’t base a diagnosis of CAS on non-speech movements or formally diagnose CAS in a child who is not yet speaking. In addition, we need to make sure that our speech tasks are appropriate for the child’s motor and language levels, such that we are not creating errors due to the difficulty of the task. Last, we can’t rule out a diagnosis of CAS based on the use of phonological patterns.
In next month’s blog, I’ll discuss four more common mistakes I see when evaluating for CAS.
References
American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech [Technical report]. Available from www.asha.org/policy
Iuzzini-Seigel, J., Hogan, T., & Green, J. (2017). Speech Inconsistency in Children With Childhood Apraxia of Speech, Language Impairment, and Speech Delay: Depends on the Stimuli. Journal of speech, language, and hearing research : JSLHR. 60. 1-17. 10.1044/2016_JSLHR-S-15-0184.
Masso S, McLeod S, Baker E. (2018). Tutorial: Assessment and Analysis of Polysyllables in Young Children. Lang Speech Hear Serv Sch. 49(1):42-58. doi: 10.1044/2017_LSHSS-16-0047. PMID: 29282474.
Namasivayam AK, Li-Han LY, Moore JG, Wong W, Van Lieshout P. (2025). The articulatory basis of phonological error patterns in childhood speech sound disorders. Front Hum Neurosci. 19:1635096. doi: 10.3389/fnhum.2025.1635096. PMID: 41143150; PMCID: PMC12549640.
Namasivayam, A. K., Coleman, D., O’Dwyer, A., & van Lieshout, P. (2020). Speech sound disorders in children: An articulatory phonology perspective. Frontiers in Psychology, 10, 2998. https://doi.org/10.3389/fpsyg.2019.02998
