Literacy Skills of Children with Childhood Apraxia of Speech

What is Childhood Apraxia of Speech?

Children with Childhood Apraxia of Speech (CAS) present with severe speech difficulties. The underlying deficits of CAS are not completely understood and may be impacting the children’s success with reading and writing activities.

CAS is generally defined as a speech motor planning deficit that affects speech production (American Speech-Language and Hearing Association [ASHA], 2007). The child’s production of speech is highly inconsistent; at times, words or sentences may be clearly articulated, while at other times they are highly unintelligible. CAS may occur as a result of known neurologic impairment, occurring with other conditions such as seizure disorders or identified brain damage. CAS may also present in children who have no known neurological concerns. (ASHA, 2007)

Why did we do this study?

Many studies have shown that children with CAS also have language deficits that can hinder learning to read and write (e.g., Lewis, Freebairn, Hansen, Iyengar, & Taylor, 2004).

  • It is well documented that early literacy skills are highly predictive of success with reading and writing (e.g., National Early Literacy Panel, 2008).
  • A few studies have looked at a limited set of early literacy skills, such as phonological awareness and letter knowledge in English speaking children with CAS, and have found that the children may have difficulties in these areas (e.g., McNeil, Gillon and Dodd, 2009).
  • There is newer evidence that children with CAS also may have fine-motor deficits that could affect other early literacy skills such as handwriting (e.g., Peter & Raskind, 2011).
  • Our study built on previous research by looking at a larger set of early literacy skills (including languageand motor-based skills) in two different languages: English and French.
  • We did this study because a better understanding of the underlying early literacy deficits of CAS will contribute to the prevention of reading and writing difficulties by ensuring intervention focuses on these children’s needs.

What did we want to learn?

The research questions were:

How do 4 to 5 year-old children with suspected CAS (sCAS) perform on early literacy tasks targeting phonological awareness, print awareness, letter knowledge and handwriting compared to typically developing peers?

How do English-speaking children with sCAS perform compared to French-speaking participants on the same tasks?

Who participated in this study?

We chose to study children with no known neurological reason for their sCAS because this would provide a ‘clearer’ understanding of how sCAS impacts upon early literacy skills. These children were not formally diagnosed with CAS by a physician; however, each child demonstrated a profile of speech difficulties consistent with CAS. Our sample included children with sCAS and a group of typically developing children matched on age and gender. 

All met these criteria:

  • Aged 4 years to 5 years and 11 months
  • Attended either school (JK or SK) or a preschool program with educational curriculum.
  • Had no history of sensory, cognitive, or neurological impairment.
  • Had a dominant language that was either English or French.

In order to meet eligibility criteria for sCAS, the children in the French Speaking CAS and the English Speaking CAS groups had:

  • normal receptive language skills,
  • impaired speech-sound production,
  • oro-motor difficulties, and
  • inconsistent speech-sound errors.

11 children with sCAS met inclusion criteria (9 English and 2 French speaking children) and were matched to 11 peers based on age and gender.

What was done?

  • All consent procedures were reviewed and approved through the Children’s Hospital of Eastern Ontario and the University of Ottawa Research Ethics Boards.
  • Children with sCAS were recruited from the caseload of speech-language pathologists (SLPs) in the Ottawa region.
  • The typically developing children were recruited through general advertisements.
  • Each child with sCAS participated in two 90-minute assessment sessions. The children with typical development participated in one 90-minute assessment.
  • A certified bilingual speech-language pathologist assessed all children.
  • Early literacy assessment protocols were developed in both languages and included language- and motor-based early literacy skills.

When a child with sCAS or a typical peer qualified for the project, they were assessed for their early literacy skills in the areas of:

1. phonological awareness :

  • syllable segmentation (can the child segment words into syllables?)
  • rhyme awareness (can the child identify the non-rhyming word from a set of 4 words?)
  • aliteration awareness (can the child identify which words start with the same sound?)

2. letter knowledge 

  • can the child identify the names of letters?

3. print awareness

  • e.g., does the child know that print goes left-to-right, that letters make sounds, what a word looks like and other print symbols (i.e., punctuation?)

4. handwriting 

  • e.g., how does the child hold the pencil, how well formed is his/ her printing?

5. visual-motor integration skills 

  • e.g., how well does the child do with eye hand coordination activities?

What was found?

The preliminary results revealed that of the 11 children with sCAS:

  • 6/11 presented with a delay in at least one task of phonological awareness.
  • 1/11 showed a delay in the area of print awareness.
  • 5/11 scored below the developmental level expected in the area of letter knowledge.
  • 8/11 presented with a delay in handwriting motor skills.
  • Both French and English speaking children with CAS, as a group, scored lower than matched typical developing peers in all areas.

What do the findings mean?

  • Children with sCAS appear to be at risk for literacy deficits. Half of our sample showed difficulties in both language and motor-based early literacy skills, while the other children with sCAS had different profiles (some children only had language difficulties while others only had motor difficulties). These preliminary results suggest that sCAS might represent a cluster of children who may have motor coordination issues and early literacy difficulties in addition to their speech motor planning deficits.
  • Speech/language pathologists, occupational therapists, and educators need to screen for these possible areas of difficulty and provide support before the child experiences failure, due to difficulties with language and motorbased early literacy skills.
  • The measures used in this study have been made available in English and French and are suggested as a preliminary screening tool for children with suspected CAS.

What is next?

The authors will present this work at national and international conferences in order to inform their colleagues about the importance of screening early literacy skills in this population of children.

The authors have applied for additional funding to study a larger sample of children with CAS. We would like to increase our sample of French speaking children in order to determine if there are linguistic differences between English- and French-speaking children with CAS.

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We are grateful to the Pollock Foundation for funding this study.


American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech [Technical Report]. Available from

Lewis, B. A., Freebairn, L. A., Hansen, A. J., Iyengar, S. K., & Taylor, H. G. (2004). School-age follow-up of children with childhood apraxia of speech. Language, Speech, and Hearing Services in Schools, 35, 122. National Early Literacy Panel. (2008). Developing early literacy: Report of the National Early Literacy Panel. Washington, DC: National Institute for Literacy.

McNeill, B. C., Gillon, G. T., & Dodd, B. (2009). Phonological awareness and early reading development in childhood apraxia of speech (CAS). International Journal of Language & Communication Disorders, 44, 175-192.

Peter, B., & Raskind, W. H. (2011). A multigenerational family study of oral and hand motor sequencing ability provides evidence for a familial speech sound disorder subtype. Topics in Language Disorders, 31, 145-167.