What in the World is Childhood Apraxia of Speech?

What is CAS?

Childhood Apraxia of Speech, or CAS for short, is a speech disorder that results in children being unable to form the words they intend to, even though they know what they want to say.  It is associated with very low intelligibility and is arguably one of the most frustrating speech challenges kiddos and their parents face.  CAS is also sometimes also called Developmental Apraxia, but unlike this name suggests, children do not often improve spontaneously; skilled speech therapy is required to treat it.

Origins of CAS

CAS is estimated to occur in only 1 or 2 of every 1,000 children in America.  Unlike acquired apraxia, which is most often seen in adults who have had strokes or traumatic brain injury, the cause of CAS is unknown.  Rarely are there any observable differences in the brain, though CAS can sometimes occur as a symptom of a syndrome, genetic disorder, or metabolic condition (e.g., galactosemia).  CAS is known to exist at higher rates in children who have other neurodevelopmental conditions such as ADHD, Autism, and epilepsy.

Mechanics of CAS

The act of speech is a series of incredibly precise fine motor skills that requires very refined movement of the lips, tongue, and jaw.  If the neurological planning of these movements is disrupted, as in the case of CAS, low intelligibility results.  Recent research indicates that children with CAS may have difficulties with sensory feedback loops required to learn and judge the accuracy of speech. Sensory feedback is important for the subliminal knowledge of proximity between speech structures (e.g., lips, tongue, teeth, palate) during speech, which plays a role in execution of movement.

What CAS is Not

CAS does not involve physical issues with the mouth, such as muscle weakness or muscle coordination difficulties. It also does not involve the brain itself, but rather nerve pathways responsible for planning speech movements.  

CAS vs Phonological Disorder

Many times, parents of children who exhibit very low intelligibility research causes online and conclude that Childhood Apraxia of Speech is to blame for their child’s unintelligible speech.  However, children with severe phonological disorders can be just as unintelligible, or even more so, than children with CAS.  Your speech-language pathologist will need to analyze your child’s speech to discern whether distinct error patterns (e.g., deleting or substituting certain sounds in various word positions) are present, as in a phonological disorder, or whether the errors are inconsistent or random, as in CAS.  CAS and phonological disorders can also coexist.

Errors related to CAS often change as a word is repeated, and these errors cannot be grouped into categories, unlike phonological errors.  Other characteristics of CAS which distinguish it from a severe phonological disorder include errors on vowels, prosodic errors (relating to stress and intonation), increased errors as utterance length increases, and increased errors in spontaneous speech over rehearsed speech.  When your child’s speech is evaluated, your speech-language pathologist will provide an appropriate diagnosis in order to follow with appropriate treatment methods.

By Kathleen Winger MS CCC-SLP

Gestalt Language Processing

Let’s unpack some buzz words that you may have been hearing lately:

“Echolalia” is the repetition of language spoken by others. It can be repeated either immediately or after some delay. With echolalia, language is stored as a “chunk”, or a whole unit.

“Scripting” is another term that refers to echolalia. “To infinity…and beyond!” is an example of a script from media. “See you later alligator” is an example of a script that may be heard in conversation. When children are “scripting”, they may be observed reciting dialogue from a TV show, singing lyrics from a YouTube song, or copying phrases they’ve heard other people use. The message is often identical to the source where they heard it, and has the same melody.

“GLP” stands for Gestalt Language Processing. This is a form of language development where children learn the meaning of language in chunks first, then over time learn to break the chunks down and formulate their own original language.

Let’s bust some myths:

Are most autistic children GLPs? YES!

Does being a GLP automatically mean a child is on the Autism Spectrum? NO! Some neurotypical children learn language via chunks as well. 

Unsure if your child may be a “GLP”? Here are some common signs:

1. They echo back what you say or the last part of phrases you say, without appearing to process the language.

2. They have difficulty answering questions in conversation.

3. They like to hum or sing songs rhythmically. 

4. They have a preference for intonation-rich sound input, such as music or videos.

5. They replay certain portions of video clips over and over.

6. They like to repeat play scenes in the same way over and over.

7. They like to play with the WHOLE set – if a figurine is missing, they are not pleased. They are seeing the world in a “gestalt” way.

8. They like to label objects they see around them and can recite their ABCs or count 1-2-3, though have trouble using their language to ask for help or communicate other important functions. 

I think my child is a GLP… Now what?

1. Find a Speech-Language Pathologist near you that has been trained in Gestalt Language Processing. They can help determine which stage of the Natural Language Acquisition framework your child is in and give tailored advice on how to support your child’s language development at home. 

2. Follow social media accounts such as @meaningfulspeech and @bohospeechie, which provide brief, useful posts related to GLP.

3. Take a look at free resources on the website www.meaningfulspeech.com. If you have extra time, consider taking Meaningful Speech’s parent friendly course. 

4. Check out Marge Blanc’s book, “Natural Language Acquisition on the Autism Spectrum. The Journey from Echolalia to Self-Generated Language.”

Things to Keep in Mind:

  • Echolalia is not just a “stimming behavior” that should be ignored, decreased or extinguished… Echolalia communicates. 
  • We should acknowledge children’s scripts by nodding our heads or repeating back what they say, even if we are unsure what they mean.
  • Speech therapists are here to help! 

By Julia Navarra MA CCC-SLP

The Top 10 Tools and Activities Used by Occupational Therapists

April is Occupational Therapy Month. This month is designated to celebrate the field of occupational therapy and what occupational therapists do to support their clients and families in living life to their fullest potential. In a pediatric setting, this includes supporting children with their participation in age appropriate activities of daily living (ADLs), play activities, feeding activities, educational activities, as well as any activity that is meaningful to the child and their family. Occupational therapists use a variety of techniques and activities to support their clients in building a variety of skills. In honor of occupational therapy month, here are the top 10 tools and activities therapists use during pediatric occupational therapy sessions. 

10 of Our Therapists Favorite Tools and Activities

1. Swings – Swings can be used in a variety of ways. Swings provide vestibular input which is sensory input that tells the brain and body how they are moving in relation to the environment.  Vestibular input can be calming or alerting to the child’s body depending on how the therapist directs the swing movement. Swings can also be used in a variety of ways other than for swinging movement. A swing can be a balance beam, or a surfboard, or a log. Using swings in a variety of imaginative ways can target lots of different skills. 

2. Climbing Items- Climbing uses a child’s muscles in ways that can help regulate their sensory systems and support their self regulation abilities. Climbing also supports a child’s gross motor skill development and helps them learn more about where their body is and improve their body awareness.

3. Arts and Crafts Materials- Paper, pipe cleaners, tissue paper, beads, you name it, we have probably used it in our sessions at some point. Whether it’s ripping, cutting, gluing, or stringing there are a variety of skills that can be developed through craft activities. While fine motor control and visual motor skills can be developed through the use of arts and crafts we can also work on executive functioning, motor planning, and attention skills through crafts that have multiple steps or parts. Arts and crafts can also be tailored to a child’s interest, getting the child excited about working on a lot of skills at once.

4. Putty/Playdoh- Playdoh and putty can be used for a wide variety of things. Therapists use these activities to build hand strength, work on tactile differentiation (the kids have to find items in the putty-feel the differences between the putty and the item), using both hands together, spatial awareness (the play doh has to be rolled big enough to fit the cookie cutter), and many other skills. 

5. Crash pads/Bean Bags- Kids can have the opportunity to crash or get under crash pads or get squeezed by bean bags. This can support a child’s sensory processing skills and therefore allow them to have greater self-regulation abilities. 

6. Games – Not only do games help therapists teach social skills through sharing and turn taking but they can often be paired with gross motor activities to support kids sensory processing skills and abilities while also incorporating a variety of skills that can be targeted depending on the game. Using games also allows the child some choice in the session activities and creates greater buy-in. 

7. Dressing tools/items- One of the things that OTs work on with children is their ability to dress themselves and tolerate a variety of clothing textures. Using button boards, zipper boards, as well as, socks, shoes, shirts, and pants are important tools to support building those skills. 

8. Crayons, Markers, and Pencils- One of the most common things people think occupational therapists work on is handwriting. While it is just one of many things that we address. Using crayons, markers, and pencils are important to help a child build an appropriate grasp. Using small markers, broken crayons, or writing on a vertical surface all help facilitate an appropriate grasp. 

9. Weighted Items- Using weighted items can support a child’s sensory processing and increase their attention, engagement, and regulation. Weighted vests and ankle weights can be worn during a variety of activities to provide the child with additional sensory input and therefore increase regulation. Therapists also use weighted blankets, lap pads or stuffed animals to help a child calm their body and attend to a task for a greater period of time. 

10. Balls- Balls of all shapes and sizes are wonderful tools to use in occupational therapy sessions. Balls can be used at chairs to allow the child to wiggle a little extra while sitting at the table. They can be used under a child’s belly to build their core, shoulder and hand muscles while they support themselves. A therapist can use throwing and catching a ball as a way to build the child’s hand eye coordination, as well as, their upper limb coordination. Balls can also be used to apply pressure to a child’s body through rolling over their back, legs or arms, to support increased sensory regulation. 

Bonus Number 11: Messy Play Activities- Messy play activities, such as shaving cream, water, slime, finger painting, etc., can be a great way for children to decrease their tactile sensitivities (or their resistance to having dirty hands) through exposure in a fun way. Messy play can also work on a child’s sensory processing abilities that support feeding skills. Therapists will sometimes use messy play for development of visual motor skills as well, drawing in shaving cream or paint can help a child learn the way to make letters and shapes without the added skill of needing to hold a pencil. 

Occupational therapists use a variety of activities in conventional and sometimes very creative ways to support the skill development of the kids they treat. The most important part of all the activities used by pediatric occupational therapists is to ensure that they are fun and that the kids are motivated by them. Sometimes that requires some really impressive imagination! Skill development through play is the goal of pediatric occupational therapists at SmallTalk. 

By Erin Christensen, OTR/L

April is Autism Acceptance Month

Mark Your Calendars, It’s Almost Autism Acceptance Month

Next month, it’s Autism Acceptance month! This is a worldwide event to celebrate Autistic pride and here at SmallTalk Pediatric Therapy, that’s cause for celebration! 

There are many fun events and activities happening next month to celebrate families on the spectrum! We wanted to give you the inside scoop before April rolls around. Join us in some of the fun while we celebrate differences and promote social inclusion and acceptance! 

Local Organizations and Events:

April 1, 2023 Race for Autism

  • WHERE: Balboa Park: 6th Ave & Laurel St. San Diego, CA 92103
  • WHEN: Saturday, April 1, 2023 6:30am to 11:30am
  • WHY?: Kick off April’s AUTISM ACCEPTANCE MONTH by joining us for the 19th annual Race for Autism SUPERHERO 5K and 1 Mile Family Walk in beautiful Balboa Park
  • MORE INFO: https://www.raceforautism.org/

Small Talk Pediatric Therapy will be at the Race for Autism! We are Supergirl sponsors for the race, so be sure to stop by our booth and say hi to the therapists. We’re excited to see you there!

April 3, 2023 Autism Acceptance Night – San Diego Padres vs. Arizona Diamondbacks

April 8, 2023 Family Pool & Pizza Party

April 29, 2023 Lights! Camera! Autism! 

Autism Society of San Diego

The Autism Society of San Diego offers support groups throughout the county year-round to provide support to families and their children. More information can be found on their meetup page at: http://www.meetup.com/autismsocietysandiego/. A monthly list of events are as follows:

  • Spectrum Social (group for autistic adults 18+)
  • Spanish Support Group (group is led in Spanish)
  • Adult Information and Support (group for parents and caretakers of adults on the autism spectrum)
  • Coffee Talk (daytime group open to all)
  • Happy Hour (evening group open to all)

By Madison Trussell, SLP-CF

Touchy, Feely

It’s the season of love! Everyone shows their love in different ways such as a hug or a kiss. However as Valentine’s Day rolls around the corner, it’s important to remember not everyone will be struck by cupid’s arrow. Some children have difficulty tolerating sensations such as touch that we often associate with this month of love. This aversion to touch sensations is called tactile defensiveness and may present in a child in a variety of ways. 

Our tactile system helps us learn more about the world around us and also serves as a protective system to alert us when touch sensations are dangerous. Children who have tactile defensiveness have trouble processing touch sensations which can lead to an over reaction of their nervous system. They may find everyday touch to be uncomfortable or lead to a fight or flight response (Chu, 1999). 

Ways tactile defensiveness may present in a child: 

  • Avoidance of certain clothing textures
  • Avoidance of having messy hands or engaging in messy play (shaving cream, fingerpaints, sand, etc)
  • Avoidance of being close to other people or children: May not like to stand in lines or be in crowded spaces
  • Avoidance of being picked up, hugged, or cuddled
  • Avoidance of activities of daily living (showering/bathing, finger nail cutting, teeth brushing, hair brushing, diaper changing, washing face)
  • Rub or scratch skin after being touched

If you have noticed your child has difficulty with any of the following, you are not alone and can rely on your occupational therapist to provide customized recommendations to best suit your child’s needs. Below are a list of general recommendations you can use to help your child better process tactile sensations.

Strategies to help your child with tactile defensiveness:

Provide deep pressure:

  • Give your child tight bear hugs or place hands firmly on shoulders or head
  • Ask permission or alert your child before providing these hugs or tactile input

Change environment:

  • Provide enough space for your child when in a crowded area
  • Give them a designated space for sitting with a bunch of children
  • Organize the waiting line to have your child stand first or last or shorten the amount of time they need to be in line
  • Prepare a calming area of your house to allow your child to have time to process sensory meltdowns

Adapt their wardrobe:

  • Find fabrics your child can tolerate such as soft cottons or athletic fabrics
  • Buy tagless clothing
  • Wash new clothing before wearing it to decrease stiffness of fabrics

Participate in heavy work activities that are calming and organizing to the body:

  • Encourage child to carry groceries, participate in chores such as vacuuming or moving laundry baskets
  • Play push/pull activities or jumping games
  • Walk like an animal

We all express our love in different ways, so it is important to be mindful of the cues children provide us. Children learn best through play. As parents, you can create routines to allow opportunities for children to participate in these activities and encourage small steps. Move at your child’s pace and applaud them for small successes they make towards tolerating touch. 

By Katherine Danella, OTD, OTR/L


Chu, S. (1999). Tactile defensiveness: Information for parents and professionals. Dyspraxia foundation.


Feeding the Picky Eater 

Eating is a very complex and sometimes challenging task for some of our friends with sensory processing challenges. The looks, smells, textures, and tastes of foods can sometimes be very overwhelming for these kiddos. When it comes to meal times which include foods not on their, sometimes minimal, list of preferred foods, these overwhelming feelings can result in big behaviors or even shutting down completely.  Below are some simple strategies to encourage your child to explore new foods at mealtimes while taking the pressure and stress out of the situation. 

Setting up the Environment 

How and where the child is sitting during mealtimes can be the first consideration in allowing for the greatest success at mealtime. Giving children the appropriate postural support while sitting at the table allows them to focus more on the food presented and less on having to use their muscles to sit. It is ideal to position your child so that they are seated with their hips, knees, and ankles all bent at a 90-degree angle with their feet resting on something. If your child’s feet can not reach the ground while sitting in the chair, try putting a box or stool under their feet to give them something to rest their feet on. If the dining room chair is too deep for them to keep their hips and knees at 90-degrees, try putting a pillow behind their back to help them maintain that upright position. Another key aspect of setting up the optimal environment for mealtimes is to turn off screens. When screens are not present, this allows kids to engage with the foods with all of their senses, building new sensory pathways and flexibility in order to support engaging with more foods in the future. 

Increasing Engagement with Foods 

There are a few different ways to increase your child’s engagement with novel and different foods. If your child has a really limited diet and only eats a few foods, one way to modify their foods and increase engagement is to change the shape or color of their preferred foods. Get your kids involved in changing the color by allowing them to add a drop or two of food coloring or allow them to change the shape of their foods by using a cookie cutter. Another way to increase engagement around food is to talk about the food during mealtime. Talk about the shape of the foods, the color of the foods, the smell of the foods, how they feel about the foods, etc. Talking about the sensory aspects of the foods can support the foundational sensory pathways that support adding new foods to their diet. Serving foods family-style and allowing your child to scoop the amount of food they want on their plate is another way to increase engagement with foods during meal time. 

Presentation of New Foods

When presenting new foods to your child, first take all pressure out of eating it. Provide choices to your child about how they want to interact with the new food. For example, “Do you want the food on your plate or on the napkin next to your plate?” Giving your child options in how they engage with the new foods allows them to feel a little more in control in a situation where their sensory systems often feel out of control. Also, when presenting new foods, encourage your child to play with them. Can your child drive the green bean like a car or make their cracker smash the pea? What about, sneeze the piece of chicken off their head or draw a mustache with the soup? Encouraging play with foods allows the child to experience these foods and exposes their sensory systems to the various sights, textures, and smells of these foods without the pressure of actually eating the novel or non-preferred food. 

Feeding these kiddos with sensory processing challenges can definitely be tricky for all involved. By setting up the environment for success, making small changes to their preferred foods and getting them to engage with foods in novel ways you can support them in growing their food repertoire and hopefully make mealtimes less stressful for everyone.

By Erin Christensen, OTR/L

OT’s Favorite Toys

As the holidays approach, we’re hearing many parents ask for gift recommendations! We
thought we’d put together another gift guide for 2022.

Experience Gifts

Your family could make gingerbread houses, bake a family recipe together, or play some
seasonal music while going for a drive to look at the lights in festive neighborhoods. Consider
packing dinner and going to see a seasonal movie together at the Santee Drive in. A family day
trip out to Julian or to Mt Laguna after a big rain to see the snow is often treasured more than
any gift or gadget! Experience gifts are wonderful ways to share new sensory experiences
together, and you can build in options for flexibility to support your children.

Gross Motor Play

For your busy child who seeks movement, consider obstacle course materials like balance
stones or beams, a mini trampoline, a pop up tunnel, or even a three-wheeled scooter or a
balance bike! If you’ve got outdoor space, perhaps consider a climbing dome or a new swing
or trapeze attachment for your play structure. For items that can be easily packed away, we
love the floor is lava game, parachutes, basketball hoops that hook anywhere, and bean
bags. Your child’s occupational therapist would love to show you at least 4 different exercises
for your child on a child-sized therapy ball. Our other favorite balls for indoor or outdoor play
include soft weighted balls, playground balls, and beach balls or balloons for children still
learning how to catch.

Pretend Play

You name it, they’ve made it: doctor’s kits, cash registers, dress up outfits, tool sets, and
sets with pots, pans, and pretend food. Pretend play enables children to experiment with the
social and emotional roles of life. They take another person’s perspective and enjoy controlling
the narrative. Children tend to develop skills in pretend play which start with familiar, everyday
experiences (sleeping, eating.), expand to less frequent experiences (visiting the doctor, going
on a plane). Children may feel more competent acting out scenes of a movie they’ve seen many
times than pretending to be adults they’ve only encountered a few times like a doctor or even a
grocery clerk. Start with your children’s strengths and interests, and build from there!

Hands-On (Fine Motor and Tactile) Play

From creative activities like drawing or painting to scooping and digging through kinetic sand,
play activities that build up the muscles of the hand are excellent for your child’s development.
We love easels you can put outside for a messy paint project or in the house for drawing on the
whiteboard. Some children may engage better while standing and working at a vertical surface
than seated at a table. We love dot-to-dot or maze books for quiet times. For children who
need extra pizazz with this type of play, we love jumbo chalk along with a water spray bottle
to erase, doodle boards that light up or play music when you draw, scratch paper books, and
of course, you can never go wrong with a fresh batch of playdoh.

Food-Related Play

If you’re looking for tools to bring your child into the kitchen, we’ve got a few favorites! Toddler
towers or kitchen helpers can provide opportunity for your child to get in among the action,
drizzling (or dumping!) ingredients together, using plastic tongs to move foods from one
container to another, or even just small measuring scoops and a sponge to play with soapy
water at the sink (and to keep them busy while you cook!). For children old enough to
participate, consider child-safe kitchen knives, shaped like a real knife but with a plastic/nylon
blade, or perhaps pick out a child-friendly cookbook together.

Constructional Play

To support your child’s skills in problem solving, fine motor control, dexterity, and spatial
awareness, consider constructional play materials. We love wooden block sets, lincoln logs,
marble runs, and of course the tried and true lego (or duplo / mega blocks for younger
children). We like constructional play activities that come with picture cards that provide a visual
goal for what to build, like light bright or k’nex, and we also love toys that encourage children
to ditch the models and create their own ideas. And for the child who loves a challenge,
stacking rocks as well as magnet building tiles may build both caution and resilience.

Social and Emotional Play

We love games and materials that encourage expression of a wide range of emotions, like
wooden eggspressions toys, the Big Feelings Pineapple, or books like Grumpy Monkey or
The Color Monster. Board games are a wonderful gift for family fun. For children who often
end competitive games with a chip on their shoulder, we love cooperative board games like
Mermaid Island, Dinosaur Escape, and Count your Chickens. We also love social
inferencing games like Hedbandz or Charades.

For more ideas on gifts specific to your child, check out our article from 2021! If you’d like ideas
specific to your child, please don’t hesitate to ask your child’s therapist for their input.

By Rachel Marshall, OTR/L

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