Identifying Apraxia in Toddlers

Now let’s get more specific and talk about identifying apraxia in toddlers. We’re going to look at what the research tells us are the specific kinds of speech errors noted in the speech of toddlers under three who will go on to be diagnosed with apraxia. First, we’ll take a look at a list that’s been around for a while, from Overby and colleagues in 2015. It’s considered the best list we have to differentiate apraxia from other kinds of speech disorders in kids who are under three. Next, we’ll look at a newer piece of research, also by Overby and colleagues, from 2019, with super specific speech indicators.

Here’s the first list:

Indicators of Apraxia in Toddlers

Less vocalizations overall

Fewer consonants

A less diverse phonetic repertoire

Later consonant acquisition

Let’s discuss these characteristics so that you know what to look for in your youngest clients.

Toddlers with apraxia may be much quieter than other kids, including children with other kinds of speech-language delays. Many toddlers with language delays are not quiet. Their parents expect to hear real, understandable words any day now because their kids are already trying to talk, whereas parents of children with apraxia often report that their toddlers have always been super quiet. A common example is when parents describe their children as “good” because they never vocalize as much as their other children. These parents probably don’t say “vocalized” to their SLP, but say something more along the lines of: “He’s never complained or cried as much as my other babies did.”

When babies are described as quiet, they probably didn’t babble or string together an array of sounds like many babies do as they near their first birthdays. Many toddlers who are late talkers skip the babbling phase as babies but develop a noisier phase just before they begin to use real words. Our little guys with apraxia may not babble or “jabber” ever and use mostly single-syllable utterances for a while when they begin to talk. When kids have apraxia, the reason for this lack of vocalizations or babbling is difficulty sequencing sounds.

Toddlers with apraxia don’t use as many consonants and may talk mostly in vowels. Words may be reduced to the vowel sound, so the word “bubble” may be “uh uh”—or even “uh” if the child can’t sequence vowels yet.

Due to a less diverse phonetic repertoire, they may have fewer vowel sounds too. It’s not uncommon for a toddler with apraxia to use only a handful of sounds or a default syllable for everything. For example, a parent may say that a child speaks in grunts or an “uh” for everything, or that he says “da” but it might mean ten different words.

Later consonant acquisition is also mentioned as a frequent indicator for apraxia vs. other speech disorders. By age two, a child should be using at least three to four different initial consonants. Toddlers with typically developing speech skills produce three to six different consonant sounds by 18 months and six to eight different consonant sounds by 24 months from the following list:

Initial Consonants — /p, b, m, t, n, d, h, w, k, g/

Characteristics of Apraxia in Toddlers

Newer research in 2019 confirms these findings with even more specificity about consonant sound acquisition and apraxia. Below are the most current guidelines proposed for identifying apraxia in two-year-olds. These may turn out to be an SLP’s best gauge of differential diagnosis for kids with speech errors:

1. Limited vocalization in the first two years of life, especially for sounds in the language.

2. Lack of a consonant by 12 months of age.

3. Use of fewer than three consonants by 16 months of age, and/or fewer than five consonants by 24 months of age.

4. Limited to no velar (/k/, /g/) production.

5. Favoritism of stops (/b/, /p/, /t/, /d/) and nasals (/m/, /n/, “ng”) over other consonants.

6. Productions at 13–18 months are largely vowels with little use of other syllable shapes (such as consonant-vowel-consonant, etc.)

The bottom line for differential diagnosis is not only confirming a diagnosis, but ruling out diagnoses or labels that are not appropriate. For example, when a late-talking toddler is noisy and uses word approximations comprised of more than six different consonants with accurate vowels in most words, apraxia is probably not the diagnosis!

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