Is it Apraxia or a Phonological Disorder? Sorting out the Differences in Toddlers & Preschoolers

Many parents who start researching speech disorders have questions about the differences in apraxia, or motor planning difficulties, as compared to a phonological disorder.  “They sound the same to me,” is what many parents tell me. Actually many professionals have questions too! This is a common debate during the diagnostic process for many clinicians. First, I’ll provide a brief overview of both disorders, then I’ll give you my clinical opinion.

Apraxia/Verbal Dyspraxia

Apraxia is a neurological speech disorder that affects a child’s ability to plan, execute, and sequence the movements of the mouth necessary for intelligible speech. Apraxia can also be referred to as developmental verbal apraxia, childhood apraxia of speech, or verbal dyspraxia. Most SLPs use the terms interchangeably. Characteristics of apraxia include:

  • Limited babbling is present in infancy. These are quiet babies.
  • Few or no words when other babies are talking by age 2
  • Poor ability to imitate sounds and words
  • Child substitutes and/or omits vowel and consonant sounds in words. Errors with vowel sounds are not common with other speech disorders.
  • His word attempts are off-target and may not be understood even by parents.
  • He may use a sound such as  da for everything.
  • Often his errors are inconsistent, or he may be able to say a word once and then never again. The child understands much more than he can say.
  • There is sometimes (but not always) a family history of communication difficulty.  (i.e. All the boys in our family talk late, or My husband’s grandfather still has trouble pronouncing some hard words.)

Phonological Disorders

A phonological disorder is difficulty with the rules or patterns for combining sounds intelligibly in speech in English. For example, phonological processes patterns include prevocalic consonant deletion (leaving off consonant sounds that precede a vowel such as at for hat), syllable reduction (producing only one syllable in a multisyllabic word such as bay for baby), or reduplication (simplifying a multisyllabic word to a duplicated pattern such as saying bubu for bubble or even dog dog for doggie).

There are many patterns for analyzing a child’s speech according to a phonological processes model. All of these processes are common in typically developing children as well. It becomes a problem when most children are maturing in their patterns of production, and a child is not. For example, final consonant deletion (leaving off ending consonant sounds in words) typically disappears between 2 1/2 to 3 years of age. If a child is not including final consonants by this age, it would be considered disordered or atypical since most of his same-age peers are now using a more mature pattern.

A child with only a phonological disorder exhibits typically developing language, meaning that his vocabulary and utterance length are the same as his peers, but he continues to exhibit patterns that are consistent with a younger child’s speech errors.

Important Diagnostic Differences

1.Vowel Sounds- Indicators for me always include a child’s vowel sounds. Both children with apraxia and phonological disorders make errors with consonant sounds. Children with apraxia also substitute, or in some cases omit, vowel sounds too. For the most part, children with a phonological disorder?use consistently accurate vowel sounds. (Remember that vowels are A, E, I, O, U, and sometimes Y. Consonants are the other remaining letters of the alphabet.)

2.Consistency in Errors – Children with phonological disorders are generally consistent with their errors. This means that if they mess up a word, they usually mess it up all or most of the time, and usually in the same manner (until they start learning new pattern in therapy, and then they will likely revert between their “old” way of saying a word and their “new” way.)

Children with apraxia are very inconsistent. This means that they may say a word correctly once, and say it incorrectly a minute later. Words may be so “off-target” that the intended word is unrecognizable. For minimally verbal apraxic children, they may say the word once, and then you may not hear it again for a long time.

Children with a phonological disorder exhibit patterns with errors. For example, a child may omit final consonant sounds all of the time. A child with apraxia may include a final consonant sound in one word, but not be able to produce the same final consonant sound in the same word or the same sound in another word.

3. Language Skills- Children with apraxia almost always have delayed expressive language skills (especially before therapy starts.) They do not have the same vocabulary size and utterance length as children their age.

Children with a phonological disorder may have expressive language skills within or closer to the normal range. They use lots of words and try to combine them into phrases like their same-age peers, but you may not be able to understand very much. (This is different than jargon, or “baby talk.” Children with a phonological disorder are saying real words, but they substitute or leave off so many consonant sounds that you don’t know what they are saying.)

4. Other Characteristics while Speaking- Children with apraxia often look like they are “groping” for words. Things parents say to describe this include:

  • “He sometimes opens his mouth to talk, but then it looks like he forgot what he was going to say.”
  • “She doesn’t know what to do with her tongue when she talks.”
  • “I see him watching my mouth closely, and he tries to move his mouth in funny ways to copy mine, but he can’t.”

Children with phonological disorders do not have these issues.  For the most part, they can and do try to repeat what you’ve said to them without the hesitations.

5. Verbal Imitative Abilities- Children with apraxia have major difficulties imitating or repeating what you’ve said (especially before therapy begins). Children with a phonological disorder can repeat you, but the word may not be accurate.

6.Oral Imitative Abilities- Children with apraxia have difficulties with using their mouths?to talk or to imitate or perform certain movements on request, but not in other activities like eating or if the activity is “automatic.” For example:

  • “He can stick his tongue out when he’s licking a sucker, but he can’t do it when I show him.”
  • “She blew out her birthday candles last week. I don’t understand why she won’t blow for you.”

Children with phonological disorders are more consistent with what they can and can’t do with their mouths.

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Hopefully this helped sort out some of the questions for you. I hope it doesn’t leave you more confused! Be sure to discuss these things with your child’s speech-language pathologist. He or she should be able to give you good reasons why or why not he/she believes a diagnosis is or isn’t appropriate for your child.

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Comments

  1. Laura says

    Don’t forget to check our ARCHIVES for other articles! You can also SEARCH for what you’re looking for! Look under the logo and click the option. If you can’t find what you’re looking for, send me a comment, and I’ll do my best to help you.

  2. says

    Hi Laura,

    What a wonderful site! Someone at Seven Counties Services told me about this site today. I’m surely giving the site link to all my fellow SLP’s and preschool teacher friends to check out. Lots of good common sense strategies that parents can understand and do. Sometimes I think we get too involved in special education speak and lose the parents.

    Thanks for the information.

    Dana Moore

  3. Laura says

    Thanks so much Dana! I hope you’ll share this site often – especially since you’re in Louisville like us! It’s so nice that Seven Counties is helping spread the word too. Last night we got word that our site has been recommended by another state’s early intervention program as a resource for families, and we are thrilled! I hope that all of our readers, whether they be other SLPs like you, as well as moms, will continue to pass our site along to anyone who may need practical suggestions for home. These are the same strategies that I recommend for parents everyday, so I know they work! Thanks again! Laura

  4. Erika says

    Great article! Still not sure where my son falls though. His errors are very consistant (meaning he says “mame” for “game” and “baball” for baseball but it is always that it’s never anything else and he doesn’t “grope” for words) and he eventually corrects them. His vowels aren’t the problem it connecting the consinents into more syllables or words. For instance at 24 months I was “ma” unless he was really upset I was “mamamama” and then I was “mom” and now I can be “mom” or “mama” but he can’t say “mommy” if I say “Hi Mommy” he repeats “Hi mmy” or “Hi mama.” But he was very delayed. He had 4 true words and several “environmental” sounds at age 2 which were mostly vowel realted like “ooh,” “eeh,” “whee” “whoa” etc. His last evaluation before transitioning to the elementary school system said his language skills were at 24 month with scattered skills to 36 months. So confusing yet enlightening!! As a side note, he has really responded to the suggestion (I believe it was last Friday’s radio show) to clapping or tapping the floor or his hand whatever…to break down syllables almost immediately…he can now say “all right” on command without the clapping and “thank you” clear as day.

  5. Laura says

    Erika – I think the important thing is that he’s getting better – regardless of what his “diagnosis” is. Glad the clapping and patting worked to help him with syllables! We’ll be talking about more of these issues related to intelligibility in 2 & 3 year olds in this Friday’s (September 5) show. I’d love to have you join us for that! Call in if you can! We’d love to hear from you! Laura

  6. Erika says

    I agree completely! Diagnosis isn’t as important as just getting the help as early as possible! It helps not only speech but their emotional state as well. I find that if he feels heard, he is more willing to attempt words and it really boosts his confidence.

    I will see if I can listen to the show on Friday and call in….I have dial-up and have just been downloading later.

  7. Laura says

    Erika – You don’t have to be listening live to call in. As a matter of fact, it’s best if you’re not because the Listen Live version is on about a 10 second delay, and it’s so distracting to hear what you’ve just said from your computer’s speakers! Then you can go back and “hear” yourself later, although I still haven’t gotten used to that yet!!!

    The call in number is toll free and 1-718-766-4332. Hope it works out for you! I LOVE to get callers, especially when I know a little background about your situation already. Hope to talk to you on Friday! Laura

  8. Erika says

    Laura-That sounds great! If I am home and my little guy is cooperating I will give that a try! I would love to join in! Thank you!

    Erika

  9. says

    My daughter was diagnosed with severe phonological delay when she was 2 1/2. She is now 6 1/2. I had to translate everything she said until she was 4 1/2. She also has some oral motor issues. (not tongue-tied) She can’t lick all around her lips, and can’t figure out how to lick stuff off of her bottom lip. I had looked at apraxia of speech, but while some aspects fit her many aspects didn’t. (She definitely was NOT a quiet baby).

    Over the years, it hasn’t seemed like speech has done much to help her, as opposed to just maturation. I did teach her to read, and it was one of the only things that has had an enormous impact. (Her consonant blends came into her conversational speech within 3 weeks).

    These days, she is definitely much clearer, but she can still be difficult to understand. To convolute matters, she has also been diagnosed as gifted. Her mind and her mouth go at about 5000 mph. Trying to get her to SLOW DOWN, has always been very difficult and next to impossible, and that only makes understanding her that much more difficult.

    Considering she has been in speech for 4 years, I’m beginning to wonder when and if things will clear up. I recognize the improvement, but it is very slow going. Is 30 minutes a week through the school district enough?

    What is the best technique to use to help her at home? How do you get these sorts of kids to slow down?

    Thanks,
    Tammy

  10. Laura says

    Tammy – So sorry therapy hasn’t helped her significantly in 4 years. I have to remind parents (and myself) that therapy is really not magic or voodoo. Fortunately most of the time, parents can usually cite progress, but when any disorder is classified as “severe,” the issues are usually not going to go away for a long, long time, maybe never.

    Part of the slow progress could possibly be attributed to the intensity of therapy. 30 minutes/week is usually not enough for any issue, speech or language (or even motor issues) that are classified as “severe.” I’d revisit this with your IEP team. Certainly her teachers should be wanting more help with this too and can probably be a good advocate for her concerning this.

    I’d also advise you to revisit her diagnosis. Although some SLPs are reluctant to diagnose apraxia in young children, some of the things you’re describing, especially the oral stuff she can’t do, lack of consistent progress in therapy, AND combined with her rate problem, really would make me think twice about a straight phonological disorder diagnosis. That being said, I haven’t seen her and your SLP(s) have, but if you can afford it or have insurance coverage, I’d recommend that you take her to be evaluated by a person in private practice who can give you an objective, unbiased evaluation. Sometimes school SLPs’ hands are tied within the diagnostic realm since more complicated diagnoses require more intensive treatment. Sometimes this is feasible for school districts, Unfortunately, those considerations are things that do happen most everywhere, most everyday.

    Clapping and using a sing-song style of speaking can help some kids to slow down. Since she’s reading you may also try to do some “pacing” with her pointing to written words as she says them to “practice” using a slower rate. However, I don’t treat school-aged kids, so please know that there are probably many other effective techniques that can and should be explored. Again, I think a private eval with an experienced SLP with a wonderful reputation is really the way to go. Laura

  11. ananymous says

    My son is 20 months old and has been receiving speech therapy since he was 15 months old. So far he uses about 30-40 words and is combining them. He has only one major issue, his vowel sounds. He has many consonants down and only struggles with k/g. He has a difficult time combining vowels with consonants. He cannot say “no” he says “na” or can imitate “na oh”. Can’t say “moo” for cow, but can imitate “ma oo” and the word “wow” is not there. He was 17 months old before he could say the “oh” sound. It seems like his vowels are coming in after his consonants. He has made significant progress and has just started imitating random words when I ask him to. Some of the words he imitates sound alike as well. He can say many vowel sounds in isolation, but has a hard time putting it into a word correctly. It’s confusing because he has many words for a diagnosis such as apraxia, or is that still a possibility? And he imitates pretty good. He also doesn’t seem to lose words. He does seem to change the way he says a word many times, but that’s only when it’s new. He was a very quiet baby and has many red flags for Apraxia, can’t lick lips or blow bubbles, but his progress has stumped many people. Any ideas of what this could be? I bought both of your Dvd’s, “Teach me to talk” and “phonological/apraxia” and they were fantastic and extremely motivating. His progress did take off after watching them! Thank you.

  12. cara says

    Hi Laura,
    I have posted here before about my twin boys. I also bought your DVD Teach Me to Talk. I am happy and proud to announce that at almost age 3 my son Jake has caught up to his peers and now speaks age appropriately. He does not qualify for therapy! He does have a tongue thrust and a lisp and we will adrress that separately, but I am overjoyed.

    My other twin son Cole is making great progress as well but just qualified for speech therapy through the school. They mentioned Phonological Processing Disroder because the SLP noticed fronting and stopping and atypical consonant substitutions (p/k etc). However, she wrote that he did not make these phonological mistake more than 40% of the time so they coulnd’t say that is was an “active process”. What does this mean? Does this mean that maybe he does not have phonological processing disorder and that with time and some help these issues will resolve? I am a little confused about that 40% comment. Overall, Cole is very hard to understand – he will be 3 in 2 weeks and is about 50% understandable. I am glade he is getting therapy but I also don’t want to put a label on him if its not warranted.

    Any advice would be appreciated!
    Thanks
    Cara

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