Research Strategy:

Background & Etiology:

•  Childhood apraxia of speech (CAS) is a rare disease (an uncommon occurrence) of children, affecting only 0.1% of the general population, is present from birth, with a genetic predilection higher towards the male gender, with a 2–3:1 ratio (Hall, Jordan, & Robin, 1993; Lewis et al., 2004).
• The incidence of CAS has been reported to occur in 1–2 children per 1,000 (0.1%–0.2%; Shriberg et al., 1997).
•  Children suffering from CAS have difficulty planning and producing the precise, refined, and specific movements of the tongue, lips, jaw, and palate that are necessary for intelligible speech.
• In most cases of CAS, the etiology is unknown (idiopathic), but some cases are associated with a known neurological cause (such as intrauterine or early childhood stroke, infection, trauma, brain cancer or tumor resection, traumatic brain injury, etc.), and other cases occur as part of a complex neurobehavioral disorder (such as autism, epilepsy, fragile X syndrome, galactosemia, Rett syndrome, Prader-Willi syndrome or certain types of chromosome abnormalities).
• Studies have also indicated that genetic mutations involving alterations (mutations) in the FOXP2 gene or loss of genetic material involving the FOXP2 gene have been associated with the onset of CAS.

Management:

• Speech-language therapy (SLT) is the main treatment for apraxia of speech. Speech-language Pathologists (SLPs) often use a variety of methods to treat it.

• According to the U.S. NIH's National Institute on Deafness and other Communication Disorders (NIDCD), highlights that speech-language therapy is necessary for children with CAS. The speech-language pathologists (SLP's) use different approaches to treat COS, and no single approach has been proven to be the most effective.
• The therapy is tailored to the individual and is designed to treat other speech or language problems that may occur together with COS.
• Frequent, intensive, one-on-one speech-language therapy sessions are needed for both children and adults with AOS (acquired apraxia of speech). The repetitive exercises and personal attention needed to improve AOS are difficult to deliver in group therapy.
• Children with severe COS may need intensive speech-language therapy for years, in parallel with normal schooling, to obtain adequate speech abilities.

•  Various research studies have indicated that a higher efficacy is associated with 3-5 individual SLT sessions per-week, versus the traditional and less intensive 1-2 sessions per week (Hall et al., 1993; Skinder-Meredith, 2001; Strand & Skinder, 1999). For younger children, the frequency and length of sessions may need to be adjusted; shorter, more frequent sessions are often recommended (Skinder-Meredith, 2001). Refer to the attached google spreadsheet for a mini systematic review of scientific literature supporting the evidence.
• A variety of treatment approaches have been implemented in improving the speech production which includes (i) motor programming approaches, (ii) linguistic approaches, (iii) combination approaches, and (iv) rhythmic (prosodic) approaches.

•  Children with CAS require frequent and intensive individual speech therapy from an experienced SLP. Based on individual patients' needs and the disease severity determines how frequently the child needs speech therapy. Generally, the more severely the child is affected, the greater the need for frequent and intensive speech therapy. With the passage of improvement with appropriate therapy, less frequent individual speech therapy will be needed.
•  Speech therapy for children with CAS is focused on providing the child with a number of opportunities to practice planning, programming, and then producing accurate movements for speech. Additionally, children with CAS will likely need to work on other language and communication skills during speech therapy. Some children will learn a bit of sign language or use a communication device while they continue to work on their speech skills.
• According to the American Speech-Language-Hearing Association (ASHA) recommendations, "a child with CAS should work with SLP and may begin therapy 3-5 times per week; as the speech improves treatment may be scheduled less-often."
•  SpeechPathology.com blog by Dr. Amy Skinder-Meredith (Ph.D.), who has been a speech-language pathologist for 12 years, and an Associate Professor of Communication Sciences and Disorders at the University of Minnesota-Duluth. In her blog, she addresses a key question regarding the frequency of SLT sessions for the management of COS.
• Given that motor learning is involved in CAS disease, frequent therapy is needed to learn the motor skills necessary for speech.
•  Children with delayed speech due to a phonologic delay only will not generally need as many sessions as a child who has apraxia. In other words, if the child only has a mild apraxic component and a moderate phonologic delay, SLT therapy may be warranted up to 2-3 times a week with the majority of the time spent working on the phonological processes and a little bit of the time focusing on motor planning.
• Children with severe apraxia of speech need more frequent sessions (i.e., SLT up to 4-5 times a week for 30-45 minutes each session).

Legislative Precedence concerning Insurance Coverage on CAS:

• In December 2002, a father in Michigan filed a request on behalf of his young son that the Commissioner of Financial and Insurance Services (CFIS) review the denial of benefits for speech services by Blue Cross Blue Shield of Michigan (BCBSM).
• The child had initially been diagnosed with suspected Childhood Apraxia of Speech (CAS) and delayed expressive language skills. After a period of treatment, the speech-language pathologist subsequently confirmed the CAS diagnosis. The child demonstrated improvement through treatment and both the SLP and the child’s physician stated that with further treatment the child would continue to improve.
• The insurance - BCBSM, claimed that the child’s condition was developmental and was therefore not a covered service. BCBSM further claimed that the child was being treated for stuttering and for articulation errors, both of which they argued were developmental.
• An Independent Review Organization (IRO) appointed by the insurance commissioner (CFIS) concluded that speech disorders in children are often both developmental and organic and one does not automatically exclude the other. The IRO found that although the child’s speech issues were longstanding, developmental, and possibly congenital, the impairment was also neurological, and thus organic.
• The IRO noted that the (i) child’s speech treatment had benefited him and that the services were effective in the remediation of disorders, (ii) that were both organic and developmental in nature. The commissioner then ruled that the child’s condition was not strictly developmental in nature and therefore the speech therapy was a covered service.

• A 2003 ruling by an insurance commissioner in Michigan that the diagnosis of childhood apraxia of speech (CAS) can be viewed as both developmental and neurological has facilitated reimbursement for speech-language pathology services and may have broader implications. The ruling, made on a review, stated that developmental and neurological issues are not mutually exclusive, but both may exist in relation to a diagnosis.

Potential Collaboration and Helpful Resources:

• Organizations Supporting the childhood apraxia of speech (CAS) include the (i) American Speech-Language-Hearing Association (ASHA), and the (ii) Childhood Apraxia of Speech Association of North America (CASANA).
• The ASHA organization has helped clients in the past to file appeals against insurance denials. They also provide a CAS appeal packet that contains the information about CAS which can be adapted and personalized. ASHA members who have received and want to appeal a CAS denial can request the packet from Janet McCarty, jmccarty@asha.org.
• According to ASHA's article, which acknowledges the frustration for parents and children with CAS. Of which, most important is when the health insurance plans deny coverage for speech-language treatment for the disorder. ASHA has outlined a set of pointers to file a successful appeal. 
• CAS is a motor speech disorder that is neurologically based.
• CAS is not a developmental delay. It is an issue of health and normal physiological function.
• A child with CAS has limited control of muscles and problems saying sounds, syllables, and words. The difficulty is not due to muscle weakness or paralysis. The child’s brain has difficulty planning the movements of the body parts needed for speech.
• Treatment for CAS is medically necessary because the disorder is a medical condition consistent with the definition of disease and illness. It is a disorder of body function. (Include any neurological exams that show abnormal characteristics).
• Scientific findings shed light on the cause of CAS. British neurogeneticists identified a gene mutation that appears responsible for CAS, or verbal apraxia (Nature, 413, 519–523; 2001). Studies suggest that the basal ganglia, brain regions that control movement, may be different for those with verbal apraxia.
• The appropriate ICD-9 diagnostic code (International Classification of Diseases, ninth edition) for CAS is 784.69 (Other symbolic dysfunction; acalculia, agnosia, agraphia, apraxia).
• Provide supporting evidence of the disorder (for example, specific childhood apraxia of speech test).
• An additional guide to resolving reimbursement related to CAS can be accessed here.
• Another alternative is applying for Social Security Disability Benefits for a child with apraxia.
• Additional reading regarding Practice Portal’s Childhood Apraxia of Speech page can be accessed here.