Assessing and Treating Suspected Childhood Apraxia of Speech
Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 1 Assessing and Treating Suspected Childhood Apraxia of Speech NSLHA Fall Convention September 28, 2018 Kearney, NE Cari Ebert, MS, CCC-SLP www.CariEbertSeminars.com Facebook Page: Cari Ebert Seminars Instagram: cariebertseminars Disclosure Financial Disclosure: Cari Ebert co-authored the book “The SLP’s Guide to Treating Childhood Apraxia of Speech” which she will reference in today’s seminar. Cari receives royalties from book sales and cariebertseminars.com product sales.
Nonfinancial Disclosure: Cari Ebert has a son with autism and apraxia and shares personal experiences in her seminars and webinars.
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 2 Overview of Apraxia Helping Professionals and Families Make Sense of an Abstract Concept Root Word: Praxis
- Praxis: Greek word which means movement.
- Components of praxis include: imitation, initiation, grading of force, sequencing, timing, and motor planning. Defining Apraxia
- “Apraxia is a neurological disorder characterized by the inability to perform learned movements on command, even though the command is understood and there is a willingness to perform the movement. Both the desire and the capacity to move are present, but the person cannot execute the act.” Web MD
- Apraxia can occur throughout the body.
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 3 Types of Apraxia (specific to different areas of the body)
- Limb Apraxia: Also referred to as dyspraxia and developmental coordination disorder. Refers to the inability to make precise movements with the fingers, arms or legs on command.
- Non-Verbal Oral Apraxia: Refers to the inability to coordinate and carry out oral-facial movements on command.
- Verbal Apraxia: Refers to the inability to coordinate & sequence sounds necessary for speech on command.
- A child may present with characteristics of one type of apraxia, a combination of two types, or all three types of apraxia (global apraxia).
- Apraxia may be the primary diagnosis or a secondary diagnosis. (When apraxia is a secondary diagnosis it can be harder to detect and thus more challenging to diagnose.)
- Verbal apraxia can occur in both children and adults. When verbal apraxia occurs in adults it is acquired.
- In children, verbal apraxia can be congenital (born with it) or it can be acquired anytime during the period of speech acquisition.
- The terms apraxia and dyspraxia have caused much debate for speech-language pathologists (SLPs) over the years.
- The prefix “a” means “without” or “total loss” while the prefix “dys” means “partial loss.”
- SLPs have argued that verbal dyspraxia is a more appropriate term than verbal apraxia—however, dyspraxia is already a term used to refer to limb apraxia.
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 4 Verbal Apraxia Verbal apraxia has experienced somewhat of an identity crisis. SLPs borrowed the term “verbal apraxia” from the adult neurogenic population following a stroke or other brain injury (i.e. acquired apraxia). In an effort to make it relate to children, verbal apraxia has been referred to by numerous names over the years including: developmental apraxia of speech, developmental verbal dyspraxia, speech apraxia, childhood verbal apraxia, articulatory apraxia... ASHA’s Technical Report
- The American Speech-Language-Hearing Association (ASHA) commissioned an Ad Hoc Committee on childhood apraxia to determine what to call verbal apraxia in children, to provide a clinical definition, and to provide scientific foundations for assessment and treatment of this motor-speech disorder.
- In 2007, ASHA released the 84-page Technical Report on Childhood Apraxia of Speech. ASHA’s Technical Report (2007)
- ASHA’s position is that Childhood Apraxia of Speech, or CAS, is the preferred term for verbal apraxia in children.
- ASHA’s Definition: Childhood apraxia of speech (CAS) is a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g. abnormal reflexes, abnormal tone)...the core impairment in planning results in errors in speech sound production and prosody.
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 5 “Developmental”
- CAS used to be called Developmental Apraxia of Speech (DAS) or Developmental Verbal Dyspraxia (DVD). These terms, however, are no longer recommended.
- The word developmental indicates (to third party payors) that apraxia is something that children can outgrow, and this is not accurate. Etiologies: CAS can occur in 3 clinical contexts 1. CAS may occur as a result of neurologic impairment before or after birth (e.g. stroke, infection, trauma). These children usually present with positive findings on brain MRI scans.
2. CAS may be associated with a complex neurobehavioral disorder (genetic, metabolic, mitochondrial). 3. CAS may occur as an idiopathic (unknown origin) neurogenic speech sound disorder (i.e. no neurologic impairment and no neurobehavioral disorder). According to the Technical Report (page 3), Childhood Apraxia of Speech, or CAS, is the unifying term for all presentations of apraxia of speech in children, regardless of the etiology (whether it is acquired or congenital).
Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 6 Types of Apraxia 1.
Limb Apraxia/Dyspraxia 2. Oral Apraxia 3. Verbal Apraxia 3a. Childhood Apraxia of Speech (CAS) 3b. Acquired Apraxia of Speech (AOS) Explanation for Families Instead of offering a complex clinical definition, try explaining what you suspect is going on in a familyfriendly manner. Your child appears to have some difficulty with motor planning. He seems to know what he wants to say, but he’s having trouble getting the message from his brain to his mouth. It’s as though his brain says “speak” but his mouth isn’t responding. Together in therapy, we will identify specific strategies to help his mouth respond when his brain says “speak.” Why I don’t use the “A” word...
I don’t want to give families anything to Google!
If the family already knows the “A” word... “Tell me what you already know about apraxia.”
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 7 Resources for Professionals & Families
- ASHA’s Technical Report on Childhood Apraxia of Speech (available at www.asha.org/policy/TR2007-00278)
- Maas tutorial on principles of motor learning, 2008
- The SLP’s Guide to Treating Childhood Apraxia of Speech by Dave Hammer & Cari Ebert
- Here’s How to Treat Childhood Apraxia of Speech by Margaret Fish
- Speaking of Apraxia: A Parents’ Guide to Childhood Apraxia of Speech by Leslie Lindsay
- Apraxia-Kids (used to be called CASANA) Apraxia-Kids (CASANA) www.apraxia-kids.org
- Located in Pittsburgh, PA
- Apraxia-Kids has a 3 day conference on CAS every year (it will be in Pittsburgh in July 2019)
- Apraxia Kids offers 90 minute webinars (follow them on Facebook for more info)
- They have a one-page template for teachers that explains CAS. The form can be personalized for the child with CAS.
Boot Camp for SLPs (intensive 40 hour training) Assessment Practical Strategies for Assessing Minimally Verbal Young Children
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 8 Terminology
- Preverbal: Term used to describe young children who are not yet talking.
- Minimally Verbal: Term used to describe young children with limited verbal output.
- Nonverbal: Term used to describe older children who are not verbal despite years of speech therapy. It is not likely that these children will become verbal communicators. They will need voice output AAC. (Consider using the term “essentially non-verbal.”) Formal vs. Informal Assessment
- Formal vs. informal assessment tools (quantitative vs. qualitative)
- Formal/standardized language tests designed for the birth – 3 population do not assess the integrity of the motor planning system
- In order to administer a standardized apraxia test, the child must: – have verbal imitation skills – be a willing participant in the testing process Informal Assessment
- It is critical for SLPs to assess the prelinguistic stages as well as the early stages of speech and language development.
- SLPs should be determining if the child is following a typical or atypical pattern of development (delay vs. disorder).
- Retrospective video analysis can provide critical information related to prelinguistic milestones (Childstones app by Dr. Eli Adler).
- Let’s review what typical looks like...
Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 9 Typical Development of Pre-Linguistic Sounds 1. Phonation Stage: Birth – 2 months of age natural/vegetative sounds (cry, cough, grunt, hiccup, sneeze) 2.
Cooing & Gooing Stage: 2 – 3 months of age primitive movements of the lips and tongue; beginning of vowel-like & consonant-like sounds 3. Expansion Stage: 4 – 6 months of age beginning to produce fully resonant vowel sounds; squealing, yelling, growling, raspberries, laughter; marginal babbling (not word-like) 4. Canonical Babbling Stage: 6 – 10 months of age produces sounds recognized as true syllables with mixed consonant and vowel sounds including reduplicated canonical babbling (“babababa” or “mamamama”) and non-reduplicated canonical babbling (“bamamaba” or “deedabeeda”) 5. Jargon Stage: 10 - 15 months of age complex babbling plus prosody; may sound like gibberish; babble takes on the tones and inflections of adult speech 6.
First words: begin to emerge by 15 months of age According to ASHA’s Technical Report... The three key diagnostic features of CAS include: 1. Inconsistent errors on consonants and vowels in repeated productions of syllables or words. 2. Lengthened and disrupted coarticulatory transitions between sounds and syllables. 3. Inappropriate prosody, especially in the realization of lexical or phrasal stress.
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 10 Informal Assessment of Suspected CAS
- Many young children we evaluate and treat aren’t verbal enough to detect those 3 key diagnostic features – so we have to identify key characteristics of very young, minimally verbal children with suspected CAS
- One of these symptoms alone does not mean the child has CAS
- Clinically, we are looking for that large cluster of symptoms that suggests the child presents with motor planning difficulties/atypical development In minimally verbal children, the SLP is looking for symptoms that indicate the child’s speech motor planning system is compromised. The treating SLP needs to be alert to red flags for CAS as the child becomes more verbal.
- Clinical Markers of Minimally Verbal Children with Suspected CAS
- History of being an unusually quiet baby – limited cooing, babbling, and jargon – often described as good, quiet, or content
- May not have gone through typical oral exploration phase as a baby
- Limited vocal play as a baby
- Late to say first word
- Limited repertoire of consonant & vowel sounds (restricted sound inventory)
- Limited or absent verbal imitation skills
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 11
- Receptive language skills > expressive (large gap)
- Overuse of neutral vowel sounds “uh, eh, ah”
- Limited syllable & word shapes (speech often lacks syllableness; V & CV are the most common syllable shapes used early on)
- Inability to spontaneously simplify words (not communication risk takers; not using phonological processes to simplify the motor plan)
- History of saying a word or phrase clearly one time and never repeating it (pop-out words)
- Voicing errors may occur (voiced for voiceless)
- Slow speech rate (due to difficulty connecting phonemes)
- Use of one syllable for all words (“go-to” sound) Rome’s “go to” sound Rome driving the car with his baby sister
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 12 Madison’s “go-to” sound
- Inconsistent speech sound errors (child sees a fish and says “bis,” then “sif,” and then “shif”)
- Atypical speech sound errors (“nak” for “milk” or “shog” for “dog”)
- Ability to produce a speech sound in one word, but not in others (/m/ in “mama” but not in “moo”)
- Inappropriate prosody/melody of speech (prosody consists of rate, rhythm, loudness, pitch, intonation, stress); choppy sounding speech due to ineffective coarticulatory transitions (may sound robotic)
- Significant difficulty with coarticulatory transitions (sequencing sounds and syllables) Coarticulation Coarticulation refers to the interweaving movements of consonants and vowels resulting in smoothly produced speech with no verbal gap between syllables and words. The distinct spaces in written language (I am three) are not present in spoken language (Iyamthree) because of coarticulation. Hammer & Ebert, 2018 Speech sounds are produced because of specific sequences of movement that are not discrete but blend from one gesture to another. Speech production involves continuous movement... Edythe Strand, CSHA Presentation 2017
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 13
- Doesn’t add new words to expressive vocabulary on a regular basis; replaces words, doesn’t maintain them (e.g. child says “mama,” but once he starts saying “dada” he stops saying “mama”) – SLP must regularly check for maintenance of words in the child’s expressive vocabulary
- Inability to maintain correct production of a sound or syllable in context of the actual word – movement between sounds causes substitution or deletion (Noah example)
- May have acquired some later mastered sounds while missing earlier mastered sounds = atypical acquisition of speech sounds Phonetic Norms (Acquisition of Speech Sounds)
- Vowels: – 97 % of vowels are mastered by age 3; the rhotic vowels are the ones that are mastered later Pollock & Berni, 2003
- Consonants: – Early 8: m, n, y, b, w, d, p, h – Middle 8: t, ng, k, g, f, v, ch, j – Late 8: sh, zh, l, r, s, z, th, th Blends Shriberg, 1993
- Use of atypical phonological processes (backing, initial consonant deletion, pervasive consonant omissions; more difficult to correct in therapy— according to Pam Marshalla these are indicative of a more severe and persistent speech sound disorder)
- May reverse sounds or syllables (“kitchen” produced as “chicken” or “sock” produced as “kos”)
- Increased errors in longer, more complex word shapes (shop...shopping...shopping mall)
- Vowel errors are prevalent (Quin and his “stecks”)
- Limited success talking with new people or in new situations: increased pressure = decreased verbal success
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 14
- May avert eye gaze when pressured to speak (not “poor eye contact”)
- Social avoidance (perhaps due to awareness of communication struggles)
- Adds a vowel to the end of words (up-uh, bug-uh)
- Use of the intrusive schwa (Hen-uh-ry, buh-lue, tuhrain, suh-wing)
- Speech appears effortful (posturing/groping)
- Demonstrates a strong desire to communicate as evidenced by elaborate gesturing skills and communication persistence
- Plays silently—even during high energy activities
- Lack of progress in traditional speech therapy Research by Overby & Caspari (2013, 2015) Examined speech of 0-24 month old babies later diagnosed with CAS Findings of early speech characteristics
- Limited canonical babbling
- Lack of diversity in place, manner & voicing
- Difficulty with voiceless productions
- Difficulty with fricatives
- Reduced syllable shapes (mostly V & CV) Later Academic Difficulties & CAS
- Academic issues related to spelling, reading & writing may become evident as child with CAS gets older
- “A child who demonstrates communication delays as a toddler and during preschool is at greater risk for later language-based learning disabilities.” Agin 2004
- “The speech processing system is not only the basis for speech and language development but also the foundation for literacy development; ‘written language’ being an extension of ‘spoken language’.” Stackhouse www.apraxia-kids.org
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 15
- May continue to produce “telegraphic” speech & omit little grammatical words such as the, and, a
- Expressive language may be impaired - grammatical errors, problems with word order (Yoda speech), pronoun errors
- May have poor phonological/phonemic awareness skills (rhyming, sound segmentation, sound blending, beginning & ending sounds) **precursors to reading
- “Between 40% and 75% of children who have trouble with language development present with reading difficulties later in life.” (Aram, Bashir) Due to the lack of word, phrase, and sentence practice opportunities associated with motorplanning constraints, syntax and grammar can be adversely affected. Getting the sounds and syllables in the correct sequence is challenging enough...having to worry about correct word order and intact grammatical markers adds another layer of difficulty. Word retrieval is often affected as well, given that an early foundation in the brain’s “word bank” has not been established.
Hammer & Ebert, 2018 Formal Apraxia Assessment Tools A standardized test can be administered to assist with making the diagnosis of CAS, but it should be done in conjunction with informal assessment. -Kaufman Speech Praxis Test for Children (2-5 years) -Verbal Motor Production Assessment for Children (3-12 years) -The Apraxia Profile (3-13 years) -Moving Across Syllables/Test of Syllable Sequencing Skills (Pre-K to 5th grade) -LAT (Linguisystems Articulation Test) has a built-in CAS screener (3-21 years) -The Dynamic Evaluation of Motor Speech Skills (DEMSS) by Edyth Strand (not released yet)
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 16 The DEMSS
- Was developed to assist in the differential diagnosis of younger children and those with severe speech production skills (neither articulation nor phonology tests can differentially diagnose CAS)
- Examines the following: – Articulatory accuracy – Inconsistency of errors across repeated trials (including vowels) – Accuracy within prosodic elements
- As with all SSD tests, the child has to be able to verbally imitate Cari’s Informal Assessment Guide for Use With Minimally Verbal Children 1. Pair informal assessment with standardized testing. Look at the whole child, not just the “hole” in the head (the mouth!) by assessing all five developmental domains:
- Physical (health, hearing, vision, gross motor, fine motor, sensory)
- Adaptive (self-help) In Early Intervention there are tests designed to look at all 5 domains: DAYC-2, BDI, Bayley, AEPS, Brigance, HELP
- During feeding time
- During play time
- During teeth brushing To make oral mech exams effective, consider using the Throat Scope (and call it a light saber!) 3. Obtain a speech & language sample and list child’s use of intentional vocalizations and verbalizations. – Vocalizing refers to the act of turning the voice on and does not imply the use of true words.
Verbalizing refers to the act of talking and implies the use of true, meaningful words or word approximations. If the child is verbal, determine intelligibility level of spontaneous speech. – Obtain a language sample during free play and during structured play. – Differentiate between the two – many children are vocal but not yet verbal!
Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 18 4. Assess the child’s shared attention and desire to interact and communicate with others. – Have caregivers describe how the child communicates wants, needs and feelings on a daily basis.
Determine the child’s level of persistence related to communication. 5. Assess the child’s awareness of his articulators. – Did the child go through a typical period of vocal play as a baby?
Is the child aware of his articulators? 6. Determine which consonants are in the child’s sound inventory. – Are sounds produced consistently or inconsistently? – Does the child say a sound in specific syllables/ words but not in other phonemic contexts? – Is the child stimulable for producing other speech sounds with cues? 7. Determine which vowels are in the child’s sound inventory. – Vowels serve as the foundation for the words we speak (they shape the oral cavity).
Accurate vowel productions are critical for speech intelligibility. – The human ear is able to interpret a child’s speech when the consonants are produced incorrectly, but it is much more challenging to interpret a child’s speech when vowel errors are prevalent.
Example: Interpret the following utterances. Which ones are more intelligible and why? Child 1: “I wa too-tee” Child 1: “I wa mo” Child 2: “I wa kuh-kuh” Child 2: “I wa ma”
Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 19 – Crisp, clear vowel sounds lead to increased speech intelligibility. – Explain why most articulation tests only assess consonant sounds (i.e. What are we “fixing” in artic therapy?”). Articulation Therapy: Focus of treatment is on accurate articulation of consonant sounds in the initial, medial and final position of words. Motor Planning Therapy: Focus of treatment is on coarticulatory transitions between sounds and syllables.
8. Assess the child’s ability to produce sound effects during play time, making note of prosodic features.
9. Assess the child’s ability to coarticulate between sounds, syllables and words. Determine the level of motor planning complexity at which the child’s coarticulation skills disintegrate: at the sound level (limited inventory of sounds), at the syllable level, at the word level, at the phrase level, at the sentence level, or at the conversational level. 10. Assess diadochokinetic rate (puh-tuh-kuh) to examine the speed and agility of the child’s articulatory movements.
11. Assess the child’s use of different syllable shapes (V, C, CV, VC, C₁V₁C₁V₁, C₁V₁C₁V₂, C₁V₁C₂V₂, CVC, etc.). – Young children with suspected CAS may reduce words to one syllable to simplify the motor plan. – V and CV are the most common syllable shapes used by young children with suspected CAS. – The child’s speech may lack syllableness. Examples: mama = ma water = wa baby = beh bubble = buh butterfly = buh
Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 20 Early levels of syllableness to assess: ✓ Reduplication baba poo-poo dada mama ✓ Two-syllable words with harmonious consonants: baby puppy daddy mommy ✓ Two-syllable words with non-harmonious consonants: bottle panda doggie monkey ✓ Multi-syllable utterances (not just multi-syllabic words): baby cry panda bear banana my mama (CV.CV.CCV) (CVC.CV.CV) (CVCVCV) (CV.CV.CV) 12.
List the child’s spontaneous use of words or word approximations (functional vocabulary).
13. Assess the child’s ability to verbally imitate and say words on command (requires motor planning!). 15. Determine how the child responds when pressured to speak. (Does the child try to verbally respond, respond with gestures, avert eye gaze, have no response at all?) 16. Assess grossand fine-motor imitation skills. 17. Determine if any co-existing conditions are present (i.e. oral or limb apraxia, dysarthria, SPD, language impairment) 18. Analyze speech sound errors; determine if errors are consistent or inconsistent across different trials. Are there any speech error patterns (phonological processes)?
19. Make note if talking appears effortful for the child (as evidenced by groping, silent posturing, facial grimacing, moments of silence). 20. Assess receptive and expressive language skills, documenting if there is a significant gap. 21. Describe how the communication impairment is affecting the family’s interactions with their child.
Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 21 22. Comment on how the communication struggles affect the child: – Has frequent tantrums due to frustration – Avoids participating in activities where talking is expected – Withdraws from social situations – Has difficulty making friends – Is becoming apathetic in speech therapy – Is showing signs of learned helplessness (“I can’t”) Document your Findings (Why do you suspect CAS?) Joey presents with many characteristics consistent with Childhood Apraxia of Speech.
His speech acquisition is atypically developing and is due primarily to deficits in motor planning. Characteristics include: numerous inaccurate coarticulatory transitions between sounds and syllables, limited inventory of consonants and vowels, oral groping for articulatory configurations, inconsistent sound errors, overuse of the centralized vowel “uh,” voicing errors, history of “pop-out” words, and lack of syllableness in his speech. Receptive language skills are age appropriate. There is no evidence of cognitive impairment, pragmatic language deficits or dysarthria. Document your Findings (Why do you not suspect CAS?) Mikey exhibits a severe phonological impairment characterized by consistent patterns of stopping, fronting, final consonant deletion, and cluster reduction.
There is no evidence of Childhood Apraxia of Speech. Mikey’s speech contains normal prosody, accurate vowel productions, appropriate speech rate, and accurate coarticulatory transitions between sounds and syllables. Receptive and expressive language skills are in the average range. There is no evidence of cognitive impairment, pragmatic language deficits or dysarthria.
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 22 Diagnosis Who Diagnoses CAS?
- CAS is a speech sound disorder, therefore, it is diagnosed by a speech-language pathologist.
- The SLP should document the atypical speech development (emphasizing the motor planning struggles) and explain how this differs from a “late talker” (i.e. a child with a delay).
- There may be supporting documentation by a pediatrician or pediatric neurologist to support the neurologic or neurobehavioral component of CAS (remember the etiologies of CAS). Reasons to Refer to a Neurologist
- Presence of “soft” neurological signs such as hypotonia, gross and fine motor coordination problems, sensory issues
- Presence of tremors, balance issues, difficulty crossing midline, facial asymmetry
- Potential seizure activity
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 23 Primary Reason to Refer to a Developmental Pediatrician
- To rule out complex neurobehavioral disorders as potential etiologies for the speech disorder
- To rule out genetic syndromes If the SLP refers to a neurologist or a developmental pediatrician, it is not for an apraxia diagnosis – it is to assist with identifying the etiology (neurological, neurodevelopmental, or idiopathic) The SLP makes the diagnosis of CAS Other professionals may be able to identify some of the core features of CAS, but the SLP is the specialist who can differentially diagnose CAS from other speech sound disorders The SLP diagnoses CAS; however, the Scope of Practice document by ASHA states, “It is recognized that levels of experience, skill, and proficiency...vary among individual providers.” The ASHA Code of Ethics specifies that SLPs may only practice in areas where they are competent based on their education, training, and experience. Therefore, not all SLPs may be equipped to differentially diagnose CAS. To expand their level of competence in diagnosing and treating CAS, it may be necessary for SLPs to pursue continuing education and training to expand their personal scope of practice.
Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 24 ICD-10 Codes The ICD-10 went into effect on 10/1/15 ➢ Childhood Apraxia of Speech (CAS): R48.2 ➢ Phonological and Articulation Disorders: F80.0 ➢ Expressive Language Disorder: F80.1 ➢ Mixed Receptive-Expressive Language Disorder: F80.2 ➢ Dysarthria (in children/non post CVA): R47.1 ➢ Dyspraxia (limb apraxia, clumsy child syndrome, developmental coordination disorder): F82 At What Age Can a Diagnosis of CAS Be Given?
- The 2-3 year age range is the most challenging to assess and diagnose (differentiating won’t vs. can’t in young children, who are by nature stubborn, can be difficult).
- “The complexity of diagnosis in young children under age 3 is that the child must be able to participate sufficiently in the assessment. Unless the child can attempt to imitate utterances that vary in length and phonetic complexity it is very difficult to make a definitive diagnosis.” Dr. Strand
- There is no specific age when it is deemed “ok” to make a formal diagnosis of CAS. The SLP can make the diagnosis when the child has enough connected speech to assess coarticulatory transitions between sounds, syllables and words.
Reasons why it can be difficult to give a firm diagnosis of CAS prior to age 3: 1. Many of our youngest referrals are preverbal or minimally verbal (we can’t diagnose a speech disorder in children who don’t yet have speech) 2. There is still a lot of brain development occurring prior to age 3 3. CAS is a dynamic speech sound disorder 72
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 25 CAS is a Dynamic Speech Disorder CAS is a Dynamic Speech Disorder “We need to remember that classifications or labels may change over time with neural maturation and appropriate treatment. For example, children with CAS often progress to the point at which speech characteristics are more appropriately labeled phonologic impairment or residual articulation errors.” Strand & McCauley Neuroplasticity: CAS is a Dynamic SSD
- Neuroplasticity is the capacity of nervous systems to change. Children with motor speech disorders demonstrate neuroplasticity for speech.
- This means that with neural maturation and appropriate treatment, the child’s speech symptoms will gradually change over time.
- Thus, the SLP must be able to recognize the phonological impairment and articulation errors that may occur as the child’s motor-speech skills evolve. Speech therapy goals will likely need to be adjusted to accommodate these changes.
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 26 Working Diagnosis With minimally verbal young children, the SLP may decide to use a working diagnosis of suspected childhood apraxia of speech. sCAS “When using a working diagnosis of sCAS, it is recommended that SLPs document in the written report that at least six months of individual therapy is needed until a more definitive diagnosis can be made.” Dave Hammer
- We know there are many disorders that can contribute to struggles with verbal communication skills including: – Autism Spectrum Disorder (ASD) – Cognitive impairment – Hearing impairment – Genetic disorder – Articulation disorder – Phonological disorder – Motor speech disorder (dysarthria, CAS)
- Communication disorders can have many overlapping symptoms. Often times the primary concern is that the child “doesn’t talk” or has limited verbal output.
Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 27 Differential Diagnosis Differential Diagnosis Differential diagnosis is the process of “ruling out” some disorders to ensure proper treatment. Ongoing diagnostic therapy is a crucial component of the therapeutic process. As SLPs, we must be comfortable with and skilled at diagnostic therapy in order to make a differential diagnosis by identifying specific characteristics to validate our diagnosis of suspected CAS in young children.
- When It’s More than CAS Hammer & Ebert, 2018
- CAS rarely occurs on it’s own.
- When a child presents with additional challenges, parents and SLPs must be cautious about lumping all atypical findings in the “CAS features” category. The co-morbid issues need to be addressed as separate therapy goals alongside the motor speech goals.
Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 28 Autism Spectrum Disorder Differentiating CAS from ASD Some young children with CAS may be misdiagnosed as having ASD (autism spectrum disorder) because there are four primary overlapping symptoms that commonly occur in both disorders including: 1. Being minimally verbal 2. Having social deficits 3. Having poor eye contact 4. Presenting with sensory differences CAS + SPD can mask as ASD Apraxia + Sensory can mask as Autism
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 29 CAS/sCAS
- Receptive language skills stronger than expressive
- Communicates wants and needs effectively— just not verbally
- Strong desire to communicate and interact with others
- Exhibits typical play time interests (limb apraxia may interfere with execution of play skills) ASD
- Impaired receptive language skills
- Does not communicate effectively verbally or nonverbally
- Demonstrates little desire to communicate and interact with others (autism is inherently a communication disorder and communication is inherently social)
- Exhibits aberrant play skills CAS/sCAS
- Good joint attention & social referencing; averts eye gaze when pressured to speak
- Limited speech attempts because child anticipates failure based on past talking experiences; child is NOT a communication risk taker
- May have sensory differences ASD
- Poor joint attention and social referencing; poor overall eye contact
- Limited speech because child doesn’t understand the symbolic nature of language; inappropriate speech evidenced in echolalia and scripting
- Likely has sensory differences Regarding sensory processing disorder... It is important to understand that while most children with autism have sensory differences, not all children with sensory differences have autism!
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 30 Dysarthria Dysarthria (the other motor speech disorder)
- “Dysarthria manifests as disrupted or distorted oral communication due to paralysis, weakness, abnormal tone or incoordination of the muscles used in speech. Symptoms may include slurred speech, weak or imprecise articulatory contacts, weak respiratory support, low volume, incoordination of the respiratory stream and hypernasality.” Strand & McCauley, 2008
- All motor processes of speech can be disrupted including respiration, phonation, resonance, articulation and prosody.
- Difficulty planning and sequencing the precise movements necessary for speech production
- Limited inventory of consonants and vowels (overuse of neutral vowels)
- Not associated with muscular dysfunction/ weakness
- Inconsistent speech errors Dysarthria
- Difficulty executing the previously planned and programmed movements for speech production
- Distortion of consonants and vowels
- Characterized by muscular dysfunction/ weakness
- Articulation is imprecise, distorted, slurred, mumbled, but speech errors are consistent
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 31 CAS/sCAS
- No difficulty with involuntary motor control for eating (unless there is also an oral apraxia)
- Receptive language skills may be significantly better than expressive language skills (large gap evident on standardized testing)
- Voice quality is intact Dysarthria
- Difficulty with voluntary motor control for eating due to muscle weakness and incoordination
- Typically there is no significant discrepancy between receptive and expressive language skills
- Voice quality impaired depending on type of dysarthria; voice may be harsh, hoarse, hypernasal, breathy CAS/sCAS
- Prosody is disrupted; rate, rhythm, inflection patterns and stress impaired – better control of pitch and loudness Dysarthria
- Impaired prosody; difficulty controlling loudness levels and pitch (monotone voice is common)
- Both CAS and Dysarthria will result in poor speech intelligibility―determining the cause of the unintelligible speech guides our treatment methods.
- When CAS and Dysarthria co-occur, the SLP must determine the relative contribution of the dysarthric features and the apraxic features in order to establish appropriate treatment goals.
Dr. Lof has explained that articulatory strength needs for speech production are very low (only 10-20% of articulator strength is needed for speaking), which is why NSOME are not part of evidence-based treatment for CAS.
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 32
- Kids with CAS don’t have strength issues, they have movement issues. Dr. Lof reminds us that we don’t need strong articulators, we need agile articulators (i.e. strengthening the oral-facial muscles will not support speech development in children with CAS).
- Speech production requires rapid and accurate alternating movements of the articulators (i.e. speed and agility).
- Diadochokinetic rate (puh-tuh-kuh) is part of assessment for differential diagnosis of CAS as it measures how accurately a person can produce a series of rapidly alternating sounds. Speech/Language Delay Speech/Language Delay (late talker)
- While children develop skills at different ages, the most important factor is that the prelinguistic milestones are acquired in a typical or sequential manner. – Delay: prelinguistic milestones achieved late, but they are acquired in the correct developmental sequence – Disorder: prelinguistic milestones are achieved in an atypical manner/out of sequence (scattered skills)
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 33 CAS/sCAS
- Makes slow, inconsistent progress in therapy
- Limited babbling history (research by Overby & Caspari)
- Disruption in the normal sequence of speech development
- Therapy based on the principles of motor learning will be necessary for speech to develop Speech/Language Delay
- Makes more rapid, consistent progress in therapy
- More typical babbling history
- Mild lag in development; speaks like a child who is chronologically younger
- Increase in ambient language exposure will enhance speech and language development CAS/sCAS
- Limited # of speech sounds in repertoire
- Over-use of the neutral vowel “uh”
- Limited or absent verbal imitation skills (child is not a communication risk taker)
- Prosody is impaired
- Not consistently adding words to expressive vocabulary (history of popout words) Speech/Language Delay
- Wider variety of speech sounds in repertoire
- Relies on the grunt to communicate
- Verbal imitation skills improve when addressed in therapy
- Prosody is intact
- Adds words to expressive vocabulary when in a language-rich environment Phonological Disorder
- Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 34 Phonological Disorder
- A phonological disorder involves patterns of sound errors.
- A child with a phonological disorder consistently makes the same errors, regardless of the speaking situation. In fact, familiar listeners can easily “decode” the child’s speech because the error patterns are so consistent.
- Common phonological processes young children use include: final consonant deletion, cluster reduction, gliding, fronting, stopping and de-affrication. CAS/sCAS
- Motor planning level
- Limited number of vowels and diphthongs
- Inconsistent speech errors on vowels and consonants
- Effortful speech (groping, oral posturing, moments of silence)
- Prosody is impaired
- On-demand speech most difficult Phonological Disorder
- Phonemic level
- Vowels are typically intact
- Consistent patterns of errors that can be grouped into categories
- Speech is not effortful (child talks a “blue streak” but speech is unintelligible to unfamiliar listeners)
- Prosody is intact
- Verbal success is not situationally dependent Speech Sound Disorders Articulation disorder: phonetic level Phonological disorder: phonemic level CAS: motor planning level Dysarthria: motor execution level
Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 35 Differential Diagnosis When assessing minimally verbal young children, SLPs should be differentially diagnosing between the following: ➢ speech/language delay ➢ suspected childhood apraxia of speech ➢ dysarthria ➢ autism spectrum disorder ➢ once the child becomes more verbal we will also have to differentially diagnose between CAS and a phonological disorder Therapy Solutions Articulation Disorder An articulation disorder is the atypical production of speech sounds characterized by substitutions, omissions, additions, or distortions that interfere with intelligibility.
An articulation disorder affects the PHONETIC level, meaning the child has difficulty accurately producing specific speech sounds (consonants).
Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 36 Articulation Disorder Treatment for an articulation disorder focuses on teaching the child how to correctly articulate specific sounds in the initial, medial and final position of words. Articulation errors are considered developmental early on. Phonological Disorder Phonology is the sound system of language. A phonological disorder affects the PHONEMIC (not the phonetic) level. A child with a phonological disorder has difficulty organizing speech sounds into a system of phonemic patterns.
The child uses phonological processes, or simplifications, to modify the adult-speech system. The child can make the speech sounds in isolation (phonetic level), but hasn’t yet learned the rules for how sounds fit together to make words (phonemic level). Phonological Disorder Treatment for a phonological disorder focuses on teaching the child the rules of the sound system within the language by eliminating phonological processes, or simplifications.
Phonological processes are considered developmental early on.
Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 37 Motor Speech Disorder A motor speech disorder occurs when a child struggles to produce speech because of problems with motor planning or problems with motor execution. Motor planning difficulty (neurological) = apraxia Motor execution difficulty (neuromuscular) = dysarthria Children do not “grow out of” motor speech disorders (i.e. the issues are not developmental and treatment is warranted early on) Motor Speech Disorder Treatment for a child with a motor speech disorder focuses on the motor planning or motor execution elements of speech production.
Motor planning treatment (apraxia) focuses on establishing coarticulatory transitions (movement) between sounds and syllables. Motor execution treatment (dysarthria) focuses on establishing the neuromuscular control related to the basic processes of speech production. Principles of Motor Learning in Treatment of Motor Speech Disorders (Maas et al 2008) Motor learning is related to several factors: 1. Pre-practice (motivation, avoid frustration) 2. Structure of practice (frequency, distribution, variability, schedule) 3. Stimulus selection (high frequency, motivating words) 4. Nature of feedback (KR vs.
Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 38 Tools for Success with sCAS ➢For children with apraxia, repetitive motor-speech practice is the key to becoming functionally verbal; but repetitive speech practice isn’t exactly fun. ➢What do SLPs do to make something intrinsically not fun, fun? This is the million dollar question! ➢What tools do you currently have available to make your therapy sessions for children with CAS/sCAS more successful?
Establishing Neural Pathways Through Repetitive Speech Practice Purpose of speech therapy is to build new neural pathways or fix existing ones & teach these children HOW to talk Temporary pathway 2 Primary Therapy Goals when Treating sCAS (Davis & Velleman, 2000) 1.
Establish a consistent form of communication so the child can express his wants, needs and feelings. a. Manual sign (must r/o limb apraxia) b. Picture communication 2. Teach the child to talk.
Assessing and Treating Suspected Childhood Apraxia of Speech Cari Ebert, MS, CCC-SLP NSLHA 2018 Fall Convention 39 Tools for Success with sCAS 1. Increase functional communication through gestures, signs and/or pictures. “Research shows that children with communication challenges do best when introduced to augmentative and alternative communication as early as 12 months.” Davidoff, 2017 Sign Language: – Sign language can used to establish functional communication (sign = output) – Even if the child does not actively use signs to communicate, the SLP can use sign language as visual cues to support speech motor planning skills (sign = input) – If the child has limb apraxia/weak gross and fine motor imitation skills then sign language may not be a viable option for establishing functional communication Signing Strategies for SLPs and Parents a.
Always say the word as you make the sign. b. Signs may not always be made the “right” way, so accept the child’s best approximations (sign accuracy improves as fine motor imitation skills expand). c. Use simplified signs to increase the child’s success. d. If tolerated, provide gentle hand over hand assistance to help the child have success when learning new signs.
e. Incorporate signs into everyday routines and activities and repeat them frequently.