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2/6/2017

Childhood Apraxia of Speech: Building Confidence in your Clinical Skills

Georgia Organization of School-based Speech-Language Pathologists, Atlanta, Georgia

March 10, 2017 © Sue Caspari, 2017

Childhood Apraxia of SpeechBuilding Confidence in Clinical Skills

Childhood Apraxia of SpeechBuilding Confidence in Clinical Skills

Part 1 - AssessmentPart 1 - Assessment

Sue Caspari, MA, CCC/SLPInstructor, Clinical SupervisorTemple University

Georgia Organization of School-based

Speech-Language Pathologists

Atlanta, GA

DisclosuresDisclosures

� Financial Disclosure: Ms. Caspari receives an honorarium and travel expenses as an

invited speaker to this workshop.

� Non-financial Disclosure: Ms. Caspari is an advisory board member of the Childhood

Apraxia Association of North America and receives no compensation as a board

member.

� Financial Disclosure: Ms. Caspari receives an honorarium and travel expenses as an

invited speaker to this workshop.

� Non-financial Disclosure: Ms. Caspari is an advisory board member of the Childhood

Apraxia Association of North America and receives no compensation as a board

member.

2/6/2017




What we will cover this morning

CAS Assessment

What we will cover this morning

CAS Assessment

Understand Speech

Development

Understand CAS as a Breakdown in Speech Motor

Control

Assessment: Comprehensive

History and Direct Assessment

Analyze Results Make Differential

Diagnosis

Hands-On Practice in Assessment

Understand speech developmentUnderstand speech development

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Phonology

Speech Motor Control

Phonology


Understand Speech

Development

Phonology - General Stages of

Early Speech Sound Development

Phonology - General Stages of

Early Speech Sound Development

0

2

4

6

8

10

12

14

16

Phonation Cooing/Gooing Expansion Stage Canonical Stage First Words

(Bleile, 2006, Oller, 2000, Serkhane et al, 2007)

Months

Understand Speech

Development

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Phonology Development

Summary: Early Years

Phonology Development

Summary: Early Years

� Phonology

� Increasing number of speech sounds (Shriberg, 1993, Lof, 2004)

� Early 8 – /m, b, y, n, w, d, p, h/ by age 3

� Variety of differentiated vowel sounds

� Increasing number and diversity of place, manner and voicing features

� Bilabial, Alveolar, Palatal, Glottal

� Oral Stop, Nasal, Glide

� Voiced and Unvoiced

� Phonology


� Early 8 – /m, b, y, n, w, d, p, h/ by age 3

� Variety of differentiated vowel sounds


� Bilabial, Alveolar, Palatal, Glottal

� Oral Stop, Nasal, Glide


Understand Speech

Development

Phonology Later Development

3-4 Years


3-4 Years


� Mid 8 – t, k, g, ng, f, v, ch, j (3-4 years); Early 8 – m, b,y, n, w, d, p, h


� Labiodental, Postalveolar, Velar, Bilabial, Alveolar, Palatal, Glottal

� Fricative, Affricate, Oral Stop, Nasal, Glide


� Intelligibility Index (Coplan & Gleason, 1988)

� 4 years – 100% intelligible in conversation


� Mid 8 – t, k, g, ng, f, v, ch, j (3-4 years); Early 8 – m, b,y, n, w, d, p, h


� Labiodental, Postalveolar, Velar, Bilabial, Alveolar, Palatal, Glottal

� Fricative, Affricate, Oral Stop, Nasal, Glide


� Intelligibility Index (Coplan & Gleason, 1988)

� 4 years – 100% intelligible in conversation

Understand Speech

Development

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5.5 - 8 Years


5.5 - 8 Years


� Late 8 – sh, th (both), s, z, l, r, zh; Mid 8 – t, k, g, ng, f, v, ch, j; Early 8 – m, b,y, n, w, d, p, h


� Interdental, Labiodental, Postalveolar, Velar, Bilabial, Alveolar, Palatal, Glottal

� Liquid, Fricative, Affricate, Oral Stop, Nasal, Glide



� Late 8 – sh, th (both), s, z, l, r, zh; Mid 8 – t, k, g, ng, f, v, ch, j; Early 8 – m, b,y, n, w, d, p, h


� Interdental, Labiodental, Postalveolar, Velar, Bilabial, Alveolar, Palatal, Glottal

� Liquid, Fricative, Affricate, Oral Stop, Nasal, Glide


Understand Speech

Development

Phonology


Phonology


Understand Speech

Development

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Model of Speech Production


Model of Speech Production

Cognition

• Ideas

Language

• Word Retrieval

• Phonological Mapping

• Syntactic Framing

Motor Speech

• Planning

• Programming

• Execution

Understand Speech

Development

(Caruso & Strand, 1999)

Speech Motor Control Speech Motor Control

� What is involved in a motor task?

� A movement can have a beginning and an end – it starts and stops

� A movement can be short or long

� A movements can be simple or complex

� What is involved in a motor task?

� A movement can have a beginning and an end – it starts and stops

� A movement can be short or long

� A movements can be simple or complex

Understand Speech

Development

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Speech is a Complex Motor Task



� What is involved in a speech motor task?

� How many muscles and body parts are involved in speaking?

� How fast do they move when we speak?

� How precise must our speech be – pie vsbye?

� What is involved in a speech motor task?

� How many muscles and body parts are involved in speaking?

� How fast do they move when we speak?

� How precise must our speech be – pie vsbye?

(Thelen, 1991; Caruso & Strand, 1999; Borden, 1984)

Understand Speech

Development

� In speech, what are the units of movement?

� Sounds?

� Syllables?

� Words?

� Phrases?

� Utterances?

� Other? ______________

� In speech, what are the units of movement?

� Sounds?

� Syllables?

� Words?

� Phrases?

� Utterances?

� Other? ______________




Speech is a Complex Motor Task Understand Speech

Development

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� Utterance: unit of vocal expression preceded & followed by silence. Can be made up of

� Words

� Phrases

� Clauses

� Sentences

� Utterance: unit of vocal expression preceded & followed by silence. Can be made up of

� Words

� Phrases

� Clauses

� Sentences

Understand Speech

Development





� Utterances as Movement Envelopes

[-----------------------------]

� Utterances as Movement Envelopes

[-----------------------------]

Understand Speech

Development

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� Movement Envelope Parameters

� Length [---] vs. [---------------------]

� Number of syllables

� Number of movements

� Glides more difficult?

� Diphthongs more difficult?


� Length [---] vs. [---------------------]

� Number of syllables

� Number of movements

� Glides more difficult?

� Diphthongs more difficult?

Understand Speech

Development


Length [---] vs. [------------------]


Length [---] vs. [------------------]

HippopotamusHippopotamus He can eat a mouseHe can eat a mouse

Understand Speech

Development

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Length [---] vs. [------------------]


Length [---] vs. [------------------]

He can eat a mouseHe can eat a mouse Sylvester can devour a rodentSylvester can devour a rodent

Understand Speech

Development


Complexity [^--^--] vs. [^--^^-^^^]


Complexity [^--^--] vs. [^--^^-^^^]


� Complexity [^--^--] vs. [^--^^--^^^^]

� Phonotactic structure


� Complexity [^--^--] vs. [^--^^--^^^^]

� Phonotactic structure

Understand Speech

Development

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Complexity [^--^--] vs. [^--^^-^^^]


Complexity [^--^--] vs. [^--^^-^^^] Understand Speech

Development

� Complexity [^-^] vs. [^^-^-^^--^-^^^-] hierarchy of phonotactic complexity (Velleman,

2002)

� Simple open syllable (CV) – “bye”

� Reduplicated open syllables (CVCV same syllable repeated) - "bye-bye"

� Harmonized (C or V) non-reduplicated disyllabic open syllable forms: CVCV – “baby”

� Non-harmonized non-reduplicated disyllabic open syllable forms - “today”

� Harmonized closed syllables - “mom”

� Non-harmonized closed syllables - “dog”

� CVCVC words (reduplicated, harmonized, or neither) – “movies”

� Words with initial, medial, and/or final clusters “strong”, “monster”, “complex”

� Complexity [^-^] vs. [^^-^-^^--^-^^^-] hierarchy of phonotactic complexity (Velleman,

2002)

� Simple open syllable (CV) – “bye”

� Reduplicated open syllables (CVCV same syllable repeated) - "bye-bye"

� Harmonized (C or V) non-reduplicated disyllabic open syllable forms: CVCV – “baby”

� Non-harmonized non-reduplicated disyllabic open syllable forms - “today”

� Harmonized closed syllables - “mom”

� Non-harmonized closed syllables - “dog”

� CVCVC words (reduplicated, harmonized, or neither) – “movies”

� Words with initial, medial, and/or final clusters “strong”, “monster”, “complex”


Complexity [^--^--] vs. [^--^^-^^^]


Complexity [^--^--] vs. [^--^^-^^^] Understand Speech

Development

� Complexity [^-^] vs. [^^-^-^^--^-^^^-] Index of Phonetic Complexity (IPC) (Jakielski, 2014):

>points = >complexity

� 1 point each for:

� Dorsal place /k, g, A/

� Fricative, affricate, liquid manner /f, v, s, z, h, ‘,;,c,x,.,j,l,r/

� Rhotic vowel (vowel plus /r/)

� Syllable shapes ending with consonant (VC, CVC, etc.)

� 3+ syllable lengths

� Time consecutive singleton consonants that vary by place (coat)

� Consonant clusters (step)

� Heterorganic clusters – consonants vary by place in cluster (play)

� Complexity [^-^] vs. [^^-^-^^--^-^^^-] Index of Phonetic Complexity (IPC) (Jakielski, 2014):

>points = >complexity

� 1 point each for:

� Dorsal place /k, g, A/

� Fricative, affricate, liquid manner /f, v, s, z, h, ‘,;,c,x,.,j,l,r/

� Rhotic vowel (vowel plus /r/)

� Syllable shapes ending with consonant (VC, CVC, etc.)

� 3+ syllable lengths

� Time consecutive singleton consonants that vary by place (coat)

� Consonant clusters (step)

� Heterorganic clusters – consonants vary by place in cluster (play)

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Complexity [^--^--] vs. [^--^^-^^^]


Complexity [^--^--] vs. [^--^^-^^^]

HippopotamusHippopotamus PhantasmagoricPhantasmagoric

Understand Speech

Development


Length and Complexity Practice



� Thatch – 6 letters, 1 word

� How many movements?

� ___

� How complex?

� ___ (IPC?)

� Sprigs – 6 letters, 1 word


� ___

� How complex?

� ___ (IPC?)

� Thatch – 6 letters, 1 word


� ___

� How complex?

� ___ (IPC?)

� Sprigs – 6 letters, 1 word


� ___

� How complex?

� ___ (IPC?)

Understand Speech

Development

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� Sue ran away (3 words)


� ___

� How complex? (IPC?)

� ___

� Samantha cooperates nicely (3 words)


� ___


� ___

� Sue ran away (3 words)


� ___


� ___

� Samantha cooperates nicely (3 words)


� ___


� ___

Understand Speech

Development


NOW describe this…



“Home”“Home”� Length?

� ___ movements

� Complexity? IPC?

� ___

� Length?

� ___ movements


� ___

Understand Speech

Development

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“Daniel’s home is in

Atlanta Georgia”

“Daniel’s home is in

Atlanta Georgia”

� Length?

� ___ movements

/d-a-n-y-e-l-z-h-o-m-i-z-i-n-a-t-l-a-n-t-a-dg-o-er-dg-uh


� ___

CVCCVCCCVCVCVCVCCVCCVCVVCV

� Length?

� ___ movements

/d-a-n-y-e-l-z-h-o-m-i-z-i-n-a-t-l-a-n-t-a-dg-o-er-dg-uh


� ___

CVCCVCCCVCVCVCVCCVCCVCVVCV

Understand Speech

Development


Development


Development

� Motor Control - Speech becomes increasingly adult-like over

developmental time (Maassen, et al, 2007)

� Early Development

� Dominance of mandible in early articulation movements

� Singleton Mono- and Disyllabic Syllable Structures

� V, CV, VC, CVC, VCV, CVCV, VCVC

� Later Development

� Emerging independent movements over time

� Consonant clusters acquired after singletons (Levelt et al, 1999)

� CV – CVC – V – VC followed by

Either CVCC – VCC – CCV – CCVC

OR CCV – CCVC – CVCC – VCC

� Motor Control - Speech becomes increasingly adult-like over

developmental time (Maassen, et al, 2007)

� Early Development

� Dominance of mandible in early articulation movements

� Singleton Mono- and Disyllabic Syllable Structures

� V, CV, VC, CVC, VCV, CVCV, VCVC

� Later Development

� Emerging independent movements over time

� Consonant clusters acquired after singletons (Levelt et al, 1999)

� CV – CVC – V – VC followed by

Either CVCC – VCC – CCV – CCVC

OR CCV – CCVC – CVCC – VCC

Understand Speech

Development

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Speech Development

Summary

Speech Development

Summary

� Phonology

� Increasing sound inventory

� Increasing intelligibility


� Phonology

� Increasing sound inventory

� Increasing intelligibility


� Speech Motor Control

� Increasing independent movements

� Increasing utterance length

� Increasing complexity of syllable shapes with consonant clusters later

� Speech Motor Control

� Increasing independent movements

� Increasing utterance length

� Increasing complexity of syllable shapes with consonant clusters later

Understand Speech

Development

Understand CAS as a Breakdown

in Speech Motor Control

Understand CAS as a Breakdown

in Speech Motor Control

Definition/Causes/Prevalence

Markers


Markers

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Cognition

• Ideas

Language

• Word Retrieval

• Phonological Mapping

• Syntactic Framing

Motor Speech

• Planning - Apraxia

• Programming – Apraxia and Stuttering

• Execution - DysarthriaØ

Childhood Apraxia of Speech

Definition


Definition Understand CAS as a Breakdown in Speech Motor

Control


Definition


Definition

� “Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) 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). CAS may occur as a result of known neurological impairment, in association with

complex neurobehavioral disorders of known or unknown origin, or as an idiopathic

neurogenic speech sound disorder. The core impairment in planning and/or

programming spatiotemporal parameters of movement sequences results in errors in

speech sound production and prosody”(ASHA 2007b)

� “Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) 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). CAS may occur as a result of known neurological impairment, in association with

complex neurobehavioral disorders of known or unknown origin, or as an idiopathic

neurogenic speech sound disorder. The core impairment in planning and/or

programming spatiotemporal parameters of movement sequences results in errors in

speech sound production and prosody”(ASHA 2007b)


Control

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Prevalence (ASHA, 2015c)


Prevalence (ASHA, 2015c)

Children in general population

Speech Disorders

2-25%

CAS0.1%


Control


Markers


Markers


Control

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Markers for CAS

Later Speech Development

Markers for CAS


� Specific Red flags to look for in Later Speech Development - Markers for CAS (3-5 years)

(ASHA, 2007a)

� Inconsistent errors on consonants and vowels in repeated productions of syllables or words

� Vowel errors

� Lengthened and disrupted coarticulatory transitions between sounds and syllables

� Inappropriate prosody, especially in the realization of lexical or phrasal stress

� Specific Red flags to look for in Later Speech Development - Markers for CAS (3-5 years)

(ASHA, 2007a)

� Inconsistent errors on consonants and vowels in repeated productions of syllables or words

� Vowel errors

� Lengthened and disrupted coarticulatory transitions between sounds and syllables

� Inappropriate prosody, especially in the realization of lexical or phrasal stress


Control

Markers for CAS


Markers for CAS


� Other specific markers seen in children with CAS (ASHA, 2007a)

� Increased errors in longer or more complex syllable and word shapes, esp. omissions, and in word-initial positions

� Unusual errors that defy process analysis

� Persistent or frequent regression

� Groping during speech attempts

� Differences in performance of automatic (overlearned) vs. volitional (spontaneous or elicited) activities, with volitional more affected

� Other specific markers seen in children with CAS (ASHA, 2007a)

� Increased errors in longer or more complex syllable and word shapes, esp. omissions, and in word-initial positions

� Unusual errors that defy process analysis

� Persistent or frequent regression

� Groping during speech attempts

� Differences in performance of automatic (overlearned) vs. volitional (spontaneous or elicited) activities, with volitional more affected


Control

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Markers for CAS

Associated Features (ASHA, 2007a)

Markers for CAS

Associated Features (ASHA, 2007a)

Language & Literacy Speech Perception Metalinguistic Non-speech motor

Significant language deficits

Deficits in auditory perception

Increased self awareness of their own speech limitations

General awkwardness or clumsiness

Receptive language often significantly better than expressive language

Deficits in auditory discrimination

Oral apraxia – groping and impaired oral volitional movements

Rhyming deficits (producing rhymes)

Deficits in auditory memory

Mildly low muscle tone

Deficits in word attack, word identification and spelling

Mild delays in motor development

At risk for phonological awareness deficits

Abnormal orosensoryperception

Limb apraxia


Control

Associated FeaturesAssociated Features

� At risk for literacy impairments

� Children with SSD achieve “lower levels of reading” then normally developing peers – even when their language skills are age appropriate and regardless of the severity of their speech disorder (Rvachew, 2007)

� Important to assess speech perception and phonological awareness skills in pre-school years

� Some evidence that there is a “core” “phonological deficit in SSDs (Anthony, et al, 2011) that parallels the core phonological deficit asserted in RD” (Stanovich, 1988)

� Children with CAS are particularly susceptible to PA and RD (NcNeill, Gillon and Dodd, 2009)

� At risk for literacy impairments

� Children with SSD achieve “lower levels of reading” then normally developing peers – even when their language skills are age appropriate and regardless of the severity of their speech disorder (Rvachew, 2007)

� Important to assess speech perception and phonological awareness skills in pre-school years

� Some evidence that there is a “core” “phonological deficit in SSDs (Anthony, et al, 2011) that parallels the core phonological deficit asserted in RD” (Stanovich, 1988)

� Children with CAS are particularly susceptible to PA and RD (NcNeill, Gillon and Dodd, 2009)


Control

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AssessmentAssessment

Roles and Responsibilities

History

Direct Assessment


History

Direct Assessment

Roles and ResponsibilitiesRoles and Responsibilities

� Who diagnosis CAS anyway?

� Neurologist

� Pediatrician

� Developmental Pediatrician

� Speech Language Pathologist

� Who diagnosis CAS anyway?

� Neurologist

� Pediatrician

� Developmental Pediatrician

� Speech Language Pathologist

Assessment

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Roles and ResponsibilitiesRoles and Responsibilities

� Goal of the Assessment

� Determine underlying cause (differential diagnosis) for speech/language difficulties

� Determine severity of delay/disorder

� Make recommendations for appropriate therapy plan

� Goal of the Assessment

� Determine underlying cause (differential diagnosis) for speech/language difficulties

� Determine severity of delay/disorder

� Make recommendations for appropriate therapy plan

Assessment

Motor Speech

CAS Markers

Language

Speech

Sounds Syllables

Intell

Oral Motor

Family and Birth History

Early Speech History

Medical History

Genetics

Associated Features/

Preliteracy

Develop-mental History

Assessment

Red Flags in History

+

Red Flags in Sp/Language Skills

=

CAS Profile

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History

Direct Assessment


History

Direct Assessment

Assessment

HistoryHistory

� Comprehensive

� Family History

� Birth History

� Medical History

� Fine and Gross Motor Development

� Speech and Language Development

� Educational/Pre-literacy/Therapy

� Comprehensive

� Family History

� Birth History

� Medical History

� Fine and Gross Motor Development

� Speech and Language Development

� Educational/Pre-literacy/Therapy

Assessment

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Family

History

Family

History

� Red flags to look for in family history (parents, grandparents, aunts, uncles, cousins)

� History of speech delays/disorders

� History of developmental delays

� History of genetic syndromes

� History of neurodevelopmental disorders

� Red flags to look for in family history (parents, grandparents, aunts, uncles, cousins)

� History of speech delays/disorders

� History of developmental delays

� History of genetic syndromes

� History of neurodevelopmental disorders

Assessment

Birth

History

Birth

History

� Red flags to look for in Birth History

� Instrument, breech, caesarian delivery

� Decreased physical status at birth (decreased apgars <7)

� Premature birth

� Decreased size/weight at birth

� Hospitalization immediately following birth

� Red flags to look for in Birth History

� Instrument, breech, caesarian delivery

� Decreased physical status at birth (decreased apgars <7)

� Premature birth

� Decreased size/weight at birth

� Hospitalization immediately following birth

Assessment

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Medical

History

Medical

History

� Red flags to look for in Medical History

� Neurodevelopmental disorders (Shriberg, 2011)

� Autism

� Chromosome Translocations

� Down syndrome (Trisomy 21)

� Rolandic Epilepsy

� Fragile X syndrome (FMR1)

� Joubert syndrome (CEP290; AHI1)

� Galactosemia

� Rett syndrome (MeCP2)

� Russell-Silver syndrome (FOXP2)

� Velocardiofacial syndrome (22q11.2 deletion)

� Red flags to look for in Medical History

� Neurodevelopmental disorders (Shriberg, 2011)

� Autism

� Chromosome Translocations

� Down syndrome (Trisomy 21)

� Rolandic Epilepsy

� Fragile X syndrome (FMR1)

� Joubert syndrome (CEP290; AHI1)

� Galactosemia

� Rett syndrome (MeCP2)

� Russell-Silver syndrome (FOXP2)

� Velocardiofacial syndrome (22q11.2 deletion)

� Other red flags, cont.

� Neurological event (e.g., stroke, TBI)

� Neurological condition (seizures)

� Medications/responses to medications

� Feeding/swallowing difficulties

� Hearing disorders, multiple ear infections/otological care/surgeries; failed newborn screening

� Illness/high fevers with change in speech status

� Other red flags, cont.

� Neurological event (e.g., stroke, TBI)

� Neurological condition (seizures)

� Medications/responses to medications

� Feeding/swallowing difficulties

� Hearing disorders, multiple ear infections/otological care/surgeries; failed newborn screening

� Illness/high fevers with change in speech status

Assessment

Fine/Gross Motor Developmental

History

Fine/Gross Motor Developmental

History

� Red flags to look for in Developmental History (ASHA, 2007a)

� Fine motor delays/difficulties – feeding, dressing, toileting, difficulty manipulating items with the hands/coordinating hand/finger movements

� Gross motor delays/difficulties – crawling, walking, riding a bike, jumping rope

� Red flags to look for in Developmental History (ASHA, 2007a)

� Fine motor delays/difficulties – feeding, dressing, toileting, difficulty manipulating items with the hands/coordinating hand/finger movements

� Gross motor delays/difficulties – crawling, walking, riding a bike, jumping rope

Assessment

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Language/Functional Comm

History

Language/Functional Comm

History

� Red flags to look for in Language/Communication Development (ASHA, 2007a)

� Receptive Language > Expressive Language

� Supplementing verbal communication with gesture, sign, AAC systems/devices

� Red flags to look for in Language/Communication Development (ASHA, 2007a)

� Receptive Language > Expressive Language

� Supplementing verbal communication with gesture, sign, AAC systems/devices

Assessment

Early Speech Development

History

Early Speech Development

History

� Red flags to look for in Early Speech Development (Davis & Velleman, 2000; Highman, Leitao, Hennessey, & Piek, 2012; Maassen, 2002)

� Decreased or lack of babbling – “Quiet baby”

� Delayed onset of first words – later than 12 months

� Limited consonant and vowel inventory (preferred Vs and Cs possible); gaps in types of sounds, few voiceless sounds

� Vowel errors

� Simple syllable shapes (eg, V and CV)

� Increased difficulty with more complex articulatory gestures

� Limited intonation

� Words appear and then disappear

� Difficulty attaining and maintaining articulatory postures

� Groping/lack of flexibility when imitating speech

� Possible groping and/or difficulty with feeding

� Red flags to look for in Early Speech Development (Davis & Velleman, 2000; Highman, Leitao, Hennessey, & Piek, 2012; Maassen, 2002)

� Decreased or lack of babbling – “Quiet baby”

� Delayed onset of first words – later than 12 months

� Limited consonant and vowel inventory (preferred Vs and Cs possible); gaps in types of sounds, few voiceless sounds

� Vowel errors

� Simple syllable shapes (eg, V and CV)

� Increased difficulty with more complex articulatory gestures

� Limited intonation

� Words appear and then disappear

� Difficulty attaining and maintaining articulatory postures

� Groping/lack of flexibility when imitating speech

� Possible groping and/or difficulty with feeding

Assessment

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Educational/Preliteracy/Therapy

History

Educational/Preliteracy/Therapy

History

� Red flags for Educational/Preliteracy/Therapy History

� Phonological Processing deficits

� Previously in Speech Therapy

� Documented speech disorder/delay

� Not progressing in speech therapy

� NO speech-specific work

� Red flags for Educational/Preliteracy/Therapy History

� Phonological Processing deficits

� Previously in Speech Therapy

� Documented speech disorder/delay

� Not progressing in speech therapy

� NO speech-specific work

Assessment

Evidence shows motor

planning is task specific

Evidence shows motor

planning is task specific

� Consensus opinion - the evidence is against the use of Oral Motor Exercises for improving speech in children with CAS.

� Some evidence that oral motor control for non-speech movement separate from oral motor control for speech movements (McCauley, et al 2009)

� “Conservative conclusion is that evidence [for the use of OME’s in treating speech sound disorders] is equivocal” (Kent, 2015)

� Consensus opinion - the evidence is against the use of Oral Motor Exercises for improving speech in children with CAS.

� Some evidence that oral motor control for non-speech movement separate from oral motor control for speech movements (McCauley, et al 2009)

� “Conservative conclusion is that evidence [for the use of OME’s in treating speech sound disorders] is equivocal” (Kent, 2015)

Assessment

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History

Direct Assessment


History

Direct Assessment

Assessment

Motor Speech

CAS Markers

Language

Speech

Sounds Syllables

Intell

Oral Motor

Family and Birth History

Early Speech History

Medical History

Genetics

Associated Features/

Preliteracy

Develop-mental History

Assessment

Red Flags in History

+

Red Flags in Sp/Language Skills

=

CAS Profile

2/6/2017




Direct Assessment

Skills

Direct Assessment

Skills

� Language Skills

� Receptive

� Expressive

� Functional Communication/Pragmatics (including AAC)

� Oral Motor and Speech Skills

� Oral Motor

� Structure and function

� Oral, non-verbal motor skill

� Speech Skills

� Intelligibility

� Articulation – sound analysis and phonetic inventory

� Phonology – phonological pattern errors

� Motor Speech Skill – markers for motor planning and programming difficulty (CAS)

� Syllable structure analysis

� Voice/fluency

� Language Skills

� Receptive

� Expressive

� Functional Communication/Pragmatics (including AAC)

� Oral Motor and Speech Skills

� Oral Motor

� Structure and function

� Oral, non-verbal motor skill

� Speech Skills

� Intelligibility

� Articulation – sound analysis and phonetic inventory

� Phonology – phonological pattern errors

� Motor Speech Skill – markers for motor planning and programming difficulty (CAS)


� Voice/fluency

Assessment

Direct Assessment

Standardized Tests for CAS?

Direct Assessment

Standardized Tests for CAS?

� None that are reliable or valid (McCauley & Strand, 2008)

� Do we need them? What should we do without them?

� None that are reliable or valid (McCauley & Strand, 2008)

� Do we need them? What should we do without them?

Assessment

2/6/2017




Direct Assessment

Tasks - Language Assessment

Direct Assessment

Tasks - Language Assessment

� Receptive Vocabulary

� Receptive Language

� Expressive Language

� Functional Communication/Pragmatic

� Receptive Vocabulary

� Receptive Language

� Expressive Language

� Functional Communication/Pragmatic

� Use standardized assessment for rec/exp

lang – PPVT, REEL, CELF, OWLS, PLS, etc.

� Determine if Receptive > Expressive

� Observe functional communication and

pragmatics during speech sample activity

and throughout session

� If specific pragmatic concerns may use standardized test for pragmatics

� Use standardized assessment for rec/exp

lang – PPVT, REEL, CELF, OWLS, PLS, etc.

� Determine if Receptive > Expressive

� Observe functional communication and

pragmatics during speech sample activity

and throughout session

� If specific pragmatic concerns may use standardized test for pragmatics

Assessment

Direct Assessment

Tasks - Oral Motor Exam

Direct Assessment

Tasks - Oral Motor Exam

� Structural-Functional Examination

� Structures – size, symmetry, abnormalities, dental occlusion

� Function – ROM, Strength, Speed, ability to vary muscular tension of jaw, kips, tongue

� Structural-Functional Examination

� Structures – size, symmetry, abnormalities, dental occlusion

� Function – ROM, Strength, Speed, ability to vary muscular tension of jaw, kips, tongue

� Observe structure and function of oral

structures

� Note deviancies

� Observe structure and function of oral

structures

� Note deviancies

Assessment

2/6/2017




Direct Assessment

Tasks - Oral Non-Verbal Apraxia

Direct Assessment

Tasks - Oral Non-Verbal Apraxia

� Oral, non-verbal apraxia assessment� Oral, non-verbal apraxia assessment

� Informal - Ask the child to perform single,

non-verbal oral movements on command

(e.g., blow, pucker lips, puff out cheeks,

cough) and judge if the child can imitate

the oral movements immediately and

without effort, hesitation, groping, etc.

� Informal - Ask the child to perform single,

non-verbal oral movements on command

(e.g., blow, pucker lips, puff out cheeks,

cough) and judge if the child can imitate

the oral movements immediately and

without effort, hesitation, groping, etc.

Assessment

Direct Assessment

Tasks - Speech/Language Sample

Direct Assessment

Tasks - Speech/Language Sample

� Phonetic inventory


� Intelligibility analysis – word level and utterance level

� Mean Length of Utterance

� Functional Communication/AAC

� Pragmatics

� Voice/fluency/prosody

� Phonetic inventory


� Intelligibility analysis – word level and utterance level

� Mean Length of Utterance

� Functional Communication/AAC

� Pragmatics

� Voice/fluency/prosody

� Video tape 10minutes of play with

parents (or therapist)

� Transcribe and analyze

� Video tape 10minutes of play with

parents (or therapist)

� Transcribe and analyze

Assessment

2/6/2017




Direct Assessment

Tasks - Articulation Assessment

Direct Assessment

Tasks - Articulation Assessment

� Standardized Artic Assessment

� Phonetic Inventory

� Standard Score

� Informal analysis of phonological pattern errors

� Standardized Artic Assessment

� Phonetic Inventory

� Standard Score

� Informal analysis of phonological pattern errors

� Use word level articulation assessment

such as Goldman Fristoe, or DEAP

� Use word level articulation assessment

such as Goldman Fristoe, or DEAP

Assessment

Direct Assessment

Tasks - Phonological Assessment

Direct Assessment

Tasks - Phonological Assessment

� Standardized Phonological Assessment

� Phonological Pattern Errors

� Standardized Phonological Assessment

� Phonological Pattern Errors

� Use word-level phonological assessment

such as the HAPP-3

� Use word-level phonological assessment

such as the HAPP-3

Assessment

2/6/2017




Direct Assessment

Tasks – Pre-literacy Assessment

Direct Assessment

Tasks – Pre-literacy Assessment

� Standardized pre-literacy/literacy

assessments

� Phonological Awareness

� Decoding

� Standardized pre-literacy/literacy

assessments

� Phonological Awareness

� Decoding

� Select an assessment depending on the

age of the child

� CTOPP

� TOWRE

� Select an assessment depending on the

age of the child

� CTOPP

� TOWRE

Assessment

Direct Assessment

Tasks - Motor Speech Exam

Direct Assessment

Tasks - Motor Speech Exam

� Imitation Tasks

� Increasingly longer words*

� Young child – 1-, 2-, and 3- syllable

� Older child – 3+ syllable

� Developmentally appropriate sounds

� Variety of consonants and vowels

� DDK

� 3-6 Year Norms (Robbins & Klee, 1987)

� 6-13 Year Norms (Fletcher, 1972)

� Imitation Tasks

� Increasingly longer words*

� Young child – 1-, 2-, and 3- syllable

� Older child – 3+ syllable

� Developmentally appropriate sounds

� Variety of consonants and vowels

� DDK

� 3-6 Year Norms (Robbins & Klee, 1987)

� 6-13 Year Norms (Fletcher, 1972)

� Imitation Tasks (any age)

� Have the child repeat increasingly longer words/utterances (length and complexity determined by age and language abilities)

� Have child repeat each one 2X

� Listen for key signs of CAS

� DDK (3+ years old)

� Measure Rate and judge with norms

� Listen for articulatory accuracy

� Listen for sound sequencing

� Imitation Tasks (any age)

� Have the child repeat increasingly longer words/utterances (length and complexity determined by age and language abilities)

� Have child repeat each one 2X

� Listen for key signs of CAS

� DDK (3+ years old)

� Measure Rate and judge with norms

� Listen for articulatory accuracy

� Listen for sound sequencing

* Use something you already have or design your own – DEMSS hopefully to come soon

Assessment

2/6/2017




Analyze ResultsAnalyze Results

Differential Diagnosis

Determine Confidence in Diagnosis

Determine Severity/Prognosis





Mayo Clinic System


Mayo Clinic System

� Gold Standard: CAS Classification using a Pediatric Adaptation of the Mayo Clinic System a (Shriberg & Strand, 2014)

� Vowel distortions

� Difficulty achieving initial articulatory configurations or transitionary movement gestures

� Equal stress; lexical or phrasal stress errors

� Distorted substitutions

� Syllable or word segregation

� Groping

� Intrusive schwa

� Voicing errors

� Slow speech rate and/or slow DDK rates

� Increased difficulty with multi-syllabic words

� > 4 signs over > 3 speech tasks = CAS

� Gold Standard: CAS Classification using a Pediatric Adaptation of the Mayo Clinic System a (Shriberg & Strand, 2014)

� Vowel distortions

� Difficulty achieving initial articulatory configurations or transitionary movement gestures

� Equal stress; lexical or phrasal stress errors

� Distorted substitutions

� Syllable or word segregation

� Groping

� Intrusive schwa

� Voicing errors

� Slow speech rate and/or slow DDK rates

� Increased difficulty with multi-syllabic words

� > 4 signs over > 3 speech tasks = CAS

Analyze Results

2/6/2017





Madison Speech Assessment


Madison Speech Assessment

� Articulation Task

� Challenging Word Tasks (2)

� Challenging Phrase Task

� Consonants Task

� Conversational Sample

� DDK Task

� Phonation Task

� Syllable Repetition Tasks (2)

� Stress Tasks (2)

� Vowel Tasks (3) (Shriberg & Strand, 2014)

� Articulation Task

� Challenging Word Tasks (2)

� Challenging Phrase Task

� Consonants Task

� Conversational Sample

� DDK Task

� Phonation Task

� Syllable Repetition Tasks (2)

� Stress Tasks (2)

� Vowel Tasks (3) (Shriberg & Strand, 2014)

Analyze Results


Recent Studies


Recent Studies

� Pause Marker Method to ID CAS (Shriberg

& Strand, 2014)

� Pause Marker Method to ID CAS (Shriberg

& Strand, 2014)

� The Type I “Pause Marker” provides a

“single sign marker that likely can be used

cross-linguistically to discriminate CAS

from speech delay, and to scale the

severity of CAS”

� Type I = atypical pause - abrupt, change,

grope, other

� NOT Type II = more typical addition,

repetition/revision. long, breath

� The Type I “Pause Marker” provides a

“single sign marker that likely can be used

cross-linguistically to discriminate CAS

from speech delay, and to scale the

severity of CAS”

� Type I = atypical pause - abrupt, change,

grope, other

� NOT Type II = more typical addition,

repetition/revision. long, breath

Analyze Results

2/6/2017





Recent Studies


Recent Studies

� 30-Minute Assessment (Murray, et. al.

2015)

� 30-Minute Assessment (Murray, et. al.

2015)

� Two assessments

o Polysyllabic word picture-naming task (Gozzard et al, 2004)

o OME (Robbins and Klee, 1987)

� Four-measure combination had 91%

predictive accuracy

o Syllable segregation – polysyllabic naming task

o Percentage of lexical stress matches –polysyllabic naming task

o PPC – polysyllabic naming task

o Accuracy on repetition of /p1t1k1/

� Two assessments

o Polysyllabic word picture-naming task (Gozzard et al, 2004)

o OME (Robbins and Klee, 1987)

� Four-measure combination had 91%

predictive accuracy

o Syllable segregation – polysyllabic naming task

o Percentage of lexical stress matches –polysyllabic naming task

o PPC – polysyllabic naming task

o Accuracy on repetition of /p1t1k1/

Analyze Results

Other assessments?Other assessments?

� Syllable Repetition Task (Shriberg et al., 2012)

� Repeat non-words with simple sounds: 2-4 syllables in length [dama, nadamaba]

� Maximal Performance Tasks (Thoonen et al., 1996, 1999; Rvachew, Hodge & Ohberg, 2005)

� Maximal sound prolongations (vowels and fricatives)

� Diadochokinetic tasks (DDKs)

� AMR (pa-pa-pa…; ta-ta-ta…; ka-ka-ka…)

� SMR (pa-ta-ka-pa-ta-ka…)

� Syllable Repetition Task (Shriberg et al., 2012)

� Repeat non-words with simple sounds: 2-4 syllables in length [dama, nadamaba]

� Maximal Performance Tasks (Thoonen et al., 1996, 1999; Rvachew, Hodge & Ohberg, 2005)

� Maximal sound prolongations (vowels and fricatives)

� Diadochokinetic tasks (DDKs)

� AMR (pa-pa-pa…; ta-ta-ta…; ka-ka-ka…)

� SMR (pa-ta-ka-pa-ta-ka…)

2/6/2017





Take-Away from Recent Studies…


Take-Away from Recent Studies…

� Prosody is a critical feature for dx of CAS – syllable segregation and stress errors� Prosody is a critical feature for dx of CAS – syllable segregation and stress errors

Analyze Results

Differential DiagnosisDifferential Diagnosis

Apraxia

Inconsistent errors

No swallowing

issues

No weakness

Phonological

Predictable pattern of

errors

No swallowing

issues

No weakness

Dysarthria

Generally consistent

errors

Swallowing often

affected

Weakness of musculature

More detailed comparison chart found at:http://www.apraxia-kids.org/library/a-comparison-of-childhood-apraxia-of-speech-dysarthria-and-severe-phonological-disorder/

Analyze Results

2/6/2017










Analyze Results

Confidence in Diagnosis Robbie 2;7Confidence in Diagnosis Robbie 2;7

CAS

Markers

Family History

Red Flags

Early Speech Dev

Red Flags

Rec Lang > Exp Lang

Analyze Results

2/6/2017










Analyze Results

Determine SeverityDetermine Severity

� Speech Sound Production Severity Rating

Scale (Tennessee Department of

Education, 2009)

� Sound production

� Motor speech skill

� Intelligibility

� Mild 4-7

� Moderate 8-11

� Severe to Profound 12-18

� Speech Sound Production Severity Rating

Scale (Tennessee Department of

Education, 2009)

� Sound production

� Motor speech skill

� Intelligibility

� Mild 4-7

� Moderate 8-11

� Severe to Profound 12-18

Analyze Results

2/6/2017




PrognosisPrognosis

� Children with CAS can go on to develop normal-sounding speech

� Determine a prognosis during assessment based on

� Concomitant disabilities

� Ability to improve speech accuracy when given assistance

� Age at assessment

� Severity of disorder

� Children with CAS can go on to develop normal-sounding speech

� Determine a prognosis during assessment based on

� Concomitant disabilities

� Ability to improve speech accuracy when given assistance

� Age at assessment

� Severity of disorder

Analyze Results

Mock Assessment

Diagnosis Student #1

Mock Assessment


� ____________ signs over __________ tasks � ____________ signs over __________ tasks

Hands-On Practice

2/6/2017




Mock Assessment


Mock Assessment


� ____________ signs over __________ tasks � ____________ signs over __________ tasks

Hands-On Practice

Real-time Video AssessmentReal-time Video Assessment

� Diagnosis?� Diagnosis? � Confidence?� Confidence?

Hands-On Practice

2/6/2017




Advocating for

Children with CAS

Advocating for

Children with CAS

Advocate for Children with CASAdvocate for Children with CAS

Understand Speech Development


Control

Assessment: Comprehensive

History and Direct Assessment

Analyze Results Make Differential Diagnosis

2/6/2017




Advocate for Children with CAS

ASHA Practice Portal – CAS (ASHA, 2015a)

http://www.asha.org/Practice-Portal/Clinical-Topics/Childhood-Apraxia-of-

Speech/Childhood-Apraxia-of-Speech-Content-Development/


ASHA Practice Portal – CAS (ASHA, 2015a)

http://www.asha.org/Practice-Portal/Clinical-Topics/Childhood-Apraxia-of-

Speech/Childhood-Apraxia-of-Speech-Content-Development/

� What are the signs and symptoms of CAS

� What are the causes of CAS

� Who should diagnose CAS

� How do I assess for CAS

� How do I diagnose CAS

� What is the incidence and prevalence of CAS

� What are my roles and responsibilities as a Speech Language Pathologist working with a child with CAS

� What are some good resources for CAS

� What are the signs and symptoms of CAS

� What are the causes of CAS

� Who should diagnose CAS

� How do I assess for CAS

� How do I diagnose CAS

� What is the incidence and prevalence of CAS

� What are my roles and responsibilities as a Speech Language Pathologist working with a child with CAS

� What are some good resources for CAS


On-line Resources for CAS


On-line Resources for CAS

� Childhood Apraxia of Speech Association of America (CASANA)

� www.apraxia-kids.org

� Annual conference – San Antonio July 9-11, 2015

� Facebook

� Twitter

� Email listserve

� Sponsors Walks to Support CAS

� More…

� Childhood Apraxia of Speech Association of America (CASANA)

� www.apraxia-kids.org

� Annual conference – San Antonio July 9-11, 2015

� Facebook

� Twitter

� Email listserve

� Sponsors Walks to Support CAS

� More…

2/6/2017




What we will cover this afternoon

CAS Treatment

What we will cover this afternoon

CAS Treatment

Have Confidence in the Diagnosis

Use Assessment Results to Plan

Treatment

Initiate Measurable

Therapy

Monitor in the School Years

Hands-on Practice

Treatment

Questions/DiscussionQuestions/Discussion

2/6/2017




ReferencesReferences

� American Speech-Language-Hearing Association. (2007a). Childhood Apraxia of Speech

[Technical Report]. Available from www.asha.org/policy.

� American Speech-Language-Hearing Association. (2007b). Childhood Apraxia of Speech

[Position Statement]. Available from www.asha.org/policy.

� American Speech-Language-Hearing Association (2015 a). Childhood Apraxia of Speech

(Practice Portal). Retrieved January 13, 2015 from www.asha.org/Practice-Portal/Clinical-

Topics/Childhood-Apraxia-of-Speech/.

� American Speech-Language Hearing Association. (2015 b). How does your child hear

and talk?. Retrieved March 5, 2015 from:

http://www.asha.org/public/speech/development/chart/

� American Speech-Language-Hearing Association (2015 c). Speech Sound Disorders:

Articulation and Phonology (Practice Portal). Retrieved March 5, 2015 from:

http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935321&section=Incidence_an

d_Prevalence

� American Speech-Language-Hearing Association. (2007a). Childhood Apraxia of Speech

[Technical Report]. Available from www.asha.org/policy.

� American Speech-Language-Hearing Association. (2007b). Childhood Apraxia of Speech

[Position Statement]. Available from www.asha.org/policy.

� American Speech-Language-Hearing Association (2015 a). Childhood Apraxia of Speech

(Practice Portal). Retrieved January 13, 2015 from www.asha.org/Practice-Portal/Clinical-

Topics/Childhood-Apraxia-of-Speech/.

� American Speech-Language Hearing Association. (2015 b). How does your child hear

and talk?. Retrieved March 5, 2015 from:

http://www.asha.org/public/speech/development/chart/

� American Speech-Language-Hearing Association (2015 c). Speech Sound Disorders:

Articulation and Phonology (Practice Portal). Retrieved March 5, 2015 from:

http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935321&section=Incidence_an

d_Prevalence


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� Centers for Disease Control and Prevention. Learn the signs. Act early. Developmental Milestones. Retrieved March 5, 2015 from: http://www.cdc.gov/ncbddd/actearly/milestones/milestones-3yr.html

� Childhood Apraxia of Speech Association of North America (CASANA): Advisory Board (2004). A Comparison of Childhood Apraxia of Speech, Dysarthria, and Severe Phonological Disorder. Available from http://www.apraxia-kids.org/site/c.chKMI0PIIsE/b.980831/apps/s/content.asp?ct=464135

� Anthony, J.L., Aghara, R. G., Dunkelberger, M.J., Anthony, T. I., Williams, J.M., Zhang, Z. (2011). What factors place children with speech sound disorders at risk for reading problems? American Journal of Speech Language Pathology. 20:146-160.

� Bleile, K. (2006). Manual of articulation and phonological disorders. Thomson Delmar Learning: Delmar, NY.

� Borden, G.J., & Harris, K.S. (1984). Speech Science Primer: Physiology, Acoustics, and Perception of Speech. Baltimore: Williams and Wilkins.

� Caruso, A., & Strand, E. A. (Eds.). (1999). Clinical management of motor speech disorders in children. New York: Thieme Medical.

� Centers for Disease Control and Prevention. Learn the signs. Act early. Developmental Milestones. Retrieved March 5, 2015 from: http://www.cdc.gov/ncbddd/actearly/milestones/milestones-3yr.html

� Childhood Apraxia of Speech Association of North America (CASANA): Advisory Board (2004). A Comparison of Childhood Apraxia of Speech, Dysarthria, and Severe Phonological Disorder. Available from http://www.apraxia-kids.org/site/c.chKMI0PIIsE/b.980831/apps/s/content.asp?ct=464135

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� Maassen, B. 2002: Issues contrasting adult acquired versus developmental apraxia of speech. Seminars in Speech and Language 23, 257–66.

� Green, J. R., Moore, C. A., Higashikawa, M. & Steeve, R. W. (2000). The physiologic development of speech motor control: Lip and jaw coordination. Journal of Speech, Language and Hearing Research, 45, 66-79.

� Highman, C., Leitao, S., Hennessey, N., & Piek, J. (2012) Prelinguistic communication development in children with childhood apraxia of speech: A retrospective analysis. International Journal of Speech-language Pathology, 14, 35-47.

� Kent, RD (2015). Nonspeech oral movements and oral motor disorders: A narrative review. American Journal of Speech-Language Pathology, 24, 763-789.

� Levelt, CC, Schiller, NO, and Levelt WJM (1999).. A developmental grammar for syllable structure in the production of child language. Brain and Language, 68, 291-299.

� Lof, G.L. (2004). Confusion about speech sound norms and their use. On-line language conference 2004, MGH Institute of Health Professions. Available from: http://www.speech-language-therapy.com/Lofspeechnorms.pdf

� Maas, E., Gildersleeve-Neumann, C. E., Jakielski, K. J., & Stoeckel, R. Motor-based intervention protocols in treatment of childhood apraxia of speech (CAS). Current Developmental Disorders Reports. 2014; 1 (3).

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� McNeill, B.C., Gillon, G.T., Dodd, B. (2009). Phonological awareness and early reading development in childhood apraxia of speech (CAS). International Journal of Languaeg a& Communication Disorders, 44(2), 175-192.

� Moore, C.A., Caulfield, T.J., & Green, J.R. (2001). Relative kinematics of the rib cage and abdomen during speech and nonspeech behaviors of 15-month-old children. Journal of Speech, Language and Hearing Research, 44, 80-94.


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Learning Disabilities, 21, 590-604.

� Strand, E.A. (2005). Differential diagnosis and treatment of childhood apraxia of speech.

Conference on Childhood Apraxia of Speech, Saint Louis, MO.

� Strand, E.A., McCauley R, Weigand, S., Stoeckel, R., Baas, B. (2013). A motor speech

assessment for children with severe speech disorders: Reliability and validity evidence.

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Speech: A Treatment Efficacy Study. Journal of Medical Speech-Language Pathology, 14,

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Rating Scales., Retrieved March 5, 2015 from:

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