Childhood Apraxia of Speech:
Toward Effective Treatment
Planning and Implementation
Structure of Todayʼs Talk


Background
Assessment
–With a focus on symptoms/signs related to diagnosis for CAS
AND treatment planning

Treatment –



Rebecca McCauley
Specific treatment approaches for CAS
Adaptations and other relevant treatment approaches
Special considerations
• Younger children
• Older children
Department of Speech & Hearing Science

Ohio State University

Consider hypothetical cases
Answer questions about actual cases presented by
audience members
1
Part I. Background
2
Group Exercise

•
•
What does this disorder look
like?
What does the latest research
say about it?

Write down a list of
characteristics that
you have seen in
children with this
disorder
Share these with
someone sitting next
to you
3
4
Davis et al. Speech Criteria
Characteristics of
CAS (DAS)
(1) Limited C and V
repertoire
(2) Frequent omissions
(3) High incidence of
vowel errors
(4) Inconsistent
articulation errors
Based on a study by
Davis, Jakielski and
Marquardt, 1998
5
(5) Altered
suprasegmentals
(6) Increased errors
with output length
(7) Difficulty in imitation
(groping or refusal)
(8) Use of simple
syllable shapes
•Probably the most SENSITIVE & SPECIFIC
characteristics
6
1
Davis et al. Nonspeech Criteria
Other characteristics?
(1) Impaired volitional oral
movements (oral apraxia)
(2) Reduced expressive compared
to receptive language skills
(3) Reduced diadochokinetic rates

That youʼve seen
but that havenʼt
been mentioned
yet?
7
8
What does this tell us about
CAS?
Difficulties in CAS Diagnosis
(Davis, Jakielski, & Marquardt, 1998)
22 children referred with
CAS
- 4 articulation disorder
only
-11 articulation &
expressive language
disorder
- 3 articulation & receptive
& expressive laguage
disorder
4 children finally
diagnosed with CAS
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
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Relatively rare--with implications for the
professionʼs learning curve in identifying and
treating this disorder
Many symptoms in common with other
communication disorders  need to identify
specific (i.e., discriminative) symptoms
Also difficult for clinicians to deal because of the
variety of symptoms shown
9
Childhood apraxia of speech-A definition (ASHA, 2007)
10
Alternative Terms for CAS
“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)….
The core impairment in planning and/or
programming spatiotemporal parameters of
movement sequences results in errors in
speech sound production and prosody.” (p. 1)
11
12
2
Discriminative characteristics from the
2007 ASHA position statement on CAS
Whatʼs the relationship of this disorder to
other childhood disorders affecting speech
production?
“inconsistent errors on consonants and
vowels in repeated productions of
syllables or words,”
 “lengthened and disrupted coarticulatory
transition between sounds and syllables,”
 “inappropriate prosody, especially in the
realization of lexical or phrasal stress.”

(ASHA, 2007, p. 2)
13
Whatʼs the relationship of CAS to other
development speech sound system
disorders?
Developmental Dysarthria



A disorder of muscle tone, strength or balance,
caused by neurological impairment
Directly affects oral movements
and speech production skills
Involvement may :
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14
2
major classification systems:
 Shriberg
 Dodd
Affect specific oromotor speech muscle groups or
Be pervasive throughout the oromotor musculature
Support systems (respiration, phonation) may
also be affected
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16
Focus on CAS in Shribergʼs
system
Shribergʼs Classification of Childrenʼs
Speech Sound Disorders (1994, 1997)
Viewed as distinctive from other types of
disorders
 Considered rare--less than 0.07% of all
children
 Shriberg considers at least one subtype
of this rare disorder as indicated by
difficulty with prosody (especially, syllabic
and sentential stress patterns)

Intelligibility
decrements
Milder problems
17
18
3
Whatʼs the relationship of CAS to other
development speech sound system
disorders?
Doddʼs system (1995)


5 categories that have been studied across
languages and within bilingual children for their
value in predicting treatment needs
These 5 categories consist of:
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Articulation disorder
Delayed phonological acquisition
Consistent deviant disorder
Inconsistent disorder inconsistent production of
repeated single word
Other - includes suspected dysfluency, dyspraxia, or
dysarthria



Not simply a distinct speech sound disorder due
to severity
Suspected origin – motor planning deficit rather
than problems in linguistic representation or
motor execution
3 presentations

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Idiopathic – Unknown origin
Syndromic - In association with complex
neurobiological disorders of a genetic or metabolic
nature – e.g., Fragile X, Galactosemia, Autism
Acquired – e.g., intrauterine stroke,infection, trauma
19
20
What does the latest research
say about it?
Genetic source strongly implicated



The KE family - 1/2 of the family affected;
gene suspected on Chromosome 7
suspected = FOXP2
Feuk paper in Am J. of Human Genetics (in
press) - 13 children with CAS—some with
Autism, as well
Possibly part of a larger dyspraxic
syndrome for some children


Developmental Discoordination syndrome
Megan Hodge - U. of Alberta
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Group exercise
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22
Part II. Principles Guiding
Discuss with your
neighbors what
information about
classification
systems and new
research was most
helpful to your
thinking about
children with CAS.
Assessment & Treatment
(1)
(2)
23
WHO classification of chronic
disease – Understanding all of
the ramifications of CAS
Levels of impairment –
Conceptualizing the nature of the
speech difficulty in CAS
24
4
The ICIDH Model of Chronic
Disease
(1) Understanding the implications of
CAS – Helpful in planning dx and tx
The World Health Organization
(W.H.O.) International Classification
system (ICIDH, 1980) =
A model for understanding the effects
of chronic disease

Pathophysiology

Impairment

Functional Limitation

Disability or Disablement

Societal Limitation
25
The ICIDH Model of Chronic
Disease & CAS (and other SSD)
Group Exercise

Pathophysiology – Effects on tissues, cells  unknown

Impairment – Loss of anatomical function  Movement
difficulty for speech

Functional Limitation – Breakdown in speech
production leading to Reduced intelligibility
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
26

Does the WHO
classification make you
think of any new or
additional issues that you
might want to address in

Disability - Reduced communicative competence

Limitation on Social Roles - Lack of peer acceptance;
assessment and
treatment for children with
reduced intelligibility?
reduced access to teachers/information in classroom
27
My thoughts on how this affects
assessment
28
My thoughts on how this affects
treatment
29
30
5
(2) Level of the speech production process
and level of impairment
Level of impairment affects how speech is
targeted
Speech Production Stages &
Level of Impairment
Speech Production Stages & Level of Impairment
Cognitive/
Linguistic
Motor Planning/
Programming
Motor execution
Phonologic
Impairment
Cognitive/
Linguistic
Phonologic
Impairment
Phonological approaches
addressing linguistic knowledge
& functional use
CAS
Motor Planning/
Programming
CAS
Motor learning principles
With special attention to motor
planning and timing
Motor execution
Dysarthria
Dysarthria
Motor learning principles and
With special attention to
physiology, e.g., weakness
31
In addition, multiple levels may be affected and
need to be targeted—For example, problems of a
former client with PDD-NOS and apraxia
32
Part III. Components of a Dx
Battery – The highpoints for dx
EX: use of /mam/ and /hai mam/ - in imitation only


Speech Production Stages & Level of Impairment
Need to address use of
speech sounds in functional
Cognitive/
Linguistic
Phonologic
Impairment
Motor Planning/
Programming
CAS
Motor execution
Dysarthria

communication
Need to address
motor learning principles


History
Description of
Neuromuscular Status
Structural-Functional
Exam
Motor Speech
Examination
Sound System
Description
33
❀History
Purposes:

 Obtain information
about course of
speech development

and disorder
 Identify suspected

etiology and coexisting problems
34
The common historical element for
all children with severe speech sound
disorders
Obtain information about
the impact on the child
and the family

Obtain information about
family understanding
Delay in development of intelligible
speech
And gain information to
help with identification of
level of impairment
35
36
6
Other shared problems

Less frequently shared
problems
Family histories of communication
disorders, sometimes similar to childʼs

Clues to the identification
of levels of impairment
Increased risk for concurrent language
problems, especially expressive

Psychosocial issues
Sources: Hall, Jordan & Robin, 1993; Strand & McCauley, 1999
38
37
Children with Speech Sound
Disorders
More common
concerns:
Children with CAS
Less frequent concerns:


Frequent reports of otitis
media

Concerns about emotional 
sensitivity

Parentsʼ concerns about
behavior management and
about their childʼs
acceptance by peers
Milestones regarding
quantity of speech

Reduced quantity of vocalization/speech in early
history (EX: Child who as an infant was reported to cry only
about 1 time/week; one proto word at age 2; at age 5 /s:, b, m:/
and /a/)

Relatively few concerns
about gross or fine motor
skills
Reports of feeding problem; oromotor concerns
(same child; difficulty nursing; then fine except mushy food only
until age 2)



Fine/gross motor incoordination not uncommon &
perhaps related to developmental coordination
disorder
“Soft” neurological signs
Slow progress in conventional treatments
39
Children with Developmental
Dysarthria
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

40
❀
Neuromuscular Status
Most often associated with medical diagnoses, such as
cerebral palsy, Moebius syndrome, Down syndrome,
etc.
Reports of feeding problems and oro/motor concerns
Fine/gross motor difficulties
==>Therefore,
distinguishing between DD
and CAS rarely involves either History
or Sound System Description
41
42
7
Signs of Neuromuscular
Involvement
Clumsy gait, not due
to structural problems
➢ Asymmetry in muscle
mass
➢ “Low tone” - reduced
elasticity of muscles;
droopy eyes and
facial muscles
➢
❀Structural-Functional
Adventitious
movements sporadic, involuntary
➢ Differences in
strength and
coordination
➢
(=synergistic interaction of
muscle groups)
➢
Exam
Purposes
(1) To identify structural deficits that may
contribute to communication problems
(2) To identify the presence/absence of
oral apraxia
Pathological reflexes
(especially for DD)
43
44
Elements of Motor Control =
5 Movement Parameters
Components
 Structure
 Sensory
function (helpful in highlighting the
possibility of SENSORImotor problems, especially re:
feedback related to movement)
 Motor
control for oral movement
45
46
47
48
8
Motor Speech Examination – Considered
the Most Important Element of a DX Battery
for identification of CAS
Components
Purposes
(1) To obtain information about motor
planning for sounds and sound
combinations across contexts (differing in
length and phonetic complexity)
(2) To determine whether cueing can help
improve performance
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52
Videoclip of “Matthew”

Matthew About age 4

Note - inconsistency
in production during
DDK task
Example of an utterance
hierarchy (Strand & McCauley, 1999)
Utterance type
Example
Vowels in isolation
[o], [u], [i]
CVs and VCs, varying Vs
me, my, hi, up, on
CVCs with C1VC1 then C1VC2
mom, pop, cake, hit, cup, ball
Vary input to facilitate best
performance during hierarchy
Direct imitation

Modeling with visual and auditory cueing

Tactile and gestural cues (e.g., gently closing jaw and lips
to help child achieve bilabial closure)

Phonetic placement cues (e.g., showing where to place
tongue)

Slowed rate and/or simultaneous production with the child
Words of increasing length come, compute, computer
Multisyllabic words
refrigerator, alligator
Phrases
I want, me too
Sentences
I want more. I want more milk. I
want more milk please.
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9
Group Exercise



The Dynamic
Evaluation of Motor
Speech Skill
DEMSS
Edythe Strand - Mayo
Clinic

For you own later use,
jot down 2 things that
youʼve learned thus far
that youʼd like to
remember
55
Components of a Sound
System Analysis

Independent
analysis

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
Phonetic inventory
Syllable/word shapes

Consistency

Prosody

Developmental
Processes
Nondevelopmental
Processes
Phonological process analysis
Developmental phonological processes

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
Intelligibility/
Comprehensibility
57
Developmental phonological
processes*
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Assimilation consonant harmony
Fronting
Final consonant
deletion
Weak syllable
deletion
Patterns seen in normal development; often
persistent in children with speech sound disorders
Typically available with formal measures
Nondevelopmental processes
Relational analysis
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Patterns not seen in normal development; some
seen more frequently in children with CAS
Typically minimally represented on formal
measures or assessed informally
58
A child with several developmental
processes
Stopping
Gliding
Cluster simplification
Depalatalization
Deaffrication
Vocalization
*10 most common processes in standardization of
Bankson & Bernthal Test of Phonology (1990)
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60
10
Nondevelopmental phonological
processes
More nondevelopmental
processes
(Processes in red especially associated with CAS)
 Use of favorite sound (also called sound
preference) EX: substitution of /f/ for most initial


consonants

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Substitution of fricatives for stops
Initial consonant deletion EX: “at” for “cat”
Idiosyncratic cluster reduction - loss of the
“harder” sound in a cluster EX: “red” for “bread”
EX “sandle” for candle

Glottal replacement EX “buh-er” for “butter”

Backing EX “koo” for “too”

Additions to adult form - EX “fmy” for “my”

Vowel errors EX “fush” for “fish”
(Dodd, 1995; Edwards, 1992; Leonard, 1985; Pollock
& Hall, 1991; Stoel-Gammon & Dunn, 1985)
61
Clues to differential diagnosis in
relational analyses
Children with CAS are more likely to exhibit
 Developmental processes involving
deletions
 Nondevelopmental processes,
especially
• vowel deviations,
• favorite sounds,
• initial consonant deletion
62
Phonological analysis procedures for singleword productions

ALPHA-R: Assessment Link Between Phonology
and Articulation - Revised (Lowe, 1995)

Hodson Assessment of Phonological Patterns
(3rd edition) (Hodson, 2003)

Clinical Assessment of Articulation and
Phonology (CAAP) (Secord & Donohue)

Goldman-Fristoe-2 (2000) & KLPA-2 (2002)

Diagnostic Evaluation of Articulation and
Phonology (DEAP) (Dodd et al., 2006)
63
Consistency
64
Informal procedure to assess
consistency (Shriberg, Aram & Kwiatkowski, 1997)
Similarity of word production across
repetitions
 Related to older concept of
stimulability yet now emphasis is on
word, not single sound, integrity
 Considered valuable for the diagnosis
of CAS

65
Obtain 2 spontaneous and 2 imitated
tokens of selected words on a standard
articulation test, particularly multisyllabic
words
 Expectations:

Children without CAS will usually improve
across trials and with model
 Children with CAS are more likely to show
degraded performance across trials

66
11
Examples of inconsistencies
considered typical of CAS
The DEAP consistency subtest
The Diagnostic Evaluation of
Articulation and Phonology
 Barbara Dodd, Zhu Hua, Sharon
Crosbie, Alison Holm, and Anne
Ozanne
 3 to 8:11 years

67
68
Letʼs listen to child with Shelley
Velleman
Prosody
Suprasegmental characteristics of
speech, including phrasing, rate, and
stress
 Frequently assessment is quite subjective;
however, better methods are emerging


Production of several
words and sentences

Notice stress patterns
(e.g., Shriberg, Kwiatkowski & Rasmussen, 1990; PEPC – Peppe, forthcoming)

What are you most likely to see?

Equal-excessive stress (Shriberg, Aram, & Kwiatkowski, 1997)
69
Videoclip of Matthew at 6 or 7
70
IV. The Bigger Picture for
Intervention
Co-occurring deficits
and special
considerations
 Long-term expectations
 Prognosis

71
72
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Co-Occurring Deficits & Special
Considerations



Expressive oral
language deficits
Receptive oral
language deficits
Written language
deficits


Reading
Spelling



Writing
Phonemic
Awareness
Case study of long-term effects of
CAS (Stackhouse, 1992)
Case study of “Keith” from 2 years, 8 months to 17 years
At age 4,

Behavioral Issues
(e.g., withdrawal,
frustration, anger,
etc.)


Diagnosed with DAS & oral apraxia,
General clumsiness and severe unintelligibility,
Very restricted phonetic repertoire (/b/, /d/, /r/ & glottal stop in words
and some V errors
At age 17, high average IQ



Resolved motor problems in other domains, but
Speech errors on multisyllabic words
Persistent reading and spelling problems
73
74
Longitudinal comparison study
(Lewis et al., 2004)

Results at Time 1 (ages 4 to 6)
3 Groups



CAS < Speech only group on all measures,
but looked similar to Speech and Language
group on most measures
Children with CAS (n=10)
Children with Speech Disorders only (SD) (n=15)
Children with Speech and Language problems (S&L)
(both of the nonCAS groups had moderate to severe sp problems)


2 Ages (preschool and school age)
Dependent measures





CAS compared to both other groups
language tests,
speech tests,
syllable sequencing,
nonsense word repetition,
phonological awareness


made more uncommon errors and
had difficulties in sequencing
75
76
Results at Time 2 (age 8 to 10)
Children with CAS (n=10)
Lewis et al.ʼs conclusions
8 showed some improvement in speech skills, BUT
continued difficulty with
Hard to distinguish S&L impairment from CAS
prior to age 6
Differential diagnosis depends on informal
measures
1.
ddk,
multisyllabic real and
nonsense words,
2.
Single word production skills improved more than speech
production in connected speech
S&L group made greater gains in language than CAS
group
CAS group continued to show receptive as well as
expressive difficulties
6 diagnosed with reading problems; 8 with spelling
problems; 4 with ADHD
77
syllable sequencing,
metathetic errors,

nondevelopmental errors

abnormal prosody)
Phonological awareness deficits should be addressed
unless they are “more severely affected,” then use an
approach that doesnʼt depend upon it


3.
78
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Negative Prognostic Factors
Positive Prognostic Factors




Severity
Extent of family
members with similar
problems
Presence of coexisting problems
Cognitive deficits
 Beginning
intervention
early
 Higher intensity
of treatment
 Family support
(Hall et al., 1993)
(Hall et al., 1993)
79
THEREFORE as first steps in planning
treatment of all, always take into account
Group Exercise
Concomitant speech and language deficits
Severity
Prognosis as well as
What treatment opportunities are available
What family/environmental support is available
and
How all of these will affect


80


the childʼs comprehensibility and
subsequently the childʼs societal limitation
81
Based on preceding
discussions or personal
experience, are there
other big issues that will
need to be addressed to
assure the best possible
intervention?
Jot down a brief list and
prepare to share with
group as a whole
82
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