Importance of Differential
Diagnosis and Treatment Approach
in Childhood Apraxia of Speech
Laura K Smith, MA, CCC-SLP
Metro Speech-Language Symposium
Lone Tree, CO
11-11-2013
About me
• I’m a Denver Native
• Received my BA from MSCD
• Received MA from UNC distant learning
program
• Currently work for DPS and Lowry Speech
Therapy
• Live with my husband and two kids
• My daughter was dx with CAS at 2yrs 11mo
Ashlynn’s fourth Birthday
First time singing Happy Birthday Song!
First time blowing out her candles on her own!
Importance of early intervention
• Importance of early intervention is well
documented throughout the literature
• Importance of early intervention for CAS requires
differential diagnosis. Techniques designed for
typical speech and language delays are not
effective treatment approaches for CAS.
• Principles of motor learning theory should drive
therapy. (11/6/07 ASHA Leader, Magill 1998,
Schmidt 2004).
Speech disorders
• Speech Sound Disorders
– Articulation
– Phonological Processing
• Motor Speech Disorders
– Childhood Apraxia of Speech
– Dysarthria
What is Childhood Apraxia of Speech
(CAS)?
• 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 technical report, 2007)
Definition continued
(ASHA, 2007)
• Three generally agreed upon diagnostic markers
– inconsistent errors on consonants and vowels in
repeated productions of syllables or words
– lengthened and disrupted co-articulatory transitions
between sounds and syllables (difficulty moving from
one sound to the next, or one syllable to the next)
– inappropriate prosody, especially in the realization of
lexical or phrasal stress. (may sound monotone,
robotic, and may have a tendency to always stress the
first syllable etc.)
Other Diagnostic indicators
(ASHA, 2007)
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- little to no babbling as a baby
- lack of vowel variation; overuse of schwa
- vowel distortion
-regression or loss of once produced words
- impaired rate/accuracy on diodochokinetic tasks
- higher receptive versus expressive language
- impaired volitional oral movements (oral apraxia),
groping
• - makes inconsistent sound errors, or may produce
target accurately in one context, but not another.
Non-speech motor signs
• Non-speech motor signs of CAS that are most commonly
proposed in the literature (some of which are also cited as
signs of dysarthria) include the following: general
awkwardness or clumsiness, impaired volitional oral
movements, mild delays in motor development, mildly low
muscle tone, abnormal oro-sensory perception (hyper- or
hyposensitivity in the oral area), and oral apraxia (e.g.,
Davis et al., 1998; McCabe et al., 1998; Shriberg et al.,
1997a). The non-speech motor features typically listed for
oral apraxia are impaired volitional oral movements
(imitated or elicited postures or sequences such as “smilekiss”) and groping (e.g., Davis et al., 1998; McCabe et al.,
1998; Shriberg et al., 1997a).
Motor Speech Examination
(Strand 1996, Stoeckel 2005)
• Examine ability to sequence phonetic
sequences in various contexts.
– CV, VC, and CVC combos using various vowels
– Mono and multi-syllabic word repetitions
– Phrase and sentence repetition increasing
sentence length.
* Not a lot of commercially available tests on the
market for this. One used at my clinic is the
Kaufman Speech Praxis Test for Children.
Motor speech Exam continued
• Vary temporal relationship between stimulus
and response
– Simultaneous
– Immediate vs. delayed repetition
Evaluate Prosody!
Causes?
• No known cause to date for all cases
• Researchers in 1998 discovered a gene that causes CAS
called FOXP2. However, only a small percentage of
children with CAS had FOXP2 abnormalities.
• Idiopathic CAS can run in families.
• It can also be diagnosed in children where there is no
family history of CAS.
• Can be the result of a neurological impairment caused
by infection, illness, or injury before or after birth,
which may, or may not show up as positive findings on
MRI scans.
A note about Ashlynn’s characteristics
• Low muscle tone, open mouth posture, drooled
excessively as a baby, even when not teething
• Army crawled at 9 months, walked at 17 months,
used whole hand to point, couldn’t imitate signs
• Very clumsy. Impaired balance
• Would forget to masticate during the swallow
(choke risk!)
• Oral apraxia – couldn’t pucker, kiss, or blow
Comparison Chart
(CASANA advisory board)
Verbal Apraxia
Severe
Phonological processing disorder
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Inconsistencies in articulation
performance–the same word may
be produced several different ways
• Consistent errors that can usually
be grouped into categories
(fronting, stopping, etc.)
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Errors include substitutions,
omissions, additions and
repetitions, frequently includes
simplification of word forms.
Tendency for omissions in initial
position. Tendency to centralize
vowels to a “schwaa”
• Errors may include substitutions,
omissions, distortions, etc.
Omissions in final position more
likely than initial position. Vowel
distortions not as common.
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Number of errors increases as
length of word/phrase increases
• Errors are generally consistent as
length of words/phrases
increases
Comparison chart continued
(CASANA advisory board)
Verbal apraxia
Severe Phonological Processing
Disorder
• Well rehearsed, “automatic”
speech is easiest to produce,
“on demand” speech most
difficult
• No difference in how easily
speech is produced based
on situation
• Receptive language skills are
usually significantly better
than expressive skills
• Sometimes differences
between receptive and
expressive language skills
• Rate, rhythm and stress of
speech are disrupted, some
groping for placement may be
noted
• Typically no disruption of
rate, rhythm or stress
A controversial diagnosis
• Diagnostic indicators vary in the research
from study to study.
• There is currently no gold standard, that
when identified, leaves little doubt that
CAS is present
• CAS characteristics can overlap with
phonological processing characteristics
• Clinicians in the field have devised their
own diagnostic schemas
• Leads to potential misdiagnosis/over
diagnosis
How early to diagnose
• A note about age
– Difference between a “late talker” and CAS
• Generally speaking, regardless of age, a child
can be diagnosed with CAS if they can commit
to a full motor speech examination.
Why is differential diagnosis
important?
• In a word: TREATMENT!!!
• Children diagnosed with CAS need a motor
based speech approach to therapy
• Traditional articulation and phonological
therapies are not successful for children with
CAS (Cycles, minimal pairs, maximum
opposition, etc)
– These approaches are designed to remediate a
sound, or sound error patterns.
What is a motor based approach to
therapy?
• Focuses on the planning, sequencing, and coordination of muscle
movements for the development of intelligible speech
• It does NOT include oral motor exercises designed to strengthen the
oral/motor musculature, since apraxia is an issue of motor
planning, not motor weakness.
• Motor planning approaches include: integral stimulation (Strand &
Debertine, 2000), as well as other commercially available
approaches: The K-SLP, PROMPT, and SpeechEZ.
– Research is ongoing to prove the efficacy of these programs.
– Integral Stimulation (DTTC) and PROMPT have demonstrated
effectiveness in the literature (Strand & Debertine, 2000; Dale &
Hayden, 2013)
– Integral stimulation emphasizes auditory and visual models
– Other programs emphasize tactile and/or gestural cues
Motor learning theory
(Schmidt 1988, Stoeckel 2005)
• Three factors relevant to the treatment of
motor speech disorder:
– Prepractice
– Conditions of practice
– Knowledge of results and effects of rate
Motor learning continued
Pre-practice
Inspire motivation
Conditions of practice
Awareness of goal
Frequent practice
Repetitive motor drill
Mass vs. Distributed
Blocked vs Randomized
• Knowledge of Results
– Give child frequent
information about
movement performance
Therapy strategies
• Ancillary learning techniques do NOT work for
CAS.
• Oral motor exercises are NOT reported in any
literature to improve CAS. If you want to improve
speech, work on speech!
• Develop a core vocabulary list/book (Hammer
2005, Kaufman 2013)
• Start with simple syllable shapes and move up
the hierarchy incorporating principles of motor
learning.
Other strategies that work
- Stabilize vowels
- Successive approximations (Kaufman 2013)
- Built confidence! Follows typical phonology
patterns
- Errorless teaching (Kaufman 2013)
- Use of some type of visual or tactile cue
(Hammer 2013, Kaufman 2013, Stoeckel 2013)
- Key is consistency
- Backward chaining
Strategies Continued
• Don’t forget language!
– Carrier phrases
– Pivot phrases (Kaufman 2013)
– Repetitive books
– Modeling, recasting, expansion and repetition
techniques
Case in Point
• Video Olivia 3.7
• Early intervention since 2 years
• Came with 3 words and maybe 10 word
approximations
Olivia 4:11
• Motor based approach to therapy initiated.
• Only seen client 1x week for 45 minutes
• Went from 10 words to over 50 and combining
words in her repertoire
Resources
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Apraxia-kids.org
http://www.kidspeech.com/
http://slpmommyofapraxia.blogspot.com/
Facebook pages
– APRAXIA KIDS: Every Child Deserves a Voice
– Apps for Apraxia Kids
– Apraxia Bloggers
– Colorado Families Living with Apraxia
Bibliography/References
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American Speech-Language-Hearing Association (2007). The technical report on childhood apraxia
of speech. www.asha.org/policy
American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech (position
statement). www.asha.org/policy
Beate, P. (2013) Childhood Apraxia of Speech in Multigenerational Families: Genes and Generations.
Childhood Apraxia of Speech Symposium, Denver, CO.
Childhood Apraxia of Speech Association of North America. (2005). Key characteristics of childhood
apraxia of speech. www.apraixa-kids.org
Dale, P. & Hayden, D. (2013) Treating speech subsystems in Childhood Apraxia of Speech with
tactual input: The PROMPT Approach. American Journal of Speech/Language Pathology.
Gildersleeve-Neumann, C. (2007, November 06). Treatment for Childhood Apraxia of Speech : A
Description of Integral Stimulation and Motor Learning. The ASHA Leader.
Hammer, D. (2013) A Multi-Sensory Approach for Childhood Apraxia and Speech Sound Disorders.
Metro Speech-Language Symposium, Denver, CO.
Jakielski, K. (2013) State of the Art in Childhood Apraxia of Speech Research: A synopsis of the 2013
Childhood Apraxia of Speech Symposium, Denver, CO.
Kaufman, N. (2013) The Kaufman Speech to Language Protocol: Effective Strategies for CAS.
National Conference on Childhood Apraxia of Speech, Denver, CO.
Stoeckel, R. (2005) Childhood Apraxia of Speech: Assessment and Treatment, Aurora, CO.
Stoeckel, R. (2013) Dynamic Temporal and Tactile Cueing (DTTC): Why, When, How. National
Conference on Childhood Apraxia of Speech, Denver, CO.