Wednesday, June 29, 2016

How to Uncover Emerging Skills with a Dynamic Assessment for CAS

Where do I start in therapy for Childhood Apraxia of Speech? 

Uncover emerging skills with a dynamic assessment approach for CAS and yield some powerful information to kickstart progress in speech therapy!

How to Uncover Emerging Skills with a  Dynamic Assessment for Childhood Apraxia of Speech

What is a dynamic assessment?

Dynamic assessment means we are cuing the child, and seeing how they respond to different levels of cuing.

To me, this is a game-changer. I was frustrated with my usual assessment battery. I wondered if I had enough evidence for an accurate diagnosis, and I wanted more direction on where to start in therapy to get the biggest bang for my buck!

 If you haven't been trained in using a dynamic approach to your motor speech exam, I hope you will read on!

This is part 4 in my series for SLPs on Childhood Apraxia of speech: Let's Talk!

If you have been following, you know that I attended an amazing small-group intensive workshop this spring with Dr. Strand, of the Mayo Clinic. With her permission, I am sharing with you.

In my last post, we talked about

Part 3: 4 Essential Steps in Assessing Childhood Apraxia of Speech
Dr. Strand recommends:
1. a spontaneous speech sample
2. a standardized elicited speech test
3. a structural-functional exam
4. a dynamic motor speech exam, using imitation tasks and cuing.

Let's talk more about that last one!


What are the advantages of a "dynamic assessment" approach?

Dynamic assessment can help us to:

How to Uncover Emerging Skills with a  Dynamic Assessment for Childhood Apraxia of Speech

1. Make a differential diagnosis

We may see characteristics when the child is asked to say unfamiliar syllables and respond to cuing that may not be evident in conversational speech. These include groping, inconsistency across trials, and segmentation of multi-syllabic words (ex."") not evident in conversational speech.

2. Provide a better picture of emerging skills, and beginning therapy targets

A dynamic approach allows us to observe what the child does when attempting specific syllable shapes, versus what she may habitually do in spontaneous speech. The use of cuing may prompt a child to attempt certain movement gestures we may not see otherwise.

3. Determine severity, which is important for prognosis and therapy planning

We can observe the child's response to various levels of cuing. A child that requires intensive cuing would be considered severe, a child who responds with minimal cuing may be considered mild.

4. Identify which cues are more effective for the child.

This can really help get the ball rolling toward making progress.

Is there a published instrument to use for a dynamic motor speech assessment?

There has long been a need for an assessment that could assist with differential diagnosis in young children and those with severe apraxia of speech. Dr. Strand and her colleagues have been developing a standardized assessment, the Dynamic Evaluation of Motor Speech Skill (DEMSS) Strand, McCauley, Wigand, Stockel & Bass, 2103).

You can read more about the DEMSS here: A Motor Speech Assessment for Children With Severe Speech Disorders: Reliability and Validity Evidence.

The DEMSS is nearing commercial publication, according to Dr. Strand. Personally, I can't wait, because I think it will be a really valuable tool. However, it is not yet available. So what to do? Design your own!


So how to you design a dynamic assessment for CAS?

1. First, choose a hierarchy of syllable shapes, consonants and vowels. Here are some examples:
  • CV- me, two
  • VC: eat, up
  • CVCV (same C): mama, bye-bye
  • CVC1 (same C): bib, mom
  • CVC2 (different C): wipe, done
  • Bisyllabic: baby, movie
  • Multisyllabic: banana, potato

2. Ask the child to repeat the utterance (immediate direct imitation)

3. Vary the length of the pauses between your production and theirs.  (delayed direct imitation) If correct, see if they can still do it when you add a delay or pause between your model and their production. (I'm going to say a word, and I want you to say it when I point to you.") Are they consistent?

4. Use cuing as needed to elicit improved production

Cues To Try:

  • ask the child to watch you as you say the word "Watch me, I'll help you." (If children are more accurate when watching you than not, this is a key sign of CAS)
  • ask the child to say the word simultaneously with you "Let's say it together, ready?"
  • slow your model slightly (but never, never segment within a syllable! Say "Mmmoooomm" rather than M-o-m.)
  • hold the initial articulatory position a little longer when modeling. "mmmop"
  • provide tactile cues

Judging performance:

While eliciting your word list, take note of:
  • Consonant accuracy and how it changes with cuing
  • Consistency in repeated productions
  • Vowel accuracy
  • Prosody in multisyllabic words or in phrases. (We don't judge prosody in monosyllables)
  • Additional characteristics to watch for across all assessment tasks

Remember, there are currently no specific set of markers that are agreed upon as absolutely differentiating childhood apraxia of speech, and some characteristics are stronger indicators of CAS than others. However, these characteristics can provide valuable information, and if a child has a high number of characteristics, CAS is more likely.

Read more about this in my second post: Is It CAS? Navigating Differential Diagnosis.

Watch for these characteristics:

  • Difficulty achieving the first articulatory position (ex: doesn't bring lips together in the beginning of "Mom'
  • Inaccurate movement between articulatory positions during transitions
  • Groping
  • The addition of a schwa
  • Trial and error behavior
  • Even and equal stress, or stress in the wrong place
  • Segmenting or breaking up multisyllabic words
  • Greater difficulty with multisyllabic words
  • Distortions of substitutions (can also be due to dysarthria)
  • Slow rate (can also be due to dysarthria)

Use the characteristics you have observed in your dynamic assessment, along with other evidence you have gathered to make your differential diagnosis and impression of severity in your diagnostic statement. A thorough description of your conclusion and the evidence for it is important for treatment planning. 


If you haven't viewed Dr. Edythe Strand's videos for parents on YouTube, I highly recommend that SLPs watch them as well. 

You will see clips of children during assessment and treatment and examples of some of the characteristics. You can see all the segments here: Childhood Apraxia of Speech: Information for Parents. or watch them segment by segment.

These particular segments have video examples of children speaking with various characteristics of speech sound disorders, including CAS, which can be helpful to watch. Try watching them and seeing if you can observe the characteristics in our list for practice. 

You may also want to read my earlier posts in my childhood apraxia of speech series:

Part 1: Childhood Apraxia of Speech: What SLPS Need To Know - What CAS is, and important definitions we need to understand

Part 2: Is It CAS? Navigating Differential Diagnosis - The characteristics of CAS, and which ones help us differentiate CAS from dysarthria, ataxia or a phonological disorder

Next time we will talk about planning therapy for a child diagnosed with CAS, and what the principles of motor learning theory have to do with it!

See you then!

Strand, E, McCauley, R, Weigand, S, Stoeckel, R & Baas, B (2013) A Motor Speech Assessment for Children with Severe Speech Disorders: Reliability and Validity Evidence. Journal of Speech Language and Hearing Research, vol 56; 505-520.

Monday, June 13, 2016

Best-Ever Books For Speech Therapy: Peck, Peck, Peck

Summertime means it's time to find some great books to read!

I can head to the library, and I have time to peruse the stacks all I want. For this book-lover, that's a treat! So have I found a great mystery to read? Science fiction maybe? Or perhaps a biography?

My first trip to the library yielded an armload of children's stories.

Read about my favorite book for articulation therapy! Love using storybooks to teach speech and language? This adorable book is perfect for final /k/ and rhyme too.

I don't even have any little ones at home! (I will go back and find that perfect summer read for me, just not yet!) I can't resist trying to discover a few more storybooks to use with my little ones in speech therapy, while I have the time.  If you have read about my free Sound-Loaded Storybooks for Articulation list you know I love using terrific children's literature in therapy.  So now I have some new gems to share with you.

Today's find is Peck, Peck, Peck by Lucy Cousins.

This book is totally sound-loaded with final /k/ and it's adorable too! The story is about a little woodpecker who learns to peck. He is growing up, and it's time to learn new things. The story repeats the word "peck" a bunch, as the little guy ventures out and pecks everything in sight! Perfect for auditory bombardment.

Read about my favorite book for articulation therapy! Love using storybooks to teach speech and language? This adorable book is perfect for final /k/ and rhyme too.

 One thing I really love about this story is that it is the daddy that teaches the youngster, and tells him how great he is. I think we need more children's books where the daddy is the teacher and nurturer. So many of my children at school do not have a daddy at home every day, and I love having them read about a good fatherly role model!

 Read about my favorite book for articulation therapy! Love using storybooks to teach speech and language? This adorable book is perfect for final /k/ and rhyme too. www.speechsproutstherapy.comRead about my favorite book for articulation therapy! Love using storybooks to teach speech and language? This adorable book is perfect for final /k/ and rhyme too. www.speechsproutstherapy.comSo off the little woodpecker goes, out into the world to practice.

He finds a gate to peck and makes a hole right through it. Then  he spots a big blue door. This can't be good!

As the little woodpecker makes holes in everything he sees, the word "peck" is repeated constantly.  

It is also printed on the page next to everything the woodpecker is pecking.

I like to work on print awareness with my preschoolers, so this is great. I can have them point to the word "peck" on each page. We will take note of the "k" on the end of the word, and practice making the sound it spells. Lots of velar practice. Love that.

The text rhymes too.

We can work on listening for rhymes as we point out rhyming pairs. Then we will generate a few new rhymes to go with them. Wait and gate, door and more, hat and mat. Perfect!

It's lots of fun seeing the growing number of holes in the pages.

The little woodpecker works his way through an armchair, a teddy bear and even a book named Jane Eyre. Yup, rhymes make me smile.

Maybe we'll count the holes. For sure we can talk about the words "a few, more and most." Quantity concept time.

My children love characters that do something a bit wrong. 

The little woodpecker heads to the bathroom  and pecks some blue shampoo, and he even pecks the toilet too! Eww!  The kids will love that. It's just the right amount of gross.

As the woodpecker heads through the house, we can talk about each room, what he might find there, and work on a bit of categorization. This is why I love children's books, there are so many, many natural opportunities to teach language concepts.

Finally, there is nothing left to peck.

The little woodpecker is tired out, and he's ready to head home. He tells his daddy about his day. About the many, many holes he's made and how much he loved it.

Daddy tucks him in, tells him he loves him and gives him a kiss. So sweet.

This book will be on the top of my list when we do a final /k/ unit.

 I hope you can find this wonderful storybook in your library too! I know I will be checking out more stories by this author, Lucy Cousins.

If you are looking more more fun books, read my review of  Press Here by Herve' Tullet. Click this link, Best-Ever Books For Speech Therapy: Press Here. It's sure to be a favorite of any child who reads it!

What are your favorite storybooks for speech therapy with preschoolers and kindergarteners?  

I am always looking for more suggestions, so comment if you have one to share!

Happy Reading! 

Hope you have lots of time to enjoy a good book if you are on break, or soon to be. You can find more of my favorites for littles here: Storybooks.  Until next time.

Sunday, May 29, 2016

10 Tips To Get You Organized at The End of The School Year- You'll Thank Yourself Later!

Summer is coming. Get organized now.

 Whether you are an SLP or a teacher, just a few organizational tweaks now can make your life easier in the fall. You might even want to kiss your brain for being so forward thinking!

10 Great Tips for SLPs to Organize at the End of The School Year That Will Make Your Life Easier in The Fall!

May and June is crunch time for school-based SLPs. 

This is the time of year when school-based speech language pathologists are rushing to complete end of the year tasks. It seems like there are a thousand things to do, IEPS, last minute assessments, reports, COSFs, Medicaid Billing, progress reports and meetings. Oh, the meetings. Many, maaaany meetings.

You may not be thinking about back to school right now. But you should be.

Do a few things now to get organized, and back to school will be easier and smoother for you! Beginning the school year is also a challenging, hectic time. When we get back, it is always a transition to get up and going again. So what can you do to prepare?

I asked some school-based slpeeps for their best ideas, and got some great tips to share with you.

10 Things You Can do Now to Make Your Life Easier When You Get Back to School

  1. Inventory- We have to do inventory at the end of each year. Before you sign it and turn it in, make yourself a copy and file it. I also keep a check-out list for materials I share with others. Check items back in when returned. It will make it much easier next year to know what is still in your room, and what others have. 
  2. To Do List- Make a to do list for the first week back to school. You may be surprised what you can forget after a long relaxing summer! I include priority tasks such as IEPs and assessments due soon, who needs accommodations distributed to teachers, parents to contact about scheduling, AT to distribute or set up, consults to complete. Keep this list in the very front of your file cabinet.
  3. Passwords- Make a list of passwords, because if you are like me, you WILL forget these over the summer! Sarah says it may be a tech no-no, but you may need it! Keep your password list in a secure location.
  4. Student folders- Sue keeps a folder for each student to grab for their session. At year's end she stocks these with fresh attendance calendars, logs and an intro letter. Then she is ready to go in the fall.
  5. Students moving- When Lynda knows a student will not be returning, but is still in her district, she puts a post-it note on her working file with next year's school so she knows where to send the file. Those moving out of district go to the "moved" drawer. 
  6. Bulletin Boards- Kathy puts her fall bulletin boards up now, then covers them with paper or trashbags. 
  7. Prep Forms- Jenn preps her beginning of the year release of information forms she will need, so they are ready to go and current. She preps a referrals list too.
  8. Location of Items- Tracy uses Google Keep to record her notes to self about locations of keys, files and tasks. She loves this because she can add to her notes from her phone, no matter where she is, when the thought strikes her!
  9. Computer Cables- At my school, we have to unplug everything, and it can be a jumbled mess in the fall. Joan labels her computer cables because everything gets disassembled. 
  10. Room furniture and equipment- Teachers often get back and are setting up their rooms very early, before I am there, especially new teachers. Sometimes they scout for "spare" equipment and things can go umm... awol. I put away surge protectors, headphones, cables and remotes in a file cabinet.  I label my teacher rolling chairs, table, trashcans, bookcase and anything that is not nailed down with my name. Helps prevent confusion and items growing legs!
10 Great Tips for SLPs to Organize at the End of The School Year That Will Make Your Life Easier in The Fall!
Graphics by Kinka Art and Creative Clips

Hope you found some helpful tips! If you have a favorite tip to share, leave me a comment. I would love to hear from you.

Happy summer everyone!

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Sunday, May 15, 2016

4 Essential Steps in Assessing Childhood Apraxia of Speech

You have an evaluation scheduled. This child is highly unintelligible, and you suspect childhood apraxia of speech, or CAS.  But just how do you design your assessment?

4 Essential Steps in Assessing Childhood Apraxia of Speech

How many phonological assessments have you done? Probably hundreds for me, and I bet you can practically assess for a  phonological disorder in your sleep! But we don't see that many children with childhood apraxia of speech, unless we specialize in that area. So it may be a little less clear as to how to design the most effective assessment and how it may look different from what we usually do for our phonological children.

This is Part 3 in my series on Childhood Apraxia of Speech, Let's Talk! 

To start at the first post, head to Childhood Apraxia of Speech. What SLPs Need to Know.

If you have been following, you know I recently had the wonderful opportunity to learn from Dr. Edythe Strand, a leading expert in CAS. Me? I am not an expert. Dr. Strand generously gave permission and asked us to share what we learned, because she knows that many SLP's have not had the opportunity for in-depth training in CAS, and often feel unsure about how to approach assessment and treatment.

Do you have questions? Grab a cup of coffee, and let's talk!


You've gone over the child's history, and made some initial observations. 

You have noted some of the characteristics we talked about in my last post: Is it CAS? Navigating Differential Diagnosis. You suspect CAS. What's next?

Planning Your Assessment

A carefully planned assessment can help you make a differential diagnosis between childhood apraxia of speech, a phonological disorder, dysarthria or ataxic dysarthria. Let's take a look at what Dr. Strand recommends. 

4 Essential Steps in Assessing Childhood Apraxia of Speech

1. Spontaneous Speech: Take a Language Sample
This is a great place to start, especially if the child is not a talker, or very limited in verbalization. Be sure you include both free play and structured play. 
  • Do you note any differences in communication between the two? 
  • How does the child communicate: verbal, gesture, pointing? 
  • Does he imitate you? 
  • Make some initial observations about his phonemic and phonetic inventories. Does he use sounds meaningfully (in at least two contexts), or is it vocal play?  
  • How would you rate his intelligibility? 
  • Do you see groping or awkward movements of the articulators?

4 Essential Steps in Assessing Childhood Apraxia of Speech

2. Elicited Speech: 
If you recall from my last post, breakdown in CAS often occurs in elicited speech more than spontaneous speech. Note if there are differences.
  • Articulation or Phonology Test:  Do a standardized test if the child is capable. He he is non-verbal or very limited, you may not get much here.  
  • Imitation Tasks. 

4 Essential Steps in Assessing Childhood Apraxia of Speech

3. Structural/ Functional Exam- a good oral motor exam can help you determine or rule out whether dysarthria or oral apraxia is present. You don't always have to do each task because you can often observe informally when function is normal, but if you notice abnormal function, test further. Here's what you are looking for:
  • Signs of dysarthria: Check jaw, lips, tongue and velum for weakness, reduced range of motion, strength, speed, and drooling.
  • Signs of oral apraxia: You will want to rule this out if you suspect weakness or dysarthria.  Have the child blow, pucker, smack lips, cough and do sequential imitation (diadokokinesis tasks).  Can the child do it? Does he grope? Is it uncoordinated? 
  • Signs of ataxic dysarthria:  This can often look similar to CAS with inaccurate/ inconsistent movements. We can also see voicing errors. Watch as the child says one syllable (puh) and compare to 3 syllables (puh-puh-puh).  
    • In severe CAS: the errors are more inconsistent and they will do better with a single syllable than three. 
    • In ataxic dysarthria (which is caused by damage to the cerebellum) errors are more consistent across tasks, there will be uncoordinated movements, regardless of number of syllables, and you may see a wide-based gait or intention tremor. 

NOTE! We often hear "the child has low tone." Tone is how much muscle contraction there is at rest. A child can have low tone, but normal strength in action. Low tone is usually not weakness and is not a problem for speech!

4 Essential Steps in Assessing Childhood Apraxia of Speech

4. Motor Speech Exam: This type exam has traditionally been used with adults to assess for acquired apraxia of speech, but has not been widely used for CAS.  A motor speech exam allows us observe how a child's speech varies across contexts, and watch for signs of praxis. Start at the level the child is capable of. You can look at:
  • Vowels
  • CV, VC, CVC words
  • one, two and three syllable words
  • phrases
  • sentences of increasing length

Dynamic Assessment

Dr. Strand advocates for a dynamic assessment approach to the motor speech exam. 

What do we mean by "dynamic?" 

We are cuing the child, and watching to see how performance changes with different levels of cuing. This in in contrast to a "static" assessment, which measures a child's performance after a single response with no cuing or assistance. Most standardized tests are "static."  

Why do a dynamic assessment?  It helps us:

1. Determine level of severity. Lots of cuing needed means a more severe presentation of CAS. Less cuing would be mild or moderate. Great information to help us recommend frequency and intensity of services, and level of cuing support needed.
2. Find out which cues are most effective for this child.
3. Reveal emerging skills- very helpful for planning initial therapy targets. We may see movements a child is able to make with cuing that we may not see in a "static" assessment.
4. Helps with differential diagnosis by allowing us to see:
  • groping we may not see in spontaneous speech
  • inconsistency across trials with and without cuing.
  • whether the child is segmenting syllables (ba-na-na). We usually see this with unfamiliar or multisyllabic words. 


How are you doing? 

Is this coming together for you? I'll tell you, writing these posts is really helping me review and frame my thinking and approach. Re-visit and re-read, it really helps! 

4 Essential Steps in Assessing Childhood Apraxia of Speech

Dr. Strand has a YouTube series you need to check out.

 These videos were made to help explain CAS to parents, but they have terrific information and excellent video examples for SLPs too. I highly recommend you take a look, and share with parents.

This video is 52 minutes long, and contains all the segments. But you can also view her videos in shorter segments.

This video shows video examples of children with different severity levels of CAS:

This video shows video examples of children with a phonological disorder, and dysarthria.

Now we have the pieces of a thorough plan. 

You may be saying, "So exactly how do I conduct a dynamic assessment?  We'll talk about that in my next post in the series. 

If you are enjoying this series, please comment, share, pin and post to help spread the word!

 Until next time, friends!

Monday, May 2, 2016

Best Year-End Picks for SLPs: Speech and Language Activities that Will Help You Sail into Summer!

SLP's and Teachers have worked hard all year.

May and June means progress reports, finishing evaluations, End of year IEPs, COSF reporting, billing and more. I know, because I am there too.

Find the best resources to make your year-end planning a breeze!

Time to treat ourselves!

 The Frenzied SLPs know how hectic the end of the year can be. We know need some extra love and slam-dunk resources to make your year-end therapy planning a breeze.

To say thanks, we are joining Teachers Pay Teachers to show some extra appreciation for all you do with a Speechy & Teachers Appreciation Sale! Teachers Pay Teachers is celebrating their 10 amazing years with this year-end bonanza.

Woo hoo! You will find everything in Speech Sprouts store on sale for 28% off when you use the code: CELEBRATE. 

That's terrific, but...

 There are literally thousands of resources to choose from. Mind-boggling for sure. No worries, the Frenzied SLPs have you covered. We will help you de-frenzy (Is that even a word? OK, I just made it up :)

We have gathered up some of our best picks for you to save you time and make your shopping fun and easy.  

My year-end favorites from Speech Sprouts

Definately my Oceans of Fun Bundle. You get plenty of under-the-sea fun in this two-pack with  Smiley Shark Speech Therapy Book Companion and Diver, Diver Who Can it Be? A Reader Focusing on Where? Questions. Tons of ocean-themed language, phonological and articulation activities- you are sure to cover nearly everyone on your caseload with this one. 

Best Year-End Picks for SLPs:Speech Therapy Oceans of Fun Bundle

Best Year-End Picks for SLPs: Smiley Shark Book Companion         Best Year-End Picks for SLPs: Diver Diver Where Can You Be? Reader

Another favorite for year-end vocabulary fun is Antonym Picnic.

Pack your picnic, make a cootie catcher, make a fun sandwich-shaped mini-book to send home or play one of several included games as you teach those antonyms.

Best Year-End Picks for SLPs: Antonym Picnic           Best Year-End Picks for SLPs: Antonym Picnic

Best Year-End Picks for SLPs: Antonym Picnic              Best Year-End Picks for SLPs: Antonym Picnic

I'm packing my cart with this resource from Twin Speech Language and Literacy, LLC. This Summer-Themed Articulation Bundle will be perfect for my artic groups or a send-home summer packet.

Best Year-End Picks for SLPs: Speech and Language Activities that Will Help You Sail into Summer!
From Twin Speech Language and Literacy, LLC

This one will make my life easier this fall too, when all those referrals come pouring in! Grab these Speech and Language Checklists from All Y'all Need, and be ready.

Best Year-End Picks for SLPs: Speech and Language Checklists
From All Y'All Need

Hope you enjoy  these easy-breezy resources!

Be sure to hop through the link-up and see what else the frenzied SLPs have in store for you. Go ahead and pop your favorites in your cart ahead of time, and you will be ready with a fast and easy checkout. 

Stop by Speech Sprouts and see what else I have in store for you.

 Everything, including my bundles, will be and extra 28% off with the code CELEBRATE, so don't forget to use that code! (Easy to forget, I speak from experience, drat!)

Here's the Link-up from more of my Frenzied Friends:

Happy Shopping!

Wednesday, April 27, 2016

Is It CAS? Navigating Differential Diagnosis

Childhood Apraxia of Speech or CAS can be a particularly tricky speech disorder to diagnose. 

You assess a highly unintelligible child, and after giving a battery of tests and carefully looking at the results, you still wonder, is it CAS? How can I tell? Just how does CAS look different from a severe phonological disorder? Has this happened to you?  I've been there, and I knew I needed to learn more.

CAS: Making a differential diagnosis is tricky. What SLPs need to know.
Childhood Apraxia of Speech can be difficult to diagnosis- so how do you know if it's CAS?

 This is Part 2 in my series on Childhood Apraxia of Speech, Let's Talk! 

This April, I was selected to be part of a CAS intensive training workshop sponsored by the Once Upon a Time Foundation and the Department of Audiology and Speech Language Pathology of the University of North Texas. Twenty five SLPs were invited to spend three days and evenings with Dr. Edythe Strand, of Mayo Clinic, learning from her expertise in the area of CAS.  Read my first post in this series, Childhood Apraxia of Speech: What SLP's Need to Know to learn more about Dr. Strand and just what childhood apraxia of speech really is.

Please be aware, I am not an expert in childhood apraxia of speech. I am learning, just like you. I figure if I have questions and doubts about how to approach CAS, some of you may too. Dr. Strand, who is an extraordinary clinician, researcher and teacher, shared her experience and expertise with us. I am sharing what I learned with you, with Dr. Strand's permission and blessing. So let's talk about diagnosis.

Differential diagnosis: How do I know if a child has CAS?

Is it a motor speech impairment or a phonological impairment? If it is a motor speech impairment, how do I determine if it is apraxia or dysarthria? Any of these impairments can be severe and result in highly unintelligible speech. So how in the world do you sort it out?  First, let's talk about some key terms. 

Praxis or Planning Deficits Versus Execution Deficits

This is a very important distinction. You need to know this.

What is Praxis?

 Praxis is motor planning of skilled, voluntary movements. What does that mean? Think about how we use proprioceptive information (feedback about the position and movements of our body) to plan how to move the muscles: up, down, whether they are tight or loose, how far to move, with how much force, and the timing of the movements. Programming of all those factors is motor planning or praxis.

Difficulty planning muscle movements of the articulators for speech is termed childhood apraxia of speech or CAS.

Imagine how fast and with what precision all this information needs to be processed to result in accurate, intelligible speech. All these factors need to be processed in virtually a nanosecond for our brain to plan the coordinated movements.  It's kind of amazing we can do that at all. Really amazing.

A deficit in praxis is at the core of CAS.

Difficulty planning oral movements not related to speech is termed oral non-verbal apraxia.

A child can also have difficulty with planning or praxis for oral movements that are not speech- related (kiss, pucker, smack lips, blow). 

What do we mean by "execution deficits"?

A deficit in "execution" is related to the muscles themselves. (Versus planning as in praxis). This can be caused by weakness or paralysis. We call the resulting problems in speech production "dysarthria".

With weakness, or execution deficits you may see:
1. reduced range of motion
2. reduced strength
3. reduced speed

The only type of dysarthria that is not associated with weakness is ataxia. This can make it difficult differentiate from apraxia, but the good news is ataxic dysarthria is treated with the same approach as apraxia.

 (Wide-based gait may one thing you notice with ataxia.)

Is this getting deep? Breathe, you've got this. 

In a nutshell, we need to determine whether difficulty with articulation may be due to problems with:
1. Phonological/ linguistic skills
2. Praxis
3. Dysarthria/Weakness

OK, We've got our labels.That's not so bad now is it? But here's the rub: Children do not fit neatly in just one box. So you may see a child with two or even all three of these labels.  These deficits can co-occur. A child often has apraxia and phonological impairment as well. Or maybe apraxia plus weakness.

 Our labels can change over time as a child progresses and develops.

Children change. Characteristics of a disorder look different with time and therapy. Labels should change with them. You may have a new student or client that comes with a history of CAS. Yet, that label may or may not be currently appropriate.

You will want review your labels, and do a differential diagnosis as children progress to see if they are still appropriate.

If the labels can change, how do they help? Labels help us guide our current treatment approach.  For instance, a child who may have presented with characteristics of CAS initially may present with residual phonological impairment more than apraxia as time goes on. Treatment approaches can therefore change as well.

Childhood Apraxia of Speech: Characteristics That Help SLPs Make a Differential Diagnosis
Some characteristics are more likely to discriminate CAS than others. Learn what to look for!

Now for the nitty-gritty. What characteristics are present in CAS?

While researchers have identified characteristics seen in CAS, there is not a validated list of features that differentiates CAS from other speech sound disorders. (ASHA 2007a). Many of these characteristics are shared with other speech sound disorders. Children with CAS may have some or all of these. 

 Let's look more closely at the characteristics you may see.

Characteristics that may be present, but are not exclusive to CAS:

1. Limited consonant and vowel inventories 
2. Use of simple syllable shapes (such as CV, VC, CVCV)
3. Frequent omission of sounds
4. A high number of errors and low standard scores on tests of articulation
5. Poor intelligibility

Dr. Strand pointed out that:
  • Numerous errors and poor intelligibility may be seen in children with all types of speech sound disorders (SSD's), whether the child has dysarthria, CAS or a phonological impairment.
  • Substitution errors may occur more in children with phonological impairments.

Characteristics that are more likely to discriminate CAS:

1. Difficulty moving from one articulatory configuration to another. You may see awkward or imprecise movement as the child tries to move smoothly across the syllable. (For instance when attempting to say peek-a-boo). Errors may increase with number of syllables in a word and and complexity.
2. Groping or trial and error on initial consonants. You will usually see this more in elicited words but not in spontaneous speech.
3. Vowel Distortions. This is not a substitution of the vowel, rather the intended vowel is distorted.
4. Errors in Prosody. Lexical stress pattern errors: you may see equal, even stress or pauses between phonemes or syllables causing segmentation. (ex. instead of banana, you get ba-na-a)
5. Inconsistent Voicing Errors. It may be hard to tell if the consonant is voiced or unvoiced, due to errors in the timing of voicing onset.

These characteristics are more likely to  be seen in children with CAS, and less likely to be seen in children with other speech sound disorders (SSDs).

CAS: Making a differential diagnosis is tricky. What SLPs need to know.
It's important to differentiate CAS from other speech disorders!
Learn more by following this series on childhood apraxia of speech.

Whew! That's a lot of information. 

Are you hanging in there? So far, we talked about the definition of CAS in my first post  Childhood Apraxia of Speech: What SLP's Need to Know. Today, we covered key terms you need to know and characteristics you may see in CAS.

Questions? Thoughts? I would love to know what has been helpful for you. Any aha moments yet? Anything you would like to know more about? I encourage you to leave me a comment, let's talk! Please remember, I am not an expert, but I will try to answer or find a resource for you..

For more information, you may want to head over to ASHA's Practice Portal on CAS.

Dr. Strand has a YouTube series you need to check out.

 These videos were made to help explain CAS to parents, but they have terrific information and excellent video examples for SLPs too. I highly recommend you take a look, and share with parents.

This video is 52 minutes long, and contains all the segments. But you can also view her videos in shorter segments.

This video shows video examples of children with different severity levels of CAS:

This video shows video examples of children with a phonological disorder, and dysarthria.


Thanks for reading! 

If you are finding these posts helpful, please follow and share. Pin, post and help spread the word. Increasing our knowledge base is so important for children with childhood apraxia of speech!

In my next post I will talk about how to plan your assessment. You can find it here:
4 Essential Steps in Assessing Childhood Apraxia of Speech

Until next time!

Monday, April 18, 2016

Childhood Apraxia of Speech: What SLPs Need to Know

Childhood Apraxia of Speech: Lets Talk About It

Are you a speech language pathologist who has questions about diagnosis and treatment of childhood apraxia of speech or CAS? 

Childhood Apraxia of Speech: What SLPs Need to Know by Speech Sprouts
Childhood Apraxia of Speech: What SLPs Need to Know

This post is the first in a series. 

I have been given an amazing opportunity to learn about assessment and treatment of childhood apraxia of speech, and I have been tasked to spread the word about what I have learned to other speech language pathologists. So I hope you will grab a hot cup of coffee and sit down with me, and let's talk about it!

I love learning. The nerdy side of me gets excited about diving into a topic that interests me and I love unraveling as much information as I can absorb. Childhood apraxia of speech is one of those topics that I have been craving to know more about. As a speech language pathologist, I have seen how this speech disorder can affect a child's communication, and I want to discover as much as I can about how to help.

Learning from Dr. Edythe Strand

This past weekend, I had the privilege to participate with 25 other clinicians in a marathon of learning on childhood apraxia of speech sponsored by the Once Upon a Time Foundation. The University of North Texas hosted Dr. Edythe Strand, Ph.D to teach us. I have attended one-day workshops given by Dr. Strand and couldn't have been more thrilled to have this opportunity to learn more.

Childhood Apraxia of Speech: What SLPs Need to Know by Speech Sprouts
CAS Intensive Training Workshop.
Dr. Strand is a dynamic teacher, researcher and also a clinician herself. She is an Emeritus Consultant of the Department of Neurology at the Mayo clinic in Rochester, Minnesota and Emeritus Professor at the Mayo College of Medicine. She is the former head of the Department of Speech Pathology at Mayo Clinic.  Dr. Strand has done groundbreaking research on CAS and developed an evidence-based treatment approach known as DTTC. She is considered a leading expert in the field. She is currently working on development of a dynamic assessment for CAS.  Dr. Strand is also funny, kind, encouraging and passionate about her work.

Twenty hours of intensive focus meant we covered a LOT of ground. 

This small group intensive training extended for three days, all day and evening sessions too. So I want to share in chunks. Let's talk about one piece at a time.

I want you to know that I am not an expert on childhood apraxia of speech. I am a clinician who, like many of you, serves children with CAS and seeks to learn as much as I can about how to provide the best treatment for this tricky disorder. One purpose of this wonderful training was to share the knowledge we learned, and help advance understanding about diagnosis and treatment of CAS. So I am simply sharing my take-aways from what I have learned from Dr. Strand and a bit of my experience with CAS. 

Coming to this training, I had many questions, and I know many of you do too. We talked about this in my earlier post, Childhood Apraxia of Speech: Your Questions.  What are your questions? I hope this series will answer some of them for you. 

So let's start at the beginning.

Just What is Childhood Apraxia of Speech?

In graduate school, SLPs are taught that CAS is a motor speech disorder. 

The American Speech-Language-Hearing Association or ASHA has a position statement on Childhood Apraxia of Speech adopted in 2007 and recommends this 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. 

Childhood Apraxia of Speech: What SLPs Need to Know by Speech Sprouts

Let's look more closely at that. 

CAS is not a medical diagnosis.

 CAS is a childhood neurologically based speech sound disorder. A speech sound disorder. Dr. Strand emphasized that CAS is not a medical diagnosis. 

Some SLPs, particularly school-based SLPs, have reported that they have been told by their employers that they can not identify or diagnose CAS, as we cannot make medical diagnoses. If this is what you have been told, I encourage you to do your research and discuss this with your employer, because identification of the disorder is essential to framing thinking about treatment planning. 

SLPs regularly identify speech and language disorders: phonological disorders, fluency disorders, expressive and receptive language disorders. Similarly, it should be appropriate to identify CAS, if you have the specialized training and experience to do so. If you do not, please refer a child to an SLP that does have specialized training, as accurate diagnosis is important. I will talk more about diagnosis of CAS in the next post.

CAS is a disorder of movement.

CAS is an impairment in the precision and consistency of the muscle movements necessary to produce speech. Programming of the movements is impaired, not the phonemes themselves. This is important in framing our approaches to remediation. This is why therapy for CAS based on principles of Motor Learning Theory works and why a phonological approach, which emphasizes teaching the sounds of speech, is not the most effective approach to apraxia. 

I should note here that there are several approaches to treatment, many of which show promise, and one size does not fit all. But more about that later.

CAS is not the result of muscle weakness. 

The movements underlying speech are impaired in the absence of neuromuscular deficits. CAS is not a result of weakness, abnormal tone or reflexes. The core impairment is in planning the sequence of movements needed for speech production. When we speak, our brain must program which muscles to move, when, in what order, how hard, and how far. A child with CAS has difficulty coordinating these movements, resulting in inaccurate speech sound production and prosody.

CAS can co-occur with other disorders, or present by itself.

This is one reason it can be so tricky to diagnose, even for the experts! A child with CAS can also have other diagnoses such as dysarthria, velopharyngeal insufficiency, ataxia or autism.  Often children will have linguistic deficits as well:  difficulty with phonology, semantics and syntax.

How many children have CAS?

Experts have identified many characteristics seen in CAS, but a lack of clear guidelines has made determining the actual incidence and prevalance of CAS difficult as discussed in ASHA's Technical Report on Childhood Apraxia of Speech. Estimates at this time are 1 or 2 in 100 children have CAS (Shriberg et al., 1997) and that 3.4%-4.3% of children identified with a speech disorder have CAS (Delaney & Kent, 2004). 

The incidence of CAS is greater in boys than girls, and prevalence is reported to be higher in children with certain medical conditions. So if you have a caseload of 50 children, you might expect to have one or two children with CAS on average. Of course the actual number on your specific caseload can vary.

Dr. Strand has a YouTube series you need to check out.

 These videos were made to help explain CAS to parents, but they have terrific information and excellent video examples for SLPs too. I highly recommend you take a look, and share with parents.

This video is 52 minutes long, and contains all the segments. But you can also view her videos in shorter segments.

In this video, Dr. Strand talks explains what childhood apraxia of speech is, and talks about key terms. Definitions and Descriptions of Childhood Apraxia of Speech


So how do I assess and exactly what do I look for?

 In my next post in the series, I will be talking about diagnosis.  I invite you to follow my blog, and sign up for my e-mail list, so you don't miss a post on CAS. I also invite and encourage your questions and comments, let's learn together!

Read the second post in this series  Is it CAS? Navigating Differential Diagnosis 

Until next time!