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 www.speechsproutstherapy.com


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!


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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 www.speechsproutstherapy.com

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."bi...cy...cle") 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!

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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. 

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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! 

You will find the next post here: How to Create an Amazing Therapy Plan for Childhood Apraxia of Speech.

See you then!

References:
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.





4 comments:

  1. I have been loving this informative series! Thank you so much for giving us such a great resource!

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    1. Thanks Linda, I really appreciate you following.

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  2. I wish all therapists who evaluated students would look at this!! The motor part is HUGE!! My little one was diagnosed with Childhood Apraxia by our outside speech therapist BUT when going through the school they never looked at the motor part, and when we brought it up they brushed it off! They kept saying she has autism! They wouldn't even consider Apraxia!! Shocking how the autism signs have decreased IMMENSELY now that she has more speech and an ability to communicate! Still a long road to go but we are on our way!

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  3. Angie, you are right. CAS can be very tricky to diagnose, even for the experts, especially in very young children. And when little ones struggle to communicate, they can get frustrated and act out. Understandable! I'm so glad you found the right path and your daughter is on her way now.

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