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'm not an expert in childhood apraxia of speech. I'm 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'm 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 to 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'll want to 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 the number of syllables in a word 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 phonological disorders, and children with 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'll 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!

Monday, April 4, 2016

April Showers! Why You Should Include Water Play in Speech and Language Therapy

Water Play in Speech Therapy

I am delighted to be linking up with the Frenzied SLPs for an April Showers post because I LOVE using water in my therapy.  Why should you include water activities in speech and language therapy? Glad you asked!

April Showers! Water Play in Speech and Language Therapy by Speech Sprouts

Water play and preschoolers are a natural combination.

What preschooler can pass a puddle, or keep their hands out of a running faucet or bucket of water? I haven’t met a little guy yet who can resist, and we know children learn language best through play. 

So grab a bucket, add a few floating objects, a couple of cups for pouring water and I guarantee, you’ve got their attention! 
You’ll find all kinds of natural language opportunities and you can easily engineer articulation practice into water play too.

Here’s what we did last week in my preschool speech therapy program. 

April Showers! Water Play in Speech and Language Therapy by Speech Sprouts

Last week's focus was final “sh’, so of course the topic was fish.

What goes with fish?  A bucket of water of course.

After reading some of my favorite fish stories, like Rainbow Fish and A Fish Out of Water, we discussed fish. Where do they live, how do they move, how many kinds can you think of?

We work on lots of wh questions during story-book reading, 

but also include describing, categories, prepositions, basic concepts and sentence formulation too. 

How? Just start off with an “I wonder” statement. “I wonder where fish live?” Hmmm, this is a goldfish. I wonder what other kinds there are? I wonder if all fish are small like this one.” Children love to have a conversation with you, and you will encourage more than the usual one-word answer that a direct what? or who? or where? question will generate. You are discovering things together!

April Showers! Water Play in Speech and Language Therapy by Speech Sprouts

 Several of my smart little guys even knew that sharks were fish! 

 Time to break out the bucket and wash a fish. 

Not having any cute goldfish at my disposal, we used the sharks. Add a washcloth, sponge and a toothbrush, and those sharks were in for a scrubbing! (Articulation targets included wash, fish, and toothbrush)

Lots of great language happened while we were elbow deep in suds and water!

We talked about verbs and synonyms: wash, clean, scrub, brush, rinse. There were plenty of descriptive words to discuss too: wet, dry, soapy, bubbly, shiny. So much fun!

Ready to "dive in" and bring in some water play?

I would love to hear about your favorite activities that make a splash!

Check out more great water activities here and link up your water play posts! Thanks for stopping  by.