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.
Do you have questions? Grab a cup of coffee, and let's talk!
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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.
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?
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 is non-verbal or very limited, you may not get much here.
- Imitation Tasks.
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. 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.
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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!
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. You can find it here: How to Uncover Emerging Skills with a Dynamic Assessment for CAS.
If you are enjoying this series, please comment, share, pin and post to help spread the word!