Sunday, February 17, 2019

Diagnosing Childhood Apraxia of Speech: A Review of the DEMSS from the Trenches

 The  Dynamic Evaluation of Motor Speech Skills (DEMSS) is a tool I've been waiting for.

Diagnosing childhood apraxia of speech (CAS) in young children can be tricky- the DEMSS is a new tool to assess for CAS and help SLPs plan speech therapy treatment for childhood apraxia of speech. Read this post to find out why every SLP needs this in their toolkit. #speechsprouts #apraxia #speechtherapy #speechandlanguage
The DEMSS is a criterion-referenced dynamic assessment of childhood apraxia of speech.

 Does this sound familiar? You're evaluating a young child with a severe speech sound disorder. You note a limited consonant and vowel inventory, use of mostly simple word shapes (V, CV, VC or maybe CVC), numerous sound ommissions and really poor intelligibility.

Is it childhood apraxia of speech (CAS) or another speech sound disorder? 

 It may CAS, but we can see these characteristics in children with severe phonological disorders or dysarthria too. Assessing and making a differential diagnosis for childhood apraxia of speech can be really difficult in many cases, even for the most experienced clinicians. You need a tool to help you make a differential diagnosis because that diagnosis will help you shape your treatment plan.

If this is CAS, where do we start?

This is a child who struggles to communicate. You want to design the most effective treatment plan for this child to help him or her increase functional communication and intelligibility as quickly as possible. You have more questions: What initial targets should I choose in therapy? What are the most effective cues and strategies specifically for this child?

If you've read my blog post series on childhood apraxia of speech, you know that I have a particular interest in assessing and treating children with CAS.

 I had the wonderful opportunity to do a deep-dive and learn more about CAS when I attended a small-group, intensive 2-day training with Dr. Edythe Strand of the Mayo Clinic in 2016 and was inspired to "spread the word" about CAS. I wrote a blog series about childhood apraxia of speech for SLPs.  You can read the first post in this series here: Childhood Apraxia of Speech: What SLPs Need to Know.

Dr. Strand and Dr. Rebecca McCauley had been working on developing a dynamic assessment for childhood apraxia of speech for several years. We learned about the DEMSS and got a sneak peek in our training, although it wasn't yet ready for publication.

In the interest of full disclosure, I've been watching for this assessment and am excited it's now published. Why?  Because I would love a standardized tool that uses a dynamic assessment approach to help me make my clinical decisions when I suspect childhood apraxia of speech.

When I learned the DEMSS had been published,  I reached out to Paul H. Brookes Publishing Company and requested a copy so I could share a review with you. I received a copy of the DEMSS at no cost from Brookes Publishing for the purpose of this review. I was not financially compensated for this post. The opinions within are completely my own and based on my experience.


My review of the Dynamic Evaluation of Motor Speech Skills (DEMSS)

First Impressions

When my copy of the DEMSS arrived, the first thing I noticed was the small, thin box which contained a paperback manual. But where are the protocols? The manual explains that DEMSS response forms, as well as a tutorial, are available online.

You can fill out the response forms online and save them to your computer, or print a copy for hand-coding. A key code is provided to access them.  The response form is also in the back of the manual, but I think it's best to print online rather than try to flatten out the book on a copier.

SLPs are used to speech or language tests contained in large, unwieldy boxes that take up a lot of precious storage space, so the small footprint is a plus.

We're also used to receiving a certain number of protocols with our purchase of the test and then needing to purchase more when those run out.
The ability to print the response forms or complete them online at no extra cost is definitely budget-friendly.

Administering and scoring the DEMSS

The manual provides details about administration and scoring. There are also video tutorials online that provide practice and pointers as you watch an SLP administer the DEMSS.  Dr. Strand states in her introduction that the tutorials are supplemental practice, and clinicians should read the manual for full information about the administration of the DEMSS.

She's right. This is not easy, grab it out of the box and go assessment. You'll need to put in some time to learn the test, especially if you have limited experience with CAS. There's a lot to watch for.


Online Tutorials

Recognizing vowel distortions and prosody errors can be tricky.

Dr. Strand provides practice for you with her audio and video tutorials for the DEMSS. These tutorials will initially take a couple hours to go through at the minimum but are really helpful. Don't skip these!  The examples include notes on what to watch for, how to score, and examples of correct administration as well as common errors in administration we can hopefully avoid.

Even though I've trained with Dr. Strand, I absolutely benefitted from going through the examples, and will likely listen again if I haven't assessed CAS for a while.  The tutorials definitely provide added value to the DEMSS.

Part 1 of the tutorial is a downloadable file that contains a PowerPoint with audio and video examples of vowel distortions and prosodic errors. The purpose is to help train your ear to recognize these distortions during the administration of the DEMSS. I listened to each example several times

Parts 2 & 3 are video examples of full assessments which give you practice evaluating and scoring responses of two different patients, one with mild CAS and one with more severe CAS.

I found the videos very helpful in training me to listen for subtle vowel distortions and for prosody errors and how to score them. You watch a clinician administer the DEMSS.  Dr. Strand does voice-overs during the video, gives administration tips and points out errors in the child's speech to listen for.

I liked that the scores for each child's response were printed at the bottom of the video so you can compare your judgment of the response in real time with the clinician's scoring.

You also have the opportunity to watch how the clinician cues the child during the assessment to see if production improves. This is the "dynamic" aspect of the DEMSS that is not included in other tests for CAS I've used.


I've administered the DEMSS to four children as of this post. I've read the manual and watched the videos. I feel semi-confident in my administration of the assessment so far. I think I'll need more practice to feel fully confident that I'm administering and scoring as accurately as possible. I also think it's totally worth it. Keep reading. You'll see why.

Administration Time:

The manual estimates it will take 10-30 minutes to administer the DEMSS depending on the child. It took me a little longer for my first couple of administrations, but with familiarity, it's getting faster.

Stimulus words

The DEMSS begins with simple CV syllable shapes with a variety of consonants and vowels such as me and bye. The stimulus words progress in complexity to bisyllabic and multi-syllabic words such as movie or peekaboo. A total of 60 words can be administered. Children with severe CAS may only be able to complete a portion of the test.


Because of the nature of CAS, there are many subtle things to watch and listen for as you test. Articulatory accuracy of consonants, vowel accuracy, and prosody are scored during the test.

On the DEMMS, you cue incorrect attempts providing up to six cued trials and then record accuracy on the next imitation trial.  You're watching for and noting voicing errors, groping, consistency, rate, segmentation, difficult transitions and more.

I like that the response form includes check boxes for these "notes" on each page. The ability to quickly check instead of writing your observations is helpful. The form also breaks down the type of prosodic errors you may hear (for words with more than one syllable) including segmentation, equal or incorrect stress, syllables that are added or deleted.

That's a lot to monitor all at once! Even if you videotape the assessment, you'll need to score while giving it so you'll know when to cue. Be prepared, this will take some practice.

After four administrations, I'm still working on it. In return, you'll gather a ton of specific information about the child's performance that will be golden as you make your diagnosis and treatment plan. That's my "why." Totally worth the effort in my opinion. No more "Where do I start?" You'll know.

Read on for more details about the DEMSS.

Articulatory Accuracy

Initial attempt
Scored from 1 to 4 points.
Scores are based on whether the word is correct on the initial attempt, if it's a consistent developmental substitution error, or if the child self-corrects without a model. 

Cued trials

If the word isn't correct on the first try, the clinician provides cued trials. You record whether the child gets the word correct on the first cued trial, whether it's correct with additional cuing, or no attempts were correct. 

I suggest making notes as you go, noting specific cues which were effective for the child and the level of cuing needed.  Great information for a starting point in treatment. 


Each stimulus word is presented for a minimum of two trials, allowing for a consistency score. Consistency is scored as 1 for consistent across trials or 0 for inconsistent across 2 or more trials. 

I really like this feature of the DEMSS. Information about the consistency of productions is so important to differential diagnosis and is not available on "static" tests which score a single production of a stimulus word. 

Vowels and Prosody

Prosody is scored on words with more than one syllable and is either scored 1 for correct for 0 for incorrect.

Vowels are scored on all words, with 2 for correct, 1 for uncertain, and 0 for incorrect. Uncertain? Yes! Sometimes I definitely know I've heard a vowel distortion or the response is accurate, but sometimes it's pretty mild and I'm unsure.

The ability to score as "uncertain" is a unique (and appreciated) feature of scoring vowels on the DEMSS, allowing for that middle ground.



The DEMSS is intended to be a criterion-referenced measure which is one of several tools used for a complete and thorough evaluation. 

The DEMSS Total Score yields a measure of the likelihood that the diagnosis of childhood apraxia of speech is correct. Total scores of 0-323 are considered significant evidence of CAS, scores of 323-373 yield some evidence for at least mild CAS and scores of 373 to 426 yield little or no evidence of CAS.

This information, along with other characteristics of the child's speech noted during the DEMSS is combined with all other information gathered in the assessment battery to make a diagnosis, an estimate of severity and recommendations for a treatment plan.


Overall, the DEMSS is a powerful tool to use when a diagnosis of childhood apraxia of speech is suspected. I feel the dynamic assessment approach yields rich information that's not provided when only a "static" assessment is used.

If you'd like to learn more about the difference between static and dynamic assessment click to read my post on How to Uncover Emerging Skills With a Dynamic Assessment or for an in-depth look at CAS  you can start with the first post in the CAS series HERE.


I hope this review has been helpful.

Diagnosing childhood apraxia of speech (CAS) in young children can be tricky- the DEMSS is a new tool to assess for CAS and help SLPs plan speech therapy treatment for childhood apraxia of speech. Read this post to find out why every SLP needs this in their toolkit. #speechsprouts #apraxia #speechtherapy #speechandlanguage Please comment if you've tried or would like to try the DEMSS. What are your questions and struggles when it comes to assessing childhood apraxia of speech? I would love to know your thoughts.

I also encourage you to share and pin my posts on CAS to help "spread the word" to clinicians who are wanting to learn more about CAS. It's so important!

Thank you, my friends. Until next time,

Wednesday, January 2, 2019

14 Preschool Songs and Fingerplays for Winter Speech Therapy

Songs and fingerplays will brighten up your winter preschool speech therapy sessions. 

14 Winter songs and fingerplays which are terrific preschool speech therapy activities to boost speech and language skills. Do you love penguins, bears and snowmen? This post has you covered! #speechsprouts #preschool #kindergarten #speechandlanguage #winter

Winter means snowballs, snowmen, penguins and bears... all of which are fascinating to your little ones and a great starting point for speech and language activities. 

Why not learn about winter in your speech therapy session with songs, fingerplays and movement activities to engage your littles? Bonus- you'll boost their learning in multiple ways.

If you read my post on 14 Songs and Fingerplays for Fall in Preschool Speech Therapy, we talked about those benefits. What a natural language-boosting way to work on skills! 

What speech and language areas can you target with songs and fingerplays?

Oh my goodness, songs and fingerplays are a smorgasbord of language-learning opportunity in speech therapy! Think about all the skills you can practice. Here are a few, I'll bet you can think of even more.

1.  Prosody: We know that simple catchy music gives children practice with the melody of language: pitch, rhythm, and duration. Sounds like the perfect opportunity to work on prosody doesn't it? 

Did we sing that word softly or loud? Fast or slow? High or low? When did we use an excited voice? 

2.  Sentence length and structure: The repetitive lines give children lots of practice with longer more complex sentences that language delayed children may not yet be producing on their own. Great for increasing MLU and children who leave out small words and word endings.

3. Rhyme: Sing the song or recite the fingerplay. Which words rhyme? Where in the sentences are you finding the rhymes, at the beginning or the end? Can you tell me another word that rhymes with it?

4. Vocabulary: Many songs and fingerplays repeat thematic vocabulary words over and over. Studies tell us it takes multiple exposures spaced out over time to learn a new word. This is even more important for our language delayed children. 

Presenting the words in multiple ways through songs, fingerplays and thematic units is powerful! Snowflake, melt, cave, and penguin are just a few of the words you can practice. 

5. Auditory memory: Repeated exposures to the lines help children remember and process the words in the songs and fingerplays. 

6. WH questions: Sing your song, recite and act out your fingerplay. Then ask questions. What did she see? Where were the shadows?

7. Adjectives and describing:  "I'm a little snowman, short and fat." How did the snowman look? Was he tall?

8. Prepositions: On the ground, in my cave, down I'll go! 
 "There once was a bear, who loved to play. (from Dr. Jean's Hibernating Bear). Where did he play? In the woods, every day!

9. Articulation: Did I say snowman? Snowflake? Snowball? Repetition of /sn/ blends and other articulation opportunities abound in repetitive songs and fingerplays. Have fun with your artic sessions.

10.  Narratives: Children can practice sequencing and story-retelling after the songs and rhymes are learned. 


Tips for using songs and fingerplays for language development

  • Repetition: Look for repetitive songs providing multiple opportunities to practice.  Don't present the song or fingerplay just once. Enjoy the same one multiple times in a session and over several sessions. 
  • Pacing: If you are following along with a video to present the song, be sure to choose a video with a slightly slower pace. Many are too fast for our language-delayed students to keep up. 
  • Pre-teach the words and motions at a slower pace.
  • Visuals: Use pictures, story-telling pieces or other visuals.

Here are my picks: 14 winter songs and fingerplays for preschool speech therapy.

Snowflakes from Teach Preschool

10 Little Snowflakes from the Teaching Mama. I love this song because it repeats snowflakes with lots of s-blend practice (One little, two little three little snowflakes), and each verse ends by saying where the snowflake is: On my tongue, on my hat.... great for where questions too.

Snowflake, Snowflake action song by Intellidance is wonderful! Watch the video demonstration of the song and actions with dance-like moves.

The Snowman from Teach Preschool

Dr. Jean Warren is always a treasure of great songs and fingerplays!

I'm a Little Penguin by Dr. Jean Warren on the Preschool Express. This is sung to the tune of "I'm a Little Teapot" and I love the action words waddle, dive and swim for acting out as you sing!

Hibernating Bear by Dr. Jean Warren on the Preschool Express is sung to "Up on the Housetop". Winter is a great time to teach the position concepts of "inside" and "outside". The bear goes inside his cave. Who goes inside when it's cold? Who is outside?

I See Shadows by Dr. Jean Warren is fun for Groundhog's Day in February. Some are short and scary, some are tall! Perfect segway to a lesson on short and tall.

Lights, camera, music! Videos of Winter Songs

If you have a computer, tablet or whiteboard to show a YouTube video, try Snowflakes, Snowflakes by the Kiboomers.

I'm a little Snowman by Super Simple Songs has a nice slow pace for our little language learners and repeats the simple verse several times. Love that for helping children learn and participate.

Fingerplays, Poems and Chants

Here's a Hill shared by is a fun little action rhyme about zooming down a hill on your sled.

The Mitten Chant from the Teaching Mama. This fingerplay includes describing words: snug, fuzzy, warm and colorful. Work on describing and categories after the chant. What else is soft? Fuzzy? Yes no questions: Is a shovel fuzzy? A cat?

The Mitten Chant also has singular mitten and plural mittens. A great jumping off point to talk about plurals. the concept of a pair, winter wear and winter activities. You need two mittens in the winter. What else do you wear two of? (boots, earmuffs, socks, skates, skis)

 Preschool Express has many great songs and fingerplays. Two more favorites:

The Snowman by Dr. Jean Warren shared on the Preschool Express includes the concepts of large, middle-sized and small.  Roll a snowball large, then one of middle size...

A Funny Little Snowman from the Preschool Express This cute little rhyme talks about the snowman and his carrot nose, then along came rabbit...what do you suppose? Fun for prediction and rhyming!

Snowball by Shel Silverstein shared on Goodreads is a funny little poem about a child who made himself a snowball and kept it as a pet! The absurdities are fun to talk about as you answer why questions (Why can't you keep a snowball as a pet? Why was the bed wet?) and predict what will happen!

If you've never read Shel Silverstein, go to the library and take out one of his books right now. Don't wait another minute, his poems are so funny and silly and...awesome!

14 Winter songs and fingerplays which are terrific preschool speech therapy activities to boost speech and language skills. Visuals like this build a snowman activity are perfect accompany the rhymes.  #speechsprouts #preschool #kindergarten #speechandlanguage #winter

What's your favorite winter song, poem or fingerplay?

If you have other favorites, share with us! I'd love to hear them. Be sure to pin this post to your Pinterest Boards so you can find the links again easily when you need them. 

 Stay warm and cozy, and have fun!