Childhood Apraxia of Speech Childhood Apraxia of Speech Checklist: A Series of Characteristics to Facilitate Diagnosis

Kay Giesecke, MS, CCCCCC-SLP Specialist in CAS since 1995 Heather MacFadyen, MA, CCCCCC-SLP General Definition:
1. Previously known as: Developmental/Verbal Apraxia, verbal dyspraxia, etc. etc. ASHA and CASANA now use Childhood Apraxia of Speech (CAS) common among all titles is the word praxis praxis. 2. Motor Speech disorder: a disruption in motor planning and/or programming

What is Praxis?:
Praxis
planned movement neurological process by which cognition directs motor action actionability to formulate or plan different actions actionsbefore the actual motor execution execution (Ayres, 1985)

What is Motor Planning?

The execution of a motor plan is the result of

praxis
the visible result of a successful invisible process

Not simply a series of postures, must include

Apraxia lack of praxis

information about the sequencing of these postures; In regards to speech, how the articulators will transition from one posture to the next.
(Velleman, (Velleman, 2003)

More specific definition of CAS

Symptom complex complex/syndrome
No one feature is adequate for diagnosis Each child has a different combination of speech errors errors thus the need for a checklist of CAS characteristics.

Top 3 Features from ASHA

1. Inconsistent errors on consonants and vowels in repeated productions of syllables or words 2. Lengthened and disrupted cocoarticulatory transitions between sounds and syllables 3. Inappropriate prosody In addition, ASHA lists 18 other speech features that might be present.

CAS Assessment Protocol

Traditional assessment which includes: Case History Hearing Pure Tone and Tympanometry Developmentally appropriate exp. and rec. language measurement (if possible) Language Sample calculate MLU, examine morphology and intelligibility Oral Mechanism Exam Oral Motor Screening Test

CAS Assessment Protocol Cont.

Speech: Single word articulation test (if possible); child may have to imitate items after examiner Formal or informal phonological analysis, including syllable and word shapes Consonant inventory isolation and stimulability Vowel/diphthong inventory isolation and syllables Prosodic analysis CAS Checklist

Childhood Apraxia of Speech Checklist

Developed by Kay Giesecke in 1996 Used in her private practice to facilitate diagnosis of CAS Based on previous research in the area of apraxia One of the tools used in the diagnostic process
2007

CAS Checklist Items

1. Severely delayed speech development (Jaffe, 1984; Watkins, 1992) *Persistent speech sound disorder; ASHA Ad hochoc-CAS, 2. Language comprehension superior to language production (Jaffe, 1984; Watkins, 1992; Velleman, 2003) 3. Slow or minimal improvement despite intervention (Hall, Jordan, & Robin, 1993; Velleman & Strand, 1994; Shriberg, Shriberg, et al., 1997; ASHA Ad hochoc-CAS, 2007)
**delayed progress may be due to inappropriate intervention

4. Single words more intelligible than conversation (Crary , (Crary, 1993; Hall et al., 1993) *Reduced Intelligibility; ASHA Ad hochoc-CAS,
2007

CAS Checklist Items, cont.

5. Strong occurrence of phonological processes (Crary, Crary, 1993) 6. Omission errors are the most prominent (Crary , (Crary, 1993; Hall et al., 1993) 7. Initial consonants tend to be more misarticulated than final (Kamen , 1995) (Kamen,
**initial consonants may be as affected as final consonants in the the case of severe speech disorders

CAS Checklist Items, cont.

9. Isolated movements better than sequenced movements (Hall et al, 1993; Kamen, Kamen, 1996) 10. Errors increase as word length or performance load increases (Crary , 1993; Edwards, 1973; (Crary, Velleman & Strand, 1994) 11. Probable differences between repetition and conversation (Crary , 1993) (Crary, 12. Prosodic aspects of speech are abnormal (Crary, Crary, 1993; Hall et al., 1993; Rosenbek & Wertz, 1972; Yoss & Darley, Darley, 1974; Top 3, ASHA Ad hochoc-CAS, 2007)

8. Difficulties in sound sequencing (Crary , 1993; (Crary, Hall et al, 1993) *Syllable sequencing, ASHA Ad hochoc-CAS, 2007

CAS Checklist Items, cont.

13. Presence of groping behaviors or salient posturing of articulators (Hall et al, 1993; Jaffe, 1984; Kamen, Kamen, 1996) *Effortful productions; ASHA Ad hochoc-CAS, 2007) 14. Inconsistency of errorserrors-misarticulate a word one time, then say it correctly another time (Hall et al, 1993; Kamen, Kamen, 1996; Rosenbek & Wertz, 1972; Top 3, ASHA Ad hochoc-CAS, 2007) 15. Variability of errorserrors-different errors in the same word and word position during repeated trials (Hall et al, 1993; Kamen, Kamen, 1996; Top 3, ASHA Ad hochoc-CAS,2007) 16. Problems with nasality (Hall et al, 1993; Jaffe, 1984)

CAS Checklist Items, cont.

17. Voicing errors (Hall et al, 1993; Jaffe, 1984; Yoss & Darley, Darley, 1974; AHSA Ad hochoc-CAS, 2007) 18. Vowel and dipthong errors (Hall et al, 1993; Watkins, 1992; ASHA Ad hochoc-CAS, 2007) 19. Most difficulty with fricatives, affricates, and consonant blends; least difficulty with bilabials and nasals (Jaffe, 1984; Kamen, Kamen, 1996; Dean 2008) 20. EpenthesisEpenthesis-addition of schwa in consonant clusters (Hall et al, 1993; Dean, 2008)
**Difficult to assess if the child is not producing consonant clusters clusters

Administration of the checklist

Information obtained from observations, formal testing, and parent report. If the child demonstrates the listed characteristic= 1 point If the child does not demonstrate the characteristic = 0 points If the child does not produce sufficient spontaneous speech to determine the presence/absence of the characteristic and/or the errors are so severe the characteristic does not apply= 1 point under N/A N/A Add the total N/A N/A items to the total characteristics exhibited exhibited to obtain the severity rating

Interpreting the Results

Based on a review of 80 different case studies the following guidelines were developed for interpreting the results from the CAS checklist checklist

Diagnostic Categories
Speech delay/disorder, not CAS Group 1 Score = 0 to 12 (out of 20) - 26 cases Demonstrated 5 to 12 of the characteristics listed on the checklist. Features not sufficient for diagnosis of CAS Prognosis same as type and severity of disorder diagnosed.

Severe Speech delay, not CAS Case History #1

Jacob, 3;8 (at initiation of therapy) Was previously in speech therapy with no progress Previous therapist did not encourage parent involvement Enrolled in intensive speech therapy and was dismissed in 14 months

Pre-test 3/19/1998 53 errors PR= -1%

Post-test 5/13/1999 4 errors PR= 71%

Severe Speech delay, not CAS Case History #2

Michelle, 2;6 Previously enrolled in individual and group therapy, strong parent involvement Previous SLP diagnosed her with CAS Received a brief assessment and scored a 6 on the CAS checklist Parent sent a tape to Kaufman to confirm diagnosis of apraxiaKaufman stated that this child may have been apraxic but was not any longer

Assessment Results 43 errors PR= 8%

CAS Characteristics Demonstrated: -Severely delayed speech -Lang comp superior to Lang exp -Single words more intelligible than conversation -Isolated movements better than sequenced movements -Differences between repetition and conversation -Most difficulty with affricates, fricatives and blends (age appropriate)

Group 2
Severe Articulation & Phonological Disorder with Apraxia Components
Score= 13 to 15 (out of 20) 16 cases

Presented with severe speech sound errors, expressive language delays, and groping, but exhibited:
No problems with vowel production No difficulties with prosody (a differential diagnostic characteristic according to research by Shriberg et al, 1997) No initial consonant omissions No variability in errors in the same word during repeated trials

Group 2
Severe Articulation & Phonological Disorder with Apraxia Components
Require use of apraxic therapy techniques, techniques, such as: drill and repetition, use of hierarchies, and adjustment of performance load. Continue to struggle with production of new words even after dismissal from therapy (based on parent surveys). Prognostic implications demonstrated speech skills within normal limits after 1 to 2 years of intense therapy.

Severe Articulation & Phonological Disorder with Apraxia Components

Case History
Carl, 3;11 (at initiation of therapy) Demonstrated 15 out of 20 characteristics on checklist. Did NOT demonstrate vowel errors, abnormal prosody, problems with nasality. Demonstrated final consonant deletion, fronting, syllable reduction, deaffrication Dismissed from therapy in 22 months

Pre-test 9/15/1999 55 errors PR= -1%

Post-test 7/2/2001 5 errors PR= 52%

Group 3 Moderate to Severe CAS w/out Major Concomitant Disorders

Score= 16 to 20 (out of 20) 13 cases All but one case (who scored a 16), demonstrated vowel errors. errors. That one case produced mostly vowels and a few initial consonants. These children also all had problems with prosody, inconsistency and variability of errors, and disrupted coco-articulatory transitions.

Group 3 Moderate to Severe CAS w/out Major Concomitant Disorders

Prognostic Implications Two out of nine of these students were able to have speech that sounded normal after 2 to 4 years of intense individual apraxia therapy with extensive parental involvement. The other 7 are still in therapy.

Moderate to Severe Childhood Apraxia of Speech Case History

Andrew, 5.1 (at initiation of therapy) Demonstrated 18 out of 20 characteristics on checklist. Demonstrated vowel errors, abnormal prosody, inconsistency of errors, disrupted coco-articulation. Demonstrated final consonant deletion, backing, syllable reduction, cluster reduction, deaffrication Had gross motor problems & learning differences. Left to finalize therapy goals in public school after 46 months of therapy with Apraxia Dallas.

Case Study
At initiation of therapy at Apraxia Dallas Andrew was unable to complete an Articulation Test but on 16 imitative productions he said: tuh/tub tuh/tub dada/pajamas nah/knife pu/spoon pu/spoon guh/girl guh/girl muhti/monkey muhti/monkey wa/watch wa/watch kah/car kah/car bu/blue bu/blue ka/carrot buh/brush buh/brush teh/chair teh/chair

After 8 months 9/3/2004 51 errors PR= -1%

Post-test 7/21/2008 0 errors PR= 99%

Group 4 Severe Childhood Apraxia of Speech with Major Concomitant Disorders

Score= 16 to 20 (out of 20) 18 cases Demonstrated all 3 top features from ASHA The presence of other complicating issues, such as cognitive delays, medical conditions, and disorders/syndromes will effect the child childs progress in therapy. Prognostic implications - unlikely to be dismissed from therapy as within normal limits but can usually improve speech.

Severe Childhood Apraxia of Speech Case History

Joseph, 7;6 (at initiation of therapy) Diagnosed with hypoplasia and MR Previously enrolled in therapy for 6 years, pursuing augmentative communication Demonstrated 20 out of 20 items on the checklist (didn (didnt demonstrate initial consonants worse than final or epenthesis) Discontinued private therapy after 7 years

Pre-test: 4/15/2002 66 errors* PR= -1% *all items were imitated

After 6 months of therapy: 11/4/2002 33 errors PR= -1%

After 1 year of therapy: 5/2003 27 errors PR= <1

After 3 years of therapy): 3/9/2005 14 errors PR= 3

After 7 years of therapy): 3/27/2009 10 errors PR= 3

Group 5 Unable to complete checklist

Score=N/A 7 cases There will be a group of children for which a clinician may not be able to complete this checklist, checklist, due to limited expressive language and phonemic repertoire. In these cases it is recommended that the child enroll in trial therapy to obtain additional information regarding the possible presence of apraxia or be referred to an appropriate specialist .

Unable to complete checklist checklist Case History

Hannah, 3;8 Diagnosed with PraderPrader-Willi Syndrome Only produced /n, m/ and a few vowels at the evaluation Could not complete formal speech/language testing or the CAS checklist Received additional therapy at school, where they diagnosed her with a severe receptive and expressive speech disorder, severe speech disorder, moderate oraloral-motor impairment, and hypernasal vocal quality.

References
References American SpeechSpeech-LanguageLanguage-Hearing Association (2007) Childhood Apraxia of Speech Position Statement; www.asha.org/policy. www.asha.org/policy. Ayres, A. J. (1985). Developmental dyspraxia and adultadult-onset apraxia. Torrence, Torrence, CA: Sensory Integration International. Crary, Crary, M. (1993). Developmental motor speech disorders. San Diego, CA: Singular Publishing Group, Inc. Dean, Lucinda. (Feb.,2008) Short Course on CAS at the Texas Speech Speech and Hearing Association Convention. Edwards, M. (1973). Developmental verbal dyspraxia. British Journal of Communication Disorders, 8, 6464-70. Hall, P., Jordan, L., & Robin, D. (1993). Developmental apraxia of speech: Theory and clinical practice. Austin, TX: ProPro-Ed. Jaffe, M. (1984). Neurological impairment of speech production: Assessment and treatment. In J. Costello (ed.), Speech Disorders in Children. (pp. ?). City?: CollegeCollege-Hill Press. Kamen, Kamen, R. (1996). Class handouts on Developmental Apraxia of Speech. Dallas, TX: UTD. Morley, M., Court, D., & Miller, H. (1954). Developmental dysarthria. dysarthria. British Medical Journal, 1, 88-10. Rosenbek, Rosenbek, J.C., & Wertz, R.T. (1972). A review of 50 cases of developmental developmental apraxia of speech. Language, Speech, and Hearing Services in Schools, 3, 2323-33. Shriberg, Shriberg, L.D., Aram, Aram, D.M., & Kwiatkowski, J. (1997). Developmental apraxia of speech: speech: III. A subtype marked by inappropriate stress. Journal of Speech, Language and Hearing Research, 40(2), 313313-337. Strub, Strub, R.L., & Black, F.W. (1981). Organic brain syndromes: An introduction to neurobehavioral disorders. disorders. Philadelphia: Davis. Velleman, S., & Strand, K. (1994). Developmental Verbal Dyspraxia. Dyspraxia. in J.Bernthal & N. Bankson (Eds.) Child Phonology: Characteristics, Assessment, and Intervention with Special Populations Populations (pp. 110110-139). New York: Thieme Medical Publishers. Velleman, S. (2003). Childhood apraxia of speech research guide. Clifton Park, NY: Thomson Delmar Learning. Watkins, R. (1992). Class notes on Developmental Apraxia of Speech. Speech. Dallas, TX: UTD. Yoss, Yoss, K.A., & Darley, Darley, F.L. (1974). Developmental apraxia of speech in children. Journal of Speech and Hearing Research, 17, 399399-416. **Additional speech assessment measures: -Verbal Motor Production Assessment for Children (VMPAC; Hayden & Square 1999) -Test of Syllable Sequencing Skills (packaged with Moving Across Syllables; Kirkpatrick et al., 1990) - Profiling Elements of Prosodic SystemsSystems-Child version (PEPS(PEPS-C; Wells & Peppe 2003)