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This course is offered forThis course is offered for 0.X0.X ASHA CEUs (ASHA CEUs (IntermediateIntermediate level,level,ProfessionalProfessional area).area).
ASHAASHA--Approved CE ProviderApproved CE Provider
ChildhoodChildhood ApraxiaApraxia of Speech (CAS):of Speech (CAS):Differential DiagnosisDifferential Diagnosis
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PresenterPresenter
Ruth Stoeckel, PhD, CCCRuth Stoeckel, PhD, CCC--SLPSLPSpeechSpeech--Language Pathologist, Mayo ClinicLanguage Pathologist, Mayo Clinic
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Learning OutcomesLearning Outcomes
–– identify and describe appropriate assessmentidentify and describe appropriate assessmenttasks for differential diagnosis of childhoodtasks for differential diagnosis of childhoodapraxiaapraxia of speechof speech
–– interpret assessment data and provide ainterpret assessment data and provide arationale for treatment decisionsrationale for treatment decisions
–– differentially diagnose childhooddifferentially diagnose childhood apraxiaapraxia ofofspeech versus (or in addition to) otherspeech versus (or in addition to) otherchildhood speechchildhood speech--language disorderslanguage disorders
Section 1:Section 1:Differential Diagnosis BasicsDifferential Diagnosis Basics
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Severe PhonologicSevere PhonologicDisorderDisorder
Motor SpeechMotor SpeechDisorderDisorder
CASCAS
DysarthriaDysarthria
Severe ChildhoodSpeech SoundDisorders(SSD)
Differential DiagnosisDifferential Diagnosis
Strand & McCauley, 2008
CASCAS
DysarthriaDysarthria
PhonologicalPhonologicalDisorderDisorder
LanguageLanguageDisorderDisorder
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AssessmentAssessment
Function NeuralProcess
Possible CommunicativeDisorder
Communicative Idea Cognitive Pragmatic language deficit(difficulty demonstratingcommunicative intent)
Word retrievalphonologicaldelay/impairmentSyntactic/ grammaticalordering
Linguistic Language delay/impairmentPhonological mapping
Specifying range ofmotion,Direction, speed andforce of movement
Motorplanning andprogramming
ChildhoodApraxia of Speech(CAS)
Execution of movementresulting in acousticoutput
Motorexecution
Dysarthia
Strand & McCauley, 2008
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Strand & McCauley, 2008
Function NeuralProcess
Possible CommunicativeDisorder
Communicative Idea Cognitive Pragmatic language deficit(difficulty demonstratingcommunicative intent)
Word retrievalphonologicaldelay/impairmentSyntactic/ grammaticalordering
Linguistic Language delay/impairmentPhonological mapping
Specifying range ofmotion,Direction, speed andforce of movement
Motorplanning andprogramming
ChildhoodApraxia of Speech(CAS)
Execution of movementresulting in acousticoutput
Motorexecution
Dysarthia
Download FromDownload FromResourcesResources
Late TalkersLate Talkers–– Begin to use some speechBegin to use some speech
by age 2½by age 2½–– Have difficulty primarilyHave difficulty primarily
with expressive skillswith expressive skills–– Have ageHave age--expectedexpected
receptive languagereceptive language–– General communicationGeneral communication
skills are intact (nonverbal,skills are intact (nonverbal,social interaction aspects)social interaction aspects)
–– No cognitive delayNo cognitive delay–– Few/no other risk factorsFew/no other risk factors
(Paul, 1996;(Paul, 1996; ThalThal, 1991;, 1991;Whitehurst &Whitehurst & FischelFischel, 1994), 1994)
Language ImpairmentLanguage Impairment–– Delays in receptive asDelays in receptive as
well as expressivewell as expressivelanguagelanguage
–– Less use of gesturesLess use of gestures–– Reduced sound inventoryReduced sound inventory–– Limited play schemesLimited play schemes
(Paul, 1991;(Paul, 1991; RescorlaRescorla, 1991;, 1991; ThalThal,,Tobias & Morrison, 1991)Tobias & Morrison, 1991)
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Phonologic Delay/DisorderPhonologic Delay/Disorder::Difficulty with the sound patterns that codeDifficulty with the sound patterns that codemeaning.meaning.
TeaTea KeyKeyBowBow BoatBoat
Strand & McCauley, 2008
Function NeuralProcess
Possible CommunicativeDisorder
Communicative Idea Cognitive Pragmatic language deficit(difficulty demonstratingcommunicative intent)
Word retrievalphonologicaldelay/impairmentSyntactic/ grammaticalordering
Linguistic Language delay/impairmentPhonological mapping
Specifying range ofmotion,Direction, speed andforce of movement
Motorplanning andprogramming
Childhood Apraxia of Speech(CAS)
Execution of movementresulting in acousticoutput
Motorexecution
Dysarthia
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1) inconsistent errors on consonants andvowels in repeated productions ofsyllables or words,
2) lengthened and disrupted coarticulatorytransitions between sounds andsyllables, and
3) inappropriate prosody, especially in therealization of lexical or phrasal stress
CASCAS
ASHA Technical Report, 2007
CAS Indicators: A Review of Two CasesCAS Indicators: A Review of Two Cases
Think About:
Who has more certain diagnosis andWhy?
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Children with CAS are at higher risk forlater literacy issues and may need short orlong-term of use alternative/augmentativemodes of communication
Strand & McCauley, 2008
Function NeuralProcess
Possible CommunicativeDisorder
Communicative Idea Cognitive Pragmatic language deficit(difficulty demonstratingcommunicative intent)
Word retrievalphonologicaldelay/impairmentSyntactic/ grammaticalordering
Linguistic Language delay/impairmentPhonological mapping
Specifying range ofmotion,Direction, speed andforce of movement
Motorplanning andprogramming
ChildhoodApraxia of Speech(CAS)
Execution ofmovement resulting inacoustic output
Motorexecution
Dysarthia
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Dysarthria isDysarthria is
…a group of related motor speech disorders…a group of related motor speech disordersresulting from disruption in the ability toresulting from disruption in the ability toexecute movements accurately due toexecute movements accurately due toimpairment in muscular control.impairment in muscular control.
DysarthriaDysarthria
Disruption may be noted inDisruption may be noted in–– RespirationRespiration–– PhonationPhonation–– ResonanceResonance–– ArticulationArticulation–– ProsodyProsody
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Subsystem EffectedSubsystem Effected
Section 2:Section 2:Challenges in DiagnosisChallenges in Diagnosis
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Oral Motor Deficits
Execution Praxis
Reduced strength,range of motion,speed
MotorPlanning/Programmingmovement
DysarthriaNonverbalOral apraxia
CAS
Nonverbal Verbal VerbalNonverbal
Adapted from Strand & McCauley, 2008
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MildMild SevereSevere
X
No “gold standard” for diagnosis
Differences among training programs and CEUofferings
Variability in expression of the disorder andpotential for change
Challenges in DiagnosisChallenges in Diagnosis
Difficulty differentiating types of motorDifficulty differentiating types of motorproblemsproblems
Identifying the relative contributions ofIdentifying the relative contributions oflanguage, phonology, and motor problemslanguage, phonology, and motor problems
Recognizing effects of coRecognizing effects of co--occurring disordersoccurring disorders
Challenges in DiagnosisChallenges in Diagnosis
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Lack of Adequate Test InstrumentsLack of Adequate Test Instruments
Types of Motor Speech Stimuli
0102030405060708090
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AP -PSAP-PS
KSPTOSME -3
POSPS TDAS-2
VDP VMPAC
Vowels Cs/Sylls Single Ws Multiple Ws Connected Sp DDK
From: McCauley & Strand, 2008From: McCauley & Strand, 2008
Section 3:Section 3:Assessment ProceduresAssessment Procedures
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Assessment ProceduresAssessment Procedures
Review developmental historyReview developmental historyEvaluate general communication skillsEvaluate general communication skillsAssess language skillsAssess language skillsEvaluate speech production skillsEvaluate speech production skills
1. Structural1. Structural--functional evaluationfunctional evaluation2. Documentation of speech sound inventory2. Documentation of speech sound inventory3. Examination of motor speech skill3. Examination of motor speech skill
Review Developmental HistoryReview Developmental History
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Evaluate General Communication SkillsEvaluate General Communication Skills
Communicative behaviors may be used forCommunicative behaviors may be used for•• Joint attentionJoint attention•• Behavior regulationBehavior regulation•• Social interactionSocial interaction
Limited Verbal OutputLimited Verbal Output
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Evaluate Language SkillsEvaluate Language Skills
Receptive language > Expressive language =
Severe phonological disorder?
CAS?
Language: BilingualismLanguage: Bilingualism Download FromDownload FromResourcesResources
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Evaluate CurrentEvaluate CurrentSpeech Production SkillsSpeech Production Skills
1.1. StructuralStructural--functional examinationfunctional examination
Download FromDownload FromResourcesResources
RefusalRefusal vsvs InabilityInability
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Evaluate Current Speech Production SkillsEvaluate Current Speech Production Skills
2.2. Documentation of sound inventoryDocumentation of sound inventory
Target Words:
•House•Window•Tree•Phone
•Cup•Knife•Spoon
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Evaluate Current Speech Production SkillsEvaluate Current Speech Production Skills
3.3. Examination of motor speech skillsExamination of motor speech skills
Direct Imitation
Incorrect Correct
Simultaneousproduction
Simultaneous withslowed rate
Add tactile and/orgestural cues
Delayedrepetition
Continue to add cuesContinue to add cuesas needed to determine ifas needed to determine ifthe child can achieve correctthe child can achieve correctproduction with increasingproduction with increasingassistanceassistance
Motor Speech ExaminationMotor Speech Examination
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Putting Pieces TogetherPutting Pieces Together
MSE InterpretationMSE Interpretation
We are observing the child’s responses forWe are observing the child’s responses forcharacteristics of CAScharacteristics of CAS–– Inconsistent errorsInconsistent errors–– Lengthened/disrupted coarticulatoryLengthened/disrupted coarticulatory
transitionstransitions–– Disrupted prosodyDisrupted prosody
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Comparison of Childhood Apraxia of Speech,Dysarthria and Severe Phonological Disorder
Verbal Apraxia Dysarthria Severe Phonological Disorder
No weakness, incoordination orparalysis of speech musculature
Decreased strength and coordination ofspeechmusculature that leads toimprecise speech production, slurringand distortions
No weakness, incoordination orparalysis of speech musculature
No difficulty with involuntary motorcontrol for chewing, swallowing, etc.unless there is also an oral aprax ia
Difficulty with involuntary motor controlfor chewing, swallowing, etc. due tomuscle weakness and incoordination
No difficulty with involuntary motorcontrol for chewing and swallowing
Inconsistencies in articulationperformance--the same word may beproduced several different ways
Articulation may be noticeably"different" due to imprecision, buterrors generally consistent
Consistent errors that can usually begrouped into categories (fronting,stopping, etc.)
Errors include substitutions,omissions, additions and repetitions,frequently includes simplification ofword forms. Tendency for omissionsin initial position. Tendency tocentralize vowels to a "schwaa"
Errors are generally distortions Errors may include substitutions,omissions, distortions, etc. Omissionsin final position more likely than initialposition. Vowel distortions not ascommon.
Number of errors increases as lengthof word/phrase increases
May be less precise in connectedspeech than in single words
Errors are generally consistent aslength of words/phrases increases
Well rehearsed, "automatic" speech iseasiest to produce, "on demand"speech most difficult
No difference in how easily speech isproduced based on situation
No difference in how easily speech isproduced based on situation
Receptive language skills are usuallysignificantly better than expressiveskills
Typically no significant discrepancybetween receptive and expressivelanguage skills
Sometimes differences betweenreceptive and expressive languageskills
Rate, rhythm and stress of speech aredisrupted, some groping for placementmay be noted
Rate, rhythm and stress are disruptedin ways specifically related to the typeof dysarthria (spastic, flaccid, etc.)
Typically no disruption of rate, rhythmor stress
Generally good control of pitch andloudness, may have limited inflectionalrange for speaking
Monotone voice, difficulty controllingpitch and loudness
Good control of pitch and loudness, notlimited in inflectional range forspeaking
Age-appropriate voice quality Voice quality may be hoarse, harsh,hypernasal, etc. depending on type ofdysarthria
Age-appropriate voice quality
From www.apraxia-kids.org
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Bilingual ConsiderationsBilingual Considerations
The vast majority of research on CAS involvesThe vast majority of research on CAS involvesEnglish or languages with similar structuralEnglish or languages with similar structuralpropertiesproperties
We would expect the same core features toWe would expect the same core features toapply regardless of languageapply regardless of language
GildersleeveGildersleeve--Neuman, 2008Neuman, 2008
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Section 4:Section 4:Case StudyCase Study
Case StudyCase StudyFemale, age 2:5Female, age 2:5
DevelopmentalDevelopmentalHistoryHistory–– No motor delaysNo motor delays–– Normal muscle toneNormal muscle tone–– No feeding issuesNo feeding issues–– “Quiet” baby with“Quiet” baby with
limited reduplicatedlimited reduplicatedbabblingbabbling
–– No hearing problemsNo hearing problemsor ear infectionsor ear infections
GeneralGeneralCommunicationCommunication–– Active communicator,Active communicator,
uses 3uses 3--5 signs in an5 signs in an“utterance”“utterance”
–– Expresses a variety ofExpresses a variety ofpragmatic functionspragmatic functionsnonverballynonverbally
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Case StudyCase StudyFemale, age 2:5Female, age 2:5
LanguageLanguage–– REELREEL--3 receptive 95,3 receptive 95,
expressive <55 (noexpressive <55 (nocredit for signing)credit for signing)
–– Following twoFollowing two--stepstepdirections consistentlydirections consistently
–– AgeAge--appropriate playappropriate playskills, imaginative playskills, imaginative playschemesschemes
StructuralStructural--FunctionalFunctionalExaminationExamination–– No structuralNo structural
anomaliesanomalies–– Range of motion,Range of motion,
strength, speed ofstrength, speed ofmovement sufficientmovement sufficientfor speechfor speech
–– Normal resonanceNormal resonance(based on limited(based on limitedsample)sample)
Case StudyCase StudyFemale age 2:5Female age 2:5Speech Sound InventorySpeech Sound Inventory
Motor Speech ExamMotor Speech Exam
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No, consider this…..No, consider this…..What sounds/syllables would you considerWhat sounds/syllables would you consider
for additional probing in a motor speechfor additional probing in a motor speechexamination?examination?What other information would be helpfulWhat other information would be helpful
for informing diagnosis?for informing diagnosis?What might you be looking for if youWhat might you be looking for if you
recommend diagnostic therapy?recommend diagnostic therapy?
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Section 5: SummarySection 5: Summary
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Be Careful!Be Careful!
Careful assessment proceduresCareful assessment proceduresare important, becauseare important, because
accurate diagnosis leads toaccurate diagnosis leads toappropriate treatment.appropriate treatment.
Determine if there is sufficientDetermine if there is sufficientevidence to make the diagnosis ofevidence to make the diagnosis ofCAS versus (or in addition to) otherCAS versus (or in addition to) otherspeechspeech--language problemslanguage problems
Identify a starting point for therapyIdentify a starting point for therapy
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Consider….Consider….
The contribution of abilities thatThe contribution of abilities thatinclude cognition, language, motorinclude cognition, language, motorpraxis and motor executionpraxis and motor execution
•• it may not be possible to rule in/ruleit may not be possible to rule in/ruleout CAS initiallyout CAS initially
•• CAS may not be the primaryCAS may not be the primaryimpairmentimpairment
Continual Changes…Continual Changes…
Likely that diagnostic classification willLikely that diagnostic classification willchange over time as a result ofchange over time as a result ofmaturation and/or treatmentmaturation and/or treatment
Differential diagnosis is an ongoingDifferential diagnosis is an ongoingprocess!process!
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Michele LashMichele LashInstructional Designer/Program ManagerInstructional Designer/Program Manager
SharonSharon WilligWillig, MA,, MA, CCCCCC--SLPSLPContent Coordinator/Content Coordinator/SLPSLP PracticesPractices
Parrish SwannParrish SwannInstructional Technology ManagerInstructional Technology Manager
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Rohan MahadevanRohan MahadevanPeer Review/Pilot Test ManagerPeer Review/Pilot Test Manager
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