The Ineffectiveness of Checklists in Diagnosing Childhood Apraxia of Speech (CAS)

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By Margaret Fish, MS, CCC-SLP, author of Here’s How to Treat Childhood Apraxia of Speech, Second Edition

Sorting through evaluation findings for young children with complex speech sound disorders can be confusing and challenging. As SLPs we strive to complete thorough evaluations and make sense of our evaluation findings to achieve an accurate diagnosis; however, many of the characteristics of CAS overlap with other types of speech sound disorders. Certain key characteristics from a CAS checklist such as inconsistency, atypical prosody, groping, or vowel errors may raise red flags for a diagnosis of CAS, but these characteristics alone should not predetermine the diagnosis until a thorough analysis of the child’s speech productions is completed.

Following are case studies of two children recently seen for consultations. Both children had an incoming diagnosis of CAS, but only one child was given a definitive diagnosis of CAS at the conclusion of the consultation. The other child demonstrated a number of characteristics commonly associated with CAS, but after careful examination of the child’s speech, the underlying nature of the challenges was not consistent with the core impairment of CAS that ASHA (2007) describes as the “planning and/or programming (of) spatiotemporal parameters of movement sequences.”

Case Study 1.

Mark, age 3 years, 7 months, had recently received a diagnosis of CAS by a diagnostic team at a local hospital. The diagnosis was based primarily on the following factors:

  • Reduced speech intelligibility (judged to be 50% intelligible)
  • A nearly complete repertoire of consonants and vowels
  • Inconsistent productions of the same word
  • Occasional vowel errors
  • Atypical speech prosody

Because of Mark’s limited speech intelligibility, inconsistency, vowel errors, and prosody differences, it was understandable how a diagnosis of CAS was made, as these characteristics often are associated with a positive diagnosis of CAS. Indeed, the use of a checklist of CAS characteristics alone could lead a clinician to conclude that Mark had CAS.

Deeper analysis of Mark’s speech productions revealed that Mark was able to produce many words with rather complex syllable sequences correctly or nearly correctly (e.g., “splashed,” “plant,” “umbwella”) with apparent effortlessness. Mark’s phrase and sentence productions were not marked by noticeable gaps between syllables commonly observed in children with CAS (Murray, McCabe, Heard, & Ballard, 2015). In addition, Mark’s prosody was not marked by excessive, equal stress, which is common in CAS (ASHA, 2007), but rather by use of a high-pitched, singsong type prosody. Further speech and language analysis was required to determine other possible reasons why Mark’s speech productions were inconsistent at times and why his speech prosody was unusual.

Observations and assessment of Mark’s language and play skills revealed the following challenges:

  • Receptive language (below age level)
  • Expressive language (below age-level expressive vocabulary and syntax; word retrieval difficulties)
  • Social communication (limited reciprocity; use of a limited range of language functions)
  • Play skills (repetitive and narrow play themes; strong desire to collect and look at toys without using them in functional or creative ways)

In fact, Mark’s speech production skills were relatively strong in comparison to his receptive and expressive language skills and his social language development. It seemed quite plausible that Mark’s speech inconsistencies were related to difficulty generating accurate phonological representations for words and that his prosody differences may have been related to social communication challenges rather than a result of impaired motor speech planning.

Following the initial consultation, a regular, biweekly speech-language treatment schedule was established. A preliminary diagnosis of mixed receptive and expressive language disorder and pragmatic language disorder was made and goals were developed to address these areas. After eight months of therapy, Mark had made substantial gains in each of the areas addressed in treatment. In addition, he made tremendous gains in his speech intelligibility even though no goals were established to address speech-sound production or motor planning.

Case Study 2

Claire had just turned three at the time of her initial consultation. She had been receiving speech-language therapy for four months and would soon be aging out of the birth-to-three program providing her treatment. The SLP working with Claire made a diagnosis of suspected CAS because of Claire’s challenges with imitation of syllables and words. Claire’s speech was characterized by the following:

  • Fairly sizable consonant repertoire /p, b, t, d, k, g, m, n, h, f, v, s, z, ʃ/
  • Limited vowel repertoire /i, u, oʊ, ʊ, a, ʌ/
  • Limited syllable shape repertoire: V, VC, VCV, CV, and CVCV reduplicated
  • Frequent omission of initial consonants
  • Difficulty achieving an accurate initial articulatory configuration for words
  • Groping

In addition, Claire demonstrated mildly delayed receptive language skills, a spontaneous vocabulary of fewer than 15 words, and very strong social communication skills. Her attention span was excellent and she put forth substantial effort in attempting to imitate words.

Upon more extensive analysis of Claire’s speech productions, it was noted that she demonstrated limited flexibility in combining phonemes to form words. She exhibited a strong preference for V, VC, and VCV syllable shapes with CV and CVCV reduplicated words accounting for a very small percentage of her productions. Claire had substantial difficulty with both spontaneous and imitative production of words, even words with relatively simple syllable shapes containing phonemes within her repertoire. Examples include: /i/ for me and mommy, /ap/ for pop, and /a/ for hi. After Claire’s speech and language findings were analyzed, she was given a diagnosis of CAS and expressive language disorder along with mild receptive language disorder.

Speech-language treatment was initiated with an early emphasis on building Claire’s confidence and willingness to take risks with speech attempts and to establish more consistent use of CV syllable shapes using a multisensory treatment approach. In the short time Claire has been receiving therapy, she has begun to use many more CV and CVCV reduplicated words and her expressive vocabulary is expanding nicely.

Summary

The above case studies illustrate how checklists of speech-related characteristics are insufficient in establishing an accurate diagnosis of CAS. Careful analysis of a child’s speech patterns through formal and informal assessment is important when evaluating a child with a complex speech sound disorder. Only then can it be determined if the child’s speech patterns are consistent with underlying challenges in motor speech planning so appropriate treatment plans can be established to support the child’s communicative development.

References

American Speech-Language Hearing Association (ASHA). (2007). Childhood apraxia of speech [Technical report]. Retrieved November 6, 2015, from http://www.asha.org/policy

Murray, E., McCabe, P., Heard, R., & Ballard, K. J. (2015). Differential diagnosis of children with suspected apraxia of speech. Journal of Speech, Language, and Hearing Research, 58, 43-60. doi:10.1044/2015­_JSLHR-S-13-0179

About the Author

Margaret Fish, MS, CCC-SLP, is a speech-language pathologist working in private practice in Highland Park, Illinois. She has more than 30 years of clinical experience working with children with severe speech-sound disorders, language impairments, and social language challenges.

2 thoughts on “The Ineffectiveness of Checklists in Diagnosing Childhood Apraxia of Speech (CAS)

  1. I am in the process of trying to publish a workbook for Apraxia. I have an artist that I am working with, the set of target words and activities. I am doing research now and would like to talk to someone about the process of publishing speech material. If you could find the time to speak with me, I would greatly appreciate it.

    P S. Loved the case studies

    Cynthia Soder, MA, CCC/SLP

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