4735 Apraxia DX.pptstatic.crowdwisdomhq.com/asha/4735 Handouts.pdf · 4 Presenter Ruth Stoeckel, PhD, CCC-SLP Speech-Language Pathologist, Mayo Clinic

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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


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


Download FromDownload FromResourcesResources

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Motorexecution

Dysarthia


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









Childhood Apraxia of Speech(CAS)


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










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.


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


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


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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4735 Apraxia DX.pptstatic.crowdwisdomhq.com/asha/4735 Handouts.pdf · 4 Presenter Ruth Stoeckel, PhD, CCC-SLP Speech-Language Pathologist, Mayo Clinic