If you are a speech language pathologist who is wondering how to do a childhood apraxia of speech evaluation, check this article out! This is meant to be a get-started guide for apraxia evaluation with resources, tips, and examples. This is useful for pediatric SLPs and school SLPs who work with younger children.
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What is Childhood Apraxia of Speech?
CAS (childhood apraxia of speech) is a neurological speech sound disorder that is characterized by difficulty with planning and programming movement that is required for speech.
Childhood Apraxia of Speech Therapy Evaluation
I’m now going to break down all of the necessary components that are important for the apraxia evaluation and report.
In this section, SLPs should mention the reason for the referral.
I typically state the student’s name, chronological age, grade, who made the referral (parent? teacher? pediatrician), and the concern.
Case History and Background Information
It is always important, no matter what diagnosis we are suspecting, to get case history information for a student. This gives speech therapists a “picture” of the child.
This can be a little more challenging at times for school SLPs, so a parent questionnaire is necessary. Super Duper Inc has a free case history intake form that SLPs can download.
While you’re at it, why not have the parent also fill out an Intelligibility in Context Scale (ICS)?
Typical intake forms usually ask questions such as birth information (how long was the pregnancy?), birth complications, developmental history, and general health information.
It is also extremely important to note what language is spoken at home, as well as who the child lives with (such as any siblings).
Speech pathologists will find it helpful to know if the student is receiving additional speech therapy services (or if they have ever been in speech).
SLPs also need to know exactly how the child is currently communicating at home. This could include body language, gestures, sounds, words, or other means.
Parents can also let the SLP know the behavioral characteristics of their child. For example, if a child is shy, easily frustrated, or willing to try new things.
For a child with suspected CAS, speech therapists would also want to know some additional information, such as if the child was a “late talker”, if the child babbled or made many sounds as an infant, if the child struggles with eating, and if they feel frustrated when communicating.
In my clinical experience, I often have had children with apraxia of speech demonstrate global motor concerns, so it’s useful to know if the child is receiving PT or OT as well.
The SLP will want to make note of vocal quality. Some descriptors can include rough, breathy, strained, abnormal pitch, frequent coughing, or excessive throat clearing.
This information can sometimes be obtained from the school nurse, but this may depend on your setting. SLPs will want to make note if a hearing screening was failed (and further evaluation is recommended), or if results indicated that the child passed the hearing screening for the frequencies 250, 500, 1,000, 2,000, and 4,0000 at 25 dB HL.
Oral Mechanism Examination
The SLP should examine the structure, size, symmetry, and resting posture of the jaws, cheeks, lips, tongue, palate, velum, and teeth. The speech therapist determines if the structure and function of the oral mechanism are adequate or inadequate for speech.
This is where SLPs should note things like lingual and labial resting posture (such as ‘open mouth posture’), labial or lingual frenums, enlarged tonsils, and overbites.
Diadochokinetic (DDK) Rates
For a suspected apraxia evaluation, it is also useful to obtain Diadochokinetic syllable rate (DDK). An atypical diadochokinesis (DDK) is associated with motor speech disorders (Kent et al).
Now, if you scroll down on that link, you’ll find that Table 13 contains the Mean (x¯̅), median (M), and range (R) of monosyllabic, trisyllabic, and laryngeal diadochokinesis (DDK) rates for all ages.
If you remember this from SLP grad school, DDK involves rapid repetitions of individual syllables (how many times did you repeat ‘puhtuhkuh’?)
When making a differential diagnosis, SLPs have a lot of variables to consider.
Testing fatigue doesn’t always allow for this, but if you have the opportunity to test across multiple sessions, it is helpful to obtain a) a dynamic evaluation of speech movement and b) an articulation test, if possible.
CAS is often accompanied by other speech sound disorders.
Dynamic Motor Speech Assessment
Speech pathologists will absolutely want to conduct a dynamic assessment if CAS is suspected. A dynamic assessment involves the use of cues. The child is not just saying the word once, without help. The clinician is able to analyze how much cueing is required and see if the child’s productions change (are inconsistent) across multiple trials.
This is different than administering a typical articulation test, which just measures the child’s skills after one response and without the clinician providing cues.
Characteristics of Childhood Apraxia of Speech
While administering a dynamic assessment, the SLP can be on the lookout for characteristics of childhood apraxia of speech. The main 3 characteristics of childhood apraxia of speech, as reported by ASHA, include inconsistent errors in repeated productions, inappropriate prosody, and difficulty with sequencing and movement. Additional characteristics can include groping, awkward movement transitions, consonant distortions, vowels errors, schwa insertion, a slow rate, voicing errors, and pausing between sounds, syllables, or words.
Syllable shapes assessed often include CV (consonant-vowel, such as go), VC (vowel-consonant, such as off), reduplicated syllables (i.e. boo-boo), CVC with the first same and last phoneme (i.e. peep), CVC with different first and last phoneme (i.e. mine), bisyllabic (one consonant and two vowels- uh-oh, more varied- forget), and multisyllabic (i.e. honeydew).
Example Assessments and Criterion-Referenced Measures
The DEMSS (Dynamic Evaluation of Motor Speech Skill) is one example of a dynamic assessment I highly recommend! The DEMSS (Dr. Edythe A. Strand Ph.D., Dr. Rebecca J. McCauley Ph.D.) is a criterion-referenced measure. It is useful for SLPs because it allows them to search for evidence of difficulty with motor planning and programming. When I explain this to parents, I let them know that this assessment lets me examine movement.
The DEMSS contains example administration videos, and the best part about it is that there’s no need to purchase additional protocols- ever. The protocols are provided as a download and can be printed again for each use.
***The DEMSS is what this SLP author has the most experience using and the most knowledge to write about. I have also taken DTTC Training (part one). There are additional tests and measures that can be used. Another tool that some SLPs may have access to includes the Kaufman Speech Praxis Test for Children. In a recent CEU apraxia course I took provided by SpeechTherapyPD.com, I learned that the Verbal Motor Production Assessment for Children, which is currently out of print, is in beta testing for a revised edition.
Standardized Articulation Assessment
If possible, a standardized articulation assessment can be administered. There are many options to choose from. As a reminder, a standardized articulation assessment is not dynamic, and will not measure movement.
It is useful to know which speech sounds (consonants and vowels/ dipthongs) a child has in his inventory. I created this free speech sound inventory for SLPs to use.
It is recommended that receptive and expressive language skills be assessed. There are several standardized receptive and expressive language assessments that SLPs might use. Children with a diagnosis of childhood apraxia of speech typically present with significantly lower expressive language skills. Receptive language skills are much higher.
Evaluation Summary and Diagnostic Statement
At the end of the evaluation report, an overall summary is provided and a diagnostic statement is made.
Sometimes the SLP needs more data before diagnosing apraxia. This is especially common with younger children. A provisional diagnosis (“suspected childhood apraxia of speech) is acceptable, as time in therapy can further help an SLP to make an appropriate diagnosis.
Example Diagnostic Statements
CHILD exhibits a severe delay in speech acquisition, due to difficulty with planning and programming movement gestures required for speech (CAS- childhood apraxia of speech). Characteristics that support this diagnosis included inconsistent errors in repeated productions, inappropriate prosody, difficulty with sequencing and movement, groping, vowel distortions, and slow rate. In addition, CHILD is exhibiting a severe expressive language disorder.
CHILD exhibits a severe delay in speech acquisition (“suspected CAS- childhood apraxia of speech”). At this time, a diagnosis of apraxia of speech cannot be ruled out, as CHILD is demonstrating characteristics that indicate possible planning/ programming movement gesture difficulties, including …. (list characteristics, such as inconsistent errors in repeated productions, inappropriate prosody, difficulty with sequencing and movement, groping, and slow rate).
CHILD exhibits a severe delay in speech acquisition, due to difficulty with planning and programming movement gestures required for speech (CAS- childhood apraxia of speech). Characteristics that support this diagnosis included inconsistent errors in repeated productions, inappropriate prosody, difficulty with sequencing and movement, groping, vowel distortions, and slow rate. In addition, CHILD’s speech intelligibility is further compromised by a phonological disorder. Active phonological processes, including (list active phonological processes, such as cluster reduction), were observed.
Childhood Apraxia of Speech. (2023). Retrieved 13 June 2023, from https://www.asha.org/practice-portal/clinical-topics/childhood-apraxia-of-speech/#collapse_2
Baker, Sarah. Differential Diagnosis of Childhood Apraxia of Speech. SpeechTherapyPD. https://www.speechtherapypd.com/courses/Assessment-and-Treatment-of-Childhood-Apraxia-of-Speech
Strand, Edythe. (2021). Diagnosis & Management of Childhood Apraxia of Speech Using DTTC. UT Dallas. https://calliercenter.utdallas.edu/events/CAS#ASHA
Bauman-Waengler, J. A. (2013). Chapter 10: Articulatory and Phonological Disorders in Selected Populations. In Articulatory and phonological impairments: A clinical focus (pp. 348–353). essay, Pearson Education Limited.
Peña-Brooks, A., & Hegde, M. N. (2007). Articulation and phonological disorders: Assessment and treatment resource manual. PRO-ED.
Related SLP Articles
This article contained advice for completing a childhood apraxia of speech therapy evaluation for SLPs. Speech pathologists may also wish to read 5 tips for running a childhood apraxia of speech treatment session for busy preschoolers!