4 Essential Steps in Assessing Childhood Apraxia of Speech

You have an evaluation scheduled. This child is highly unintelligible, and you see characteristics that lead you to suspect childhood apraxia of speech, or CAS.  But just how do you design your evaluation when assessing childhood apraxia of speech?

How many phonological assessments have you done? Probably hundreds for me, and I bet you can practically assess for a phonological disorder in your sleep! But we don’t see nearly as many children with childhood apraxia of speech unless we specialize in that area.

So it may be a little less clear as to how to design the most effective assessment and how it may look different from what we usually do for our phonological children.

This is Part 3 in my series on Childhood Apraxia of Speech, Let’s Talk

If you’ve missed the earlier posts, I suggest starting at the first post. Head to Childhood Apraxia of Speech. What SLPs Need to Know.

If you’ve been following along, you know that I had the wonderful opportunity to learn from Dr. Edythe Strand, a leading expert in CAS in the very first intensive 3 day workshop she gave.

Me? I’m not an expert. Dr. Strand generously gave permission and asked us to share what we learned, because she knows that many SLPs have not had the opportunity for in-depth training in CAS, and often feel unsure about how to approach assessment and treatment.

So if you have questions about what to do when assessing childhood apraxia of speech, grab a cup of coffee, and let’s talk!

Planning your assessment

You’ve gone over the child’s history and made some initial observations. You’ve noted some of the characteristics we talked about in my last post: Is it CAS? Navigating Differential Diagnosis. You suspect CAS. What’s next?

A carefully planned assessment can help you make a differential diagnosis between childhood apraxia of speech, a phonological disorder, dysarthria, or ataxic dysarthria. Let’s take a look at what Dr. Strand recommends. 

Four steps in assessing childhood apraxia of speech

1. Spontaneous Speech: Take a Language Sample

This is a great place to start, especially if the child is not a talker, or very limited in verbalization. Be sure you include both free play and structured play. 

• Do you note any differences in communication between the two? 
• How does the child communicate: verbal, gesture, pointing? 
• Does he imitate you? 
• Make some initial observations about his phonemic and phonetic inventories. Does he use sounds meaningfully (in at least two contexts), or is it vocal play?  
• How would you rate his intelligibility? 
• Do you see groping or awkward movements of the articulators?

2. Elicited Speech

If you recall from my last post, breakdown in CAS often occurs in elicited speech more than spontaneous speech. Note if there are differences.

• Articulation or Phonology Test:  Do a standardized test if the child is capable. He is non-verbal or very limited, you may not get much here.  
• Imitation Tasks. 

3. Structural/ Functional Exam

A good oral motor exam can help you determine or rule out whether dysarthria or oral apraxia is present. You don’t always have to do each task because you can often observe informally when function is normal, but if you notice abnormal function, test further. Here’s what you are looking for:

1. Signs of dysarthria: Check jaw, lips, tongue, and velum for weakness, reduced range of motion, strength, speed, and drooling.
2. Signs of oral apraxia: You will want to rule this out if you suspect weakness or dysarthria.  Have the child blow, pucker, smack lips, cough, and do sequential imitation (diadokokinesis tasks).  Can the child do it? Does he grope? Is it uncoordinated? 
3. Signs of ataxic dysarthria:  This can often look similar to CAS with inaccurate/ inconsistent movements. We can also see voicing errors. Watch as the child says one syllable (puh) and compare to 3 syllables (puh-puh-puh).
   • In severe CAS: the errors are more inconsistent and they will do better with a single syllable than three. 
   • In ataxic dysarthria (which is caused by damage to the cerebellum) errors are more consistent across tasks, there will be uncoordinated movements, regardless of the number of syllables, and you may see a wide-based gait or intention tremor. 

NOTE! We often hear “The child has low tone.” Tone is how much muscle contraction there is at rest. A child can have low tone, but normal strength in action. Low tone is usually not weakness and is not a problem for speech.

4. Motor Speech Exam

This type of exam has traditionally been used with adults to assess for acquired apraxia of speech but has not been widely used for CAS.  A motor speech exam allows us to observe how a child’s speech varies across contexts, and watch for signs of praxis. Start at the level the child is capable of. You can look at:

• Vowels
• CV, VC, CVC words
• one, two, and three-syllable words
• phrases
• sentences of increasing length

Dynamic Assessment

Dr. Strand advocates for a dynamic assessment approach to the motor speech exam. 

What do we mean by “dynamic assessment?” 

We are cuing the child, and watching to see how performance changes with different levels of cuing. This in in contrast to a “static” assessment, which measures a child’s performance after a single response with no cuing or assistance. Most standardized tests are “static.”  

Why do a dynamic assessment?  It helps us:

1. Determine the level of severity. Lots of cuing needed means a more severe presentation of CAS. Less cuing would be mild or moderate. Great information to help us recommend the frequency and intensity of services and the level of cuing support needed.

2. Find out which cues are most effective for this child.

3. Reveal emerging skills- very helpful for planning initial therapy targets. We may see movements a child is able to make with cuing that we may not see in a “static” assessment.

4. Helps with differential diagnosis by allowing us to see:

• groping we may not see in spontaneous speech
• inconsistency across trials with and without cuing.
• whether the child is segmenting syllables (ba-na-na). We usually see this with unfamiliar or multisyllabic words. 

How are you doing? 

Is this coming together for you? I’ll tell you, writing these posts is really helping me review and frame my thinking and approach. Re-visit and re-read, it really helps! 

Dr. Strand has a YouTube series you need to check out.

 These videos were made to help explain CAS to parents, but they have terrific information and excellent video examples for SLPs too. I highly recommend you take a look, and share with parents.

Childhood Apraxia of Speech: Information for Parents This video is 52 minutes long, and contains all the segments. But you can also view her videos in shorter segments.

Examples of Different Levels of Severity in Childhood Apraxia of Speech Watch video examples of children with different severity levels of CAS

Differentiating CAS From Other Types of Speech Sound Disorders Watch video examples of children with phonological disorders, and dysarthria.

Now we have the pieces of a thorough plan for assessing childhood apraxia of speech. 

You may be saying, “So exactly how do I conduct a dynamic assessment?  We’ll talk about that in my next post in the series. You can find it here: How to Uncover Emerging Skills with a Dynamic Assessment for CAS.

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