Assessment issues: Developmental verbal dyspraxia

ASHA recommendations
report does not include specific guidelines for the assessment and treatment of CAS primarily due to lack of research support to date Deferred to future ASHA policy documents General recommendations by expert clinical practitioners included under Professional issues

ASHA Assessment domains for childhood apraxia of speech

Non-speech oral motor skills Speech production Prosody Voice Speech perception Language Metalinguistic literacy skills (older children) Case History

Assessment of any child with a speech disorder

Detailed case history Hearing information and auditory discrimination Language skills (VC & VX) Screening of speech output Detailed assessment of speech output Assessment of Oral skills Phonological awareness skills

Case History

Family history Early speech development, including babbling Feeding history and current Oral skills history and current Hearing General motor development Language development Current speech and language skills

Hearing and auditory discrimination

Important to know whether the child has normal hearing Look out for intermittent conductive hearing loss caused by glue ear Also need to check that child is able to discriminate words, non-words and sounds

Language skills
It is important to assess the language skills (receptive and expressive language) of any child who has a speech disorder Many children with verbal dyspraxia have expressive language delay/disorder; some also have receptive language difficulties

Phonological awareness skills(1)

The ability to reflect on and manipulate the structure of spoken language PA tasks include: rhyme, syllable and sound segmentation and blending Important skill required to make sense of alphabetic script PA is associated with reading and spelling performance

Phonological awareness (2)

PA tasks at level of phoneme are best predictors of reading outcome eg segmenting or blending of individual sounds: c-a-t to make cat Letter knowledge is also a strong predictor of reading outcome Focus on synthetic phonics to teach reading is back in favour in UK

Oral Skills Why do we assess them?

The assessment of oro-motor skills is an integral part of the initial assessment of a child presenting with disordered speech Bradford and Dodd 1996

Oral Dyspraxia (1)

Inability to copy volitional movements of oral organs (tongue, lips, jaw face) on command or demonstration in the absence of attempts to articulate (Milloy 1991) Drooling or dribbling may be indicators of poor control of oral movements.

Oral Dyspraxia (2)

The

child has difficulties with carrying out oral movements on verbal request, or through copying these may be single or sequences of movements. Literature suggests sequences of movement are particularly difficult.

Key features of Oral Dyspraxia

Child can: Lick an ice cream which is close to his mouth
Child cannot: Stick out his tongue

Difficulties are with volitional control

Does Oral Dyspraxia always accompany Verbal Dyspraxia?

Oral dyspraxia is considered a dominant, although not mandatory, attribute of developmental apraxia of speech Crary (1993)

Relationship between Oro-motor and Speech Difficulties (1)

Wide variation in clinical presentation some children with typical features of DVD have severe OM difficulties; others do not (Evans 1994)

Relationship between Oro-motor and Speech Difficulties (2)

Some children with poor speech have good oro-motor skills and others with strong speech skills have very poor oro-motor skills; Some authors therefore propose that control of oro-motor and speech skills are independent. (Lancaster and Pope 1989) Others report a close neurological link between non-speech oral movement and speech production. (Crary 1993)

What are DDK skills?

Diadochokinesia motor control integrity in bodily functions through performance in rapidly alternating movements In speechsound/ syllable repetition at a maximum rate of utterance (Fletcher 1972)

Relationship between Diadochokinetic (DDK) skills and DVD

Difficulties with DDK tasks often used to select participants with dvd in research
Difficulties with DDK tasks apply to children with other speech disorders (i.e. not only those w DVD) (Ozanne 1996) As part of a speech assessment, DDK tasks can be useful for assessing motor programming and planning skills.

What published oro-motor assessments can be used?

Diagnostic Evaluation of Articulation and Phonology (DEAP) oromotor assessment (Dodd, Hua, Crosbie, Holm and Ozanne 2002) Nuffield Dyspraxia Programme (NDP) assessment oromotor assessment (1985; 1992; 2004) Paediatric Oral Skills Package (POSP), (Brindley, Cave, Crane, Lees and Moffat 1996)

DEAP
Standardised screening assessment of oral skills (based on Ozannes study 1992) Isolated oral movements Sequenced oral movements DDK assessment

NDP assessment:
Oro-motor

tasks easily achieved by 4 year olds (80% + level)

Sharples (1989)

Ozannes study (1992)

Study

of sequenced oral movements and movements in context for children aged 3-5 years

Ozannes findings:

Below 4 years wide variability in oro-motor function

Above 4 years most children can perform routine oro-motor tasks Tasks vary in difficulty tongue elevation most difficult Children often cooperated for tasks in context (e.g. licking and blowing) but would not produce oral movements on command or imitation.

Williams and Stackhouse (2000)

Study of 30 normallydeveloping 3 -5 year olds, on production of isolated and sequenced oral movements

Williams and Stackhouse (2000)

Difficulties with tongue elevation were shown by :
7/10 three year olds 4/10 four year olds

7/10 five year olds

Williams and Stackhouse (2000)

Difficulties on silent lip and tongue DDK sequences: 3 years 4 years 5 years
Lips Tongue 4/10 7/10 1/10 3/10 1/10 5/10

Fletcher 1972; 1978

384 children aged 6 13

Assessed on: single consonant repetition repetition of 2-consonant sequences repetition of 3-consonant sequences

Fletcher 1972 /1978

Speed of performance increased with age on all tasks.

Williams and Stackhouse (2000)

Study of 30 normally-developing 3-5 year olds Assessed on spoken DDK tasks: Repetition of real words Repetition of non-words 2 and 3 syllable sequences Scored for accuracy, consistency and rate

Williams and Stackhouse (2000)

3-year olds varied in performance, but generally highly consistent even if inaccurate 4 and 5 year olds generally both accurate and consistent Speed increases with age. Little difference between 3, 4 and 5 year olds

Assessing speech production

ASHA ideally assessment in multiple contexts: Spontaneous Elicited Imitation Syllable Single word Phrase Sentence Discourse

Tests for screening speech

Diagnostic Evaluation of Assessment and Phonology (UK)- standardised South Tyneside Assessment of Phonology (UK) Goldman-Fristoe (USA) Hodson Assessment of Phonological Patterns-3rd edition (USA)

Published Dyspraxia Assessments

Apraxia Profile (USA) Kaufman Speech Praxis Test (USA) Screening test for DAS (USA) Verbal Motor Production Assessment (USA) Nuffield Centre Dyspraxia Programme (UK)

Speech assessment - DEAP

Typical profile of a child with dvd: Poor performance on oro-motor assessment Poor performance on isolated speech sounds Poor performance on Inconsistency assessment

Speech assessment - NDP

Imitation of single sounds (consonants and vowels) Single word naming (CV, VC, CVC, CVCV, multisyllabic, clusters etc Imitation of phrases and sentences Oro-motor assessment DDK assessment Prosody assessment Connected speech assessment

NDP - Data are analysed at each level, in terms of:

Sounds, or sequences of sounds, correct Sounds, or sequences of sounds, incorrect Patterns in incorrect sounds/sequences Problems with syllable structure and junction between sounds Voice and prosodic features

NDP - Interpretation
NDP is not standardized. Research into earlier edition: a normally developing 4 year old can say almost all single sounds and words on the CV, CVC, and CVCV lists. But will make some errors on more complex multi-syllabic, clusters and phrases and sentences For more information see NDP Manual, chapter 3

How can the NDP assessment data be used?

To provide an individual profile of the childs speech difficulties To help identify the nature of the childs problem (differential diagnosis) To set therapy targets To provide a basement measurement to record progress following intervention