Targeting both speech perception and production for CAS

We think of childhood apraxia of speech (CAS) as a motor speech disorder, so it makes sense that our interventions mostly treat speech production. But what about all the children with CAS who also have language and reading weaknesses? Some evidence suggests that therapy to improve speech perception (think phonological awareness skills) can also benefit children with CAS. 


In this study, Hume et al. used a combined perception and production treatment with six children with CAS (ages 4–7) who were making slow progress in therapy. They used a pretest–posttest design (basically six case studies)—so the study design isn’t the strongest. But we don’t have a ton of treatment studies on children with CAS, and descriptive studies can still give us ideas for our clients, so the results are still worth a look.

During individual, 50-minute sessions, an SLP led children in: (1) rhyming practice, (2) phonological awareness activities using target sounds or sound patterns, (3) speech production practice, and (4) generalization practice (using target sounds in a new context). Following 30 treatment sessions, all children improved their production of untaught words and their consistency of word productions, and five of the six children improved on tests of phonological awareness.

Again, with a nonexperimental study, we can’t say whether the treatment caused children’s progress. However, the results match findings from other studies that suggest perception practice might benefit children with CAS. If you have clients with CAS who are making slow progress in therapy and who also struggle with reading or pre-reading skills, tacking on some phonological awareness practice might be worth a try. 

Hume, S. B., Schwarz, I., & Hedrick, M. (2018). Preliminary investigation of the use of phonological awareness paired with production training in childhood apraxia of speech. Perspectives of the ASHA Special Interest Groups, 3 (SIG 16), 38–52.

Teasing out morphology vs. speech skills in preschoolers

Researchers tend to talk about speech OR language impairment, when in reality, we know that it’s rarely so simple. Two studies this month looked at morphology skills in preschoolers with speech sound disorders, and ways to untangle the effects of each.


Murray et al. looked at assessment data from studies of preschoolers with childhood apraxia of speech (CAS) who all were given the CELF-P2. They found that children with CAS had lower expressive than receptive language skills overall. Morphology was particularly difficult for children with CAS, and errors were inconsistent across the same morphemes. While some morpheme errors were speech-based, others were language-based. Unfortunately, assessing morphology skills independently of speech skills is difficult, especially in connected speech.

The takeaway is that morphological skills should be part of our assessment process for children with CAS, but we need to consider whether children’s speech skills are causing the morpheme errors we see.

So, how can we do that? Howland et al. have some suggestions. They looked at grammatical morpheme production in preschoolers with phonological impairment (defined as speech sound disorder with pattern-based errors). They found that, for these kids:

  • Past tense –ed was harder than all other morphemes. Morphemes like third person singular -s were harder than morphemes like plural or possessive -s.  

  • Morphemes in clusters (e.g., wants) were harder than morphemes in singletons (e.g., sees) or syllables (e.g., washes).

  • Children who could produce final clusters in single-morpheme words (e.g., waste) were more likely to use morphemes correctly overall.

So basically, children’s speech skills affect their ability to use morphemes. We can try to see whether the issue is caused by phonology or morphology by sampling sounds and clusters in single-morpheme vs. multi-morpheme words. Standardized tests don’t necessarily do this well, so it’s worth our time to do more probe testing to tease it out. What could this look like? Check out the example word pairs below. We’re asking, is it clusters that this child can’t do? Or morphemes?


Early speech and language disorders affect later spelling

SLPs are well-aware that speech, language, and literacy are all interconnected, but we’re also aware that they’re not necessarily interconnected in a nice, clear, easy-to-understand way. This study helped to sharpen our vision on whether we should expect later spelling difficulty in children with early speech and language disorders.

First, a quick refresher. There are a couple of skills kids need in order to have good spelling skills. One is phonological awareness. The other is RAN, or rapid automatized naming (e.g., naming a set of colors or animals as fast as possible). While RAN is usually studied in the context of reading, it can also affect spelling, and can predict spelling difficulty in children, especially for irregular words (see here for more on RAN and spelling).  In addition to the skills associated with spelling, there is also a genetic factor: spelling difficulty (and reading, learning, language, etc.) can run in families. On top of all of that, we know from existing research and clinical experience that children with speech sound and language disorders are at risk for later reading and spelling impairments.  

The authors tested participants from a large longitudinal study to explore how these factors contribute to spelling ability in middle- and high-school students. Children who were tested between 4- and 6-years of age were split into groups* based on diagnosis:

  • No SSD/DLD

  • SSD only

  • SSD + DLD

  • CAS (these children also all had DLD)

All children were assessed again at middle school or high school age on phonological awareness, RAN, reading decoding, and spelling. Interestingly, the results indicated that having SSD alone was not associated with spelling difficulty in later school years, but children with SSD + DLD and children with CAS (who also met criteria for DLD) showed continued spelling difficulty into middle- and high-school. Taking a closer look at the underlying skills needed for spelling, phonological awareness was related to spelling scores at middle- and high-school, but RAN was only related to spelling scores in the high school group.


The authors also looked at heritability of spelling skills. Heritability looks at the probability that differences in a trait (in this case, spelling) occur because of genetic reasons and not because of environmental factors or by chance. Controlling for diagnosis and socio-economic status, the authors found strong heritability only in the high school group, meaning that genetic factors are probably more important in later spelling skills while environmental factors are more at play in the earlier years. Based on the results of the study, authors suggest we should keep a close eye on children with early SSD and DLD and intervene for those students who are showing early signs of spelling and reading difficulty.

*SSD = speech sound disorder; DLD = developmental language disorder; CAS = childhood apraxia of speech)


Lewis, B. A., Freebairn, L., Tag, J., Benchek, P., Morris, N. J., Iyengar, S. K., …, & Stein, C., M. (2018). Heritability and longitudinal outcomes of spelling skills in individuals with histories of early speech and language disorders. Learning and Individual Differences. Advance online publication. doi: 10.1016/j.lindif.2018.05.001

Is the Kaufman Speech to Language Protocol effective for children with CAS? (Spoiler: We don’t know)

Sometimes the popularity of a treatment program doesn’t match the evidence supporting it. Enter the Kaufman Speech to Language Protocol (K-SLP) for treating children with childhood apraxia of speech (CAS; aka: Kaufman cards, Kaufman kit) which Gomez et al. point out “is a treatment program that, anecdotally, is widely used by clinicians despite the lack of theory to support the approach.”


To test the K-SLP, the authors conducted a small experimental study. Two children with CAS, ages 4 and 5, received 3 weeks of treatment, with four 1-hour sessions per week. As prescribed by the K-SLP, treatment focused on successive word approximations. The K-SLP was also modified slightly; the children had to match the correct prosody for the words, and the authors incorporated principles of motor learning.

After treatment, the authors compared children’s performance on treated words to untreated control words. This is where it gets tricky—children’s baseline performance on control words was not consistent, likely because inconsistent productions are a hallmark of CAS. Both children’s average percent phonemes correct (PPC) increased, but only one child showed generalization by improving production of similar but untreated words. Both children’s PPC went down after treatment was withdrawn, but had not returned to baseline levels at 3 months post-treatment.

So, does the K-SLP work? This study is too small and preliminary to answer that question, and it’s the first published experimental study to ask it. It also doesn’t tell us how the K-SLP compares to other treatments, or which children it might work best for. In the meantime, there are other treatments for CAS with more evidence.

Gomez, M., McCabe, P., Jakielski, K., & Purcell, A. (2018). Treating childhood apraxia of speech with the Kaufman Speech to Language Protocol: A Phase I pilot study. Language, Speech, and Hearing Services in Schools, [Advance online publication], 1-13. doi: 10.1044/2018_LSHSS-17-0100.

Perspective Pieces

Recall that TISLP doesn’t review Perspective Pieces. However, we do love them (sometimes our FAVORITE publications each month are Perspective Pieces), and think you should be reading these gems, too. There were a TON published this month. Browse the titles for topics you’re interested in, and enjoy!

·      Understanding Word Reading Difficulties in Children With SLI

·      Practitioner Reflection That Enhances Interprofessional Collaborative Practices for Serving Children Who Are Deaf/ Hard-of-Hearing

·      Using Multilinguistic Strategies to Improve Decoding in Older School-Age Students in a Contextualized and Motivational Approach

·      A Review of Psychosocial Risks and Management for Children with Cleft Lip and/or Palate

·      The Role of Semantic Knowledge in Learning to Read Exception Words

·      Technology Training in Speech-Language Pathology: A Focus on Tablets and Apps

·      Reading Longer Words: Insights Into Multisyllabic Word Reading

·      Small Group Reading Instruction: Activities for Teaching Phonemic Awareness, the Alphabetic Principle, and Phonics in a Tier 2 Setting

·      Speech Assessment in Children With Childhood Apraxia of Speech

·      Does Access to Visual Input Inhibit Auditory Development for Children With Cochlear Implants? A Review ofthe Evidence

·      Efficacious Treatment of Children With Childhood Apraxia of Speech According to the International Classification of Functioning, Disability and Health

·      Beyond Eyes and Ears: The Need for Movement Analysis of Speech and Nonspeech Behaviors in ChildrenWith Cerebral Palsy

·      Leading the Way With Supervision Training: Embracing Change and Transforming Clinical Practice

·      Perceptions of Mentoring SLPs and Clinical Fellows During the Clinical Fellowship

·      How Stuttering Develops: The Multifactorial Dynamic Pathways Theory

·      Examination of Coaching Behaviors Used by Providers When Delivering Early Intervention via Telehealth to Families of Children Who Are Deaf or Hard of Hearing

·      We’ve Got Some Growing Up to Do: An Evidence-Based Service Delivery Model for the Transition of Care for the Young Adult with Cleft Lip and Palate

·      Are We Slipping Them Through the Cracks? The Insufficiency of Norm-Referenced Assessments for Identifying Language Weaknesses in Children With Hearing Loss

And more...

  • This study is a reminder that children with cochlear implants (CI) can’t be expected to have equivalent speech–language skills to hearing peers. As a group, children with CIs had less-grammatical spoken language when compared to hearing-age matched peers (though a portion of the CI group performed equivalently to peers), years after implantation. The authors suggest that clinicians must look beyond the morpheme-level features known to be affected by speech perception (e.g. –s, –ed endings), and also consider that syntax may be delayed in this population as well.
  • Remember how we’ve mentioned previously that ReST is one of our best evidence-based options for treatment of childhood apraxia of speech (CAS)? And how you can learn how to do ReST here? Well, this paper indicates that, “…combined clinician­–parent delivery of ReST was less efficacious than previously reported clinician-only delivered ReST.” So better leave this one to the SLPs/SLTs for now.
  • This study links language scores at age 2 with adult communication and social skills in people with autism.
  • This study showed that stuttering alone was not a predictor of higher anxiety in a sample of over 800 11-year-old children. Also, for a group of 3–6-year-olds, this study showed that stuttering and temperament (including “precursors to anxiety”) were not associated. Clearly, we don't have a great handle on the link between stuttering and anxiety, because other research has identified associations between anxiety and stuttering.
  • This study reviews the communication profiles of children from birth to early adulthood with Angelman syndrome. For clinicians with such a child currently on his/her caseload, this article may provide a good framework for what to expect in communication skill development.
  • This study examines archival longitudinal data to show that children with language disorders, “…as 6-year-olds continued to show language and reading deficits as 14-year-olds,” and review other longitudinal studies with similar results. The author also highlights substantial individual differences in children with language disorders, showing varying patterns of strengths and weaknesses across language domains. The author suggests that comprehension of challenging middle-school texts may need to be preceded by appropriate identification of individual patterns of language skill.
  • In this meta-analysis, they update current predictions for the male-to-female ratio of children with autism, and find that it’s, “not 4:1, as is often assumed; rather, it is closer to 3:1.”

Armstrong, R., Whitehouse, A.J.O., Scott, J.G., Copland, D.A., McMahon, K.L., Fleming, S., & Arnott, W. (2017). A relationship between early language skills and adult autistic-like traits: evidence from a longitudinal population-based study. Journal of Autism and Developmental Disorders, 47, 5, 1478–1489.

Guo, L-Y., & Spencer, L.J. (2017). Development of Grammatical Accuracy in English-Speaking Children With Cochlear Implants: A Longitudinal Study. Journal of Speech, Language, and Hearing Research, 60, 1062–1075.

Kefalianos, E., Onslow, M., Ukoumunne, O.C., Block, S., & Reilly, S. (2017). Temperament and Early Stuttering Development: Cross-Sectional Findings From a Community Cohort. Journal of Speech, Language, and Hearing Research, 60, 772–784.

Loomes, R., Hull, L., & Mandy, W.P.L. (2017). What is the male-to-female ration in autism spectrum disorder? A systematic review and meta-analysis. Child and Adolescent Psychiatry. Advance online publication.

Nippold, M.A. (2017). Reading Comprehension Deficits in Adolescents: Addressing Underlying Language Abilities. Language, Speech, and Hearing Services in the Schools, 48, 125–131.

Smith, K.A., Iverach, L., O'Brian, S., Mensah, F., Kefalianos, E., Hearne, A., & Reilly, S. (2017) Anxiety in 11-Year-Old Children Who Stutter: Findings From a Prospective Longitudinal Community Sample. Journal of Speech, Language, and Hearing Research. Advance online publication. doi:10.1044/2016_JSLHR-S-16-0035.

Thomas, D.C., McCabe, P., & Ballard, K.J. (2017). Combined clinician–parent delivery of rapid syllable transition (ReST) treatment for childhood apraxia of speech. International Journal of Speech–Language Pathology. Advance online publication. doi:10.1080/17549507.2017.1316423.

Quinn, E.D., & Rowland, C. (2017). Exploring Expressive Communication Skills in a Cross-Sectional Sample of Children and Young Adults With Angelman Syndrome. American Journal of Speech–Language Pathology. Advance online publication. doi:10.1044/2016_AJSLP-15-0075.



Evidence-Based Treatment of Childhood Apraxia of Speech

This is an exciting article to include as a “throwback pub," because it’s quite new (2014), and arguably the most thorough evaluation of childhood apraxia of speech (CAS) treatment options to date. When someone says, “I need a research study to help me decide among treatment strategies for CAS”, send them this!
This systematic review covers “…all levels of evidence that may be critical to inform clinical practice…” from the 1970s through 2012. From over 1000 studies, detailed inclusion/exclusion criteria were employed to narrow it down to 23. One issue that arose across studies was consistency in the definition of CAS (see ASHA’s 2007 consensus). The authors found that, “The most commonly overlooked CAS characteristic across studies was dysprosody…” Other studies were excluded for lack of clearly-reported treatment outcomes. Of the final 23 studies, most were motor approaches, with some linguistic and two AAC approaches. All delivered treatment individually, with a range in treatment schedule and dose.
So, what did the authors of this systematic review conclude? They found that:

“… currently two motor treatments (Integral Stimulation/DTTC and ReST [Rapid Syllable Transition]) and one linguistic treatment (Integrated Phonological Awareness Intervention) are best suited to interim clinical use…”

And, voilà—from there you start. Want another paper? Try this one. Maas et al. also examined the evidence behind several treatment approaches, and suggest that, “At present, a DTTC-type integral stimulation approach has the strongest evidence base…”

So—exciting as it is to know where you should start with these clients, I know what you all are thinking: Do either of these articles tell me how to "do" these techniques? How do I implement DTTC in the therapy room? Well... unfortunately, that's beyond the purpose of these papers (<sigh>). But, I know you all need this. So let's talk where to go next in the comments section, below. I'll show you what I've found, and you all chime in, too! We should be able to crowd-source some of the best current resources for SLPs (extra credit for web-based continuing ed courses, folks!)

See: Murray, E., McCabe, P., & Ballard, K.J. (2014). A Systematic Review of Treatment Outcomes for Children With Childhood Apraxia of Speech. American Journal of Speech-Language Pathology, 23, 486–504.

UPDATE (2018):

Want more information on the CAS treatment? Try this this Cochrane Review. It shows that even though we have some nice research on childhood apraxia of speech, it’s still not a very strong evidence base. And we definitely don’t have enough evidence to recommend one CAS treatment approach over another.

Teletherapy for CAS using Rapid Syllable Transitions

This article is a good one, not only because it’s a nice example of telepractice via online video conferencing (not many of those!), but also because it uses a treatment technique that you should know about, as well. Rapid Syllable Transitions (ReST) has been studied before, here and here, among others. It is “a relatively new treatment for CAS [childhood apraxia of speech] that uses pseudo-word targets with varying lexical stress patterns to target... articulatory accuracy, fluent transitions between syllables, and lexical stress” (Thomas et al., 2016).
The current study is small (five kids, age 5–11) and the first of its kind (so interpret with caution), but demonstrates “significant… generalization of the treatment effect to untreated imitated pseudo-words and real words”. Therapy was delivered four times per week for three weeks, so high intensity and short duration. The authors point out that ReST doesn’t require hands-on cueing and tends to work best for clients with milder forms of CAS, and thus may be well-suited for teletherapy.
See: Thomas, D. C., McCabe, P., Ballard, K. J. and Lincoln, M. (2016), Telehealth delivery of Rapid Syllable Transitions (ReST) treatment for childhood apraxia of speech. International Journal of Language & Communication Disorders. doi: 10.1111/1460-6984.12238