Motor Performance in Children With Childhood Apraxia of Speech and Speech Sound Disorders

Are Speech Sound Difficulties Risk Factors for Difficulties in Language and Reading Skills? A Systematic Review and Meta-Analysis

BACKGROUND

Children with speech sound difficulties often require educational psychology services, yet systematic reviews examining the association between these difficulties and language or reading problems are lacking. This meta-analysis examines whether these children are at higher risk of language and reading difficulties compared to their peers.

METHOD

The study analyzed 290 effect sizes from cross-sectional and longitudinal studies that compared language and reading skills between children with speech sound difficulties and controls. Additionally, we evaluated 37 effect sizes from correlational studies in general populations to examine the relationship between speech sound skills and language or reading skills.

RESULTS

Children with speech sound difficulties showed significant concurrent language (Hedges' g = -0.60) and reading (Hedges' g = -0.58) problems. Correlational studies also demonstrated a relationship between speech sound skills and language (r = .23) and reading (r = .23) skills. Phonological awareness and study quality were significant moderators. Longitudinal studies showed persistent or increasing group differences over time in language (Hedges' g = -0.85) and reading (Hedges' g = -0.50). These findings were consistent regardless of the severity or types of speech sound difficulties, nonverbal IQ, country, age, and publication year. However, a precision-effect test and the precision-effect estimate with standard errors analysis suggested a potential decrease in effect size due to publication bias from small sample sizes in primary studies.

CONCLUSION

Children with speech sound difficulties are at an increased risk of language and reading difficulties, emphasizing the need for broader language assessments and early interventions to mitigate future academic difficulties.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.27849828.

Acoustic Analysis of Spatiotemporal Variability in Children With Childhood Apraxia of Speech

PURPOSE

The purpose of this study was to investigate acoustic spatiotemporal variability in children with childhood apraxia of speech (CAS) compared to children with typical development (TD). Increased spatiotemporal variability in children with CAS relative to nonapraxic peers has been documented in multiple kinematic studies. To date, few studies have investigated spatiotemporal variability in CAS using an acoustic signal.

METHOD

Data were drawn from 10 children with CAS and 10 children with TD, ranging in age from 5;0 to 11;2 (years;months), who participated in an online study. All children with CAS had a verified diagnosis and showed at least five CAS features across at least two tasks, independently confirmed by two speech-language pathologists with expertise in CAS. Children repeated the sentences "Buy Bobby a puppy" (BBAP) and "Mom pets the puppy" (MPP) 10 times each. The acoustic spatiotemporal index (STI), calculated from the amplitude envelope, was used to investigate acoustic spatiotemporal variability. Using a regression analysis, we analyzed group differences in STI values while controlling for age and gender.

RESULTS

Children with CAS did not produce enough usable tokens of BBAP to analyze. MPP revealed significantly higher acoustic STI values in children with CAS compared to children with TD. No significant effects were observed for age or gender. Acoustic data collected online without the use of specialized equipment yielded high-quality audio data from which amplitude envelope tracing could be reliably accomplished.

CONCLUSIONS

This study adds to a growing body of empirical data indicating that children with CAS produce speech with more variable spatiotemporal control compared to children with TD. In addition to producing more variable speech, children with CAS were less consistently able to form productions free of phonetic errors. These findings also demonstrate the feasibility of using remote data collection to investigate acoustic spatiotemporal variability, which allows for the recruitment of larger samples of low-incidence populations.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.26814883.

Long-Term Outcomes for Individuals With Childhood Apraxia of Speech

PURPOSE

The study's primary aims were to describe the long-term speech outcomes for adolescents and young adults with a history of childhood apraxia of speech (CAS) and to examine the association of persistent speech sound errors with measures of literacy skills, phonological processing, motor speech production, and parent report of early motor difficulty.

METHOD

Data from a large longitudinal 25-year study were used to explore outcomes for 32 individuals with a history of CAS, ages 12;6 (years;months) to 25 years (M = 17.4, SD = 4.7). Persistent and nonpersistent groups were compared on decoding, phonological processing, multisyllabic word repetition, diadochokinetic rate, and parent report of motor involvement. Parametric (Welch's t tests) and nonparametric tests (Wilcoxon and Fisher exact tests) were used to identify differences between the groups' distributions. Developmental trajectories of speech production were plotted.

RESULTS

Outcomes for individuals with CAS are highly variable, with some demonstrating speech sound errors into adolescence and young adulthood. Speech sound errors were primarily on later developing sounds. Persistence was significantly associated with early motor difficulties. Difficulties with multisyllabic words, phonological processing, and literacy were often present regardless of persistence or nonpersistence of speech errors.

CONCLUSIONS

Children with CAS are at risk for persistent speech sound errors into adulthood. For children showing limited progress with more traditional speech therapy, alternative interventions should be explored. Individuals with persistent speech sound errors are more likely to have a history of early motor deficits. Regardless of persistence, participants with CAS demonstrated ongoing weaknesses in literacy, phonological processing skills, and complex speech production tasks.

Research Priorities for Childhood Apraxia of Speech: A Long View

This article introduces the Journal of Speech, Language, and Hearing Research Special Issue: Selected Papers From the 2022 Apraxia Kids Research Symposium. The field of childhood apraxia of speech (CAS) has developed significantly in the past 15 years, with key improvements in understanding of basic biology including genetics, neuroscience, and computational modelling; development of diagnostic tools and methods; diversity of evidence-based interventions with increasingly rigorous experimental designs; and understanding of impacts beyond impairment-level measures. Papers in this special issue not only review and synthesize the some of the substantial progress to date but also present novel findings addressing critical research gaps and adding to the overall body of knowledge. A second aim of this prologue is to report the current research needs in CAS, which arose from symposium discussions involving researchers, clinicians, and Apraxia Kids community members (including parents of children with CAS). Four primary areas of need emerged from discussions at the symposium. These were: (a) What questions should we ask? (b) Who should be in the research? (c) How do we conduct the research? and (d) How do we move from research to practice? Across themes, symposium attendees emphasized the need for CAS research to better account for the diversity of people with CAS and improve the timeliness of implementation of high-level evidence-based practice across the lifespan. It is our goal that the articles and prologue discussion in this special issue provide an appreciation of advancements in CAS research and an updated view of the most pressing needs for future research.

Dynamic Temporal and Tactile Cueing: Quantifying Speech Motor Changes and Individual Factors That Contribute to Treatment Gains in Childhood Apraxia of Speech

PURPOSE

Speech motor skill is refined over the course of practice, which is commonly reflected by increased accuracy and consistency. This research examined the relationship between auditory-perceptual ratings of word accuracy and measures of speech motor timing and variability at pre- and posttreatment in children with childhood apraxia of speech (CAS). Furthermore, the degree to which individual patterns of baseline probe word accuracy, receptive language, and cognition predicted response to treatment was explored.

METHOD

Probe data were collected from seven children with CAS (aged 2;5-5;0 [years;months]) who received 6 weeks of Dynamic Temporal and Tactile Cueing (DTTC) treatment. Using a multidimensional approach to measuring speech performance, auditory-perceptual (whole-word accuracy), acoustic (whole-word duration), and kinematic (jaw movement variability) analyses were conducted on probe words produced pre- and posttreatment. Standardized tests of receptive language and cognition were administered pretreatment.

RESULTS

There was a negative relationship between auditory-perceptual measures of word accuracy and movement variability. Higher word accuracy was associated with lower jaw movement variability following intervention. There was a strong relationship between word accuracy and word duration at baseline, which became less robust posttreatment. Furthermore, baseline word accuracy was the only child-specific factor to predict response to DTTC treatment.

CONCLUSIONS

Following a period of motor-based intervention, children with CAS appeared to refine speech motor control in conjunction with improvements in word accuracy. Those who demonstrated the poorest performance at treatment onset displayed the greatest degree of gains. Taken together, these results reflect a system-wide change following motor-based intervention.

A Goal-Writing Framework for Motor-Based Intervention for Childhood Apraxia of Speech

PURPOSE

There are multiple frameworks for goal writing that are applicable to the practice of speech-language pathology. Motor-based speech disorders are a subset of speech sound disorders that are thought to require specific elements of intervention that are typically not addressed in the traditional frameworks used in the clinical setting. The purpose of this tutorial is to review general approaches of goal writing and suggest additional elements that may be used to improve the efficiency and effectiveness of treatment for childhood motor speech disorders, specifically childhood apraxia of speech (CAS).

METHOD

Existing models of goal writing were reviewed to ascertain elements common to most of these models. A basic framework was chosen and modified to include behaviors, conditions, and approaches to goal measurement tailored to the clinical needs of children with CAS. A resource for clinical decision making for children with CAS was developed to inform goal writing at the onset of treatment and adaptations that occur over the course of treatment. Case studies are presented to demonstrate how the presented framework can be applied to writing goals for motor-based treatment for two different children with CAS.

DISCUSSION

Children with CAS require a specialized approach to intervention, which requires goals to reflect the unique clinical needs of this population. This tutorial offers resources that use the best available research evidence and current understanding of effective treatment practices for CAS to guide clinical decision making for motor-based intervention and goal writing. This tutorial is intended to guide treatment planning across varied settings to facilitate progress and optimize treatment outcomes for children with CAS.

Dynamic Temporal and Tactile Cueing in Young Children With Childhood Apraxia of Speech: A Multiple Single-Case Design

PURPOSE

Childhood apraxia of speech (CAS) is a multivariate motor speech disorder that requires a motor-based intervention approach. There is limited treatment research on young children with CAS, reflecting a critical gap in the literature given that features of CAS are often in full expression early in development. Dynamic Temporal and Tactile Cueing (DTTC) is a treatment approach designed for children with severe CAS, yet the use of DTTC with children younger than 3 years of age has not been examined.

METHOD

A multiple single-case design was employed to examine the use of DTTC in seven children with CAS (aged 2.5-5 years) over the course of 6 weeks of intervention. Changes in word accuracy were measured in treated words from baseline to posttreatment and from baseline to maintenance (6 weeks posttreatment). Generalization of word accuracy changes to matched untreated words was also examined. A linear mixed-effects model was used to estimate the change in word accuracy for treated and untreated words across all children from baseline to posttreatment and to maintenance. A quasi-Poisson regression model was used to estimate mean change and calculate effect sizes for treated and untreated words.

RESULTS

Group-level analyses revealed significant changes in word accuracy for treated and untreated words at posttreatment and maintenance. At the child level, six of seven children displayed medium-to-large effect sizes where word accuracy increased in an average of 3.4/5 words across all children. Each child displayed some degree of generalization to untreated targets, specifically for words with the same syllable shape as the treated words.

CONCLUSIONS

These results demonstrate that DTTC can yield positive change in some young children with CAS. Key differences in each child's performance are highlighted.

Development of Self-made Gestures as an Adaptive Strategy for Communication in an Individual With Childhood Apraxia of Speech

Individuals with childhood apraxia of speech often exhibit greater difficulty with expressive language than with receptive language. As a result, they may benefit from alternative modes of communication. Here, we present a patient with childhood apraxia of speech who used pointing as a means of communication at age 2 ¼ years and self-made gestures at age 3½, when he had severe difficulties speaking in spite of probable normal comprehension abilities. His original gestures included not only word-level expressions, but also sentence-length ones. For example, when expressing "I am going to bed," he pointed his index finger at himself (meaning I ) and then put both his hands together near his ear ( sleep ). When trying to convey the meaning of "I enjoyed the meal and am leaving," he covered his mouth with his right hand ( delicious ), then joined both of his hands in front of himself ( finish ) and finally waved his hands ( goodbye ). These original gestures and pointing peaked at the age of 4 and then subsided and completely disappeared by the age of 7, when he was able to make himself understood to some extent with spoken words. The present case demonstrates an adaptive strategy for communication that might be an inherent competence for human beings.

Manual Rhythmic Sequencing Skills in Children With Childhood Apraxia of Speech

PURPOSE

Rhythm is one procedural mechanism that underlies language and motor skill acquisition and has been implicated in children with childhood apraxia of speech (CAS). The purpose of this study is to investigate manual rhythmic sequencing skills in children with a history of or current CAS (hx/CAS) compared to children with typical development (TD).

METHOD

Thirty-eight children (18 with hx/CAS, 20 with TD), ages 5;0-12;8 (years;months), from across the United States participated in an online study. Participants imitated two rhythms in two different conditions, clapping and tapping. We assessed overall accuracy, mean number of beats, pause marking, and rhythmic sequence variability using the Mann-Whitney U test. Effect sizes were calculated to examine the influence of coordinative complexity on performance.

RESULTS

Compared to children with TD, children with hx/CAS marked fewer trials with a pause in both conditions of the easier rhythm and showed lower overall accuracy and more variable rhythmic sequences in both rhythms and conditions. The mean number of beats produced by children with hx/CAS and children with TD did not differ in three out of four rhythms/conditions. Unlike children with TD, children with hx/CAS showed little improvement from clapping to tapping across most dependent measures; reducing coordination demands did not improve performance in children with hx/CAS.

CONCLUSIONS

We found that children with hx/CAS show manual rhythmic deficits that are similar to the deficits they display in speech. These findings provide support for a domain-general cognitive mechanisms account of the rhythmic deficits observed across linguistic and nonlinguistic tasks in children with hx/CAS.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24052821.

Motor Speech Phenotypes in Children With Epilepsy: Preliminary Findings

PURPOSE

This exploratory study aimed to characterize motor speech impairments in a small sample of children with epilepsy, both with and without a known seizure etiology. A secondary aim was to evaluate the validity of the Profile for Childhood Apraxia of speech and Dysarthria (ProCAD), a newly developed tool for differential diagnosis of childhood apraxia of speech and dysarthria.

METHOD

Thirteen children with seizure disorders completed a comprehensive speech and language assessment. Three expert speech-language pathologists rated the presence of auditory-perceptual features of motor speech impairment using the ProCAD. Motor speech features, diagnoses, and standardized test scores were compared between children with a known seizure etiology and children with idiopathic epilepsy.

RESULTS

Nine of the 13 children exhibited motor speech impairment; dysarthria was the most common diagnosis. Most children (11/13) exhibited language impairment. Group comparisons showed that children with a known seizure etiology had more atypical motor speech features and lower language scores than children with idiopathic seizures.

CONCLUSION

These preliminary findings suggest a high rate of motor speech impairment among children with epilepsy.

Comorbidity and Severity in Childhood Apraxia of Speech: A Retrospective Chart Review

PURPOSE

The purpose of this study was to investigate comorbidity prevalence and patterns in childhood apraxia of speech (CAS) and their relationship to severity.

METHOD

In this retroactive cross-sectional study, medical records for 375 children with CAS (M age = 4;9 [years;months], SD = 2;9) were examined for comorbid conditions. The total number of comorbid conditions and the number of communication-related comorbidities were regressed on CAS severity as rated by speech-language pathologists during diagnosis. The relationship between CAS severity and the presence of four common comorbid conditions was also examined using ordinal or multinomial regressions.

RESULTS

Overall, 83 children were classified with mild CAS; 35, with moderate CAS; and 257, with severe CAS. Only one child had no comorbidities. The average number of comorbid conditions was 8.4 (SD = 3.4), and the average number of communication-related comorbidities was 5.6 (SD = 2.2). Over 95% of children had comorbid expressive language impairment. Children with comorbid intellectual disability (78.1%), receptive language impairment (72.5%), and nonspeech apraxia (37.3%; including limb, nonspeech oromotor, and oculomotor apraxia) were significantly more likely to have severe CAS than children without these comorbidities. However, children with comorbid autism spectrum disorder (33.6%) were no more likely to have severe CAS than children without autism.

CONCLUSIONS

Comorbidity appears to be the rule, rather than the exception, for children with CAS. Comorbid intellectual disability, receptive language impairment, and nonspeech apraxia confer additional risk for more severe forms of CAS. Findings are limited by being from a convenience sample of participants but inform future models of comorbidity.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22096622.

Speech Error Variability and Phonological Awareness in Preschoolers

PURPOSE

The purpose of this article was to investigate the relationship between speech error variability and phonological awareness.

METHOD

This article begins with a narrative review of the theoretical interpretation of speech error variability. The post hoc exploratory analysis of the relationship between speech error variability and phonological awareness included 40 children: 20 with typical speech and language and 20 with speech sound disorder and typical language. Groups were matched on gender, age, maternal education, receptive and expressive vocabulary, nonverbal intelligence, and expressive morphosyntax. Multiple regression was used to identify the best fit model for the relationship between vocabulary, speech errors, and phonological awareness.

RESULTS

Segmental variability was associated with poor phonological awareness in preschool-aged children.

CONCLUSION

Children with high levels of segmental variability have poor phonological awareness, likely due to unstable phonological representations.

A case with cardiac, skeletal, speech, and motor traits narrows the subtelomeric 19p13.3 microdeletion region to 46 kb

Subtelomeric 19p13.3 deletions have been associated with diverse anatomical and developmental phenotypes. A recent study of eight patients with subtelomeric interstitial 19p13.3 microdeletions at 0.3-1.4 Mb (hg 19) showed associations with growth restrictions, skeletal deformities, craniofacial anomalies, congenital heart defects, renal malformations, hernias, immune system deficits, fine and gross motor delays, speech delays, and developmental and learning delays. The authors defined two small regions of overlap containing four and 11 genes, respectively, with potential haploinsufficiency. Here, we present a new case with a de novo 184 kb deletion containing eight genes, three of which fall into the second previously identified small region of overlap, reducing the shared region to 46 kb. Phenotypic traits include most of the core findings in the previously reported cases but not growth restrictions, craniofacial anomalies, renal malformation, and learning disability. A closer look at the speech and motor delays reveals apraxic speech and discoordination in the fine and gross motor domain, consistent with cerebellar involvement across motor systems. Findings are consistent with a role of AZU1 in the observed immune deficiencies and PTBP1 in the observed skeletal, abdominal, speech, language, motor, and sensory traits. This case thus contributes to a more nuanced understanding of the subtelomeric 19p13.3 deletion region.

Relationship among Connectivity of the Frontal Aslant Tract, Executive Functions, and Speech and Language Impairment in Children with Childhood Apraxia of Speech

Childhood apraxia of speech (CAS) is a subtype of motor speech disorder usually co-occurring with language impairment. A supramodal processing difficulty, involving executive functions (EFs), might contribute to the cognitive endophenotypes and behavioral manifestations. The present study aimed to profile the EFs in CAS, investigating the relationship between EFs, speech and language severity, and the connectivity of the frontal aslant tract (FAT), a white matter tract involved in both speech and EFs. A total of 30 preschool children with CAS underwent speech, language, and EF assessments and brain MRIs. Their FAT connectivity metrics were compared to those of 30 children without other neurodevelopmental disorders (NoNDs), who also underwent brain MRIs. Alterations in some basic EF components were found. Inhibition and working memory correlated with speech and language severity. Compared to NoND children, a weak, significant reduction in fractional anisotropy (FA) in the left presupplementary motor area (preSMA) FAT component was found. Only speech severity correlated and predicted FA values along with the FAT in both of its components, and visual-spatial working memory moderated the relationship between speech severity and FA in the left SMA. Our study supports the conceptualization of a composite and complex picture of CAS, not limited to the speech core deficit, but also involving high-order cognitive skills.

Three children with different de novo BCL11A variants and diverse developmental phenotypes, but shared global motor discoordination and apraxic speech: Evidence for a functional gene network influencing the developing cerebellum and motor and auditory cortices

BCL11A is implicated in BCL11A-Related Intellectual Development Disorder (BCL11A-IDD). Previously reported cases had various types of BCL11A variants (copy-number variations [CNVs], singlenucleotide variants [SNVs]). Phenotypes included global, cognitive, and motor delays, autism spectrum disorder (ASD), craniofacial dysmorphology, and speech and language delays described generally, with only two reports specifying childhood apraxia of speech (CAS). Here, we present three additional children with CAS and de novo BCL11A variants, a p.Ala182Thr nonconservative missense and a p.GLu611.Ter nonsense variant, both in exon 4, and a 106 kb deletion harboring exons 1 and 2. All three children have fine and gross motor discoordination, feeding difficulties, and visual motor disorders. Intellectual and learning disabilities and disordered language skills were seen only in the child with the missense variant and the child with the deletion. These findings align with, and expand, previous findings in that BCL11A variants have significant and highly penetrant apraxic effects across motor systems, consistent with cerebellar involvement. The deletion of exons 1 and 2 is the smallest BCL11A CNV with the full phenotypic expression reported to date. The present results support previous findings in that BCL11A-IDD can result from BCL11A variants regardless of type (deletion, SNVs). A gene expression study shows that BCL11 is expressed highly in the early developing cerebellum and primary motor and auditory cortices. Significant co-expression rates in these regions with genes previously implicated in disorders of spoken language and in ASD support the phenotypic overlaps in children with BCL11A-IDD, CAS, and ASD.

Prologue to the Forum: Care of the Whole Child: Key Considerations When Working With Children With Childhood Apraxia of Speech

PURPOSE

This prologue introduces the LSHSS Forum: Care of the Whole Child: Key Considerations When Working With Children With Childhood Apraxia of Speech. The goals of the forum are to provide (a) an overview of several co-occurring conditions and challenges that may affect children in this population and (b) methods and materials to enhance diagnostic accuracy and treatment efficacy to help children with childhood apraxia of speech (CAS) to thrive.

METHOD

The prologue provides an overview of what it means to care for the whole child and introduces the five articles in the forum, including research and clinical focus articles as well as tutorials. Infographics, assessment templates, video examples, case studies, and treatment goals are included throughout the forum to promote translation from research to practice.

CONCLUSION

Children with CAS may experience a breadth of skills, challenges, and diagnoses. By learning (a) to identify possible co-occurring conditions, (b) when to make referrals, and (c) how to best accommodate and treat children when different conditions are present, speech-language pathologists can further increase the quality of care provided and ability to advocate for some of our most vulnerable clients and their families.

An Investigation of Developmental Coordination Disorder Characteristics in Children With Childhood Apraxia of Speech

PURPOSE

Children with childhood apraxia of speech (CAS) evidence a high rate of co-occurring fine and gross motor deficits. This clinical focus article reports a preliminary investigation of characteristics of developmental coordination disorder (DCD), a neurodevelopmental disorder categorized by poor motor proficiency and functional limitations, in this population.

METHOD

Children with CAS underwent a comprehensive motor evaluation using the Movement Assessment Battery for Children-Second Edition, the Developmental Coordination Disorder Questionnaire, and a developmental history questionnaire to determine if they met criteria for a DCD diagnosis as specified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

RESULTS

Six out of seven participants met DCD criteria based on the DSM-5 criteria. Four of these children had a co-occurring diagnosis of developmental language disorder, and all met criteria for DCD.

CONCLUSIONS

Consistent with previous research, the majority of participants demonstrated motor deficits and 85% met criteria for DCD. Despite this high rate of motor deficits, only 57% had previously undergone a physical/occupational therapy evaluation and intervention and only one had a previous diagnosis of DCD. These findings suggest that formal movement assessments are essential for children with a CAS diagnosis.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20540193.

Reading Skills in Children With Suspected Childhood Apraxia of Speech and Children With Reading Disorders: Same or Different?

PURPOSE

The primary aim of this study was to compare decoding and literacy-related skills of children with suspected childhood apraxia of speech (sCAS) to children with reading disorders (RD) and no history of speech sound disorder (RD-no SSD) to determine if the groups differ in decoding and the endophenotypes that contribute to RD. We also explored the association between language impairment (LI) and decoding and literacy-related skills within the participant group with sCAS.

METHOD

Participants were school-age children and adolescents, 8-14 years of age, with a diagnosis of sCAS (n = 13) or RD-no SSD (n = 16). The sCAS and RD-no SSD groups were compared on measures of single-word decoding, oral language, motor-speech skills, phonological processing, and speech-in-noise perception, employing t tests and analysis of covariance. The sCAS + LI and sCAS-only groups were compared on similar measures using t tests.

RESULTS

Compared to the RD-no SSD group, the sCAS group performed significantly worse on measures of phonological processing, multisyllable word repetition, diadochokinetic rate, and speech-in-noise perception. The groups did not differ on measures of single-word decoding, with mean scores for both groups falling below average. All participants with sCAS + LI demonstrated deficits in literacy and literacy-related skills compared to a smaller percentage of the sCAS-only group.

CONCLUSIONS

Children with sCAS and children with RD-no SSD demonstrate similar impairments in literacy. However, the endophenotypes underlying these difficulties can differ between the groups. Deficits in skills needed for literacy may require specifically tailored interventions to address reading difficulties for children with sCAS, especially for those with comorbid LI.

Translating principles of precision medicine into speech-language pathology: Clinical trial of a proactive speech and language intervention for infants with classic galactosemia

Precision medicine is an emerging approach to managing disease by taking into consideration an individual's genetic and environmental profile toward two avenues to improved outcomes: prevention and personalized treatments. This framework is largely geared to conditions conventionally falling into the field of medical genetics. Here, we show that the same avenues to improving outcomes can be applied to conditions in the field of behavior genomics, specifically disorders of spoken language. Babble Boot Camp (BBC) is the first comprehensive and personalized program designed to proactively mitigate speech and language disorders in infants at predictable risk by fostering precursor and early communication skills via parent training. The intervention begins at child age 2 to 5 months and ends at age 24 months, with follow-up testing at 30, 42, and 54 months. To date, 44 children with a newborn diagnosis of classic galactosemia (CG) have participated in the clinical trial of BBC. CG is an inborn error of metabolism of genetic etiology that predisposes up to 85% of children to severe speech and language disorders. Of 13 children with CG who completed the intervention and all or part of the follow-up testing, only one had disordered speech and none had disordered language skills. For the treated children who completed more than one assessment, typical speech and language skills were maintained over time. This shows that knowledge of genetic risk at birth can be leveraged toward proactive and personalized management of a disorder that manifests behaviorally.

A Tool for Differential Diagnosis of Childhood Apraxia of Speech and Dysarthria in Children: A Tutorial

PURPOSE

While there has been mounting research centered on the diagnosis of childhood apraxia of speech (CAS), little has focused on differentiating CAS from pediatric dysarthria. Because CAS and dysarthria share overlapping speech symptoms and some children have both motor speech disorders, differential diagnosis can be challenging. There is a need for clinical tools that facilitate assessment of both CAS and dysarthria symptoms in children. The goals of this tutorial are to (a) determine confidence levels of clinicians in differentially diagnosing dysarthria and CAS and (b) provide a systematic procedure for differentiating CAS and pediatric dysarthria in children.

METHOD

Evidence related to differential diagnosis of CAS and dysarthria is reviewed. Next, a web-based survey of 359 pediatric speech-language pathologists is used to determine clinical confidence levels in diagnosing CAS and dysarthria. Finally, a checklist of pediatric auditory-perceptual motor speech features is presented along with a procedure to identify CAS and dysarthria in children with suspected motor speech impairments. Case studies illustrate application of this protocol, and treatment implications for complex cases are discussed.

RESULTS

The majority (60%) of clinician respondents reported low or no confidence in diagnosing dysarthria in children, and 40% reported they tend not to make this diagnosis as a result. Going forward, clinicians can use the feature checklist and protocol in this tutorial to support the differential diagnosis of CAS and dysarthria in clinical practice.

CONCLUSIONS

Incorporating this diagnostic protocol into clinical practice should help increase confidence and accuracy in diagnosing motor speech disorders in children. Future research should test the sensitivity and specificity of this protocol in a large sample of children with varying speech sound disorders. Graduate programs and continuing education trainings should provide opportunities to practice rating speech features for children with dysarthria and CAS.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19709146.

Evaluation of Diadochokinesis in Greek Preschoolers With Speech Sound Disorders Using a Diadochokinetic Rates Protocol

The study aimed at evaluating the diadochokinetic (DDK) skills of Greek-speaking preschool children with phonological disorder (PD) by means of a structured evaluation protocol and at proposing cut-off points for children at risk of speech impairment. The participants were 36 children with PD and 60 typically developing (TD) peers. The groups were matched on age and gender. The PD group performed significantly slower than the TD group in all speech DDK tasks but not in the oral-motor tasks. The ROC analysis showed a statistically significant positive discrimination for all speech tasks. The internal consistency of the protocol was excellent (Cronbach’s α = .844), while complex stimuli showed a better discriminatory ability. The obtained results agree with Dodd’s classification for speech sound disorders (SSDs). Different types of speech stimuli must be included in the evaluation of DDK performance as a clinical predictor for preschoolers with SSDs who face difficulties in speech maturation.

Speech feature profiles in Swedish 5-year-olds with speech sound disorder related to suspected childhood apraxia of speech or cleft palate

Purpose: To study the occurrence of speech features commonly associated with Childhood Apraxia of Speech (CAS) in Swedish children with suspected CAS (sCAS) or Speech Sound Disorder (SSD) related to Cleft Palate and/or Lip (CP ± L).Method: Thirty-four children (4.10-5.11) with SSD related to sCAS (n = 15) or repaired CP ± L (n = 19) participated. Consensus judgement of presence/absence of CAS features in single words were based on a checklist with operationalised definitions. Speech sound production measures were based on semi-narrow phonetic transcription. Intra- and inter-transcriber agreement was determined.Result: Twelve participants (ten with sCAS (67%) and two with CP ± L (11%)) shared a CAS profile of phonemic speech inconsistency for consonants and vowels and a set of four features: vowel error, voicing error, difficulty achieving initial articulatory configurations or transitionary movement gestures and stress errors. The most frequent speech difficulties in children with non-CAS CP ± L (n = 17) were consonant distortion (88%) and hypernasal resonance (76%). Prosodic impairment was rare.Conclusion: A distinct CAS speech feature profile was found for children with CAS, differing in number and distribution compared to children with CP ± L and SSD. CAS was found more frequently in CP ± L and SSD compared to reported estimates of clinical prevalence.

The Relationship Between Single-Word Speech Severity and Intelligibility in Childhood Apraxia of Speech

PURPOSE

The purpose of this study was to investigate the association between perceived single-word speech severity and intelligibility in children with childhood apraxia of speech (CAS), with and without comorbid language impairment (LI), and to investigate the contribution of different CAS signs to perceived single-word speech severity and single-word intelligibility.

METHOD

Thirty children with CAS, 18 with comorbid LI, completed the Goldman-Fristoe Test of Articulation-Second Edition (GFTA-2). Trained judges coded children's responses for signs of CAS and percent phonemes correct. Nine listeners, blind to diagnoses, rated speech severity using a visual analog scale. Intelligibility was assessed by comparing listeners' orthographic transcriptions of children's responses to target responses.

RESULTS

Measures of speech severity (GFTA-2 standard score, number of unique CAS signs, total CAS signs, and mean severity rating) were significantly correlated with measures of intelligibility (GFTA-2 raw score, percent phonemes correct, and mean intelligibility score). Speech severity and intelligibility did not differ significantly between children with and without LI. Only consonant errors contributed significant variability to speech severity. Consonant errors and stress errors contributed significant variability to intelligibility.

CONCLUSIONS

Findings suggest that visual analog scale ratings are a valid and convenient measure of single-word speech severity and that GFTA-2 raw score is an equally convenient measure of single-word intelligibility. The result that consonant errors were by far the major contributor to single-word speech severity and intelligibility in children with CAS, with stress errors also making a small contribution to intelligibility, suggests that consonant accuracy and appropriate lexical stress should be prime therapeutic targets for these children in the context of treatment addressing motor planning/programming, self-monitoring, and self-correcting.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19119350.

Implicit learning in children with Childhood Apraxia of Speech

BACKGROUND

Childhood Apraxia of Speech is a severe and persistent clinical subtype of Speech Sound Disorder. Given the difficulties in the acquisition, programming and control of the movements underlying speech and the slowdown in a wide range of non-linguistic skills, the difficulty in implicit learning of sequential information could play a role in the disorder, contributing to understand its etiopathological mechanisms and behavioral manifestations.

AIMS

The present study was aimed at investigating implicit learning in children with Childhood Apraxia of Speech.

METHODS AND PROCEDURES

Twenty-five children with Childhood Apraxia of Speech, aged between 4 and 12 years, were matched for IQ and age to a control group of 25 typically developing children. Implicit learning of participants was assessed by Serial Reaction Time Task.

OUTCOME AND RESULTS

Children with Childhood Apraxia of Speech did not show implicit learning, as documented by the absence of differences between reaction times in the sequenced block and the random block, usually considered as a measure of implicit learning effect.

CONCLUSION AND IMPLICATIONS

Our results underline an implicit learning deficit in children with Childhood Apraxia of Speech, supporting the concept of a disorder not only confined to the speech domain, but also involving non-linguistic skills, in a composite and complex picture.

Differences and Commonalities in Children with Childhood Apraxia of Speech and Comorbid Neurodevelopmental Disorders: A Multidimensional Perspective

Childhood apraxia of speech (CAS) is a motor speech disorder often co-occurring with language impairment and complex neurodevelopmental disorders. A cohort of 106 children with CAS associated to other neurodevelopmental disorders underwent a multidimensional investigation of speech and language profiles, chromosome microarray analysis and structural brain magnetic resonance (MR). Our aim was to compare the clinical profiles of children with CAS co-occurring with only language impairment with those who, in addition to language impairment, had other neurodevelopmental disorders. Expressive grammar was impaired in the majority of the sample in the context of similar alterations of speech, typical of the core symptoms of CAS. Moreover, children with complex comorbidities also showed more severe and persistent receptive language deficits. About 25% of the participants harbored copy number variations (CNVs) already described in association to neurodevelopmental disorders. CNVs occurred more frequently in children with complex comorbidities. MR structural/signal alterations were found in a small number of children and were of uncertain pathogenic significance. These results confirm that CAS needs multidimensional diagnostic and clinical management. The high frequency of language impairment has important implications for early care and demands a personalized treatment approach in which speech and language goals are consistently integrated.

Retrospective Case-Control Study of Communication and Motor Abilities in 143 Children With Suspected Childhood Apraxia of Speech: Effect of Concomitant Diagnosis

Purpose

This study sought to determine if children with childhood apraxia of speech (CAS) plus another major diagnosis (CAS+) are equivalent in communication and motor profiles to those with a primary diagnosis of CAS and no indication or report of any other diagnosis (CAS-Primary).

Method

This retrospective case-control study included a chart review of 143 children who were suspected of having CAS at Children's Hospital-Wisconsin between 1998 and 2004. Participants were between 30 and 127 months old and included 107 males. Participants were assigned to the suspected CAS-Primary group (n = 114) if they had characteristics of CAS but no other major diagnosis (e.g., galactosemia) and to the CAS+ group (n = 29) if a comorbid diagnosis was present. Groups were compared across demographic, communication, and motor characteristics.

Results

Children with CAS+ evidenced more severe motor profiles than those with CAS-Primary, χ2 = (1, n = 122) = 4.952, p = .026, and a small-to-medium effect size (Φ = .201). On average, communication profiles also tended to be more severe among those with CAS+ wherein receptive language was poorer and phonemic inventories were smaller than those with CAS-Primary.

Conclusions

These retrospective data suggest that comorbid diagnosis may play an important role in communication and motor development in children with suspected CAS. These exploratory findings should motivate future prospective studies that consider the role of concomitant diagnoses in symptom profile and response to treatment in children with CAS.

Procedural Learning, Grammar, and Motor Skills in Children With Childhood Apraxia of Speech, Speech Sound Disorder, and Typically Developing Speech

Purpose This case-control study sought to determine if (a) children with childhood apraxia of speech (CAS), other speech sound disorders (SSDs), and typical development would perform differently on a procedural learning assessment and (b) whether grammatical ability would impact group differences. Method Communication, motor, and procedural learning abilities were assessed in 48 children with CAS (n = 13), SSD (n = 20), and typical development (n = 15), between 43 and 97 months of age (M = 66 months, SD = 12 months). Results On average, children with CAS demonstrated grammatical and motor impairments and required an increased number of exposures to the visuospatial sequence to demonstrate procedural learning, compared to peers with SSD or typical development. A subset of children from each group demonstrated an unanticipated procedural learning pattern wherein they evidenced an uptick in reaction time during the second sequenced block. Children with CAS with this pattern still evidenced procedural learning gains by the fifth sequenced block. In contrast, children with SSD and typical development with this pattern showed poor procedural learning outcomes and were characterized by lower scores on language and motor assessments as well. Conclusions This research provides partial support for the procedural learning deficit hypothesis in children with CAS and for a subset of children with SSD as well. Future research should examine the role of a serial reaction time task in identifying children at risk of multisystem communication and motor deficits. Supplemental Material https://doi.org/10.23641/asha.14173532.

Comparing global motor characteristics in children and adults with childhood apraxia of speech to a cerebellar stroke patient: evidence for the cerebellar hypothesis in a developmental motor speech disorder

Individuals with childhood apraxia of speech (CAS) have motor deficits in systems beyond speech and also global deficits in sequential processing, consistent with cerebellar dysfunction. We investigated the cerebellar hypothesis of CAS in 18 children and adolescents with CAS, 11 typical controls, an adult with a probable CAS history, and an adult with a history of a cerebellar stroke. Compared to the controls, children and adolescents with CAS had the greatest difficulty with rapid syllable repetition when alternating between two different syllables types, less difficulty when switching among three different syllables, and no difficulty when repeating the same syllable. They also showed difficulty with alternating but not repetitive key tapping. Motor speeds during the syllable repetition and key tapping tasks where correlated, consistent with a central motor delimiter that governs both systems. Participants with CAS obtained low scores in a test of fine motor ability, where the tasks required rapid integration of complex hand movement sequences. The adult with the probable CAS history obtained motor performance scores that generally resembled those in the children and adolescents with CAS, consistent with motor deficits that persist into adulthood. The participant with the cerebellar stroke history showed deficits in tests of fine and gross motor ability as well as balance. His repetitive and alternating key tapping was slow in the ipsilateral hand relative to the stroke lesion. The shared deficits in sequential motor functions among all participants with CAS and the cerebellar stroke patient are consistent with persisting cerebellar dysfunctions in CAS.

Differential Diagnosis of Childhood Apraxia of Speech Compared to Other Speech Sound Disorders: A Systematic Review

Purpose The aim of this study was to determine the discriminative features that might contribute to differentiation of childhood apraxia of speech (CAS) from other speech sound disorders (SSDs). Method A comprehensive literature search was conducted for articles or doctoral dissertations that included ≥ 1 child with CAS and ≥ 1 child with SSD. Of 2,071 publications screened, 53 met the criteria. Articles were assessed for (a) study design and risk of bias; (b) participant characteristics and confidence in diagnosis; and (c) discriminative perceptual, acoustic, or kinematic measures. A criterion was used to identify promising studies: American Academy of Neurology study design (Class III+), replicable participant descriptions and adequate confidence in diagnosis (≥ 3), and ≥ 1 discriminative and reliable measure. Results Over 75% of studies were retrospective, case-control designs and/or assessed English-speaking children. Many studies did not fully describe study design and quality. No studies met the Class I (highest) quality rating according to American Academy of Neurology guidelines. CAS was mostly compared to speech delay/phonological disorder. Only six studies had diagnostic confidence ratings of 1 (best). Twenty-six studies reported discriminative perceptual measures, 14 reported discriminative acoustic markers, and four reported discriminative kinematic markers. Measures were diverse, and only two studies directly replicated previous findings. Overall, seven studies met the quality criteria, and another eight nearly met the study criteria to warrant further investigation. Conclusions There are no studies of the highest diagnostic quality. There are 15 studies that can contribute to further diagnostic efforts discriminating CAS from other SSDs. Future research should utilize careful diagnostic design, support replication, and adhere to standard reporting guidelines. Supplemental Material https://doi.org/10.23641/asha.13158149.

The Neurodevelopmental and Motor Phenotype of SCA21 (ATX-TMEM240)

Spinocerebellar ataxia type 21 (SCA21/ATX-TMEM240) is a rare form of cerebellar ataxia that commonly presents with motor, cognitive, and behavioral impairments. Although these features have been identified as part of the clinical manifestations of SCA21, the neurodevelopmental disorders associated with SCA21 have not been well studied or described. Here we present extensive phenotypic data for 3 subjects from an SCA21 family in the United States. Genetic testing demonstrated the c.196 G>A (p.Gly66Arg) variant to be a second recurrent mutation associated with the disorder. Standardized developmental assessment revealed significant deficits in cognition, adaptive function, motor skills, and social communication with 2 of the subjects having diagnoses of autism spectrum disorder, which has never been described in SCA21. Quantitative gait analysis showed markedly abnormal spatiotemporal gait variables indicative of poor gait control and cerebellar as well as noncerebellar dysfunction. Clinical evaluation also highlighted a striking variability in clinical symptoms, with greater ataxia correlating with greater severity of neurodevelopmental disorder diagnoses. Notably, neurodevelopmental outcomes have improved with intervention over time. Taken together, this case series identifies that the manifestation of neurodevelopmental disorders is a key feature of SCA21 and may precede the presence of motor abnormalities. Furthermore, the coexistence of ataxia and neurodevelopmental disorders in these subjects suggests a role for spinocerebellar pathways in both outcomes. The findings in this study highlight the importance of evaluation of neurodevelopmental concerns in the context of progressive motor abnormalities and the need for timely intervention to ultimately improve quality of life for individuals with SCA21.

Differential Diagnosis of Apraxia of Speech in Children and Adults: A Scoping Review

Purpose Despite having distinct etiologies, acquired apraxia of speech (AOS) and childhood apraxia of speech (CAS) share the same central diagnostic challenge (i.e., isolating markers specific to an impairment in speech motor planning/programming). The purpose of this review was to evaluate and compare the state of the evidence on approaches to differential diagnosis for AOS and CAS and to identify gaps in each literature that could provide directions for future research aimed to improve clinical diagnosis of these disorders. Method We conducted a scoping review of literature published between 1997 and 2019, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. For both AOS and CAS, literature was charted and summarized around four main methodological approaches to diagnosis: speech symptoms, quantitative speech measures, impaired linguistic-motor processes, and neuroimaging. Results Results showed that similar methodological approaches have been used to study differential diagnosis of apraxia of speech in adults and children; however, the specific measures that have received the most research attention differ between AOS and CAS. Several promising candidate markers for AOS and CAS have been identified; however, few studies report metrics that can be used to assess their diagnostic accuracy. Conclusions Over the past two decades, there has been a proliferation of research identifying potential diagnostic markers of AOS and CAS. In order to improve clinical diagnosis of AOS and CAS, there is a need for studies testing the diagnostic accuracy of multiple candidate markers, better control over language impairment comorbidity, more inclusion of speech-disordered control groups, and an increased focus on translational work moving toward clinical implementation of promising measures.