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Purpose Adolescent psychosocial outcomes of individuals with histories of childhood apraxia of speech (CAS) were compared to outcomes of individuals with histories of speech sound disorders (SSD) only and SSD with language impairment (LI). It was hypothesized that individuals with more severe and persistent disorders such as CAS would report poorer psychosocial outcomes. Method Groups were compared using analyses of variance on a psychosocial assessment battery that included measures of hyperactivity and inattention, anxiety, depression, internalizing and externalizing behaviors, thought problems, and social outcomes. Results Results revealed significant group differences on self-report of social problems and parent report of hyperactivity, thought problems, and social problems at adolescence. Compared to the SSD-only group, the CAS group had significantly higher parental ratings of hyperactivity and social problems in adolescence. The CAS and SSD + LI groups did not differ on psychosocial measures, possibly due to the high rate of comorbid LI in the CAS group. The CAS group also had more individuals who scored in the borderline/clinical range on self-report of social problems than the SSD-only group. The CAS group did not differ from the SSD + LI group in the number of participants scoring in the borderline/clinical range on measures. Conclusions Individuals with histories of CAS demonstrate increased rates of social problems and hyperactivity based on parent ratings compared to adolescents with histories of SSD only; however, most do not score within the clinical range. The persistence of speech sound errors combined with self-reported and parent-reported social difficulties suggests that speech-language pathologists should be sensitive to the social and emotional impact of CAS and make appropriate referrals to mental health professionals when warranted.

Purpose This article examines the need for increased research into the prelinguistic trajectory of childhood apraxia of speech (CAS). We discuss the significant gains made in the early identification of disorders such as autism spectrum disorder, fragile X syndrome, and Rett syndrome that have resulted through the study of early (i.e., prelinguistic) developmental behaviors of infants and toddlers at risk for these disorders. We suggest that notable gains in understanding CAS could be made by increasing investigative focus on infants and toddlers later diagnosed with CAS or who are at risk for it (i.e., have an older sibling diagnosed with the disorder). Conclusions Currently, there are few studies to guide clinical decision making for infants and toddlers who may have CAS. To address this gap, we present a call to action with recommendations for researchers and clinicians. We recommend more retrospective investigative designs be conducted, inclusive of retrospective parent questionnaires and retrospective home video analysis, as well as prospective longitudinal studies of at-risk infants. We suggest that studies not be limited to exploring an affected infant's vocal output, but that efforts be made to acquire a broad view of an affected infant's early developmental trajectory (e.g., social skills, eye gaze, and imitative skills). A more comprehensive understanding of CAS will guide clinicians not only in identification of the disorder but will inform treatment decisions as well.

Background The Rapid Syllable Transition (ReST) treatment is an effective intervention designed to address the planning and programming disorder found in childhood apraxia of speech. To date, no study has considered its use with children who speak languages other than English. Aim This pilot study aimed to examine the use of ReST treatment with Italian children. We hypothesized that the ReST approach would improve the overall accuracy of the targeted behaviors of lexical stress, smoothness, and phonemic accuracy, whereas phonemic and phonetic accuracy of untreated items would remain stable. Method Two monolingual Italian-speaking children with childhood apraxia of speech received therapy in 12 one-hour sessions, 2–3 times per week, using a single-case experimental design. The treatment procedures used in English were replicated in Italian with one change: In English, two stress patterns are treated. Italian commonly uses three stress patterns; therefore, the stimuli were modified accordingly. Accuracy of articulation, lexical stress, and smoothness were assessed at pretreatment and 1 day, 1 week, and 4 months posttreatment in treated and untreated pseudowords and in real words and sentences. Results Both children improved on treated pseudowords and real words with moderate effect sizes, but only one child generalized to untreated pseudowords. Maintenance of treatment results was observed in both participants. Articulation of control phonemes did not change. Conclusions ReST treatment in Italian is feasible, and a treatment effect was found, showing that its use may be valid in languages other than English. Further research is required. Supplemental Material https://doi.org/10.23641/asha.14348060

IntroductionPitch variation, which refers to one's ability to vary fundamental frequency (F0) within or between syllables when speaking, has not been investigated in children with childhood apraxia of speech (CAS). However, pitch variation plays an important role in tone languages, as varying F0 patterns communicate different lexical meanings. This study investigated pitch variation abilities in individuals with CAS via the tone-sequencing tasks (TSTs), focusing on task performance and the effects of syllable structure, lexical status, and tones.MethodThree Cantonese-speaking children with CAS (aged 3;7–5;8 [years;months]) and six children without CAS participated in the study. Children without CAS were divided into two control groups, comprising those with speech and/or language impairment or typical development. TSTs consisted of 56 sets of five repetitions of stimuli. The stimuli varied in syllable structure, lexical status, and tones. Percentage of tones correct (PTC), consistency scores, F0 values, and acoustic repetition duration were measured.ResultsThe CAS group performed more poorly than the control groups on the TST with respect to tone accuracy, consistency, and repetition duration. No interaction effects between group and syllable structure or group and lexical status were found. No significant difference was found on F0 values across time between Tone 1 and Tone 2 syllables in the CAS group. However, interaction effects between group and time points of F0 values on Tone 2 syllables were found.DiscussionThe results suggest that children with CAS have difficulty with pitch variation, which was revealed on the TST with respect to tone accuracy, consistency, and repetition duration. Moreover, children with CAS have difficulty in varying F0 values to produce high-rising tones and tend to use high-level tones to substitute. Clinically, the TST may be useful to assist in the diagnosis of CAS. Isolated vowel stimuli may be useful to test young children or children with severe impairment. Future investigations and development of a normed tool for children with CAS are suggested.

Purpose To assess the concurrent validity of two tasks used to inform diagnosis of childhood apraxia of speech (CAS), this study evaluated the agreement between the Syllable Repetition Task (SRT) and the Maximum Repetition Rate of Trisyllables (MRR-Tri). Method A retrospective analysis was conducted with 80 children 7–16 years of age who were referred for treatment studies. All children had a speech sound disorder, and all completed both the SRT and the MRR-Tri. On each task, children were classified as meeting or not meeting the tool's threshold for CAS based on the sound sequencing errors demonstrated. Results The two tasks were in agreement for 47 participants (59% of the sample); both tasks classified 13 children as meeting the threshold for CAS and 34 children as not meeting the threshold for CAS. However, the two tasks disagreed on CAS classification for 33 children (41% of the sample). Overall, the MRR-Tri identified more children as having sound sequencing errors indicative of CAS ( n = 39) than did the SRT ( n = 20). Conclusions These two tasks of sound sequencing differ in the children they identify with CAS, possibly due to aspects of the underlying task requirements (e.g., time pressure). The SRT and the MRR-Tri should not be used in isolation to identify CAS but may be useful as part of a balanced CAS assessment battery that includes additional tasks that inform the nature of the impairment and that aid treatment planning. Supplemental Material https://doi.org/10.23641/asha.14110280

Purpose What does it mean to be social? In addition, how is that different from behaving socially appropriately? The purpose of this clinical focus article is to tackle these two questions along with taking a deeper look into how communication challenges in childhood apraxia of speech impact social competencies for young children. Through the lens of early social development and social competency, this clinical focus article will explore how speech motor challenges can impact social development and what happens when young learners miss early opportunities to grow socially. While not the primary focus, the clinical focus article will touch upon lingering issues for individuals diagnosed with childhood apraxia of speech as they enter the school-aged years. Conclusion Finally, it will address some foundational aspects of intervention and offer ideas and suggestions for structuring therapy to address both speech and social goals.

Purpose This article uses two case studies to illustrate clinical decision making using the best available evidence to approach the assessment and intervention for children with childhood apraxia of speech. The cases represent children seen in the authors' clinical practice, with personal information altered or omitted to protect the identity of the individuals. The case discussions exemplify choices that may be made for children of different ages, highlighting common elements across ages, as well as treatment aspects that may differ by age. Conclusions While research regarding best practice for assessment and treatment for childhood apraxia of speech has not been conclusive and, in fact, at times has been equivocal, there is empirical evidence from which to develop a rationale for assessment and treatment decisions. Accountability is important even as decisions are being made based on the best available evidence. In each case study, modifications in treatment depended on data that allowed the clinician to evaluate the children's response to therapy and adapt accordingly.

Purpose The study of speech motor control has led to great advancements in the current understanding of childhood apraxia of speech (CAS). There remains a significant need to bridge the gap between theory and practice to fully understand the clinical implications of past research. Method This review article reviews the speech motor control research in CAS and discusses how these works have offered key information about the underlying motor deficits (Grigos et al., 2015; Terband et al., 2019), the influence of structured practice on speech performance (Case & Grigos, 2016; Grigos & Case, 2018), and the role of task complexity (Case, 2019; Case & Grigos, 2016; Grigos & Case, 2018). We highlight salient points from this existing literature and clinical implications to the assessment and treatment of CAS. Conclusion The study of speech motor control has shed light on a number of key factors related to CAS. Even within perceptually accurate speech, children with CAS display differences in movement patterning and timing control. Assessment must aim to more directly tax speech motor skills to obtain a thorough and accurate illustration of production deficits. Intervention is challenged with the task of not only improving production accuracy but also facilitating more efficient motor planning and programming. Motor-based intervention that applies motor learning principles and introduces variability across motor, phonetic, and prosodic contexts is believed to achieve this goal, though research is needed to better understand changes in speech motor control with treatment.

Purpose Childhood apraxia of speech (CAS) is a speech disorder that many generalist speech-language pathologists feel underqualified to treat. For children with CAS, this may result in ad hoc interventions resulting in slower progress. Research evidence for various CAS treatments is primarily limited to single-case experimental design studies; however, two treatments (Rapid Syllable Transition Treatment [ReST] and the Nuffield Dyspraxia Programme, Third Edition) have been compared in a single randomized controlled trial. Conclusion This tutorial describes one of those treatments: ReST which was designed to address the three consensus core features of CAS simultaneously: consistency and accuracy of sounds, sequencing, and prosody. The treatment uses nonwords to help children build and store accurate motor plans and programs using principles of motor learning. Treatment data are described, and commonly reported clinical issues are discussed. Recommendations for which children may be suitable for ReST and for evidence-based practice are described.

Purpose A number of justification have examined the effects of speech interventions on outcomes in childhood apraxia of speech (CAS). The findings have been summarized in the form of systematic reviews (SRs) and meta-analyses, which are used to support evidence-based clinical practice decisions. Yet without acceptable rigor, SRs/meta-analyses may be biased in their recommendations. We appraised the quality of existing SRs for CAS treatment using a tool developed within epidemiology, the AMSTAR-2 (A MeaSurement Tool to Assess Systematic Reviews). Method A search of five databases to identify published SRs that coalesced treatment research for CAS revealed six systematic reviews that met inclusion criteria. Two examiners coded each article with the AMSTAR-2 to rate the methodologic rigor of the SRs and extracted summary data. Results One rigorous systematic review included only one randomized controlled trial. A second moderately rigorous review examined multiple single participant research designs. The weight of high-quality evidence supported the positive effects of motor programming treatments for children with CAS. Conclusions Findings of six systematic reviews, two of which were conducted with relative rigor, suggest that motor programming treatments have the best evidence base for treatment decisions pertaining to CAS. Clinicians are referred to online resources to implement these treatments according to published protocols.

Purpose The purpose of this article is to describe a treatment approach, Dynamic Temporal and Tactile Cueing (DTTC), and to provide clinicians and clinical researchers a clear understanding of the theory and principles that contributed to the design of the treatment as well as the clinical decisions that must be made when implementing it. While brief descriptions of DTTC have been provided in textbooks, a complete summary of the rationale, essential elements, method, and procedures has not yet been published. Such a summary is important so that clinicians can gain a better understanding of and more confidence in using the method for appropriate children. Furthermore, this article provides clinicians and clinical researchers essential information for measurement of fidelity. Method The important elements of the DTTC method with rationale for their inclusion are described. The temporal hierarchy of DTTC is depicted, and the dynamic procedure is described in detail, with suggestions for fidelity measurement. Finally, a discussion of important decisions clinicians must make when implementing DTTC is presented. Conclusions The goal of DTTC is to improve the efficiency of neural processing for the development and refinement of sensorimotor planning and programming. The rationale for DTTC in general, as well as the key elements important to its administration, are supported by models of speech production and theories of motor learning. Important clinical decisions regarding stimuli, organization of practice, and feedback are based on principles of motor learning in order to facilitate acquisition, retention, and continued improvement of motor speech skills.

Purpose Little is known about how clinicians develop expertise in childhood apraxia of speech (CAS), a rare speech disorder with heterogeneous presentation. The purpose of this survey study was to examine the beliefs and practices of clinicians specializing in CAS. Method Speech-language pathologists who self-identify as having expertise in CAS ( n = 165) completed an online survey regarding influences on clinical practice and beliefs about CAS. Practice patterns and perspectives regarding CAS were analyzed for respondents who self-identify as having expertise in CAS, across 4 experience bands (1–5, 6–10, 11–15, and 15+ years). Results A majority of the respondents to this survey provide treatment to preschool-age children with CAS. Respondents report features used in differential diagnosis aligned with the American Speech-Language-Hearing Association's (2007 ) technical report, with inconsistency as a key feature. Results suggest that continuing education courses are highly influential in the perceived development of expertise and perspectives regarding CAS. Respondents expressed uncertainty about comorbidity of CAS with other communication disorders. Overall, beliefs and practices are relatively uniform across levels of clinical experience. Conclusions Practices and perspectives of clinicians who self-identify as having expertise with CAS are influenced by factors noted in previous literature. Results of this survey highlight the need for research on the development of expertise in the clinical management of CAS, updated consensus statements that reflect advances in current research, clarification regarding comorbidity of CAS with other communication disorders, and evaluation of continuing education opportunities. Supplemental Material https://doi.org/10.23641/asha.9755459

BackgroundWith respect to the clinical criteria for diagnosingchildhood apraxia of speech(commonly defined as a disorder of speech motor planning and/or programming), research has made important progress in recent years. Three segmental and suprasegmental speech characteristics—error inconsistency, lengthened and disrupted coarticulation, and inappropriate prosody—have gained wide acceptance in the literature for purposes of participant selection. However, little research has sought to empirically test the diagnostic validity of these features. One major obstacle to such empirical study is the fact that none of these features is stated in operationalized terms.PurposeThis tutorial provides a structured overview of perceptual, acoustic, and articulatory measurement procedures that have been used or could be used to operationalize and assess these 3 core characteristics. Methodological details are reviewed for each procedure, along with a short overview of research results reported in the literature.ConclusionThe 3 types of measurement procedures should be seen as complementary. Some characteristics are better suited to be described at the perceptual level (especially phonemic errors and prosody), others at the acoustic level (especially phonetic distortions, coarticulation, and prosody), and still others at the kinematic level (especially coarticulation, stability, and gestural coordination). The type of data collected determines, to a large extent, the interpretation that can be given regarding the underlying deficit. Comprehensive studies are needed that include more than 1 diagnostic feature and more than 1 type of measurement procedure.

Purpose Childhood apraxia of speech (CAS) is hypothesized to arise from deficits in speech motor planning and programming, but the influence of abnormal speech perception in CAS on these processes is debated. This study examined speech perception abilities among children with CAS with and without language impairment compared to those with language impairment, speech delay, and typically developing peers. Method Speech perception was measured by discrimination of synthesized speech syllable continua that varied in frequency (/dɑ/–/ɡɑ/). Groups were classified by performance on speech and language assessments and compared on syllable discrimination thresholds. Within-group variability was also evaluated. Results Children with CAS without language impairment did not significantly differ in syllable discrimination compared to typically developing peers. In contrast, those with CAS and language impairment showed significantly poorer syllable discrimination abilities compared to children with CAS only and typically developing peers. Children with speech delay and language impairment also showed significantly poorer discrimination abilities, with appreciable within-group variability. Conclusions These findings suggest that speech perception deficits are not a core feature of CAS but rather occur with co-occurring language impairment in a subset of children with CAS. This study establishes the significance of accounting for language ability in children with CAS. Supplemental Materials https://doi.org/10.23641/asha.5848056

Purpose The aim of the study was to propose the speech motor learning approach (Van der Merwe, 2011) as a treatment for childhood apraxia of speech and to determine if it will effect positive change in the ability of a 33-month-old child to produce untreated nonwords and words containing treated age-appropriate consonants (Set 1 sounds), untreated age-appropriate consonants (Set 2), and untreated age-inappropriate consonants (Set 3) and also to determine the nature and number of segmental speech errors before and after treatment. Method An A-B design with multiple target measures and follow-up was implemented to assess the effects of treatment of Set 1. Effect sizes for whole-word accuracy were determined, and two criterion lines were generated following the conservative dual criterion method. Speech errors were judged perceptually. Results Conservative dual criterion analyses indicated no reliable treatment effect due to rising baseline scores. Effect sizes showed significant improvement in whole-word accuracy of untreated nonwords and real words containing age-appropriate treated sounds and real words containing age-appropriate untreated sounds. The number of errors for all three sound sets declined. Sound distortion was the most frequent error type. Conclusions Preliminary evidence suggests potentially positive treatment effects. However, rising baseline scores limit causal inference. Replication with more children of different ages is necessary. Supplemental Materials https://doi.org/10.23641/asha.5596708

Purpose Although childhood apraxia of speech (CAS) is generally considered a motor speech disorder, there is evidence implicating deficits in speech perception as a causative factor. If this is the...

Purpose The current research sought to determine (a) if speech inconsistency is a core feature of childhood apraxia of speech (CAS) or if it is driven by comorbid language impairment that affects a large subset of children with CAS and (b) if speech inconsistency is a sensitive and specific diagnostic marker that can differentiate between CAS and speech delay. Method Participants included 48 children ranging between 4;7 to 17;8 (years;months) with CAS ( n = 10), CAS + language impairment ( n = 10), speech delay ( n = 10), language impairment ( n = 9), or typical development ( n = 9). Speech inconsistency was assessed at phonemic and token-to-token levels using a variety of stimuli. Results Children with CAS and CAS + language impairment performed equivalently on all inconsistency assessments. Children with language impairment evidenced high levels of speech inconsistency on the phrase “buy Bobby a puppy.” Token-to-token inconsistency of monosyllabic words and the phrase “buy Bobby a puppy” was sensitive and specific in differentiating children with CAS and speech delay, whereas inconsistency calculated on other stimuli (e.g., multisyllabic words) was less efficacious in differentiating between these disorders. Conclusions Speech inconsistency is a core feature of CAS and is efficacious in differentiating between children with CAS and speech delay; however, sensitivity and specificity are stimuli dependent.

This article uses the International Classification of Functioning (ICF) framework to outline the assessment needs of children with apraxia of speech. Specifically, the level of breakdown for children with apraxia of speech—that of motor planning and programming at the level of body functions—is delineated using operationally defined criteria for greater diagnostic transparency.

There is increasing evidence for treatment approaches designed for children with childhood apraxia of speech (CAS). Despite this, no treatment has conclusive evidence to date. The CAS population is heterogeneous, with children presenting with varying symptom profiles, severity levels, and comorbidities. Consequently, treatment planning for children with CAS represents a clinical challenge. To assist clinicians in providing optimal care, this paper uses the International Classification of Functioning, Disability and Health (ICF) as a framework for identifying the body structures and functions, activities, and personal/environmental factors that should be considered when working with children with CAS. Evidence-based interventions are described and resources outlined to help guide the treatment planning process.

Purpose Articulatory control and speech production accuracy were examined in children with childhood apraxia of speech (CAS) and typically developing (TD) controls within a novel word–learning task to better understand the influence of planning and programming deficits in the production of unfamiliar words. Method Participants included 16 children between the ages of 5 and 6 years (8 CAS, 8 TD). Short- and long-term changes in lip and jaw movement, consonant and vowel accuracy, and token-to-token consistency were measured for 2 novel words that differed in articulatory complexity. Results Children with CAS displayed short- and long-term changes in consonant accuracy and consistency. Lip and jaw movements did not change over time. Jaw movement duration was longer in children with CAS than in TD controls. Movement stability differed between low- and high-complexity words in both groups. Conclusions Children with CAS displayed a learning effect for consonant accuracy and consistency. Lack of change in movement stability may indicate that children with CAS require additional practice to demonstrate changes in speech motor control, even within production of novel word targets with greater consonant and vowel accuracy and consistency. The longer movement duration observed in children with CAS is believed to give children additional time to plan and program movements within a novel skill.

Speech sound disorders (SSDs) are commonly viewed as involving impaired articulation and/or phonological skills. Speech language pathologists working with individuals with (SSDs) assess the articulation of speech sounds and the coordination of articulatory structures with other components of the speech mechanism, including the phonatory, respiratory, and resonatory subsystems. The sound system of the language and the rules that govern how phonemes are combined are equally critical for clinicians to explore. While the terms “articulation” and “phonology” provide clinicians with a framework for classification, children who are broadly identified with (SSDs) may also display characteristics of a motor speech impairment, which can obscure the decision making process with respect to both diagnosis and treatment. One such motor speech disorder is childhood apraxia of speech (CAS). The focus of this paper is to discuss motor speech deficits in children and to review research that aims to distinguish motor speech patterns in children with (SSDs) with and without CAS. We will also address the relationship between emerging speech motor and linguistic skills.

Purpose The purpose of this research was to examine spatial and temporal aspects of articulatory control in children with childhood apraxia of speech (CAS), children with speech delay characterized by an articulation/phonological impairment (SD), and controls with typical development (TD) during speech tasks that increased in word length. Method The participants included 33 children (11 CAS, 11 SD, and 11 TD) between 3 and 7 years of age. A motion capture system was used to track jaw, lower lip, and upper lip movement during a naming task. Movement duration, velocity, displacement, and variability were measured from accurate word productions. Results Movement variability was significantly higher in the children with CAS compared with participants in the SD and TD groups. Differences in temporal control were seen between both groups of children with speech impairment and the controls with TD during accurate word productions. As word length increased, movement duration and variability differed between the children with CAS and those with SD. Conclusions These findings provide evidence that movement variability distinguishes children with CAS from speakers with SD. Kinematic differences between the participants with CAS and those with SD suggest that these groups respond differently to linguistic challenges.

PurposeThis randomized controlled trial compared the experimental Rapid Syllable Transition (ReST) treatment to the Nuffield Dyspraxia Programme–Third Edition (NDP3; Williams & Stephens, 2004), used widely in clinical practice in Australia and the United Kingdom. Both programs aim to improve speech motor planning/programming for children with apraxia of speech (CAS), but they differ in types of stimuli used, level of stimulus complexity at initiation of treatment, and the principles of motor learning that they apply.MethodTreatment was delivered to 26 children with mild to severe CAS aged 4–12 years through trained and supervised speech-language pathology students in 1-hr sessions, 4 days a week for 3 weeks at a university clinic. Articulation and prosodic accuracy were assessed at pretreatment, 1 week, 1 month, and 4 months posttreatment using blinded independent assessors to compare treatment, maintenance, and generalization effects.ResultsThe ReST and NDP3 treatments demonstrated large treatment effects. ReST maintained treatment gains from 1-week to 4-months posttreatment more effectively than the NDP3. Significant generalization to untreated stimuli was observed for both ReST and NDP3.ConclusionsReST and NDP3 have strong evidence of treatment and generalization gains in children with CAS when delivered intensively. Overall, ReST has greater external evidence from multiple sources but both treatments have support for clinical use.Supplemental Materialhttps://doi.org/10.23641/asha.6170300

Persistent Speech Disorder (PSD) is present when a speech impairment extends beyond 8–9 years of age. Persistent Speech Disorder can extend into adolescence and adulthood. While PSD can include individuals with residual speech errors, such as distortions of /r/, /s/, and /z/, clinicians are particularly concerned in cases where PSD affects speech intelligibility. This paper is presented in two parts. Part 1 reviews the limited literature available on speech, language, literacy, educational, vocational, and socio-emotional outcomes in people with PSD of currently unknown origin. Part 2 presents a case study of a 22-year-old man, known as BJ, who has Nonverbal IQ in the normal range and severe PSD, specifically Childhood Apraxia of Speech. Longitudinal data on BJ from 3;3 years to 22 years is presented, alongside BJ's insights into PSD written via e-mail or using his electronic communication device. These two sources of information add to the limited body of information about the course of PSD and the experience of PSD in an individual through to adulthood.

Purpose Previous articles in this supplement described rationale for and development of the pause marker (PM), a diagnostic marker of childhood apraxia of speech (CAS), and studies supporting its validity and reliability. The present article assesses the theoretical coherence of the PM with speech processing deficits in CAS. Method PM and other scores were obtained for 264 participants in 6 groups: CAS in idiopathic, neurogenetic, and complex neurodevelopmental disorders; adult-onset apraxia of speech (AAS) consequent to stroke and primary progressive apraxia of speech; and idiopathic speech delay. Results Participants with CAS and AAS had significantly lower scores than typically speaking reference participants and speech delay controls on measures posited to assess representational and transcoding processes. Representational deficits differed between CAS and AAS groups, with support for both underspecified linguistic representations and memory/access deficits in CAS, but for only the latter in AAS. CAS–AAS similarities in the age–sex standardized percentages of occurrence of the most frequent type of inappropriate pauses ( abrupt ) and significant differences in the standardized occurrence of appropriate pauses were consistent with speech processing findings. Conclusions Results support the hypotheses of core representational and transcoding speech processing deficits in CAS and theoretical coherence of the PM's pause-speech elements with these deficits.

Purpose The purpose of this 2nd article in this supplement is to report validity support findings for the Pause Marker (PM), a proposed single-sign diagnostic marker of childhood apraxia of speech (CAS). Method PM scores and additional perceptual and acoustic measures were obtained from 296 participants in cohorts with idiopathic and neurogenetic CAS, adult-onset apraxia of speech and primary progressive apraxia of speech, and idiopathic speech delay. Results Adjusted for questionable specificity disagreements with a pediatric Mayo Clinic diagnostic standard, the estimated sensitivity and specificity, respectively, of the PM were 86.8% and 100% for the CAS cohort, yielding positive and negative likelihood ratios of 56.45 (95% confidence interval [CI]: [1.15, 2763.31]) and 0.13 (95% CI [0.06, 0.30]). Specificity of the PM for 4 cohorts totaling 205 participants with speech delay was 98.5%. Conclusion These findings are interpreted as providing support for the PM as a near-conclusive diagnostic marker of CAS.

Purpose Three previous articles provided rationale, methods, and several forms of validity support for a diagnostic marker of childhood apraxia of speech (CAS), termed the pause marker (PM). Goals of the present article were to assess the validity and stability of the PM Index (PMI) to scale CAS severity. Method PM scores and speech, prosody, and voice precision-stability data were obtained for participants with CAS in idiopathic, neurogenetic, and complex neurodevelopmental disorders; adult-onset apraxia of speech consequent to stroke and primary progressive apraxia; and idiopathic speech delay. Three studies were completed including criterion and concurrent validity studies of the PMI and a temporal stability study of the PMI using retrospective case studies. Results PM scores were significantly correlated with other signs of CAS precision and stability. The best fit of the distribution of PM scores to index CAS severity was obtained by dividing scores into 4 ordinal severity classifications: mild, mild-moderate, moderate-severe, and severe. Severity findings for the 4 classifications and retrospective longitudinal findings from 8 participants with CAS supported the validity and stability of the PMI. Conclusion Findings support research and clinical use of the PMI to scale the severity of CAS.

Purpose The goal of this article (PM I) is to describe the rationale for and development of the Pause Marker (PM), a single-sign diagnostic marker proposed to discriminate early or persistent childhood apraxia of speech from speech delay. Method The authors describe and prioritize 7 criteria with which to evaluate the research and clinical utility of a diagnostic marker for childhood apraxia of speech, including evaluation of the present proposal. An overview is given of the Speech Disorders Classification System, including extensions completed in the same approximately 3-year period in which the PM was developed. Results The finalized Speech Disorders Classification System includes a nosology and cross-classification procedures for childhood and persistent speech disorders and motor speech disorders (Shriberg, Strand, & Mabie, 2017). A PM is developed that provides procedural and scoring information, and citations to papers and technical reports that include audio exemplars of the PM and reference data used to standardize PM scores are provided. Conclusions The PM described here is an acoustic-aided perceptual sign that quantifies one aspect of speech precision in the linguistic domain of phrasing. This diagnostic marker can be used to discriminate early or persistent childhood apraxia of speech from speech delay.

Purpose To present a systematic review of single-case experimental treatment studies for childhood apraxia of speech (CAS). Method A search of 9 databases was used to find peer-reviewed treatment articles from 1970 to 2012 of all levels of evidence with published communication outcomes for children with CAS. Improvement rate differences (IRDs) were calculated for articles with replicated (n > 1), statistically compared treatment and generalization evidence. Results Forty-two articles representing Phase I and II single-case experimental designs (SCEDs; n = 23) or case series or description studies ( n = 19) were analyzed. Six articles showed high CAS diagnosis confidence. Of the 13 approaches within the 23 SCED articles, treatments were primarily for speech motor skills ( n = 6), linguistic skills ( n = 5), or augmentative and alternative communication ( n = 2). Most participants responded positively to treatment, but only 7 of 13 approaches in SCED studies reported maintenance and/or generalization of treatment effects. Three approaches had preponderant evidence (Smith, 1981). IRD effect sizes were calculated for Integral Stimulation/Dynamic Temporal and Tactile Cueing, Rapid Syllable Transition Treatment, and Integrated Phonological Awareness Intervention. Conclusions At least 3 treatments have sufficient evidence for Phase III trials and interim clinical practice. In the future, efficacy needs to be established via maintenance and generalization measures. Supplemental Material https://doi.org/10.23641/asha.6170225

Purpose Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT; Hayden, 2004; Hayden, Eigen, Walker, & Olsen, 2010)—a treatment approach for the improvement of speech sound disorders in children—uses tactile-kinesthetic-proprioceptive (TKP) cues to support and shape movements of the oral articulators. No research to date has systematically examined the efficacy of PROMPT for children with childhood apraxia of speech (CAS). Method Four children (ages 3;6 [years;months] to 4;8), all meeting the American Speech-Language-Hearing Association (2007) criteria for CAS, were treated using PROMPT. All children received 8 weeks of 2 × per week treatment, including at least 4 weeks of full PROMPT treatment that included TKP cues. During the first 4 weeks, 2 of the 4 children received treatment that included all PROMPT components except TKP cues. This design permitted both between-subjects and within-subjects comparisons to evaluate the effect of TKP cues. Gains in treatment were measured by standardized tests and by criterion-referenced measures based on the production of untreated probe words, reflecting change in speech movements and auditory perceptual accuracy. Results All 4 children made significant gains during treatment, but measures of motor speech control and untreated word probes provided evidence for more gain when TKP cues were included. Conclusion PROMPT as a whole appears to be effective for treating children with CAS, and the inclusion of TKP cues appears to facilitate greater effect.

Purpose To compare the relative effects of random vs. blocked practice schedules in treatment for childhood apraxia of speech (CAS). Although there have been repeated suggestions in the literature to use random practice in CAS treatment, no systematic studies exist that have directly compared random with blocked practice in this population. Method Using an alternating treatments single-subject design with multiple baselines across behaviors, the authors compared random and blocked practice in 4 children diagnosed with CAS in terms of retention and transfer. Random and blocked practice were implemented in the context of a version of Dynamic Temporal and Tactile *Cueing treatment (Strand, Stoeckel, & Baas, 2006). Perceptual accuracy of target utterances was scored, and effect sizes were calculated to quantify the magnitude of treatment effects. Results Findings were mixed, with 2 children showing a blocked practice advantage, 1 child showing a random practice advantage, and 1 child showing no clear improvement in either condition. Conclusions These findings suggest that the random practice advantage observed in the nonspeech motor learning literature may not extend to treatment for CAS. Furthermore, the findings add to the small body of literature indicating that integral stimulation treatment can lead to improvements in speech production for children with CAS.

This paper presents an overview of clinical and neuroscience research that is relevant to distinguishing characteristics of childhood apraxia of speech (CAS) from perceptual/phonological disorders (PPD) in children with speech sound disorders. An initial attempt at developing a clinical checklist of as few as seven speech production characteristics, based on a literature review, may be useful for distinguishing CAS from PPD. Data on 11 children seen for intensive speech language intervention in 2008 are presented. The paper also provides longitudinal data on four children seen over two decades that presented with CAS vs. PPD. Clinical implications of a treatment outcome study, the CAS checklist, and longitudinal case studies are discussed.

Purpose Dysprosody is considered a core feature of childhood apraxia of speech (CAS), especially impaired production of lexical stress. Few studies have tested the effects of intervention for dysprosody. This Phase II study with 3 children investigated the efficacy of a treatment targeting improved control of relative syllable durations in 3-syllable nonwords representing strong-weak (SW) and weak-strong (WS) stress patterns (e.g., BAtigu or baTIgu). Treatment sessions were structured along the principles of motor learning (PML) approach. Method Three children, age 7 to 10 years, with mild to moderate CAS and normal language development participated in an intensive 3-week treatment. Within-participant designs with multiple baselines across participants and behaviors were used to examine acquisition, generalization, and maintenance of skill. Results All children improved in their ability to control relative duration of syllables in SW and WS nonwords. Improvement was also noted in control of loudness and pitch contrasts. Treatment effects generalized to untreated nonword stimuli, but minimal change was seen in production of real words. Conclusion Findings support the efficacy of this approach for improving production of lexical stress contrasts. Structuring the intervention according to the PML approach likely stimulated strong maintenance and generalization effects.

Purpose To review the content and psychometric characteristics of 6 published tests currently available to aid in the study, diagnosis, and treatment of motor speech disorders in children. Method We compared the content of the 6 tests and critically evaluated the degree to which important psychometric characteristics support the tests' use for their defined purposes. Results The tests varied considerably in content and methods of test interpretation. Few of the tests documented efforts to support reliability and validity for their intended purposes, often when relevant information was probably available during the test’s development. Conclusions Problems with the reviewed tests appear related to overly broad plans for test development and inadequate attention to relevant psychometric principles during the development process. Recommendations are offered for future test revisions and development efforts that can benefit from recent research in test development and in pediatric motor speech disorders.

Purpose: The primary aim of this study was to examine differences in speech/language and written language skills between children with suspected childhood apraxia of speech (CAS) and children with other speech-sound disorders at school age. Method: Ten children (7 males and 3 females) who were clinically diagnosed with CAS (CAS group) were followed from the preschool years (ages 4–6) to school age (ages 8–10) and were compared with children with isolated speech-sound disorders (S group; n =15) and combined speech-sound and language disorders (SL group; n =14). Assessments included measures of articulation, diadochokinetic rates, language, reading, and spelling. Results: At follow-up, 8 of the children with CAS demonstrated improvement in articulation scores, but all 10 continued to have difficulties in syllable sequencing, nonsense word repetition, and language abilities. The children also exhibited comorbid disorders of reading and spelling. Group comparisons revealed that the CAS group was similar to the SL group, but not the S group during the preschool years. By school age, however, the SL group made more positive changes in language skills than the CAS group. Clinical Implications: These findings suggest that the phenotype for CAS changes with age. Language disorders persist in these children despite partial resolution of articulation problems. Children with CAS are also at risk for reading and spelling problems.

investigations, the need for a multimodal approach to communication when working with children with suspected CAS is stressed. It should be noted that relatively little research with only a small number of children has been conducted to examine the impact of using AAC with children who have suspected CAS. Much of this research has been in the form of case studies (e.g., Bornman, Alant, & Meiring, 2001; Cumley & Swanson, 1999; Waller et al., 2001), with a few researchers reporting experimentally controlled data (i.e., Binger et al., 2006; Binger & Light, 2007; Harris et al., 1996; Kent-Walsh, 2003). The aided AAC tools that have been used with children with suspected CAS include (a) remnant books; (b) theme-specific boards (e.g., a board for playing with vehicles; a board for going to a particular restaurant); (c) communication dictionaries (e.g., a book of graphic symbols arranged by category, such as food, people, places); and (d) pre-programmed messages on a voice output device (Binger et al.; Binger & Light; Bornman et al.; Culp, 1989; Cumley & Swanson; Harris et al.; Waller et al.).

Two prior studies in this series (Shriberg, Aram, & Kwiatkowski, 1997a, 1997b) address the premise that children with developmental apraxia of speech (DAS) can be differentiated from children with speech delay (SD) on the basis of one or more reliable differences in their speech. The first study compared segmental and prosody-voice profiles of a group of 14 children with suspected DAS to profiles of 73 children with SD. Results suggest that the only linguistic domain that differentiates some children with suspected DAS from those with SD is inappropriate stress. The second study cross-validated these findings, using retrospective data from a sample of 20 children with suspected DAS evaluated in a university phonology clinic over a 10-year period.The present study is of particular interest because it cross-validates the prior stress findings, using conversational speech samples from 19 children with suspected DAS provided by five DAS researchers at geographically diverse diagnostic facilities in North America. Summed across the three studies, 52% of 48 eligible samples from 53 children with suspected DAS had inappropriate stress, compared to 10% of 71 eligible samples from 73 age-matched children with speech delay of unknown origin.Discussion first focuses on the implications of stress findings for theories of the origin and nature of DAS. Perspectives in psycholinguistics, neurolinguistics, and developmental biolinguistics lead to five working hypotheses pending validation in ongoing studies: (a) inappropriate stress is a diagnostic marker for at least one subtype of DAS, (b) the psycholinguistic loci of inappropriate stress in this subtype of DAS are in phonological representational processes, (c) the proximal origin of this subtype of DAS is a neurogenically specific deficit, (d) the distal origin of this form of DAS is an inherited genetic polymorphism, and (e) significant differences between acquired apraxia of speech in adults and findings for this subtype of DAS call into question the inference that it is an apractic, motor speech disorder. Concluding discussion considers implications of these findings for research in DAS and for clinical practice.

This second paper in a series on developmental apraxia of speech (DAS) (Shriberg, Aram, & Kwiatkowski, 1997a) reports findings from two studies. Study I compares speech and prosody-voice profiles of a group of 14 children with suspected DAS to profiles of 73 children with speech delay (SD). Results suggest that the only linguistic domain that differentiates some children with suspected DAS from those with SD is inappropriate stress. Study II cross-validates these findings, using retrospective data from a sample of 20 children with suspected DAS evaluated in a university phonology clinic over a 10-year period. Discussion considers methodological and conceptual issues in the measurement of linguistic stress. Theoretical issues and implications for research and clinical practice are deferred for synthesis of the present findings with those from a multi-site crossvalidation project (Shriberg, Aram, & Kwiatkowski, 1997b).

DAS is a motor control problem in which the purposeful production of speech is faulty. The underlying problem affects movement control of the speech-production musculature for speech and non-speech activities. Diagnostic criteria for DAS should be based on the speech and motor control problems manifested by these children, and not other language or cognitive symptoms, even though these frequently co-occur with the apraxia. Treatment programs should be based on the development of motor skills and, as such, adhere closely to the principles of motor learning.

In a previous letter to the parent(s) of children with developmental apraxia of speech (DAS), the speech characteristics often exhibited as part of the disorder were described. In this second letter, the issues involved in current thinking about the nature of the disorder are explored. Also shared is information concerning what is thought to be known about the causes of the disorder. An appendix of publications exploring these issues appears at the end of the letter.

The conclusions and discussion were based on only 16 children who were identified based on clearly described criteria. Those subjects have widely varying ages, unspecified treatment histories, and varying receptive language status. The authors did not claim that these results are generalizable to a larger population of children, but I fear that their results will be interpreted that way by others. Identifying unusual phrasal stress deficits in 8 of 16 children with suspected DAS should not be construed or implied as evidence for a diagnostic marker for a subtype of DAS. I strongly agree with the authors that longitudinal studies of children with persistent and unusual speech disorders are needed. Studies concerning children's responses to treatment are also needed. Although models of adult onset apraxia (AOS) may provide useful procedures for measuring or describing speech and nonspeech characteristics of DAS, using AOS as a theoretical model or clinical analogy to DAS leads us to ask less relevant questions about children with unusual and persistent speech disorders. Children with suspected DAS are different from adults who have AOS. Children who have never spoken normally or used language normally are different from adults who have acquired a speech disorder after decades of using spoken and written language normally. In order to intervene efficiently and appropriately, we need to know whether and how children with DAS differ from other children, not how they might resemble adults with an acquired disorder.

Efficacy of phonological intervention is rooted in the assessment of the speech disorder—its nature, characteristics, severity, and prognosis for improvement. From the assessment that a clinician completes on a child, appropriate phonologic goals are targeted that will maximize treatment outcomes. Our treatment goal is to achieve the greatest amount of change in the least amount of time. According to Gierut (1986), our treatments are only as effective as our assessment is accurate and complete. In a typical 60 to 90 minute evaluation session with a child, what do you assess? This is a simple question, and one that clinicians and researchers face daily. It has become so routine to many of us that we no longer question what we will do in an evaluation session. Yet the procedures we choose are a reflection of what we believe speech disorders are, whether speech is viewed as part of a linguistic structure, and how we can utilize treatment to restructure a child’s sound system. The questions embedded in the assessment decision include the following: What data do you collect? What aspects of the child’s communication abilities do you include in your assessment? What analyses do you complete? How do you differentially diagnose articulation impairment (AI) from phonological impairment (PI)? Further, how do you determine whether there is an organic motor speech disorder or a nonorganic basis of the speech disorder? If you accept the possibility of a diagnosis of childhood apraxia of speech (CAS), how would you differentially diagnose CAS from AI and PI? Finally, what are your recommendations for intervention? The goal of this clinical forum is to provide five different perspectives on this essential question of what to assess when the clock is ticking. The contributors discuss their assessment procedures within a time frame and provide a rationale for their procedures. The contributors to this forum were invited to present their evaluation perspective because of their clinical and scholarly competence and their qualifications in working with children who have speech disorders. They also represent a wide variety of perspectives, which provides a range of viewpoints in the assessment of speech disorders in children. In addition to the articles by contributors who practice primarily in university settings, there is also a clinician’s perspective from a community viewpoint. Finally, two brief commentaries from leading experts in child phonology appear at the end of the forum to address assessment issues that are open for debate. It has been about a decade since a forum has been devoted to clinical assessment of child speech. Shelton and others discussed assessment procedures in the 1993 forum in Seminars in Speech and Language for a child, Matthew, who exhibited a persistent sound disorder. Fey (1992) coordinated a clinical forum in Language, Speech, and Hearing Services in Schools (LSHSS) that addressed critical issues in clinical phonology and helped to clarify and expand our thinking with regard to the range and extent of phonological principles in the assessment and treatment of children with speech disorders. As this forum’s articles demonstrate, our field has moved beyond the articulation/ phonology debate discussed in those earlier forums. The present collection of articles does not focus on whether to incorporate phonological principles into the assessment of children’s speech, but rather on the rationale for incorporating specific aspects of phonological principles. The current forum moves previous discussions forward in a way that will allow the reader to compare and contrast the different assessment methodologies, particularly with regard to how each demonstrates the theory-practice coherence and assessment-intervention congruence that Schwartz (1992) and Kamhi (1992) discussed in the LSHSS forum.