Word of Mouth 27:1 September/October 2015
•• There was no difference between the HFA and TD
groups in the range of communicative functions they
used.
•• Differences were greater between the older TD and HFA
groups than between the younger TD and HFA groups.
•• TD adolescents showed decreases in errors and
increases in response to cues, which was not seen in
HFA adolescents.
Can the instrument provide significant discrimination
between the diagnostic groups?
•• The total error score provides a measure of specificity
(correctly identifying TD children), and the total cue
score provides a measure of sensitivity (correctly
identifying the HFA students).
•• The diagnostic accuracy for the Pragmatic Protocol
was good—better for the older students than the
younger students.
Does the instrument meet psychometric standards of
reliability, internal consistency, validity, sensitivity, and
specificity?
•• Interrater reliability was very high.
•• Scores from the four conversational domains and the
total score demonstrated high consistency.
•• Overall sensitivity and specificity are only fair. The
authors do not intend the Protocol to be used primary
for diagnostic purposes but rather to identify pragmatic
deficits in ASD and serve as an index of pragmatic
skills in students whose diagnoses may be borderline or
difficult to determine. A larger sample size might have
yielded better sensitivity and specificity.
Clinical Implications
The Pragmatic Protocol may also be useful with
students diagnosed under the new diagnostic category,
social pragmatic disorder. It might also enable clinicians
Diagnosing Childhood Apraxia of Speech
Murray, E., McCabe, P., Heard, R., & Ballarda, K. J. (2015). Differential diagnosis of children with
suspected childhood apraxia of speech. Journal of Speech, Language, and Hearing Research, 58, 43–60.
Summarized by Carol Westby
Speech-language pathologists (SLPs) often struggle
with making a differential diagnosis of children with
4
to identify students’ pragmatic strengths and weaknesses
and design more targeted intervention programs.
References
Adams, C., Green, J., Gilchrist, A., & Cox, A. (2002).
Conversational behaviour of children with Asperger
syndrome and conduct disorder. Journal of Child Psychology
and Psychiatry, 43, 679–690.
Adams, C., & Lloyd, J. (2005). Elicited and spontaneous
communicative functions and stability of conversational
measures with children who have pragmatic language
impairments. International Journal of Language &
Communication Disorders, 40, 333–348.
Adams, C., Lockton, E., Freed, J., Gaile, J., Earl, G., McBean, K.,
. . . Law, J. (2012). The Social Communication Intervention
Project: A randomized controlled trial of the effectiveness of
speech and language therapy for school-age children who have
pragmatic and social communication problems with or without
autism spectrum disorder. International Journal of Language &
Communication Disorders, 43, 233–244.
Bishop, D. (2006). Children’s Communication Checklist–Second
Edition. London, England: Psychological Corporation.
Creaghead, N. (1984). Strategies for evaluating and targeting
pragmatic behaviors in young children. Seminars in Speech
and Language, 5, 241–252.
Gutiérrez-Clellen, V., & Peña, E. (2001). Dynamic assessment
of diverse children: A tutorial. Language, Speech, and
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Klin, A., Jones, W., Schultz, R., & Volkmar, F. (2003). The
enactive mind or from actions to cognition: Lessons from
autism. Philosophical Transactions of the Royal Society B:
Biological Sciences, 358, 345–360.
Lidz, C., & Peña, L. (1996). Dynamic assessment: The model,
its relevance as a nonbiased approach, and its application to
Latino American preschool children. Language, Speech, and
Hearing Services in Schools, 27, 367–372.
O’Neil, D. (2009). Language Use Inventory. Ottawa, Ontario,
Canada: Knowledge in Development.
Volkmar, F., Lord, C., Bailey, A., Schultz, R., & Klin, A. (2004).
Autism and pervasive developmental disorders. Journal of
Child Psychology and Psychiatry, 45, 135–170.
Young, E., Diehl, J., Morris, D., Hyman, S., & Bennetto, L. (2005).
The use of two language tests to identify pragmatic language
problems in children with autism spectrum disorders. Language,
Speech, and Hearing Services in Schools, 36, 62–72.
moderate–severe speech sound disorders. Are the
speech sound disorders due to deficits in the
phonological rule system or to apraxia? Childhood
apraxia of speech (CAS) is considered an impairment
 Word of Mouth 27:1 September/October 2015
of speech motor control or praxis. Most researchers
agree that the core deficit for children with CAS is a
reduced or degraded ability to convert abstract
phonological codes to motor speech commands,
referred to as motor planning and/or programming
(American Speech–Language–Hearing Association
[ASHA], 2007b; Shriberg, Lohmeier, Strand, &
Jakielski, 2012). This consensus has been supported by
behavioral studies (ASHA, 2007a, 2007b; McCauley,
Tambyraja, & Daher-Twersky, 2012), classification
paradigms (Shriberg et al., 2010), and computational
modeling studies (Terband & Maassen, 2010). The
impairment then manifests itself as disordered
articulation, difficulty sequencing sounds and syllables,
inconsistent production of repeated sounds and
syllables, and disruption at the suprasegmental level
(i.e., dysprosody; ASHA, 2007a, 2007b). Despite the
recent advances in our theoretical understanding of
CAS, it remains difficult to differentially diagnose CAS
from other disorders. In the absence of a clinically
available validated assessment procedure, the current
gold standard for diagnosis is expert opinion (Maas,
Butalla, & Farinella, 2012). The purpose of this study
was to determine, after expert diagnosis, whether a
quantitative measure or set of measures differentiated
CAS from non-CAS in a sample of children referred
from the community with suspected CAS.
Despite much research, there is currently no single
neurological or behavioral diagnostic marker for all cases
of CAS (ASHA, 2007b). Behavioral measures that have
been considered have included inconsistent speech
features (e.g., Iuzzini, 2012), coarticulation and timing
errors (Sussman, Marquardt, & Doyle, 2000), prosody
(Munson, Bjorum, & Windsor, 2003), speech production
(Thoonen, Maassen, Gabreëls, & Schreuder, 1999), speech
perception (Nijland, 2009), linguistic skills (Lewis,
Freebairn, Hansen, Iyengar, & Taylor, 2004), and
nonspeech oral motor skills (Murdoch, Attard, Ozanne, &
Stokes, 1995).
Participants were recruited via a website
advertisement and flyers as well as e-mails and listserv
posts to SLPs, inviting them to volunteer for a research
treatment study. The inclusion criteria for participants
were (a) a clinical diagnosis of suspected CAS by a
community-based SLP, (b) age between 4 and 12 years,
(c) no previously identified language comprehension
difficulty, (d) normal or adjusted-to-normal hearing and
vision, (e) native English speaker, and (f) no other
developmental diagnoses not associated with CAS
(e.g., intellectual disability, autism, cerebral palsy). All
participants had received SLP intervention prior to this
study, and all had normal hearing. Forty-seven
participants qualified for the study.
Five tests were administered to all children:
1. The Diagnostic Evaluation of Articulation and
Phonology (DEAP) Inconsistency subtest (Dodd,
Hua, Crosbie, Holm, & Ozanne, 2002), used to
assess the word-level token-to-token inconsistency
in naming 25 pictured words over three test
administrations.
2. The Single-Word Test of Polysyllables (Gozzard,
Baker, & McCabe, 2008), a 50-item picture-naming
task used to assess articulation, sound and syllable
sequencing, and lexical stress accuracy (i.e., prosody).
3. A connected speech sample of at least 50 utterances
recorded over at least 10 min (McLeod, 1997), for
detection of perceptual features of CAS in connected
speech and calculation of articulation rate.
4. The Oral and Speech Motor Control Protocol, a
published oral motor assessment (OMA) including
diadochokinesis (DDK; Robbins & Klee, 1987),
used to rule out any structural or functional
abnormalities in the oral mechanism.
5. The Clinical Evaluation of Language Fundamentals
(CELF; Fourth edition or Preschool–2nd edition,
Australian versions), used to assess receptive and
expressive language skills (Semel, Wiig, & Secord,
2006; Wiig, Secord, & Semel, 2006).
Initially, responses to the assessments were used for
expert qualitative judgments of presence or absence of
CAS and, following this, for generating 24 quantitative
measures for statistical analyses to address the study aim.
The first and second authors independently, both
with more than 10 years of experience in differential
diagnosis of children with speech sound disorders,
diagnosed the presence and severity of CAS for all
children based on their perceptual ratings of each
child’s speech samples, using the following procedure.
To be diagnosed with CAS in this study, participants
had to demonstrate the following:
(a) The three consensus-based features listed in the
ASHA Technical Report (2007a, 2007b):
1. Inconsistent errors on consonants and vowels in
repeated productions of syllables or words,
2. Lengthened and disrupted coarticulatory transitions
between sounds and syllables, and
5
 Word of Mouth 27:1 September/October 2015
3. Inappropriate prosody, especially in the realization
of lexical or phrasal stress, and
(b) Any 4 of the 10 features in Strand’s 10-point
checklist (Shriberg, Potter, & Strand, 2009):
  1. Difficulty achieving initial articulatory
configurations and transitions into vowels,
  2. Syllable segregation (noticeable gaps in syllables),
  3. Lexical stress errors or equal stress,
  4. Vowel or consonant distortions including distorted
substitutions,
  5. Groping (nonspeech),
  6. Intrusive schwa,
  7. Voicing errors,
  8. Slow rate,
  9. Slow DDK rate, and
10. Increased difficulty with longer or more
phonetically complex words.
The tasks included the DEAP inconsistency subtest,
the Polysyllable test, and a connected speech sample.
Of the 47 children, the expert evaluators classified 28
(60%) as having CAS. Another four children (8%) met the
criteria for CAS but presented with comorbid dysarthria
and receptive and/or expressive language disorder (CAS+).
Children diagnosed with CAS or CAS+ showed a median
of 6 out of 10 features on the Strand 10-point checklist
(Shriberg, Potter, et al., 2009). Fifteen (32%) of the 47
children did not demonstrate all three features in the
ASHA feature list and were classified as non-CAS in this
study. Non-CAS diagnoses included ataxic dysarthria,
flaccid dysarthria, submucous cleft, or primarily
phonological disorder. Phonological impairment was
identified in those who had clear phonological processes
(Rvachew & Brosseau-Lapré, 2012) and an absence of
oromotor or speech motor deficits (e.g., DDK deficits)
excluding them from motor speech diagnosis.
Twenty-four qualitative measures were extracted
from the five tests that were administered:
•• Percentage inconsistency,
•• Percentage of lexical stress matches,
•• Distortion occurrences,
•• Syllable segregation occurrences,
•• Intrusive schwa occurrences,
•• Voicing error occurrences,
•• Percentage phonemes correct,
•• Percentage phonemes correct-revised,
•• Percentage vowels phonemes correct,
6
•• Magnitude of change score,
•• Articulation rate (syllables per minute),
•• Presence of false articulatory starts and restarts and/
or inaudible within-speech groping and/or audible
within-speech groping and/or hesitations,
•• Presence of nonspeech groping in lip and tongue oral
function tasks,
•• /pə/ rate over 3 s on 2 trials,
•• /tə/ rate over 3 s on 2 trials,
•• /kə/ rate over 3 s on 2 trials,
•• Accuracy on /pətəkə/ over 3 s on 2 trials,
•• Accuracy on /pətəkə/ DDK task on 2 trials,
•• Oral structure score,
•• Oral function score,
•• Maximum phonation time,
•• Receptive language score, and
•• Expressive language score.
Simple bivariate followed by hierarchical multivariate,
discriminant function analysis (DFA; McKean &
Hettmansperger, 1976) was used to determine whether
one or more of the 24 quantitative measures could
reliably predict the expert assignment of children to CAS
or non-CAS groups. For children with CAS only
(children without comorbid language disorders and
children with non-CAS [submucous cleft]), four
measures in conjunction accounted for 91% of the CAS
diagnosis: syllable segmentation, percentage of stress
matches, percentage correct consonants (PCC) on the
Single-Word Test of Polysyllables, and accuracy on DDK
tasks (/pətəkə/) from the Oral and Speech Motor Control
Protocol. Using statistical procedures, the researchers
developed a formula using weighted scores from these
four measures. The formula had 100% sensitivity and
100% specificity, that is, all children with CAS were
accurately diagnosed, and no children without CAS were
diagnosed with CAS. The strength of model was further
tested with data from the four CAS+ children and three
children with submucous cleft who had been excluded
from the DFA. Sensitivity remained high at 97%, with
one CAS+ participant being misdiagnosed as non-CAS;
specificity remained at 100%, with all submucous cleft
participants accurately classified as non-CAS. The four
measures are considered together in a hierarchical format
to make a diagnosis; individual cutoff scores for each
measure, although clinically appealing, do not capture
the relationships between the variables and therefore the
diagnosis. These four measures were derived from just
assessment tasks: a polysyllabic word picture-naming
task (Gozzard, Baker, & McCabe, 2004) and an oral
 Word of Mouth 27:1 September/October 2015
mechanism examination (Robbins & Klee, 1987), taking
less than 30 min to complete.
The inclusion of lexical stress errors in the ASHA
list of strong discriminative behaviors of CAS was
supported by this study, but the other two features
(inconsistency and lengthened and disrupted
coarticulatory transitions) were not supported. The
second feature, “lengthened and disrupted coarticulatory
transitions between sounds and syllables,” had only
54% accuracy in diagnosis when used independently.
The third ASHA criterion, “inconsistent errors on
consonants and vowels in repeated productions of
words and syllables,” did not add anything to the
discriminative model, yet inconsistency has been the
feature most used by clinicians to identify CAS (Forrest,
2003). The present study measured inconsistency with
the DEAP Inconsistency subtest, as it most closely
matched the definition of inconsistency used in the
ASHA Technical Report. When used as a sole predictor
in a bivariate DFA, inconsistency discriminated the
groups with 30% accuracy and did not contribute
significantly to predicting diagnosis in the multivariate
analyses.
The Strand 10-point checklist (Shriberg, Potter,
et al., 2009) includes both “syllable segregation” and
“lexical stress errors” as features. Accuracy on the
/pətəkə/ DDK task was not used to measure any criterion
from the Strand checklist. To be diagnosed with CAS
using the Strand checklist, children need to show
evidence of any 4 of the 10 features on the list, with no
differential weighting of any feature. The sensitivity
and specificity of Strand’s checklist have not been
tested, and it may not be sufficiently specific, with
potential risk of diagnosing negative cases with CAS.
Nonspeech groping (i.e., groping during nonspeech
tasks) has been used in CAS checklists over time,
presumably as a feature of CAS (e.g., Ozanne, 2005),
and nonspeech groping was the second most prevalent
feature in diagnosis in a survey of clinicians (Forrest,
2003). Despite this, the current study results suggest
that nonspeech groping had low diagnostic accuracy
independently and did not add to the diagnostic model.
Nonspeech features are indicative of oral apraxia rather
than CAS. Therefore, nonspeech difficulties are best
considered as concomitant rather than core features.
This study identified two tests that appear central to
differentiating CAS from other disorders, namely, a
complete OMA including a DDK task and a sufficiently
large sample of polysyllabic single-word production
(Gozzard et al., 2004). (The authors noted that there was a
subset of children who presented with obvious structural
and neurological deficits that were not identified prior to a
diagnosis of CAS.) Both the real-word polysyllabic test
and the nonword /pətəkə/ DDK task from the OMA were
motorically challenging and appear to successfully elicit
behaviors that reflected the underlying motor planning
and programming deficits in CAS at both the segmental
and suprasegmental levels (Shriberg, Lohmeier, Campbell,
et al., 2009). These two tests alone may be sufficient for
reliable diagnosis of CAS in verbal children. However,
SLPs using these tasks still need to consider normal
acquisition and development in terms of both segmental
and prosody accuracy.
References
American Speech-Language-Hearing Association. (2007a).
Childhood apraxia of speech [Position statement]. Retrieved
from http://www.asha.org/policy
American Speech-Language-Hearing Association. (2007b).
Childhood apraxia of speech [Technical report]. Retrieved
from http://www.asha.org/policy
Dodd, B., Hua, Z., Crosbie, S., Holm, A., & Ozanne, A. (2002).
Diagnostic evaluation of articulation and phonology
(DEAP). London, England: The Psychological Corporation.
Forrest, K. (2003). Diagnostic criteria of developmental apraxia of
speech used by clinical speech-language pathologists. American
Journal of Speech-Language Pathology, 12, 376–380.
Gozzard, H., Baker, E., & McCabe, P. (2004). Single word test
of polysyllables. Unpublished manuscript.
Gozzard, H., Baker, E., & McCabe, P. (2008). Requests for
clarification and children’s speech responses: Changing
“pasghetti” to “spaghetti.” Child Language Teaching &
Therapy, 24, 249–263.
Iuzzini, J. (2012). Inconsistency of speech in children with
childhood apraxia of speech, phonological disorders, and
typical speech (Doctoral dissertation). Available from
ProQuest Dissertations and Theses. (Accession No.
929147038)
Lewis, B. A., Freebairn, L. A., Hansen, A. J., Iyengar, S. K., &
Taylor, H. G. (2004). School-age follow-up of children with
childhood apraxia of speech. Language, Speech, and Hearing
Services in Schools, 35, 122–140.
Maas, E., Butalla, C. E., & Farinella, K. A. (2012). Feedback
frequency in treatment for childhood apraxia of speech. American
Journal of Speech-Language Pathology, 21, 239–257.
McCauley, R. J., Tambyraja, S., & Daher-Twersky, J. (2012,
February). Diagnostic methods in childhood apraxia of
speech research: 2001–2010. Paper presented at the
University of Sydney International Program Development
Fund Childhood Apraxia of Speech Assessment Meeting,
Santa Rosa, CA.
McKean, J. W., & Hettmansperger, T. P. (1976). Tests of hypotheses
based on ranks in the general linear model. Communication in
Statistics—Theory and Methods, 8, 693–709.
McLeod, S. (1997, Autumn). Sampling consonant clusters: Four
procedures designed for Australian children. Australian
Communication Quarterly, pp. 9–12.
7
 Word of Mouth 27:1 September/October 2015
Munson, B., Bjorum, E. M., & Windsor, J. (2003). Acoustic and
perceptual correlates of stress in nonwords produced by
children with suspected developmental apraxia of speech and
children with phonological disorder. Journal of Speech,
Language, and Hearing Research, 46, 189–202.
Murdoch, B. E., Attard, M. D., Ozanne, A. E., & Stokes, P. D.
(1995). Impaired tongue strength and endurance in
developmental verbal dyspraxia: A physiological analysis.
European Journal of Disorders of Communication, 30,
51–64.
Nijland, L. (2009). Speech perception in children with speech
output disorders. Clinical Linguistics & Phonetics, 23,
222–239.
Ozanne, A. (2005). Childhood apraxia of speech. In B. Dodd
(Ed.), Differential diagnosis and treatment of children with
speech disorder (2nd ed., pp. 71–83). London, England:
Whurr.
Robbins, J., & Klee, T. (1987). Clinical assessment of
oropharyngeal motor development in young children.
Journal of Speech and Hearing Disorders, 52, 271–277.
Rvachew, S., & Brosseau-Lapré, F. (2012). Developmental
phonological disorders: Foundations of clinical practice.
San Diego, CA: Plural.
Semel, E., Wiig, E., & Secord, W. (2006). Clinical evaluation of
language fundamentals, Australian standardised (4th ed.).
Sydney, Australia: Pearson.
Shriberg, L. D., Fourakis, M., Hall, S. D., Karlsson, H. B.,
Lohmeier, H. L., McSweeny, J. L., & Wilson, D. L. (2010).
Extensions to the Speech Disorders Classification System
(SDCS). Clinical Linguistics & Phonetics, 24, 795–824.
Developing Life Stories
Bohn, A., & Berntsen, D. (2008). Life story development in childhood: The development of life story
abilities and the acquisition of cultural life scripts from late middle childhood to adolescence.
Developmental Psychology, 44, 1135–1147.
Summarized by Carol Westby
Introduction
There is empirical evidence that children are able to
remember autobiographical events from quite an early
age and that their ability to narrate these memories
improves over the preschool and early school years
(e.g., Fivush, Haden, & Adam, 1995; Peterson, 2002;
Reese, 2002; van Abbema & Bauer, 2005). Better
autobiographical memory predicts better future mental
time travel (the ability to see oneself in the future),
which is important for self-regulation. Memory for past
events helps persons learn what to avoid and how to
behave in the future. Memory detail for past and future
events predicts social problem solving (Brown,
Dorfman, Marmar, & Bryant, 2012). SLPs know a
Shriberg, L. D., Lohmeier, H. L., Campbell, T. F., Dollaghan, C.
A., Green, J. R., & Moore, C. A. (2009). A nonword
repetition task for speakers with misarticulations: The
Syllable Repetition Task (SRT). Journal of Speech, Language,
and Hearing Research, 52, 1189–1212.
Shriberg, L. D., Lohmeier, H. L., Strand, E. A., & Jakielski,
K. J. (2012). Encoding, memory, and transcoding deficits in
childhood apraxia of speech. Clinical Linguistics &
Phonetics, 26, 445–482. doi:10.3109/02699206.2012.
655841
Shriberg, L. D., Potter, N. L., & Strand, E. A. (2009, November).
Childhood apraxia of speech in children and adolescents
with galactosemia. Paper presented at the American Speech-
Language-Hearing Association National Convention, New
Orleans, LA.
Sussman, H. M., Marquardt, T. P., & Doyle, J. (2000). An
acoustic analysis of phonemic integrity and contrastiveness
in developmental apraxia of speech. Journal of Medical
Speech Language Pathology, 8, 301–313.
Terband, H., & Maassen, B. (2010). Speech motor development
in childhood apraxia of speech: Generating testable
hypotheses by neurocomputational modeling. Folia
Phoniatrica et Logopedica, 62, 134–142.
Thoonen, G., Maassen, B., Gabreëls, F., & Schreuder, R. (1999).
Validity of maximum performance tasks to diagnose motor
speech disorders in children. Clinical Linguistics &
Phonetics, 13, 1–23.
Wiig, E., Secord, W., & Semel, E. (2006). Clinical evaluation of
language fundamentals preschool, Australian and New
Zealand standardised. Sydney, Australia: Pearson.
great deal about how children develop individual
narratives, particularly fictional narratives. However,
not much is known about children’s ability to combine
narratives of individual autobiographical memories
into a coherent life story. In fact, there is no empirical
evidence for the existence of life stories in children,
and it has been proposed that the ability to construct a
coherent life story is not developed before adolescence
or young adulthood (Habermas & Bluck, 2000; Singer,
2004). Life stories are critical in a developing sense of
self or identity and the ways one approaches life
experiences. Given that children with language/learning
disabilities exhibit delays and deficits in comprehension
and production of single-event narratives, it is likely
that they exhibit delays and deficits in autobiographical
memory and development of life stories, which can
influence their self-regulation.