Assessment of Organic and Neurogenic Speech Sound Disorders

Question 1

How to identify Speech Sound
Disorders
And type of Disorders

Answer 1

To identify SSD associated with structural, sensory,
or neurological clinical conditions.
 Assessment goals and procedures for the following
disorders:
 Childhood Apraxia of Speech
 Developmental Dysarthria in Cerebral Palsy
 Cleft Lip and Palate
 Hearing Impairment

Question 2

Childhood Apraxia of Speech

Answer 2

Childhood apraxia of speech (CAS) is a neurological
childhood speech sound disorder in which the precision and
consistency of movements underlying speech are impaired in
the absence of neuromuscular deficits (e.g. abnormal reflexes,
abnormal tone)”.
 The core impairment in planning and/or programming
spatiotemporal parameters of movement sequences results in
errors in speech sound production and prosody (ASHA, 2007a,
Definitions of CAS section, para. 1).


Question 3

Oral apraxia

Answer 3

Oral apraxia - difficulty with volitional control of
nonspeech movement (e.g. difficulty sticking out and
wagging their tongue, or difficulty sequencing movements
for the command, “Show me how you kiss, now smile, now
blow”.

Question 4

Speech apraxia

Answer 4

Speech apraxia - difficulty with volitional movement for the
production of speech. This can be at the level of sounds,
syllables, words, or even phrases (connected speech). The
motor struggle is most typically seen with sound sequencing.

Question 5

CAS may occur due to:

Answer 5

CAS may occur due to:
 known neurological impairment (TBI, intrauterine stroke)
 complex neuro-behavioral disorder of known and
unknown origin (autism, DS)
 idiopathic neurogenic speech sound disorder.

Question 6

Segmental features of CAS:

Answer 6

Segmental features of CAS:
 Poor speech intelligibility in connected speech, varies
depending on length and complexity of utterances
 Inconsistency of sound errors (consonants and vowels) in
repeated productions of syllables and words
 Atypical articulation errors (prolongation, addition,
nonphonemic sound production (e.g. bilabial fricatives)

Question 7

Description CAS continues (Segmental):
Type of articulate groping

Answer 7

Description CAS continues (Segmental):
 Sound and syllable sequencing difficulties: difficulty sequencing sounds in syllables and words of different length and
complexity, and on diadochokinetic speech tasks.
 Articulatory groping and silent posturing
- silent posturing errors (static articulatory gesture without
audible sound)
- articulatory groping errors (a series of articulatory movements in
an effort to find the right position for a specific sound )

Question 8

Suprasegmental features of CAS
and
Associated problems:
Type of prosody problems

Answer 8

Suprasegmental features of CAS:
 Resonance issues: poor motor control of the velopharyngeal
mechanism may result in hypo/hypernasality
 Prosody problems: aprosody (monotone); dysprosody
(inappropriate variation in frequency and duration);
inappropriate stress patterns (errors on syllabic stress)
Associated problems: slow progress in therapy; fine/gross
motor coordination difficulties; decreased oral awareness;
presence of oral apraxia; expressive language problems, learning
disabilities, family hx

Question 9

The CAS symptoms described above may vary and should be
used with caution
The 6 characteristics

Answer 9

The CAS symptoms described above may vary and should be
used with caution
 A survey of 75 SLPs working with CAS identified six CAS
characteristics commonly agreed upon (Forrest, 2003):
1. Inconsistent speech sound productions
2. OM problems
3. Articulatory groping
4. Difficulty imitating modeled sound productions
5. Increased problems with increased utterance length
6. Difficulty sequencing sounds

Question 10

Assessment goals for CAS

Answer 10

Assessment of artic/phon. skills across varied tasks and situations
 Assess other communication skills: Auditory compreh/verbal
expression/reading/writing/Resonance/prosody/fluency
 Assess OM skills during speech and non-speech tasks
 Estimate severity
 Differential diagnosis
 Identify potential treatment targets
 Prognosis
 Identify child’s strengths and intact skills (to facilitate treatment)

Question 11

Assessment techniques for CAS

Answer 11

Developmental hx (identify problems in sucking, delays in
language development)
 Assess nonimitative (use of GFTA) and imitative speech
production skills (model sounds/words/sentences and ask to
imitate, first without visual cues)
 Assess consistency and variability of errors (in informal
tasks/formal tests, in varied phonetic contexts). Assess productions of the same phoneme in the same words in multiple trials.
 Assess diadochokinetic syllable rate
 Assess intelligibility, resonance, prosodic problems, fluency

Question 12

Formal tests used:

Answer 12

Apraxia profile (AP; Hickman, 2000) - and the Preschool Profile and
the School-Age Profile
 the Kaufman Speech Praxis Test for Children (KSPT; Kaufman,
1995); Ages: 2;0 – 5;11
 Screening Test for Developmental Apraxia of Speech-2 (Blakely,
2001); Ages: 4;0 – 7;0.
 Verbal Motor Production Assessment for Children (Hayden &
Square, 1999); Ages: 3;0 – 12; 11

Question 13

Cerebral Palsy

Answer 13

Cerebral Palsy – neuromotor disorder (non-progressive), as a result
of brain damage that can be:
 Prenatal (HIV; exposure to radiation , drugs, or metal toxicity, fetal anoxia,
cerebral hemorrhage, chromosomal abnormalities etc.)
 Perinatal (brain trauma, cerebral hemorrhage, anoxia during birth etc.)
 Postnatal (premature birth; sepsis, encephalitis/meningitis; head trauma etc.)

 Different types of Cerebral Palsy:
 Spastic: most common type; increased muscle tone, slow effortful/jerky
movements; pyramidal lesion.
 Dyskinetic: abnormal patterns of posture/movement (involuntary,
uncontrolled, and recurring movements of the body); extrapyramidal lesion.
 Ataxic: damage to the cerebellum ; affects equilibrium – issues with balance
and posture, rhythm, accuracy of movement of the body.
 Mixed

Question 14

Different types of Cerebral Palsy

Answer 14

Spastic: most common type; increased muscle tone, slow effortful/jerky
movements; pyramidal lesion.
 Dyskinetic: abnormal patterns of posture/movement (involuntary,
uncontrolled, and recurring movements of the body); extrapyramidal lesion.
 Ataxic: damage to the cerebellum ; affects equilibrium – issues with balance
and posture, rhythm, accuracy of movement of the body.
 Mixed

Question 15

Developmental Dysarthria

Answer 15

motor speech sound disorder associated with CP.

Question 16

Dysarthria subtypes identified
5 aspects of speech that are affected
4 types of dysarthria

Answer 16

Cerebral Palsy may affect various parameters of speech production (respiration,
Phonation, Resonance, Articulation, Prosody)

 Dysarthria subtypes identified:
 Flaccid (lower motor neurons in brain stem/spinal cord and cranial/spinal
nerves to muscle fibers affected)
 Spastic (CNS; upper motor neurons and tracts to brainstem/spinal cord
damaged)
 Ataxic (cerebellar system damaged; movement incoordination)
 Dyskinetic/Hyperkinetic (CNS; basal ganglia damaged)
 Mixed

Question 17

Description of Dysarthria

Answer 17

Articulatory difficulties:
 Imprecise articulation (due to poor muscle strength, tone, speed,
range of motion),
 Slurred speech (especially ataxic)
 Slow rate of speech movements and speaking rate
 Difficulty with phonation (prolonging sounds)
 More omissions than substitutions or distortions, especially on final
sounds
 Production in connected speech is worse than in single words
 Predominance of cluster reduction, stopping, depalatalization,
fronting, gliding

Question 18

Description of Dysarthria
Phonatory problems
Resonance problems

Answer 18

Resonance problems
 Hypernasality and nasal emissions
 Poor oral resonance (diff. controlling intraoral breath pressure)

Phonatory problems
 Weak voice, loss of voice at the end of phrase (leads to whisper)
 Poor volume and control of volume
 High pitch or strained vocal quality (hyperadduction of VFs)
 Breathiness (due to hypoadduction of VFs)

Question 19

Description of Dysarthria (continues)
Respiratory problems
Prosodic problems
Associated problems

Answer 19

Description of Dysarthria (continues)
Respiratory problems
 Reduced activity of the chest and neck muscles, rapid breathing rate
 Indented sternum (sucked-in)
 Inadequate use of air (air wastage) during speech (leads to final cons.
omissions, short phrases)

Prosodic problems
 Monotone
 Lack of variation in intensity

Associated problems
 Slow/jerky jaw movements
 Poor coordination of the tongue movements during speech
 Slow diadochokinetic syllable rates
 Hearing loss, MR, ADD, language disorder, learning disability

Question 20

Assessment Goals: for dysarthria

Answer 20

Assessment Goals:
 Collaborate with assessment team: doctors, nurses,
psychologists, audiologists, educators, social workers, OT, PT
 Assess physiological structures during OM examination (head
control, neck stability, coordination of respiration and
phonation)
 Assess communication deficits relevant to CP
 Assess child’s strengths and intact skills
 Follow up assessments
 Assess the need/ability for use of alternative/augmentative
communication system

Question 20

Assessment procedures: for dysarthria

Answer 20

Assessment procedures:
 Observe/obtain information on:
 neuromotor functions (request doctor’s reports and consult with other
specialists)
 Speech and Motor development
 Cognitive development

 Assess OM mechanism and Feeding
 Presence of structural deviations
 muscle tone, breathing patterns
 Sucking, chewing, biting, swallowing
 Consider oral structural deviations (tongue weakness, asymmetries,
palate, jaw, malocclusions )

 Speech and language sample (if verbal)
 Analyze speech intelligibility and articulation errors/phon. pattern errors

 Formal tests

Question 21

Assessment (continues) dysarthria

Answer 21

Assessment (continues)
 Assess prosodic patterns
 Clinical judgement : Stress patterns, intonation, rate of speech, pauses

 Assess voice and respiratory function
 Clinical judgement re: vocal loudness/pitch (variation: jerky vs smooth)
 Vocal quality (harsh, hoarse, breathy, strained, strangled)
 Difficulty in voicing related to hyper/hypo- adduction of VFs
 Adequacy of breath support

 Assess resonance problems
 Hyper/hyponasality, nasal emissions, reduced oral resonance
 Obtain information on velopharyngeal functioning

 Assess the need for augmentative communication
 Assess oral communication abilities; OT and PT should be involved to
determine possibility of augmentative communication system use

Question 22

Cleft Lip and Palate

Answer 22

Cleft Lip and Palate
Definition: A Cleft is a congenital anomaly, a structural
malformation, that may ‘affect the tissue/ muscles/ bony processes
of the upper lip, alveolar process, hard palate, soft palate, and
uvula” (Pena-Brooks & Hedge, 2015. p. 321).
 Occurs during embryonic development: the fusion and growth
of palate and/or lips is disrupted.

 Etiology: may be due to genetic syndromes (Apert, Pierre
Robin, Woude etc.), and environmental toxins (excessive
alcohol consumption, illegal and prescription drug use).
 Cleft lip can be unilateral or bilateral
 Cleft palate involves hard (anterior 2/3 of roof of mouth, bony
foundation and muscular overlay) and soft palate (1/3, muscle
and mucosa).

Question 23

Cleft Lip and Palate
Speech sound disorders

Answer 23

Cleft Lip and Palate
Speech sound disorders
 More difficulty with voiced sounds
 Difficulty with sounds requiring build up of intraoral pressure
(weak production of fricatives, affricates, stops)
 Nasals sounds substituted for non-nasal sounds
 Nasal emissions for voiceless sounds
 Distortion of vowels
 Compensatory errors (sound substitutions to account for
inadequate closure of velopharyngeal mechanism; tongue is
moved back to stop the air )
 Reduced speech intelligibility

Question 24

Cleft Lip and Palate
Phonatory disorders
Resonance disorders
Associated problems:

Answer 24

Cleft Lip and Palate
Phonatory disorders
 Hyperfunction of the voice (due to velopharyngeal inadequacy)
 Vocal nodules, edema of VFs
 Hoarse voice, reduced vocal intensity, Monotone voice
 Strangled vocal quality: too much tension to avoid hypernasality

Resonance disorders
 Hypernasality on vowels and voiced oral consonants
 Hyponasality/Denasality (near absence of nasal resonance on
nasal sounds)

Associated problems:
 Velopharyngeal incompetence, hx of recurrent ME infections
and HL, language disorders

Question 25

Cleft Lip and Palate
Assessment procedures:

Answer 25

Cleft Lip and Palate
Assessment procedures:
 Collect a comprehensive case history
 Assess hearing function
 Assess oral-motor mechanism (pay attention to unrepaired clefts)
 Assess resonance (nasal flow is assessed by placing mirror under
the nares as the child prolongs /i/ - mirror should remain clear
unless child is hypernasal).
 Assess connected speech production (speech sample)
 Assess articulation and phonological skills using formal tests
 Assess phonatory problems, based on clinical judgement (vocal
quality, abusive behaviors)
 Assess velopharyngeal mechanism (sustained phonation of “ah”
allows to look at the movement of soft palate and assess
symmetry, tone, range, speed).

Question 26

Hearing impairment
Hearing loss types
Range of normal hearing:

Answer 26

Hearing impairment
1. Range of normal hearing: child – 0-15dB; adult – 0-25dB
 Hard of hearing: (less than 90dBHL) – have some residual hearing, can be
maximized through amplification devices (hearing aid)
 Deaf: profound HL of at least 90dB HL.

2. Hearing loss types ( mild to profound):
    Conductive HL – interrupted transmission of sound to the cochlea (outer or
   middle ear pathology).
    Common cause of conductive HL: Otitis media (inflammation of ME),
   other causes see in textbook (p. 327)
    Sensorineural HL - hair cells of the cochlea (sensory loss) or fibers of the
   acoustic nerve (peripheral neural loss) are damaged.
    Permanent HL
    Mixed HL

Question 27

Communication difficulties associated with
a hearing loss:
1. Articulation problems:
2. Voice and resonance problems
3. Fluency and prosodic disturbances

Answer 27

Communication difficulties associated with
a hearing loss:
1. Articulation problems:
a. Omission of I and F consonants and consonant clusters, omission of /s/ across word
positions
b. Prevalence of voiced consonants in place of voiceless, nasal for oral consonants
c. Distortion of stops and fricatives sounds
d. Vowel substitutions, increased duration of vowels, breathiness
e. Addition of vowels
f. Inappropriate release of final stops

2. Voice and resonance problems
   a. High-pitched voice, harshness , hoarseness
   b. Nasal emissions , hypernasality, lack of normal intonation
3. Fluency and prosodic disturbances
   a. Slow rate of speech, abnormal flow and rhythm, increased rate of dysfluencies