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Dear Neurodevelopmental Pediatrician: Please Don’t Do That!

Recently I got yet another one of the dreaded phone calls which went a little something like this:

Parent: Hi, I am looking for a speech therapist for my son, who uses PROMPT to treat Childhood Apraxia of Speech (CAS). Are you PROMPT certified?

Me: I am PROMPT trained and I do treat motor speech disorders but perhaps you can first tell me a little bit about your child? What is his age? What type of speech difficulties does he have? Who diagnosed him and recommended the treatment.

Parent: He is turning 3. He was diagnosed by a neurodevelopmental pediatrician a few weeks ago. She recommended speech therapy 4 times a week for 30 minutes sessions, using PROMPT.

Me: And what did the speech therapy evaluation reveal?

Parent: We did not do a speech therapy evaluation yet.

Sadly I get these type of phone calls at least once a month. Frantic parents of toddlers aged 18 months to 3+ years of age call to inquire regarding the availability of PROMPT therapy based exclusively on the diagnosis of the neurodevelopmental pediatrician. In all cases I am told that the neurodevelopmental pediatrician specified speech language diagnosis, method of treatment, and therapy frequency, ALBEIT in a complete absence of a comprehensive speech language evaluation and/or past speech language therapy treatments.

The conversation that follows is often an uncomfortable one. I listen to the parental description of the child’s presenting symptoms and explain to the parents that a comprehensive speech language assessment by a certified speech language pathologist is needed prior to initiation of any therapy services. I also explain to the parents that depending on the child’s age and the assessment findings CAS may or may not be substantiated since there are a number of speech sound disorders which may have symptoms similar to CAS.

Following my ‘spiel’, the parents typically react in a number of ways. Some get offended that I dared to question the judgement of a highly qualified medical professional. Others hurriedly thank me for my time and resoundingly hang up the phone. Yet a number of parents will stay on the line, actually listen to what  I have to say and ask me detailed questions.  Some of them will even become clients and have their children undergo a speech language evaluation.  Still a number of them will find out that  their child never even had CAS! Past misdiagnoses ranged from ASD  (CAS was mistaken due to the presence of imprecise speech and excessive jargon related utterances) to severe phonological disorder to dysarthria secondary to CP.  Thus, prior to performing a detailed speech language evaluation  on the child I had no way of knowing whether the child truly presented with CAS symptoms.

Before I continue I’d like to provide a rudimentary definition of CAS.  Since its identification years ago it has been argued whether CAS is linguistic or motoric in nature with the latest consensus being that CAS is a disorder which disrupts speech motor control and creates difficulty with volitional, intelligible speech production.  Latest research also shows that in addition to having difficulty forming words and sentences at the speech level, children with CAS also experience difficulty in the areas of receptive and expressive language, in other words,  “pure” apraxia of speech is rare (Hammer, 2007).

This condition NEEDS to be  diagnosed by a speech language pathologist! Not only that, due to the disorder’s complexity it is strongly recommended that if parents suspect CAS they should take their child for an assessment with an SLP specializing in assessment and treatment of motor speech disorders. Here’s why.

  • CAS has a number of overlapping symptoms with other speech sound disorders (e.g., severe phonological disorder, dysarthria, etc).
  • Symptoms which may initially appear as CAS may change during the course of intervention by the time the child is older (e.g., 3 years of age) which is why diagnosing toddlers under 3 years of age is very problematic and the use of  “suspected” or “working” diagnosis is recommended (Davis & Velleman, 2000) in order to avoid misdiagnosis
  • Diagnosis of CAS is also problematic due to the fact that there are no valid or reliable standardized assessments sensitive to CAS  (McCauley & Strand, 2008). However, a new instrument Dynamic Evaluation of Motor Speech Skill (DEMSS) (Strand et al, 2013) is showing promise with respect to differential diagnosis of severe speech impairments in children
  • Thus for children with less severe impairments SLPs need to design tasks to assess the child’s:
    • Automatic vs. volitional control
    • Simple vs. complex speech
    • Consistency of productions on repetitions of same word
    • Vowel productions
    • Imitation abilities
    • Prosody
    • Phonetic inventory BEFORE and AFTER intervention
    •  Types and levels of cueing the child is presently stimulable to
      • in order to determine where the breakdown is taking place (Caspari, 2012)

These are just some of the reasons why specialization in CAS is needed and why it is IMPOSSIBLE to make a reliable CAS diagnosis by  simply observing the child for a length of time, from a brief physical exam, and from extensive parental interviews (e.g., a typical neurodevelopmental appointment).

In fact, leading CAS experts state that you DON’t need a neurologist in order to confirm the CAS diagnosis (Hammer, 2007).

Furthermore, “NO SINGLE PROGRAM WORKS FOR ALL CHILDREN WITH APRAXIA!!” (Hammer, 2007). Hence SLPs NEED to individualize not only their approach with each child but also switch approaches with the same child when needed it in order to continue making therapy gains. Given the above the PROMPT approach may not even be applicable to some children.

It goes without saying that MANY developmental pediatricians will NOT do this!

But for those who do, I implore you – if you observe that a young child is having difficulty producing speech, please refer the child for a speech language assessment first. Please specify to the parents your concerns (e.g., restricted sound repertoire for the child’s age, difficulty sequencing sounds to make words, etc) BUT NOT the diagnosis, therapy frequency, as well as therapy approaches.  Allow the assessing speech language pathologist to make these recommendations in order to ensure that the child receives the best possible targeted intervention for his/her disorder.

For more information please visit the Childhood Apraxia of Speech Association of North America (CASANA) website or visit the ASHA website to find a professional specializing in the diagnosis and treatment of CAS near you.


  1. Caspari, S (2012)  Beyond Picture Cards! Practical Assessment and Treatment Methods for Children with Apraxia of Speech. Session presented for New Jersey Speech Language Hearing Association Convention, Long Branch, NJ
  2. Davis, B., & Velleman, S. L. (2000). Differential diagnosis and treatment of developmental apraxia of speech in infants and toddlers. Infant-Toddler Intervention: The Transdisciplinary Journal, 10, 177–192.
  3. Hammer, D (2007) Childhood Apraxia of Speech: Evaluation and Therapy Challenges. Retrieved from
  4. McCauley RJ, Strand EA. (2008). A Review of Standardized Tests of Nonverbal Oral and Speech Motor Performance in Children. American Journal of Speech-Language Pathology, 17,81-91.
  5.  Strand, E, McCauley, R, Weigand, S, Stoeckel, R & Baas, B (2013) A Motor Speech Assessment for Children with Severe Speech Disorders: Reliability and Validity Evidence. Journal of Speech Language and Hearing Research, vol 56; 505-520.
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Product Review: Interactive WH question Megabundle by Speech2u

coverToday I am excited to review a cool WH question 97 page Mega Bundle  by Kelly of Speech2u.

Kelly created this activity to help children with significant language impairments (e.g., ASD, intellectual disability, etc) answer who, what and where questions given fun visuals.

Her intent was to allow the SLPs to control the levels of difficulty by adjusting the # of choices or selecting similar choices to reduce the task complexity.

Bundle content:

48 WHERE cards

where mat
32 WHO cards

36 WHAT cards

126 QUESTION cards

who magic xharacters
Teaching slides/graphic organizers for each question type


Question sorting Mat

wh mats

Game and Activity ideas for each set of cards

9 homework sheets with generalization questions

who questions list
Sample Goal Hierarchies

smaple goals

If using Sorting Mats Kelly recommends printing, laminating and cutting out PEOPLE, OBJECT and LOCATION cards. Then having the students sort the cards based on the type of question they need to answer.  Some of her game recommendations include personalization: such as cutting out Logos from popular stores/restaurants from ads (ex. Walmart, Target) and asking questions like “Where do we go to get ______, or What is your favorite ______? etc. Other game suggestions include adding pictures of familiar buildings or places: favorite parks, museums, relatives houses and asking questions like:  “Where did you go on ____?” Or “Where did ____ last week?”

I love how many activities games and suggestions Kelly offers in this bundle.  In contrast to other ‘wh’ question sets available on the market from popular SLP vendor companies, hers just happens to be very visually appealing in terms of graphics, as well as offers a number of extra features for teaching concrete ‘wh’ questions.  You can find this bundle in Kelly’s TPT store HERE  or you can head over to her BLOG and enter to win a free copy in a Rafflecopter Giveaway!

Kelly is also currently reviewing my Speech Language Assessment of Older Internationally Adopted Children packet on her BLOG . So I will also be giving away a copy of it in a Rafflecopter Giveaway below.

a Rafflecopter giveaway

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And Now on the Value of Wordless Picture Books

Today I am writing on one of my favorite topics: how to use wordless picture books for narrative assessment and treatment purposes in speech language pathology.  I love wordless picture books (or WLPBs as I refer to them) for a good reason and its not just due to their cute illustrations.  WLPBs are so flexible that use can use them for both assessment and treatment of narratives.  I personally prefer the Mercer Meyer  series: ‘A Boy, a dog, a frog and a friend’ for sentimental reasons (they were the first WLPBs I used in grad school) but some of you may want to use a few others which is why I’ll be proving a few links containing lists of select picture books for you to choose from at the end of this post.

So how do I use them and with which age groups?  Well, believe it or not you can start using them pretty early with toddlers and go all the way through upper elementary years. For myself, I found them to be most effective tools for children between 3-9 years of age.  During comprehensive language assessments I use WLPBs in the following way.  First I read a script based on the book. Depending on which WLPBs you use you can actually find select scripts online instead of creating your own.  For example, if you choose to use  the “Frog Series” by Mercer Meyer, the folks  at SALT SOFTWARE already done the job for you and you can find those  scripts HERE in both English and Spanish with audio to boot. 

After I read/play the script, I ask the child to retell the story (a modified version of dynamic narrative assessment if you will) to see what their narrative is like.  I am also looking to see whether the child is utilizing story telling techniques appropriate for his/her age.

For example,  I expect a child between 3-4 years of age to be able to tell a story which contains 3 story grammar components (e.g., —Initiating event, —Attempt or Action, —Consequences), minimally interpret/predict events during story telling, use some pronouns along with references to the characters names as well as discuss the character’s facial expressions, body postures & feelings (utilize early perspective taking) (Hedberg & Westby, 1993 ). By the time the child reaches 7 years of age, I expect him/her to be able to tell a story utilizing 5+ story grammar elements along with a clear ending, which indicates a resolution of the story’s problem, have a well developed plot, characters and a clear sequence of events, as well as keep consistent perspective which focuses around an incident in a story (Hedberg & Westby, 1993 ).

Therefore as children retell their stories based on the book I am keeping an eye on the following elements (as relevant to the child’s age of course):

  • Is the child’s story order adequate or all jumbled up?
  • Is the child using relevant story details or providing the bare minimum before turning the page?
  • How’s the child’s grammar? Are there errors, telegraphic speech or overuse of run-on sentences?
  • Is the child using any temporal (first, then, after that) and cohesive markers (and, so, but, etc)?
  • Is the child’s vocabulary adequate of immature for his/her age?
  • Is there an excessive number of word-retrieval difficulties which interfere with story telling and subsequently its comprehension?
  • Is the child’s story coherent and cohesive?
  • Is the child utilizing any perspective taking vocabulary and inferring the characters, feeling, ideas, beliefs, and thoughts?

Yes all of the above can be gleaned from a one wordless picture book!

If my assessment reveals that the child’s ability to engage in story telling is impaired for his/her age and I initiate treatment and still continue to use WLPBs in therapy.  Depending on the child’s deficits I focus on remediating  either elements of macrostructure (use-story organization and cohesion), microstructure (content + form including grammar syntax and vocabulary) or both.

Here are a few examples of story prompts I use in treatment with WLBPs:

  • —What is happening in this picture?
  • —Why do you think?
  • —What are the characters doing?
  • — Who /what else do you see?
  • —Does it look like anything is missing from this picture?
  • —Let’s make up a sentence with __________ (this word)
  • —Let’s tell the story. You start:
  • —Once upon a time
  • — You can say ____ or you can say ______ (teaching synonyms)
  • —What would be the opposite of _______? (teaching antonyms)
  • — Do you know that _____(this word) has 2 meanings
    • —1st meaning
    • —2nd meaning
Below are the questions I ask that focus on Story Characters and Setting —
  • Who is in this story?
  • —What do they do?
  • —How do they go together?
  • —How do you think s/he feels?
    • —Why?
    • —How do you know?
  • —What do you think s/he thinking?
    • — Why?
  • —What do you think s/he saying?
  • — Where is the story happening?
    • —Is this inside or outside?
      • —How do you know?
  • — Did the characters visit different places in the story?
    • —Which ones?
    • How many?

Here are the questions related to Story Sequencing

  • —What happens at the beginning of the story?
  • —How do we start a story?
  • — What happened second?
  • —What happened next?
  • —What happened after that?
  • —What happened last?
  • —What do we say at the end of a story?
  • —Was there trouble/problem in the story?
    • —What happened?
    • —Who fixed it?
    • —How did s/he fix it?
  • —Was there adventure in the story?
    • If yes how did it start and end?

As the child advances his/her skills I attempt to engage them in more complex book interactions—

  • —Compare and contrast story characters/items
  • —(e.g. objects/people/animals)
  • —Make predictions and inferences about what going to happen in the story
  • —Ask the child to problem solve the situation for the character
    • —What do you think he must do to…?
  • —Ask the child to state his/her likes and dislikes about the story or its characters
  • —Ask the child to tell the story back
    • —Based on Pictures
    • —Without Pictures

Wordless picture books are also terrific for teaching vocabulary of feelings and emotions

  • —Words related to thinking
    • —Know, think, remember, guess
  • —Words related to senses
    • —See, Hear, Watch, Feel
  • —Words related to personal wants
    • — Want, Need, Wish
  • —Words related to emotions and feelings
    • — Happy, Mad, Sad
  • —Words related to emotional behaviors
    • — Crying, Laughing, Frowning

So this is how I use wordless picture books for the purposes of assessment and therapy.  I’d love to know how you use them?

Before I sign off here are a few WDPBs links for you, hope you like them!

 Start having fun with your wordless picture books today!

Helpful Smart Speech Therapy Resources: 

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Types and Levels of Cues and Prompts in Speech Language Therapy

types and levels of cuesDo you need a handy guide explaining “Types and Levels of Cues and Prompts in Speech Language Therapy”?

Are you trying to understand the difference between cues and prompts?

Want to know the difference between phonemic and semantic prompts?

Trying to figure out how to distinguish between tactile and gestural cues? The grab my new handy guide which will succinctly explain all of the above information on just a handful of slides.

Does this product sound like something you need/you are interested in? You can find it in my online store HERE


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Introduction to Social Pragmatic Language Disorders

SPLDI have been making a lot of materials lately in order to disseminate information on a variety of helpful topics including insurance coverage for speech language services, improving feeding abilities in picky eaters, the importance of oro-facial observations during speech- language assessments  and so on. I’ve also created an “introduction” series, which offers handouts on popular topics of interest, most recently on the topic of Auditory Processing Disorders (APD), which can be currently found in my online store HEREContinue reading Introduction to Social Pragmatic Language Disorders

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Speech Language Services and Insurance Coverage: What Parents Need to Know

insurance coverageBased on popular demand I created this 26 slide presentation to provide basic information regarding insurance coverage for common outpatient speech language assessment and therapy services. This handout contains important questions parents must ask when speaking to their insurance representatives regarding service coverage. —It lists common pediatric diagnostic (ICD-9) and therapeutic (CPT) codes as well as discusses common service exclusions in policies. —It also provides some suggestions on how to initiate appeals for denial of services and includes links to helpful resources parents can access to obtain further elaboration on the information provided in this presentation. Continue reading Speech Language Services and Insurance Coverage: What Parents Need to Know

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If you give a mouse a cookie, it will want some phonemic awareness to go with it

I love book companion packs! Honestly I can’t get enough of them!

One of the reasons I particularly enjoy using them is because they nicely supplement thematic language therapy activities (see Twin Sister’s Post HERE on thematic therapy).  This is why I jumped at the opportunity to review Speech Universe’s  If You Give A Mouse A Cooke Phonemic Awareness Packet.

Phonemic Awareness activities are incredibly important for young (Pre-K-1st grade) language impaired learners.  They are especially important for children from low SES households as well as young  limited English proficiency learners.

Jen’s packet is terrific at addressing a number of phonemic awareness skills including:

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Being Functional is APP-ealing!

apfun sampleIf you’ve been following my blog for a while ,then you know that I place a lot of emphasis on function. This is reflected in the assessments I select and the materials I choose. I want them to be practical, multifaceted, and useful for a wide variety of clients.  My caseload at the hospital and in private practice is pretty varied with diagnoses ranging from über verbal high functioning Asperger’s to non-verbal autistic clients.

It is for the latter clients that I am always in search of more materials, since it is much easier to find/adapt materials for the high functioning verbal students then for the low-functioning non-verbal ones. Especially because you want to make sure that whichever materials you select are not just educational and functional but also fun and easy to interact with.  That is why I was so excited when I got the opportunity to review Teach Speech 365 APP-ealing Functional Communication Packet. Continue reading Being Functional is APP-ealing!