Guest blog by Elissa Flagg, MHSc, PhD, SLP(C), Reg. CASLPO, Interim Clinical & Executive Director, The Speech & Stuttering Institute
“SLPs in Ontario can’t diagnose Childhood Apraxia of Speech.”
Although this is a frequently encountered statement, it is actually misleading. Ontario Speech-Language Pathologists (SLPs) with sufficient training and clinical experience in children’s speech disorders can determine that a child’s speech meets criteria for Childhood Apraxia of Speech (CAS), just like SLPs in other jurisdictions. Unfortunately, this misunderstanding of the Ontario SLP’s role in identifying CAS has persisted for some time.
Fortunately, the College of Speech Language Pathologists and Audiologists of Ontario (aka CASLPO), shared critical information that addresses this misunderstanding in a Practice Advice column from September 2018, titled “Communicating Clinical Information Or a Diagnosis: Do You Know the Difference?” (CASLPO, 2018). This document is available online to both SLPs and members of the public.
While this resource does not exclusively focus on CAS, both parents of children with (suspected) CAS and SLPs working with children with speech sound disorders in Ontario will benefit from taking a close look at its content.
According to CASLPO, it is within the SLP’s scope of practice to use the term CAS to describe a set of speech symptoms observed in the course of evaluating of a child. CAS is specifically listed among “[e]xamples of terms that describe symptoms…” that can be used by SLPs when communicating assessment results. It’s just like an SLP identifying stuttering based on their observations of a client’s speech dysfluencies, and like many of the other examples provided of speech-language disorders that SLPs and audiologists assess, identify, and treat.
So why do so many people, including some SLPs, continue to accept the statement that SLPs can’t diagnose CAS in Ontario?
It turns out that it’s all about wording. Specifically, it’s about the way the word “diagnosis” is used in the legislation governing the practice of SLPs, the Regulated Health Professions Act (RHPA). It’s not that Ontario SLPs can’t determine or even communicate that a child has CAS…they just can’t communicate CAS as a “diagnosis.”
To make a long story short, the term “diagnosis” has a very specific significance within Ontario law – it entails identifying an underlying disease or disorder that causes a patient’s outwardly observable symptoms. Under the Ontario law, SLPs cannot communicate the underlying medical cause – that is, the diagnosis – that is responsible for a speech or language disorder. In fact, SLPs in Ontario cannot use the term “diagnosis” (or any of its related words, e.g. diagnose, diagnosed with, etc.) in their clinical work. However, this doesn’t mean that SLPs cannot communicate the clinical information that they have identified a specific speech or language disorder, such as when a child’s speech difficulties meet criteria for CAS.
So, why isn’t CAS a “diagnosis” according to this way of looking at things? Simply because CAS is a term for a speech disorder, not a medical condition. This is consistent with the way that experts in motor speech disorders use the term. In a seminal book Management of Motor Speech Disorders in Children and Adults, the authors addressed this issue as follows:
This point is very important. CAS is identified by clinical features that can be observed by the SLP, i.e. characteristics of a child’s speech production difficulties. The determination that a child has CAS does not include identification of a specific underlying medical cause. In fact, an underlying cause often cannot be found for CAS, should a child’s physician recommend medical testing, such as neurological examination, brain imaging, or genetic testing.
Of course, CAS is considered to have a neurological basis because it is the brain that controls motor planning and programming, and therefore the brain is implicated in motor planning and programming deficits. Nonetheless, CAS may exist in the absence of an identifiable disease state of the brain; some brains just develop or function differently. Furthermore, we wouldn’t want to conclude that CAS should only be identified when an underlying medical diagnosis/cause exists; rather, all children whose speech meets criteria for CAS should be accurately identified by an SLPs so that an appropriate intervention plan can be put into place without delay. Crucially, viewing CAS as a speech disorder, identified based on observable speech characteristics, means that SLPs in Ontario are the best placed professionals to identify it and recommend appropriate treatment, even if a medical cause hasn’t yet been or may never be found.
Sometimes there will be a related medical diagnosis, but most of the time there won’t, i.e. idiopathic CAS (McCabe, Murray and Thomas, 2022). Much research work to understand the possible cause(s) of CAS is ongoing, including promising work in genetics (Kaspi et al., 2022). If a medical team recommends investigations aimed at determining whether or not an underlying condition is responsible for a child’s speech (and/or other developmental concerns), the information that CAS is part of a child’s profile could even be helpful, given that some conditions are associated with an elevated risk of CAS.
So, now that we understand the technical/legal sense of the word “diagnosis” as used in Ontario, it illuminates the fact that SLPs simply cannot use this term when communicating their clinical findings to patients and caregivers, because (1) the speech and language disorders that SLPs identify are not underlying medical conditions in the first place, but rather labels for different types of communication difficulties, and (2) it is not part of the SLPs scope of practice of SLPs to investigate (or verify) the underlying cause of a speech-language disorder within the patient’s brain or body.
Nonetheless, as many families have experienced, these technical considerations can create unfortunate practical consequence. Families, schools, and even other health professionals may not realize that the barrier to receiving an “official diagnosis” of CAS in Ontario has more to do with what “diagnosis” means, and who is and isn’t allowed to use that term, than it does with an SLP’s capacity to identify CAS.
These issues can be remedied by clear wording that identifies CAS without using the word diagnosis, which we have seen would not apply in its technical sense to an SLP’s evaluation anyway. For example, an SLP may summarize speech assessment findings as follow:
Evaluation of Sam’s speech production skills revealed severely reduced speech intelligibility (i.e. clarity) at the single word level, with decreasing clarity as utterance length increased. Speech production difficulties were reported by Sam’s parents to date back to the onset of speech development, which for Sam was delayed until 25 months of age.
Formal testing using the GFTA-3 (Goldman Fristoe Test of Articulation, 3rd Edition) revealed that Sam’s speech sound production at the single word level fell below the 1st percentile when compared to age-matched peers, representing a severe-to-profound speech sound disorder. The following characteristics were observed during both formal testing and informal observation of spontaneous speech:
- inconsistent vowel and consonant productions when repeating the same word, or words with the same sounds
- atypical prosody, including errors with lexical stress
- groping for initial articulatory configurations
- difficulty with smooth transitions between sounds and syllables
- poor control and coordination of the jaw, lip and tongue movements required for speech production
The above findings reflect a severe motor speech disorder, Childhood Apraxia of Speech. Intensive speech therapy, targeting the development of speech motor planning/programming skills, is recommended to help Sam achieve age-appropriate speech production.
Clearly, it is possible for an SLP to convey that the results of a child’s speech-language assessment indicate the presence of CAS without violating the restrictions on use of the term “diagnosis.”
It must be noted, however, that identifying CAS is not always immediate or straightforward. Depending on a child’s age and ability to participate in assessment and therapy tasks, the clinical interpretation by the SLP may take time. This feature article from the ASHA Leader is a good example of all of the considerations that may be part of the SLP’s assessment/evaluation process: Appraising Apraxia: When a speech sound disorder is severe, how do you know if it’s childhood apraxia of speech? (Strand, 2017).
The question of whether or not it really matters if a child receives an “official diagnosis” of CAS frequently enters into discussions. There is debate about how access to publicly funded therapy, or other services/accommodations through the school system, may/may not be enhanced for children with an official diagnosis recorded by a health care professional who is permitted to do so. This may actually differ by jurisdiction, even within Ontario. However, it is always important for the parents/caregivers and professionals involved with children with speech disorders to understand the nature and type of the child’s speech disorder, whether or not it can be called a diagnosis by their SLP. With accurate identification of CAS, parents/caregivers and professionals can:
- seek up-to-date information on the disorder (e.g. research on best practices for speech therapy in CAS);
- prepare for the challenges frequently associated with CAS (e.g. long-term speech-language therapy) and for known risk factors (e.g. potential difficulties with development of literacy skills);
- find professionals with the right background and expertise for the child’s needs;
- join a supportive community of other families dealing with the same speech needs;
- help children understand their own challenges and develop self-advocacy skills, and
- differentiate between difficulties that are and are not related to CAS; challenges that cannot be attributed to a motor speech disorder should be further investigated and treated separately by the appropriate health professionals (e.g. sleep disturbances, sensory processing issues, delayed toilet training, etc.)
We hope that this discussion has provided clarity about why the statement “SLPs in Ontario can’t diagnose Childhood Apraxia of Speech” is actually misleading. All SLPs responsible for assessing and treating children with motor speech disorders, including Childhood Apraxia of Speech, can benefit from understanding their role in helping families in Ontario get the information they need to support their children’s speech therapy journey.
References
CASLPO. 2018. Practice Advice: Communicating Clinical Information Or A Diagnosis: Do You Know The Difference? College of Audiologists & Speech Language Pathologists of Ontario. Retrieved from https://www.caslpo.com/sites/default/uploads/files/PA_EN_Communicating_a_Diagnosis.pdf
Kaspi A, Hildrebrand MS, Jackson VE, Braden R, van Reyk O, Howell T, Debono S, Lauretta M, Morison L, Coleman MJ, Webster R, Coman D, Goel H, Wallis M, Dabscheck G, Downie L, Baker EK, Parry-Fielder B, Ballard K, Harrold E, Zigenfusz S, Bennett MF, Robertson E, Wang L, Boys A, Fisher SE, Amor DJ, Scheffer IE, Bahlo M & Morgan AT. 2022. Genetic aetiologies for childhood speech disorder: novel pathways co-expressed during brain development. Molecular Psychiatry. https://doi.org/10.1038/s41380-022-01764-8.
McCabe P, Murray E & Thomas D. 2022. Evidence Summary ‐ Childhood Apraxia of Speech – July 2022. Retrieved from https://rest.sydney.edu.au/wp-content/uploads/2022/07/CAS_evidence_brief_2022.pdf
Strand, ES. (2017). Appraising Apraxia: When a speech-sound disorder is severe, how do you know if it’s childhood apraxia of speech? The ASHA Leader, 1 March 2017. https://doi.org/10.1044/leader.FTR2.22032017.50
Yorkston KM, Beukelman DR, Strand EA & Hakel M. 2010. Chapter 1: Perspectives on Motor Speech Disorders, A Clinical Point of View. In Management of Motor Speech Disorders in Children and Adults – Third Edition (p. 9). Austin, Texas: Pro-Ed.
Note: a previous verison of this blog post was published October 31st, 2019 at https://www.speechandstuttering.com/ssi-blog/