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Dyspraxia or inconsistent phonological disorder? Why correct
diagnosis and intervention is an economic necessity
Di Nicholson, Northumbria Healthcare NHS Foundation Trust
Helen Stringer, Newcastle University
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We will.....
• Demonstrate how correct assessment, differential diagnosis of developmental verbal dyspraxia (DVD or childhood apraxia of speech) and inconsistent speech disorder (ISD) can save time and money
Nicholson & Stringer September 2012
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Assessment
The danger of assessing the wrong thing and sticking with phonological processes
Nicholson & Stringer September 2012
Phonology
Oro-motor skills
Articulation
Inconsistent word production
Valid & reliable Screening test
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Incidence
Nicholson & Stringer September 2012
DVD/CAS ISD
0.1-0.2% (Shriberg et al
1997)
9.4% (Broomfield & Dodd 2004)
0.03% (Law et al 2007) 5% (Stringer, & Nicholson 2011)
3.4-4.3% (Delaney & Kent
2004)
12% (Dodd, 1994)
Rare Not So Rare
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Differential diagnosis
• SLTs should always look for inconsistent speech disorder
Nicholson & Stringer September 2012
Oh no! over 40%
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Inconsistent speech
• What it isn’t
• What it is
Nicholson & Stringer September 2012
phonological
representation
phonological
recognition motor
programming
semantic
representation
phonetic
discrimination
speech/non-speech
discrimination
motor
planning
motor
execution
peripheral
auditory
perception
motor
program
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Intervention
Assessment diagnosis hypothesis and theory effective intervention positive outcome
Nicholson & Stringer September 2012
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Intervention
• Combining linguistic and psycholinguistic theories
• Core vocabulary intervention
consistent production
opens gates for phonology
to develop
Nicholson & Stringer September 2012
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Evidence
• 7 children with ‘DVD’ recruited into intervention study
• ‘lifers’
• Reality: 1 DVD
1 oro-motor and consistent phonological disorder
5 inconsistent speech disorder
Nicholson & Stringer September 2012
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The economics of SB SB: Percentage consonants correct (PCC); inconsistency % over periods of
intervention and consolidation
Nicholson & Stringer September 2012
0
10
20
30
40
50
60
70
80
90
1 2 3 4 5
PCC (%)
Inconsistency (%)
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Inconsistency qualitative data SB data Age 6;0 Age 6;1 Age 6;2 Age 6;3 Age 6;6
Sounds not Stimulable
ɹ, ʤ, z ɹ ɹ, ʤ
Stopping CR Gliding Devoicing Voicing FCD Deaffrication Harmony
6 19 8 2 2 4 2
1
7 22 6 1 3 3 3 1
12 17 9 2 1 0 4
1
10 11 14 0 1 0 3
1
0 10 6 3 0 0 0
0
Dialectic errors
2 2 2 2 2
Non-process errors
28 22 12 12 8
Vowel errors 4 2 3 0 0
Number words correct
6 7 8 12 27
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Cost comparison SB
Phase Duration Contacts Staff hours
Speech status Cost
Pre-study
26 months 49 30.25 Assumed to be no better than pre-study levels
£1180
Study 6 months 19 19 PCC pre-study 37.41% PCC post study 78.16% inconsistency pre-study 84.00% inconsistency post study 24%
£741
Post-study
36 months 9 9 On review for language/reasoning. Speech targets: articulation for /ʃ/ & /ʧ/ Reminders for gliding. Now Intelligible
£351
Nicholson & Stringer September 2012
Based on Band 7 @£39/hour
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Cost comparison KS
Nicholson & Stringer September 2012
Phase Duration Contacts Staff hours
Speech status Cost
Pre-study
23 months 42 30.25 Assumed to be no better than pre-study levels
£1224
Study 6 months 19 19 PCC pre-study 45.48% PCC post study 74.48% inconsistency pre-study 76% inconsistency post study 20%
£741
Post-study
24 months 7 5 School programme and review. Now Intelligible.
£195
Based on Band 7 @£39/hour
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Points to note
• Expensive intervention with little/no improvement
• Use of evidence based assessment and intervention proves more effective and cost efficient
• Reconfiguration of services?
Nicholson & Stringer September 2012
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Conclusion For children with persistent speech difficulties: • SLTs should rule out inconsistent speech before
looking at phonological processes (DEAP screen) or DVD
• Developmental Verbal Dyspraxia has low prevalence compared to inconsistent speech
• Time spent on assessment (e.g. 10 minutes on DEAP screen) and accurate differential diagnosis is time well spent
• Appropriately targeted and evidence based intervention will save time and money
Nicholson & Stringer September 2012
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For more information: Di Nicholson [email protected]
Helen Stringer [email protected]
Nicholson & Stringer September 2012