AJSLP
Review Article
A Systematic Review of Treatment
Outcomes for Children With Childhood
Apraxia of Speech
Elizabeth Murray,a Patricia McCabe,a and Kirrie J. Ballarda
Purpose: To present a systematic review of single-case
experimental treatment studies for childhood apraxia of
speech (CAS).
Method: A search of 9 databases was used to find
peer-reviewed treatment articles from 1970 to 2012 of all
levels of evidence with published communication outcomes
for children with CAS. Improvement rate differences (IRDs)
were calculated for articles with replicated (n > 1), statistically
compared treatment and generalization evidence.
Results: Forty-two articles representing Phase I and II
single-case experimental designs (SCEDs; n = 23) or case
series or description studies (n = 19) were analyzed.
Six articles showed high CAS diagnosis confidence. Of the
13 approaches within the 23 SCED articles, treatments were
primarily for speech motor skills (n = 6), linguistic skills (n = 5),
C
hildhood apraxia of speech (CAS) is a developmen-
tal disorder of speech motor planning and/or pro-
gramming (American Speech-Language-Hearing
Association [ASHA], 2007). It is also known as develop-
mental verbal dyspraxia in the United Kingdom (excluding
being the result of any known neurological disorder) and
has previously been called developmental apraxia of speech
and dyspraxia. CAS causes reduced speech intelligibility
because of a hypothesized impairment in the “transformation
of an abstract phonological code into motor speech com-
mands” (Terband, Maassen, Guenther, & Brumberg, 2009,
p. 1598). Such impairment leads to the current consensus-
based core CAS features of “(a) inconsistent errors on con-
sonants and vowels in repeated productions of syllables or
words, (b) lengthened and disrupted coarticulatory transitions
between sounds and syllables, and (c) inappropriate prosody,
a
University of Sydney, New South Wales, Australia
Correspondence to Elizabeth Murray:
Elizabeth.murray@sydney.edu.au
Editor: Carol Scheffner Hammer
Associate Editor: Ken Bleile
Received March 27, 2013
Revision received July 7, 2013
Accepted December 1, 2013
DOI: 10.1044/2014_AJSLP-13-0035
486 American Journal of Speech-Language Pathology • Vol. 23 • 486–504 • August 2014 • A American Speech-Language-Hearing Association
or augmentative and alternative communication (n = 2). Most
participants responded positively to treatment, but only 7 of
13 approaches in SCED studies reported maintenance and/or
generalization of treatment effects. Three approaches had
preponderant evidence (Smith, 1981). IRD effect sizes were
calculated for Integral Stimulation/Dynamic Temporal and
Tactile Cueing, Rapid Syllable Transition Treatment, and
Integrated Phonological Awareness Intervention.
Conclusions: At least 3 treatments have sufficient evidence
for Phase III trials and interim clinical practice. In the future,
efficacy needs to be established via maintenance and
generalization measures.
Key Words: dyspraxia, intervention, efficacy,
methodological rigor, generalization
especially in the realization of lexical or phrasal stress” (ASHA,
2007, p. 4).
Although impaired movement planning and program-
ming are considered to underlie CAS, there are also reports of
disrupted development of speech perception, language, and
phonology (including phonological awareness) in children
with CAS (Groenen, Maassen, Crul, & Thoonen, 1996; Lewis
et al., 2004; Maassen, Groenen, & Crul, 2003). It is unclear
whether these are primary deficits or flow-on effects from
CAS, comorbid impairments, or perhaps compensatory be-
haviors, as children with CAS develop their linguistic, pho-
nological, and motor skills concurrently (Alcock, Passingham,
Watkins, & Vargha-Khadem, 2000; Marion, Sussman, &
Marquardt, 1993; Ozanne, 2005). Children with CAS can
therefore present with a range of difficulties requiring therapy
from speech-language pathologists (SLPs; Royal College of
Speech and Language Therapists, 2011).
The long-term functioning of people with CAS is
largely unreported. The available longitudinal studies suggest
that CAS is a persistent disorder that requires therapy (Hall,
Jordan, & Robin, 1993; Jacks, Marquardt, & Davis, 2006;
Stackhouse & Snowling, 1992). Children with CAS, like others
with persistent speech sound disorder, are also at risk for
Disclosure: The authors have declared that no competing interests existed at the
time of publication.
literacy, academic, social, and vocational difficulties (e.g.,
Lewis et al., 2004; Moriarty & Gillon, 2006).
A Cochrane systematic review, a subsequent journal
article, and a treatment review have reported no published
randomized controlled trials (RCTs) or nonrandomized
controlled trials (NRCTs) for any intervention for CAS
(Morgan & Vogel, 2008, 2009; Watts, 2009). Despite this
lack of high-level evidence, many published articles on the
treatment of CAS could facilitate practice and could help
identify potential lines of further research. Narrative reviews
have identified a range of treatment methods for children
reported to have CAS, likely reflecting the diversity of symp-
toms seen in these children and potentially the research and
clinical interests of the authors (ASHA, 2007; Strand &
Skinder, 1999). They encompass motor treatments (including
electropalatography), linguistic approaches, augmentative
and alternative communication (AAC), or some combina-
tion thereof (ASHA, 2007; Gillon & Moriarty, 2007; Hall,
2000; Morgan & Vogel, 2008). Few of these lower level
treatment studies have been examined rigorously, as they
were excluded on the basis of quality in previous systematic
reviews (Morgan & Vogel, 2008; Watts, 2009). Provision
of recommendations regarding which treatments have sup-
portive evidence has therefore not been possible (ASHA,
2007; Morgan & Vogel, 2008; Pannbacker, 1988). This article
presents a systematic review of all levels of evidence that
may be critical to inform clinical practice until high-level
evidence becomes available.
Two primary challenges face a systematic review of
intervention for CAS. The first challenge is in identifying the
rigor of each study in terms of research phase (Robey, 2004),
the research design, the level of evidence generated (ASHA,
2004; Perdices et al., 2006), as well as the level of certainty that
the effects reported for a given treatment approach are real
(Smith, 1981). Treatment research often follows a develop-
mental pathway that is associated with increasing research
rigor and different research questions. Robey (2004) defined
five phases in a research program. Phase I and Phase II
studies represent pilot or feasibility studies seeking to deter-
mine whether effects justify more rigorous study. These can
generate Level III or Level IIb evidence (ASHA, 2004;
Perdices et al., 2006). Level III evidence constitutes quasi-
experimental group (case series) or single case reports with
pre- to posttreatment measurement and no within-subject
comparison or control conditions. Level IIb evidence comes
from more rigorous single-case experimental designs (SCEDs)
that systematically apply and withdraw treatment and es-
tablish control using a stable baseline phase or limited change
in control conditions (Byiers, Reichle, & Symons, 2012;
Olswang & Bain, 1994; Perdices & Tate, 2009).
The second challenge is that there is not yet a validated
assessment tool for diagnosing CAS. Thus, before evaluation
of the treatment in any intervention study, the descriptions
of participants must be scrutinized to determine the level of
confidence in the authors’ diagnosis. This involves determin-
ing to what extent the participants are described as meeting
the three consensus-based core features of CAS listed earlier
(ASHA, 2007).
Murray et al.: Systematic Review of Treatment Outcomes for CAS
Smith’s (1981) level of certainty hierarchy considers the
research design and the possible effects of the intervention
to provide an overall judgment on how likely the results are to
be true. For the CAS literature, this can also be extended
to include confidence in diagnosis. SCEDs can show early
evidence for an intervention, with results from such studies
being classed as suggestive or “possibly true.” However,
statistically compared outcomes from SCEDs with confident
CAS diagnoses, replication (n > 1), and evidence of both
treatment effects and generalization of treatment effects could
be considered preponderant evidence or “probably true.”
SCED designs are usually designated as Phase II and Level IIb
evidence (but see Hegde, 2007; Kearns & de Riesthal, 2013).
Currently, Phase III studies (Robey, 2004) are typically RCTs
and NRCTs. These generate Level IIa evidence using groups
of participants to reduce bias and to eliminate individual
variance as a factor in treatment success. It is only through
meta-analyses and systematic reviews of several Phase III
studies of a given treatment approach, coupled with Phase IV
effectiveness studies in real-world clinical situations, that
results can be defined as conclusive or “undoubtedly true”
(Smith, 1981). As all studies of CAS treatments to date are
classified as Phase I and Phase II, the goal of this review is
to identify treatment approaches with suggestive or prepon-
derant evidence.
Central to this review is treatment efficacy. Efficacy
considers clinical cause-and-effect relationships between
the provision of intervention and change in participant be-
havior (e.g., McReynolds & Kearns, 1983; Olswang & Bain,
2013). Demonstration of efficacy extends beyond treatment
effects, requiring assessment of maintenance and generaliza-
tion of treatment effects that signify instrumental change.
Response generalization evaluates a child’s performance on
untrained items that are somehow related to trained items,
to determine whether more widespread change is occurring
(Olswang & Bain, 1994). Stimulus generalization assesses
performance on untrained materials, people, or settings/
environments (Olswang & Bain, 1994). Such change is neces-
sary to meet the overall goals of an intervention.
Aims
This systematic review evaluated studies of interven-
tion, published between 1970 and October 2012, that state
an intention to treat children with CAS. The aims fall into
four broad areas:
1. Study quality: to describe for each identified study the
research phase, the level of evidence, and the level of
confidence in CAS diagnosis;
2. Treatment procedures: to define the behavioral goals
and structure of treatment (e.g., intensity and dosage
according to Warren, Fey, & Yoder, 2007) for each
SCED study (at/above Level IIb evidence) and to
group similar treatment types to facilitate treatment
outcome analysis;
3. Treatment outcomes: to examine reported treatment,
maintenance, and generalization outcomes; and
487
4. Certainty of evidence: to determine the level of cer-
tainty for each treatment approach (Smith, 1981) and
to determine the effect size for any intervention ap-
proach classed as having preponderant evidence.
Method
Systematic Search Strategy
The search strategy used follows Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA)
search guidelines (Moher, Liberati, Tetzlaff, & Altman,
2009). The flow diagram of study selection is presented in
Figure 1.
Identification
Nine databases related to speech-language pathology
were comprehensively searched for peer-reviewed journal
articles. These were Allied and Complementary Medicine,
Cumulative Index to Nursing and Allied Health Literature,
Evidence-Based Medicine Reviews–Cochrane Database
of Systematic Reviews, Education Resources Information
Center, Linguistic Language Behavior Abstracts, Medline,
PsycINFO, Scopus, and speechBITE. Specific search terms
varied on the basis of each database catalogue of terms in its
search directories. Key words used were as follows: “apraxia”
or “dyspraxia” or “childhood apraxia of speech” and
“child*” or “develop*” and “motor speech therapy” or
“interven*” or “treat*” or “speech therapy/pathology” or
“efficacy” or “evaluation” or “effect” and “speech” or “com-
munication” or “language” or “articulation impairments”
or “speech impairments” or “speech disorders” or “speech
intelligibility” or “prosody.” A total of 1,301 studies were
identified from database searches.
Screening
All references were exported to EndNote X5 (Thomson
Reuters, 2011), where duplicates were removed. References
were also screened to ensure that authors stated an intention to
treat children with CAS (using synonyms; e.g., developmental
verbal dyspraxia). Thus, references were searched by title,
abstract, and key words in EndNote X5 and were excluded
if treatment articles involved other diagnoses without ref-
erence to CAS: “cerebral palsy,” “dysarthria,” “cleft palate,”
“swallowing,” “ataxia,” “cochlear implants,” “deaf,”
“stutter,” “fluency,” “acquired,” “Down syndrome,” “autism,”
“phonolog*,” and “gait apraxia.” All references that related
to assessment, diagnosis, or description/exploration of symp-
toms were excluded. Of the intervention articles that remained,
the intervention names and authors were searched again in
all the above databases as well as Google Scholar to ensure
that all relevant articles were found. The reference lists of
all review articles obtained were also searched to find any
additional articles. Screening removed 913 articles, leaving
119 to be assessed for eligibility.
Eligibility
Copies of articles were obtained and assessed against
the final inclusion criteria before being reviewed. These
488 American Journal of Speech-Language Pathology • Vol. 23 • 486–504 • August 2014
criteria were as follows: (a) peer-reviewed articles published
between 1970 and October 2012; (b) in English (to allow
analysis by monolingual English speaking authors); (c) treat-
ing at least one child/adolescent under 18 years of age with
CAS or suspected CAS; and (d) reporting quantitative par-
ticipant data outcomes focused on speech (i.e., articulation,
phonology, prosody, intelligibility, rate), communication (i.e.,
pragmatics, social communication, AAC use), or language
(i.e., phonology, phonological awareness, grammar, mor-
phology, receptive or expressive language, reading, spelling
or writing). There was no exclusion on the basis of the type
of therapy provided or who provided it. All named and
unnamed interventions were included, as were all levels of
evidence, except for systematic reviews, as they do not con-
tain individual participant data (ASHA, 2004). This yielded
42 articles for review. Intrarater reliability (first author) for
inclusion of these studies was 96% (n = 1,032) with >2 months
between assessments. Interrater reliability with an indepen-
dent rater was 91% (see Supplemental Appendix 1 in the
online supplemental materials for the list of excluded articles
and reason for exclusion). Raters were not blinded to article
title or authors, and raters did not review their own publi-
cations. Excluded articles were not further analyzed.
Finally, an additional search was undertaken for other
documents, such as published treatment manuals and the-
oretical or opinion articles on the individual treatment ap-
proaches, to confirm the type of behavior(s) targeted (e.g.,
speech motor or phonological), cues, and stimuli used. This
search used reference lists of already identified articles as well
as database and Google searches using intervention names
and key authors as search terms.
Data Analysis
Review of studies for Aims 1, 3, and 4 was based on
information provided in each article (e.g., Moseley, Herbert,
Maher, Sherrington, & Elkins, 2008). In one case, only group
data were published, and we contacted an author (Brigid
McNeill) for individual data (from McNeill, Gillon, & Dodd,
2009a). Addressing Aim 2 at times required reference to treat-
ment manuals and other publications describing a treat-
ment’s theoretical framework.
Aim 1: Study Quality
Each study was assigned to a phase of research (Robey,
2004), from Phase I to Phase V. The experimental design
and level of evidence were defined on the basis of published
guidelines (ASHA, 2004; Perdices et al., 2006). In addi-
tion, confidence in CAS diagnosis was assessed as detailed
below.
Confidence in CAS diagnosis. A 5-point rating scale
was used to rate confidence in CAS diagnosis (see Table 1;
Wambaugh, Duffy, McNeil, Robin, & Rogers, 2006). This was
based on description of primary versus nondiscriminative
features (McCabe, Rosenthal, & McLeod, 1998; see the
online supplemental materials, Supplemental Table 1). Pri-
mary features were the three consensus-based features listed
in ASHA’s (2007) technical report, hypothesized to represent
Figure 1. Flow diagram of study selection (adapted from Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA]; Moher
et al., 2009). CAS = childhood apraxia of speech; Ax = assessment; Dx = diagnosis; RCT = randomized controlled trial; NRCT = nonrandomized
controlled trial; SCED = single-case experimental design; AAC = augmentative and alternative communication.

impaired speech motor planning and/or programming. Non-
discriminative features were those shared with other dis-
orders, such as poor intelligibility, slow progress, or delayed
language (ASHA, 2007; McCabe et al., 1998). Clear cases
of comorbid disorders were also noted, such as receptive
language impairment or dysarthria. On the basis of this
analysis, participants were classified either as CAS only or as
CAS+, in which CAS was the primary diagnosis, but other
disorders were present. A rating of 1 indicated high con-
fidence in CAS diagnosis, and a rating of 5 indicated no
confidence. Intrarater reliability (first author) on four judg-
ments (presence of each of the three primary features and
CAS diagnosis) for 83/83 children studied was 94%. Inter-
rater reliability between the first and second authors for a

Murray et al.: Systematic Review of Treatment Outcomes for CAS 489

Table 1. Five-point rating scale of confidence in diagnosis of CAS (adapted from the Academy of Neurologic Communication Disorders and
Sciences guidelines; Wambaugh et al., 2006).

Level Primary characteristics Nondiscriminative characteristics Comorbidity

Level 1 All the primary characteristics were
described as follows:
• Inconsistency and
• Lengthened and disrupted
coarticulatory transitions between
sounds and syllables and
• Inappropriate prosody.
Level 2 All the primary characteristics were
described as follows:
• Inconsistency and
• Lengthened and disrupted
coarticulatory transitions between
sounds and syllables and
• Inappropriate prosody.
Level 3 Two of the three primary characteristics
were described:
• Inconsistency and/or
• Lengthened and disrupted
coarticulatory transitions between
sounds and syllables and/or
• Inappropriate prosody.
Level 4 Only one of the three primary
characteristics was reported, or
incomplete/inadequate description of
the primary characteristics of CAS
was provided.
Level 5 Diagnosis of CAS was reported or
implied, but no primary characteristics
were described.
CAS was the primary diagnosis
described. Any characteristics that
were attributable to other disorders
may have been described but
were not used to diagnose CAS.
CAS was the primary diagnosis
described. Other characteristics
attributable to other disorders (e.g.,
dysarthria) were described and may
have been used to diagnose CAS.
CAS was described. Other
characteristics that were attributable
to other disorders (e.g., dysarthria)
were described and may have been
used to diagnose CAS.
Other characteristics that were
attributable to other disorders may
have been described, and it is unclear
whether these were used to diagnose
CAS.
Unclear whether CAS diagnosis was
likely and/or whether CAS was the
primary diagnosis.
CAS without another comorbid disorder
was reported (excluding expressive
language delay).
This includes the following:
• CAS without another comorbid
disorder (excluding expressive
language delay) or
• Clear cases of comorbid CAS,
in which CAS was the primary
diagnosis.
This includes the following:
• CAS without another comorbid
disorder or
• Clear cases of comorbid CAS, in
which CAS was the primary
diagnosis or
• Cases of CAS in which another
comorbid disorder had the same
severity (e.g., language delay,
dysarthria).
Unclear whether CAS was the primary
diagnosis.
Other comorbid disorders may be
present.

random 33/83 children was 91%. Discrepancies were resolved
by consensus.
Exclusions. Articles that lacked experimental control
(Level III evidence; n = 19) were excluded, as they could
not be used to determine treatment outcomes. The remain-
ing 23 Level IIb articles were analyzed to address Aims 2, 3,
and 4. No articles were excluded because of confidence in
CAS diagnosis; however, confidence in CAS diagnosis was
a factor in determining certainty of evidence—see Aim 4
below.
Aim 2: Treatment Procedures
Articles designed with adequate experimental control
(see Aim 1 above) were analyzed descriptively regarding the
nature of the treatment. Using the stated treatment goals,
selected stimuli, and specific cueing strategies reported, treat-
ments were categorized as primarily (a) motor, (b) linguistic/
phonological (including literacy), or (c) AAC (ASHA,
2007; Gillon & Moriarty, 2007; Hall, 2000; Martikainen &
Korpilahti, 2011). The structure of treatment delivery was
also determined (Warren et al., 2007), including dose (trials
per session), dose frequency (number of times a dose is
provided over days or weeks), and total intervention time
(number of sessions). When reported, home practice and
service delivery model were documented.
Aim 3: Treatment Outcomes
Reported treatment, maintenance, and generalization
outcomes for each intervention were analyzed for (a) number
of participants with a treatment gain (change immediately
after treatment compared with baseline); (b) assessment
measures and statistics used in determining treatment effects;
(c) maintenance of treatment gains at least 2 weeks post-
treatment, from report or by comparing treatment data with
performance in maintenance probes; (d) response generaliza-
tion data, when statistical analysis was used; and (e) stimulus
generalization data.
Aim 4: Certainty of Evidence
Smith’s (1981) three levels of certainty were applied, on
the basis of design (i.e., level of evidence, research design,
confidence in CAS diagnosis, and statistical comparison) and
possible effects of the intervention/outcomes. A treatment
approach was categorized as having preponderant evidence
when it showed Level IIb or better evidence (SCEDs), rep-
licated cases, diagnostic confidence ratings of 1–3, statistically
significant treatment and generalization effects (or at least
moderate effect sizes), and clear maintenance of treatment
gains at least 2 weeks posttreatment. Any Level IIb or better
evidence that did not meet all the above criteria received the
lowest rating of suggestive evidence.

490 American Journal of Speech-Language Pathology • Vol. 23 • 486–504 • August 2014

 For studies with preponderant evidence, effect sizes
were calculated using improvement rate difference (IRD
[also known as risk difference]; Parker, Vannest, & Brown,
2009), a valid and reliable tool for SCEDs used frequently in
medical research. This method utilizes visual analysis and has
reduced assumptions in comparison with other effect size
calculations allowing use over a range of SCED designs. It is
more discriminative to change than other nonoverlap tech-
niques (e.g., percentage of nonoverlapping data) and is at
least moderately correlated with commonly used effect sizes
(Parker et al., 2009). An IRD is the difference between the
improvement rates of the treatment and baseline/withdrawal/
maintenance phases. The improvement rate was calculated
for each phase by determining the number of improved
points in each phase (those exceeding the data points of the
adjacent phase) divided by all the data points of the phase
(Parker et al., 2009). Thus, an IRD eliminates overlap across
phases in its determination of effect size.
IRDs were determined for treatment effects for each
participant and each behavior within an article. The IRDs
were then averaged across participants for the treated be-
havior(s) to determine an omnibus IRD for each article, as per
Parker et al. (2009), with 95% confidence intervals determined
using WinPEPI (Abramson, 2011). Effects for each article
were averaged again to determine an omnibus IRD for a given
treatment approach.
IRDs were also calculated for generalization effects
for each participant and each behavior/condition within an
article. No further omnibus IRDs were determined for gen-
eralization because of the various and often heterogeneous
measures used.
Results
Aim 1: Study Quality
The 42 studies that met the inclusion criteria were
classified as Phase I or Phase II. Of these, 23 represented
Level IIb evidence (SCEDs), and 19 represented Level III
evidence (one quasi-experimental case series and 18 case
reports or descriptions; see Figure 1). There was a shift to-
ward higher quality single case studies over time, with six
Level IIb and 12 Level III articles prior to 2006, and with
17 Level IIb and five Level III articles from 2006 to 2012.
No RCT or NRCT designs have been published to date.
Overall, there were 83 participants across the 42 single
case studies. Within the 23 SCED articles, 32 participants
were reported to have CAS, and 19 participants were reported
to have comorbid CAS (CAS+). Of the 23 articles, four ar-
ticles (17.4%) received a Level 1 rating for high confidence
in diagnosis, two articles (8.7%) received a Level 2 rating for
clear cases of CAS with comorbid disorders, seven articles
(30.4%) received a Level 3 rating, seven articles (30.4%) re-
ceived a Level 4 rating, and three articles (13.0%) received a
Level 5 rating for no confidence (see Table 2).
Within the 19 case series and description articles,
25 participants were reported to have CAS, and eight par-
ticipants were reported to have comorbid CAS (CAS+).
Murray et al.: Systematic Review of Treatment Outcomes for CAS
Of the 19 articles, three articles (15.8%) received a Level 1
rating for high confidence in diagnosis, zero articles (0.0%)
received a Level 2 rating, five articles (26.3%) received a
Level 3 rating, five articles (26.3%) received a Level 4 rating,
and six articles (31.5%) received a Level 5 rating for no con-
fidence (see the online supplemental materials, Supplemen-
tal Table 2). The 19 Level III articles were not analyzed
further because of lack of experimental control.
Aim 2: Treatment Procedures
The first section details the classification of treatments
on the basis of their approach. The second section presents
results on service delivery models used.
Classification of Treatment Goals and Approaches
Eleven of 23 SCED studies were classified as primarily
motor approaches (see Table 3). They included primary
measures for accuracy of articulation and/or prosody. Two
studies included secondary measures of speech intelligibility
or comprehensibility (Strand & Debertine, 2000; Strand,
Stoeckel, & Baas, 2006). All utilized articulatory placement
and imitation cues as well as multimodal cues (e.g., kinesthetic/
touch cues, manipulating speech rate and timing, picture
or orthographic stimuli). The majority (90%) made explicit
reference to incorporating principles of motor learning (PML;
see Maas et al., 2008, for a review).
Ten studies were classified as primarily linguistic ap-
proaches. Of these, six studies reported primary measures of
speech sound production (phonological processes or stimul-
ability), phonological awareness accuracy, and spoken lan-
guage utterance length, which also used some motor cueing
(Iuzzini & Forrest, 2010; Krauss & Galloway, 1982; McNeill,
Gillon, & Dodd, 2009a, 2009b, 2010; Moriarty & Gillon, 2006).
The other four studies targeted expressive language skills
(e.g., multisymbol messages or elaborated phrase structures)
using AAC systems in children with previously established
AAC use (Binger, Kent-Walsh, Berens, Del Campo, & Rivera,
2008; Binger & Light, 2007; Binger, Maguire-Marshall, &
Kent-Walsh, 2011; Harris, Doyle, & Haaf, 1996).
Two studies were classified as AAC, measuring com-
municative effectiveness in children with severe comorbid
CAS (CAS+), by introducing AAC systems (Bornman, Alant,
& Meiring, 2001; Culp, 1989). These children had reportedly
shown slow or minimal progress in speech production at-
tempts and/or used AAC to alleviate frustration and behav-
ioral problems due to communication failure.
A total of 13 treatment approaches were identified
across the 23 studies; six were solely or primarily motor,
five were linguistic, and two were AAC (see Table 3). Seven
of these 13 approaches represented combined approaches.
Of these, two combined two motor treatments (Lundeborg
& McAllister, 2007; Rosenthal, 1994), and another two
combined linguistic treatments (Iuzzini & Forrest, 2010;
McNeill et al., 2009a), not affecting their classification.
Another two combined a linguistic treatment (melodic
intonation therapy [MIT]) with a motor treatment, either
touch cue method (TCM; Martikainen & Korpilahti, 2011)
491
492 American Journal of Speech-Language Pathology • Vol. 23 • 486–504 • August 2014

Table 2. Research design, level of evidence, participant description, and diagnosis analysis of the 23 Level IIb (SCED) articles.

Intervention name/ Level of Participant Diagnostic

approach Published articles Research design evidence description Diagnosis confidence rating

Aided AAC modeling Binger and Light (2007) Multiple baseline across IIb 2/5 (4;2 [years;months] Severe CAS+ (GDD) 4 (dysprosody and
3 participants SCED and 4;4, male, had sequencing NR)
previous SLP)
Binger, Kent-Walsh, Multiple baseline IIb 1/3 (3;4, female, previous Severe CAS+ 4 (dysprosody and
Berens, Del Campo, across probes SCED SLP NR) (suspected VCFS inconsistency NR)
and Rivera (2008) with profound VPI)
Binger, Maguire- Multiple baseline IIb 1/3 (6 years, female, Severe CAS+ (receptive 5
Marshall, and across 3 participants previous SLP NR) and expressive LD)
Kent-Walsh (2011) SCED
Articulation with Stokes and Griffiths (2010) ABA single case IIb 1 (7 years, male, Mild SSD (Hx of CAS) 4 (dysprosody and
facilitative vowel design 1 year previous SLP) nconsistency NR)
contexts
Combined intraoral Lundeborg and ABABABABA single IIb 1 (5;1, female, 1.50 years Severe CAS 3 (dysprosody NR)
stimulation, McAllister (2007) case design previous SLP)
Electropalatography
(EPG) with NDP
Combined melodic Martikainen and Multiple baseline IIb 1 (4;7, female, Severe CAS 1
intonation therapy Korpilahti (2011) across participants 1 year previous SLP)
(MIT) and touch cue SCED
method (TCM)
Combined stimulability Iuzzini and Forrest (2010) Multiple baseline IIb 4 (3;7–6;10, 2 males, Severe CAS 4 (dysprosody and
(STP) and modified SCED 2 females, previous sequencing NR)
core vocabulary (mCVT) SLP for 3/4)
Computer-based Harris, Doyle, Multiple baseline IIb 1 (5 years, male, Severe CAS+ 3 (dysprosody NR)
and Haaf (1996) across discourse approximately 3 years (Hx OME, receptive
contexts SCED previous SLP) and expressive LD)
(table continues)
 Table 2 (Continued).

Intervention name/ Level of Participant Diagnostic

approach Published articles Research design evidence description Diagnosis confidence rating

Integral Stimulation/ Strand and Debertine Multiple baseline SCED IIb 1 (5 years, female, Severe CAS (Hx of VPI) 1
Dynamic Temporal (2000) 4 years previous SLP)
and Tactile Cueing Strand, Stoeckel, Multiple baseline SCED IIb 4 (5;5–6;1, all male, Severe CAS+ 4 (for all cases;
(DTTC) and Baas (2006) 2–4 years (2 with mild spastic dysprosody
previous SLP) and/or ataxic and inconsistency
dysarthria, 1 with mild NR, clearly comorbid)
intellectual disability,
and 1 with OME)
Baas, Strand, Elmer, Multiple baseline SCED IIb 1 (12;8, male, 10 years Severe CAS+ (CHARGE 5
and Barbaresi (2008) previous SLP) syndrome intellectual
disability)
Edeal and Gildersleeve- AB—alternating IIb 2 (6;2 and 3;4, male, 6;2—severe CAS+ 1
Neumann (2011) treatments single 1–4 years (repaired CLP, severe
design (with three previous SLP) receptive LD),
stable baselines) 3;4—severe CAS
Maas and Farinella Multiple baseline SCED IIb 4 (5;0–7;9, 2 females, CAS001—moderate– 3 (by consensus);
(2012) 2 males, previous severe CAS; CAS001 = 1, CAS002 = 3
Murray et al.: Systematic Review of Treatment Outcomes for CAS

SLP NR) CAS002—severe (dysprosody NR, clearly

CAS+ (dysarthria); comorbid), CAS005 = 2
CAS005—moderate– (clearly comorbid),
severe CAS+ CAS010 = 4 (inconsistency
(dysarthria and coarticulation NR,
and receptive LD); clearly comorbid)
CAS010—mild-
moderate CAS+
(sensory processing,
fine and gross
motor skill delay,
hypotonia,
moderate–severe
receptive LD)
Maas, Butalla, and Multiple baseline SCED IIb 4 (3 in common with CAS001; 2 (by consensus); as
Farinella (2012) Maas & Farinella, above and CAS012 = 2
2012) (clearly comorbid)
(5;4–8;4, 2 females, CAS002;
2 males, previous CAS005—see above;
SLP NR) CAS012—CAS+
(moderate–severe
receptive LD,
Hx OME)
(table continues)
493
494 American Journal of Speech-Language Pathology • Vol. 23 • 486–504 • August 2014

Table 2 (Continued).

Intervention name/ Level of Participant Diagnostic

approach Published articles Research design evidence description Diagnosis confidence rating

Integrated Phonological Moriarty and Gillon Multiple baseline SCED IIb 3 (6;3–6;10, 2 males, Male 1—Severe CAS+ 3 (Male 1 = 4 inconsistency
Awareness Intervention (2006) 1 female, up to (receptive and and dysprosody NR;
(N = 5) 2 years previous expressive LD); Male 2 and Female = 3)
SLP) Male 2—Severe
CAS+ (receptive
and expressive LD);
Female—mild–
moderate CAS
McNeill, Gillon, and Multiple baseline SCED IIb 12 (4;2–7;6, 3 females, Mild–moderate to 3 (dysprosody NR)
Dodd (2009a) 9 males, previous severe CAS
SLP NR) (no other diagnoses
reported)
McNeill, Gillon, and Multiple baseline SCED IIb 2 (identical twins also CAS (small interstitial 3 (dysprosody NR)
Dodd (2009b) in McNeill et al., deletion on
2009a) chromosome
(4;5, male, moderate– 10 (deletion at
severe) 10q21.2–22.1)
McNeill, Gillon, and Quasi-experimental group IIb Same participants as Mild–moderate 3 (dysprosody NR)
Dodd (2010) (following SCED) McNeill et al. (2009a) to severe CAS
(no other diagnoses
reported)
Rate control therapy Rosenthal (1994) ABAB single case design IIb 4 (10–14 years, 3 males, CAS (severity not 4 (dysprosody and
(with alternating 1 female, all had stated) inconsistency NR)
treatments) previous SLP)
MIT Krauss and Galloway ABAA single case design IIb 2 (6 and 5 years, male, CAS (severity not 4 (dysprosody and
(1982) had previous SLP) stated) inconsistency NR)
Partners in augmentative Culp (1989) ABA single case design IIb 1 (8 years, female, Severe CAS+ 2 (comorbid CAS)
communication 5 years previous SLP) (intellectual disability,
training (PACT) Hx tube insertion,
congenital
heart defect)
Rapid Syllable Transition Ballard, Robin, McCabe, Multiple baseline IIb 3 (7;8–10;10, 2 males, Mild or mild– 1
Treatment (ReST) and McDonald (2010) across behaviors and 1 female, 1–5 years moderate CAS
participants design previous SLP)
Voice output devices Bornman, Alant, and ABA single case design IIb 1 (6;6, male, 2.50 years CAS+ (anoxia causing 5
Meiring (2001) previous SLP) slight left hemiplegia,
grand mal fits)

Note. Please see the online supplemental materials, Supplemental Table 3, for the 19 Level III articles. SLP = speech-language pathology; CAS+ = comorbid childhood apraxia of speech;
GDD = global developmental delay; NR = not reported; VCFS = velocardiofacial syndrome; VPI = velopharyngeal incompetence; LD = language delay/disorder; A = baseline/withdrawal
phase; B = treatment/intervention phase; SSD = speech sound disorder; Hx = history of; NDP = Nuffield Dyspraxia Programme; OME = otitis media with effusion/glue ear; CHARGE
syndrome = coloboma, heart disease, atresia of the choanae, retarded growth and mental development, genital anomalies, and ear malformations and hearing loss; CLP = cleft lip
and palate.
 Table 3. Treatment outcomes for the 23 SCED articles.

Treatment across all participants

Response Stimulus
Cases with Maintenance generalization generalization
Therapy Therapy reported (Significant in no. (Significant in no. Judgment
type approach Rx effect Measures Statistics used? Attained? Time of participants) of participants) of certainty
R
Motor Articulation with 1/1 Accuracy (/ /) Yes—significant Yes 2 weeks 1/1 NR Suggestive
with facilitative vowel effects post
cueing contextsa
Combined intraoral 1/1 (1) PCC, Yes—significant NR NR NR NR Suggestive
stimulation and (2) PPC, effects for all
EPG (with NDP)b (3) PWC, measures
(4) intelligibility,
(5) assessment of
visual deviancy
Combined MIT and 1/1 (1) PVC, Yes†—1/5 post-MIT Varied—PVC 12 weeks NR NR Suggestive
TCMc (PVC; however, maintained. post
(2) PCC, PCC declined)— PCC and PMLU
(3) PMLU, 3/5 significant only significant
(4) PWP, post-TCM after MIT
(5) PWC withdrawn.
Greater changes
after withdrawal.
Murray et al.: Systematic Review of Treatment Outcomes for CAS

Integral Stimulation/ 11/13 Rx accuracy Yes—9/13 Yes for 5/7 (6 NR) 2–4 weeks 6/7 (6 NR) NR Preponderant
DTTCd moderate–large post
effect sizes
ReSTe 3/3 Perceptual stress Yes—significant Yes for 2/3 4 weeks 3/3 NR Preponderant
matches effects post
Rate Control 4/4 Rx accuracy No NR NR NR 0/4 to discourse Suggestive
Therapyf
Linguistic Combined STP 4/4 (only 3/4 (1) PCC, No NR NR NR NR Suggestive
with and mCVTg for CSIP)
some
motor
aspects
(2) phones added to
inventory, (3) ↓
inconsistency
(CSIP),
(4) ↓ inconsistency
(ISP)
Integrated 11/15 (1) % suppression of Yes—significant Yes—as group 6 months 11/15 NR Preponderant
Phonological process usage, effects of 12 (3 NR) post
Awareness (PA) (2) PA accuracy
Interventionh
MIT with traditional 2/2 (1) Porch Index of Yes—significant NR NR NR NR Suggestive
therapyi Communicative verbal naming and
Ability in imitation
Children, (2) MLU

(table continues)
495
496 American Journal of Speech-Language Pathology • Vol. 23 • 486–504 • August 2014

Table 3 (Continued).

Treatment across all participants

Response Stimulus
Cases with Maintenance generalization generalization
Therapy Therapy reported (Significant in no. (Significant in no. Judgment
type approach Rx effect Measures Statistics used? Attained? Time of participants) of participants) of certainty

Linguistic Aided AAC 4/4 Rx frequency Yes—moderate– Yes for all 2, 4, and NR (1) 3/3, Suggestive
with modeling (with large effect sizes 8 weeks
some communication post
AAC board or voice
output devices)j (1) multisymbol (2) NR
messages
(2) morpheme ↑ speech and
accuracy participation,
↓ frustration
Computer-based 1/1 Rx accuracy No NR NR NR NR Suggestive
AACk (1) book reading
(2) discourse
AAC Voice output 1/1 No. of appropriate No Yes 4 weeks NR Spoke intelligibly Suggestive
devices— responses post after 1 year
Macawl
PACTm 1/1 Communicative No NR NR NR ↑ participation Suggestive
effectiveness
(frequency
of turns)

Note. Rx = medical prescription; PCC = percentage of consonants correct; PPC = percentage of phonemes correct; PWC = percentage of words correct; PVC = percentage of vowels
correct; PMLU = phonological mean length of utterance; PWP = proportion of whole-word proximity; CSIP = consonant substitute inconsistency percentage; ISP = inconsistency severity
percentage; MLU = mean length of utterance.
a
Stokes and Griffiths (2010). bLundeborg and McAllister (2007). cMartikainen and Korpilahti (2011). dStrand and Debertine (2000), Strand et al. (2006), Baas et al. (2008), Edeal and
Gildersleeve-Neumann (2011), Maas and Farinella (2012), and Maas et al. (2012). eBallard et al. (2010). fRosenthal (1994). gIuzzini and Forrest (2010). hMoriarty and Gillon (2006) and McNeill
et al. (2009a, 2009b, 2010). iKrauss and Galloway (1982). jBinger and Light (2007) and Binger et al. (2008, 2011). kHarris et al. (1996). lBornman et al. (2001). mCulp (1989).
†
MIT completed in the first block, and TCM completed in the second block.
or traditional articulation therapy (Krauss & Galloway, 1982).
The first was classified as a motor approach because of the
goals and PML incorporated; the second was classified as a
linguistic approach, as MIT was the primary experimental
approach, and linguistic outcomes were primarily sought and
reported. Finally, for one motor treatment, the participant
continued regular AAC therapy during the research (Edeal
& Gildersleeve-Neumann, 2011).
Structure of Treatment Delivery
All 23 treatments were delivered individually, with
22 delivered in a clinic and one delivered at the participant’s
home (Lundeborg & McAllister, 2007). Caregiver and child
training sessions were utilized in the two AAC studies within a
consultative-collaboration service delivery model (Bornman
et al., 2001; Culp, 1989). Inclusion of parent training and
home practice protocols or activities was more prevalent in
AAC-based treatments and was used in six of 23 articles.
For motor treatments reporting dose frequency, the
median was three times a week, with a maximum of once a
day and minimum of twice a week. Sessions were between
20 and 60 min long. Most linguistic and AAC approaches
provided treatment two to three times a week for between
15- and 60-min sessions. A small number gave intensive daily,
short-term training. Dose in terms of treatment trials com-
pleted within sessions was adequately described in five of
23 articles or three of 13 approaches and ranged from 60 to
120 trials for motor approaches and from 10 to 30 trials
for linguistic and AAC approaches (Ballard, Robin, McCabe,
& McDonald, 2010; Binger et al., 2008; Binger & Light,
2007; Binger et al., 2011; Stokes & Griffiths, 2010). Further
details of the treatment procedure analyses for each study
and approach are provided in the online supplemental mate-
rials, Supplemental Table 3.
Aim 3: Treatment Outcomes
Analyses of treatment, maintenance, and generalization
outcomes for the 23 SCED articles are reported in Table 3.
All studies used baseline phases, and 91% incorporated un-
trained control items intended to demonstrate some exper-
imental control.
Treatment and Maintenance Data
All articles reported treatment effects for the majority
of the participants, despite a range of goals and measures
being used. Statistical comparison of at least one key outcome
was provided for 16 of 23 studies.
Of the 23 participants given motor-based treatment, 21
were reported to demonstrate positive treatment effects, and a
statistical analysis of effects was reported for 17 (see Table 3).
Not all participants showed significant changes in all mea-
sures assessed. The majority of measures consisted of percent-
age of accuracy on treated items or percentage of consonant,
vowel, phonemes, or words correct. Three studies demon-
strated improvement for treated prosodic accuracy: Ballard
et al. (2010) for three of three participants using the Rapid
Syllable Transition Treatment (ReST) and Maas, Butalla,
Murray et al.: Systematic Review of Treatment Outcomes for CAS
and Farinella (2012) and Maas and Farinella (2012) for three
of four participants following Dynamic Temporal and Tactile
Cueing (DTTC; in any PML condition). The combined
MIT/TCM treatment showed significantly improved percentage
of vowels correct; however, it significantly reduced percent-
age of consonants correct for the participant immediately
post the first block of MIT. The greatest gains were noted
after withdrawal of treatment. Despite the authors suggesting
this to be due to the treatments given, this equally may be due
to maturation or improvement after withdrawal of treatment
providing unclear evidence to the effect of these treatments.
Six studies of linguistic-based treatment reported a
treatment effect for speech measures for 17 of 21 participants,
with 16 of 21 participants supported by statistical compar-
ison (Iuzzini & Forrest, 2010; Krauss & Galloway, 1982;
McNeill et al., 2009a, 2009b, 2010; Moriarty & Gillon, 2006).
With Integrated Phonological Awareness Intervention, 11 of
15 participants were reported to reduce phonological pro-
cesses and to improve phonological awareness skills. Another
four articles reported that five of five participants increased
use of multisymbol messages (phrases or morphemes) with
linguistic-based treatment utilizing AAC (Binger et al., 2008;
Binger & Light, 2007; Binger et al., 2011; Harris et al., 1996).
Finally, AAC treatment studies focusing on communi-
cative effectiveness reported treatment effects for two of two
participants, with no statistical analyses conducted (Bornman
et al., 2001; Culp, 1989). The children reportedly increased
appropriate responses and frequency of turns in conversation.
Generalization
Seven articles considered response generalization, and
another five considered stimulus generalization. No article
measured both response and stimulus generalization.
Response generalization. All treatments measuring
generalization used statistical analysis. For motor-based
treatments, significant improvement in articulation accuracy
for untrained responses was noted for one participant after
facilitative vowel treatment (Stokes & Griffiths, 2010) and for
four of seven participants across any behavior/condition in
three studies applying Integral Stimulation/DTTC (Edeal
& Gildersleeve-Neumann, 2011; Maas et al., 2012; Maas
& Farinella, 2012). Significant generalization was reported
for three of three participants for lexical stress accuracy
in untrained three syllable pseudowords and for one of
three participants in untrained real word production for ReST
treatment (Ballard et al., 2010).
Only one linguistic-based approach, the Integrated
Phonological Awareness Intervention, reported response
generalization. The same 11 of 15 children who demonstrated
treatment gains also showed significant improvement in
speech intelligibility, mean length of utterance, and phono-
logical awareness skills (phoneme segregation, manipulation,
nonword reading, reading accuracy, and letter–sound cor-
respondences; McNeill et al., 2009a, 2009b, 2010; Moriarty
& Gillon, 2006).
Stimulus generalization. Only five articles (22%) re-
ported stimulus generalization, with four of these utiliz-
ing AAC treatments. Three participants, who increased
497
grammatical constituents in treatment, also generalized use of
symbol combinations across different scenarios or discourse
types (Binger et al., 2008; Binger & Light, 2007). Anecdotal
reports, predominately from caregivers, suggested improved
expressive language skills or communication across settings,
reduced frustration due to AAC device use (Binger & Light,
2007; Culp, 1989), and transition to reliance on speech
(Bornman et al., 2001). There was one reported instance of
poor stimulus generalization; rate control therapy showed
minimal generalization from the treated reading task to un-
treated conversation (Rosenthal, 1994).
Aim 4: Certainty of Evidence
The level of certainty that the effects of each treatment
were true (Smith, 1981) is reported in Table 3. No treat-
ment approaches met the criteria for conclusive evidence.
Three treatment approaches, two motor (Integral Stimulation/
DTTC, ReST) and one linguistic (Integrated Phonological
Awareness Intervention), met the criteria for preponderant
evidence (replicated evidence across participants with prom-
ising treatment, maintenance, and generalization data). The
remaining approaches qualified as suggestive evidence. These
included studies with questionable effects (e.g., combined
MIT/TCM treatment), as there was not a specific category for
these within Smith’s (1981) framework. Two studies with
suggestive evidence approached preponderant evidence: Aided
AAC modeling met all the criteria except for confidence in
CAS diagnosis, and the facilitative vowel contexts treatment
reported only one case with low confidence in CAS diagnosis.
The overall treatment effect size for each of the three
approaches with preponderant evidence was determined
using IRD (Parker et al., 2009; see Table 4). Integral Stimulation/
DTTC demonstrated a moderate effect size for articulation
and/or prosodic accuracy (IRD = 0.60) for seven participants
ranging in age from 3;4 (years;months) to 8;4 with mild–
moderate to severe CAS or CAS+. Integrated Phonological
Awareness Intervention also demonstrated moderate effect
sizes for percentage of phonemes correct (IRD = 0.51) for
15 participants ranging in age from 4;2 to 7;6 with mild–
moderate to severe CAS. Finally, ReST demonstrated a large
effect size for prosodic accuracy (IRD = 0.78) for three par-
ticipants ranging in age from 7;8 to 10;10 with mild to mild–
moderate CAS.
Generalization effects varied according to the treat-
ment and measures used, and thus a separate effect size was
calculated per measure/condition (see Table 5). The motor
treatments of Integral Stimulation/DTTC and ReST showed
predominantly small effect sizes, with some moderate-to-large
effects (ranging from IRD = –0.20 to IRD = 0.84). The Inte-
grated Phonological Awareness Intervention showed a large
effect size for percentage of phonemes correct (IRD = 0.80).
Discussion
The aim of this study was to conduct an in-depth and
systematic review of treatment efficacy studies for children
with CAS. Unlike previous reviews, we considered within-
498 American Journal of Speech-Language Pathology • Vol. 23 • 486–504 • August 2014
subject experimental designs with Level IIb evidence to identify
promising treatment approaches for further study and for
cautious application in clinical settings. Twenty-three studies
qualified for in-depth review, and three treatment approaches,
tested in seven studies, reached the level of preponderant
evidence with promising evidence of efficacy across several
participants diagnosed with CAS (confidence rating of 1–3).
Study Quality
The vast majority of studies examining treatment for
CAS are single case studies, with an increasing trend toward
more rigorous experimental designs over time. This trend
may be a consequence of critical narrative reviews in the late
1980s and 1990s (e.g., Hall et al., 1993; McCabe et al., 1998;
Pannbacker, 1988) and greater awareness of research design
and evidence-based practice (ASHA, 2004). The body of
research reflects Phase I and Phase II studies (Robey, 2004)
designed to test the feasibility and early efficacy of treatments.
At this stage, no Phase III RCT or NRCT reports are avail-
able to contribute to conclusive evidence (Smith, 1981).
Therefore, no conclusions as to which treatments are more
efficacious than others for CAS are currently possible (ASHA,
2007; Morgan & Vogel, 2009; Pannbacker, 1988). This review
identified preponderant evidence and well-designed, quasi-
experimental studies that can guide clinical decisions and that
are suitable to pursue in more substantive comparative ef-
ficacy studies.
Certainty of Evidence
Two motor treatments (Integral Stimulation /DTTC
and ReST) and one linguistic treatment (Integrated Phono-
logical Awareness Intervention) demonstrated preponderant
evidence (Smith, 1981) with positive treatment and generali-
zation effects across several children. Only Integral Stimulation/
DTTC is supported currently by studies across independent
research groups (Baas, Strand, Elmer, & Barbaresi, 2008; Edeal
& Gildersleeve-Neumann, 2011; Maas et al., 2012; Maas &
Farinella, 2012; Strand & Debertine, 2000; Strand et al., 2006),
although such replication was not directly analyzed here.
SCED ratings in the future could be elaborated beyond rep-
lication for external validity and application of the same
protocol in direct replication studies (Tate et al., 2013) to also
include independence of research groups. Currently, no direct
replication studies exist for CAS treatment.
The remaining articles were classified as suggestive
evidence. With future well-controlled investigation, some of
these treatments, as well as others excluded from this review,
will likely emerge as promising options for CAS. Addition-
ally, an extra level of certainty should be considered for future
reviews flagging studies with questionable effects (i.e., those
that did not demonstrate clear treatment effects).
Confidence in CAS Diagnosis
A critical component of any treatment study is a clear
definition of the study participants to convince readers that
the appropriate population was targeted. When the 2007
Table 4. Omnibus improvement rate differences (IRDs) for preponderant evidence—treatment effects.

Treatment No. of Confidence Omnibus Interpretation

type Treatment approach Article cases in CAS Dxa IRD 95% CI of effect

Motor Integral Stimulation/ Strand and Debertine (2000) 1 1 1.00 [0.97, 1.00] Very large
DTTCb Edeal and Gildersleeve- 2 1 0.98 [0.88, 1.00] Very large
Neumann (2011)
Maas and Farinella (2012) 4c 3 0.18 [0.03, 0.33] Small or questionable
Maas et al. (2012) 4c 2 0.22 [0.08, 0.36] Small or questionable
Overall 0.60 [0.53, 0.67] Moderate
ReST Ballard et al. (2010) 3 1 0.78 [0.54, 1.00] Large (prosody—
PVI duration)
Linguistic Integrated Phonological Moriarty and Gillon (2006) 3 3 1.00 [0.89, 1.00] Very large
Awareness McNeill et al. (2009a) 12 3 0.10 [–0.06, 0.24] Small or questionable
Intervention Overall 0.51 [0.39, 0.58] Moderate

Note. CI = confidence interval; PVI = pairwise variability index (acoustic measure).

a
1 = highest. bBaas et al. (2008) and Strand et al. (2006) were excluded from IRD because of diagnostic confidence ratings of 4 and 5.
c
Three participants in common across two studies.

consensus-based diagnostic features (ASHA, 2007) were ap-
plied, only 16.6% achieved a rating of high confidence. How-
ever, most of the studies reviewed were published prior to
2007 and were using common descriptors for their time, now
considered by many to be nondiscriminative (e.g., ASHA,
2007; McCabe et al., 1998). The most commonly overlooked
CAS characteristic across studies was dysprosody, which
was not considered a core feature of CAS in many checklists
prior to 2007. As prosody (e.g., lexical or phrasal stress) is
primarily conveyed on vowels, we counted mention of vowel
errors in participants as possible evidence of dysprosody to
accommodate older articles. Despite the chance that dys-
prosody would be overestimated because of this decision (as
only a subset of vowel errors or distortions would be indi-
cative of stress errors), only 50% of the articles (21 of 42)
reported vowel errors. Furthermore, the high rate of comor-
bidity in CAS (41% in this sample) complicates diagnosis and
could partially account for lower confidence ratings.

Table 5. Omnibus IRDs for preponderant evidence—generalization.

Confidence
Therapy Therapy No. of in CAS Dx Generalization to Interpretation
type approach Article cases (1 = highest) untrained itemsa IRD 95% CI of effect

Motor Integral Stimulation/ Strand and 1 1 NR NR NA NA

DTTCb Debertine
(2000)
Edeal and 2 1 MFF sounds 0.05 [10.47, 0.57] Small or
Gildersleeve- questionable
Neumann (2011) HFF sounds 0.60 [0.18, 1.00] Moderate
Maas and Farinella 4c 3 Blocked practice items 0.04 [–0.16, 0.24] Small or
(2012) questionable
Random practice items 0.20 [0.01, 0.39] Small or
questionable
Maas et al. (2012) 4c 2 100% feedback items –0.15 [–0.13, 0.43] Small or
questionable
60% feedback items 0.03 [–0.14, 0.20] Small or
questionable
ReST Ballard et al. (2010) 3 1 Less complex 0.84 [0.62, 1.00] Large
pseudowords
(PVI duration)
Real words 0.13 [–0.21, 0.47] Small or
(PVI duration) questionable
Linguistic Integrated Moriarty and Gillon 3 3 NR NR NA NA
Phonological (2006)
Awareness McNeill et al. 12 3 Untrained PPC 0.80 [0.64, 0.88] Large
Intervention (2009a)

Note. NA = not applicable; MFF = moderate frequency feedback; HFF = high frequency feedback.
a
Generalization items were individualized for each participant. bBaas et al. (2008) and Strand et al. (2006) were excluded from IRD because of
diagnostic confidence ratings of 4 and 5. cThree participants in common across two studies.

Murray et al.: Systematic Review of Treatment Outcomes for CAS 499

Experimental Control
Experimental control is essential to ensure that treat-
ment effects are attributable to the intervention approach
provided and are an essential element to calculating effect
sizes for single-subject designs (Olswang & Bain, 1994). Only
experimental designs with some experimental control were
included in the treatment outcome analysis. Experimental
control was best demonstrated when SCEDs reported change
in at least one condition beyond baseline levels after with-
drawal of treatment and when control data were used to
estimate improvement due to maturation (Byiers et al., 2012;
Olswang & Bain, 1994; Perdices & Tate, 2009). Not all of
the studies analyzed here demonstrated clear experimental
control and treatment effects on the basis of these conditions.
In future research, CAS SCEDs would ideally use more
than two phases (i.e., beyond just baseline and treatment but
also withdrawal and other treatment phases), including at
least three data points per phase (including baselines) and
replication across cases (Tate et al., 2013).
Within this review, 22% (five of 23) of the articles at
Level IIb of evidence reported some changes in untreated
speech behaviors, which were hypothesized to be unrelated to
the treated behaviors. This phenomenon reflects a loss of
experimental control and may undermine the claim of posi-
tive treatment effects. However, it may also reflect the
underspecification of theories of speech motor control, in that
there is limited evidence to guide how and why speech
behaviors are related motorically (Folkins & Bleile, 1990).
This issue has been more fully discussed in studies of treat-
ment of acquired apraxia of speech (Ballard, 2001; Ballard,
Maas, & Robin, 2007). These unexpected generalization
outcomes may provide interesting directions for exploring
relationships between different speech skills and for guiding
the selection of generalization and control stimuli in future
treatment trials.
Treatment Approaches
The reviewed treatments for CAS can be categorized as
targeting motor or linguistic skills or using AAC to provide
a primary means of communication. The approaches used
can also be viewed in light of the International Classification
of Functioning, Disability, and Health (ICF; World Health
Organization, 2002). Motor and linguistic approaches were
primarily directed at the impairment (body functions/structure)
level of the ICF (McLeod & McCormack, 2007), commonly
addressing articulation, prosody, phonological awareness, or
expressive language skills. AAC approaches were instead di-
rected at the activity/participation levels of the ICF, facilitating
communicative effectiveness with a greater emphasis on con-
sultation, training, and home practice. The literature suggests
that the primary concern in CAS is developing intelligible
speech, either through addressing articulatory and prosodic
accuracy or through improving phonology, although concen-
tration on AAC and expressive language may be required.
The majority of SCEDs intentionally combined treat-
ments, a trend that appears to be increasing. This may be
500 American Journal of Speech-Language Pathology • Vol. 23 • 486–504 • August 2014
due to the hypothesized links between speech motor and
linguistic difficulties in children with CAS (Souza, Payão, &
Costa, 2009). However, the studies using combined approaches
had participants without comorbid CAS and often combined
approaches within the same therapy type (e.g., two motor
treatments). The theoretical motivation for combining such
treatments is unclear, and no comparisons of single versus
combined treatments for children with clear diagnoses of
CAS are yet available.
Treatment Outcomes
It is well accepted that the strongest evidence for a
treatment efficacy is demonstration of skill maintenance
beyond the treatment period and generalization of treatment
effects to related behaviors and/or communication contexts
(e.g., McReynolds & Kearns, 1983; Schmidt & Lee, 2011).
Such effects constitute instrumental clinical change (Olswang
& Bain, 1994, 2013). Few of the 23 studies evaluated reported
maintenance of treatment or generalization effects. As
such, the robustness of most reported treatment effects over
time is not known.
The six approaches that demonstrated maintenance
and response or stimulus generalization were the three ap-
proaches with preponderant evidence (Integral Stimulation/
DTTC, ReST, and Integrated Phonological Awareness
Intervention) and the aided AAC modeling and facilitative
vowel context interventions. Degree of generalization varied,
seemingly influenced by specific stimuli chosen, incorpora-
tion of PML, dosage, frequency and intensity of sessions,
potential critical thresholds for skill mastery, and participant
characteristics. Notably, only those participants demon-
strating strong gains for treated behaviors tended to maintain
or generalize skills (e.g., Maas & Farinella, 2012; McNeill
et al., 2009a). The exception to this was the phonological
treatment within the Integrated Phonological Awareness
Intervention, which showed large generalization effects despite
demonstrating moderate treatment effects. This is an expected
outcome in interventions that focus on learning linguistic
rules that can be rapidly generalized across a range of contexts
(Gierut, 1998; Gierut & Hulse, 2010) versus learning new
motor skills. There are at least two possible explanations for
why children with probable CAS, a motor speech disorder,
responded to a phonological treatment. First, phonological
therapy involves production of speech targets and so pro-
vides practice in planning, programming, and executing the
movements for these targets. Second, the participants had a
number of phonological processes, and perhaps their con-
comitant phonological disorders were a primary concern for
treatment at this time. These findings warrant thoughtful
comparison of specific participant characteristics, each inter-
vention’s theoretical framework, the stimuli and activities used
during intervention, and stimuli used to assess generalization
of skill to determine whether there is in fact any benefit in one
approach over the other.
Likewise, stimulus generalization provides important
information about how skills treated in therapy generalize to
other contexts or situations for improvement in everyday
communication. Only rate control therapy (Rosenthal, 1994)
and AAC approaches considered such generalization. Such
measures should be employed as we move toward Phase III
and Phase IV studies to demonstrate real change in com-
munication skills in children with CAS.
It is important to note that, despite most children in the
studies showing positive effects in treatment, all children
required additional therapy to work on other communica-
tion goals after treatment blocks spanning between nine
and 195 sessions. This demonstrates that children with CAS
often require ongoing therapy, spanning many goals and
needs.
Further investigation is warranted to explore inter-
actions between participant variables and the degree of
treatment outcome to help tailor treatments, particularly for
those who did not demonstrate treatment effects. For exam-
ple, Integral Simulation/DTTC was initially designed for
children with severe CAS using functional core vocabulary
stimuli (Strand & Skinder, 1999). Whereas studies addressing
severe CAS have reported positive treatment effects across
multiple participants, those addressing mild-to-moderate
CAS and specific sound, prosody, and/or word structure
goals have had small omnibus effect sizes (Maas et al., 2012;
Maas & Farinella, 2012).
Similarly, it is yet to be determined whether AAC
approaches can promote speech gains over and above speech-
based interventions (as described in Bornman et al., 2001).
The current literature suggests that when a child experienced
frustration over low intelligibility or comprehensibility,
AAC approaches may increase communicative success as
well as stimulate development of language skills that cannot
be practiced through speaking.
Structure of Treatment Delivery
Intensive treatment delivery in impairment-based
intervention appears crucial for obtaining positive treatment
outcomes. These treatments provided therapy at least 2–3 times
a week, with sessions of up to 60 min. The dose of treatment,
defined as the “number of properly administrated teaching
episodes during a single intervention session” (Warren et al.,
2007, p. 71), should probably also be high (Edeal & Gildersleeve-
Neumann, 2011). This review suggests that at least 60 trials
per session represents a “high” dose. Williams (2012) sug-
gested that, with phonological therapy for speech sound
disorder, ≥50 trials per session over ≥30 sessions is effec-
tive, although dose and intensity need to increase as impair-
ment severity increases. Further research is indicated to
allow reliable estimates of the overall amount of therapy
needed, dose, and intensity for CAS, considering age and
severity.
SCED studies in this review all delivered treatment
in individual sessions, and 40% utilized home practice to
increase dose and intensity. The high intensity that is indi-
cated would clearly require significant resources. Thus, de-
termining effective treatments with engaging home practice
activities should maximize maintenance and generalization
of skills.
Murray et al.: Systematic Review of Treatment Outcomes for CAS
Implications
Despite a continued need for well-designed RCTs,
NRCTs, and additional SCED studies, existing evidence is
available to guide clinical practice in the treatment of CAS.
Comparing treatments is a future priority, considering the
range of treatments that are available. The treatments best
suited to inclusion in an RCT or NRCT are those that have
demonstrated maintenance and generalization effects. Fur-
ther research is needed for valid and reliable differential
diagnosis of CAS and for understanding which client groups
would benefit from which type of treatment.
In terms of clinical practice, currently two motor
treatments (Integral Stimulation/DTTC and ReST) and one
linguistic treatment (Integrated Phonological Awareness
Intervention) are best suited to interim clinical use, with ses-
sions at least twice a week and dose above 60 trials per session.
DTTC appears to work better for clients with more severe
CAS, Integrated Phonological Awareness Intervention ap-
pears to work better for children 4–7 years of age with mild to
severe CAS, and ReST appears to work better for children
7–10 years of age with mild-to-moderate CAS.
Limitations
Because of the developing nature of this literature, this
systematic review utilized some narrative review methodol-
ogy to ensure greater coverage of SCED designs that differed
considerably (Collins & Fauser, 2004). Potential bias was
reduced through the use of systematic review principles.
We considered only peer-reviewed published reports
in English. We did not control for publication bias, as we
excluded evidence that had not undergone journal-level peer
review. This means that evidence from conference presenta-
tions or dissertations was excluded, thus excluding other
approaches with potential suggestive evidence, such as Prompts
for Restructuring Oral Muscular Phonetic Targets (Dale &
Hayden, 2011; now see Dale & Hayden, 2013) or the Nuffield
Dyspraxia Programme (Belton, 2006). As in all reviews, there
is a risk that studies with negative treatment outcomes are
underrepresented because of the difficulty publishing such
studies, potentially risking overestimation of treatment effects.
Our IRD analysis examined preliminary effect sizes
but did not use moderator variables because of the small
number of articles (n = 7) and participants (n = 26). Here, we
provide some preliminary observations about which treat-
ments appear useful for different age and severity levels. As
additional studies are published, it is recommended that such
moderator variables be evaluated more fully.
It is important to note the IRD is calculated and inter-
preted differently to other effect sizes. For example, the recent
DTTC studies (Maas et al., 2012; Maas & Farinella, 2012)
used Beeson and Robey’s (2006) effect size method and found
large effect sizes for some participants and conditions and
found no effects for others. As the majority of articles did
not report means and standard deviations, such effect size
calculations were not possible across all preponderant arti-
cles. The IRDs reported here differ from those reported
501
in Maas et al. (2012) and Maas and Farinella (2012) in two
ways. First, in our calculation of IRD, only nonoverlapping
data between baseline/withdrawal and treatment phases
were considered indicative of improvement. Second, the
IRDs here were averaged across participants within studies;
thus, greater variability across participants conservatively
reduced the magnitude of the omnibus IRD.
Other aspects that could be investigated were beyond the
scope of the current study. This includes SCED methodolog-
ical quality as per reported guidelines (e.g., Tate et al., 2013;
see Wendt & Miller, 2012, for a review) and analysis of motor
learning principles utilized in each treatment (e.g., Bislick,
Weir, Spencer, Kendall, & Yorkston, 2012). We did not eval-
uate the theoretical stance of each treatment approach, which
might have revealed further information as to why some
treatments generated stronger effects than others.
Conclusion
This review identified 23 SCED articles reporting 13
treatment approaches classified as primarily motor, linguistic,
or AAC. Three treatments were judged to have preponderant
evidence to support their efficacy, indicating that the re-
ported effects were “probably true”: Integral Stimulation/
DTTC, ReST, and Integrated Phonological Awareness
Intervention. These treatments had moderate-to-large treat-
ment effects and small-to-large generalization effects, making
them strong candidates for Phase III research, comparison
in RCTs, and interim clinical use. Larger scale rigorous RCTs
and NRCTs are critically needed to compare treatments with
larger sample sizes to potentially inform a greater number
of clients with CAS (Morgan & Vogel, 2009). Such efforts will
serve to generate conclusive evidence through well-controlled
experimental designs, including measures of maintenance
and generalization of treatment effects and manipulation of
treatment intensity and other motor learning principles. This
work will be facilitated by parallel work toward a reliable
diagnostic system and exploration of participant variables
that influence treatment response.
Acknowledgments
This research was supported by the Douglas and Lola Douglas
Scholarship on Child and Adolescent Health, the Speech Pathology
Australia Nadia Verrall Memorial Research Grant and Postgraduate
Research Award, and the University of Sydney James Kentley
Memorial Scholarship and Postgraduate Research Support Scheme
awarded to the first author. This research was also supported by an
Australian Research Council Future Fellowship awarded to the
third author. We thank Catherine Mason and Donna Thomas for
assistance coding the data and completing reliability.
References
References marked with an asterisk indicate studies included in the
improvement rate difference analysis.
Abramson, J. H. (2011). WINPEPI updated: Computer programs
for epidemiologists, and their teaching potential. Epidemiologic
Perspectives & Innovations, 8, 1–9.
502 American Journal of Speech-Language Pathology • Vol. 23 • 486–504 • August 2014
Alcock, K. J., Passingham, R. E., Watkins, K. E., & Vargha-
Khadem, F. (2000). Oral dyspraxia in inherited speech and
language impairment and acquired dysphasia. Brain and
Language, 75, 17–33.
American Speech-Language-Hearing Association. (2004). Evidence-
based practice in communication disorders: An introduction
[Technical report]. Available from www.asha.org/policy
American Speech-Language-Hearing Association. (2007). Childhood
apraxia of speech [Technical report]. Available from www.asha.
org/policy
Baas, B. S., Strand, E. A., Elmer, L. M., & Barbaresi, W. J. (2008).
Treatment of severe childhood apraxia of speech in a 12-year-old
male with CHARGE association. Journal of Medical Speech-
Language Pathology, 16, 181–190.
*Ballard, K. J. (2001). Response generalization in apraxia of speech
treatments: Taking another look. Journal of Communication
Disorders, 34, 3–20.
Ballard, K. J., Maas, E., & Robin, D. A. (2007). Treating control of
voicing in apraxia of speech with variable practice. Aphasiology,
21, 1195–1217.
Ballard, K. J., Robin, D. A., McCabe, P., & McDonald, J. (2010).
A treatment for dysprosody in childhood apraxia of speech.
Journal of Speech, Language, and Hearing Research, 53,
1227–1245.
Beeson, P. M., & Robey, R. R. (2006). Evaluating single-subject
treatment research: Lessons learned from the aphasia literature.
Neuropsychological Review, 16, 161–169.
Belton, E. (2006). Evaluation of the effectiveness of the Nuffield Dys-
praxia Programme as a treatment approach for children with severe
speech disorders. London, England: University College London.
Binger, C., Kent-Walsh, J., Berens, J., Del Campo, S., & Rivera, D.
(2008). Teaching Latino parents to support the multi-symbol
message productions of their children who require AAC.
Augmentative & Alternative Communication, 24, 323–338.
Binger, C., & Light, J. (2007). The effect of aided AAC modeling on
the expression of multi-symbol messages by preschoolers who
use AAC. AAC: Augmentative and Alternative Communication,
23, 30–43. doi:10.1080/07434610600807470
Binger, C., Maguire-Marshall, M., & Kent-Walsh, J. (2011). Using
aided AAC models, recasts, and contrastive targets to teach
grammatical morphemes to children who use AAC. Journal
of Speech, Language, and Hearing Research, 54, 160–176.
doi:10.1044/1092-4388(2010/09-0163)
Bislick, L. P., Weir, P. C., Spencer, K., Kendall, D., & Yorkston,
K. M. (2012). Do principles of motor learning enhance retention
and transfer of speech skills? A systematic review. Aphasiology,
26, 709–728. doi:10.1080/02687038.2012.676888
Bornman, J., Alant, E., & Meiring, E. (2001). The use of a digital
voice output device to facilitate language development in a child
with developmental apraxia of speech: A case study. Disability
and Rehabilitation, 23, 623–634.
Byiers, B. J., Reichle, J., & Symons, F. J. (2012). Single-subject
experimental design for evidence-based practice. American
Journal of Speech-Language Pathology, 21, 397–414. doi:10.1044/
1058-0360(2012/11-0036)
Collins, J. A., & Fauser, B. C. J. M. (2004). Balancing the strengths
of systematic and narrative reviews. Human Reproduction
Update, 11, 103–104.
Culp, D. M. (1989). Developmental apraxia and augmentative or
alternative communication: A case example. AAC: Augmenta-
tive and Alternative Communication, 5, 27–34. doi:10.1080/
07434618912331274936
Dale, P. S., & Hayden, D. A. (2011, June). The efficacy of PROMPT
for treating childhood apraxia of speech. Paper presented at
 the 6th International Conference on Speech Motor Control,
Nijmegen-Groningen, the Netherlands.
Dale, P. S., & Hayden, D. A. (2013). Treating speech subsystems in
childhood apraxia of speech with tactual input: The PROMPT
approach. American Journal of Speech-Language Pathology,
22, 644–661. doi:10.1044/1058-0360(2013/12-0055)
*Edeal, D. M., & Gildersleeve-Neumann, C. E. (2011). The impor-
tance of production frequency in therapy for childhood apraxia
of speech. American Journal of Speech-Language Pathology,
20, 95–110.
Folkins, J. W., & Bleile, K. M. (1990). Taxonomies in biology,
phonetics, phonology, and speech motor control. Journal of
Speech and Hearing Disorders, 55, 596–611.
Gierut, J. A. (1998). Treatment efficacy: Functional phonological
disorders in children. Journal of Speech, Language, and Hearing
Research, 41, S85–S100.
Gierut, J. A., & Hulse, L. E. (2010). Evidence-based practice:
A matrix for predicting phonological generalization. Clinical
Linguistics & Phonetics, 24, 323–334. doi:10.3109/
02699200903532490
Gillon, G. T., & Moriarty, B. C. (2007). Childhood apraxia of
speech: Children at risk for persistent reading and spelling
disorder. Seminars in Speech and Language, 28, 48–57.
Groenen, P., Maassen, B., Crul, T., & Thoonen, G. (1996). The
specific relation between perception and production errors
for place of articulation in developmental apraxia of speech.
Journal of Speech and Hearing Research, 39, 468–482.
Hall, P. K. (2000). A letter to the parent(s) of a child with devel-
opmental apraxia of speech: Part IV. Treatment of DAS.
Language, Speech, and Hearing Services in Schools, 31, 179–181.
Hall, P. K., Jordan, L. S., & Robin, D. A. (1993). Developmental
apraxia of speech: Theory and clinical practice. Austin, TX: Pro-Ed.
Harris, L., Doyle, E. S., & Haaf, R. (1996). Language treatment
approach for users of AAC: Experimental single-subject inves-
tigation. Augmentative and Alternative Communication, 12,
230–243. doi:10.1080/07434619612331277698
Hegde, M. N. (2007). A methodological review of randomized
clinical trials. Communicative Disorders Review, 1, 15–36.
Iuzzini, J., & Forrest, K. (2010). Evaluation of a combined treatment
approach for childhood apraxia of speech. Clinical Linguistics &
Phonetics, 24, 335–345.
Jacks, A., Marquardt, T. P., & Davis, B. L. (2006). Consonant
and syllable structure patterns in childhood apraxia of speech:
Developmental change in three children. Journal of Communi-
cation Disorders, 39, 424–441.
Kearns, K. P., & de Riesthal, M. (2013). Applying single-subject
experimental research to inform clinical practice. In L. A. C.
Golper & C. Frattali (Eds.), Outcomes in speech-language
pathology (2nd ed., pp. 279–297). New York, NY: Thieme.
Krauss, T., & Galloway, H. (1982). Melodic intonation therapy with
language delayed apraxic children. Journal of Music Therapy,
19, 102–113.
Lewis, B. A., Freebairn, L. A., Hansen, A., Taylor, H., Iyengar, S.,
& Shriberg, L. D. (2004). Family pedigrees of children with
suspected childhood apraxia of speech. Journal of Communica-
tion Disorders, 37, 157–175. doi:10.1016/j.jcomdis.2003.08.003
Lundeborg, I., & McAllister, A. (2007). Treatment with a combi-
nation of intraoral sensory stimulation and electropalatography
in a child with severe developmental dyspraxia. Logopedics
Phoniatrics Vocology, 32, 71–79.
*Maas, E., Butalla, C. E., & Farinella, K. A. (2012). Feedback fre-
quency in treatment for childhood apraxia of speech. American
Journal of Speech-Language Pathology, 21, 239–257. doi:10.1044/
1058-0360(2012/11-0119)
Murray et al.: Systematic Review of Treatment Outcomes for CAS
*Maas, E., & Farinella, K. A. (2012). Random versus blocked
practice in treatment for childhood apraxia of speech. Journal
of Speech, Language, and Hearing Research, 55, 561–578.
doi:10.1044/1092-4388(2011/11-0120)
Maas, E., Robin, D. A., Austermann Hula, S. N., Freedman, S. E.,
Wulf, G., Ballard, K. J., & Schmidt, R. A. (2008). Principles of
motor learning in treatment of motor speech disorders. American
Journal of Speech-Language Pathology, 17, 277–298. doi:10.1044/
1058-0360(2008/025)
Maassen, B., Groenen, P., & Crul, T. (2003). Auditory and phonetic
perception of vowels in children with apraxic speech disorders.
Clinical Linguistics & Phonetics, 17, 447–467.
Marion, M. J., Sussman, H. M., & Marquardt, T. P. (1993). The
perception and production of rhyme in normal and develop-
mentally apraxic children. Journal of Communication Disorders,
26, 129–160.
Martikainen, A.-L., & Korpilahti, P. (2011). Intervention for child-
hood apraxia of speech: A single-case study. Child Language
Teaching and Therapy, 27, 9–20.
McCabe, P., Rosenthal, J. B., & McLeod, S. (1998). Features of
developmental dyspraxia in the general speech-impaired popu-
lation? Clinical Linguistics & Phonetics, 12, 105–126.
McLeod, S., & McCormack, J. (2007). Application of the ICF and
ICF-Children and Youth in children with speech impairment.
Seminars in Speech & Language, 28, 254–264.
*McNeill, B. C., Gillon, G. T., & Dodd, B. (2009a). Effectiveness of
an integrated phonological awareness approach for children with
childhood apraxia of speech (CAS). Child Language Teaching
and Therapy, 25, 341–366.
McNeill, B. C., Gillon, G. T., & Dodd, B. (2009b). A longitudinal
case study of the effects of an integrated phonological aware-
ness program for identical twin boys with childhood apraxia
of speech (CAS). International Journal of Speech-Language
Pathology, 11, 482–495.
McNeill, B. C., Gillon, G. T., & Dodd, B. (2010). The longer term
effects of an integrated phonological awareness intervention
for children with childhood apraxia of speech. Asia Pacific
Journal of Speech, Language & Hearing, 13, 145–161.
McReynolds, L. V., & Kearns, K. P. (1983). Single-subject experi-
mental designs in communicative disorders. Baltimore, MD:
University Park Press.
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009).
Preferred reporting items for systematic reviews and meta-
analyses: The PRISMA statement. PLoS Med, 6(7), e1000097.
doi:10.1371/journal.pmed.1000097
Morgan, A. T., & Vogel, A. P. (2008). Intervention for childhood
apraxia of speech. Cochrane Database of Systematic Reviews, 16,
1–19. doi:10.1002/14651858.CD006278.pub2
Morgan, A. T., & Vogel, A. P. (2009). A Cochrane review of treat-
ment for childhood apraxia of speech. European Journal of
Physical & Rehabilitation Medicine, 45, 103–110.
*Moriarty, B., & Gillon, G. (2006). Phonological awareness interven-
tion for children with childhood apraxia of speech. International
Journal of Language & Communication Disorders, 41, 713–734.
Moseley, A. M., Herbert, R. D., Maher, C. G., Sherrington, C., &
Elkins, M. R. (2008). PEDro scale can only rate what papers
report. Australian Journal of Physiotherapy, 54(4), 288.
doi:10.1016/S0004-9514(08)70017-5
Olswang, L. B., & Bain, B. A. (1994). Data collection: Monitoring
children’s treatment progress. American Journal of Speech-
Language Pathology, 3, 55–66.
Olswang, L. B., & Bain, B. A. (2013). Treatment research. In L. A.
C. Golper & C. Frattali (Eds.), Outcomes in speech-language
pathology (2nd ed., pp. 245–264). New York, NY: Thieme.
503
Ozanne, A. (2005). Childhood apraxia of speech. In B. Dodd (Ed.),
Differential diagnosis and treatment of children with speech
disorder (pp. 71–82). London, England: Whurr.
Pannbacker, M. (1988). Management strategies for developmental
apraxia of speech: A review of literature. Journal of Communi-
cation Disorders, 21, 363–371.
Parker, R., Vannest, K., & Brown, L. (2009). The improvement rate
difference for single-case research. Exceptional Children, 75,
135–150.
Perdices, M., Schultz, R., Tate, R., McDonald, S., Togher, L.,
Savage, S., . . . Smith, K. (2006). The evidence base of neuro-
psychological rehabilitation in acquired brain impairment (ABI):
How good is the research? Brain Impairment, 7, 119–132.
Perdices, M., & Tate, R. L. (2009). Single-subject designs as a tool
for evidence-based clinical practice: Are they unrecognised and
undervalued? Neuropsychological Rehabilitation, 19, 904–927.
doi:10.1080/09602010903040691
Robey, R. R. (2004). A five-phase model for clinical-outcome
research. Journal of Communication Disorders, 37, 401–411.
Rosenthal, J. B. (1994). Rate control therapy for developmental
apraxia of speech. Clinics in Communication Disorders, 4,
190–200.
Royal College of Speech and Language Therapists. (2011). RCSLT
policy statement. Retrieved from www.ndp3.org/documents/
rcslt2011dvdPolicyStatement.pdf
Schmidt, R. A., & Lee, T. D. (2011). Motor control and learning: A
behavioral emphasis (5th ed.). Champaign, IL: Human Kinetics.
Smith, N. L. (1981). The certainty of judgments in health evalua-
tions. Evaluation and Program Planning, 4, 273–278.
doi:10.1016/0149-7189(81)90028-8
Souza, T. N., Payão, M. C., & Costa, R. C. (2009). Childhood
speech apraxia in focus: Theoretical perspectives and present
tendencies. Pró-fono: Revista de atualização científica, 21,
76–80.
Stackhouse, J., & Snowling, M. (1992). Developmental verbal
dyspraxia: II. A developmental perspective on two case studies.
European Journal of Disorders of Communication, 27, 35–54.
Stokes, S. F., & Griffiths, R. (2010). The use of facilitative vowel
contexts in the treatment of post-alveolar fronting: A case study.
International Journal of Language & Communication Disorders,
45, 368–380. doi:10.3109/13682820903094737
*Strand, E. A., & Debertine, P. (2000). The efficacy of integral
stimulation intervention with developmental apraxia of speech.
Journal of Medical Speech-Language Pathology, 8, 295–300.
504 American Journal of Speech-Language Pathology • Vol. 23 • 486–504 • August 2014
Strand, E. A., & Skinder, A. (1999). Treatment of developmental
apraxia of speech: Integral stimulation methods. In A. Caruso &
E. Strand (Eds.), Clinical management of motor speech disorders
in children (pp. 109–148). New York, NY: Thieme.
Strand, E. A., Stoeckel, R., & Baas, B. S. (2006). Treatment of
severe childhood apraxia of speech: A treatment efficacy study.
Journal of Medical Speech-Language Pathology, 14, 297–307.
Tate, R. L., Perdices, M., Rosenkoetter, U., Wakim, D., Godbee, K.,
Togher, L., & McDonald, S. (2013). Revision of a method
quality rating scale for single-case experimental designs and
n-of-1 trials: The 15-item Risk of Bias in N-of-1 Trials (RoBiNT)
Scale. Neuropsychological Rehabilitation, 23, 619–638.
doi:10.1080/09602011.2013.824383
Terband, H., Maassen, B., Guenther, F. H., & Brumberg, J. (2009).
Computational neural modeling of speech motor control in
childhood apraxia of speech (CAS). Journal of Speech, Language,
and Hearing Research, 52, 1595–1609.
Thomson Reuters. (2011). EndNote X5 [Computer software]. New
York, NY: Author.
Wambaugh, J. L., Duffy, J. R., McNeil, M. R., Robin, D. A., &
Rogers, M. A. (2006). Treatment guidelines for acquired apraxia
of speech: A synthesis and evaluation of the evidence. Journal
of Medical Speech-Language Pathology, 14, xv–xxxiii.
Warren, S. F., Fey, M. E., & Yoder, P. J. (2007). Differential
treatment intensity research: A missing link to creating optimally
effective communication interventions. Mental Retardation
and Developmental Disabilities Research Reviews, 13, 70–77.
doi:10.1002/mrdd.20139
Watts, C. R. (2009). Lack of randomized controlled trials prohibits
analysis of effectiveness for the treatment of childhood apraxia
of speech: A systematic review of quasi-experimental group
designs and single-subject experimental designs is needed.
Evidence-Based Communication Assessment and Intervention, 3,
8–10. doi:10.1080/17489530902732924
Wendt, B., & Miller, B. (2012). Quality appraisal of single-subject
experimental designs: An overview and comparison of differ-
ent appraisal tools. Education and Treatment of Children, 35,
235–268.
Williams, A. L. (2012). Intensity in phonological intervention: Is there
a prescribed amount? International Journal of Speech-Language
Pathology, 14, 456–461. doi:10.3109/17549507.2012.68886
World Health Organization. (2002). Towards a common language
for functioning, disability and health: ICF. Geneva, Switzerland:
Author.
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