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Results of the Sensory Profile in Children with

Suspected Childhood Apraxia of Speech

Article  in  Physical & Occupational Therapy in Pediatrics · February 2009

DOI: 10.1080/01942630902805202 · Source: PubMed

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 Results of the Sensory Profile in Children
with Suspected Childhood Apraxia of
Speech
Amy J. Newmeyer Sandra Grether
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Christa Aylward Ton deGrauw

Rachel Akers Carol Grasha
Keiko Ishikawa Jaye White

Amy J. Newmeyer, MD, is Director of the Comprehensive CP Program, Section of

Developmental and Behavioral Pediatrics, Nationwide Children’s Hospital, Columbus
Ohio.
Christa Aylward, OTR/L, is Occupational Therapist, Division of Occupational Ther-
apy and Physical Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati,
For personal use only.

Ohio.
Rachel Akers, MPH, is Research Epidemiologist, Center for Epidemiology and
Biostatistics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.
Keiko Ishikawa is Doctoral Student, College of Allied Health Sciences, University
of Cincinnati, Cincinnati, Ohio.
Sandra Grether, PhD, is Speech Pathologist, Division of Developmental and Be-
havioral Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.
Ton deGrauw, MD, PhD, is Professor, Division of Neurology, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio.
Carol Grasha, MA, is Speech Pathologist, Division of Developmental and Behav-
ioral Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.
Jaye White is Care Coordinator, Division of Developmental and Behavioral Pedi-
atrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.
We wish to acknowledge our appreciation for the assistance of Dr. Winnie Dunn
in providing the data for the normative sample used for comparison with our clinic
population. We also wish to acknowledge the Cincinnati Center for Developmental
Disorders Board for their funding support through the Faculty Research Scholar Award
given to Dr. Newmeyer.
Address correspondence to: Amy J. Newmeyer, MD, Director of the Compre-
hensive CP Program, Section of Developmental and Behavioral Pediatrics, Nation-
wide Children’s Hospital, 700 Children’s Drive, Columbus, Ohio 43205 (E-mail:
amy.newmeyer@nationwidechildrens.org).
Physical & Occupational Therapy in Pediatrics, Vol. 29(2), 2009
Available online at http://www.informaworld.com/POTP

C 2009 by Informa Healthcare USA, Inc. All rights reserved.
doi: 10.1080/01942630902805202 203
 204 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

ABSTRACT. Speech-sound disorders are common in preschool-age

children, and are characterized by difficulty in the planning and produc-
tion of speech sounds and their combination into words and sentences.
The objective of this study was to review and compare the results of the
Sensory Profile (Dunn, 1999) in children with a specific type of speech-
sound disorder, childhood apraxia of speech (CAS), and to explore the
relationship between sensory processing and sound-production deficits.
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Participants were identified prospectively through an interdisciplinary

apraxia clinic at a tertiary care pediatric hospital, and results of the Sen-
sory Profile were compiled and reviewed. Thirty-eight children aged 3
to 10 years with suspected CAS were evaluated from July 2003 to July
2005. The results of the Sensory Profile indicated a difference for these
children in several factor clusters when compared to typical peers from
the normative population of the Sensory Profile. These findings imply
that children with suspected CAS may present with differences in sen-
sory processing in addition to speech impairment. When present, these
differences in sensory processing could be addressed with specific ther-
apeutic approaches through occupational therapy or consultation with
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an occupational therapist.

KEYWORDS. Sensory integration disorder, sensory processing,

speech-sound disorder

INTRODUCTION

In considering sensory-processing deficits in young children it is often

helpful to look back at early models describing sensory integration. One
such model for understanding sensory integration disorder was described
initially by Jean Ayres, and was based upon the idea that the process
of modulating and integrating sensory input is integrally related to perfor-
mance of adaptive behavior, such as feeding, dressing, and other functional
skills (Ayres, 1972). Abnormalities in the processing of sensory informa-
tion were thought to be directly related to the etiology and outcome of
a variety of learning and behavioral disorders. Most recent studies have
focused on the use of sensory integration therapy in improving the adaptive
functioning of children with autism spectrum disorders (ASD), but limited
information is available regarding how these findings apply to other disor-
ders of communication and speech (Baranek, 2002; Case-Smith & Miller,
1999; Watling, Deitz, & White, 2001).
 Newmeyer et al. 205

Characteristics of Sensory Deficits

Previous studies of sensory integration in children with communication

disorders, such as ASD, confirm the coexistence of deficits in communica-
tion and sensory integration (Ermer & Dunn, 1998; Watling et al., 2001). In
1998, Ermer and Dunn evaluated 38 children with ASD, and documented
differences from same-age peers as well as children with attention deficit
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hyperactivity disorder (ADHD) on four factors on the Sensory Profile

(Dunn, 1999), including sensory seeking, oral sensory sensitivity, inatten-
tion/distractibility, and fine motor/perceptual. Keintz and Dunn in 1997
reported the results of the Sensory Profile on 32 participants with mild to
severe autism; they found that 84 or 99 items differentiated the participants
with autism from same-age peers without autism, although no differences
were noted between mild and severe ranges of the autism spectrum (Keintz
& Dunn, 1997). A study completed by Watling et al. in 2001 compared 40
children with autism, aged 3 to 6 years, with 40 children with typical devel-
opment in the same age range. The reported findings revealed differences
from same-age peers in eight Sensory Profile (Dunn, 1999) factors, includ-
For personal use only.

ing sensory seeking, emotionally reactive, low endurance/tone, oral sen-

sitivity, inattention/distractibility, poor registration, fine motor/perceptual,
and others (Watling et al., 2001). An investigation of possible differences
on the Sensory Profile between children with autism compared to chil-
dren with Asperger’s Syndrome revealed differences between groups in
three areas: emotional/social responses, emotional reactivity, and inatten-
tion/distractibility (Myles et al., 2004). Thus, children with an underlying
communication disorder may differ from same-age peers in similar areas,
while underlying differences between the groups of children with specific
types of communication disorders still exist.

Interventions for Sensory Processing Deficits

In 1999, Jane Case-Smith published two studies addressing the effects

of occupational therapy in children with ASD. The first study was a sur-
vey of occupational therapists working primarily with students in a school
setting. They reported applying principles of sensory integration to modify
classroom environment and individual therapy approaches, and describe
subjective improvements in play skills and adjustment to the school envi-
ronment (Case-Smith & Miller, 1999). The second study by Case-Smith
was a single-subject research design focused on five preschool-age chil-
dren with autism. Improvements in engagement in appropriate behavior
 206 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

and increased frequency of goal-directed play were noted following oc-

cupational therapy services focused on sensory integration. These studies
indicate that specific therapeutic approaches to address sensory process-
ing abnormalities incorporated into a broader plan of occupational therapy
services may result in clinical improvement in behaviors often associated
with ASD (Case-Smith & Bryan, 1999; Case-Smith & Miller, 1999). A
full review of the topic of sensory therapy for children with ASD com-
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pleted by Baranek in 2002 is consistent with the outcomes of the above

studies, showing that sensory therapies are beneficial for children with
autism; however, further studies in this area still need to be completed
(Baranek, 2002). Previous studies in other types of communication dis-
orders also indicate that significant improvements in functioning are seen
when more than one therapeutic approach is integrated into the therapy set-
ting (Baranek, 2002; Miller-Kuhaneck & Glennon, 2001; Watling, Deitz,
Kanny, & McLaughlin, 1999).

Speech-Sound Disorders and Associated Deficits

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Speech-sound disorders are characterized by difficulty in forming and

stringing together sounds/phonemes, usually by substituting one sound for
another, omitting a sound, or distorting a sound (Fey, 1992; Locke, 1983).
The prevalence of speech-sound disorders at 6 years of age has been
estimated at 3.8%, making this a common disorder among preschool- and
school-age children (Shriberg, Tomblin, & McSweeney, 1999). Deficits
in other areas of development also have been identified in children with
speech-sound disorders, including language skills, cognitive functioning,
and motor skills (Lesny, 1980). One of the subtypes of speech-sound
disorders of interest in this particular study is childhood apraxia of speech
(CAS). The American Speech Language Hearing Association (ASHA)
recently released a position statement defining CAS as a “neurological
childhood (pediatric) speech sound disorder in which the precision and
consistency of movements underlying speech are impaired in the absence of
neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). The core
impairment in planning and/or programming spatiotemporal parameters
of movement sequences results in errors in speech sound production and
prosody.” (ASHA, 2007).
The results of a recent study involving longitudinal assessment of chil-
dren with a subtype of speech-sound disorder, CAS, revealed that even in
the presence of clinical resolution of the speech disorder many participants
had ongoing learning disabilities into middle childhood (Lewis, Freebairn,
Hansen, Iyengar, & Taylor, 2004).
 Newmeyer et al. 207

Children with suspected CAS may also exhibit more generalized dif-
ficulties with motor programming, which has been termed alternatively
as developmental dyspraxia, developmental coordination disorder, or
neuromotor dysfunction (Dewey, 1993; Miyahara & Mobs, 1995). Our
research group has also previously identified an association between dif-
ficulty with oral-motor imitation and abnormalities in fine motor func-
tioning (Newmeyer et al. 2007). Given that children with suspected CAS
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exhibit impairments of fine motor function and are at risk for ongoing
learning disabilities, we were particularly interested in the incidence of
differences in sensory processing in this group of children. However,
results of the Sensory Profile (Dunn, 1999) in children with suspected
CAS have not been previously reported. In particular, we were con-
cerned that sensory processing difficulties might go unnoticed, and thus
untreated in this group of children. The main purpose of this study was
twofold, i.e., to characterize the results of the Sensory Profile (Dunn,
1999) in children with suspected CAS, and to compare their results to
a group of typical peers from the normative population of the Sensory
Profile.
For personal use only.

A speech language pathologist identified the participants in this study

to have clinical characteristics of suspected CAS, including inconsistent
sound production, general oral-motor difficulties, groping articulation pat-
terns, inability to imitate sounds, increased difficulty with longer utter-
ance length, and poor sequencing of sounds (Betz & Gammon, 2005;
Forrest, 2003; Hodge & Hancock, 1994; Kent, 2000; Shriberg, Aram, &
Kwiatkowski, 1997).

METHODS

Participants

Patients seen in an interdisciplinary apraxia clinic for children with sus-

pected CAS between July 2003 and July 2005 were prospectively evaluated
and included in this study. This clinic was established in 2003 in response
to an increase in the number of children with suspected CAS referred
for additional evaluation to a developmental pediatrics clinic at a tertiary
care hospital. Approval for this study was obtained from the institutional
review board of our institution. All participants evaluated through the in-
terdisciplinary apraxia clinic took part in a standardized clinical evaluation
process, which included an evaluation by a developmental pediatrician,
speech language pathologist, and occupational therapist.
 208 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

The clinic process for evaluation included the completion of a battery

of standardized tests administered by a limited number of examiners. For
the purposes of this study, the participants were evaluated by one devel-
opmental pediatrician, one of two speech pathologists, and one of three
occupational therapists who had the necessary training and certification
to administer the standardized assessments. All evaluations chosen had
published norms for interrater reliability of trained and certified therapists.
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Inclusion criteria for the participants included (a) age at evaluation between
36 months and 120 months; and (b) a clinical diagnosis of suspected CAS.
Excluded from the study were any participant diagnosed with other known
neurodevelopmental disorders which may affect motor skills, including
autism, cerebral palsy, and mental retardation; and hypotonia noted on
neurological examination.

Procedures

Demographic data, family history, past medical history, and results of

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standardized measures including the Sensory Profile (Dunn, 1999) were

compiled into a computer database. Results of the family history, past med-
ical history, and neurological evaluation were all compiled by the same
developmental pediatrician who had examined each of the participants in-
dividually. The standardized evaluation process consisted of the completion
of a language measure, a fine motor measure, and a standardized measure
of imitation of oral-motor movements and words. The language assessment
battery consisted of the Preschool Language Scale (PLS-IV; 4th edition)
(Zimmerman, Violette, & Pond, 2002) and the Kaufman Speech Praxis
Test for Children (KSPT) (Kaufman, 1995). The PLS-IV is commonly uti-
lized to test receptive and expressive language skills in participants aged
2 weeks to 6 years 11 months, and provides a standard score (mean =
100, SD = 15) and percentile ranking for each subtest. The KSPT is a
norm-referenced and standardized measure developed to identify clinical
characteristics of abnormal speech praxis. Fine motor skills were assessed
utilizing the Peabody Developmental Motor Scales (PDMS-2) (Folio & Re-
becca, 2000). Results of the language and fine motor findings from a subset
of these patients have already been reported in the literature (Newmeyer et
al., 2007).
The Sensory Profile (Dunn, 1999) was also completed at the time of
the clinic visit by the parent or primary caregiver. The Sensory Profile
is a standardized method to measure a child’s ability to process sensory
information and to provide a profile of the effect of sensory processing
 Newmeyer et al. 209

on a child’s performance in everyday tasks. This profile was chosen given

the parameters for age, time of administration, and information obtained
regarding the child’s performance in everyday settings. Other tests available
for testing of sensory integration are the Sensory Integration and Praxis
Test (SIPT) (Ayres, 1989) and DeGangi-Berk Test of Sensory Integration
(TSI) (Berk & DeGangi, 1983). However, these instruments take significant
patient cooperation and time to administer, which were not feasible in our
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particular clinical setting. When administering the Sensory Profile (Dunn,

1999) the full version was administered rather than the short version, given
that the primary outcome of the clinical assessments were comprehensive
evaluation and recommendations for therapy.
The Sensory Profile (Dunn, 1999) is designed to function as a part of
a broader assessment of a child’s functioning, which may include other
observations, history, and diagnostic tests. The parent/caregiver reports the
frequency of the behaviors in question, utilizing a Likert scale of always,
frequently, occasionally, sometimes, and never. The Sensory Profile con-
sists of 125 items grouped into three main sections: sensory processing,
modulation, and behavioral and emotional responses. The sensory process-
For personal use only.

ing section indicates the child’s responses to the following six different sen-
sory processing systems: auditory, visual, vestibular, touch, multisensory,
and oral sensory processing. The modulation section provides informa-
tion regarding the child’s regulation of sensory input through facilitation
or inhibition of different types of responses. These five areas of sensory
modulation include sensory processing related to endurance/tone, modu-
lation related to body position and movement, modulation of movement
affecting activity level, modulation of sensory input affecting emotional
responses, and modulation of visual input affecting emotional responses
and activity level. The behavioral and emotional responses section pro-
vides information regarding the child’s behaviors that occur as an outcome
of sensory processing. The three areas include emotional/social responses,
behavioral outcomes of sensory processing, and items indicating threshold
for response.
The items on the questionnaire can also be grouped into the following
nine different factors that describe children by their response to sensory in-
put (over- or under-responsive): sensory seeking, emotionally reactive, low
endurance/tone, oral sensory sensitivity, inattention/distractibility, poor
registration, sensory sensitivity, sedentary, and fine/motor perceptual. Re-
sults can also be grouped into four quadrant scores including registration,
seeking, sensitivity, and avoiding (Dunn, 1999; Dunn, 2007). Results of
the Sensory Profile can be placed into a classification system that provides
a description of each of the above sections or factors as falling into one
 210 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

of three categories: typical performance, probable difference, and definite

difference (Dunn, 1999).
The Sensory Profile was originally normed with a group of 1,037 chil-
dren with typical development age of 3 to 10 years (Dunn, 1999). Children
were excluded if they were on a prescription medication or received spe-
cial education services. The reliability of the Sensory Profile was measured
using Cronbach’s Alpha to examine internal consistency of each section.
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The values for the various sections ranged from 0.47 to 0.91. The content
validity of the Sensory Profile was measured using literature review, ex-
pert review, and category analysis. For category analysis, 155 occupational
therapists were asked to select a primary and secondary category for each
item. Eighty percent of therapists agreed on category placement for 63%
of the items and new categories were developed for the other items. Cov-
ergent and discriminant validity were tested by comparison of the Sensory
Profile with the School Function Assessment (Coster, Deeney, Haltiwanger,
& Haley, 1998). This analysis revealed moderate correlations between the
two instruments (Dunn, 1999; Dunn, 2007).
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Statistical Analysis

Data were abstracted from clinical charts, entered into a Microsoft Ac-
cess database, and then exported to SAS (version 9.1 SAS Institute Inc.,
Cary, NC) for analysis. Means and SD were calculated for continuous
variables and frequency distributions were calculated for categorical vari-
ables. The results of the Sensory Profile were scored according to the
guidelines outlined in the Sensory Profile User’s Manual (Dunn, 1999).
The results from our population of children with suspected CAS were
then compared to the original sample population utilized by Dunn to
standardize the instrument. This group was used as the normative com-
parison group for our population, as the main objective of the statistical
analysis was to determine if children with suspected CAS had differ-
ent Sensory Profile (Dunn, 1999) characteristics compared to a typical
population of children of the same age. The mean values and 95% con-
fidence intervals were calculated for each of the Sensory Profile areas (a
total of 23 areas) (Dunn, 1999). Participants were matched by age cat-
egories to the normative data provided on the Sensory Profile (Dunn,
1999). Based on the non-normal distribution of the data, the differences
in Sensory Profile scores between the study population (n = 38) and
the normative sample were tested using the nonparametric signed ranks
test.
 Newmeyer et al. 211

A secondary objective of the statistical analysis was to determine if

there is a relationship between sensory processing problems and severity of
speech-sound impairment. As the KSPT scores are only standardized up to
the age of 6 years, this analysis was run on a subset of the participants aged
3 to 6 years. Pearson correlation coefficients were calculated to compare
the scores obtained on the Sensory Profile (Dunn, 1999) with the standard
scores obtained on the KSPT (Kaufman, 1995).
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RESULTS

Demographic Data

Thirty-eight children (33 males, 5 females) with severe suspected CAS

were evaluated through the interdisciplinary apraxia clinic between July
2003 and July 2005, and had a parent/caretaker complete the Sensory
Profile (Dunn, 1999). The mean age at clinic visit was 58 months. Ethnicity
was 92% Caucasian, 5% African-American, and 2% Asian, similar to the
For personal use only.

demographics of the population surrounding our center. Following was

the distribution by household income of our sample: $11,000–30,000: 5%;
$31,000–50,000: 63%; $51,000–70,000: 21%; and over $70,000: 11%.

Past Medical History

None of the participants in the study had other known neurodevelopmen-

tal disorders, including autism, mental retardation, hypotonia, or cerebral
palsy. None of the participants were born prematurely (prior to 36-week
gestation). Past medical history as described by the parent/caretaker was
significant for a history of language-processing difficulties in 30 of the
38 participants (79.0%); and six of the 38 participants (15.8%) had a
history of feeding problems. Family history was significant for other ex-
tended family members with speech disorders in 23 of the 38 participants
(60.5%).

Sensory Profile

Results of the Sensory Profile analysis are detailed in Table 1. The com-
parison group was same-age peers from the test standardization sample. In
the area of sensory processing, the group of children with CAS had sig-
nificant differences (p < 0.05) from same-age peers in a number of areas,
 212 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

TABLE 1. Results from the Sensory Profile on 38 Patients Aged 3 to 10 Years

with Suspected CAS

Mean Lower Limit Upper Limit

Sensory Profile Score 95% CI 95% CI p value

Sensory processing
Auditory processing 30.76 28.89 32.63 0.028
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Visual processing 37.84 36.29 39.38 0.022

Vestibular processing 48.39 46.67 50.11 0.08
Touch processing 75.60 72.65 78.55 0.011
Multisensory processing 27.18 25.65 28.71 0.006
Oral sensory processing 48.10 44.89 51.31 0.053
Modulation
Sensory processing related to 39.71 37.58 41.83 0.16
endurance and tone
Modulation related to body 41.23 38.93 43.53 0.066
position and movement
Modulation of movement affecting 24.84 23.62 26.06 0.021
activity level
Modulation of sensory input 16.52 15.54 17.51 0.003
affecting emotional responses
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Modulation of visual input 15.76 14.92 16.60 0.24

affecting emotional responses
and activity level
Behavior and emotional responses
Emotional/social responses 67.89 64.74 71.04 0.12
Behavioral outcomes of sensory 20.55 18.90 22.19 0.0001
processing
Items indicating threshold for 12.44 11.64 13.24 0.74
response
Factor clusters
Sensory seeking 63.50 59.11 67.88 0.008
Emotionally reactive 61.10 57.68 64.52 0.023
Low endurance/tone 39.71 37.58 41.83 0.16
Oral sensory sensitivity 35.94 33.28 38.61 0.016
Inattention/distractibility 26.10 24.27 27.93 0.009
Poor registration 35.73 34.52 36.94 0.36
Sensory sensitivity 17.47 16.48 18.46 0.53
Sedentary 14.71 13.70 15.71 0.65
Fine motor/perceptual 9.6 8.403 10.794 0.030
Quadrant scores
Registration 62.9 59.8 66.0 0.004
Seeking 101.2 95.3 106.9 0.0001
Sensitivity 80.5 77.1 83.9 0.001
Avoiding 115.3 110.6 120 0.002

Note. Mean scores and 95% confidence intervals for each subscale are listed. Results were compared with
a standardized pediatric normative population utilizing a nonparametric signed ranks test. p values < 0.05
are listed in bold font.
 Newmeyer et al. 213

including auditory processing, visual processing, touch processing, and

multisensory processing. In the area of modulation, significant differences
from same-age peers were noted in modulation of movement affecting ac-
tivity level and modulation of sensory input affecting emotional responses.
In the area of behavioral and emotional responses, a significant differ-
ence from same-age peers was noted in behavioral outcomes of sensory
processing.
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When analyzing factor clusters, significant differences from same-age

peers were noted in sensory seeking, emotionally reactivity, oral sensory
sensitivity, inattention/distractibility, and fine motor/perceptual factor clus-
ters. Significant differences were also reported for the four quadrant scores
of registration, seeking, sensitivity, and avoiding when comparing our sam-
ple to that of same-age peers.
The results of the Sensory Profile scores in our sample, including the
lower and upper limit of 95% confidence interval, are outlined in Table 1.
Significant p values are listed in bold font.
The results of the Sensory Profile (Dunn, 1999) were then compared with
the results of the KSPT (Kaufman, 1995) in a subset of participants aged 3
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to 6 years (n = 22). Significant positive correlation was found for scores on

quadrant score 3 (sensitivity) of the Sensory Profile when compared to the
severity of oral-motor apraxia as measured by part I and part II on the KSPT.
The presence of abnormal imitation of oral movements as indicated by the
standard score of the oral movement subtest of the KSPT was significantly
correlated with the results of the Sensory Profile quadrant 3 (sensitivity)
raw score and Pearson correlation coefficient of 0.432 (p = 0.0443). The
presence of abnormal repetition of simple phonemes as indicated by the
standard score on the simple phonemes subtest of the KSPT compared
with the quadrant 3 (sensitivity) raw score approached significance with
a Pearson correlation coefficient of 0.506 (p = 0.0538). Significance was
not found for comparisons of the other scores on the Sensory Profile and
the KSPT.

DISCUSSION

The results of this study indicate that as a group the children

seen within the interdisciplinary apraxia clinic with suspected CAS
presented with differences in sensory processing when compared to
same-age peers from the national standardization sample. Our popula-
tion of children with suspected CAS presented with differences from
same-age peers in five Sensory Profile (Dunn, 1999) factors including
 214 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

sensory seeking, emotionally reactive, oral sensory sensitivity, inatten-

tion/distractibility, and fine motor/perceptual. These findings are commen-
surate with the model of sensory integration originally proposed by Jane
Ayres, which encompassed a wide range of behavioral and learning prob-
lems, including communication disorders such as suspected CAS (Ayres,
1972).
As previous studies of the Sensory Profile in children with suspected
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CAS were not available for comparison, we utilized previous studies of

children with ASD as a comparison to our findings, given that ASD and
CAS are both part of the broader group of common pediatric communica-
tion disorders. Although our population of children with suspected CAS
specifically excluded children with features or a diagnosis of ASD, the chil-
dren in our sample did exhibit a similar profile of difficulties with sensory
processing, particularly in areas related to behavior. A thorough review of
the literature interestingly revealed that the profile of differences in sensory
processing in our population is similar to that seen in previous studies of
children with ASD utilizing a similar sample size of approximately 35
to 40 participants (Ermer & Dunn, 1998; Keintz & Dunn, 1997; Watling
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et al., 2001).
As identified in the Sensory Profile Supplement Manual, sensitivity “rep-
resents low neurological thresholds with a passive self-regulation strategy”
(Dunn, 2007). These children are sensitive to sensory input from the en-
vironment, and may respond in a passive way to that sensory input by
incorporating strategies such as asking others to be quiet or covering their
ears in a loud environment. Some children may also be described as “picky
eaters” due to sensitivity to oral stimulation from certain food textures.
There is no other study in the literature investigating the severity of sus-
pected CAS and sensory processing dysfunction with which to compare
these results. However, these results suggest that children with CAS may
respond in a passive way to sensory input, which could be overlooked in a
typical classroom environment.
Our study identified a positive correlation between the Sensory Profile
(Dunn, 1999) quadrant 3 score (sensitivity) and the severity of apraxia as
measured by the KSPT part I and part II scores (Kaufman, 1995). This
may indicate that the more severe the signs of CAS, the more likely the
child is to utilize a passive self-regulation strategy (as described above).
We did not find an association between the results of the Sensory Profile
(Dunn, 1999) and the KSPT (Kaufman, 1995) for the other section, factor,
or quadrant scores on the Sensory Profile (Dunn, 1999), which may be due
to the relatively small number of participants aged 3 to 6 years who had
completed both assessments (n = 22).
 Newmeyer et al. 215

Implications

The current study as well as a review of the existing literature support the
practical importance of evaluating sensory abnormalities in children with
suspected CAS, given the number of factors across sensory areas that were
significantly different for children with suspected CAS when compared
with typically developing children.
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The existing literature also supports the practical importance of evalu-

ating for sensory abnormalities in children with ASD, given that previous
studies have shown positive effects of sensory-based therapy with children
with this diagnosis. We can infer that an approach of incorporating sen-
sory integration techniques into occupational therapy services as part of
a comprehensive treatment plan for children with suspected CAS should
also result in improvement of these behaviors; however, further studies are
warranted in this particular area to address the effectiveness of sensory
integration therapy for children with CAS as well as comparison studies
across populations with other communication disorders such as autism.
Relatively few studies exist regarding comorbid developmental disor-
For personal use only.

ders or long-term outcomes in children with suspected CAS, but learning

disabilities in reading and deficits in neuromotor function have been re-
ported in previous long-term cohorts (Dewey, 1995; Lewis et al., 2004).
Although these children are often labeled clinically as having “just a speech
problem,” the results of this study and our previous studies revealing fine
motor dysfunction in children with suspected CAS (Newmeyer et al., 2007)
suggest that these children may present with a range of developmental dif-
ficulties affecting the areas of fine motor skills, academic abilities, and
sensory processing. These long-term impairments have an impact on the
overall outcome of these children, reinforcing the need to continue to iden-
tify these deficits at an early age and institute therapy services as soon as
possible (Rasmussen & Gillberg, 2000). The authors of this study propose
that identified sensory abnormalities should be addressed and integrated
into a comprehensive plan for occupational therapy services to ensure the
best outcome and reduce the long-term morbidity of CAS.

Limitations

One of the limitations of this study is that it was a clinic-based population

rather than a representative community-based sample of children with
suspected CAS. Children with deficits in multiple areas of development
may be more likely to be referred to our center for evaluation. However, this
 216 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

study does have clinical relevance for those children typically referred to
secondary and tertiary care centers for evaluation of suspected CAS. It also
lends strong support for an interdisciplinary model of evaluation, which
will allow for early identification of associated developmental disorders
and appropriate referral for needed therapy services.
Another limitation is that the Sensory Profile (Dunn, 1999) obtains infor-
mation via a parent/caretaker questionnaire rather than direct observation
Phys Occup Ther Pediatr Downloaded from informahealthcare.com by Childrens Hospital on 04/19/10

or testing of the subject. However, the results of the Sensory Profile are
utilized as part of a broader assessment by a trained occupational therapist,
and are incorporated into specific therapy recommendations as part of an
interdisciplinary assessment. Further, the Sensory Profile allows for report
of how the child may perform or react in a variety of settings, rather than
being limited to the testing environment.

Future Studies
For personal use only.

Long-term assessments are planned to measure progress over time and

the relationship of clinical improvement to the type and intensity of oc-
cupational therapy services received. It would be of interest to compare
the results of the Sensory Profile (Dunn, 1999) in this population with that
of children with autism within our institution to determine if differences
in individual items can be noted that would further clarify the differences
between the two groups of children and to further describe the types of
behavioral difficulties described by families. Another area of study would
be to obtain further information about home and school functioning to
determine how the differences in sensory processing are affecting every-
day functioning in those environments. We will continue to prospectively
follow additional children with suspected CAS to determine if the profile
noted in this study continues to hold in future studies of children with
suspected CAS and other disorders of communication.

CONCLUSIONS

In our clinic-based population, children with suspected CAS as a group

were noted to have significant differences in sensory processing when
compared to a normative population. These results support the recom-
mendation that children presenting with features of CAS receive a full
interdisciplinary evaluation including an occupational therapy assessment
 Newmeyer et al. 217

for abnormalities in sensory processing, thus allowing for early implemen-

tation of appropriate therapy services.

REFERENCES
Phys Occup Ther Pediatr Downloaded from informahealthcare.com by Childrens Hospital on 04/19/10

American Speech-Language-Hearing Association. (2007). Childhood apraxia of

speech: Technical report (ad hoc committee on apraxia of speech in children).
Rockville, MD: American Speech-Language-Hearing Association (ASHA).
Ayres, A. J. (1972). Sensory integration and learning disorders. Los Angeles: Western
Psychological Services.
Ayres, A. J. (1989). Sensory integration and praxis tests. Los Angeles: Western Psy-
chological Services.
Baranek, G. T. (2002). Efficacy of sensory and motor interventions for children with
autism. Journal of Autism and Developmental Disorders, 32(5), 397–422.
Berk, R. A., & DeGangi, G. A. (1983). DeGangi-berk test of sensory integration. Los
Angeles: Western Psychological Services.
Betz, S. K., & Gammon, C. (2005). Measuring articulatory error consistency in children
with developmental apraxia of speech. Clinical Linguistics & Phonetics, 19(1), 53–
For personal use only.

66.
Case-Smith, J., & Bryan, T. (1999). The effects of occupational therapy with sensory
integration emphasis on preschool-age children with autism. American Journal of
Occupational Therapy, 53(5), 489–497.
Case-Smith, J., & Miller, H. (1999). Occupational therapy with children with pervasive
developmental disorders. American Journal of Occupational Therapy, 53(5), 506–
513.
Coster, W. J., Deeney, T., Haltiwanger, J., & Haley, S. (1998). School function assess-
ment. San Antonio: Psychological Corporation/Therapy Skill Builders.
Dewey, D. (1993). Error analysis of limb and orofacial praxis in children with devel-
opmental motor deficits. Brain & Cognition, 23(2), 203–221.
Dewey, D. (1995). What is developmental dyspraxia? Brain and Cognition, 29(3),
254–274.
Dunn, W. (1999). Sensory profile user’s manual. San Antonio: Harcourt.
Dunn, W. (2007). Sensory profile supplement user’s manual. San Antonio, TX: Har-
court.
Ermer, J., & Dunn, W. (1998). The Sensory Profile: A discriminant analysis of children
with and without disabilities. The American Journal of Occupational Therapy, 52,
283–290.
Fey, M. E. (1992). Articulation and phonology: Inextricable constructs in speech
pathology. Language, Speech, and Hearing Services in Schools, 23, 225–232.
Folio, R. M. F., & Rebecca, R. (2000). Peabody developmental motor scales (2nd ed.).
Austin TX: Pro-Ed.
Forrest, K. (2003). Diagnostic criteria of developmental apraxia of speech used by clin-
ical speech-language pathologists. American Journal of Speech-Language Pathol-
ogy, 12(3), 376–380.
 218 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

Hodge, M. M., & Hancock, H. R. (1994). Assessment of children with developmental

apraxia of speech: A procedure. Clinics in Communication Disorders, 4(2), 102–
118.
Kaufman, N. (1995). Psychometric properties and normative tables for the Kaufman
speech praxis test for children. Detroit, MI: Wayne State University Press.
Keintz, M. A., & Dunn, W. (1997). A comparison of the performance of children
with and without autism on the sensory profile. American Journal of Occupational
Therapy, 51(7), 530–537.
Phys Occup Ther Pediatr Downloaded from informahealthcare.com by Childrens Hospital on 04/19/10

Kent, R. D. (2000). Research on speech motor control and its disorders: A review and
perspective. Journal of Communication Disorders, 33(5), 391–427.
Lesny, I. (1980). Developmental dyspraxia and verbal dyspraxia. Developmental
Medicine & Child Neurology, 22(3), 407.
Lewis, B. A., Freebairn, L. A., Hansen, A. J., Iyengar, S. K., & Taylor, H. (2004).
School-aged follow-up of children with childhood apraxia of speech. Language,
Speech, & Hearing Services in the Schools, 35(2), 122–140.
Locke, J. L. (1983). Clinical phonology: The explanation and treatment of speech
sound disorders. Journal of Speech and Hearing Disorders, 4, 339–341.
Miller-Kuhaneck, H., & Glennon, T. J. (2001). Combining intervention approaches in
occupational therapy for children with pervasive development disorders. Occupa-
tional Therapy Practice, 6(20), Suppl: CE-1–CE-8.
For personal use only.

Miyahara, M., & Mobs, I. (1995). Developmental dyspraxia and development coordi-
nation disorder. Neuropsychology Review, 5(4), 245–268.
Myles, B., Hagiwara, T., Dunn, W., Rinner, L., Reese, M., Huggins, A., et al. (2004).
Sensory issues in children with Asperger’s Syndrome and autism. Education and
Training in Developmental Disabilities, 39(4), 283–290.
Newmeyer, A., Grether S., White J., Akers R., Aylward C., Ishikawa K., et al. (2007).
Fine motor function and oral-motor imitation skills in preschool-age children with
suspected CAS.Clinical Pediatrics, 46(7), 604–611.
Rasmussen, P., & Gillberg, C. (2000). Natural outcome of ADHD with developmental
coordination disorder at age 22 years: A controlled, longitudinal, community-based
study. Journal of the American Academy of Child & Adolescent Psychiatry, 39(11),
1424–1431.
Shriberg, L. D., Aram, D. M., & Kwiatkowski, J. (1997). Developmental apraxia of
speech: Descriptive and theoretical perspectives. Journal of Speech, Language, and
Hearing Research, 40, 273–285.
Shriberg, L., Tomblin, B., & McSweeney, J. (1999). Prevalence of speech delay in
6-year old children and comorbidity with language impairment. Journal of Speech,
Language, and Hearing Research, 42(6), 1461–1481.
Watling, R., Deitz, J., Kanny, E. M., & McLaughlin, J. F. (1999). Current practice of
occupational therapy for children with autism. American Journal of Occupational
Therapy, 53(5), 498–505.
Watling, R., Deitz, J., & White, O. (2001). Comparison of sensory profile scores of
young children with and without autism spectrum disorders. American Journal of
Occupational Therapy, 55(4), 416–423.
Zimmerman, L. S., Violette, G., & Pond, R. E. (2002). Preschool language scale (4th
ed.). San Antonio, TX: Harcourt.

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