JSLHR
Research Article
Differential Diagnosis of Children with
Suspected Childhood Apraxia of Speech
Elizabeth Murray,a Patricia McCabe,a Robert Heard,a and Kirrie J. Ballarda
Purpose: The gold standard for diagnosing childhood
apraxia of speech (CAS) is expert judgment of perceptual
features. The aim of this study was to identify a set of
objective measures that differentiate CAS from other speech
disorders.
Method: Seventy-two children (4–12 years of age)
diagnosed with suspected CAS by community speech-
language pathologists were screened. Forty-seven
participants underwent diagnostic assessment including
presence or absence of perceptual CAS features. Twenty-
eight children met two sets of diagnostic criteria for CAS
(American Speech-Language-Hearing Association, 2007b;
Shriberg, Potter, & Strand, 2009); another 4 met the CAS
criteria with comorbidity. Fifteen were categorized as
non-CAS with phonological impairment, submucous cleft,
C
hildhood apraxia of speech (CAS) is considered an
impairment of speech motor control or praxis. Most
researchers agree that the core deficit for children
with CAS is a reduced or degraded ability to convert abstract
phonological codes to motor speech commands, referred to
as motor planning and/or programming (American Speech-
Language-Hearing Association [ASHA], 2007b; Nijland,
Maassen, & Van der Meulen, 2003; Shriberg, Lohmeier,
Strand, & Jakielski, 2012). This consensus has been supported
by behavioral studies (see ASHA, 2007b, and McCauley,
Tambyraja, & Daher-Twersky, 2012, for reviews), classifi-
cation paradigms (Shriberg et al., 2010), and computational
modeling studies (Terband & Maassen, 2010; Terband,
Maassen, Guenther, & Brumberg, 2009). The impairment
then manifests itself as disordered articulation, difficulty
sequencing sounds and syllables, inconsistent production of
repeated sounds and syllables, and disruption at the supra-
segmental level (i.e., dysprosody; ASHA, 2007b). Despite
the recent advances in our theoretical understanding of CAS,
a
The University of Sydney, Australia
Correspondence to Elizabeth Murray: Elizabeth.murray@sydney.edu.au
Editor: Jody Kreiman
Associate Editor: Ben A. M. Maassen
Received November 9, 2012
Revision received May 10, 2013
Accepted October 13, 2014
DOI: 10.1044/2014_JSLHR-S-12-0358
Journal of Speech, Language, and Hearing Research • Vol. 58 • 43–60 • February 2015 • Copyright © 2015 American Speech-Language-Hearing Association
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or dysarthria. Following this, 24 different measures from
the diagnostic assessment were rated by blinded raters.
Multivariate discriminant function analysis was used to
identify the combination of measures that best predicted
expert diagnoses.
Results: The discriminant function analysis model, including
syllable segregation, lexical stress matches, percentage
phonemes correct from a polysyllabic picture-naming task,
and articulatory accuracy on repetition of /pǝtǝkǝ/, reached
91% diagnostic accuracy against expert diagnosis.
Conclusions: Polysyllabic production accuracy and an oral
motor examination that includes diadochokinesis may be
sufficient to reliably identify CAS and rule out structural
abnormality or dysarthria. Testing with a larger unselected
sample is required.
it remains difficult to differentially diagnose CAS from
other disorders. In the absence of a clinically available vali-
dated assessment procedure, the current gold standard for
diagnosis is expert opinion (Maas, Butalla, & Farinella,
2012). The purpose of this study was to determine, after ex-
pert diagnosis, if a quantitative measure or set of measures
differentiated CAS from non-CAS in a sample of children
referred from the community with suspected CAS.
Diagnosis of Childhood Apraxia of Speech
CAS may occur as a result of known neurodevelop-
mental disorders (Kummer, Lee, Stutz, Maroney, & Brandt,
2007; Shriberg, Potter, & Strand, 2011; Spinelli, Rocha,
Giacheti, & Richieri-Costa, 1995) or deleterious genetic
mutation (e.g., Brunetti-Pierri et al., 2011; Carr et al., 2010;
Palka et al., 2012). The majority of reported cases, however,
are idiopathic.
Despite much research, there is currently no single
neurological or behavioral diagnostic marker for all cases
of CAS (ASHA, 2007b). Behavioral measures that have
been considered have included inconsistent speech fea-
tures (e.g., Iuzzini, 2012), coarticulation and timing errors
(e.g., Sussman, Marquardt, & Doyle, 2000), prosody (e.g.,
Munson, Bjorum, & Windsor, 2003; Thoonen, Maassen,
Wit, Gabreëls, & Schreuder, 1996), speech production
Disclosure: The authors have declared that no competing interests existed at the time
of publication.
43
 (e.g., Thoonen, Maassen, Gabreëls, & Schreuder, 1999),
speech perception (e.g., Nijland, 2009), linguistic skills (e.g.,
Lewis, Freebairn, Hansen, Iyengar, & Taylor, 2004), and
nonspeech oral motor skills (e.g., Murdoch, Attard, Ozanne,
& Stokes, 1995). Diagnostic marker research has included
many contributions by Shriberg and colleagues utilizing their
Madison Speech Assessment Protocol and Speech Disorders
Classification System (SDCS) to attempt to differentiate
CAS and acquired apraxia of speech from normal develop-
ment and other communication disorders (e.g., Shriberg,
Aram, & Kwiatkowski, 1997; Shriberg et al., 2010;
Shriberg, Green, Campbell, McSweeny, & Scheer, 2003;
Shriberg, Lohmeier, et al., 2009).
In the absence of a single pathognomonic feature, a
core set of validated differential diagnostic markers for CAS
is needed (ASHA, 2007b; Davis, Jakielski, & Marquardt,
1998). In 2007, ASHA released a position statement and
technical report on CAS (ASHA, 2007a, 2007b). The tech-
nical report provided a consensus position on a small set
of perceptual speech features associated with the primary
planning and programming deficits in CAS. Following a
thorough literature review of group-comparison diagnostic
studies and community consultation, three features with
some consensus were identified across investigators in apraxia:
“(a) inconsistent errors on consonants and vowels in re-
peated productions of syllables or words, (b) lengthened and
disrupted coarticulatory transitions between sounds and
syllables, and (c) inappropriate prosody, especially in the
realization of lexical or phrasal stress” (ASHA, 2007b,
pp. 4, 54, and 59).1 These features have been used for diag-
nosis in recent CAS treatment studies in which participants
had to demonstrate all three features to warrant diagnosis
(e.g., Ballard, Robin, McCabe, & McDonald, 2010; Maas
et al., 2012). Another recent checklist that is used for CAS
diagnosis in research and clinical settings is Strand’s 10-point
checklist (Shriberg et al., 2012; Shriberg, Potter, & Strand,
2009). This checklist provides 10 segmental and supra-
segmental features that can be present in CAS, although
any combination of at least four out of the 10 features across
three tasks warrants the diagnosis of CAS.
As Strand and colleagues remarked, feature lists do not
directly lead to an assessment procedure (Strand, McCauley,
Weigand, Stoeckel, & Baas, 2013). Commercial norm-
referenced assessment tools offer clear assessment tasks
but often lack essential psychometric properties (McCauley &
Strand, 2008) and may also rely on feature lists or scales for
diagnosis of CAS (Blakeley, 2001; Hickman, 1997; Kaufman,
1995). The recently published Dynamic Evaluation of Motor
Skills is reliable but risks failing to identify some persons
with CAS (Strand et al., 2013). To date, there is no ac-
cepted, operationally defined, diagnostic testing protocol or
clinically available and validated set of behavioral features,
1
The Royal College of Speech and Language Therapists also released a
Policy Statement with a wider list of consensus features for CAS (Royal
College of Speech and Language Therapists, 2011). This statement was
published after data collection for the current study and was therefore
not considered.
44 Journal of Speech, Language, and Hearing Research • Vol. 58 • 43–60 • February 2015
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with >90% sensitivity (identifying true cases of CAS) and
specificity (identifying true cases of non-CAS), discriminat-
ing CAS from a range of other expressive communication
disorders (Shriberg et al., 2012). The closest we have is
the contribution of 89% sensitivity and 100% specificity by
Thoonen and colleagues (1996, 1997, 1999) in discriminating
spastic dysarthria and CAS using maximum performance
tasks. However, the procedure may not discriminate across
subtypes of dysarthria and other speech sound disorders (SSD)
because the validation sample used was small (n = 11).
Developing a reliable testing protocol that captures
the small set of agreed behavioral features of CAS is chal-
lenging when one considers a number of methodological
constraints of previous research. These include lack of spec-
ificity of features within checklists used for diagnosis of
CAS, various participant selection criteria, insufficient
operationalization of methods for replication, and different
comparison groups. Checklists of features, such as Strand’s
10-point checklist (Shriberg, Potter, et al., 2009) and others,
guide the clinician in making presence or absence decisions
for a range of speech, oromotor, and linguistic behaviors;
however, for the most part, these checklists do not include
explicit definitions of the features or methods for determining
how much or how often any single behavior must be observed
(e.g., Crary, 1995; Davis & Velleman, 2000; cf. Thoonen
et al., 1999; see Rvachew, Hodge, & Ohberg, 2005, for a tu-
torial), which affects application or replication of the results.
The wide range of behaviors that have been considered for
these checklists reflects (a) the belief that symptoms of CAS
change with age and/or maturation and (b) the different
theoretical perspectives as to whether CAS has core or co-
occurring motor, oral motor, phonological or linguistic
memory, and literacy impairments (Alcock, Passingham,
Watkins, & Vargha-Khadem, 2000; Marion, Sussman, &
Marquardt, 1993; Shriberg et al., 2012). Furthermore, many
surface behavioral features are shared by a range of commu-
nication disorders, making discrimination of phonological-
linguistic and phonetic-motoric errors difficult (see Ballard,
Granier, & Robin, 2000; McCabe, Rosenthal, & McLeod,
1998; McNeil, Robin, & Schmidt, 2009).
The methods of participant selection have also dif-
fered across studies, contributing to confusion. Some studies
have included participants with CAS and concomitant
hearing impairment, intellectual disability, and language
impairment (Shriberg et al., 2012), whereas others have
used participants with idiopathic CAS and no known
comorbid disorders (e.g., Thoonen et al., 1997). When
comparison groups have been used, specifically selected diag-
noses have been compared to CAS. Groups of participants
have included those with “speech delay” or “speech sound
disorder” with or without language delay or impairment
(e.g., Lewis et al., 2011; Shriberg, Green, et al., 2003; Shriberg
et al., 2012), dysarthria (e.g., Morley, Court, & Miller,
1954; Rosenbek & Wertz, 1972; Thoonen et al., 1999),
phonological impairment (e.g., Williams, Ingham, &
Rosenthal, 1981; Yoss & Darley, 1974), specific language
impairment (e.g., Lewis et al., 2004), or stuttering (Byrd &
Cooper, 1989). Ultimately a set of quantifiable measures is
 needed that will reliably discriminate CAS from a wide
range of communication disorders that could present with
overlapping symptoms, whether within individuals or be-
tween groups of individuals.
The predominant approach in current treatment re-
search studies of CAS is, first, to use a range of standard-
ized assessments to rule out frank receptive and expressive
language impairment or orofacial structural abnormality
and, second, to use a checklist to note CAS-type behaviors
observed and so justify a diagnosis of CAS (e.g., Ballard
et al., 2010; Martikainen & Korpilahti, 2011). However, as
stated above, the feature lists have not been operationalized,
validated, or standardized, and no standard approach or
battery for assessment of these specific features has yet been
developed (ASHA, 2007b; Shriberg et al., 2012). As such,
it is likely that expert and novice clinicians would demon-
strate low interrater reliability, as already shown in studies
of CAS (Shriberg, Campbell, et al., 2003) and dysarthria
(Zeplin & Kent, 1996; Zyski & Weisiger, 1987) using per-
ceptual, criterion-based diagnostic methods. This uncertainty
results in clinicians in practice making diagnoses of “sus-
pected CAS,” with risk of under- or overidentification
(Davis et al., 1998; Forrest, 2003; Shriberg, Campbell,
et al., 2003). The result can be selection of inappropriate
treatment approaches and the frequent complaint that chil-
dren with CAS progress slowly in therapy (Forrest, 2003).
This study furthers the CAS diagnostic literature by attempt-
ing to determine if clinically available measures can discrimi-
nate CAS from other expressive communication disorders
in a sample of verbal children.
Aim
The primary aim of this study was to use objective
statistical methods to identify one or more quantitative
measures of speech that reproduce the expert classification
of children as having CAS or not. This approach has poten-
tial to provide a clinically feasible assessment protocol that
reliably identifies features of CAS and reduces reliance on
expert opinion.
Method
This study formed part of a larger clinical trial:
Unique Trial Number: U1111-1132-5952, Trial Registration
Number: ACTRN12612000744853. The research protocol
was approved by the Human Research Ethics Committee of
the University of Sydney (12924) and is published (Murray,
McCabe, & Ballard, 2012).
This diagnostic study was conducted in three phases
to address the research aim. First, children were recruited
and assessed according to the protocol below. Second, the
first two authors (E. M. and P. M.) judged presence or ab-
sence of CAS by listening to speech samples from the as-
sessment protocol and completing two published checklists
of CAS characteristics. Third, the first author (E. M.) and
independent raters blinded to the diagnosis of CAS gener-
ated 24 quantitative measures from assessment data. These
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measures were analyzed using bivariate and hierarchical
multivariate discriminant function analysis (DFA) to deter-
mine if any combination of the 24 measures reliably pre-
dicted the assigned CAS diagnosis.
Participants
Participants were recruited via a website advertisement
and flyers as well as e-mails and listserv posts to speech-
language pathologists (SLPs), inviting them to volunteer for
a research treatment study. The treatment component of this
study is not discussed in this article. The inclusion criteria for
participants were (a) a clinical diagnosis of suspected CAS
by a community-based SLP, (b) age between 4 and 12 years,
(c) no previously identified language comprehension diffi-
culty, (d) normal or adjusted-to-normal hearing and vision,
(e) native English speaker, and (f ) no other developmental
diagnoses not associated with CAS (e.g., intellectual disability,
autism, cerebral palsy). All participants had received speech-
language pathology intervention prior to this study, and
all had normal hearing. Participants needed to attend the
on-campus clinic at the University of Sydney, Australia, to
participate. Parents or caregivers provided informed consent
on behalf of the children prior to participation.
Of the 72 participants who inquired regarding the
study, 47 passed the initial screening. All 47 were Australian-
English speaking, 33 (70%) were boys, 14 were girls (30%),
and the average age was 70.5 months (SD = 25.7 months).
No information on race, ethnicity, or socioeconomic status
was collected.
Clinical Assessment
The first author responded to all inquiries to partic-
ipate in the study and followed a two-tiered assessment
protocol (see Figure 1). The first tier involved screening of
parents or caregivers and SLPs by phone and previous
speech pathology reports to determine the child’s suitability
for entry into the study. The criteria were applied conser-
vatively, in that children with another developmental disor-
der that could be associated with symptoms or consequences
of CAS (e.g., selective mutism) were included. For those
who passed the initial screening, the second tier involved ad-
ministration of a 2-hour speech and language assessment
battery. Responses to these tests were used for all analyses
of CAS features and to determine the presence of comorbid
conditions such as dysarthria or language impairment. The
assessment battery was video- and audio-recorded using
a Sony IC Recorder ICD-UX71F and either an Echo Layla
24/96 multitrack recording system, Marantz PMD660 solid-
state recorder, or Roland Quad-Capture UA-55 at the sam-
pling rate 48000 Hz with 16-bit resolution with an AKG
C520 headset microphone at 5 cm mouth-to-microphone
distance.
Speech and Language Assessment Battery
First, a parent or caregiver case history questionnaire
and hearing screening was completed (ASHA, 1978). Next,
Murray et al.: Differential Diagnosis of CAS 45
 Figure 1. Results of differential diagnostic process. Participants with childhood apraxia of speech (CAS) shown in white, comorbid CAS in yellow,
and non-CAS or excluded in blue.
a
No articulation or prosodic impairment noted by parents, no CAS suspected by SLP.
the diagnostic assessment utilized five published tests com-
monly available in clinical settings and culturally appropriate
for Australian children (see Table 1). The five tests were the
following:
1. the Diagnostic Evaluation of Articulation and
Phonology (DEAP) Inconsistency subtest (Dodd, Hua,
Crosbie, Holm, & Ozanne, 2002), used to assess the
word-level token-to-token inconsistency in naming
25 pictured words over three test administrations, each
administration separated by other assessment tasks;
2. the Single-Word Test of Polysyllables (Gozzard, Baker,
& McCabe, 2004, 2008), a 50-item picture-naming
task used to assess articulation, sound and syllable
sequencing, and lexical stress accuracy (i.e., prosody);
3. a connected speech sample of at least 50 utterances
recorded over at least 10 minutes (McLeod, 1997), for
detection of perceptual features of CAS in connected
speech and calculation of articulation rate;
4. the Oral and Speech Motor Control Protocol, a
published oral motor assessment (OMA) including
diadochokinesis (DDK; Robbins & Klee, 1987), used
to rule out any structural or functional abnormalities
in the oral mechanism; and
5. the Clinical Evaluation of Language Fundamentals
(CELF; 4th edition or Preschool–2nd edition,
Australian versions), used to assess receptive and
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expressive language skills (Semel, Wiig, & Secord,
2006; Wiig, Secord, & Semel, 2006).
All tests were administered and scored by the first
author according to the relevant manual. For the DEAP
Inconsistency subtest, broad transcription was used and dis-
tortions and developmental errors were scored as correct,
according to Dodd et al. (2002, p. 25).
Initially, responses to the assessments were used for
expert qualitative judgments of presence or absence of CAS
and, following this, for generating 24 quantitative measures
for statistical analyses in order to address the study aim.
There was overlap in the speech samples used to make the
expert judgments and to generate the quantitative measures;
however, expert judgments were made prior to extracting the
wider range of measures from the assessment, and measure
calculations did not influence the initial classifications made.
In addition, three raters scored 100% of the data: the first
author and two independent raters blinded to expert diagnosis.
A detailed description of reliability calculations is provided
in the Reliability section.
Expert Diagnosis of CAS
The first and second authors, each with more than
10 years’ experience in differential diagnosis of pediatric
speech sound disorders, independently diagnosed the pres-
ence and severity of CAS for all children based on their per-
ceptual ratings of each child’s speech samples, using the
 Table 1. Assessment tasks and diagnostic features used for assigning an expert diagnosis of childhood apraxia of speech.

ASHA consensus-based
feature list a Strand’s 10-point checklistb Assessment tasks considered in diagnosisc

1. Inconsistent errors on Not in list DEAP Inconsistency subtest (inconsistency defined

consonants and vowels in
repeated productions of
syllables or words
2. Lengthened and disrupted
coarticulatory transitions
between sounds and syllables
3. Inappropriate prosody,
especially in the realization of
lexical or phrasal stress
as a score ≥40%),d (Polysyllable Test,e connected
speech samplef )
1. Difficulty achieving initial articulatory Polysyllable Test,e connected speech samplef
configurations and transitions into vowels (DEAP Inconsistency subtestd)
2. Syllable segregation
3. Lexical stress errors or equal stress Polysyllable Teste (DEAP Inconsistency subtest,d
Connected speech samplef )
4. Vowel or consonant distortions including Polysyllable Teste (DEAP Inconsistency subtest,d
distorted substitutions Connected speech samplef )
5. Groping (nonspeech) Oral and Speech Motor Control Protocol (any three
nonspeech tasks)g
6. Intrusive schwa Polysyllable Teste (DEAP Inconsistency subtest,d
Connected speech samplec)
7. Voicing errors Polysyllable Teste (DEAP Inconsistency subtest,d
Connected speech samplef )
8. Slow rate Connected speech samplef Polysyllable Teste
(DEAP Inconsistency subtestd)
9. Slow DDK rate Polysyllable Teste (DEAP Inconsistency subtest,d
Connected speech samplef )
10. Increased difficulty with longer or more Polysyllable Teste (DEAP Inconsistency subtest,d
phonetically complex words Connected speech samplef )

Note. DEAP = Diagnostic Evaluation of Articulation and Phonology; DDK = diadochokinesis.

a
ASHA, 2007b, p. 4. ASHA criteria = 3/3 needed for CAS diagnosis. bShriberg, Potter, et al., 2009, p. 8. Strand criteria = 4/10 needed for CAS
diagnosis over three tasks. c The primary task or tasks used for detection of each feature are written first, with the secondary tasks needed to determine
features over three tasks shown in brackets. dDodd et al. (2002). eGozzard et al. (2004, 2008). fMcLeod (1997). gRobbins and Klee (1987).

following procedure. To be diagnosed with CAS in this study,
participants had to demonstrate (a) the three consensus-based
features listed in the ASHA Technical Report (2007b) and
(b) any four of the 10 features in Strand’s 10-point checklist
(Shriberg, Potter, et al., 2009) over at least three assessment
tasks as shown in Table 1. For the 10-point checklist, a verbal
behavior was marked as present when perceptually detected
in speech samples from three tasks: the DEAP Inconsistency
assessment, the Single-Word Test of Polysyllables, and the
connected speech sample. Neither published list provides
operational definitions or cutoffs for the listed features.
The first and second authors listened to the speech
samples and independently made a perceptual judgment as
to whether each feature was present or absent, except in the
case of inconsistency of speech errors. For this one feature
only, decisions were based on the score from the DEAP
Inconsistency subtest, the only published test that defines
inconsistency in the same way as the ASHA Technical
Report (ASHA, 2007b). Syllable segregation was defined
by the authors as “noticeable gaps between syllables.” Two
criteria showed potential overlap, and, because no previous
definitions were available, the authors defined difficulty
achieving initial articulatory configurations and transitions
into vowels to include within-speech groping, false starts,
restarts, and hesitations and defined groping as nonspeech
oral groping. Nonspeech groping was determined over
three oral motor tasks within the Robbins and Klee protocol
(1987). For expert perceptual diagnosis of CAS, interrater
agreement between the first two authors was 100%.
Appendix A shows the CAS features judged to be
present and the expert decision on presence or absence of
CAS for each of the 47 participants. Of these 47, 28 (60%)
were classified as having CAS (ASHA, 2007b; Shriberg,
Potter, et al., 2009). Another four children (8%) met the
criteria for CAS but presented with comorbid dysarthria and
receptive and/or expressive language disorder (CAS+),
similar to the Shriberg et al. (2010) classification of motor
speech disorder–apraxia of speech plus (MSD-AOS+).
Children diagnosed with CAS or CAS+ showed a median
of 6 out of 10 features on the Strand 10-point checklist
(Shriberg, Potter, et al., 2009). Fifteen (32%) of the 47 chil-
dren did not demonstrate all three features in the ASHA
feature list and were classified as non-CAS in this study.
Non-CAS diagnoses included ataxic dysarthria (n = 1), flaccid
dysarthria (n = 1), submucous cleft (n = 3), or primarily
phonological disorder (n = 10; see Figure 1). Phonological
impairment was identified in those who had clear phono-
logical processes (Rvachew & Brosseau-Lapré, 2012) and
an absence of oromotor or speech-motor deficits (e.g., DDK
deficits) excluding them from motor speech diagnosis.
Quantitative Measures
Quantitative measures were extracted from the five
tests administered in the clinical assessment. Table 2 lists
the 24 measures generated and the associated assessment
task and CAS checklist feature. For measures that were
not standard scores from norm-referenced tools, nine raters

Murray et al.: Differential Diagnosis of CAS 47

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 48

Table 2. Extracted measures from assessment tasks completed with means and standard deviations for the CAS, CAS+, and non-CAS groups.
Journal of Speech, Language, and Hearing Research • Vol. 58 • 43–60 • February 2015

CAS (n = 28) CAS+ (n = 4) Non-CAS (n = 15)

Assessment task Relation to diagnostic criteria Measure M SD M SD M SD

Case history None Age in months 66.5 24.8 72.5 26.0 77.3 27.6
DEAP Inconsistency Inconsistent errors on consonants and Percentage inconsistency (across three 63.8 12.8 75.0 15.1 39.9 24.5
subtesta vowels in repeated productions of repetitions of 25 words)a
syllables or wordsf
Single-Word Test of Inappropriate prosody, especially in the Percentage of lexical stress matches 9.8 9.1 16.3 17.5 67.3 22.4
Polysyllablesb realization of lexical or phrasal stressf (relative to gloss)h
and equal or lexical stress errorsg
Vowel or consonant distortions including Distortion occurrences (out of a possible 39.4 5.8 45.2 8.8 46.24 22.9
distorted substitutionsg 328 phones)h
Syllable segregationg Syllable segregation occurrences (out of a 30.2 8.8 8.5 8.4 1.2 2.1
possible 114 opportunities)i
Intrusive schwag Intrusive schwa occurrences (out of a 1.1 1.3 0.5 1.0 0.0 0.0
possible 15 clusters)i
g
Voicing errors Voicing error occurrences (out of a possible 3.4 4.0 6.0 5.0 1.7 1.5
90 opportunities)h
None PPCh 52.2 15.0 24.3 20.6 73.1 26.3
None PCC-Rh,j 54.0 20.0 22.8 23.8 70.9 26.4
None PVC on polysyllable testh 50.5 11.4 24.8 19.0 75.1 27.3
DEAP Inconsistencya vs. Increased difficulty with longer or more Magnitude of change score: NPC on 12 1.23 0.2 2.52 1.9 2.07 2.91
Polysyllablesb phonetically complex wordsg monosyllables/NPC on 12 polysyllables
(>1 = ↑ difficulty with polysyllables)
Connected speech Slow rateg Articulation rate (syllables per minute)k 1.7 1.0 0.9 0.6 2.6 1.0
samplec Lengthened and disrupted coarticulatory Presence of false articulatory starts and 0.9 0.4 1.0 0.0 0.1 0.3
transitions between sounds and restarts and/or inaudible within-speech
syllablesf and difficulty achieving initial groping and/or audible within-speech
articulatory configurations and groping and/or hesitations (min. = 0,
transitions into vowelsg max. = 1)l,m
Oral and Speech Motor Groping (nonspeech)g Presence of nonspeech groping in lip and 0.5 0.5 0.5 0.6 0.0 0.0
Control Protocold tongue oral function tasks (min. = 0,
max. = 1)
Slow DDK rateg /pǝ/ rate over 3 s on two trialsd 3.6 1.0 3.0 1.7 4.5 2.0
Slow DDK rateg /tǝ/ rate over 3 s on two trialsd 3.4 1.0 2.3 1.3 4.4 1.7
Slow DDK rateg /kǝ/ rate over 3 s on two trialsd 2.9 1.2 1.8 1.0 4.3 1.9
Slow DDK rateg /pǝtǝkǝ/ rate over 3 s on two trialsd 0.9 0.6 0.5 0.1 1.4 0.8
Slow DDK rateg /pætikeɪk/ rate over 3 s on two trialsd 1.0 0.4 0.7 0.4 1.3 0.7
None Accuracy on /pǝtǝkǝ/ DDK task on 48.5 22.6 23.8 9.0 75.9 23.2
two trialsd
None Oral structure scored 23.4 .91 21.0 2.6 21.8 2.4
None Oral function scored 76.6 13.8 60.0 12.4 88.5 18.7
None Maximum Phonation Timed 9.6 5.5 6.8 4.1 12.9 6.7
CELFe None Receptive Language Scoree 100.3 12.2 65.5 18.4 91.4 20.5
None Expressive Language Scoree 85.5 20.1 55.5 7.3 79.7 19.2

Note. CAS = childhood apraxia of speech; M = mean; SD = standard deviation; PPC = percentage phonemes correct; PCC-R = percentage consonants correct–revised; PVC = percentage
vowels correct; NPC = number of phonemes correct; CELF = Clinical Evaluation of Language Fundamentals (Semel, Wiig, & Secord, 2006; Wiig, Secord, & Semel, 2006).
a
Dodd et al. (2002). bGozzard et al. (2004, 2008). cMcLeod (1997). dRobbins and Klee (1987) includes some norms. eSemel et al. (2006) with norms. fASHA (2007b). gShriberg, Potter, et al.
(2009). hComputerized Profiling (Long et al., 2006). iCounted by hand from transcription. jShriberg, Austin, Lewis, McSweeny, and Wilson (1997). kLogan et al. (2011) includes norms.
l
McNeil et al. (2009). mDuffy (2012).

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 were employed to make measurements blinded to the chil-
dren’s expert diagnosis of CAS presence or absence for reli-
ability purposes. The raters were qualified SLPs with an
average of 3 years of clinical experience. The first author
trained each rater on the methods of measurement until a
minimum of 85% interrater reliability was achieved on a
training sample not included in the study. Raters were ran-
domly assigned samples from 12 to 13 children (M = 12.70,
SD = 4.83). Each participant’s results were rated by at least
two raters. In the event of any discrepancies, a third inde-
pendent rater measured the sample(s), and the first author’s
scores were retained based on above 85% agreement for all
measures (see the Reliability section).
The DEAP Inconsistency subtest was transcribed
using broad transcription following the manual (Dodd et al.,
2002). Responses to the Single-Word Test of Polysyllables
were transcribed from an audio recording into the PROPH
module in Computerized Profiling (Long, Fey, & Channell,
2006). Transcription included broad transcription supple-
mented with International Phonetic Alphabet diacritics to
mark distortions where clearly present. Measures extracted
from PROPH were percentage consonants correct–revised
(PCC-R; Shriberg, Austin, Lewis, McSweeny, & Wilson,
1997), percentage vowels correct (PVC), percentage phonemes
correct (PPC), occurrences of intrusive schwa, distorted
substitutions and voicing errors, and percentage of syllable
stress matches compared to the gloss for each word. Syllable
segregation (transcribed as a plus sign “+” between sylla-
bles) and intrusive schwas between cluster elements were
recorded by simple counts of occurrence.
PCC-R is a revised metric of PCC in which typical and
atypical distortions are removed from the index (Shriberg,
Austin, et al., 1997). PCC-R was used as a general index of
speech sound disorder severity, regardless of specific diag-
nosis, for all three groups. This metric was used in this study
because it was more sensitive for the participant sample with
a diverse range of age and speech status (Shriberg, Austin,
et al., 1997). Distortions were counted as their own measure
because it may facilitate differential diagnosis of speech
disorders. Thus, using PCC-R allowed us to identify any
potential effects related to general severity rather than a spe-
cific diagnosis of CAS. Accordingly, distortions were not
part of the PCC-R measure, yet were measured separately
under the Occurrence of Consonant and Vowel Distortions
Including Distorted Substitutions measurement according
to Shriberg, Potter, and Strand (2009).
The Oral and Motor Speech Protocol and connected
speech sample were transcribed or scored from a video re-
cording. Articulation rate was calculated by counting sylla-
bles per second produced in 1 min of monologue connected
speech. This was undertaken using Adobe Audition software
(Version 1.5), in which the sample was isolated and vowels
identified and counted to determine syllable rate following
Logan, Byrd, Mazzocchi, and Gillam (2011).
Strand’s criterion of increased difficulty with polysyl-
labic words (Shriberg, Potter, et al., 2009) was determined
using a magnitude-of-change score. This score was gen-
erated for each participant, comparing the mean number of
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phonemes correct from the 12 monosyllable items in the
DEAP Inconsistency subtest to the first 12 items from the
Single-Word Test of Polysyllables. A magnitude of change
score greater than 1 indicated that production of polysyllabic
words was more difficult than monosyllabic words. The only
binary measures used were for presence of (a) false articula-
tory starts, restarts, or within-speech groping and (b) non-
speech groping movements.
Reliability
Intrarater and interrater transcription reliability was
calculated on a point-to-point basis for all unstandardized
dependent measures for each participant. Intrarater reliabil-
ity was calculated on 20% of each measure for every partici-
pant’s data with each rater calculating the measure once
and then a second time at least 2 weeks after the initial cal-
culation. Intrarater reliability for the first author was 94.6%
(SD = 3.6, range = 88–98) and across all nine independent
raters was 95.2% (SD = 3.1, range = 88.3–99.1). Interrater
reliability was calculated first between the first author
and the nine raters and then between the nine independent
raters. Mean interrater reliability with the first author across
all measures was 94.2% (SD = 1.7, range = 91.3–96.2) and
between the nine raters was 93.3% (SD = 2.9, range = 86.4–
98.1). For a breakdown of each rater’s and measure’s reli-
ability, see online Supplemental Appendices 1 and 2.
Statistical Analyses
Simple bivariate followed by hierarchical multi-
variate, discriminant function analysis (DFA; McKean &
Hettmansperger, 1976) was used to determine whether one
or more of the 24 quantitative measures could reliably predict
the expert assignment of children to CAS or non-CAS
groups. Therefore, the results from the expert judgment of
CAS presence or absence and the quantitative measures were
compared in this phase to address the primary research aim.
The sample size was sufficient to minimize Type I
and Type II errors (Serlin & Harwell, 2004). Before comple-
tion of the analysis, data were screened for normality, line-
arity, and homoscedasticity. No violations of assumptions
were noted. Mahalanobis Distance was calculated to check
for outliers (Allen & Bennett, 2008) and did not exceed the
critical c2 of 26.13 (df = 8; a = .001) for any cases. Finally,
screening for multicollinearity above a conservative 0.80
(cf. 0.90; Allen & Bennett, 2008; Poulsen & French, 2004;
Tabachnick & Fidell, 2007) identified the following highly
correlated measures: PVC, PCC-R, and PPC; PVC and per-
centage stress matches; PPC and oral function score; PCC-R
and oral function score, percentage stress matches and
presence of articulatory false starts, restarts and/or within-
speech groping; and finally, /pə/, /tə/, and /kə/ rates. When
two measures showed multicollinearity, only one measure
at a time was entered into the DFA as a predictor. There is
no consensus on the minimum ratio of predictor variables
to cases in DFA. Given this, we followed guidelines by
Poulsen and French (2004) and Tabachnick and Fidell
Murray et al.: Differential Diagnosis of CAS 49
 (2007) and used up to eight predictors at a time. Bivariate
DFA (for each measure predicting the given diagnosis) was
initially completed to determine the top eight theoretical
measures in discriminating CAS in this sample, taking into
account multicollinearity, for entry into the multivariate
DFA. Results for all 24 measures are presented in Table 3
for all participants and Table 4 when CAS+ and sub-
mucous clefts were excluded. When a potential predictor
correlated highly with another potential predictor, the DFA
was run twice, each time with only one of the highly corre-
lated predictors. For example, the measures that were ini-
tially entered as predictors into the first multivariate DFA
were (a) presence of articulatory false starts, restarts, and/or
within-speech groping; (b) syllable segregation; (c) DEAP
(Inconsistency subtest); (d) PPC; (e) DDK accuracy; (f) non-
speech groping; (g) intrusive schwa; and (h) /kə/ rate. The
predictor percentage lexical stress matches correlated highly
(i.e., was multicollinear with) the variable presence of artic-
ulatory false starts. Similarly, PVC was multicollinear with
the variable PPC and /pətəkə/ rate was multicollinear with
the variable /kə/ rate. Analyses were rerun, substituting per-
centage stress matches, PVC or PCC-R, and /pətəkə/ for
multicollinear variables. As measures were identified as not
making a significant contribution to the hierarchical DFA,
they were replaced by other measures of potential clinical
importance (r < .5) to see whether they increased the predic-
tive accuracy of the model. For ease of reading, DFA anal-
yses are presented in the more familiar layout of multiple
regression, rather than as traditional discriminant functions.
Results
Table 4 reports the descriptive statistics for each of
the 24 variables measured across the three groups: CAS
(± expressive language disorder), CAS+ (CAS with comorbid
dysarthria and language impairment), and non-CAS (sub-
mucous cleft, phonological disorder, and dysarthria). First,
the effects of severity and age were determined. In terms
of PCC-R, an index of general severity of speech sound dis-
order, the groups were significantly different, F(2, 45) =
7.865, p = .001. A Scheffé post-hoc analysis adjusted for
multiple comparisons revealed that the CAS+ group had
significantly lower PCC-R scores than the CAS, p = .042,
and non-CAS, p = .02, groups, but importantly, the latter
two were not differentiated. This is consistent with the
CAS+ group having more complex speech disorders. There
was no effect of age between groups, F(2, 45) = 0.853,
p = .433, and age was not correlated above .5 with any of
the 24 measures.
Two models are provided that represent the set of
variables with highest predictive accuracy for (a) all partici-
pants with CAS (n = 32) against all non-CAS (n = 15) and
(b) participants with CAS (CAS+ cases removed, n = 28)
against non-CAS (cases with submucous cleft removed,
n = 12). Model 2 removed cases with CAS+ (where partici-
pants shared features across both groups and confounded
the analysis) and participants in the non-CAS group with
submucous cleft palates, which could be discriminated in
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a relatively straightforward manner with visual inspection
of the palate before differential diagnosis of CAS. The un-
standardized (B) and standardized (b) regression coefficients
are reported for the two hierarchical DFAs in Table 5. The
standardized b coefficient indicates the contribution of each
measure in predicting the initial diagnosis. A high score on
a positive coefficient and a low score on a negative coeffi-
cient predict CAS.
For Model 1 (full data set), the hierarchical DFA
showed that together the percentage of stress matches and
occurrence of syllable segregation, both from the Single-
Word Test of Polysyllables, accounted for a significant 82%
of the variance in CAS diagnosis in this sample, R2 = .82,
adjusted R2 = .81, F(2, 45) = 96.26, p ≤ .001. Additional
measures increased the overall predictive accuracy by only
1%–2%, at most.
For Model 2 (limited data set), results indicated that
four measures in conjunction accounted for 91% of the CAS
diagnosis, R2 = .91, adjusted R2 = .90, F(4, 38) = 87.45,
p ≤ .001. These measures were syllable segregation, percent-
age of stress matches, PPC on the Single-Word Test of
Polysyllables, and accuracy on DDK tasks (/pətəkə/) from
the Oral and Speech Motor Control Protocol. A formula
can be derived from Model 2 for predicting an individual’s
group membership. This involves multiplying each individ-
ual’s raw scores on the four measures in the DFA with their
standardized b coefficient (i.e., a weighting), then summing
the products and the model constant, and rounding the
resulting single value to zero decimal places. A result of 1
indicates likely CAS, a score of 0 indicates likely non-CAS:
Diagnosis ¼ ðConstant þ ð% lexical stress matches
its weightÞ
þ ðsyllable segregation score
its weightÞþ ðPPC

its weightÞþð=pətəkə=DDK accuracy
its weightÞ
Roundð0ÞÞ
All participants used to create the model were correctly
diagnosed using the formula (100% sensitivity, or true positive
rate, and 100% specificity, or true negative rate). The model
had high positive and zero negative likelihood ratios and a
diagnostic odds ratio of 1,425; see Appendix B). The strength
of Model 2 was further tested with data from the four CAS+
children and three children with submucous cleft who had
been excluded from the DFA. Sensitivity remained high
at 97%, with one CAS+ participant being misdiagnosed as
non-CAS; specificity remained at 100%, with all submucous
cleft participants accurately classified as non-CAS. Again,
the positive likelihood ratio was high (16), and there was a
zero negative ratio, with a diagnostic odds ratio of 651 (see
Appendix B). Table 6 demonstrates use of this formula for
four participants in this sample, two with CAS and two with-
out CAS. The formula can be used in Microsoft Excel to
calculate automatically from evaluation test score input.
Discussion
The purpose of the current study was to determine
whether expert diagnosis of CAS in a sample of 47 children
 Table 3. Model 1: Results from bivariate DFA for all measures in order from highest to lowest accuracy in discriminating CAS/CAS+ group from
the non-CAS group participants.

Accuracy in diagnosing
Measure Bivariate DFA p CAS /CAS+ vs. non-CAS

Syllable segregation 0.890 <.001 79%

Percentage of stress matches (lexical stress) on polysyllable test −0.882 <.001 77%
Presence of false articulatory starts, restarts, or within-speech groping 0.764 <.001 58%
DEAP (Inconsistency subtest) 0.551 <.001 30%
PVC on the polysyllable test −0.546 <.001 30%
/pǝtǝkǝ/ accuracy −0.535 <.001 29%
Nonspeech groping movements 0.536 .002 29%
PPC on the polysyllable test −0.515 <.001 27%
Oral structure score 0.492 .004 24%
Intrusive schwa 0.477 <.001 23%
/kǝ/ rate −0.445 .002 17%
Articulation rate (syllables per second) in connected speech −0.428 .006 17%
Oral function score −0.386 .007 15%
PCC-R on the polysyllable test −0.389 .007 15%
/pǝtǝkǝ/ rate −0.356 .014 13%
/tǝ/ rate −0.352 .024 12%
/pætikeɪk / rate −0.321 .028 10%
Vowel or consonant distortions 0.067 .669 Not significant
Maximum phonation time /a / (MPT) −0.261 .091 Not significant
CELF receptive language score 0.270 .080 Not significant
CELF expressive language score 0.142 .365 Not significant
/pǝ/ rate −0.291 .058 Not significant
Voicing errors 0.231 .136 Not significant
Increased difficulty with polysyllable words (change score) 0.205 .196 Not significant

Note. DFA = discriminant function analysis; DEAP = Diagnostic Evaluation of Articulation and Phonology; PVC = percentage vowels correct;
PPC = percentage phonemes correct; PCC-R = percentage consonants correct–revised.

Table 4. Model 2: Results from bivariate DFA for all measures in order from highest to lowest accuracy in discriminating the CAS group
(excluding CAS+) from the non-CAS group (excluding submucous cleft) participants.

Accuracy in diagnosing
Measure Bivariate DFA p CAS vs. non-CAS

Percentage of stress matches (lexical stress) on polysyllable test −0.893 <.001 80%
Syllable segregation 0.873 <.001 76%
Presence of false articulatory starts, restarts, or within-speech groping 0.732 <.001 54%
DEAP (Inconsistency subtest) 0.670 <.001 45%
PVC on the polysyllable test −0.615 <.001 38%
/pǝtǝkǝ/ accuracy −0.606 <.001 37%
Nonspeech groping movements 0.507 .002 26%
PPC on the polysyllable test −0.540 <.001 29%
Oral function score −0.467 .002 22%
Vowel or consonant distortions 0.464 .003 22%
Intrusive schwa 0.449 .004 20%
PCC-R on the polysyllable test −0.429 .007 18%
Articulation rate (syllables per second) in connected speech −0.429 .006 18%
/kǝ/ rate −0.388 .013 15%
CELF receptive language score 0.362 .022 13%
/tǝ/ rate −0.326 .040 12%
Oral structure score 0.280 .081 Not significant
/pǝtǝkǝ/ rate −0.258 .109 Not significant
/pætikeɪk / rate −0.214 .185 Not significant
Maximum phonation time /a / (MPT) −0.166 .306 Not significant
CELF expressive language score 0.215 .183 Not significant
/pǝ/ rate −0.269 .093 Not significant
Voicing errors 0.237 .141 Not significant
Increased difficulty with polysyllable words (change score) −0.208 .199 Not significant

Murray et al.: Differential Diagnosis of CAS 51

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 Table 5. Unstandardized (B) and standardized (β) regression coefficients for each predictive measure in a regression model predicting CAS
diagnosis.

Accuracy in diagnosing
Participants included Variable/measure B βa p CAS in this sample

Model 1 (Constant) 0.707 <.001 82%

CAS and CAS+ group (n = 32) vs. Percentage of stress matches on –0.009 –0.575 <.001
non-CAS (n = 15) polysyllable test
Syllable segregation 0.012 0.382 .001
Model 2 (Constant) 0.504 <.001 91%
CAS (n = 28) vs. non-CAS (n = 12) Percentage of stress matches on –0.011 –0.729 <.001
(CAS+ and submucous cleft polysyllable test
omitted) Syllable segregation 0.012 0.383 <.001
PPC on polysyllable test 0.007 0.300 .001
Accuracy on DDK task /pǝtǝkǝ/ –0.003 –0.145 .039
a
The β values indicate the contribution (weight) of each task in diagnosis of CAS. A high score on a positive coefficient predicts CAS is more
likely, whereas, on a negative coefficient, a low score predicts CAS is more likely. Taking all the measures and weightings together gives the
overall accuracy in diagnosing CAS in this sample.

could be predicted from a combination of quantitative mea-
sures often collected as part of standard clinical practice.
The current standard for diagnosing CAS utilizes experts
making judgments of presence or absence of a small set
of speech behaviors, with no operational definitions or stan-
dardized testing protocol for eliciting the behaviors. In
the current sample, 28 children were judged by this method
to have CAS (± expressive language disorder; ASHA,
2007b; Shriberg et al., 2012), four were judged to have CAS+
(CAS plus dysarthria and receptive and/or expressive language
impairment), and 15 were judged to have either submucous
cleft, phonological impairment, or dysarthria (non-CAS).
Following the diagnosis, 24 quantitative measures were ex-
tracted from clinically based assessments by raters blinded to
expert diagnosis. A series of multivariate DFAs revealed that
a combination of the two quantitative measures of percent-
age of stress matches and occurrence of syllable segregation
showed 82% diagnostic accuracy with expert diagnosis of
CAS and CAS+ versus non-CAS. However, the highest
accuracy (91%) was obtained when four CAS+ children and
three non-CAS children with structural impairment (i.e.,
submucous cleft) were excluded from analyses.

Table 6. Using the DFA Model 2 formula to diagnose CAS.

Percentage
of lexical
stress Syllable /pǝtǝkǝ/ Formula as entered
Participant characteristic matches segregation PPC accuracy into Excel Resulta

Weighting (β values) −0.011 0.012 0.007 −0.003

Participant No. 2216: CAS, Raw score 6 45 46 77 = round(0.504 + (6 × −0.011) 1
4 years, female, severe + (45 × 0.012) + (46 × 0.007)
articulation severity + (77 × −0.003), 0)
Participant No. 1217: non-CAS Raw score 33 20 25 66 = round(0.504 + (33 × −0.011) 0
(ataxic dysarthria), 4 years, + (2 × 0.012) + (25 × 0.007)
female, severe articulation + (66 × −0.003), 0)
severity
Participant No. 2219: CAS, Raw score 26 19 79 72 = round(0.504 + (26 × −0.011) 1
12 years, male, mild + (19 × 0.012) + (79 × 0.007)
articulation severity + (72 × −0.003), 0)
Participant No. 1311: non-CAS Raw score 88 0 97 100 = round(0.504 + (88 × −0.011) 0
(residual phonological + (0 × 0.012) + (97 × 0.007)
disorder), 12 years, male, + (100 × −0.003), 0)
mild articulation severity

Note. Note the importance of the whole pattern of responses, rather than considering cutoffs variable by variable. Participants No. 2216 and
no. 2219, both diagnosed with CAS, had better scores for PPC on the polysyllable test than Participant No. 1311, diagnosed without CAS.
Classification of Participants No. 2216 and No. 2219 as CAS, using the formula, occurs because their substantially poorer scores on percentage
of stress matches on polysyllable test, syllable segregation, and accuracy on DDK task “tip” them over the cutoff for CAS classification.
Participant No. 1311’s better scores on these three measures and his mildly compromised PPC on the polysyllable test all indicate he does not
fit the pattern of CAS in this sample.
a
1 = likely CAS; 0 = likely non-CAS.

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 The procedures used here for expert judgment on
presence of CAS resulted in 32% of this sample being diag-
nosed as non-CAS, from a group of children referred with
“suspected CAS” according to Australian community-based
SLPs. This is consistent with American studies (Davis et al.,
1998; Forrest, 2003; Shriberg et al., 2011) in which children
with CAS seemed to be over- rather than underdiagnosed.
However, we did not determine if CAS was underdiagnosed
in a general SSD population here. This finding is not sur-
prising, given the lack of validated and/or published assess-
ment batteries currently available for this population (ASHA,
2007b).
Of concern, there was a subset of children who pre-
sented with frank structural and neurological deficits that
were not identified prior to the community clinician assign-
ing the diagnosis of suspected CAS. An OMA is a practical,
inexpensive screen to check for any overt structural deficits
or functional impairments related to muscle strength and
tone. If such deficits are found, referral to a neurologist or
head and neck team should follow. This may seem obvious,
yet there were participants as old as 12 years in this sample
whose structural and/or dysarthric symptoms had not been
previously detected. This is relevant for those with a CAS
diagnosis as well because such diagnoses can co-occur. Fur-
thermore, only 52% (22 out of 42) of the studies reviewed
by McCauley et al. (2012) included OMAs. OMAs should
be part of standard pediatric practice, reflected in policy
guidelines and clinical pathways. In this sample, those with
dysarthria exhibited low oral structure scores on our oral
structure and function test (Robbins & Klee, 1987) due to
lack of tongue symmetry, the presence of tongue fascicula-
tions, and tongue atrophy. In the submucous cleft cases in
the non-CAS group, all three had low oral structure scores
due to poor palatal juncture and one had a bifid uvula.
Given that the primary aim of this study was to iden-
tify a set of measures for identifying children with CAS in
a group with no other known diagnoses (e.g., hearing im-
pairment, structural abnormality, or other diagnosed de-
velopmental diagnoses), the final analysis excluded those
with comorbid CAS and submucous clefts. This exclusion
allowed us to determine how performance on a specific set
of measures, taken from existing clinical tests, interacted
with each other to differentiate children with CAS from
children with other speech sound disorders. This differentia-
tion is likely to be the difficulty SLPs face in identifying
true cases of CAS in order to provide effective manage-
ment. Importantly, age and severity of speech sound dis-
order (PCC-R) of these 40 children did not explain the
variance in the CAS and non-CAS groups. Discriminant
function analysis revealed that four measures in combina-
tion had 91% predictive accuracy: (a) syllable segregation,
(b) percentage of lexical stress matches, (c) PPC, and (d) ac-
curacy on repetition of /pətəkə/ in the DDK task. The
four measures are considered together in a hierarchical for-
mat to make a diagnosis; individual cutoff scores for each
measure, although clinically appealing, do not capture
the relationships between the variables and therefore the
diagnosis. These four measures were derived from just
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two assessment tasks: a polysyllabic word picture-naming
task (Gozzard et al., 2004) and an oral mechanism exam-
ination (Robbins & Klee, 1987), taking less than 30 min to
complete.
Two of the four informative measures—syllable seg-
regation and percentage of lexical stress matches—measure
prosodic features now considered core symptoms of CAS.
These perceptual features are strongly related to acoustic
measures identified as potential markers for CAS, including
the lexical stress ratio (Shriberg, Campbell, et al., 2003), the
coefficient of variation ratio (Shriberg, Green, et al., 2003),
and the pairwise variability index (Ballard et al., 2010). Our
results support dysprosody as a potential core feature of
CAS in children with some ability to produce polysyllable
combinations. Prosody was a discriminant measure in both
DFAs regardless of whether participants with neurological,
linguistic, or structural impairments were included.
The Strand 10-point checklist (Shriberg, Potter, et al.,
2009) includes both “syllable segregation” and “lexical
stress errors” as features. PPC was not used to measure any
criterion from this feature list. Instead, six individual seg-
mental error features were noted (out of the 10 features; see
Table 1), but they were not individually discriminative. A
more global measure such as PPC could have teased apart
differences between groups, particularly because the non-
CAS group was diverse. Accuracy on the /pətəkə/ DDK
task was not used to measure any criterion from this check-
list. However, Thoonen et al. (1999) adds support for this
finding. They found trisyllabic repetition of /pataka/ was
discriminative for CAS against controls. However, they
found it did not discriminate CAS from dysarthria, which
was achieved using fricative maximum phonation. This
measure was not calculated here but could be added to an
OMA as an assessment measure in future studies. Impor-
tantly, Strand’s checklist (Shriberg, Potter et al., 2009) does
not require children to exhibit these features to be diag-
nosed with CAS: Children need to show evidence of any
four of the 10 features on the list, with no differential
weighting of any feature. To our knowledge, the sensitivity
and specificity of Strand’s checklist has not been tested, and
it may not be sufficiently specific, with potential risk of di-
agnosing negative cases with CAS. The present results show
that two participants with clear dysarthria and one with a
submucous cleft were diagnosed with CAS using the Strand
checklist.
The inclusion of lexical stress errors in the ASHA list
of strong discriminative behaviors of CAS was supported
by our analyses, but the other two features (inconsistency
and lengthened and disrupted coarticulatory transitions)
were not supported. The second feature, “lengthened and
disrupted coarticulatory transitions between sounds and
syllables,” was measured as a binary score if false starts, re-
starts, hesitations, or within-speech groping were demon-
strated by a participant in connected speech and on the
polysyllable test. In the bivariate DFA, this measure had
54% accuracy in diagnosis when used independently but did
not add any additional information to the Model 2 (limited
data set) analysis. This diagnostic information may have
Murray et al.: Differential Diagnosis of CAS 53
 been captured in the DFA by syllable segregation, which
is associated with disrupted coarticulatory transitions as
well as dysprosody. Additionally, the motorically complex
DDK task of repetitions of /pətəkə/ also examined disrupted
transitions and within-speech groping as part of its score.
Descriptions of such coarticulation, sequencing, and grop-
ing errors are common in CAS (e.g., ASHA, 2007b; Grigos
& Kolenda, 2010; Thoonen et al., 1996, 1999). These results
suggest that some behaviors on perceptually based feature
checklists are not independent.
The third ASHA criterion, “inconsistent errors on
consonants and vowels in repeated productions of words
and syllables” (ASHA, 2007b, p. 4), was most notably ab-
sent from the models of discriminative measures. Forrest
(2003) found that inconsistency was the feature most used
by clinicians to identify CAS. The present study measured
inconsistency with the DEAP Inconsistency subtest, as it
most closely matched the definition of inconsistency used
in the ASHA Technical Report (2007b)—that is, token-to-
token inconsistency across separate productions of the same
words. This has also been referred to as target stability
(Marquardt, Jacks, & Davis, 2004). When used as a sole
predictor in a bivariate DFA, inconsistency discriminated
the groups with 30% accuracy and did not contribute signif-
icantly to predicting diagnosis in the multivariate analyses.
Other available measures that capture a different type of
inconsistency might yield a different result. In Model 2
(limited data set), inconsistency may have been captured by
the repeated productions of the /pətəkə/ DDK task, which
would be more similar to token accuracy whereby greater
accuracy demonstrates less inconsistency (Marquardt et al.,
2004). Alternatively, the Inconsistency Severity Percentage
(Iuzzini & Forrest, 2010), for example, is a measure of pho-
nemic and phonetic inconsistency, similar to total token
variability (Marquardt et al., 2004), from multiple elicita-
tions of all consonants in English across varied syllable
or word contexts. Iuzzini (2012) reported that the Inconsis-
tency Severity Percentage differentiated CAS from phono-
logical disorder better than the DEAP Inconsistency measure.
Further investigation of the construct of inconsistency and
factors influencing its nature and degree would help to de-
termine the most informative measure and whether that
might have greater predictive accuracy when combined
with measures of other features associated with CAS. Given
the debate over inconsistency in the acquired AOS litera-
ture (see Staiger, Finger-Berg, Aichert, & Ziegler, 2012, for
a review) and the absence of this feature in Strand’s 10-point
checklist, further research is required on this feature, one
that is strongly represented in clinicians’ impressions of both
CAS and AOS.
Nonspeech groping (i.e., groping during nonspeech
tasks) was another noteworthy measure. Such nonspeech
oromotor tasks have been used in CAS checklists over time,
presumably as a feature of CAS (e.g., Ozanne, 2005; Royal
College of Speech and Language Therapists, 2011), and non-
speech groping was the second most prevalent feature in
diagnosis in a survey of clinicians (Forrest, 2003). Despite
this, the current study results suggest that nonspeech groping
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had low diagnostic accuracy independently and did not add
to the diagnostic models. The current data support the find-
ings of Strand and McCauley (2008), as well as studies of
acquired AOS and oral apraxia (see Ballard et al., 2000, for
a review), in that nonspeech features are indicative of oral
apraxia rather than CAS. Therefore nonspeech difficulties
are best considered as concomitant rather than core features
of CAS (ASHA, 2007b; Strand et al., 2013).
The findings from this study indicate that four mea-
sures, in combination, diagnosed CAS with high accuracy
against the current gold standard of expert opinion. The
final model (Model 2) did not include children with CAS+
or with the frank oral structural impairment of submucous
cleft, and data from these seven children were used to fur-
ther test the robustness of the model (see Appendix B). This
shows that although Model 2 was not being developed with
those participants with CAS+dysarthria, it can be used to
determine presence of CAS contributions to their speech
impairment. Only one participant with CAS+ (Participant
No. 1328) was misdiagnosed by the model’s formula as
non-CAS. This diagnosis was most likely due to his comor-
bid flaccid dysarthria and a lack of syllable segregation,
considering he was unable to produce any polysyllabic words.
Three important points are demonstrated here. First, repli-
cation of this study is required with an unselected sample
that includes more children with dysarthria. Second, an OMA
would be required before using these criteria in the future
to determine frank dysarthria and/or submucous clefts in
those who may also have CAS. Third, children with mini-
mal verbal output may not be diagnosed accurately using the
measures described here because they are based on attempts
at polysyllabic words. In future, syllable segregation could
also be examined in utterances between words rather than
just within polysyllable words using, for example, Shriberg’s
inappropriate pauses measure (Shriberg, 2013).
Data from four participants are included as case stud-
ies in Table 6 to illustrate the use of the criteria and further
explain the weightings and use of the DFA results. The
first two cases are 4-year-old girls, each with severe artic-
ulation difficulties, one of whom was diagnosed with CAS
and the other with ataxic dysarthria by the first and second
authors. These cases illustrate the importance all four cri-
teria and weightings of the measures: Each girl had poor
lexical stress matches and a high occurrence of syllable seg-
regation, both of which are features of CAS and ataxic dys-
arthria (ASHA, 2007b; Duffy, 2012). However, although
the child with CAS had poor (46%) accuracy for the PPC
measure, this child was relatively better than the participant
with ataxic dysarthria (with imprecise articulation), who
had 25% accuracy. This may have helped discriminate these
cases, because the child with ataxic dysarthria exhibited
many more distortions and articulation errors, despite the
first two measures showing a similar pattern. The second
pair of cases illustrates the contrast between two 12-year-old
boys with mild articulation difficulties, one with CAS and
the other with residual phonological impairment. The boy
with CAS had fewer lexical stress matches (26%, compared
to 88% for the child with phonological impairment), more
 instances of syllable segregation, and poorer /pətəkə/ accu-
racy than the boy with phonological impairment. These
three features are hypothesized to reflect an underlying im-
pairment of motor planning and programming or praxis
(e.g., ASHA, 2007b; Shriberg, Green, et al., 2003; Thoonen
et al., 1999). The criteria provide confidence in discrimi-
nating those with some underlying praxis deficits, demon-
strating CAS is at least part of the child’s presentation.
Therefore, the combination of the four discriminant measures
and their weightings appear crucial in separating verbal
participants with different types of expressive communica-
tion disorder and wide ranges of age and severity.
It is important to consider that the assessment proce-
dures used here assessed children at a single time point.
Any developmental disorder can vary in its surface presen-
tation across time. Regular review is therefore indicated to
ensure early detection of other clinical behaviors that might
emerge with therapy and maturation (e.g., literacy concerns)
and ultimately to ensure that management strategies match
presenting and prognostic features (Stackhouse & Snowling,
1992; Zaretsky, Velleman, & Curro, 2010).
Our findings advance the field in this area by identify-
ing two tests that appear central to differentiating CAS
from other disorders, at least in this sample: namely, a com-
plete OMA including a DDK task and a sufficiently large
sample of polysyllabic single-word production (e.g., Gozzard
et al., 2004). Both the real-word polysyllabic test and the
nonword /pətəkə/ DDK task from the OMA were motori-
cally challenging and appear to successfully elicit behaviors
that reflected the underlying motor planning and program-
ming deficits in CAS at both the segmental and supra-
segmental level (Shriberg, Lohmeier, et al., 2009; Thoonen
et al., 1996, 1999). These two tests alone may be sufficient
for reliable diagnosis of CAS in verbal children. However,
SLPs using these tasks still need to consider normal acquisi-
tion and development in terms of both segmental and prosody
accuracy (Ballard, Djaja, Arciuli, James, & van Doorn,
2012; James, 2006; Shriberg, Lohmeier, et al., 2009).
Limitations
The major limitation of this study is that it utilized
a selected clinical sample of children with suspected CAS
and selection criteria designed to find idiopathic CAS
rather than comorbid CAS. This approach is not uncom-
mon (e.g., McCauley et al., 2012; Rosenbek & Wertz, 1972;
Yoss & Darley, 1974) and was warranted in exploring and
identifying quantitative measures for further investigation.
As in any multivariate DFA, the results are heavily reliant
on the characteristics of the sample used and the measures
selected for analysis, and there are inherent risks that the
findings might not generalize to a similar but larger sample
or to a different group of children (e.g., children with co-
morbid intellectual disability and receptive language im-
pairment). For example, the formula used PPC to separate
CAS from ataxic dysarthria. However, there is no reason
that a child with CAS may not have severe articulation
errors. Also, the participant sample here all demonstrated
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prosodic errors being features on both the ASHA consensus-
based (2007b) and Strand 10-point feature lists (Shriberg,
Potter, & Strand, 2009). However, other samples that dem-
onstrate dysprosody may only account for a subset of chil-
dren with CAS (e.g., Shriberg, Aram, & Kwiatkowski, 1997)
or younger children may demonstrate other errors of greater
prevalence, such as inconsistency (Iuzzini & Forrest, 2010).
The Model 2 DFA formula based on the limited data set is
reported here to facilitate replication, but caution must be
used in applying it to clinical populations or cases that differ
from the studied sample.
In this study, we relied on perceptual measures of
speech behaviors. This was a deliberate decision considering
that perceptual measures are most commonly used in clini-
cal practice (Duffy, 2012) and have been shown to correlate
highly with acoustic measures of lexical stress (e.g., pair-
wise variability indices; Ballard et al., 2010). However, the
relatively subjective nature of these measures could result
in discrepancies and therefore errors in the formula’s result,
particularly in untrained SLPs. In the current study, train-
ing of raters was required to maintain interrater reliability
above 85%. To assist replication in future studies, efforts to
make the measures more objective would be warranted by
providing defined features, measures, and scoring criteria in
a manual or by finding more objective kinematic or acous-
tic measures. There are promising acoustic measures (e.g.,
Ballard et al., 2012; McKechnie et al., 2008; Shriberg, Green,
et al., 2003) and potential for automation (Hosom, Shriberg,
& Green, 2004; Rosen et al., 2010). However, manual
acoustic measures can be time-intensive and also require a pe-
riod of training. It may be some time before such acoustic
measures are available in a format that allows rapid auto-
mated analysis in clinical settings.
Studies aiming to identify quantitative measures that
differentiate disorders suffer an inherent circularity (ASHA,
2007b; Guyette & Diedrich, 1981). However, here the aim
was not to validate the original checklists (ASHA, 2007b;
Shriberg et al., 2009) used for initial diagnosis. Instead, the
aim was to test the assessment samples to determine whether
a more replicable and efficient method (or set of measures
in combination) could reproduce the initial expert diagnosis
with high accuracy. Our findings suggest that a set of just
four measures strongly predicts presence of CAS in verbal
children. This is a more parsimonious solution than a
checklist of multiple features, of which only a subset is re-
quired for diagnosis (e.g., Hickman, 1997; Kaufman, 1995;
Shriberg, Potter, & Strand, 2009).
Further Directions
This preliminary study used a sample of children ages
4–12 years with idiopathic and comorbid CAS and com-
pared them to others who had been suspected to have CAS
but were instead diagnosed with phonological or language
impairment, submucous cleft, or dysarthria. Further re-
search is necessary to test the robustness of the sets of cri-
teria and the resultant formula identified when diagnosing
an unselected community sample of children with suspected
Murray et al.: Differential Diagnosis of CAS 55
 expressive communication disorders. Other measures could
also be assessed for their predictive accuracy—for example,
the Inconsistency Severity Percentage inconsistency mea-
sure (Iuzzini & Forrest, 2010).
Further research is also warranted for children with
suspected CAS and limited verbal output. The majority of
participants in this study used some polysyllabic words.
Use of dynamic assessment procedures is likely to be a bet-
ter interim option for diagnosing children with only mono-
syllabic productions (e.g., observing the child’s responses
to cues such as reducing speech rate and providing tactile
cues; see Strand et al., 2013). Moreover, efforts should be
directed toward finding and testing more objective, possibly
acoustic or kinematic measures of behaviors that correlate
highly with our perception. Likewise, structural and func-
tional neuroimaging studies might shed light on the nature
of CAS and its response to different types of intervention.
Conclusions
This study commenced with expert diagnosis of chil-
dren with suspected CAS and then extracted quantitative
measures that were analyzed to determine whether any com-
bination predicted the expert diagnosis. CAS and non-CAS
in verbal 4- to 12-year-olds in this sample could be discrimi-
nated with 91% accuracy based on four measures, follow-
ing completion of a thorough OMA including accuracy on
/pətəkə/ (Robbins & Klee, 1987) and a 50-word sample
of polysyllable words (Gozzard et al., 2004). The results met
Shriberg’s criteria of >90% sensitivity and specificity, but
within a selected sample. A formula based on the results of
DFA is provided to assist in application and replication.
Further research is required with a larger unselected sam-
ple to ensure that the four measures and the resultant for-
mula can differentiate CAS in a wider population from
typical development and other speech, neurological, and
linguistic disorders. Investigation of kinematic, acoustic,
and other assessment tools for CAS features would also
be beneficial.
Acknowledgments
This research was supported by the Douglas and Lola Douglas
Scholarship on Child and Adolescent Health, the Nadia Verrall
Memorial Research Grant (2010), a Postgraduate Research Award
(2011) from Speech Pathology Australia, and the James Kentley
Memorial Scholarship and Postgraduate Research Support Schemes
to Elizabeth Murray; a University of Sydney International Pro-
gram Development Fund Grant to Patricia McCabe and Kirrie
Ballard; and an Australian Research Council Future Fellowship
(FT120100255) to Kirrie Ballard. Parts of this article were presented
at the Motor Speech Conference in Santa Rosa, CA, 2012, and the
Speech Pathology Australia Conference in Hobart, Tasmania, 2012.
We thank research assistants Morin Beausoleil, Virginia Caravez,
Claire Formby, Jennifer Fortin Zornow, Sally Hanna, Claire Layfield,
Aimee-Kate Parkes, Gemma Patterson, Alyssa Piper, and Caitlin
Winkelman. Thank you also to Samantha Warhurst, Kate Anderson,
and Claire Layfield for editorial suggestions.
56 Journal of Speech, Language, and Hearing Research • Vol. 58 • 43–60 • February 2015
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 Appendix A
Diagnostic results for all participants using the ASHA criteria (2007b) and the Strand 10-point checklist (Shriberg, Potter, &
Strand, 2009).

ASHA Strand
Group Participant no. criteria meta criteria metb Diagnosis

Non-CAS 1217 2/3 5/10 Ataxic dysarthria (+ receptive & expressive language disorder)
1314 2/3 6/10 Flaccid dysarthria (CNXII) (+ receptive & expressive language
disorder)
0236 0/3 1/10 Phonological disorder (+ expressive language disorder)
1313 1/3 1/10 Phonological disorder
0235 0/3 0/10 Phonological disorder (+ receptive & expressive language disorder);
hoarse voice
0333 0/3 3/10 Phonological disorder (+ receptive & expressive language disorder);
suspected global developmental delay
0334 0/3 1/10 Phonological disorder (+ receptive & expressive language disorder)
0237 0/3 2/10 Phonological disorder (+ receptive & expressive language disorder)
1311 0/3 2/10 Phonological disorder
2315 0/3 1/10 Phonological disorder
1312 0/3 2/10 Comorbid phonological disorder and stuttering
0138 1/3 6/10 Submucous cleft palate (+ expressive language disorder)
0139 1/3 2/10 Submucous cleft palate
1310 1/3 2/10 Submucous cleft palate
0335 0/3 1/10 Phonological disorder (+ expressive language disorder)
No. of non-CAS participants 0/15 3/15
that met criteria
CAS+ 0332 3/3 7/10 CAS and ataxic dysarthria (+ receptive & expressive language
disorder)
2105 3/3 8/10 CAS and flaccid dysarthria (CNXII) (+ expressive language disorder)
1214 3/3 9/10 CAS and flaccid dysarthria (CNXII) (+ expressive language disorder)
1328 3/3 8/10 CAS, flaccid dysarthria (CNXII) (+ receptive & expressive language
disorder)
No. of CAS+ participants 3/3 8/10
that met criteria
CAS 1103 3/3 8/10 CAS (+ expressive language disorder)
1101 3/3 7/10 CAS
1102 3/3 8/10 CAS (+ expressive language disorder)
1104 3/3 6/10 CAS
2106 3/3 9/10 CAS (+ expressive language disorder)
2107 3/3 7/10 CAS (+ expressive language disorder)
2108 3/3 8/10 CAS (+ expressive language disorder)
1210 3/3 8/10 CAS
1211 3/3 9/10 CAS (+ expressive language disorder)
2212 3/3 8/10 CAS (+ expressive language disorder)
1213 3/3 7/10 CAS (+ expressive language disorder)
1215 3/3 6/10 CAS
2216 3/3 7/10 CAS
2217 3/3 7/10 CAS
2218 3/3 7/10 CAS
2219 3/3 5/10 CAS
2320 3/3 7/10 CAS (+ expressive language disorder)
1321 3/3 5/10 CAS
2322 3/3 8/10 CAS (+ expressive language disorder)
2323 3/3 5/10 CAS
1324 3/3 5/10 CAS
1325 3/3 7/10 CAS (+ expressive language disorder)
2326 3/3 6/10 CAS
1329 3/3 6/10 CAS
1330 3/3 7/10 CAS
0331 3/3 7/10 CAS (+ expressive language disorder)
1316 3/3 5/10 CAS (+ expressive language disorder)
2109 3/3 6/10 CAS
No. of CAS participants 28/28 28/28
that met criteria
a
ASHA criteria = 3/3 needed for CAS diagnosis. bStrand criteria = 4/10 needed for CAS diagnosis over three tasks.

Murray et al.: Differential Diagnosis of CAS 59

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 Appendix B
Sensitivity and specificity based on the Model 2 DFA.

Model 2 participants Expert diagnosis

CAS (n = 28) (excluding CAS+) Non-CAS (n = 12) (excluding submucous clefts)

Predicted diagnosis (from DFA) True positive = 100% (n = 28) False positive = 0% (n = 0)
False negative = 0% (n = 0) True negative = 100% (n = 12)

Note. Positive likelihood ratio = infinity; negative likelihood ratio = 0.

All participants Expert diagnosis

CAS (n = 32) (including CAS+) Non-CAS (n = 15) (including submucous clefts)

Predicted diagnosis (from DFA) True positive = 97% (n = 31) False positive = 0% (n = 0)
False negative = 3% (n = 1) True negative = 100% (n = 15)

Note. Positive likelihood ratio = 16; negative likelihood ratio = 0.

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