Fact or fiction?:  “SLPs in Ontario can’t diagnose Childhood Apraxia of Speech.” 

Although this is a frequently encountered statement, it is actually misleading. Ontario SLPs (Speech-Language Pathologists) with the right training and clinical experience in children’s speech disorders can determine that a child’s speech meets criteria for CAS (Childhood Apraxia of Speech), just like SLPs in other jurisdictions. Unfortunately, there has been a persistent misunderstanding of the SLP’s role in identifying CAS in Ontario for some time.

Fortunately, the College of Speech Language Pathologists and Audiologists of Ontario (aka CASLPO), shared critical information that addresses this misunderstanding in a Practice Advice column from September 2018, titled “Communicating Clinical Information Or a Diagnosis:  Do You Know the Difference?” (CASLPO 2018).  This document is available online to both SLPs and members of the public:

http://www.caslpo.com/sites/default/uploads/files/PA_EN_Communicating_a_Diagnosis.pdf

Although this document does not exclusively focus on diagnosing CAS, both parents of children with suspected CAS and SLPs working with children with speech sound disorders in Ontario can benefit from reviewing this document.

According to CASLPO, it is within the SLP’s scope of practice to use the term CAS to describe a set of speech symptoms observed in the course of evaluating of a child.  It’s just like an SLP identifying stuttering based on their observations of a client’s speech dysfluencies, and many of the other examples provided of disorders that SLPs and audiologists assess, identify, and treat.

So why do so many people, including some SLPs, continue to accept the statement that SLPs can’t diagnose CAS in Ontario?  It turns out that it’s all about wording.  Specifically, it’s about the word “diagnosis.”

To make a long story short, SLPs in Ontario cannot use the term “diagnosis” (or any of its related words, e.g. diagnose, diagnosed with, etc.) in their clinical work.  This is because the term “diagnosis” has a very specific significance within Ontario law – it entails identifying an underlying disease or disorder that causes a patient’s outwardly observable symptoms. To take an example, an SLP may conclude based on speech-language assessment findings that an adult patient’s new onset communication difficulties represent aphasia (an acquired language disorder), but cannot tell the patient it is due to a stroke, brain tumour, head injury or other medical issue.  Those are diagnoses, in the technical sense, and can only be communicated to the patient by the medical doctor, based on medical investigations.  

The same considerations apply to CAS.  CAS is identified by clinical features that can be observed by the SLP, i.e. characteristics of a child’s speech production difficulties.  The determination that a child has CAS does not include identification of a specific underlying medical cause.  In fact, an underlying cause often cannot be found for CAS when children undergo medical testing, such as neurological examination, brain imaging, or genetic testing.  Of course, CAS is considered to have a neurological basis because it is the brain that controls motor planning and programming, and therefore the brain is implicated in motor planning and programming deficits. Nonetheless, CAS may exist in the absence of an identifiable disease state of the brain; some brains just develop differently.  Furthermore, we wouldn’t want to conclude that CAS should only be identified when an underlying medical diagnosis/cause exists; rather, we want all children whose speech meets criteria for CAS to be accurately identified by SLPs so that an appropriate speech treatment plan can be put into place.  Sometimes there will be a related medical diagnosis, but most of the time there won’t (i.e. idiopathic CAS).  In addition, sometimes there may be an unrelated co-occurring medical, physical, or developmental diagnosis that does not itself cause CAS, but often there won’t.  Crucially, viewing CAS as a speech disorder, identified based on observable speech characteristics, means that SLPs in Ontario are best placed to identify it and recommend appropriate treatment.

So, now that we understand how the word “diagnosis” is used in the technical/legal sense in Ontario, it makes sense that SLPs cannot use this term when communicating their findings to patients/caregivers, because (1) the various speech and language disorders that SLPs identify are not underlying conditions in the first place, but labels for different types of communication difficulties, and (2) it is not even within the scope of practice of SLPs to investigate (or verify) the underlying cause of a speech-language disorder within the patient’s brain or body.

Nonetheless, as many families have experienced, these technical considerations can create practical issues.  Families, schools, and even other health professionals may not realize that the barrier to receiving an “official diagnosis” of CAS in Ontario has more to do with what “diagnosis” means, and who is allowed to use that term, than it does with an SLP’s ability to identify CAS.

These issues can be remedied by clear wording that identifies CAS without using the word diagnosis, which would not apply in its technical sense to an SLP’s evaluation anyway.  For example, an SLP may summarize speech assessment findings as follow:

Evaluation of Sam’s speech production skills revealed severely reduced speech intelligibility (i.e. clarity) at the single word level, with decreasing clarity as utterance length increased.  Speech production difficulties were reported by Sam’s parents to date back to the onset of speech development, which for Sam was delayed until 25 months of age. 

 Formal testing using the GFTA-3 (Goldman Fristoe Test of Articulation, 3rd Edition) revealed that Sam’s speech sound production at the single word level fell below the 1st percentile when compared to age-matched peers, representing a severe-to-profound speech sound disorder.  The following characteristics were observed during both formal testing and informal observation of spontaneous speech:

  • inconsistent vowel and consonant productions when repeating the same word, or words with the same sounds
  • atypical prosody, including errors with lexical stress
  • groping for initial articulatory configurations
  • difficulty with smooth transitions between sounds and syllables

 The above findings reflect a severe motor speech disorder, Childhood Apraxia of Speech. Intensive speech therapy, targeting the development of speech motor planning/programming skills, is recommended to help Sam achieve age-appropriate speech production. 

Clearly, it is possible for an SLP to convey that the results of a child’s speech-language assessment indicate the presence of CAS without violating the restrictions on use of the term “diagnosis.”

It must be noted, however, that identifying CAS is not always immediate or straightforward.  Depending on a child’s age and ability to participate in assessment and therapy tasks, the clinical judgment of the SLP may take time.  This article from the ASHA Leader is a good example of all of the considerations that may be part of the SLP’s assessment/evaluation process:

https://leader.pubs.asha.org/doi/10.1044/leader.FTR2.22032017.50

The question of whether or not it matters if a child receives an “official diagnosis” of CAS frequently enters into discussions.  There is debate about how access to publicly funded therapy, or other services/accommodations through the school system, may or may not be enhanced for children with an official diagnosis.  This may actually differ by jurisdiction, even within Ontario.  However, it is always important for the parents/caregivers and professionals involved with children with speech disorders to understand the nature of the child’s speech disorder, whether or not it can be called a diagnosis by their SLP.  With accurate identification of CAS, parents/caregivers and professionals can:

  • seek up-to-date information on the disorder (e.g. research on best practices for speech therapy in CAS);
  • prepare for the challenges frequently associated with CAS (e.g. long-term speech-language therapy) and for known risk factors (e.g. potential difficulties with development of literacy skills);
  • find professionals with the right background and expertise for the child’s needs;
  • join a supportive community of other families dealing with the same speech needs;
  • help children understand their own challenges and develop self-advocacy skills, and
  • differentiate between difficulties that are and are not related to CAS; challenges that cannot be attributed to a motor speech disorder should be further investigated and treated separately by the appropriate health professionals (e.g. sleep disturbances, sensory processing issues, delayed toilet training, etc.)

We hope that this discussion has provided clarity about why the statement “SLPs in Ontario can’t diagnose Childhood Apraxia of Speech” is actually misleading.  Based on our extensive experience assessing and treating children with motor speech disorders, including Childhood Apraxia of Speech, the SLPs at The Speech & Stuttering Institute in Toronto are passionate about helping families in Ontario get the information they need to support their children’s speech therapy journey.