[PDF] The Diadochokinetic Skills of Children with Speech Difficulties

39516_7TheDiadochokineticSkillsofChildrenwithSpeechDifficulties.pdf

The Diadochokinetic Skills of Children with

Speech Difficulties

By:

Pamela Williams

A thesis submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy

The University of Sheffield

Department of Human Communication Sciences

September 2015

Amended March 2016

Acknowledgements

I have so many people to thank! Firstly, a huge thank you must go to my supervisor, Professor Joy

Stackhouse, for everything she has done in enabling me to reach the point of finalising this thesis.

Joy has been my absolute rock and I am so grateful to her for sharing her knowledge and expertise with me and for her continual guidance and encouragement. Without her, I know I would have given up years ago! I would also like to thank Dr. Maggie Vance and Professor Bill Wells for their very

valuable contributions. In particular, to Bill, for his thought-provoking comments during the writing

up phase and for sharing his wisdom and experience with me.

I would like to thank all the academic staff, support staff and fellow post-graduate students in the

Department of Human Communication Sciences, for making me so welcome during my flying visits

to Sheffield. In particular, Dr Silke Fricke for her help in dealing with some of the statistical

challenges in analysing my data and Joy Newbold for carrying out the inter-tester ratings and making

the Praat recordings. Next I want to thank my team of Speech and Language Therapists at the Nuffield Hearing and Speech Centre, Hilary Stephens, Frances Ridgway, Shula Burrows and Jenny Gorle. In part, because they helped me recruit participants for the research, but mainly because they have taken on extra duties without complaining, and offered so much help and kindness, to enable me to complete this

thesis. Thanks also go to my line managers at RNTNE Hospital, Anne O͛Sulliǀan Θ Dr. Ruth Epstein,

who have also been so supportive and allowed me to take time off work to complete this thesis. I am also very grateful to Claire Hammond, Principal Speech and Language Therapist in Hertfordshire Community NHS Trust and to all the SLTs and SLTAs who did so much to enable me to recruit

participants, as well as in providing help during the data collection sessions. Thanks also to the three

speech and language therapy students, Stella Vorka, Lucy Smith and Caroline Nelly at University College London, who collected the typically-developing data. Without the children, no study would

have taken place so a big thank you goes to them and their parents for allowing me to carry out this

project. Finally, grateful thanks go to my long-suffering family, my husband, Doug, my children, Sarah and Michael and my mother, Mary Boreham, for allowing me the thinking time and space to do this work

and for being so patient and tolerant, especially in the last few weeks. I hope I will now have more

time to spend with you all and life can return to pre-thesis writing normality!

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Abbreviations and conventions

Abbreviations

A Articulation difficulties/disorder

AA Articulation Age

ASHA American Speech- Language and Hearing Association

C Consonant

CA Chronological age

CAS Childhood apraxia of speech

sCAS Suspected Childhood apraxia of speech

CCD Common Clinical Distortions

CPD Consistent Phonological Disorder

CV Consonant-vowel (and other syllable structures: CVCV, CVC, CVCVC, CCVC) DDK Diadochokinesia; Diadochokinesis, Diadochokinetic; DEAP Diagnostic Evaluation of Articulation and Phonology (Dodd, Hua, Crosbie, Holm & Ozanne, 2002)

DVD Developmental Verbal Dyspraxia

IPD Inconsistent Phonological Disorder

IQ Intelligence Quotient

MDT Mispronunciation Detection Task

NHS National Health Service

NT Not tested

NW Non-word(s)

PCC Percentage Consonants Correct

PPC Percentage Phonemes Correct

RCSLT Royal College of Speech and Language Therapists

RW(s) Real words(s)

s.d. Standard deviation

SS(s) Syllable sequences

SLP Speech and Language Pathologist

SLT Speech and Language Therapist

SLTA Speech and Language Therapy Assistant

TD Typically-developing

V Vowel

Conventions

Clinical children or Clinical group are used for ease of reference to refer to the children with speech

difficulties as individuals or as a group.

Small capitals e.g. BABY are used to represent a spoken real word target in naming or repetition tasks.

Abstract

The Diadochokinetic Skills of Children with Speech Difficulties

Background and Purpose

Diadochokinetic skills (DDK) are thought to reflect speech motor competence. However, there is limited information concerning DDK performance in children with speech difficulties (SD) and how it relates to performance on other speech measures. The main purpose of this study was to investigate relationships between DDK accuracy, consistency and rate and measures of speech and oro-motor skill. A related aim was to identify whether there

are distinct DDK profiles that map onto proposed subgroups of speech difficulty such as

Developmental Verbal Dyspraxia (DVD).

Method

Forty children with SD in the age range 4;0-7;11 were assessed on DDK tasks involving a range of

stimuli types and lengths, along with a battery of speech and oro-motor assessments. The children͛s

performance was compared to that of forty age-matched typically-developing (TD) children.

Results

The children with SD performed more poorly than the TD group on all three DDK measures. DDK

accuracy correlated strongly with accuracy on speech output tasks and on an input task of

mispronunciation detection. DDK consistency correlated with consistency on a single-word naming

task. No correlation was found between DDK rate and other speech tasks. Furthermore, no

relationship was found between DDK performance and oro-motor skills. Six distinct DDK profiles

were identified in the group of children with SD but there was no robust evidence that these profiles

map onto the subgroups of speech difficulty that have been proposed in the literature.

Conclusion and Implications

DDK skills should be assessed and evaluated in the context of performance on other speech tasks. Theoretical implications are discussed and recommendations for clinical practice are made regarding methods for administering DDK tasks. There was little support for DDK being a unique marker of DVD, rather it appeared to be a marker of speech difficulties in general.

Chapter One

Introduction and Literature Review 1

DDK Studies and Classification of Childrens Speech Difficulties

1.1 Introduction

Diadochokinesis (DDK) refers to the ability to perform rapidly alternating muscular movements, such as flexion and extension of a limb, pronation and supination of the hand and side to side movements of the tongue. The term has also been applied to speech, as the ability to perform repetition of syllables at a maximum rate of production (Fletcher, 1978). DDK tasks for speech require a participant to imitate mono-syllables, such as //, //, // and/or a nonsense sequence, involving two or three syllables and consonant sounds made with different articulatory placements e.g. // or //, and then repeat that target three, five, or ten times as fast as possible. For young children, two and three syllable real words, involving consonant sounds with different phonetic placements e.g. PARTY or PAT-A-CAKE, may be used instead or in addition to nonsense sequences. Such DDK tasks allow xecute repetitive, (Johnson, 1980, p.63; Cohen, Waters & Hewlett, 1998). DDK is considered to be a task which is not affected by the many phonological complications of conversational speech (Tiffany, 1980; Yaruss & Logan, 2002), but which approximates the co- ordination and execution of rapid articulatory movements which take place in spontaneous speech. For this reason, speech and language therapists (SLTs) use DDK tasks to assess speech

motor skills both with adults who have speech difficulties following a cerebral vascular

accident or consequent to a neurological condition, with adults and children who stammer, and with children who have developmental speech difficulties. The subject of this thesis is DDK performance by children with developmental speech difficulties. These are children who have difficulties making speech sounds and using them in words and sentences, with the result that their speech is unclear and listeners experience 2 difficulties in understanding what they are saying. Speech difficulties are recognised to be the most common paediatric communication disorder (Verdon, McLeod & Wong 2015; McLeod & Harrison, 2009; ASHA, 2000; Law, 1992). However, prevalence numbers vary considerably depending on whether children who have known and unknown aetiologies are included. Isolated speech impairment (i.e. in the absence of other co-occurring conditions) has been estimated to affect between 2.3% to 24.6% in children under 16 years (Law et al., 2000), but the median prevalence estimate is approximately 6% (McCormack et al., 2009; Rvachew & Brosseau-Lapre, 2012). The numbers are greater in younger children with a prevalence rate of

7.5% being reported for isolated speech impairment (i.e. without associated or co-occurring

language problems) in children aged 3-11 years (Shriberg & Kwiatkowski, 1994; Lee & Gibbon,

2015).

Children with speech difficulties are not a homogeneous group; they differ in terms of their presenting speech errors, the severity of their speech difficulties, the underlying cause of their difficulties, the involvement of other aspects of language and literacy, their prognosis and their response to treatment (Dodd, 2005; Dodd & McIntosh, 2008). Different approaches have been proposed for how best childrens speech difficulties should be classified. Howeer, as of yet there is no clear consensus agreement and this remains an unresolved issue in speech pathology. Although some childrens speech difficulties improve spontaneously during their pre-school and early school years, others do not and require referral to speech and language therapy services for assessment and intervention. The outcomes for children who receive speech and language therapy are generally positive (Law et al., 1998; 2000; Rvachew & Brosseau-Lapre,

2012), but the length of time reuired for interention will ary according to the childs

individual profile of strengths and weaknesses. Despite this often positive outcome, the consequences of having speech difficulties during the pre-school and early school years can be significant and potentially long-term. In addition to the communication breakdown which frequently occurs as a result of the speech errors made, a speech problem can affect the childs ability to deelop social relationships with both peers and adults (McCormack et al.,

2009). Children often experience feelings of failure and/or frustration at not being understood

and these affect the childs oerall emotional well-being, confidence and self-esteem (Nash & Stenglehofen, 2002; Hartshorne, 2006; Bercow, 2008). Literacy acquisition may also be affected, particularly if the speech difficulties persist beyond 5 ½ year (Snowling, Bishop & 3 Stothard, 2000; Nathan et al., 2004; Leitao, Fletcher & Hogben, 2004;) and this in turn inhibits academic progress at school (Teverovsky, Bickel & Feldman, 2009).

It is recognised in clinical practice and in the literature that children with speech difficulties of

differing ages, often experience difficulties in performing DDK tasks (Yoss & Darley, 1974; Henry, 1990; Ozanne, 1995; Preston & Edwards, 2009; Murray et al., 2015). However, interpretation of an indiidual childs performance on DDK tasks is not straight-forward and studies have applied different methodologies which makes it difficult to compare results. Furthermore, although there is now an amount of evidence concerning DDK performance in typically-developing children, there is still limited information available about DDK performance in children with speech difficulties. In studies which have included children with speech difficulties, there has not always been a detailed description of the nature of the indiidual childrens speech difficulties and the ages of the children studied have varied. Furthermore, there has been little attempt to relate a childs performance on DDK tasks with their performance on other aspects of speech processing. To address gaps in the current literature, the present study aimed to: carry out a comprehensive investigation of the DDK skills of a group of children with speech difficulties, involving a range of tasks, different measurements and scoring procedures. compare the childrens performance to that of a group of age-matched typically- developing children. provide detailed information concerning the nature of the individual clinical1 childrens speech difficulties using a range of assessment procedures and by applying different theoretical approaches to classification proposed in the literature. investigate the relationship between the clinical childrens DDK performance and their performance on other speech processing measures. identify whether the children showed distinct DDK profiles (in terms of accuracy, consistency and rate) and if so, whether these map onto any subgroups proposed in the literature.

1 Clinical children or clinical group are used for ease of reference to refer to the children with speech

difficulties as individuals or as a group -please see glossary. 4 The thesis is organised into nine chapters. In chapter one and two there is a literature review of what is known currently about DDK performance and childrens deelopmental speech difficulties. The research questions addressed in the study are listed at the end of chapter two and chapter three describes the methodology used to address these. Chapters four to eight describe the results and chapter nine provides a discussion of the findings in the context of

current knowledge and details the theoretical and clinical implications, the strengths and

limitations of the study, and directions for further research.

1.2 Introduction to Literature Review

In this chapter the review of the current literature will start with a description of the

terminology which will be used, followed by a critical review of DDK performance by children with speech difficulties and a summary of normative DDK performance. It will continue with a review of classification approaches which have been applied to childrens speech difficulties medical, linguistic and psycholinguistic. The literature review will continue in chapter two with a review of typical and atypical speech motor development in children and how this relates to development of DDK skills. This is followed by a review of assessment approaches and procedures which have been applied to childrens speech difficulties and will include a detailed review of task design, measurements, and procedures which have been used to investigate DDK skills. Finally, the research questions for the current study will be listed, which have been formulated in the context of the literature reviews in chapters one and two.

1.3 Terminology

The standard measure of DDK performance is articulatory speed (Preston & Edwards, 2009) and the terms diadochokinetic rate and maximum repetition rate have been used variously in the literature by different authors. In this thesis, measures of DDK performance in addition to rate will be explored and therefore a more general term of diadochokinetic skills will be used. Terminology varies for how children with speech difficulties are best described. A wide range of descriptive terms can be found in the literature over the past twenty years including: speech disorder (Dodd, 1995; 2005); speech difficulties (Stackhouse & Wells, 1997; 2001; Pascoe, Stackhouse & Wells, 2006); speech impairment (McLeod & McCormack, 2007); speech sound 5 disorders (Bowen, 2009; 2015; Williams, McLeod & McCauley, 2010); phonological problems (Joffe & Pring, 2008); (developmental) phonological disorders (Rvachew & Brosseau-Lapre,

2012). This is despite recommendations for terminology having been made by professional

bodies. For example, ASHA (2004) advised that speech sound disorders is the preferred term in USA, whereas RCSLT (2009; 2011) prefer speech impairment, when referring to the same group of children in UK. Broad umbrella terms covering a wide range of speech problems appear to be currently favoured. For example, speech sound disorders were defined by the International Expert Panel on Multilingual Childrens Speech (IEPMCS) (2012) and quoted in Verdon, McLeod and Wong (2015) as: ͞any combination of difficulties with perception, articulationͬmotor production, and/or phonological representation of speech segments (consonants and vowels), phonotactics (syllable and word shapes), and prosody (lexical and grammatical tones, rhythm, stress and intonation) that may impact speech intelligibility and acceptability.... of both known... and presently unknown origin" (p.49). Another broad umbrella term in current use is speech difficulties, which were defined by

Pascoe et al. (2006), as:

͞....children who hae difficulties with producing speech segments in isolation, single words or in connected speech regardless of origin of difficulty." (p.2). This is the term which will be mainly utilised in this thesis, but when describing specific studies the terms used by the authors such as speech impairment, speech delay/disorder, phonological delay/disorder and speech sound disorder will occur. In the literature, DDK performance in children has been particularly associated with the motor speech condition currently known as Childhood Apraxia of Speech (CAS) in USA, which replaced the previous terminology of Developmental Apraxia of Speech (DAS) (ASHA, 2007).

CAS was defined 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). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody." (ASHA, 2007). 6 In the UK, the term Developmental Verbal Dyspraxia (DVD) is used in preference to CAS, but largely describes the same population of children, with some exceptions (RCSLT, 2011). DVD was defined in the RCSLT Policy Statement (2011) as: ͞a condition where the child has difficulty in making and co-ordinating the precise movements which are used in the production of spoken language, although there is no damage to muscles or neres." (after Ripley, Daines Barrett, 1997).

DVD will be the term of choice in this thesis but DAS, CAS and DVD will be used when

describing the research literature.

1.4 DDK Performance by Children with Speech Difficulties

Children with speech difficulties have been reported to have problems performing spoken DDK tasks, either because of slow rate of production and/or consonant sequencing difficulties (Yoss & Darley, 1974; Aram & Horwitz, 1983; Henry, 1990; Ozanne, 1995; Murray et al., 2015). However, here has been a long-standing debate in the literature as to whether DDK performance could be a specific marker of developmental verbal dyspraxia (DVD).

1.4.1 DDK proposed as a clinical marker of DVD

Over forty years ago, Yoss and Darley (1974) proposed that performance on spoken DDK tasks is one of the factors that can help differentiate a motor speech disorder from other speech disorders. In their study, 30 children, aged 5-9 years (range 5;1-9;10, mean 6;4), with moderate or severe articulation difficulties of unknown aetiology, but with average verbal intelligence and language skills, were matched by chronological age and gender to 30 typically developing controls. All the children underwent a battery of tests, which included an auditory perception and discrimination test; non-speech oro-motor tasks (isolated and sequenced volitional oral movements); DDK tasks (repetition of mono-syllables and a tri-syllable) and speech production tasks (real and nonsense words, conversational speech and a story re-tell task). The children with speech difficulties also underwent a paediatric neurological examination. Highly significant differences were found between the two groups, with the children with speech difficulties performing more poorly than the typically-developing controls on all measures. Yoss and Darley (1974) then considered whether the children with speech difficulties could be subdiided. Each childs performance on the test of isolated olitional oral movements (IVOM) (modified from De Renzi et al., 1966) was compared to that of their age-matched control and a difference score was calculated. The median point on the distribution of difference scores (for all the children) was selected as the dividing line. Fourteen children fell above the median point and were designated as Group 1, who had good performance on the IVOM. The 7 remaining sixteen fell below the median point and were designated as Group 2, who had poor performance on the IVOM. The results from the paediatric neurological examination showed that 15 of the 16 children in Group 2 had some neurological evidence of developmental

immaturity, for example difficulties in silent alternate motion rates of the tongue (e.g.

waggling tongue from side to side); difficulties in manipulating scissors, buttons, zips and

shoelaces; difficulties riding a bicycle or tricycle; frequent falls and awkward movements

observed during play in a playground. In comparison, only four of the 14 in Group 1 showed such evidence. On spoken DDK tasks, children in both groups 1 and 2 performed similarly when asked to produce rapid repetitions of the mono-syllables // and //. However, the Group 2 children performed at a slower rate when attempting to repeat the mono-syllable /Ó/ and the tri-syllable /Ó/, than the children in Group 1. The authors also reported that the children had difficulties in maintaining the correct syllable sequence on the tri-syllable task. However, it should be noted that only seven of the fourteen children in group 1 and three of the sixteen children in Group 2 managed to achieve the sequence /Ó/ at all. The above difficulties affecting co-ordination of oral movements, fine and gross motor movements, and spoken DDK skills were felt to be and Darley (1974) diagnosed the childr