Apraxia Of Speech Assessment In Adults: 11 Steps

Apraxia of speech (AOS) is a speech disorder that affects muscle coordination. This can happen because of a stroke, TBI, tumor, or progressive neurological disease.

In this article, you’ll learn how to do an apraxia of speech assessment in adults. Plus, you’ll find norms and how to differentiate AOS from aphasia and dysarthria.

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Acquired Apraxia of Speech Characteristics

Apraxia of speech can be tricky to identify, especially if it’s mild or co-occurs with severe aphasia or dysarthria (which is often does).

AOS is often a secondary communication disorder. This means that it’s present but less severe than the symptoms of aphasia or dysarthria (ASHA, n.d.)

AOS signs and symptoms include: (Duffy, 2013; McNeil et al., 2009)

Phoneme distortions and distorted substitutions or additions
Slower speech rate
Syllable segregation with extended intra- and intersegmental durations
Equal stress across adjacent syllables

Apraxia of Speech Assessment In Adults

An acquired apraxia of speech assessment in adults looks at motor-speech planning, perceptual speech, oral mechanism, voice and resonance, and language.

You’ll start with a case history, then do an oral mechanism exam and get a variety of speech samples.

Follow the 11 steps below. Then keep scrolling for help with differential diagnosis and norms.

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1. Complete a case history

Patient’s relevant goals, wants, and needs
Patient’s context (family, housing, etc.)
Current medical status (primary medical diagnosis and onset date, medications, allergies, vision status, etc.)
Medical history (surgeries, chronic disorders, etc.)

2. Oral Mechanism Examination

Observe strength, range of motion, and symmetry.

Read How To Do An Oral Mechanism Exam for step-by-step details.

Mandible	Cranial Nerve V	At rest, Open, Open with resistance, Close, Close with resistance, Lateralize, Protrude, Retract, Sensation
Lips	CN VII	At rest, Protrude, Retract, Repetitive protrude/retract, Puff cheeks, Puff cheeks against resistance, Sensation (CN IX)
Tongue	CN XII	At rest, Protrude out, Protrude out with resistance, Protrude up, Protrude up with resistance, Protrude down, Protrude down with resistance, Lateralize, Lateralize with resistance, Retract (CN V, XII), Lick teeth, Lick lips, Sensation
Velum	CN IX, CN X	At rest, Prolonged ‘ah,’ Repetitive ‘ah’, Sensation
Reflexes	CN IX, X	Gag, Facial arches
Other Observations		Dentition, Oral mucosa, Raise eyebrows (CN VII), Volitional cough, Volitional throat clearing

3. Diadochokinetic Rate

Have the patient say the following sounds as quickly and clearly as they can for 15 seconds each. They will repeat each 3 times.
“puh puh puh”
“tuh tuh tuh”
“kuh kuh kuh”
“puh tuh kuh”

Norms For DDK Rates

Males aged 65 to 74 years

Puh: 5.3-7.8
Tuh: 5.7-7.3
Kuh: 5.0-8.1
Puh tuh kuh: 3.0-8.0

Males aged 74-86 years

Puh: 5.4-8.1
Tuh: 3.6-8.2
Kuh: 3.5-7.2
Puh tuh kuh: 2.5-9.0

Females aged 65 to 74 years

Puh: 5.2-7.5
Tuh: 4.0-7.7
Kuh: 3.3-7.3
Puh tuh kuh: 3.7-7.8

Females aged 74 to 86 years

Puh: 4.1-7.6
Tuh: 3.9-7.2
Kuh: 3.2-6.9
Puh tuh kuh: 4.3-6.9

Abnormal DDK Rates?

What else to look for:

DDK rate less than norms: Muscle weakness or discoordination, reduced intelligibility, frustration while speaking

DDK rate more than norms: Muscle rigidity, reduced intelligibility

Read more about voice, motor speech and resonance norms.

4. Additional Observations

Throughout your assessment, observe:

Muscle weakness
Breath support
Vocal quality
Resonance
Phonation time
Language

If you notice a language deficit, do an informal expressive and receptive language assessment or screen.

And if language (not apraxia) is the primary deficit, complete a standardized assessment, like the Western Aphasia Battery.

5. Connected Speech and Reading Sample

Ask open-ended questions or statements (i.e., Tell me about your favorite job, a place you have lived, etc.) Have the patient read a paragraph aloud, like the Rainbow Passage:

The Rainbow Passage:

When the sunlight strikes raindrops in the air, they act as a prism and form a rainbow. The rainbow is a division of white light into many beautiful colors. These take the shape of a long round arch, with its path high above, and its two ends apparently beyond the horizon. There is, according to legend, a boiling pot of gold at one end. People look, but no one ever finds it. When a man looks for something beyond his reach, his friends say he is looking for the pot of gold at the end of the rainbow. Throughout the centuries people have explained the rainbow in various ways. Some have accepted it as a miracle without physical explanation. To the Hebrews it was a token that there would be no more universal floods. The Greeks used to imagine that it was a sign from the gods to foretell war or heavy rain. The Norsemen considered the rainbow as a bridge over which the gods passed from earth to their home in the sky. Others have tried to explain the phenomenon physically. Aristotle thought that the rainbow was caused by reflection of the sun’s rays by the rain. Since then physicists have found that it is not reflection, but refraction by the raindrops which causes the rainbows. Many complicated ideas about the rainbow have been formed. The difference in the rainbow depends considerably upon the size of the drops, and the width of the colored band increases as the size of the drops increases. The actual primary rainbow observed is said to be the effect of superimposition of a number of bows. If the red of the second bow falls upon the green of the first, the result is to give a bow with an abnormally wide yellow band, since red and green light when mixed form yellow. This is a very common type of bow, one showing mainly red and yellow, with little or no green or blue.

6. Repeat Words

Have your patient repeat 10 or more words that are increasingly longer and more complex. For example:

act, action, activity
hip, hippo, hypocrite
miss, missile, Mississippi

7. Repeat Phrases

Have your patient repeat 5 or more phrases of increasing length and complexity.

For example:

I’m tired.
Let’s go together.
A quick brown fox jumped out.
The motorcycle drove down the windy road.

8. Name Pictures

Present 10 pictures, one at a time.

Ask, “What is this? Please repeat what you just said two more times.”

Record latency time, naming accuracy, and phonetically transcribe responses, as needed.

9. Describe Pictures

Ask your patient to describe a visual scene.

Record responses and phonetically transcribe as needed.

Here’s a link to the classic Cookie Theft Picture from the Boston Diagnostic Aphasia Examination.

10. Test for Limb and Oral Apraxia

“Smile”
“Pretend that you’re blowing out a candle”
“Pucker your lips like you’re about to whistle”
“Pretend that you’re brushing your teeth”
Pretend that you’re combing your hair”
“Stick out your tongue”
“Blow a kiss”
“Give me a thumbs up”
“Snap your fingers”

If you observe difficulty with coordination, refer to OT or PT for further testing.

11. Complete a Self-Report Questionnaire

Have patients complete a self-report questionnaire to understand their beliefs and attitudes about their communication, voice, and speech.

An example is the Communicative Effectiveness Index. In it, the patient rates their communication effectiveness in different situations.

Questionnaires can be repeated for progress reports or at discharge to help measure progress.

Differential Diagnosis for Communication Disorders

Now that you’ve completed your apraxia of speech assessment in adults, it’s time to make a speech therapy diagnosis!

Remember that apraxia of speech often co-occurs with dysarthria or aphasia. So is what you’re seeing dysarthria, apraxia of speech, aphasia, or a combo?

Below is a quick guide to differential diagnosis. For more help, read Aphasia vs Dysarthria vs Apraxia.

1. It May Be Apraxia If:

Speech sounds are distorted
Saying “puhpuhpuh” is inaccurate
Saying “puhtuhkuh” is harder than “puhpuhpuh”
There are more distortions the longer the word/utterance or the faster they speak

2. It May Be Aphasia If:

They have difficulty understanding you
They have difficulty reading
They have difficulty writing

3. It May Be Dysarthria If:

Articulators seem weak (slurred or mumbled speech)
Respiration is abnormal (seems out of breath, only can say a few words per breath)
Phonation is abnormal (voice sounds strangled)
Resonance is abnormal (consistently hypernasal)

Recommended Apraxia of Speech Assessments

Here’s a list of recommended apraxia of speech assessments.

Informal Apraxia of Speech Assessments

Formal Apraxia of Speech Assessments

Apraxia Battery for Adults
Apraxia of Speech Rating Scale (scroll down to the appendix)

Other Helpful Tools

Differential Diagnosis Chart

Dysarthria Assessment PDF

For a print-and-go Motor Speech assessment template, visit our shop!