10 Questions to Ask When Differentially Diagnosing Pediatric SSDs

Differentially Diagnosing Pediatric SSDs

Any pediatric speech-language pathologist who works with Speech Sound Disorders (SSDs) knows that one of the most difficult tasks on our plate is differential diagnosis. Because many SSDs share characteristics, it’s imperative to critically assess a variety of data points to arrive confidently at an accurate diagnosis and identify relative contribution of the communication impairment. An accurate differential diagnosis is the impetus that guides our clinical decisions about treatment methods.

Differentiating Pediatric SSDs

Often, severe phonological impairment, childhood apraxia of speech, and dysarthria can be quite difficult to differentiate. Insight gleaned from a standardized articulation test alone fails to yield enough information to make this determination. A single word test of articulation or phonology is “neither a typical nor optimal measure of speech performance.”1

After 15 years in the field, I set up for my differential diagnosis by fueling myself with multiple cups of coffee, streaming my speech samples through my Dr. Dre Beats, getting my colored pens ready (don’t judge), and getting excited (I know, I know) to start my detective work to tease apart the collected information.

Top 10 Questions to Consider

When you’re preparing for analysis, I urge you to consider the following 10 questions when faced with a challenging SSD differential diagnosis:

  1. Is this child’s speech sound development consistent with or discrepant from expectations based on their developmental level and language skills?
  2. What types of speech sound errors are represented? Distortions, substitutions, omissions or additions? Have I examined the child’s phonetic inventory (sounds they produce in any context) and error inventory (production of sounds in words as compared to an adult model) for patterns of error, omission, or distortion?
  3. Does the child have predictable speech sound errors or is token-to-token inconsistency present?
  4. Do I hear differences in suprasegmentals like vocal intensity, stress, phrasing, or pitch?
  5. What type of breakdown (if any) occurs in the production of speech in a diadochokinetic task (DDK)?
  6. Does the child produce vowel errors? If so, do I hear errors with rhotic vowels, monophthongs, or
 diphthongs? Does vowel accuracy change with change in phonetic context?
  7. Do I hear differences in voice and resonance in the absence of a structural anomaly?
  8. Does the production of speech change from the word level to phrase level to connected speech? Do I see the same errors at different levels of complexity?
  9. What phonotactic structures can the child produce?
  10. Did my oral mechanism exam show any weakness in the speech musculature or physical abnormalities (e.g., oronasal fistula, significant malocclusion, signs of submucosal cleft, etc.) that may contribute to the child’s speech issues?2

The process of differential diagnosis can elicit some self-doubt, for sure. In an article given to me by a dear friend, Tara Mohr states, “You doubt, yet you also know that thoughtful consideration of what’s unclear, what’s uncertain is simply part of doing the job well.”

Cheers to differentially diagnosing SSDs with confidence in 2016! 
Check out ASHA’s practice portal for research-based information related to SSD’s articulation and phonology and childhood apraxia of speech.

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  1. Eisenberg & Hitchcock. “Using standardized test to inventory consonant and vowel production: A comparison of 11 tests of articulation and phonology”. Language, Speech and Hearing Services in Schools, Vol. 41. October, 2010. 488-503
  2. Robbins & Klee. “Clinical Assessment of Oropharyngeal Motor Development in Young Children”. Journal of Speech and Hearing Disorders, Vol 52. August 1987, 271-277