New insights into CAS population profile and interaction with Autism – a wide retrospective research

Introduction

Childhood Apraxia of Speech (CAS) profile is examined in this article to reveal new insights. These insights might have big influence on the clinical aspect of the phenomenon. One of the interesting insights founded was the close relationship between the CAS population and Autism. Since Autism is such a high incidence phenomenon, it implicates to CAS as well.     

Method

A retrospective research was conducted based on 277 entry level evaluations of children diagnosed with CAS or suspected CAS who visited a private clinic between the years 2006-2013. The analysis included speech variables along background and environmental variables. This article is dealing with the non-speech variables that enable us to observe other parts of this phenomenon.

Results

Diagnosis

The most common diagnosis among the children who came for a speech evaluation was ASD (170 cases, 61.15%). Only 15 of them (8.8%) were diagnosed with CAS as well. Another 6 of them (3.5%) were diagnosed in addition with other syndromes or deficits such as FAPA, Prader willi syndrome, tumor induced epilepsy, no ears, micro cephalic brain, and ataxia. Only 23 children (8.3%) were diagnosed with CAS only.

A big group of children (30.32%) had variety of syndromes and conditions

Shriberg, Black & Van Santen (2011) argue that the hypothesis of relationship between ASD and CAS is wrong. They haven’t found high incidence of CAS among a group of ASD children. However it important to point that the ASD group was a part of another research as well, whiles the inclusionary criteria was intelligible speech. In these conditions it is expected not to find CAS among that ASD group.  Adams (1998) found differences in oral motor and motor-speech characteristics among children with ASD in comparison to regular population. However, the groups contained only 4 participants each hence hard to conclude from that. Ming, Brimacombe & Wagner (2007) reported of a prevalence of 34% of CAS among ASD children in a cohort study. Tierney et al (2015) found high comorbidity between ASD and CAS. 63.6% of the children diagnosed with ASD were diagnosed with CAS as well.

 The children participated in the research came for a speech evaluation, hence had as speech problem. The high incidence of ASD children can’t tell us about the prevalence of CAS within ASD but can point of a significant involvement of motor speech deficits among children with ASD.

Only 8.8% of the ASD children were diagnosed with CAS as well. It suggests that the diagnosis didn’t find the significant speech difficulties as motor based. Some might consider the speech problem as part of ASD by mistake. ASD diagnosis can’t point of the neurological origin of the difficulties but rather give a general name for a communication disorder. The miss diagnosis of the CAS within the ASD can lead to the wrong treatment since the basic hypothesis is that the speech problem originates from the communication problem and not vice versa.

A large group of children had 19 different diagnoses (table 1). The largest group within that group was of Developmental Delay (DD) diagnosis (44 cases, 15.8% of all cases).  The DD diagnosis is in many cases a term for an uncertainty in diagnosis. The skill acquisition is severely delayed in comparison to the normal development but the examiner can’t find a specific known group for that symptom’s collective. In this group the CAS component of each case was evident clearly and was missed by the examiner. In the rest of the group the inability to speak was attributed to the syndrome diagnosed.

The fact that only 13.7% of the children were diagnosed with CAS regardless of comorbidity with other syndromes points of a serious diagnosis problem since the different examiners missed a main factor that contributed to the overall phenomenon.  The reasons for that might be: 1) difficulties in differential diagnosis, 2) Lack of knowledge regarding CAS syndrome and diagnosis in Israel, 3) Lack of a formal CAS diagnostic tool.   

The results show high incidence of comorbidity. 70.6% of all cases (pure CAS and DD excluded) present comorbidity. Shriberg (2011) argued that comorbidity of CAS and ASD doesn’t exist.  The group of 46 children diagnosed with ASD that participated in that research had intelligible speech hence reduces the chances for CAS existence. In the group participated in this research the speech level was very low and the incidence of ASD high. Those differences in results might suggest of two different groups; ASD with intelligible speech that doesn’t show CAS characteristics and ASD with low speech skills that might be related to CAS.  The percentage of children diagnosed with ASD and suspected CAS in this study (70.6%) is very similar to the 63.6%  founded in Tierney et al (2015) work and supports their findings.

Diagnosis conclusions and implications

High comorbidity implicates that CAS is a condition that might appear within other syndromes, specifically ASD, and a speech deficit that occur within a developmental syndrome should be considered to be CAS. The examiners should be more aware of CAS and its characteristics in order to identify it. A formal diagnosis tool will help to identify the phenomenon and to choose the best treatment method for the children.

 If the over 60% of children diagnosed with ASD have CAS it means that the population of the CAS is huge since the ASD prevalence at 2014  in the US was  1:68 (Ouhtit et al, 2015). It means that the CAS prevalence would be at least 1:136. That prevalence of phenomena requires a special approach from the governmental health agencies. It might mean special education frames and specialists to deal with the motor speech problem.

Another aspect of it is the influence of the motor speech problem on the ASD phenomena. Inability to speak can manifest different symptoms and defiantly will cause a deficit in communication. The contribution weight of the CAS deficit to the ASD diagnosis is not clear but might be crucial. It might also direct the treatment into different primary avenues.   

Age

Age of attendance

The average attendance age was 4;11 years (range 1;6 – 17 years). We know that early intervention brings better results (Al Otaiba, Puranik, Ziolkowski & Montgomery, 2009). An average age of almost 5 years old for an entry evaluation in CAS cases is high. We would rather have an average of 3-4 years old were we can intervene easily with much more time to make a significant change.  The implications of the high average age attendance can be:

1. Emotional development – The child has at least 4 years’ experience of failure regarding speech. His motivation might be low and so his compliance to treatment. He doesn’t believe in himself for making a change.
2. Families motivation – as the child’s negative experience, the families might have the same negative feelings about the speech improving chances hence will not be fully motivated. However, they approached and asked for the treatment, hence have some motivation for entering the process. It is much easier to start the journey with a young child and highly motivated family.
3. Level of severity – the older the child is the more severe his problem might be. The results of the age and speech skill correlation doesn’t support it fully (see Age and Speech skill correlation), however, we can assume that the child had time to learn and progress and didn’t do it and that implicate on the level of severity.
4. Entering school – At the age of 6 years old children move from kinder to school in Israel. The level of speech can sometimes determine the school frame the child will enter regardless of his cognitive level. If the child with CAS starts the special treatment at the age of 5 he is got only one year to get to an acceptable intelligibility for the school system. Often it is not enough time hence speech treatment for a child diagnosed with severe CAS is a long treatment that can last 2-3 years. This point is crucial. In many cases we can observe good cognitive and language skills while the speech is severely damaged. We also know that if we will promote the speech level to the intelligible one word level, the functional change will be extraordinary and might allow the child to go to a regular class. Sometimes starting at the age of 5 is too late and child potential will not be fulfilled due to speech problem and he will enter a special education school.     

There might be several reasons for the age attendance problem:

1. Parents or the professional consulting environment Unawareness of the importance of early intervention in those cases.
2. Clinic features – since it is a private, young and unordinary clinic, families might look for more public and mainstream solutions and as second or third option will address this specific clinic. However, it is important to mention that in the recent years the average age is dropping.  

Age groups

At the very young age (1-2 years)  6 children attended the clinic (see table 2) while the number jumped to 55 children at the next age group (2-3 years old) and stayed at the same level for the next 3 age groups. At group age 6-7 years old the number of children started to drop and that trend went on for the next age groups.

table 2 here

The fluctuations in group sizes can have few explanations:

1. It demonstrates the families need for the treatment. In the first group of the very early age the families are not convinced that there is a problem and rather wait with the treatment. In the ages 2-6, the speech problem greatly effects communication and social skills so the need for the intervention is the highest. After the age of 6, the belief of a possible change in speech reduces so the group sizes reduce as well.
2. The evidence of the speech problem – in the very early age the speech problem is not so acute hence not as evident. In the ages 2-6 years old, the speech problem is more acute and require the treatment hence more children will come to have the treatment. For the group ages of 6 + there might be less children needed the treatment since they have been treated already. That is reason for the reduction in group sizes will along with the increment in age. 
3. Education system structure in Israel – from early age children with special needs attend special education kinder in Israel until the age of 6. At that age they move to special education schools. The school timetable is more rigid then at kinder and the child usually will spend more time in the school. It is harder to have a secondary treatment schedule in school in comparison to kinder and that might be another reason for the change in group sizes from the age of 6.

 If the reduction in group sizes after the age of 6 is because of improvement in skill, which leads to reduction in the need for treatment, then it is a good trend that needs to be continued. I assume that this is not the only valid explanation; therefore we have children that are missing an important intervention. The family’s belief in the option to make a change in speech reduces so we need to keep it strong. There are many cases of children who started therapy after the age of 6 and managed to overcome the Apraxia. In order to deal with the second reason, the format of the educational system in Israel, we need to better cooperate with the system and come the better understanding of how to keep the special intervention within the school format.    

Age and speech skill

There is a low correlation between Age and single syllable production (SSP) skill (0.24). One would expect that the SSP would increase with age since the child is being treated for speech and there is natural learning occurring. The reason for the low correlation might be the fact that in this study we examined first evaluations which suggest a low speech control potential. If the child is coming for his first evaluation with us the possibility of a major speech problem regardless of age is high. Another explanation might be the assumption that the older the child will come to a first evaluation the more difficult his situation will be (not necessarily the final score of SSP), since he couldn’t overcome the speech problem in few years of treatment or spontaneous attempts. For the young age group I can’t predict the severity of the speech problem but the older the child is the more sever it will be.

The implication of the equal severity across age groups is that we can’t assume level of the severity using the age factor and should be ready to a variety of speech skill levels in all ages.    

Gender

The gender distribution for most of the developmental childhood syndromes involves higher rates for boys than girls. Nicholas et al (2009) found a male to female ratio of 4.7:1 in an ASD population of 8156 4 year-old. Fernell & Gillberg (2010) report boys to girls ratio of 5.1:1 in an ASD population. Boyle et al (2011) conducted a wide research to explore trends in prevalence of developmental disabilities in the US. They have found a boys to girls overall ratio of 1.89:1 and 3.89:1 in the ASD population.   In this study, 77.4% of the children were boys and 22.6% girls. A ration of 3.4:1 boys to girls.  These findings are concurrent with previous literature reports. 

The girls age was significantly higher than the boys (5.73 and 4.68 respectively, T test = 0.0029). On the other hand, The SSP scores for boys and girls didn’t differ (26.08% and 24.18% respectively, T-test= 0.66),  hence, gender had no effect on the severity of the symptoms.

Attendance per Year

Table 3 demonstrates the changes in the numbers of first time evaluations per year. In the years 2000-2005 there were only 10 cases since the clinic didn’t have a physical place. In the end of 2005 Yael Center clinic was opened hence enabled a high number of 58 new evaluations of speech that met the criteria of this research. This is the record number of first time evaluations per year for several reasons; first, a large number of candidates were available for the service given hence the number was likely to drop later on. Second, in the following years the evaluations included repeated children hence reduces the number of new evaluations. Third, over the years, more evaluations were not only speech but on other background.

table 3 here

After the pick on 2006, the numbers balanced with a range of 27-41 cases per year. The average for 2007-2012 was 33 cases per year. The evaluations were held once a week usually with no change in the structure of the service over the years; hence the structure didn’t affect the number of cases.

There is no correlation (r=0.03) between the date of the evaluation and the severity of the case therefore there were no differences in the severity of the phenomena over the years. 

The consistent number of cases shows a consistent need for treatment. It is hard to determine whether there is an increase in demand or a stable prevalence since the services and number of therapists in the clinic didn’t change much over the years to enable more evaluations. Many potentials families didn’t come to the evaluations since they didn’t have an option for direct intervention. Moreover, the consistent structure of the evaluation service didn’t enable more potential families to have an evaluation. So, it seems that there wasn’t reduce in demand for the service and if the service was wider the numbers per year might have been larger.   

Educational frame

The educational frame (kindergarten or school) has a great influence on the child’s development since he spends most of his time there. It is even more evident for the children with special needs in Israel since their day in the kinder or school starts at 8am and finished at 4:30pm. By the time they are getting home the day is over.

In Israel there are special educational frames for specific conditions: Mental Retardation in different levels, Cerebral Palsy, communication problems, language problems, General developmental Delay, hearing problems and blindness. Each child is placed into a frame that fits his condition so the frames supposed to be homogeneous. The trend in the last decade is integration of children with special needs, especially with ASD in the regular education system, in regular classes with an aide or in small supportive classes in the regular school.

One of the variables in this research was the educational frame of the child. In 17 cases there were no data regarding the educational frame. Half of the children went to a communication therapy oriented educational frame (N=132, 50.76%). 88% of them were ASD.   20% (N=52) went to regular schools while a similar group (N=51, 19.61%) went to other special education frames. Only 1.53% (N=4) attended small classes in regular schools. An interesting result was the amount of children in home schooling (N=21, 8.07%).

For CAS as a pronunciation deficit there is no specific educational frame that will support the pronunciation severe needs. If the child has a specific syndrome then he will be placed in the matched educational frame but the focus of that frame will not be speech by definition. A communication kinder will focus on communication skills, Language kinder will focus on language skills etc.  The children with pure CAS have no matched educational frame that will answer their needs. They all eventually fall between the chairs.

Most of the children were diagnosed with ASD hence naturally were placed in a communication frame. It is interesting to see that 12.12% of the children attended communication frames didn’t have ASD.  It means that children without communication problem but severe pronunciation deficits attended an educational frame that couldn’t support them. The explanations for that might be: 1) No other educational frame in their leaving area, 2) it is a very good educational frame that the parents believed will promote the child.

The formal trend of the ministry of education in Israel is towards inclusion of children with special needs in regular educational frames .It is well reflected in a large group size of 20% of children being integrated into regular classes and 1.5% integrated in small classes. The inclusion in regular classes contains great opportunities for social and academic learning but in this case the raise the question whether a good solution for the pronunciation deficit will be given.

Another large group (19.6%) attends special education schools of different kinds with no specialty in speech. The placing was made according to the primary syndrome. The last group of home schooling points of a non-system solution for the educational frame problem. An 8% of all cases are a high percentage for home schooling. In a home schooling system the parents have control over the program and can tailor the most fitted program for the child. When the conventional system gives an appropriate answer to the child’s need then there is no need in alternative. In those cases, the answers the conventional system can give to the CAS population are limited so home schooling raises.

 In the United States the system of homeschooling is common. Over 2 million children from kinder to year 12 assumed to have a homeschooling system in 2010 (Ray, 2011). It represents 4% of the children population. In their master thesis Johnson & Knuth (2010) describe the homeschooling system for children with ASD and support the benefits of that system as more beneficial for the ASD population.  Therefore it is not surprising to find such a high rate of homeschooling systems within this research, even though the costs of conducting such a system are extremely high in comparison to the full coverage the special education system supply in Israel.       

Development during first year

The Development during first year scale had 3 stages – normal, delayed and severe delayed development. Normal development was recorded for cases in which no obvious deficits were seen by the parents or the health care providers. Delayed development was recorded for cases in which 1-3 developmental deficits of all areas were seen and affected the skill acquisition.  Severe delayed development was recorded when the suffered from more than 3 developmental delays that effected development in a severe way.

In 20 cases there wasn’t enough information to assess development. In 92 cases normal development was recorded (35.93%) with average SSP of 28.86% and age average of 4;3 years. In 34 cases delayed development was recorded (13.28%) with average SSP of 23.74% and age average of 3;8 years. In 130 cases severe delayed development was recorded (50.78%) with average  SSP of 20.44% and age average of 5;5 years. The results show a tendency towards significant difference in SSP between groups ( alpha=0.1), hence there might be a relationship between the general development during the first year of life and speech level among children with CAS. The group of severe developmental delay showed the lowest speech skill even though the age average was the highest. It is not clear why general development will affect the speech acquisition. A possible explanation might be the amount of attention that the child needs to put in different areas might sometimes take the focus of other areas hence delay their development. For example, a delay in walking might delay other areas such as speech since the child is still focusing on the motor aspect of development and having control over his body.   

Babbling

Babbling is an early stage of verbal communication. It is a communication and motor phase in the first year towards first syllables and words. The absence of babbling might be a precursor for further development. We had data for scoring babbling in 187 cases (67.5%) on a 1-3 scale. The first was normal babbling during first year, the second was reduced babbling, and the third was no babbling at all. In the normal babbling group were 76 cases (40.6%) with average SSP of 26.28%.  In the reduced babbling group were 35 cases (18.7%) with average SSP of 22.88%.  In the no babbling group were 76 cases (40.6%) with average SSP of 12.19%.  The results indicate that no babbling during the first year is related with lower speech skill later and can point of more severe CAS condition. One way ANOVA test demonstrated significant differences only between the normal babbling group and the no babbling group (a=0.007)

Otitis media effusion (OME) and grommets

The ability to pronounce sounds depends among other things on the auditory input. Deafness will result many times with no speech at all, while disturbances in auditory input due to different reasons can affect speech.   Ear infection and fluids in the middle ear (otitis media effusion) is an example of that kind of disturbance (Klein,1984; Roberts, Rosenfeld & Zeisel, 2004)

 It is a question whether an auditory input deficit such as OME should be part of CAS definition or relate to CAS. The ability to plan a motor program relays on the sensory input in the first place. A good motor plan can’t be established without good input. A mastered movement doesn’t need necessarily sensory feedback in order to be performed but a novice one does (rose ,2006). Hence, learning speech with disturbed auditory feedback might jeopardize speech acquisition

In 35 cases there was insufficient data regarding OME and grommets. In 63 cases (25.6%) OME was reported. Only 40 of them (63.4%) were treated with grommets, all with success. 74.4% of all cases were reported of not having ear infection.

The blowing scores for the children with and without OME were 3.03 and 2.96 respectively.  These scores represent an average ability to blow without an accessory in the mouth but without control of power or direction. No significant difference was found between the groups; hence the OME has no influence on movement control of blowing.

The tongue movement control for the children with and without OME was 2.63 and 2.89 respectively.  These scores represent an average ability to stick tongue out and in some cases move it to the sides of the mouth.  No significant difference was found between the groups; hence the OME has no influence on movement control of the tongue.

The interaction between OME and pre-verbal skills suggest that the children had suspected CAS regardless of the OME since the occurrence of the oral motor deficit wasn’t related to OME. OME  prevalence was 25.6% which is similar to the prevalence in  typical developed children without CAS (Peterson et al, 2006). In comparison, 37% of children with down syndrome were found candidate for grommets surgery (Barr et al , 2011).) It seems that OME is not a unique factor in CAS however can contribute to the difficulties if other CAS characteristics exist.  

Diagnosis

The most common diagnosis among the children who came for a speech evaluation was ASD (170 cases, 61.15%). Only 15 of them (8.8%) were diagnosed with CAS as well. Another 6 of them (3.5%) were diagnosed in addition with other syndromes or deficits such as FAPA, Prader willi syndrome, tumor induced epilepsy, no ears, micro cephalic brain, and ataxia. Only 23 children (8.3%) were diagnosed with CAS only.

A big group of children (30.32%) had variety of syndromes and conditions (see table 1)

table 1 here.

Shriberg, Black & Van Santen (2011) argue that the hypothesis of relationship between ASD and CAS is wrong. They haven’t found high incidence of CAS among a group of ASD children. However it important to point that the ASD group was a part of another research as well, whiles the inclusionary criteria was intelligible speech. In these conditions it is expected not to find CAS among that ASD group.  Adams (1998) found differences in oral motor and motor-speech characteristics among children with ASD in comparison to regular population. However, the groups contained only 4 participants each hence hard to conclude from that. Ming, Brimacombe & Wagner (2007) reported of a prevalence of 34% of CAS among ASD children in a cohort study. Tierney et al (2015) found high comorbidity between ASD and CAS. 63.6% of the children diagnosed with ASD were diagnosed with CAS as well.

 The children participated in the research came for a speech evaluation, hence had as speech problem. The high incidence of ASD children can’t tell us about the prevalence of CAS within ASD but can point of a significant involvement of motor speech deficits among children with ASD.

Only 8.8% of the ASD children were diagnosed with CAS as well. It suggests that the diagnosis didn’t find the significant speech difficulties as motor based. Some might consider the speech problem as part of ASD by mistake. ASD diagnosis can’t point of the neurological origin of the difficulties but rather give a general name for a communication disorder. The miss diagnosis of the CAS within the ASD can lead to the wrong treatment since the basic hypothesis is that the speech problem originates from the communication problem and not vice versa.

A large group of children had 19 different diagnoses (table 1). The largest group within that group was of Developmental Delay (DD) diagnosis (44 cases, 15.8% of all cases).  The DD diagnosis is in many cases a term for an uncertainty in diagnosis. The skill acquisition is severely delayed in comparison to the normal development but the examiner can’t find a specific known group for that symptom’s collective. In this group the CAS component of each case was evident clearly and was missed by the examiner. In the rest of the group the inability to speak was attributed to the syndrome diagnosed.

The fact that only 13.7% of the children were diagnosed with CAS regardless of comorbidity with other syndromes points of a serious diagnosis problem since the different examiners missed a main factor that contributed to the overall phenomenon.  The reasons for that might be: 1) difficulties in differential diagnosis, 2) Lack of knowledge regarding CAS syndrome and diagnosis in Israel, 3) Lack of a formal CAS diagnostic tool.   

The results show high incidence of comorbidity. 70.6% of all cases (pure CAS and DD excluded) present comorbidity. Shriberg (2011) argued that comorbidity of CAS and ASD doesn’t exist.  The group of 46 children diagnosed with ASD that participated in that research had intelligible speech hence reduces the chances for CAS existence. In the group participated in this research the speech level was very low and the incidence of ASD high. Those differences in results might suggest of two different groups; ASD with intelligible speech that doesn’t show CAS characteristics and ASD with low speech skills that might be related to CAS.  The percentage of children diagnosed with ASD and suspected CAS in this study (70.6%) is very similar to the 63.6%  founded in Tierney et al (2015) work and supports their findings.

Diagnosis conclusions and implications

High comorbidity implicates that CAS is a condition that might appear within other syndromes, specifically ASD, and a speech deficit that occur within a developmental syndrome should be considered to be CAS. The examiners should be more aware of CAS and its characteristics in order to identify it. A formal diagnosis tool will help to identify the phenomenon and to choose the best treatment method for the children.

 If the over 60% of children diagnosed with ASD have CAS it means that the population of the CAS is huge since the ASD prevalence at 2014  in the US was  1:68 (Ouhtit et al, 2015). It means that the CAS prevalence would be at least 1:136. That prevalence of phenomena requires a special approach from the governmental health agencies. It might mean special education frames and specialists to deal with the motor speech problem.

Another aspect of it is the influence of the motor speech problem on the ASD phenomena. Inability to speak can manifest different symptoms and defiantly will cause a deficit in communication. The contribution weight of the CAS deficit to the ASD diagnosis is not clear but might be crucial. It might also direct the treatment into different primary avenues.   

Age

Age of attendance

The average attendance age was 4;11 years (range 1;6 – 17 years). We know that early intervention brings better results (Al Otaiba, Puranik, Ziolkowski & Montgomery, 2009). An average age of almost 5 years old for an entry evaluation in CAS cases is high. We would rather have an average of 3-4 years old were we can intervene easily with much more time to make a significant change.  The implications of the high average age attendance can be:

1. Emotional development – The child has at least 4 years’ experience of failure regarding speech. His motivation might be low and so his compliance to treatment. He doesn’t believe in himself for making a change.
2. Families motivation – as the child’s negative experience, the families might have the same negative feelings about the speech improving chances hence will not be fully motivated. However, they approached and asked for the treatment, hence have some motivation for entering the process. It is much easier to start the journey with a young child and highly motivated family.
3. Level of severity – the older the child is the more severe his problem might be. The results of the age and speech skill correlation doesn’t support it fully (see Age and Speech skill correlation), however, we can assume that the child had time to learn and progress and didn’t do it and that implicate on the level of severity.
4. Entering school – At the age of 6 years old children move from kinder to school in Israel. The level of speech can sometimes determine the school frame the child will enter regardless of his cognitive level. If the child with CAS starts the special treatment at the age of 5 he is got only one year to get to an acceptable intelligibility for the school system. Often it is not enough time hence speech treatment for a child diagnosed with severe CAS is a long treatment that can last 2-3 years. This point is crucial. In many cases we can observe good cognitive and language skills while the speech is severely damaged. We also know that if we will promote the speech level to the intelligible one word level, the functional change will be extraordinary and might allow the child to go to a regular class. Sometimes starting at the age of 5 is too late and child potential will not be fulfilled due to speech problem and he will enter a special education school.     

There might be several reasons for the age attendance problem:

1. Parents or the professional consulting environment Unawareness of the importance of early intervention in those cases.
2. Clinic features – since it is a private, young and unordinary clinic, families might look for more public and mainstream solutions and as second or third option will address this specific clinic. However, it is important to mention that in the recent years the average age is dropping.  

Age groups

At the very young age (1-2 years)  6 children attended the clinic (see table 2) while the number jumped to 55 children at the next age group (2-3 years old) and stayed at the same level for the next 3 age groups. At group age 6-7 years old the number of children started to drop and that trend went on for the next age groups.

table 2 here

The fluctuations in group sizes can have few explanations:

1. It demonstrates the families need for the treatment. In the first group of the very early age the families are not convinced that there is a problem and rather wait with the treatment. In the ages 2-6, the speech problem greatly effects communication and social skills so the need for the intervention is the highest. After the age of 6, the belief of a possible change in speech reduces so the group sizes reduce as well.
2. The evidence of the speech problem – in the very early age the speech problem is not so acute hence not as evident. In the ages 2-6 years old, the speech problem is more acute and require the treatment hence more children will come to have the treatment. For the group ages of 6 + there might be less children needed the treatment since they have been treated already. That is reason for the reduction in group sizes will along with the increment in age. 
3. Education system structure in Israel – from early age children with special needs attend special education kinder in Israel until the age of 6. At that age they move to special education schools. The school timetable is more rigid then at kinder and the child usually will spend more time in the school. It is harder to have a secondary treatment schedule in school in comparison to kinder and that might be another reason for the change in group sizes from the age of 6.

 If the reduction in group sizes after the age of 6 is because of improvement in skill, which leads to reduction in the need for treatment, then it is a good trend that needs to be continued. I assume that this is not the only valid explanation; therefore we have children that are missing an important intervention. The family’s belief in the option to make a change in speech reduces so we need to keep it strong. There are many cases of children who started therapy after the age of 6 and managed to overcome the Apraxia. In order to deal with the second reason, the format of the educational system in Israel, we need to better cooperate with the system and come the better understanding of how to keep the special intervention within the school format.    

Age and speech skill

There is a low correlation between Age and single syllable production (SSP) skill (0.24). One would expect that the SSP would increase with age since the child is being treated for speech and there is natural learning occurring. The reason for the low correlation might be the fact that in this study we examined first evaluations which suggest a low speech control potential. If the child is coming for his first evaluation with us the possibility of a major speech problem regardless of age is high. Another explanation might be the assumption that the older the child will come to a first evaluation the more difficult his situation will be (not necessarily the final score of SSP), since he couldn’t overcome the speech problem in few years of treatment or spontaneous attempts. For the young age group I can’t predict the severity of the speech problem but the older the child is the more sever it will be.

The implication of the equal severity across age groups is that we can’t assume level of the severity using the age factor and should be ready to a variety of speech skill levels in all ages.    

Gender

The gender distribution for most of the developmental childhood syndromes involves higher rates for boys than girls. Nicholas et al (2009) found a male to female ratio of 4.7:1 in an ASD population of 8156 4 year-old. Fernell & Gillberg (2010) report boys to girls ratio of 5.1:1 in an ASD population. Boyle et al (2011) conducted a wide research to explore trends in prevalence of developmental disabilities in the US. They have found a boys to girls overall ratio of 1.89:1 and 3.89:1 in the ASD population.   In this study, 77.4% of the children were boys and 22.6% girls. A ration of 3.4:1 boys to girls.  These findings are concurrent with previous literature reports. 

The girls age was significantly higher than the boys (5.73 and 4.68 respectively, T test = 0.0029). On the other hand, The SSP scores for boys and girls didn’t differ (26.08% and 24.18% respectively, T-test= 0.66),  hence, gender had no effect on the severity of the symptoms.

Attendance per Year

Table 3 demonstrates the changes in the numbers of first time evaluations per year. In the years 2000-2005 there were only 10 cases since the clinic didn’t have a physical place. In the end of 2005 Yael Center clinic was opened hence enabled a high number of 58 new evaluations of speech that met the criteria of this research. This is the record number of first time evaluations per year for several reasons; first, a large number of candidates were available for the service given hence the number was likely to drop later on. Second, in the following years the evaluations included repeated children hence reduces the number of new evaluations. Third, over the years, more evaluations were not only speech but on other background.

After the pick on 2006, the numbers balanced with a range of 27-41 cases per year. The average for 2007-2012 was 33 cases per year. The evaluations were held once a week usually with no change in the structure of the service over the years; hence the structure didn’t affect the number of cases.

There is no correlation (r=0.03) between the date of the evaluation and the severity of the case therefore there were no differences in the severity of the phenomena over the years. 

The consistent number of cases shows a consistent need for treatment. It is hard to determine whether there is an increase in demand or a stable prevalence since the services and number of therapists in the clinic didn’t change much over the years to enable more evaluations. Many potentials families didn’t come to the evaluations since they didn’t have an option for direct intervention. Moreover, the consistent structure of the evaluation service didn’t enable more potential families to have an evaluation. So, it seems that there wasn’t reduce in demand for the service and if the service was wider the numbers per year might have been larger.   

Educational frame

The educational frame (kindergarten or school) has a great influence on the child’s development since he spends most of his time there. It is even more evident for the children with special needs in Israel since their day in the kinder or school starts at 8am and finished at 4:30pm. By the time they are getting home the day is over.

In Israel there are special educational frames for specific conditions: Mental Retardation in different levels, Cerebral Palsy, communication problems, language problems, General developmental Delay, hearing problems and blindness. Each child is placed into a frame that fits his condition so the frames supposed to be homogeneous. The trend in the last decade is integration of children with special needs, especially with ASD in the regular education system, in regular classes with an aide or in small supportive classes in the regular school.

One of the variables in this research was the educational frame of the child. In 17 cases there were no data regarding the educational frame. Half of the children went to a communication therapy oriented educational frame (N=132, 50.76%). 88% of them were ASD.   20% (N=52) went to regular schools while a similar group (N=51, 19.61%) went to other special education frames. Only 1.53% (N=4) attended small classes in regular schools. An interesting result was the amount of children in home schooling (N=21, 8.07%).

For CAS as a pronunciation deficit there is no specific educational frame that will support the pronunciation severe needs. If the child has a specific syndrome then he will be placed in the matched educational frame but the focus of that frame will not be speech by definition. A communication kinder will focus on communication skills, Language kinder will focus on language skills etc.  The children with pure CAS have no matched educational frame that will answer their needs. They all eventually fall between the chairs.

Most of the children were diagnosed with ASD hence naturally were placed in a communication frame. It is interesting to see that 12.12% of the children attended communication frames didn’t have ASD.  It means that children without communication problem but severe pronunciation deficits attended an educational frame that couldn’t support them. The explanations for that might be: 1) No other educational frame in their leaving area, 2) it is a very good educational frame that the parents believed will promote the child.

The formal trend of the ministry of education in Israel is towards inclusion of children with special needs in regular educational frames .It is well reflected in a large group size of 20% of children being integrated into regular classes and 1.5% integrated in small classes. The inclusion in regular classes contains great opportunities for social and academic learning but in this case the raise the question whether a good solution for the pronunciation deficit will be given.

Another large group (19.6%) attends special education schools of different kinds with no specialty in speech. The placing was made according to the primary syndrome. The last group of home schooling points of a non-system solution for the educational frame problem. An 8% of all cases are a high percentage for home schooling. In a home schooling system the parents have control over the program and can tailor the most fitted program for the child. When the conventional system gives an appropriate answer to the child’s need then there is no need in alternative. In those cases, the answers the conventional system can give to the CAS population are limited so home schooling raises.

 In the United States the system of homeschooling is common. Over 2 million children from kinder to year 12 assumed to have a homeschooling system in 2010 (Ray, 2011). It represents 4% of the children population. In their master thesis Johnson & Knuth (2010) describe the homeschooling system for children with ASD and support the benefits of that system as more beneficial for the ASD population.  Therefore it is not surprising to find such a high rate of homeschooling systems within this research, even though the costs of conducting such a system are extremely high in comparison to the full coverage the special education system supply in Israel.       

Development during first year

The Development during first year scale had 3 stages – normal, delayed and severe delayed development. Normal development was recorded for cases in which no obvious deficits were seen by the parents or the health care providers. Delayed development was recorded for cases in which 1-3 developmental deficits of all areas were seen and affected the skill acquisition.  Severe delayed development was recorded when the suffered from more than 3 developmental delays that effected development in a severe way.

In 20 cases there wasn’t enough information to assess development. In 92 cases normal development was recorded (35.93%) with average SSP of 28.86% and age average of 4;3 years. In 34 cases delayed development was recorded (13.28%) with average SSP of 23.74% and age average of 3;8 years. In 130 cases severe delayed development was recorded (50.78%) with average  SSP of 20.44% and age average of 5;5 years. The results show a tendency towards significant difference in SSP between groups ( alpha=0.1), hence there might be a relationship between the general development during the first year of life and speech level among children with CAS. The group of severe developmental delay showed the lowest speech skill even though the age average was the highest. It is not clear why general development will affect the speech acquisition. A possible explanation might be the amount of attention that the child needs to put in different areas might sometimes take the focus of other areas hence delay their development. For example, a delay in walking might delay other areas such as speech since the child is still focusing on the motor aspect of development and having control over his body.   

Babbling

Babbling is an early stage of verbal communication. It is a communication and motor phase in the first year towards first syllables and words. The absence of babbling might be a precursor for further development. We had data for scoring babbling in 187 cases (67.5%) on a 1-3 scale. The first was normal babbling during first year, the second was reduced babbling, and the third was no babbling at all. In the normal babbling group were 76 cases (40.6%) with average SSP of 26.28%.  In the reduced babbling group were 35 cases (18.7%) with average SSP of 22.88%.  In the no babbling group were 76 cases (40.6%) with average SSP of 12.19%.  The results indicate that no babbling during the first year is related with lower speech skill later and can point of more severe CAS condition. One way ANOVA test demonstrated significant differences only between the normal babbling group and the no babbling group (a=0.007)

Otitis media effusion (OME) and grommets

The ability to pronounce sounds depends among other things on the auditory input. Deafness will result many times with no speech at all, while disturbances in auditory input due to different reasons can affect speech.   Ear infection and fluids in the middle ear (otitis media effusion) is an example of that kind of disturbance (Klein,1984; Roberts, Rosenfeld & Zeisel, 2004)

 It is a question whether an auditory input deficit such as OME should be part of CAS definition or relate to CAS. The ability to plan a motor program relays on the sensory input in the first place. A good motor plan can’t be established without good input. A mastered movement doesn’t need necessarily sensory feedback in order to be performed but a novice one does (rose ,2006). Hence, learning speech with disturbed auditory feedback might jeopardize speech acquisition

In 35 cases there was insufficient data regarding OME and grommets. In 63 cases (25.6%) OME was reported. Only 40 of them (63.4%) were treated with grommets, all with success. 74.4% of all cases were reported of not having ear infection.

The blowing scores for the children with and without OME were 3.03 and 2.96 respectively.  These scores represent an average ability to blow without an accessory in the mouth but without control of power or direction. No significant difference was found between the groups; hence the OME has no influence on movement control of blowing.

The tongue movement control for the children with and without OME was 2.63 and 2.89 respectively.  These scores represent an average ability to stick tongue out and in some cases move it to the sides of the mouth.  No significant difference was found between the groups; hence the OME has no influence on movement control of the tongue.

The interaction between OME and pre-verbal skills suggest that the children had suspected CAS regardless of the OME since the occurrence of the oral motor deficit wasn’t related to OME. OME  prevalence was 25.6% which is similar to the prevalence in  typical developed children without CAS (Peterson et al, 2006). In comparison, 37% of children with down syndrome were found candidate for grommets surgery (Barr et al , 2011).) It seems that OME is not a unique factor in CAS however can contribute to the difficulties if other CAS characteristics exist.  

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Diagnosis

The most common diagnosis among the children who came for a speech evaluation was ASD (170 cases, 61.15%). Only 15 of them (8.8%) were diagnosed with CAS as well. Another 6 of them (3.5%) were diagnosed in addition with other syndromes or deficits such as FAPA, Prader willi syndrome, tumor induced epilepsy, no ears, micro cephalic brain, and ataxia. Only 23 children (8.3%) were diagnosed with CAS only.

A big group of children (30.32%) had variety of syndromes and conditions

Shriberg, Black & Van Santen (2011) argue that the hypothesis of relationship between ASD and CAS is wrong. They haven’t found high incidence of CAS among a group of ASD children. However it important to point that the ASD group was a part of another research as well, whiles the inclusionary criteria was intelligible speech. In these conditions it is expected not to find CAS among that ASD group.  Adams (1998) found differences in oral motor and motor-speech characteristics among children with ASD in comparison to regular population. However, the groups contained only 4 participants each hence hard to conclude from that. Ming, Brimacombe & Wagner (2007) reported of a prevalence of 34% of CAS among ASD children in a cohort study. Tierney et al (2015) found high comorbidity between ASD and CAS. 63.6% of the children diagnosed with ASD were diagnosed with CAS as well.

 The children participated in the research came for a speech evaluation, hence had as speech problem. The high incidence of ASD children can’t tell us about the prevalence of CAS within ASD but can point of a significant involvement of motor speech deficits among children with ASD.

Only 8.8% of the ASD children were diagnosed with CAS as well. It suggests that the diagnosis didn’t find the significant speech difficulties as motor based. Some might consider the speech problem as part of ASD by mistake. ASD diagnosis can’t point of the neurological origin of the difficulties but rather give a general name for a communication disorder. The miss diagnosis of the CAS within the ASD can lead to the wrong treatment since the basic hypothesis is that the speech problem originates from the communication problem and not vice versa.

A large group of children had 19 different diagnoses (table 1). The largest group within that group was of Developmental Delay (DD) diagnosis (44 cases, 15.8% of all cases).  The DD diagnosis is in many cases a term for an uncertainty in diagnosis. The skill acquisition is severely delayed in comparison to the normal development but the examiner can’t find a specific known group for that symptom’s collective. In this group the CAS component of each case was evident clearly and was missed by the examiner. In the rest of the group the inability to speak was attributed to the syndrome diagnosed.

The fact that only 13.7% of the children were diagnosed with CAS regardless of comorbidity with other syndromes points of a serious diagnosis problem since the different examiners missed a main factor that contributed to the overall phenomenon.  The reasons for that might be: 1) difficulties in differential diagnosis, 2) Lack of knowledge regarding CAS syndrome and diagnosis in Israel, 3) Lack of a formal CAS diagnostic tool.   

The results show high incidence of comorbidity. 70.6% of all cases (pure CAS and DD excluded) present comorbidity. Shriberg (2011) argued that comorbidity of CAS and ASD doesn’t exist.  The group of 46 children diagnosed with ASD that participated in that research had intelligible speech hence reduces the chances for CAS existence. In the group participated in this research the speech level was very low and the incidence of ASD high. Those differences in results might suggest of two different groups; ASD with intelligible speech that doesn’t show CAS characteristics and ASD with low speech skills that might be related to CAS.  The percentage of children diagnosed with ASD and suspected CAS in this study (70.6%) is very similar to the 63.6%  founded in Tierney et al (2015) work and supports their findings.

Diagnosis conclusions and implications

High comorbidity implicates that CAS is a condition that might appear within other syndromes, specifically ASD, and a speech deficit that occur within a developmental syndrome should be considered to be CAS. The examiners should be more aware of CAS and its characteristics in order to identify it. A formal diagnosis tool will help to identify the phenomenon and to choose the best treatment method for the children.

 If the over 60% of children diagnosed with ASD have CAS it means that the population of the CAS is huge since the ASD prevalence at 2014  in the US was  1:68 (Ouhtit et al, 2015). It means that the CAS prevalence would be at least 1:136. That prevalence of phenomena requires a special approach from the governmental health agencies. It might mean special education frames and specialists to deal with the motor speech problem.

Another aspect of it is the influence of the motor speech problem on the ASD phenomena. Inability to speak can manifest different symptoms and defiantly will cause a deficit in communication. The contribution weight of the CAS deficit to the ASD diagnosis is not clear but might be crucial. It might also direct the treatment into different primary avenues.   

Age

Age of attendance

The average attendance age was 4;11 years (range 1;6 – 17 years). We know that early intervention brings better results (Al Otaiba, Puranik, Ziolkowski & Montgomery, 2009). An average age of almost 5 years old for an entry evaluation in CAS cases is high. We would rather have an average of 3-4 years old were we can intervene easily with much more time to make a significant change.  The implications of the high average age attendance can be:

1. Emotional development – The child has at least 4 years’ experience of failure regarding speech. His motivation might be low and so his compliance to treatment. He doesn’t believe in himself for making a change.
2. Families motivation – as the child’s negative experience, the families might have the same negative feelings about the speech improving chances hence will not be fully motivated. However, they approached and asked for the treatment, hence have some motivation for entering the process. It is much easier to start the journey with a young child and highly motivated family.
3. Level of severity – the older the child is the more severe his problem might be. The results of the age and speech skill correlation doesn’t support it fully (see Age and Speech skill correlation), however, we can assume that the child had time to learn and progress and didn’t do it and that implicate on the level of severity.
4. Entering school – At the age of 6 years old children move from kinder to school in Israel. The level of speech can sometimes determine the school frame the child will enter regardless of his cognitive level. If the child with CAS starts the special treatment at the age of 5 he is got only one year to get to an acceptable intelligibility for the school system. Often it is not enough time hence speech treatment for a child diagnosed with severe CAS is a long treatment that can last 2-3 years. This point is crucial. In many cases we can observe good cognitive and language skills while the speech is severely damaged. We also know that if we will promote the speech level to the intelligible one word level, the functional change will be extraordinary and might allow the child to go to a regular class. Sometimes starting at the age of 5 is too late and child potential will not be fulfilled due to speech problem and he will enter a special education school.     

There might be several reasons for the age attendance problem:

1. Parents or the professional consulting environment Unawareness of the importance of early intervention in those cases.
2. Clinic features – since it is a private, young and unordinary clinic, families might look for more public and mainstream solutions and as second or third option will address this specific clinic. However, it is important to mention that in the recent years the average age is dropping.  

Age groups

At the very young age (1-2 years)  6 children attended the clinic (see table 2) while the number jumped to 55 children at the next age group (2-3 years old) and stayed at the same level for the next 3 age groups. At group age 6-7 years old the number of children started to drop and that trend went on for the next age groups.

The fluctuations in group sizes can have few explanations:

1. It demonstrates the families need for the treatment. In the first group of the very early age the families are not convinced that there is a problem and rather wait with the treatment. In the ages 2-6, the speech problem greatly effects communication and social skills so the need for the intervention is the highest. After the age of 6, the belief of a possible change in speech reduces so the group sizes reduce as well.
2. The evidence of the speech problem – in the very early age the speech problem is not so acute hence not as evident. In the ages 2-6 years old, the speech problem is more acute and require the treatment hence more children will come to have the treatment. For the group ages of 6 + there might be less children needed the treatment since they have been treated already. That is reason for the reduction in group sizes will along with the increment in age. 
3. Education system structure in Israel – from early age children with special needs attend special education kinder in Israel until the age of 6. At that age they move to special education schools. The school timetable is more rigid then at kinder and the child usually will spend more time in the school. It is harder to have a secondary treatment schedule in school in comparison to kinder and that might be another reason for the change in group sizes from the age of 6.

 If the reduction in group sizes after the age of 6 is because of improvement in skill, which leads to reduction in the need for treatment, then it is a good trend that needs to be continued. I assume that this is not the only valid explanation; therefore we have children that are missing an important intervention. The family’s belief in the option to make a change in speech reduces so we need to keep it strong. There are many cases of children who started therapy after the age of 6 and managed to overcome the Apraxia. In order to deal with the second reason, the format of the educational system in Israel, we need to better cooperate with the system and come the better understanding of how to keep the special intervention within the school format.    

Age and speech skill

There is a low correlation between Age and single syllable production (SSP) skill (0.24). One would expect that the SSP would increase with age since the child is being treated for speech and there is natural learning occurring. The reason for the low correlation might be the fact that in this study we examined first evaluations which suggest a low speech control potential. If the child is coming for his first evaluation with us the possibility of a major speech problem regardless of age is high. Another explanation might be the assumption that the older the child will come to a first evaluation the more difficult his situation will be (not necessarily the final score of SSP), since he couldn’t overcome the speech problem in few years of treatment or spontaneous attempts. For the young age group I can’t predict the severity of the speech problem but the older the child is the more sever it will be.

The implication of the equal severity across age groups is that we can’t assume level of the severity using the age factor and should be ready to a variety of speech skill levels in all ages.    

Gender

The gender distribution for most of the developmental childhood syndromes involves higher rates for boys than girls. Nicholas et al (2009) found a male to female ratio of 4.7:1 in an ASD population of 8156 4 year-old. Fernell & Gillberg (2010) report boys to girls ratio of 5.1:1 in an ASD population. Boyle et al (2011) conducted a wide research to explore trends in prevalence of developmental disabilities in the US. They have found a boys to girls overall ratio of 1.89:1 and 3.89:1 in the ASD population.   In this study, 77.4% of the children were boys and 22.6% girls. A ration of 3.4:1 boys to girls.  These findings are concurrent with previous literature reports. 

The girls age was significantly higher than the boys (5.73 and 4.68 respectively, T test = 0.0029). On the other hand, The SSP scores for boys and girls didn’t differ (26.08% and 24.18% respectively, T-test= 0.66),  hence, gender had no effect on the severity of the symptoms.

Attendance per Year

Table 3 demonstrates the changes in the numbers of first time evaluations per year. In the years 2000-2005 there were only 10 cases since the clinic didn’t have a physical place. In the end of 2005 Yael Center clinic was opened hence enabled a high number of 58 new evaluations of speech that met the criteria of this research. This is the record number of first time evaluations per year for several reasons; first, a large number of candidates were available for the service given hence the number was likely to drop later on. Second, in the following years the evaluations included repeated children hence reduces the number of new evaluations. Third, over the years, more evaluations were not only speech but on other background.

After the pick on 2006, the numbers balanced with a range of 27-41 cases per year. The average for 2007-2012 was 33 cases per year. The evaluations were held once a week usually with no change in the structure of the service over the years; hence the structure didn’t affect the number of cases.

There is no correlation (r=0.03) between the date of the evaluation and the severity of the case therefore there were no differences in the severity of the phenomena over the years. 

The consistent number of cases shows a consistent need for treatment. It is hard to determine whether there is an increase in demand or a stable prevalence since the services and number of therapists in the clinic didn’t change much over the years to enable more evaluations. Many potentials families didn’t come to the evaluations since they didn’t have an option for direct intervention. Moreover, the consistent structure of the evaluation service didn’t enable more potential families to have an evaluation. So, it seems that there wasn’t reduce in demand for the service and if the service was wider the numbers per year might have been larger.   

Educational frame

The educational frame (kindergarten or school) has a great influence on the child’s development since he spends most of his time there. It is even more evident for the children with special needs in Israel since their day in the kinder or school starts at 8am and finished at 4:30pm. By the time they are getting home the day is over.

In Israel there are special educational frames for specific conditions: Mental Retardation in different levels, Cerebral Palsy, communication problems, language problems, General developmental Delay, hearing problems and blindness. Each child is placed into a frame that fits his condition so the frames supposed to be homogeneous. The trend in the last decade is integration of children with special needs, especially with ASD in the regular education system, in regular classes with an aide or in small supportive classes in the regular school.

One of the variables in this research was the educational frame of the child. In 17 cases there were no data regarding the educational frame. Half of the children went to a communication therapy oriented educational frame (N=132, 50.76%). 88% of them were ASD.   20% (N=52) went to regular schools while a similar group (N=51, 19.61%) went to other special education frames. Only 1.53% (N=4) attended small classes in regular schools. An interesting result was the amount of children in home schooling (N=21, 8.07%).

For CAS as a pronunciation deficit there is no specific educational frame that will support the pronunciation severe needs. If the child has a specific syndrome then he will be placed in the matched educational frame but the focus of that frame will not be speech by definition. A communication kinder will focus on communication skills, Language kinder will focus on language skills etc.  The children with pure CAS have no matched educational frame that will answer their needs. They all eventually fall between the chairs.

Most of the children were diagnosed with ASD hence naturally were placed in a communication frame. It is interesting to see that 12.12% of the children attended communication frames didn’t have ASD.  It means that children without communication problem but severe pronunciation deficits attended an educational frame that couldn’t support them. The explanations for that might be: 1) No other educational frame in their leaving area, 2) it is a very good educational frame that the parents believed will promote the child.

The formal trend of the ministry of education in Israel is towards inclusion of children with special needs in regular educational frames .It is well reflected in a large group size of 20% of children being integrated into regular classes and 1.5% integrated in small classes. The inclusion in regular classes contains great opportunities for social and academic learning but in this case the raise the question whether a good solution for the pronunciation deficit will be given.

Another large group (19.6%) attends special education schools of different kinds with no specialty in speech. The placing was made according to the primary syndrome. The last group of home schooling points of a non-system solution for the educational frame problem. An 8% of all cases are a high percentage for home schooling. In a home schooling system the parents have control over the program and can tailor the most fitted program for the child. When the conventional system gives an appropriate answer to the child’s need then there is no need in alternative. In those cases, the answers the conventional system can give to the CAS population are limited so home schooling raises.

 In the United States the system of homeschooling is common. Over 2 million children from kinder to year 12 assumed to have a homeschooling system in 2010 (Ray, 2011). It represents 4% of the children population. In their master thesis Johnson & Knuth (2010) describe the homeschooling system for children with ASD and support the benefits of that system as more beneficial for the ASD population.  Therefore it is not surprising to find such a high rate of homeschooling systems within this research, even though the costs of conducting such a system are extremely high in comparison to the full coverage the special education system supply in Israel.       

Development during first year

The Development during first year scale had 3 stages – normal, delayed and severe delayed development. Normal development was recorded for cases in which no obvious deficits were seen by the parents or the health care providers. Delayed development was recorded for cases in which 1-3 developmental deficits of all areas were seen and affected the skill acquisition.  Severe delayed development was recorded when the suffered from more than 3 developmental delays that effected development in a severe way.

In 20 cases there wasn’t enough information to assess development. In 92 cases normal development was recorded (35.93%) with average SSP of 28.86% and age average of 4;3 years. In 34 cases delayed development was recorded (13.28%) with average SSP of 23.74% and age average of 3;8 years. In 130 cases severe delayed development was recorded (50.78%) with average  SSP of 20.44% and age average of 5;5 years. The results show a tendency towards significant difference in SSP between groups ( alpha=0.1), hence there might be a relationship between the general development during the first year of life and speech level among children with CAS. The group of severe developmental delay showed the lowest speech skill even though the age average was the highest. It is not clear why general development will affect the speech acquisition. A possible explanation might be the amount of attention that the child needs to put in different areas might sometimes take the focus of other areas hence delay their development. For example, a delay in walking might delay other areas such as speech since the child is still focusing on the motor aspect of development and having control over his body.   

Babbling

Babbling is an early stage of verbal communication. It is a communication and motor phase in the first year towards first syllables and words. The absence of babbling might be a precursor for further development. We had data for scoring babbling in 187 cases (67.5%) on a 1-3 scale. The first was normal babbling during first year, the second was reduced babbling, and the third was no babbling at all. In the normal babbling group were 76 cases (40.6%) with average SSP of 26.28%.  In the reduced babbling group were 35 cases (18.7%) with average SSP of 22.88%.  In the no babbling group were 76 cases (40.6%) with average SSP of 12.19%.  The results indicate that no babbling during the first year is related with lower speech skill later and can point of more severe CAS condition. One way ANOVA test demonstrated significant differences only between the normal babbling group and the no babbling group (a=0.007)

Otitis media effusion (OME) and grommets

The ability to pronounce sounds depends among other things on the auditory input. Deafness will result many times with no speech at all, while disturbances in auditory input due to different reasons can affect speech.   Ear infection and fluids in the middle ear (otitis media effusion) is an example of that kind of disturbance (Klein,1984; Roberts, Rosenfeld & Zeisel, 2004)

 It is a question whether an auditory input deficit such as OME should be part of CAS definition or relate to CAS. The ability to plan a motor program relays on the sensory input in the first place. A good motor plan can’t be established without good input. A mastered movement doesn’t need necessarily sensory feedback in order to be performed but a novice one does (rose ,2006). Hence, learning speech with disturbed auditory feedback might jeopardize speech acquisition

In 35 cases there was insufficient data regarding OME and grommets. In 63 cases (25.6%) OME was reported. Only 40 of them (63.4%) were treated with grommets, all with success. 74.4% of all cases were reported of not having ear infection.

The blowing scores for the children with and without OME were 3.03 and 2.96 respectively.  These scores represent an average ability to blow without an accessory in the mouth but without control of power or direction. No significant difference was found between the groups; hence the OME has no influence on movement control of blowing.

The tongue movement control for the children with and without OME was 2.63 and 2.89 respectively.  These scores represent an average ability to stick tongue out and in some cases move it to the sides of the mouth.  No significant difference was found between the groups; hence the OME has no influence on movement control of the tongue.

The interaction between OME and pre-verbal skills suggest that the children had suspected CAS regardless of the OME since the occurrence of the oral motor deficit wasn’t related to OME. OME  prevalence was 25.6% which is similar to the prevalence in  typical developed children without CAS (Peterson et al, 2006). In comparison, 37% of children with down syndrome were found candidate for grommets surgery (Barr et al , 2011).) It seems that OME is not a unique factor in CAS however can contribute to the difficulties if other CAS characteristics exist.  

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Discussion

Further discussion regarding every result and implication is included as well as regarding the interaction between CAS and Autism.