childhood apraxia of speech treatment

CHILDHOOD APRAXIA OF SPEECH FOCUS ON TREATMENT

ISHA ANNUAL CONFERENCE

February 13, 2009

Presented by: Margaret Fish, M.S., CCC‐SLP

DEFINITION OF CAS

“… 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 Ad Hoc Committee on Apraxia of Speech in Children

CHARACTERISTICS HAVING GREATEST PROMISE FOR SENSITIVITY AND SPECIFICITY FOR IDENTIFICATION OF CAS

Sensitivity – Characteristic is observed in most kids with CAS Specificity – Characteristic is not observed in most kids without CAS

Inconsistent errors in production of consonants and vowels with repeated productions of syllables and words;

Lengthened and disrupted coarticulatory transitions between sounds and syllables;

Inappropriate prosody, especially in the realization of lexical or phrasal stress.

ASHA Ad Hoc Committee on Apraxia of Speech in Children

2009 ISHA Annual Conference, February 1215, 2009 Childhood Apraxia of Speech: Focus on Treatment, Margaret Fish, M.S., CCC‐SLP . . . . . 2

ADDITIONAL CHARACTERISTICS OF CAS

Presence of vowel distortions Limited consonant and vowel repertoire Use of simple syllable shapes Greater difficulty as word length or phrase length increase Connected speech more unintelligible than single‐word articulation test might suggest Poor diadochokinesis Limited production of complex word shapes Slow development of Speech‐Language Pathology Services limited speech intelligibility Limited babbling during infancy Groping, struggling to speak Possible soft palate involvement Receptive language (typically) exceeds receptive language Regression or loss of sounds or words

EVALUATION

ESSENTIAL ELEMENTS OF A MOTOR SPEECH EXAM

Produce words imitatively and spontaneously Produce words with increasingly complex syllable shapes Repeat test items more than once Execute non‐vocal oral movement Produce phrases and sentences Produce challenging words with the benefit of cueing (visual/auditory/tactile/proprioceptive)

Note the following:

Weakly produced phonemes

Groping

Resonance differences

Prosody differences (intonation, stress)

Rate and volume

FORMAL ASSESSMENT INSTRUMENTS

KSPT ‐ Kaufman Speech Praxis Test for Children (Kaufman)

VMPAC – Verbal Motor Production Assessment for Children (Hayden and Square)


TREATMENT FOR CHILDHOOD APRAXIA OF SPEECH

TREATMENT CONSIDERATIONS

Principles of Motor Learning

Shorter, More Frequent Sessions

Focus on Phoneme Sequencing – Not Just Sounds

Encourage Repeated Practice to Build Muscle Memory

Provide Optimal Reinforcement

Other Treatment Considerations

Facilitate Speech Praxis Using Multimodal Cues

Focus on Vowels

Facilitate Word Approximation as Necessary

Move Quickly to Phrases and Sentences

Choose Vocabulary Carefully

Enhance Motivation

Address Speech Prosody

Consider Purpose of Oral Motor Activities

Consider Relative Contribution of Motor Speech

Address Current and “Future” Literacy Needs


1. NUMBER OF SESSIONS PER WEEK AND LENGTH OF SESSIONS

Motor Learning Research indicates:

• Motor skills are acquired more quickly (in terms of total hours spent within practice sessions) when shorter, frequent sessions are used.

• Motor skill accuracy is better when shorter, frequent practice sessions are implemented.

• Retention of motor skills is higher for individuals receiving shorter, frequent practice sessions.

Therefore…

When possible, incorporate a treatment schedule of shorter, frequent sessions for kids with CAS.

Ex: Rather than 2, 45 min. sessions/week, schedule 3 or 4‐ 30 minute sessions

2. FOCUS ON PHONEME SEQUENCING, NOT JUST SOUNDS


Whole practice is more effective for teaching movement patterns when the component parts of the movement are highly related

Parts practice is more effective in teaching a movement pattern in which the component parts are less related

Therefore…

•Since speech movements are highly related to one another and phoneme production is highly dependent on the phonemes surrounding it (due to coarticulation), whole practice is preferable to parts practice.

Suggestions:

•Begin at least at the syllable level (CV or VC);

•Move to phrase level as quickly as possible;

•Make the words meaningful;

•If CV or VC is too challenging try:

‐ adjusting the temporal aspects of the word

‐ adding multimodal cues

‐ using isolated phonemes that denote meaning – many of which are fun, silly or emotionally charged.


PHONEME SEQUENCE HIERARCHY

C (m, s, z, sh, ch)**

CV (boy, hi, no, go, moo)

VC (up, on, in, off, out, ape)

CV‐CV with reduplication (mama, baba, wawa, moo‐moo, boo‐boo)

CV‐CV with same C but varied V (mommy, daddy, puppy, cookie, turtle)

CV‐CV with varied C and V (bunny, dino, potty, hippo, table)

CVC with assimilation (pop, pup, mom, cake, mop, five)

CVC without assimilation (cup, pin, bake, fish)

CV‐CV‐CV (banana, tomato, potato, bicycle)

CV‐CVC (button, chicken, magic, finish)

CVC‐CVC (popcorn, cupcake, basket, picnic, football)

Blends (spoon, jump, splash, jumps)

Multisyllables (motorcycle, alligator, refrigerator, Cinderella, hippopotamus)

3. ENCOURAGE REPETITION TO BUILD MUSCLE MEMORY


Mass practice (practicing fewer things many times) leads to better accuracy during initial learning of motor skill BUT inhibits carryover

Distributed practice (practicing numerous things fewer times) leads to better carryover/habituation BUT increases time to develop a new skill

Therefore …

•When teaching new movement patterns, mass practice is recommended

•When trying to habituate skills, distributed practice is recommended


Materials and Activities to Promote Repeated Practice

•Echo microphone

•Puzzles

•Sound puzzles

•String beads/pop beads

•Farm toy

•Cash register toy

•Cars, trucks and ramps

•Train track and trains

•Mr. Potato Head/Mr. Potato Head Pals

•Colored blocks

•Large blocks

•Markers/crayons/paper

•Dot Articulation (Super duper, Inc)

•Stickers/stamps

•Familiar characters and accessories

•Dollhouse and family characters

•Big truck, airplane

•Tool toys

Games for Repetitive Practice (Purchased) – Games should be:

Quick Fun Used either as:

o Reinforcer o Selected vocabulary

Sample games:

Pop‐Up Pirate

Cariboo

Crocodile Dentist

Don’t Spill the Beans

Silly Six Pins

Lego Creator

Mousetrap

Animal Buddies

Barnyard Bingo

Lucky Ducks

Milk and Cookies

Silly Faces

Colorforms

Memory Games

Lotto Games

Holiday& Seasonal Gameboards for Speech and Language (Super Duper, Inc.)


Quick and Simple Games:

Bowling/Soccer bowling

Basketball

Long jump

Picture hop

Animal walk

Treasure hunt

Mailman

Block designs

Tall tower

Dominoes

Stickers & Stamps

Progressive drawing

Earn it now – make it later

Large number dice

Large number spinner

Magnet chips

Double dice roll

100

Go Fish

Memory

Simon Says

Letter Path

Louder/softer/other variations

Hidden puzzle pieces


4. PROVIDE OPTIMAL REINFORCEMENT

Types of Feedback:

Extrinsic Feedback – Sensory information provided by an outside source. Motor Learning Research indicates Extrinsic Feedback is necessary to acquire NEW skills

o Knowledge of Performance o Knowledge of Results

Intrinsic Feedback – Sensory information within the learner. Motor Learning Research indicates Intrinsic Feedback is necessary for CARRYOVER of skills

o Auditory o Proprioceptive o Tactile

Principles of Reinforcement When Teaching a New Motor Skill

Provide frequent feedback Provide immediate feedback Provide KNOWLEDGE OF PERFORMANCE

o Tell what was not correct about the movement o Tell what should be done differently

Limit the amount of information provided Don’t overload

Principles for Development of Intrinsic Feedback

Fade extrinsic feedback progressively Begin to use intermittent reinforcement Move to providing KNOWLEDGE OF RESULTS Begin to delay feedback


5. FACILITATE SPEECH PRAXIS USING MULTIMODAL CUES

Specific Cueing Techniques (Visual, Auditory, Tactile/Proprioceptive)

PROMPT (Prompts for Restructuring Oral Muscular Phonetic Targets)

DTTC – Dynamic Temporal and Tactile Cueing (Edythe Strand and colleagues)

Variation of rate

Choral Speaking (simultaneous production)

Hand motions/positions

Tapping/clapping out phonemes and syllables

Blocks or paper/felt squares to denote number of syllables or words

Written letters and words

Sound names

Verbal descriptions and specific feedback (knowledge of performance)

Mouth Pictures

Visual – looking at self in mirror or looking at therapists face

Pictures to denote syllables or phonemes


MULTISENSORY CUEING TECHNIQUES Cueing Technique Visual Auditory Tactile

Dynamic Temporal and Tactile Cueing X X X

Rate Variations X

Choral Speaking/Simultaneous Production

X X

Direct Imitation (I say it; you say it) X X

Watching Clinician X X

Mime X

Mirror X

Hand Motions/Gestures X

Written Letters/Words X

Tapping/Clapping Out Syllables X X

Blocks/Paper Squares to Denote # of Sounds/Syllables/Words

X

Sound Names X

Verbal Descriptions of How to Produce Sounds

X

Pictures to Denote Separate Syllables X

Mouth Pictures X

PROMPT® X X X

Touch Cues X


**Adapted from Clinical Management of Motor Speech Disorders in Children. Caruso, A and Strand E.


6. VOWELS VOWEL DIAGRAM

TONGUE POSITION Front Central Back

MANDIBLE H

EIGHT

High M

id

Low


7. PROGRESSIVE APPROXIMATIONS

Sample Approximation Sequence

For the Word “Dinosaur”

• “dah no”

• “di no”

• “di no so”

• “di no saur”

Practice Approximations


8. PHRASES AND SENTENCES Sample Carrier Phrase Corresponding Language Activity

It’s a ___________ “Feely box” – place hand inside box, feel what’s inside and tell what it is

_________ in/on/up Animal characters going on a school bus.

TV toy characters climb up mountain.

I got a ___________ Go Fish game or Memory game – tell what you got when you turn over a pictures

I found a _____________ I Spy – using a flashlight, find “hidden” toys

Big/little ___________ Jack‐o‐lantern picture

(color word) ___________ Potato head

I have (a) _________

You have (a) __________

Describe clothing or physical characteristics of self and other person

I want (a) _________

I want (a) _______ _______

Tell what piece you need to complete a sticker picture, block structure, or craft project

(number word) ________ Counting books

_________ go Animals, characters or toy people going down slide or moving in vehicle

More ____________ Bubbles

Do you have a _________? Go Fish game

Bye‐bye ___________ Putting toys away


9. CONSIDERATIONS WHEN CHOOSING VOCABULARY

When choosing target words, take into consideration:

Phoneme repertoire

Syllable shapes

Planes of movement

Child’s interests

Family routines

School routines

CASE EXAMPLES

CHILD A

Age 3 years, 6 months

Consonants /b, m, d, n/

Vowels /o, oo, ah, uh/

Syllable shapes – CV, CVCV reduplicated

Interests – vehicle toys, balls, farm animals

Consistency – “bah”, “mah” are consistent. Other combinations achieved using multisensory cues

CHILD B

Age 7 years, 10 months

Consonants /p, b, m, w, t, d, n, h, f, s/

Vowels /all, though diphthongs can be difficult at rapid rate

Syllable Shapes – all except blends, thou inconsistent

Interests – action heroes, soccer, basketball

Consistency ‐ difficulty with multisyllabic words. Omits medial consonants (even at CV‐CVC) unless rate is significantly reduced.


LESSON PLAN WORKSHEET – Child A

Name____________________ Date________

Syllable Shape(s)

Phoneme(s)

C and V

Vocabulary;

Phrase Structures

Activities;

Materials


LESSON PLAN WORKSHEET – Child B

Name____________________ Date________

Syllable Shape(s)

Phoneme(s)

C and V

Vocabulary;

Phrase Structures

Activities;

Materials


RESOURCES FOR PICTURES

• Moving Across Syllables

• Kaufman Speech Praxis Treatment Kits

• Word Flips™

• Picture Express

• Becoming Verbal and Intelligible

• Boardmaker™

• Google™ Images

10. ENHANCING MOTIVATION

MOTIVATION DEVELOPS WHEN CHILDREN:

• Know they are successful

o Use clear and concrete reinforcement

o Use powerful and pragmatic vocabulary

o When choosing targets, taking into account

Phoneme repertoire

Syllable shapes

Planes of movement

o Utilize progressive approximations when necessary

• Understand the power of language

• Understand how the motor system will affect their ability to communicate

• Are having fun


11. STRESS AND INTONATION Children with CAS frequently demonstrate inappropriate stress patterns ‐ excessive equal stress is common

• Teach exclamations using over exaggeration

• Count and stop

• Emphasize key words expressing high levels of emotional content

• Questions vs. declaratives

• Statement‐Question‐Response

• Changing meaning of sentence based on which word is stressed

• Syllable stress

12. CONSIDERATIONS FOR ORAL MOTOR ACTIVITIES IN CAS

1. Time

2. Purpose

3. Research

13. RELATIVE CONTRIBUTIONS 1. Language – comprehension, narrative language, grammar, vocabulary, pragmatics, MLU

2. Social – reciprocity, Interaction, emotional regulation, play

3. Dysarthria – speaking rate, muscle weakness, articulatory precision

4. Phonology – phonological processes


14. LITERACY CONSIDERATIONS Within the context of treatment, help children to:

Recognize that words begin or end with the same sounds

Segment words into individual sounds

Blend individual syllables or sounds

Recognize rhyme patterns

Do this by:

Using written letters as sound cues

Writing target words on practice cards

Highlighting specific sounds, syllables, words

o Make the sound/syllable/word larger

o Use different color

o Underline

Focus attention to the # of sounds/syllables/words

Sort target words by

o Beginning sounds

o Ending sounds

o Number of syllables

o Ending syllables

o Vowels


TREATMENT CONSIDERATIONS FOR CHILDREN WITH

LITTLE OR NO LANGUAGE

Cast a wide net

Reinforce vocalizations

Give meaning to vocalizations

Get imitation going

Choose toys that reinforce early sound effects and simple exclamations

Imitate Child’s movements/sounds

Emphasize key words

Use small vocabulary set

Choose activities with vocabulary containing

Model slow, exaggerated articulation

Use amplification tools

Use motion

Use music

Use repetitive books and counting books

Describe what child is doing with the speech motor system from the start

Use consistent terminology


Simple books to establish use of sound effects, single words and twoword phrases

•Moo, Baa, La La La – Sandra Boynton

•Blue Hat Green Hat – Sandra Boynton

•Spot Books – Eric Hill

•Old Macdonald Had a Farm – various authors

•Who Says That – Arnold L. Shapiro

•Brown Bear Brown Bear What Do You See – Bill Martin

•Open The Barn Door – Christopher Santoro

•Baby Bop’s Toys – Kimberly Kearns and Marie O’Brien

•Mommy and Me – Neil Ricklen

•Kiss the Boo‐Boo – Sue Tarsky

•Five Little Ducks – Raffi

•Here Are My Hands ‐ Bill Martin Jr. and John Archambault

•Five Little Monkeys Jumping on the Bed – Eileen Christelow

•Five Little Monkeys Sitting in a Tree – Eileen Christelow

•Freight Train – Donald Crews

•Are You My Mother? – P.D. Eastman

•Who’s Hat – Margaret Miller

•Who’s Shoe – Margaret Miller

•Mary Wore Her Red Dress and Henry Wore His Green Sneakers – Merle Peek

•City Sounds – Craig Brown

•Animal Sounds – Aureleuo Battaglia


Books to promote increased sentence length, morphological markers, and specific phonemes

•The Three Bears – Byron Barton

•The Little Red Hen – various authors

•The Three Little Pigs – various authors

•Mr. Gumpy’s Motor Car – John Burningham

•Mr. Gumpy’s Outing – John Burningham

•Andrew’s Bath – David McPhail

•The Very Hungry Caterpillar – Eric Carle

•The Very Busy Spider – Eric Carle

•The Mitten – Jan Brett

•Owl Babies – Martin Waddell

•Dear Zoo – Rod Campbell

•The Three Little Pigs – James Marshall (and other authors)

•It Looked Like Spilt Milk – Charles Shaw

•Who’s Toes Are Those – Joyce Elias and Cathy Strum

•King Bidgood’s in the Bathtub – Audrey Wood

•A Pile of Pigs – Judith Zoss Enderle and Stephanie Gordan Tessler

•Guess Where You’re Going, Guess What You’ll Do? – A.F. Bauman

•I Wish I Could Fly – Ron Maris

•Here Comes a Bus – Harriet Ziefert

•I Went Walking – Sue Williams

•A Giraffe and a Half – Shel Silverstein

•Four Fur Feet – Margaret Wise Brown

•“Slowly, Slowly, Slowly,” said the Sloth – Eric Carle

•When Sheep Sleep – Laura Numeroff

•Here Comes a Bus – Harriet Ziefert

•A Pile of Pigs – Judith Zoss Enderle and Stephanie Gordan Tessler


Songs to promote speech for children with Apraxia

•Apples and Bananas – vowel variety

•Baby Bumblebee – animal sounds, simple word production

•Down by the Bay – rhyming, simple word production, vowel variety

•Five Little Ducks – counting, simple word production through sentence completion

•Five Little Monkeys Jumping on the Bed – counting, simple word production through sentence completion

•Head, Shoulders, Knees and Toes – simple word production, vowel variety

•I Caught a Fish Alive – counting, simple word production through sentence completion

•If You’re Happy and You Know It – vocal and non‐vocal imitation

•John Jacob Jingleheimer Schmidt – complex word production

London Bridge is Falling Down j‐ simple word production through sentence completion

•Old Macdonald had a Farm – animal sounds and vowel variety

•One, Two, Buckle My Shoe – simple word production, counting

•Pat‐a‐Cake – simple word production (esp. bilabials)

•Pop goes the Weasel – simple word production, non‐vocal imitation

•Ring Around the Rosy – simple word production

•Row, Row, Row, Your Boat – simple word production, early developing vowels /o, i/

•The Alphabet Song – vowel variety, production of CV and VC combinations

•The Wheels on the Bus – simple word production

•The Itsy Bitsy Spider – simple word production through sentence completion

•This is the Way We . . . – vocal and non‐vocal imitation, simple word production

•Twinkle, Twinkle Little Star – simple word production

• Wibbely Wobbely Woo – complex word production


CHILDHOOD APRAXIA BIBLIOGRAPHY

Professional Books, Articles, Videos and Websites: American Speech‐Language‐Hearing Association. (2007). Childhood Apraxia of Speech [Technical Report]. Available from www.asha.org/policy Apraxia Kids Retrieved September 8 , 2007, World Wide Web: http://www.apraxia‐kids.org Caruso, A. and Strand, E. Clinical Management of Motor Speech Disorders in Children. New York, NY: Thieme, (1999) Dynamic Remediation Strategies for Children with DVA, Video and Handbook. Rockville, Maryland: ASHA (1998) Gildersleeve‐Neumann, C. Treatment for Childhood Apraxia of Speech: A Description of Integral Stimulation and Motor Learning, The ASHA Leader, November 6, 2007 Hall, P., A Letter to the Parent(s) of a Child with Developmental Apraxia of Speech, Language Speech, and Hearing Services in the Schools, Vol. 31, 169‐172, (April 2000) Kilmas, N., Differential Diagnosis of Articulatory Impairment. Advance for SpeechLanguage Pathologists and Audiologists, Vol. 11, (June, 2001) Lewis, B and Ekelman, B., Literacy Problems Associated with Childhood Apraxia of Speech. Perspectives on Language, Learning and Education, Vol. 14, 10‐17 (October, 2007) Magill, R. A., Motor Learning and Control: Concepts and Applications, Seventh Edition. New York, NY: McGraw‐Hill (2004) Marshalla, P., Becoming Verbal with Developmental Apraxia. Kirkland, WA, Marshalla Speech and Language (2001) McCauley, R. and Strand, E., A Review of Standardized Tests of Nonverbal Oral and Speech Motor Performance in Children. American Journal of SpeechLanguage Pathology, Vol. 17, 81‐91 (February 2008) Phonetics: The Sounds of English and Spanish – The University of Iowa Retrieved September 8 , 2007, World Wide Web: http://www.uiowa.edu/~acadtech/phonetics/about.html Robin, D., Developmental Apraxia of Speech: Just Another Motor Problem. American Journal of Speech Language Pathology, Vol. 1 (May, 1992) Schmidt, R.A. and Wrisberg, C.A., Motor Learning and Performance: A ProblemBased Learning Approach, Third Edition. Champaign, IL: Human Kinetics (2004) Shriberg, L., Aram, D., and Kwiatkowski, J., Developmental Apraxia of Speech: I. Descriptive and Theoretical Perspectives. Journal of Speech, Language, and Hearing Research, Vol. 40, (April, 1997) Shriberg, L., Aram, D., and Kwiatkowski, j., Developmental Apraxia of Speech: II. Toward a Diagnostic Marker. Journal of Speech, Language, and Hearing Research, Vol. 40 (April, 1997) Shriberg, L., Aram, D., and Kwiatkowski, J., Developmental Apraxia of Speech: III. A Subtype Marked by Inappropriate Stress. Journal of Speech, Language, and Hearing Research, Vol. 40 (April, 1997) Strand, E. and McCauley, R., Differential Diagnosis of Severe Speech Impairment in Young Children. The ASHA Leader, Vol 13(10), 10‐13 (2008)


Strand, E., Treatment of Motor Speech Disorders in Children. Seminars in Speech and Language, Vol. 16 (1995) Strand, E., Principles of Speech Motor Learning. Workshop presented at 2007 National Conference on Childhood Apraxia of Speech, Anaheim, CA, July 12‐14, 2007 The Prompt Institute Retrieved September 8, 2007, World Wide Web: http://promptinstitute.com Velleman, S., Childhood Apraxia of Speech: Resource Guide. Clifton Park, NY: Delmar Learning (2003) Tests, Workbooks and Other Therapy Materials Barty, N., and Bellamy D. Picture Express, Comox, BC, Canada: Picture Express Software (1998) Dauer, K., Irwin, S. and Schippits, S., Becoming Verbal and Intelligible: A Functional Motor Programming Approach for Children with Developmental Verbal Apraxia, Austin, TX: Pro‐Ed, (1996) Drake, M. Just for Kids ‐ Apraxia, East Moline, IL: LinguiSystems, Inc. (1999) Frimmer, B. Totally Terrific Arctic Tongue Twisters, Greenville, SC: Super Duper Publications Granger, R., Word Flips TM for Learning Intelligible Production of Speech, Greenville, SC: Super Duper Publications (2005) Hayden, D. and Square, P., Verbal Motor Production Assessment for Children, The Psychological Corporation, (1999) Kaufman, N. Kaufman Speech Praxis Test for Children, West Bloomfield, Michigan: Northern Speech Services, (1996) Kaufman, N. Kaufman Speech Praxis Treatment Kit for Children ‐ Basic Level and Kaufman Speech Praxis Treatment Kit for Children ‐ Advanced Level. West Bloomfield, MI: Northern Speech Services, (1998) Kaufman, N, The Kaufman Speech Praxis Workout Book. West Bloomfield, MI: Northern Speech Services, (2005) Kilpatrick, J., Stohr, P., and Kimbrough, D. Moving Across Syllables: Training Articulatory Sound Sequences San Antonio, TX: Communication Skill Builders, A division of Psychological Corp., (1990)

O’Bryan, B., Sound Reps Workout: A Total Fitness Program for Articulation Strengthening. Youngtown, AZ: ECL Publications (1996) Strode, R. and Chamberlain, C., The Source for childhood Apraxia of Speech. East Moline, IL: LinguiSystems, Inc., (2006) Strode, R. and Chamberlain, C. Easy Does It for Apraxia and Motor Planning, East Moline, IL: LinguiSystems, Inc., (1993) Strode, R. and Chamberlain, C. Easy Does It for Apraxia ‐ Preschool, East Moline, IL: LinguiSystems, Inc., (1994) Webber, M and Webber S., 168 Seasonal & Holiday Open‐Ended Artic Worksheets. Greenville, SC: Super Duper Publications (1998)

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