Childhood Apraxia of Speech

Sherry Sancibrian

Texas Tech University

Health Sciences Center

CAS

Definition

• disorder in carrying out or learning

complex movements that cannot be

accounted for by disturbances of

strength, coordination, sensation,

comprehension, or attention (Strub &

Black, 1981)

• inability to carry out volitional

production of speech sounds and

sequences (Rosenbeck)

Childhood Apraxia of Speech:

Technical Report, ASHA 2007

Neurological childhood 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)

Core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody

Incidence and Prevalence

Shriberg et al, 1997

• 3-5% of the clinical population may

have CAS

Bauman-Waengler

• 1-2 per 1,000

Assessment Strategies

Etiology??

genetic? allele 31 on chrom. #7

• High rate (~86%) of family history of speech, language, reading problems; 59% have affected parent

• Suggests genetic basis in at least some cases (Lewis et al., LSHSS 2004)

SLI affecting sound-syllable-prosody?

CAS as a Secondary Diagnosis

~13% of childen with

autism spectrum

disorder may show

symptoms of CAS (Marili,

Andrianopoulos, Velleman &

Foreman, 2004)

Children with Down

Syndrome may also

have symptoms of CAS (Kumin & Adams, 2000)

Assessment Protocol

Case history

Language testing

Oral mech exam

Single word articulation test

Spontaneous speech/language

sample

Consider intelligibility vs

comprehensibility

Case history may include:

male (4:1)

late milestones

little babbling

average or above IQ (not always)

low muscle tone

drooling, feeding problems

Ball et al JMedSLP, 2002

History Limited jargon (varied C & V patterns)

Heavy reliance on gestures

Family member often acts as interpreter

Sound effects & idiosyncratic words

Significant expressive-receptive gap

Unusually slow progress if in therapy

Tends to produce a word, then “lose” it

Ball et al JMedSLP, 2002

Secondary case hx features

sleeping difficulties

irritable, difficult to comfort

auditory sensitivity

delayed toilet training

general clumsiness

difficulty crossing midline

highly emotional, easily distressed

Oral Mech Exam

Compare single movements (kiss, smile)

to sequences of movements (kiss, then

smile, then blow)

• Look for effort, groping, mis-sequencing,

irregular rhythm, overshooting, undershooting

Compare spontaneous actions to

imitation

• Look for more difficulty in imitating

Velleman, 2003

Assessment

Apraxia Profile [Hickman, 1997];

Screening Test of Developmental Apraxia

of Speech-2 [Blakely, 2001]; Verbal Motor

Production Assessment for Children

[Hayden & Square, 1999]; Kaufman

Speech Praxis Test for Children, 1995

GFTA, other artic tests--elicit words

several times to assess consistency

• compare phonetic/phonemic inventories

Imitative Utterances

• Vowels in isolation

• CV and VC (vary vowels)

• CVC

– First and last phoneme the same (mom,

cake)

– First and last phoneme different (hit, cup)

• Words of increasing length

– Come, compute, computer

• Multisyllabic words Velleman, 2003

Percentage Consonants Correct (PCC)

Analysis of spontaneous speech

sample

• Exclude unintelligible/questionable

utterances

• Consider only target Cs, not Vs

• Don’t count more than 2 instances of any

word

• Don’t score Cs in a repetition of a syllable

(e.g., ba-balloon; score only the first /b/)

• Errors include deletions, substitutions,

distortions, additions, voicing changes

Shriberg et al, 1995

PCC

• Divide # correct consonants by total

# consonants intended X 100%

• Scores: 85-100% = mild

65-85% = mild-moderate

50-65% = moderate-severe

<50% = severe

• Use to determine severity, measure

progress

Percent Word Shape Match

Refers to the percent match in syllable shape of a child’s productions versus targets in a sample

Example: Target is CVC and child production is a CVC = a match in syllable shape (regardless of accuracy of phonemes) (Tyler, Seminars in Speech & Language, 2002)

PCC and PWM

Target Production PCC PWM

leaf wip 0/2 CVC > CVC (+)

bus bUs 2/2 CVC > CVC (+)

seal sio 1/2 CVC > CVV (-)

fish sI 0/2 CVC > CV (-)

clown kaUn 2/3 CCVC > CVC (-)

5/11= 45% 2/5 = 40%

Joshua Case Analysis

Comb = hom

Cold = tot

Big = bIt Sheep = ti

School = tu

Wet = bEp

Ball = ba

Soup = tu

Joshua Case Analysis

Percent Word Shape Match

Target Production PCC PWM

comb hom 1/2 CVC > CVC (+)

cold tot 0/3 CVCC > CVC (-)

big bIt 1/2 CVC > CVC (+)

sheep ti 0/2 CVC > CV (-)

school tu 0/3 CCVC > CV (-)

wet bEp 0/2 CVC>CVC (+)

ball ba 1/2 CVC>CV (-)

soup tu 0/2 CVC>CV (-)

3/18 = 16.6% 3/8 = 37.5%

Joshua Case Analysis-

Phonological Processes

Comb = hom

Cold = tot

Big = bIt Sheep = ti

School = tu

Wet = bEp

Ball = ba

Soup = tu

Joshua’s Phonetic Inventory

bilabial

labio-

dental

inter-

dental

alveolar palatal velar glottal

stop b, p t

nasal m n

glide

fricative h

liquid

affricate

Joshua’s Inventory

Prevocalic Postvocalic

Stops b, t t, p

Nasals m

Glides

Fricatives h

Liquids

Affricates

Assessment Findings

Phonotactic Repertoire Look for:

• Relatively poor repertoire of syllable

and word shapes (e.g., using only CVCV

after 18 months)

• Developmentally unexpected repertoire

(e.g., using primarily VC syllable shape)

• Reduced flexibility (e.g., velars only

occur with back Vs)

• Frequent omissions

• Metathesis in simple words (/pam/ for

/map/)

May be discriminative:

Difficulty moving from one

articulatory configuration to another

Vowel/diphthong errors

Groping behavior and silent

posturing

Strand, 2012; Davis et al 1998; http://www.apraxia-kids.org

Typical Errors in CAS

Deficient motor planning re: timing

• Voicing errors

• Affrication/deaffrication

• Epenthesis

awareness of articulator position

• Undershooting—frication of stops, centralization of vowels

• Overshooting—vowel deviations to extreme edges of vowel quadrilateral

Processes Related to CAS

Whole word patterns

• Reduplication

• Initial consonant deletion

• Weak syllable deletion

• Metathesis

• Epenthesis

• Assimilation

• Augmentation of weak syllables

• Idiosyncratic cluster reduction (retain

later developing sound)

Suprasegmental Patterns

Inappropriate loudness or

monoloudness

Words and syllables mis-stressed or

monostressed (may omit stressed

syllable, or overstress the weak

syllable)

Inappropriate pitch or monopitch

Inappropriate or inconsistent

hypernasality and hyponasality

Language Characteristics

Receptive language typically better

than expressive and WNL

Low MLU due to:

• omission of function words

• use of gesture in place of words

Poor discourse strategies (eye

contact, initiation/response,

turntaking)

Language Characteristics

Word-sequencing errors:

• free morphemes out of order (“ball throw no”)

• misplaced bound morphemes (“Rock don’t floats.”)

Semantic substitutions (lobster for crab)

Phonemic substitutions (banister for canister)

Ball et al, 2002

Other language problems • Literacy issues

– impaired rhyming

abilities

– difficulty learning to

read

– errors in morphological

markers

• problems with

organizing multi-

scheme play episodes

Davis & Velleman, 2000, Lewis et al, 2004

Persistent problems in older

children

Speech • Stress, vowels, voicing, multisyllabic words,

sequencing (Velleman & Shriberg, 1998 , Lewis et al. 2004)

Language • Persistent receptive and expressive language

difficulties (Lewis et al., 2004)

Literacy • Word attack, word identification, and spelling

(Lewis et al., 2004)

Is it CAS or “Plain Old”

Speech Sound Disorder?

CAS • Motor symptoms

• Vowel errors

• Unusual prosody

• Sequencing errors

• Inconsistency

• Phonotactics worse than phonetics

SSD • No motor symptom

• Vowels WNL

• Prosody WNL

• Few sequence errors

• Consistent errors

• Phonotactics = or > phonetics

Is it CAS or Dysarthria?

CAS

• No muscle weakness

• Errors increase significantly with increased

complexity

• Errors may increase articulation difficulty

(e.g., using affricate instead of stop)

• Accompanying problems in morphology,

syntax, and phonological awareness

Diagnosis

SLPs make the diagnosis of CAS

Possible wording when all three core

features are not present:

• CAS cannot be ruled out

• signs are consistent with CAS

• suspected to have CAS

ASHA Technical Report, 2007

Intervention

Think in terms of movement

sequences instead of

phonemes.

Typical Goals for CAS

produce complete syllables (CV, VC)

produce closed syllables (CVC)

produce bisyllabics (CVCV)

reduce reduplication, assimilation

use varied stress patterns

use varied movement patterns

produce consonant clusters

produce more difficult phonemes Velleman, 2003

Treatment Principles use developmental norms for

choosing phonemes

use multimodal inputs

utilize facilitating contexts

use intensive, systematic drill

focus on movement sequences and

prosody

syllabic integrity matters more than

individual speech sounds Davis, 2003

Treatment Principles

use carrier phrases

use decreased rate

frequent, short sessions

because of fatigue

simultaneous production

not sound-by-sound treatment

not sounds in isolation

don’t segment models ( /b-o-t/)

http://www.apraxia-kids.org

Treatment Principles

Use distributed practice, in which

speech-motor practice is carried

out across a variety of activities,

settings, and situations, and

includes several exemplars per

pattern

Use a horizontal or cyclical goal

attack strategy

Treatment Principles

Repetitive Learning Experiences

• For severe problem, with few or no

intelligible utterances, limit training set

to 5-7 utterances.

• For moderate problem, start at set size

of 8-10 utterances.

• Challenge the system gradually and

systematically by introducing new

syllables and words.

Velleman, 2003

Treatment Principles Knowledge of results: provide

frequent information about results

• Was the production right or wrong?

Knowledge of performance: provide feedback about the production

• Need quick, unambiguous feedback for incorrect responses

• What should the child do to improve? (e.g., “open bigger”, “tighten up your tongue”)

Creaghead, 2004

Response levels (e.g., words,

sentences, narrative)

Rate

Stress, intonation, and emotion

Number of repetitions

Body position or activity

• Chanting, singing

Ruscello, 2008; Bowen, 2009

Changes That Facilitate Generalization Changes that Affect Generalization

Treatment Programs PROMPT--prompts for restructuring

oral muscular phonetic

targets=tactile-based, externally

applied cues to articulators; SLP

cues each target (Hayden & Square, 1994)

touch-cue method--adaptation of

cued speech; auditory, visual, tactile

cue for each consonant

Bashir, A., Graham-Jones, F., & Bostwick, R. (1984).

Treatment Programs

Melodic Intonation Therapy--

stereotypical intonation, exaggerated

stress, lengthened tempo, hand

tapping; adapted for children 7+

using Signed English instead of

tapping

Rate control therapy—slower rate

can improve accuracy, to a point

Treatment Programs: Integral

Stimulation

1. SLP says the utterance while child watches the clinician’s face - child repeats • a) if the child can’t repeat, move to

simultaneous production, w/ tactile or gestural cues if needed

• b) slowly fade simultaneous production first to whisper, then simultaneous mime only

Strand, E.A., & Debertine, P. (2000). The efficacy of integral stimulation intervention with developmental apraxia of speech. Journal of Medical Speech-Language Pathology, 8, 295-300.

Integral Stimulation 2. Move to immediate repetition

• SLP mouthes the word if necessary at first

3. Addition of delay • insert a delay (one to three seconds) before

imitative response

• after the child is successful at repeating the utterance after a 2 or 3 second delay, have the child repeat the target several times without intervening stimuli

4. Work to elicit the utterance spontaneously

Dynamic Temporal and

Tactile Cueing (DTTC)

Incorporates integral stimulation

Provide progressively less cueing

with more time delay

Add tactile cues as needed

Treatment by Age Group

CAS Treatment for 0-3

Evidence based strategies include:

1. Provide access to AAC

2. Minimize pressure to speak

3. Imitate the child

4. Use slower rate

5. Augment auditory, visual,

tactile, and proprioceptive feedback

6. Avoid use of nonspeech tasks

DeThorne, L., Johnson, C., Walder, L., & Mahurin-Smith, J. (2009). When “Simon Says” doesn’t work:

Alternatives to imitation for facilitating early speech development. American Journal of Speech-Language Pathology, 18, 133-145.

CAS Treatment for 0-3

Rhythm— “frame” for syllable production

• Drums, clapping, marching

• Avoid excess equal stress!

Pitch

• Songs, fingerplays, animal sound keyboard

• Books with “daddy” voices, “baby” voices

Intensity and duration

• BINGO, Wheels on the Bus

• Gross motor games (“Bear Hunt”)

Velleman, 2003

CAS Treatment for 0-3 Build core vocabulary--up, water, open,

bye, me, eat

Target utterances with strong social value

to child: names of pets, siblings; “no”,

“more”, “mad”, “mine.”

Be sure to teach some verbs! Then

combine with pronoun: I eat, they sit, we

pop/hop/nap/fall/run/pat

If at single phoneme level, use /u/, /o/, /m/.

Don’t bother with ideas child already

expresses nonverbally (e.g, head shake

for yes/no). Velleman & Strand, 1994

CAS Treatment for 0-3

Teach new words in social/linguistic

contexts:

• Verbal routines: songs, rhymes, social

routines (e.g., “good morning”), prayers

• In cloze (e.g. E-I-E-I- __; Duck, duck, __ )

• With motor movements (e.g., Head &

Shoulders, Knees & Toes)

• In utterance frames (e.g., more ___, my

___, no ___, wanna ___ )

Velleman & Strand, 1994

CAS Treatment for 0-3

Enlist as many significant others as

possible to model the same

utterances and accept the child’s

closest approximations.

Do NOT use telegraphic models!

Children need to hear function

words, even if not ready to produce

them.

CAS Treatment for 0-3

4-10 repetitions of syllables in response to picture or letter cues • Lining up animals— “moo, moo, moo”

• Sorting laundry– “sock, sock, sock”

• Reading a counting book– “ball, ball, ball”

Use Cs and Vs in repertoire; begin with repetition of 1 syllable (ba), move to alternating sequences (ba-bu-bi)

CAS Treatment for 4-7

• warm-up

– tactile stimulation & movement

– imitation of body/oral movement

– vary pitch, loudness, rhythm

• syllable/word/phrase sequences

– using phonemes in repertoire

– begin with CV, move to CVCV, then CVC

• repeating same syllable

• alternating vowels

• vary C by place and manner

– use backward chaining (o, ano, piano)

Backward Chaining for

Intervocalic /k/ Elicit “king”

Practice saying, “bay,” “may,” “way” briefly

Practice saying, “KING-bay,” “KING-may,” “KING-way”

Switch the syllable order, “bay-KING,” “may-KING,” “way-KING,” keeping the stress on KING

Shift the stress to get baking, making, waking, with the emphasis on the first syllable

Bowen, 2009 http://speech-language-

therapy.com/tx-facts-and-tricks.htm

CAS Treatment for 4-7 Use language-based approach, combining

early morphology and phonology goals in this order: • Early free morphemes (in, on)

• -ing

• Irregular forms (mouse-mice, think-thought)

• Syllabic forms (horses, patted, pushes)

• Non-syllabic forms where root word ends in V (shoes, Joe’s, goes, tried)

• Non-syllabic forms where root word ends in C (ducks, walks, bowled)

Example targets addressing both

phonology and morphosyntax

Therapy goal = CR

• Plurality – boat-boats, cup-cups

• Reg. Past – walk-walked, kiss-kissed

Therapy goal = FCD

• Plurality – toe-toes, key-keys

• Possessive – Ray-Ray’s mama-mama’s

• Reg. Past – show-showed

• 3rd pers. Singular – I go-he goes

Tyler, 2002

CAS Treatment for 4-7

Include phonological awareness and

pre-literacy skills

• Rhyming

• Segmentation and blending

• Visual recognition of similarities and

differences among words

• Recognition of letters and common

sight words

Stress Patterns

• Identify # of syllables in word by clapping, tapping, moving blocks

• Identify stressed (“loud”) syllable, represented by larger block ( ba-NAN-a)

• Stress the appropriate word in response to a question

– The mouse ate the cheese.

– The mouse ate the cheese.

– The mouse ate the cheese.

Velleman, 2003

CAS Treatment for 7+

• Use appropriate pitch

– Rising at ends of yes/no questions

– Falling for wh-questions and statements

– Rising for all but last item in a list

• Use appropriate juncture

– Use pauses at edges of noun phrases, verb

phrases, clauses

• Let’s help Jane.

• Let’s help + Jane.

Velleman, 2003

CAS Treatment for 7+

• shift focus to language problems

– text cohesion

– language for learning

• develop self-advocacy and

communication repair skills

• address multisyllabic words, clusters,

difficult phonemes

http://www.apraxia-kids.org

Internet Resources

http://www.mnsu.edu/comdis/kuster2

/sptherapy.html

http://speech-language-

therapy.com/sitemap.htm

http://slpath.com

http://www.apraxia-kids.org