Model Program: Childhood Apraxia of Speech

1. Model Program: Childhood Apraxia of Speech Laura J. Ball, Ph.D.1, Dyann Rupp, M.S.2, Wendy Quach, MSLP3 2Rite Care Clinic, Lincoln, NE 1,2 Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center, Omaha, NE 3 University of Nebraska, Lincoln Nebraska Speech-Language-Hearing Association Annual Convention 30 September 2004 Handout available at: http://aac.unl.edu

2. CAS Defined Typically defined in terms of sound production error patterns, but actually a disorder of movement. Difficulty is noted with purposeful voluntary movements for speech, creating an inability to sequence speech movements in the absence of paralysis. (Caruso & Strand, 1998)

3. Demographics • Onset • Impaired from birth • Course • Often long course of tx • Gender • 3 male: 1 female • Prevalence • Unknown (1:1000) • Aggregation • FoxP2 gene autosomal dominant (KE family) • Some familial transmission

4. CAS & Impact on Overall Communication Decreased intelligibility Disordered language Social withdrawal Behavioral aggression Academic failure

5. CAS Clinical Indicators • Reduced phonemic repertoire (esp. consonants, simple word & syllable shapes • Prosodic abnormalities (timing) • Vowel errors not affected by length of utterance • Variability, sequencing difficulties • Difficulty achieving & maintaining articulatory configurations (artic overshoot) • Use simple syllable shapes • Difficulty completing a movement gesture for a phoneme easily produced in a simple context but not in a longer context (underspecified motor plan)

6. Differential Diagnosis CAS vs. Speech Delay • Differs from errors of children with developmental delay in that does not follow developmental sequences (later sounds come in earlier, etc.) CAS vs. Phonological Processes • Differs from errors of children with phonological processes in contrast between voluntary & involuntary performance, error variability CAS vs. Dysarthria • Differs from dysarthria, which has errors in phonation, resonance, articulation & prosody related to weakness, paralysis

7. Examine the results of the following tests from a 5-year-old child and identify: • Phonological processes • Articulatory developmental errors

9. GFTA KLPA

10. GFTA KLPA

11. GFTA comparison1st 2nd

12. Movement For CAS, re-conceptualize the way you think about articulation and phonology • Move away from thinking about sounds • Don’t think about processes • Movements are the focus

13. Motor Learning Theory Motor learning occurs as a result of experience & practice • Pre-practice skills • Conditions of Practice

14. PRE-PRACTICE Not considered prerequisites, but rather beginning skills to address prior to work with actual movements.

15. Pre-practice to Establish Motor Learning Pre-practice portion of a therapy session involves • Focused attention • Motivation • General idea of task • Observational learning

16. Focused Attention “ability to focus cognitive, perceptual, sensory & activity toward the skill he/she is attempting to learn” • need intent to learn • limit extraneous stimuli • stimuli that limit cognitive, linguistic, phonetic load will enhance child’s ability to focus attention • child must look at & listen to clinician • novelty: change position, vary volume, etc

17. Motivation • consider desire to talk vs. years of failure talking • make the tasks important, useful • set goals with the child • set a reasonable standard to achieve • provide early success • reduce frustration

18. General Idea of Task • understand task clearly • ways they will learn • keep instructions simple; focuson 1-2 important aspects of movement. • DO NOT OVERINSTRUCT

19. Observational Learning • modeling & demonstration with pictures, videotapes, and live demos • show the child the movements a few times covering all stimuli being targeted in the session • be wary of verbal instructions

20. PRACTICE

21. Conditions of Practice • Reference for correct • Repetitive practice mass vs. distributed random vs. blocked • Knowledge of performance • Knowledge of results immediate vs. summary • Rate & prosody • Stimulus/response complexity

22. Establish Reference of Correctness • that child understands • use auditory feedback • i.e., for /pa/, may accept lip closure as correct to begin, later move to correct articulatory production

23. Repetitive Practice • Intensive treatment (best if 5 days/week) • Large # of movement repetitions (no less than 40), enough trials/session to allow motor learning to become automatic • use reinforcements that don’t take time • Activities should facilitate repeated opportunities for production of target movement patterns

24. Mass vs. Distributed Practice • Mass = less frequent, longer sessions • Distributed = frequent, short sessions • decision depends on severity and type • mass yields quick development of accurate production • distributed requires longer time, but get better generalization

25. Random vs. Blocked Practice • Randomized order of presentation of stimuli • Blocked is practicing the same thing over & over

26. Knowledge of Performance Feedback about the correctness of a particular movement pattern regarding accuracy of production. • I heard you say …. • I saw you…placement cues

27. Knowledge of Results Feedback about the outcome of a movement pattern regarding the environmental goal. • “Yes, you got it!” • “Close, but that’s not quite it.”

28. Using KR…new rules! To optimize motor learning, avoid extraneous activity (speaking, clinician/child movements) during the period between the response & when you deliver KR, also immediately after KR

29. Summary vs. Immediate KR Summary KR will optimize motor learning more than immediate. It’s better to wait & allow the child to process results on several responses Want to maintain motivation, so distribute feedback accordingly… if task is easy, wait for ~15; if difficult wait for ~3-5

30. Rate & Prosody Considerations • Come to neutral position btwn attempts (rest), do NOT divide into components • Breaking up words will cause the child to learn that motor pattern and not the coarticulated one • Move through hierarchy of task difficulty • Treat rhythm, stress & intonation with/as a component of articulation drills

31. Hierarchy of Response/Cued Support • simultaneous production with examiner • direct imitation • delayed imitation (gradually increase delay time) • spontaneous

32. Assessment

33. Assess at Level of Breakdown • Vowels, CV/VC combos, CVC combos NOT heard in spontaneous speech • Words with same 1st & last phoneme, then different 1st & last phoneme • Words of Increasing Length • Multisyllabic Words • Sentences of Increasing Length

34. Clinical Diagnostic Protocol • Articulation (GFTA2) • Phonology (KLPA2) • Speech Praxis (KSPT) • Speech sample: story retell task w/ picture sequence (GFTA) • Receptive Language (TACL) • Intelligibility (IASCC, TOCS+) • Receptive Vocabulary (PPVT)

35. Clinical Diagnostic Strategy • Annual testing • GFTA-2 (administer 2x) (Goldman & Fristoe, 2000) • Determine which sounds can make well • Choose dominant sounds (most often correct) • Often hear LOT of certain sounds, know which to start with (e.g., “wow! He has a lot of b’s & d’s) • KLPA-2 (Khan & Lewis, 2002) • Look at processes, are there atypical processes? • Consistency of use?

36. Kaufman Speech Praxis Test for Children(Kaufman, 1995) Get additional information Look for breakdown patterns, where breakdown begins (# syllable sequences they produce successfully) Speech Sample (GFTA Sounds in Sentences) Determine intended utterance, then transcribe sample # consonants correct/# consonant targets * 100 = PCC Index of Augmented Speech Comprehensibility in Children (Dowden, 1997) % intelligible words, without context Unfamiliar listeners Test of Children’s Speech + (Hodge) % intelligible: word and sentence level Unfamiliar listeners judge from open or closed set

37. Index of Augmented Speech Comprehensibility in Children (Dowden 1997) • Non-standardized clinical measure • Assess intelligibility & comprehensibility • Hierarchy of cueing for child: • Picture + verbal cue “What is this?” • Picture + contextual cue “It’s clothing you might wear. What is it?” • Picture + embedded model “It’s a shirt. Now you say it.” • Hierarchy of cueing for transcriptionist: • After listening to & judging the entire set of utterances without contextual cues, the listeners rewind the tape, read a contextual cue and write what they hear while listening to the tape.

38. Intervention

39. Intervention Strategy • Work on vowels when working on whole word transitions (e.g., C  V, V  C, C  V  C), don’t address vowels or consonants alone • Work on consonants when working on whole word or phrase transitions (e.g., no isolated consonants) • Kids can always say something, they may only have 1-2 sound combos that they use as words, but can start there • Take what they say in conversation that makes sense & examine the GFTA correct productions to determine correct transitions in the child’s speech

40. Session One Setting Up CAS Intervention

41. VariabilityPlan Session 1

42. Play & Success Set up play situation (find out likes; ~5 different activities, books, toys, basket of activities: they choose) allow child to be in charge, set up situation where they don’t think they are working, but rather just interjecting speech into play

43. Move into new movements • Take the correct transitions in their repertoire & ask them to directly imitate words they can say • Get successes 1st! (e.g., mom, ma, mama) • Get several delayed imitative productions of the same sound sequence (e.g., “can you say 5 of them?”) • When introduce new, start where need to with either simultaneous  direct imitation  delayed imitation

44. Reinforce Lots of Utterances • Attempt to get as many productions of each movement as possible during the session (min 40-50) • Ignore error productions • Make a big deal out of successful productions • Make the session fun & successful to the child so that they are excited to return for the next session • Give parents feedback, no homework after 1st session

45. Session Two Review & Add

46. Base List • SLP learns what child is able to say & getting imitations of these • Prior to the 2nd session, SLP creates cards with Boardmaker pictures for items on the base list • Base list is of sound combinations/ words the child can produce (observed during 1st session) • Continue with play activities from 1st session while introducing the base list combinations (e.g., uh-oh, mama, baby, oh-no, boo, baa, moo, me, my, bye)

47. Direct Imitation • Have the child attempt productions following direct imitation on all of the base list items to evaluate continued success • If child is unable to successfully produce one item, that card is pulled from the list for that session • Begin to combine the words/sequences that the child can say and attempt to get direct imitations of the combinations

48. Break Down & NewNext, 1 of the following occurs… • Produce new word not on base list. • Breaks down and has “had enough” for that session. • SLP probes for new words during play/activities

49. Produce new word (not on base list) • immediately reinforce verbally • word is added to the base list • introduce into later activities/sessions

50. Breaks down and has “had enough” for that session • session continues with play activities to re-establish comfort • reintroduce base list 3-4 min later (before session end) • end session on successful productions, ensure child is happy & feels good when leaving