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Childhood Apraxia of Speech: Evaluation and Therapy Challenges. Brisbane, Australia June 15, 2007 David W. Hammer, M.A. CCC-SLP Children’s Hospital Of Pittsburgh, PA USA. WWW.APRAXIA-KIDS.ORG “Time to Sing” CD - 2000 “Hope Speaks” DVD - 2005 “Treatment Strategies” DVD - 2006

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childhood apraxia of speech evaluation and therapy challenges

Childhood Apraxia of Speech: Evaluation and Therapy Challenges

Brisbane, Australia

June 15, 2007

David W. Hammer, M.A. CCC-SLP

Children’s Hospital Of Pittsburgh, PA USA

slide2
WWW.APRAXIA-KIDS.ORG
  • “Time to Sing” CD - 2000
  • “Hope Speaks” DVD - 2005
  • “Treatment Strategies” DVD - 2006
  • AdHoc Committee Documents - 2007
  • “Taking it Home” DVD - 2007
diagnostic challenges
DIAGNOSTIC CHALLENGES
  • Diagnosing toddlers in the 2-3 year-old range especially difficult
      • Davis-Velleman article addresses this
      • Caution diagnosing if limited sample (data)
      • Use “suspected” or “working diagnosis”
  • Don’t need neurologist to confirm
  • “Differential Diagnosis for Childhood Apraxia”
      • Video Clip -- Ross, age 3-4
differential diagnosis
Differential Diagnosis

1.Limited early sound play (cartoon)

differential diagnosis1
Limited early sound play

Sound inventory restrictions

Expressive language deficits in contrast to receptive language

Imitation superior to volitional skills

Video Clip -- Matt, age 3

Sequencing/Movement difficulties

Word/ Sentence complexity breakdowns

Video Clip -- Caleb, age 8

Video Clip -- Anna, age 3-10

Differential Diagnosis
differential diagnosis2
Prosodic deviancies

Inconsistency

Video Clip -- Jacob, age 3

Voiced/Voiceless sound errors

“Groping” behaviors

Vowel distortions

Video Clip -- Alex, age 5

12.Sound omissions

Differential Diagnosis
what does my cas assessment include
WHAT DOES MY CAS ASSESSMENT INCLUDE?
  • For young children, most is informal
  • Formal test resources available
  • Get in-depth parent information
  • Investigate other apraxic features
  • Look at nonspeech oral skills
  • Concern for misdiagnosing:

Nonverbal child

Dysarthric child

Severe phonologically disordered child

Confounding diagnosis child

adhoc committee s 3 consensus features
ADHOC COMMITTEE’S3 CONSENSUS FEATURES
  • Inconsistent errors on consonants and vowels in repeated productions of syllables or words
  • Lengthened & disrupted coarticulatory transitions between sounds & syllables
  • Innappropriate prosody, especially in relation to lexical or phrasal stress
unfortunately pure apraxia of speech is rare

Unfortunately, pure apraxia of speech is rare!!!

Video Clip - Mickey, age 6

Video Clip - Anna, age 8-1

therapy for apraxia
THERAPY FOR APRAXIA

NO SINGLE PROGRAM WORKS FOR ALL CHILDREN WITH APRAXIA!!

MUST INDIVIDUALIZE!!!

BE FLEXIBLE AND LOOK FOR SERENDIPITOUS LEARNING OPPORTUNITIES!!!!

how cas therapy differs from artic phonological
HOW CAS THERAPY DIFFERS FROM ARTIC/PHONOLOGICAL
  • Motor learning theory should drive our treatment of children with CAS.

- precursors to motor learning (trust, motivation, and focused attention)

- repetitive and variable practice

- mass vs. distributed practice

- reinforcement and feedback

  • Therapy must be more intensive, but fade intensity over time. (“fatigue factor”)
how cas therapy differs from artic phonological therapy
HOW CAS THERAPY DIFFERS FROM ARTIC/PHONOLOGICALTHERAPY
  • “Developmental” guidelines don’t dictate sound choice.
  • Contrastive/Minimal Pair approach is not suggested at early stages.
  • Increased cueing is needed.
  • May need to teach compensatory placement.
      • Video Clip, Doug, age 5-6
  • More intensive parent involvement is essential for optimal progress.
how do we get started
HOW DO WE GET STARTED?
  • Build on expressions/env sounds.
    • Video Clip -- Shane, age 3-6
  • Use “starter positions” such as “mm”, “oo” and “ee”.
    • Video Clip -- Austin, age 4-3
    • Video Clip -- Peter, age 5
  • Label sounds, but try to incorporate placement/manner cues (chart).
how do we get started1
HOW DO WE GET STARTED?
  • Build on expressions/env sounds.
    • Video Clip -- Shane, age 3-6
  • Use “starter positions” such as “mm”, “oo” and “ee”.
    • Video Clip -- Austin, age 4-3
    • Video Clip -- Peter, age 5
  • Label sounds, but try to incorporate placement/manner cues (chart).
  • Make a core vocabulary book.

- Benefits and Procedures

core vocabulary book benefits
CORE VOCABULARY BOOK- BENEFITS
  • Organizes a starting vocabulary that facilitates a mutual focus between therapists, parents, and other important adults in the child’s life.
  • Enables the child to sense early success.
  • Allows parents/caregivers to immediately feel a part of the “team.”
  • Provides foundation for future AAC device usage if necessary.
core vocabulary book
CORE VOCABULARYBOOK
  • Use photographs containing pictures of people, toys, objects, and verbs important in the life of the child, as well as words being targeted in therapy.
  • Photographs placed in a “Grandma’s Brag Book” with written word at the top (so when points does not cover word).
  • Allows for parents to feel part of “team”
      • Video Clip -- Luke and Sharon
try to incorporate early literacy skill building as soon as possible

Try to incorporate Early Literacy Skill building as soon as possible!!

Video Clip -- Doug, age 6-1

Video Clip -- Austin, age 4-5

how do we incorporate oral motor strategies
HOW DO WE INCORPORATE ORAL-MOTOR STRATEGIES?
  • My Definition of OM strategies:

“Speech therapy strategies and techniques which draw the child’s attention and effort to the oral musculature/articulators while SIMULTANEOUSLY engaging them in speech production practice”

  • Video Clips -- Luke, age 3-2
i therapy challenges
I. THERAPY CHALLENGES
  • To provide a balance between repetitive practice opportunities and activities which are motivating and result in optimal carryover/generalization of skills.
  • To make sure that optimal practice of speech sound production is accomplished so that speech motor patterns become more automatic (“drill-play” examples)
      • Video Clip -- Connor, age 2-11
therapy ideas to enhance repetition sequencing
THERAPY IDEAS TO ENHANCE REPETITION & SEQUENCING
  • Do-a-Dot Art activities
  • Hop/Jump over activity
  • Pictures on bowling pins
  • Soccer knock down (pizza tables)
  • Hide and find in sandbox
  • Cave hunt with flashlight
  • Smartie hide for /s/ clusters
  • 3 Little Pigs for reps and /l/ clusters
more therapy ideas
MORE THERAPY IDEAS
  • “Launcher” into boxes
  • “Which is funnier?” for word pairs
  • Pass/kiss for /s/ word pairs
  • Pirate Pop-Up for reps and stress
  • “Bee” figure for unstressed “be”
  • Picture drop for faster sequencing
  • Spin chair with drum for demand
  • Magna Doodle for “th” phrases
  • “Red Roll / Green Roll” for “r” phrases
i therapy challenges1
I. THERAPY CHALLENGES
  • To support home practice that is productive, maintains high expectations, and does not lead to frustration (Amy Meredith on success)

[ “Word Bin” Demonstration ]

  • To provide expanded feedback assuring optimal awareness while tapping other “systems” and strengths
ii establishing therapy goals
II. ESTABLISHING THERAPY GOALS
  • Keep “functional communication” in the forefront of decision making.
  • Choose consonants/vowels which increase likelihood of early success.
  • May need to teach isolated sounds, but move to sound sequencing as early as possible (blending with “ha”)
      • Video Clip -- Austin, age 4-3 (“s”)
      • Video Clip -- Max, age 5-6 (“sh”)
ii establishing therapy goals1
II. ESTABLISHING THERAPY GOALS
  • Use “key words” or “key contexts” to build automatic responses for more challenging sound sequences.
      • Video Clip -- Colin, age 4
  • Use “starter phrases” to build functional communication ASAP.
      • Video Clip -- Garrett, age 2-3
iii multi sensory therapy approach
III. MULTI-SENSORY THERAPY APPROACH
  • Set up “communication temptations” to elicit speech production.
  • Use a multi-sensory approach as deemed necessary, with multiple cues that are faded over time toward an oral speech focus.
      • Video Clip -- Luke, age 3-2
      • Video Clips -- Jacob, age 3-6
iii multi sensory therapy approach1
III. MULTI-SENSORY THERAPY APPROACH
  • Work simultaneously on sound production, sound sequencing, and language. Don’t wait for sound/sound sequencing accuracy before focusing on language expansion!
  • Build in suprasegmental features from the start, through the use of songs, character voices, motor activities
      • Video Clip -- Luke, age 4-4
iii multi sensory therapy approach2
III. MULTI-SENSORY THERAPY APPROACH
  • Encourage parent observations and participation as much as possible.
  • Provide specific, ongoing feedback to parents to support home practice (“Fill in the blank” strategy if reluctant talker; Word “bins”, Cueing hierarchy, etc.)
  • Use sign language, PECS, AAC devices as deemed necessary.
advantages of sign aac use
Advantages of Sign/AAC Use
  • Provides prompt for verbal speech
  • Likely to increase verbal attempts. Does not lead to less verbal output
  • Most children’s strengths are visual
  • Allows child to build language and functional communication while working on speech production
advantages of sign language
Advantages of Sign Language
  • Can use later to prompt functors (“little words”)
  • Can be held toward face for oral cues
  • Can be paired with visual cues
  • Allows for systematic fading of cues
cueing hierarchy for asl use
Cueing Hierarchy For ASL Use
  • (1) Sign plus full verbal cue
  • (2) Sign plus first sound/syllable cue
  • (3) Sign plus first sound position cue
  • (4) Sign only
visual prompts touch cues
VISUAL PROMPTSTOUCH CUES
  • Can use a systematic cueing approach (e.g. PROMPT) or a more eclectic cueing approach
      • Video Clip -- Tyler, age 3-3
visual prompts touch cues1
VISUAL PROMPTSTOUCH CUES
  • Goal is to fade the cues over time as soon as possible
  • Allows for small increments of success to document in progress notes
  • Eventually, use sign plus visual prompt/touch cue
visual prompts touch cues2
VISUAL PROMPTSTOUCH CUES
  • For some children, pictures facilitate production/sequencing
    • Video Clip -- Mickey, age 6-4
    • Video Clip -- Zachary, age 5-0

(AAC device discussion)

treatment summary
TREATMENT SUMMARY
  • MUST make activities motivating, repetitive, and easily carried over to the home
    • Video Clip -- Sean, age 4-11
  • MUST monitor intensity of treatment and adjust accordingly
  • MUST involve parents and help them to understand how to respond to their child
response hierarchy to inaccurate verbal attempts
Response Hierarchy to Inaccurate Verbal Attempts
  • (1) Just look at child with non-understanding
  • (2) Say: “You forgot your…” (sticky)

“Where’s the…?” (friend)

“I didn’t hear any…” (wind)

  • (3) Provide cue at 4 levels in reverse order

1. Sign only

2. Sign plus first sound position

3. Sign plus audible first sound/syllable

4. Sign plus full word (or full word if no sign)

associated areas of deficit
ASSOCIATED AREASof DEFICIT
  • Self-dialogue in play may be absent.
  • Pragmatic communication may be weak – where dyads can be beneficial. 
    • Video Clip -- Luke and Sean, age 5 after Luke in therapy 2 yrs
associated areas of deficit1
ASSOCIATED AREASof DEFICIT
  • Disfluencies may surface, which could indicate system overload.
  • Suprasegmental features are frequently off track (May be one of the most lingering aspects for older children with CAS with stress, timing, volume control residual features)
suprasegmental features treatment
SUPRASEGMENTAL FEATURES – TREATMENT
  • Address throughout therapy
  • Use “backward build-ups” for multi-syllabic words
  • Use activities such as “Build-A-Sentence” for word stress
      • Video Clip -- Luke, age 5-6 with frog clicker
suprasegmental features treatment1
SUPRASEGMENTAL FEATURES – TREATMENT
  • Use motor feedback for stress
    • Video Clip -- Cole, age 3-6 
  • Use songs and rhythms
    • Video Clip -- Anna, age 4-0
  • Use rhyming books, i.e., Shel Silverstein and Dr. Seuss
    • Video Clip -- Luke, age 5-6
pilot outcome study
PILOT OUTCOME STUDY
  • Asked parents to rate on 4-point scale
  • Looked at ratings of “less than half” to “about three-fourths”
  • For Phonological-disordered children, required average 29 individual Tx sessions
  • For Children with Apraxia, required average of 151 sessions so 81% more therapy
  • Find study in “Clinical Management of Motor Speech Disorders” by Caruso and Strand (1999) or on Apraxia-Kids website
outcomes
OUTCOMES
  • Previous Video Clip -- Doug, age 5
  • Video Clip -- Zachary, age 6
  • Video Clip -- Alex, age 5
  • Video Clip -- Cole, age 5
  • Video Clip -- Austin, age 5
  • Video Clip -- Luke, age 10
  • Video Clip -- Jacob, age 8
  • Video Clip -- Tyler, age 9
issues for older children
Issues for “Older” Children
  • Vocabulary demands increase, so may hear decreased multi-syllabic precision
  • “Fast speech” reflects a system that can’t handle the increased demands.
  • See breakdowns when tired (energy)
issues for older children1
Issues for “Older” Children
  • Compensatory patterns may emerge.
      • Video Clip -- Rhonda, age 7-5

Gloss for Reading

I am a yellow plastic duck and I am in great danger.

Yesterday I was snuggled safe with hundreds of bathtub toys.

We were in a crate on a big ship.

A storm came. Our crate was washed overboard.

issues for older children2
Issues for “Older” Children
  • Word retrieval deficits become more evident (inefficient storage).
  • May talk louder because can’t regulate
  • Novel words and nonsense words are more problematic from a motor planning/programming standpoint.
      • Video Clip -- Gary, age 8-8
treatment for older children
Treatment for Older Children
  • Consider single most prominent factor contributing to clarity breakdowns.
      • Video Clip -- Zackery, age 8-0
  • Focus moves to intonation, rate, and stress with less emphasis on speech.
  • Intensity of treatment is not the same.
  • Optimal may be dyad or group therapy.
treatment for older children1
Treatment for Older Children
  • Teenagers with CAS may keep sentences shorter to meet articulatory demands. Need to build confidence in longer utterances (“phrased speech”).
  • Assume progress, but does not mean should remain in therapy--TAKE BREAKS! COULD BE BEST THING FOR THEM.
  • Use “errorless teaching” with 80% success.
treatment for older children2
Treatment for Older Children
  • Use stopwatch for timing of utterances.
  • Use reading programs that are highly visual (See “Selected Resources”)
  • Videorecord for self-evaluation.
  • Talk about how they feel.