Clinical Decision-Making in
Assessment and Treatment of
Childhood Apraxia of Speech
Ruth Stoeckel, Ph.D., CCC-SLP
Mayo Clinic
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Disclosures
• Financial Disclosures:
• Compensation from ASHA for online conference
• Compensation for speaking/teaching from Childhood
Apraxia of Speech Association of North America
(CASANA)
• Compensation from Medbridge webinars
• Nonfinancial Disclosures:
• Member of the Professional Advisory Board of
CASANA
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3
Instructor, Mayo Medical School
Clinical Practice
Research
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Objectives
4
Based on best available evidence, participants
will:
1. Interpret responses during assessment to support
differential diagnosis in children with severe speech
sound disorders
2. Describe how dynamic assessment can contribute to
assessment of speech sound disorders
3. Compare motor-based versus phonological
approaches to treatment
4. Discuss evidence-based interventions for CAS
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Connecting Research to Practice: Why?
practice
research
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Why Connect Research to Practice?
• Understanding of…
• the physiology of the speech mechanism
• interactions of cognitive,linguistic, and motor
factors,
and
• effects of treatment factors
informs our clinical decision-making during
assessment and treatment
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Research to Practice:
Evidence Based Practice
• EBP does not require us to use information only
from peer-reviewed studies
• But we DO need to consider the level of
evidence when empirical studies are lacking
• Instead of asking “Is XYZ an evidence-based
practice?” ask “What is the level of evidence
for this practice?”
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Research to Practice:
Resources for Best Available Evidence
• ASHA Systematic Reviews
• Cochrane Data Base
• Speech Bite
• ASHA Technical Reports
• Consultation with experts
• Current journal articles/reviews
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Research to Practice: Assessment
• There are interactions among cognitive,
linguistic, and motor aspects of development
• The interactions of these aspects of
development change over time
(Kent, 2004; Smith & Goffman, 2004; Nip, Green & Marx, 2010)
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Research to Practice: Assessment
• Speech sound perception skills may be
impaired in some children with speech sound
disorders (Munson, Edwards, & Beckman, 2005; Preston,)
• Vowels:
• Children with CAS have difficulties
positioning and sequencing articulators for
vowels (timing, nasality, voicing) (Gibbons, 2002)
• Vowel errors contributed to long term
intelligibility problems in 3 children with CAS
(Davis, 2003)
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Research to Practice: Treatment
• There is a growing evidence base that can help
to inform decisions about
• “dosage” (frequency and length of sessions)
• choice of targets
• treatment approaches/treatment factors
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Research to Practice: Literacy
• We know that children with early speechlanguage problems are at risk for literacy
problems
• As well as less optimal outcomes for
academics in general (e.g., Lewis, et al. 2015)
A note on terminology
Let’s be clear in differentiating Phonological processING
from Phonological patterns (processES)
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Research to Practice: Personal
• Throughout the day, be thinking about:
• What information you usually gather during
assessment and treatment
• Why you choose specific assessment tools
or treatment techniques
• How you use information to arrive at a
diagnosis and to guide treatment
• When you modify treatment due to progress
or lack of progress
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ASSESSMENT
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Assessment for
Severe Childhood Speech Sound Disorders
Simple, right?
Mild motor issues?
ATTENTION
LANGUAGE
Dysarthria
CAS
COGNITION
mixed
SENSORY
EXPERIENCE
Phonological
Disorder
Adapted from Hodge, 2008
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What is
Childhood Apraxia of Speech (CAS)?
It is a
• neurologic
• pediatric
• speech sound disorder
“In which the precision and consistency of
movements are impaired in the absence of
neuromuscular deficits”
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CAS
“The core impairment in planning and/or
programming spatiotemporal parameters of
movement sequences results in errors in
speech sound production and prosody.”
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“A child is at increased risk for early and persistent
problems in
• speech,
• expressive language, and
• the phonological foundations for literacy and
• need for AAC”
(ASHA Technical Report, 2007)
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CAS
• CAS can occur in isolation (idiopathic)
• CAS can appear to be the primary disorder, with
later identification of associated problems, such as
reading difficulty
• but CAS itself is not the “cause”
• CAS can occur in conjunction with other disorders,
such as
• Genetic disorders
• Brain injury
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Results: Comorbidities
400
350
300
250
200
150
100
50
0
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Results of Mayo Study of Children with
CAS: Expressive Language Delay
4.60%
Yes
No
95.40%
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Best Available Evidence
• Suggests that many/most children with CAS will
have co-occurring problems
• (e.g,. Lewis, et.al., 2004; Lewis, et al., 2015; Baas, Stoeckel,
Kosey 2016)
Our focus today will be on the speech disorder
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Differentiating Disorders
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Phonologic Disorder
• The primary factor is thought to be linguistic
rather than motor
• Etiology is most often unknown
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Childhood Apraxia of Speech (CAS)
The primary factor is thought to be praxis:
planning/programming movements
No obvious weakness or impaired
ability to move articulators
Can be acquired (e.g., stroke, TBI)
or “developmental.”
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Dysarthria
Difficulty with execution of movements
Weakness, paralysis, or abnormal tone
resulting in decreased range of motion,
decreased speed, or impaired movement
of the articulators
Usually caused by impairment in the
central or peripheral nervous system
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Assessment
• Assessment procedures are used to
• determine the relative contribution of
• linguistic (phonology and language) skill
• cognition
• speech motor skill
• assist in planning treatment
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ASHA Evidence Map
• "The best diagnosis method is combined, that
is, clinical assessment (observation of the
child’s speech) and formal evaluation (with valid
and reliable protocols)"
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Research to Practice: Assessment
• Assess language
• Consider referrals for assessment in other
areas as needed, which may include
• Neurology – possible seizures or other neuro
involvement
• Developmental Peds – possible
developmental or genetic conditions, motor
development
• Neuropsychology/Psychology – cognitive
and learning skills
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Research to Practice:
Assessment of Speech
• Assessment should include presentation of
targets with hierarchical levels of cuing
• accommodating a child’s developmental
level, and
• using different levels of complexity
• Sound patterns
• Word vs phrase or sentence, and
• having the child attend to examiner’s face for
visual cues (Kent, 2004)
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Research to Practice:
Assessment
• Be conscious of vowel errors
• Consider assessment of speech perception –
phonological processing
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Assessment Procedure
• Develop an individualized assessment plan:
 Screen/assess language
 Examine oral structure and function, speech
subsystems
 Assess speech perception
 Obtain phonetic/phonemic inventories
 Assess motor speech skill
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Assessment:
History
• Birth history
• Family history
• Developmental milestones
• First words, word combinations
• Motor milestones
• Co-existing problems
• Sensory function issues
• Seizures, hearing loss, learning issues
• Feeding history, abnormal reflexes
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Assessment:
Structure and Function
•
Structures
•
•
•
•
•
•
Range of motion
Coordination
Strength
Ability to vary muscular tension
Speed
Tissue characteristics
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Assessment:
Observation of Speech Subsystems
• Respiration
• Articulation
• Phonation
• Resonance
• Prosody
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Video Example
• P S-F
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Assessment: Language
• Consider the child’s speech in the
context of their overall ability to
communicate
• Does the child exhibit communicative
intent
• to comment, request, engage in social
interaction?
• to initiate interactions with expected
frequency?
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Assessment:
Formal/Conventional Measures of Language
• Informal measures
> Language sampling
> Parent report
> Standardized checklists
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Assessment: Language
• Language Sampling can be done with children
who have limited intelligibility (Bingner, Ragsdale &
Bustos, 2016)
• Mean Length of Utterance in words
• Mean number of syllables per utterance
• Percentage of comprehensible words
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Assessment: Language
• Formal measures
• Receptive/expressive vocabulary
• General language tests
• Formal language sample analysis
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Assessment: Language
• Is there a discrepancy between receptive and
expressive skills? (not required for CAS dx)
Receptive > Expressive?
• Is there a discrepancy between estimated level
of language and speech sound development?
(e.g., acquiring sign language rapidly but
remaining nonverbal)
Language Level > Speech Sound Acquisition?
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Assessment: Language in Bilinguals
• Disorder will occur in all languages
• Consider the aspects of normal language
acquisition in all languages and the
characteristics of communication disorders
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Video example
• P book 1
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Assessment: Speech Perception
• Informal observations may be sufficient at initial
evaluation
• Formal assessment may be particularly helpful for
children approaching school age or already in
school
> Phonological awareness skills are necessary
but not sufficient for development of reading
skill
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Assessment: Speech Perception
Phonologic Processing
45
• Formal tests such as the CTOPP, TOPA,
Wepman, etc.
• Informal measures such as the Locke task
(1980)
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Assessment: Speech Perception
Phonologic Processing
• Evaluate the child’s understanding of phonemic
categories and other phonologic awareness
skills, which
• can influence the interaction of speech and
vocabulary development, and
• literacy/academic skills
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Assessment: Speech
Obtain Phonetic/Phonemic Inventories
• There is no single test of articulation or
phonology that is a fully adequate
measure of a child’s phonetic inventory
(Eisenberg, et al., 2010)
• Tests can be a useful means for
quickly probing a range of speech
sounds
• A spontaneous inventory provides
additional information for interpreting
results and planning treatment
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Assessment:Speech
Obtain Phonetic/Phonemic Inventories
• Sound system analysis is needed
• To describe the current phonetic/phontactic
inventory
• To guide decisions regarding intervention
approach and stimulus selection
• To establish a baseline for progress
monitoring
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In order to
teach at a
syllable level,
we have to
know the
child’s
phoneme
inventory
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Sound System Analysis:
A “Sequence” of Speech Sound Development
Early 8
around 3 years of age
Middle 8
mbjnwdph
tkgŋfvʧʤ
around 3-4 years of age
Late 8
ʃɵðszlrƷ
most between 5 ½ - 8
years of age
Think of these ages as “usually acquired by” rather than
“wait until this age to teach”
Shriberg, 1993; Lof 2004
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Sequence of Speech-Sound Development:
Vowels
• Early: /i/, /u/, /o/, /˄/,/ɑ/
• Later: /a/, /ɔ/, / ə/
• Later yet: /e ɪ/, / ɪ/, /ɛ/, /ɝ/
(Stoel-Gammon & Herrington, 1990)
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Assessment: Speech
• Phonetic Inventory
• What sounds and syllable shapes is the
child producing spontaneously?
(Helps to identify what the child can build
on)
• Error Inventory
• How does the child’s sound system map
onto adult forms?
• How do syllable shapes relate to target
forms?
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Video example
• P G-F
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ACTIVITY
• Find the production/error analysis form in your
packet
• Use the word list in your packet to record
sound substitutions and omissions in the
grey area under the heading “Relational
(elicited)” based on the transcribed
responses
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Target
Independent (spontaneous)
Initial
Medial
Final
Relational (elicited)
Initial
Medial
/h/

/w/

Final
/j/
/p/
b
b
--
/b/


/m/




-,t
/t/
/d/

/ŋ/
d/nk, h/nk
h
/g/
/f/


/n/
/k/

h
t
--,d
d
h
/v/
/Ɵ/
d
/ð/
/s/
--
/z/
/ʤ/
/Ȝ/
/ʃ/
--
/ʧ/
/r/
/l/
w
--
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ACTIVITY
• Take out the production/error analysis form
again
• Use transcription of spontaneous output in
your packet to identify sounds the child is
producing spontaneously in the white
columns
• Is there overlap in the two inventories?
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Target
Independent (spontaneous)
Initial
Medial
Relational (elicited)
Initial
Medial
Final
/h/



/w/



/j/


/p/
b
/b/


/m/


/t/


/d/

/n/


b




-




-,t



/ŋ/
d/nk, h/nk
/k/
/g/
Final
h


h
t
--,d
d
/f/
h
/v/
/Ɵ/
d
/ð/
/s/

/z/

--
/ʤ/
/Ȝ/
/ʃ/
--
/ʧ/
/r/
/l/
w
--
©2011
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Target
Independent (spontaneous)
Initial
Medial
Relational (elicited)
Initial
Medial
Final
/h/



/w/



/j/


/p/
b
/b/


/m/


/t/


/d/

/n/


b




--



Independent
inventory


-,t


Relational
inventory

/ŋ/
d/nk, h/nk
/k/
/g/
Final
h

/f/

h
t
--,d
d
Both inventories
h
/v/
/Ɵ/
d
/ð/
/s/

/z/

--
/ʤ/
/Ȝ/
/ʃ/
--
/ʧ/
/r/
/l/
w
--
©2011
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Assessment: Motor Speech Skill
• As with articulation/phonology, there is no single
test that is fully adequate to assess motor speech
skill (McCauley & Strand, 2008)
• A checklist approach to assessment is insufficient
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Types of Motor Speech Stimuli
100
90
80
70
60
50
40
30
20
10
0
Vowels
Cs/Sylls
Single Ws
Multiple Ws
Connected Sp
DDK
From: McCauley & Strand, 2008
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Assessment: Motor Speech Skill
• A motor speech exam should include
presentation of targets with hierarchical levels
of cuing
• To accommodate the child’s developmental
level
• Using different levels of complexity
• Syllables
• Syllable sequences of increasing
complexity
• While child attends to examiner’s face for
cues
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Why Use Dynamic Assessment?
• It is sensitive to changes that result from the
child’s responses to cues  acquisition of a
new skill
• It is different from standardized tests which
compare a child’s performance to a normative
group
• Two children with the same standard score on a test
may have different levels of severity and different
prognosis for change
• Response to cueing may be more informative about
prognosis than total number of errors
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Why Use Dynamic Assessment?
• It facilitates judgments of severity and prognosis
the clinician is providing different levels of
support or cuing
• Observations regarding response to types and
levels of cuing facilitate judgments regarding
• how much cuing will be needed in early therapy
to induce improvement in performance
• how long it may take to achieve initial progress
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Why Use Dynamic Assessment?
• It takes advantage of what a child can do
independently while providing support when
needed
• It is interactive, focusing on the process of
acquiring a skill
• The child’s responses guide the process,
allowing for continuous adaptation
• It follows the process that can be used in
treatment
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Motor Speech Exam
Direct
Imitation
Incorrect
Simultaneous
production
Slowed rate
Add tactile and/or
gestural cues
Continue to add
cues as needed
to determine if
the child can
achieve correct
production with
increasing
assistance
Correct
Mark as
correct
Based on Strand, 2004 and
Strand, et al., 2013
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• We are looking for:
• Estimate of severity
• Where the breakdown occurs
• What type of cueing is needed for success
A good evaluation provides a starting point for
treatment planning
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Video Examples
• J-MSE
• P-MSE
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ACTIVITY
• Use the production/error analysis form and
parent inventory list to come up with 10-15
words to probe in the motor speech
examination. Be sure to consider:
•
•
•
•
Probing for sounds you predict may be stimulable
Probing a variety of syllable shapes
Probing at least a few syllable sequences
Are they functional words that could be used to
initiate therapy?
• Choose one “challenge” word
©2011
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What are we looking for?
ASHA Technical Report (2007) possible markers;:
(a) inconsistent errors on consonants and vowels
in repeated productions of syllables or words,
(b) lengthened and disrupted coarticulatory
transitions between sounds and syllables, and
(c) inappropriate prosody, especially in the
realization of lexical or phrasal stress.
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• “Importantly, these three features are not
proposed to be the necessary and sufficient
signs of CAS.”
• “These and other reported signs change in their
relative frequencies of occurrence with task
complexity, severity of involvement, and age.”
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• A fourth candidate characteristic = vowel
distortions (e.g., Davis, Jacks, & Marquardt 2005)
• Contribute to ratings of severity of a disorder
• Are not likely to occur without consonant
errors
• Are less likely to be corrected spontaneously
by children with motor speech disorders
©2011
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Additional Possible Characteristics
• Limited early babbling/sound play
• Better performance on automatic vs volitional
speech
• Restricted sound inventory for age
• Increased errors with increased
phonetic/linguistic complexity
• Atypical phonological patterns (e.g., initial
consonant deletion)
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Additional Possible Characteristics
• Disruption in temporal and spatial
relationship of articulators
• Longer word and sentence durations
• Difficulty achieving and/or maintaining
articulatory postures
• Disrupted suprasegmentals (rate, pitch,
loudness) – can occur with dysarthria as
well
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Additional Possible Characteristics
74
• Difficulties with sound sequencing
• Sounds produced correctly in some
sequences are produced incorrectly in
others.
• Why? Perhaps due to different motor
requirements
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Assessment:
Sound System Analysis
• A child with phonologic
disorder will usually have
• Consistent patterns of
error
• “typical” patterns
such as final
consonant deletion,
fronting, stopping,
etc.
• Intact prosody
• Vowels intact
• A child with CAS may have
• Restricted sound
repertoire
• Poor differentiation of
vowels
• Few/simple syllable
shapes
• Atypical error patterns
(e.g., initial consonant
deletion, sound
preference, epenthesis,
voicing errors, etc.)
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Comparison Chart
• This is descriptive, not diagnostic
• Chart is also available at Apraxia-Kids.org
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Video Examples
• Hi
• C w/Edy
• L DEMSS
• G
• A first
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Assessment Summary
• Assessment information is used to:
• Determine if there is sufficient
evidence to make a diagnosis of CAS
• Identify the relative contribution of
cognitive, linguistic, and motor factors
• Determine priorities for treatment
• Plan appropriate treatment strategies
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Intervention
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Intervention Options
Kits or
programs
“wait and
see”
alternative
treatments
protocols
Apps
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Three Main Categories of
Intervention for CAS/Severe SSD
• Integral stimulation  Emphasizes auditory
and visual models
• DTTC
• Tactile/gestural  Touch/gestures are
emphasized
• PROMPT
• Prosodic Emphasizes melody and rhythm
as facilitators
• ReST
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Research to Practice:
Approaches with Research Evidence
Based on Systematic Reviews
• Dynamic Temporal and Tactile Cuing (DTTC) -Integral Stimulation
• Rapid Syllable Transition (ReST)
• Biofeedback
• PROMPT
• Nuffield Dyspraxia Programme (NDP3)
(Murray, McCabe & Ballard, 2014; Maas,Gildersleeve-Neumann,
Jakielski & Stoeckel, 2014)
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Research to Practice
• Strongest evidence for DTTC/Integral
Stimulation
• Small scale studies
(Edeal & Gildersleeve-Neumann, 2011; Maas, Butalla & Farinella,
2012; Maas & Farinella, 2011; Maas, et al., 2008; Strand,
Stoeckel, & Baas, 2006; current study, Maas & colleagues)
.
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Research to Practice
• Randomized, Control Study of ReST and NDP3
(Murray, McCabe & Ballard, 2016)
• Biofeedback (Ultrasound) (Preston, Brick & Landi, 2013)
• PROMPT (Grigos, Hayden & Eigen, 2010; Dale & Hayden,
2013)
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• Typical “dosages” vary for each approach,
often determined by convenience rather than
empirical guidance for number and length of
sessions or duration of intervention
• Optimal treatment intensity is specific to the
intervention(s) being used and to the speech
disorder being treated (Kaipa & Peterson,2016)
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Research to Practice
• Nonspeech exercises
• Babbling and early nonspeech oral behaviors
are not related (e.g., Moore & Ruark, 1996)
• Movements for eating and speaking are
dissociated early in life
• Speech is not a series of isolated
movements (e.g., Nip, Green & Marx, 2010).
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Research to Practice
Nonspeech Exercises
Evidence-Based Systematic Review
recommendations
1) Pursue treatments with established efficacy
instead
2) Look to basic research for evidence of a
theoretical basis for the unproven treatment
3) Use in clinically-based research
McCauley, Strand, Lof, Schooling & Frymark, 2009
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Intervention: Research to Practice
Use best available evidence to answer…
• How do I choose an appropriate treatment
approach?
• How do I choose these goals?
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Research to Practice
• Communication is a priority
For minimally verbal children, you may need to start
with imitation, AAC, etc. (DeThorne, et al., 2009)
The child needs to understand the task; intent to
improve movement (Maas, et al., 2008)
Promote early success – the child should be
stimulable for targets (Maas, et. al, 2008)
Use of functional targets can increase motivation
(Strand & Debertine, 2000)
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 Minimally Verbal Children:
Review
• Provide access to AAC
• Minimize pressure to speak
• Imitate the child
• Use exaggerated intonation and slowed tempo
• Augment auditory, visual, tactile and proprioceptive
feedback
• Avoid emphasis on nonspeech-like articulator
movements: focus on function
(DeThorne, et al., 2009)
©2011
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Intervention: Phonologic vs Motor
Phonologic Intervention
Motor Intervention
• Emphasizes the sound
patterns of language
• Emphasizes principles of
motor learning; movement vs
sounds
• Emphasizes how changes in
sound pattern affect
• Emphasizes proprioception
meaning
and how variations in
movement affect output
• Targets are single sounds or
sound patterns
• Targets are movement
sequences (syllable level or
• Coarticulation is not
higher)
considered critical
• Coarticulation is critical
©2011
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©2014 MFMER | slide-91
Functional targets based on movement
patterns vs sound patterns:
Sound patterns
Tea
Key
Movement patterns
Home
My puppy
CVC
CVCVCV
©2011
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A Treatment Framework:
DTTC
93
• Based on Integral Stimulation
• Allows opportunity for the child to take
increasing responsibility for assembling,
retrieving and executing motor plans with
progressively less cueing
• Easily accommodates principles of motor
learning
• “Mixed” approach integrates
language/phonology with motor practice
©2014 MFMER | slide-93
Dynamic Temporal and
Tactile Cuing (DTTC)
Direct Imitation
Incorrect
Correct
Simultaneous
production
Practice with varied
rate and prosody
If incorrect,
try miming or
go back to
simultaneous
Slowed rate
Delayed
repetition
Add tactile and/or
gestural cues
After simultaneous repetitions
at normal rate and prosody, probe
direct imitation
94
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• The child may be working on different stimuli at
different levels of the cueing hierarchy
• The level of cueing is constantly changing within
and between sessions, depending on the child’s
responses
• Don’t forget to allow the child adequate processing
time for their responses
Treatment is continually adjusted to adapt to
changes in the child’s
speech motor skill
©2011
©2014 MFMER | slide-95
Video example
• J- stop it sara
©2014 MFMER | slide-96
Activity
• Pair up
• Use the graphic to teach one partner “my
puppy”
• “student” can decide how to respond
• Use the graphic to teach second partner “open”
• “student can decide how to respond
©2011
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Research to Practice: Intervention
• Encourage attention to face for visual cues
• Incorporate principles of motor learning
• Teach movement sequences vs isolated
phonemes
• Use multisensory input (auditory, visual, tactile)
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Intervention: Research to Practice:
• Be conscious of frequency and intensity of
practice
• Think about range of difficulty in stimuli -challenge can facilitate motor learning
• Adjust the level of cuing carefully
©2011
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©2014 MFMER | slide-99
Research to Practice
• Communication is the priority
For minimally verbal children, you may need to start
with imitation, AAC, etc. (DeThorne, et al., 2009)
The child needs to understand the task; intent to
improve movement (Maas, et al., 2008)
Promote early success – the child should be
stimulable for targets (Maas, et. al, 2008)
Use of functional targets can increase motivation
(Strand & Debertine, 2000)
©2011
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 Understanding the Task
• Emphasis is on movement versus sounds,
however…
• Communication involves cognitive and linguistic
aspects as well as motor skill (Nip, Green & Marx,
2010)
• Are we teaching strategies appropriate for
developmental age and level of motor skill?
©2011
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©2014 MFMER | slide-101
Research to Practice
• Communication is the priority
For minimally verbal children, you may need to start
with imitation, AAC, etc. (DeThorne, et al., 2009)
The child needs to understand the task; intent to
improve movement (Maas, et al., 2008)
Promote early success – the child should be
stimulable for targets (Maas, et. al, 2008)
Use of functional targets can increase motivation
(Strand & Debertine, 2000)
©2011
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 Stimulability
• The child should be able to produce the target
with some level of cuing
• Success can lead to increased motivation/effort
• If the child is not stimulable, the result may be
frustration and distrust
©2011
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©2014 MFMER | slide-103
Research to Practice
• Communication is the priority
For minimally verbal children, you may need to start
with imitation, AAC, etc. (DeThorne, et al., 2009)
The child needs to understand the task; intent to
improve movement (Maas, et al., 2008)
Promote early success – the child should be
stimulable for targets (Maas, et. al, 2008)
Use of functional targets can increase motivation
(Strand & Debertine, 2000)
©2011
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 Functional Targets
• Think about the needs of the “whole child”
• Build vocabulary and language as well as speech
accuracy
• Give the child ways to interact with others and with
their environment
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Structure of Practice/
Principles of Motor Learning
• Choices need to be made about:
• Organization of sessions
• How many targets to include in treatment,
depending on
• severity and type of motor speech
disorder
• immediate goal (acquisition vs
stabilization/transfer)
(Maas, et al., 2008)
©2011
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Distribution: Mass vs. Distributed practice
• Mass practice = minimal time between trials or sessions
• Facilitates acquisition
• Distributed practice = a greater amount of time between
trials or sessions.
• Important for stabilization and generalization
• Within a session, mass practice can mean a large number
of repetitions of a single target. Distributed practice is fewer
repetitions spread throughout the session
©2011
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Distribution
• greater amount of time
between trials
Mass
• minimal time between
trials
Hi mom
Hi mom
Hi mom
Hi mom
Hi mom
Hi mom
Distributed
Dora
Dora
Dora
Dora
Dora
Dora
Hi mom
Hi mom
Hi mom
Dora
Hi mom
Hi mom
Hi mom
Dora
©2011
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©2014 MFMER | slide-108
Schedule: Blocked vs. Random Practice
•
Blocked practice means all practice trials of a given
stimulus are practiced together before moving on to the
next.
• Facilitates improved performance
•
Random practice means that the order of presentation of
the stimuli are randomly mixed up throughout the session.
• Facilitates retention/motor learning
©2011
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©2014 MFMER | slide-109
Scheduling
Blocked
Random
all practice trials of a given
stimulus are practiced
together before moving
on to the next
the order of presentation of
the stimuli are randomly
mixed up throughout the
session
I do
I do
I do
Home
Elmo
Elmo
Movie
Elmo
Movie
Movie
Elmo
I do
Home
Home
I do
Movie
©2011
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©2014 MFMER | slide-110
Variability: Variable vs. Constant practice
• Constant practice = working on one specific exemplar of
the target,
• Helpful early in therapy when problem is more severe
• May facilitate learning relative aspects of movement
• Variable practice incorporates variations of the target, such
as modifying rate, loudness, inflection, etc. or varying
context (single word vs phrase , etc.)
• Helpful to transfer skills later in the therapy process
• May facilitate learning of absolute aspects of movement
©2011
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©2014 MFMER | slide-111
Variability
Constant
Variable
working on one specific
exemplar of the target
incorporating variations of the
target, such as modifying
rate, loudness, pitch, etc.
I want a cookie
I want a cookie!
I want a cookie
I want a cookie!
I want a cookie
I want a cookie!
©2011
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©2014 MFMER | slide-112
Feedback: Knowledge of results vs knowledge of
performance
• Knowledge of results: provided after completion of the
movement that compares outcome to target
• (e.g., That was what I want to hear! Those were all right!)
• Knowledge of performance relates to the nature or quality of
the movement gesture
• (e.g., Close your lips tighter. Close your mouth just a little
more)
• Frequency and timing of feedback is different for children and
adults (Sullivan, Kantak, & Burtner, 2008)
©2011
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©2014 MFMER | slide-113
Summary Chart:
Principle
Acquisition
Retention
Practice Distribution
Mass
Distributed
Practice Variability
Varied context, varied
prosody, pitch, rate
Feedback Frequency
Consistent context,
consistent prosody,
pitch, rate
Blocked, predictable
order
Knowledge of
performance
Often, immediate
Rate
Slow
Normal, varied
Practice Schedule
Feedback Type
Random unpredictable
order
Knowledge of results
Inconsistent, delayed
©2014 MFMER | slide-114
I want one X40
My turn X1
Thomas X50
• Mass AND Distributed
My turn X1
• Mostly random, “blocked”
with “my turn”
Puppy X40
My turn X1
• Probably constant AND
variable
Hi mom X20
Time to go X5
©2011
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©2014 MFMER | slide-115
Conditions of Practice
• Need focused attention, even if brief
• Develop the habit of child looking at clinician’s face
• Emphasize improving movement rather than
sounds
• Challenge, but don’t frustrate
• Use activities that generate many opportunities for
repetition
• We want good quality practice; shaping to
accuracy
©2011
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©2014 MFMER | slide-116
Sessions
• “There is emerging research support for the
need to provide three to five individual sessions
per week for children with apraxia as compared
to the traditional, less intensive, one to two
sessions per week (Hall et al., 1993;Skinder-Meredith,
2001; Strand & Skinder, 1999).”
• Optimal treatment intensity is specific to the
intervention(s) being used and to the speech
disorder being treated (Kaipa & Peterson,2016)
©2011
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©2014 MFMER | slide-117
Sessions
• Number of sessions per week should be
adjusted based on
•
•
•
•
Severity of the CAS
Child’s ability to participate
Family/Educational support
Other interventions
• A child may benefit from some small group work
to facilitate development of pragmatic skills
©2011
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©2014 MFMER | slide-118
Sessions
• Length of sessions may depend on
• Child’s developmental ability to attend/participate
• Tasks to accomplish (e.g., time to counsel/educate
parent, demonstrate techniques, etc. in addition to
intervention with child)
• Allow time for a high number of repetitions per
session (Edeal & Gildersleeve-Neumann, 2011)
• Clinician preference and therapy style
©2011
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©2014 MFMER | slide-119
Targets
• Target choices should include consideration of how
to:
• promote early success in therapy
• promote generalization of learning
• “use what the child gives you” in terms of
phonetic repertoire and syllable shapes
• improve movement gestures for accurate
production of specific vowels and/or consonants
• encourage good prosody
• increase effectiveness of verbal communication
©2011
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©2014 MFMER | slide-120
How Many Targets?
• Depends on severity of child’s speech disorder
• Increase number (and complexity) as skills improve
Number of targets
25
20
15
10
5
0
severe
mild
©2011
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©2014 MFMER | slide-121
Type of Targets
• Use what the child has in their inventory and
consider:
• Single syllables vs syllable sequences
• types of syllables/sequences
• phonetic complexity
• awareness of general sequence of sound
development (e.g., early, middle, late)
• tring varied syllable shapes (CV, VC,
CVC, etc.)
©2014 MFMER | slide-122
Functional Targets:
Consider Speech Needs
Increase sound
repertoire
• Try new sounds in existing
syllable shapes
Increase
syllable
repertoire
• Use existing sounds in new
syllable shapes
• Phrases as sequences
Improve
prosody
• Accurate lexical stress
• Accurate phrasal stress
©2011
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©2014 MFMER | slide-123
Video example
• J- ee-ah
• B-S book
©2014 MFMER | slide-124
Functional Targets: Vowels
• Vowels are important for intelligibility
©2011
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©2014 MFMER | slide-125
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©2014 MFMER | slide-126
Vowels
• Can be a significant aspect of intelligibility of a
syllable
• Are primarily of concern in motor speech
disorders (CAS, dysarthria) vs phonological
disorders
• Errors are not as likely to spontaneously resolve
as consonant errors
©2011
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©2014 MFMER | slide-127
Intervention for Vowels
• Integrated into overall treatment plan
• Work for accuracy, not approximations
• Individualize to child – no set order based on
evidence in the literature
• Choose facilitating contexts, remember
coarticulation effects
• Diphthongs involve movement, good to
address early if possible
©2014 MFMER | slide-128
Facilitating Contexts
• High frequency (how often used), low density (how
many similar words can be created by changing one phoneme)
• Alveolars with high front vowels (day, see, say)
• Labials with central vowels (butt, pet, bet)
• Velars with high back vowels (go, cool, cook)
©2011
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Facilitating Contexts
• High front vowel in second syllable (mommy, daddy)
• Voiceless stop/fricative/affricate after a lax
vowel (sit, look, nap)
• Velars and fricatives in final position
• AVOID voiced plosives in final position
• Too easy to end up with added schwa (bug-uh)
©2011
©2014 MFMER | slide-130
Building Speech &
Quantifying Complexity
Toolkit
www.apraxia-kids.org
©2014 MFMER | slide-131
Functional Targets:
Consider Language Needs
Vocabulary
• Nouns
• Verbs
• Conceptual vocabulary
Grammar/
Syntax
• Length of utterances
• Complexity of utterances
Social
Interaction
• Greeting
• Requesting/directing
• Commenting
©2011
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©2014 MFMER | slide-132
Examples
• C- out1
• C –out2
• S – fruit
• B -- book
©2014 MFMER | slide-133
Language – model telegraphic utterances
or not?
• Using grammatical features may facilitate
language processing (Bredin-Oja & Fey, 2014)
• Helps child anticipate upcoming words
• Grammatical features (e.g. –ing) help the child learn
new words
• We don’t want to reinforce child speaking
telegraphically in the long run
• Typically developing children process spoken
language more quickly when grammatically correct
than when telegraphic (Fernald & Hurtado, 2006; Fey,
Long & Finestack, 2003 )
©2014 MFMER | slide-134
Don’t forget prosody!
• She likes village life butter family lives in Toronto.
• I like village life butter bin life has its advantages.
• Everything butter purse was recovered.
• Jim couldn't decide whether to go with butter Larry.
• The other butter daughter gave her was a rose.
• She said butter Ernie took it.
• Butter Lee in the morning it's still dark.
• Orange pekoe is good, butter bull tea is nice in the
winter.
• Fish live in the ocean butter chins do not.
©2011
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©2014 MFMER | slide-135
• L – reps
• J – Luigi/Mario
©2011
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©2014 MFMER | slide-136
Target “bins”
Planned Targets Current Targets Generalization
• Bamber Valley
(school)
• Mine
• My house
• Hi mom
• Penelope (sister)
• Daddy
• I want one
• Home
• Time to go
• All done (aw
done)
• Where is it?
• Lucy (dog)
• Thomas
• Sit down
• I see it
©2011
©2014 MFMER | slide-137
Target “bins”
Planned Targets Current Targets Generalization
• Bamber Valley
(school)
• Mine
• Penelope (sister) • My house
• I want one
• Daddy
• Time to go
• Thomas
• Where is it?
• All done (aw
done)
• Lucy (dog)
• Hi mom
• home
• Thomas
• Sit down
• I see it
©2011
©2014 MFMER | slide-138
Target “bins”
Planned Targets Current Targets Generalization
• Bamber Valley
(school)
• I want one
• Penelope (sister) • My house
• Time to go
• Where is it?
• Where is it?
• Thomas
• David (friend)
• Lucy (dog)
• My socks
• Sit down
• I see it
•
•
•
•
•
mine
Hi mom
Daddy
All done
Home/go home
• Time to go
• Sit down (?)
• David (friend)
©2011
©2014 MFMER | slide-139
Include Parents When Possible
• Participate in sessions (under your direction)
• Home practice activities
• See appendix for sample homework
©2014 MFMER | slide-140
Z - “I want to do 10!” – also J
141
©2014 MFMER | slide-141
Eliciting Multiple Repetitions
• See appendix for suggestions
• What tips can you share for eliciting
repetitions?
142
©2014 MFMER | slide-142
Fit the program to
the child,
not the child to
the program
Why did I choose this treatment approach?
Why did I choose these goals?
How will I know whether intervention is working?
143
©2014 MFMER | slide-143
Research to Practice
Alternative Treatments
Know our SLP scope of practice
• Fish oil, supplements, diet
• Hippotherapy
• Listening therapy
• Craniosacral therapy, massage
• Etc.
ASHA Brochure: Questions About New Products
http://www.asha.org/public/speech/consumerqa/
©2011
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©2014 MFMER | slide-144
Research to Practice: AAC
• Myth: If a child is allowed to use AAC, they will
choose to use that mode instead of talking
Schlosser & Wendt, 2008; Romski, et al., 2010
©2011
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©2014 MFMER | slide-145
Research to Practice: Bilinguals
• Bilingual treatment may facilitate greater improvement
than English-only treatment in a child with CAS
(Gildersleeve-Neumann & Goldstein, 2014).
• Minimal research on bilingual intervention suggests that
we should:
• Focus on improving communication skills in all
languages used in home and community
• Consider the extent to which each language is
used/context
• Consider CAS severity
• Be mindful of other factors: cognition,etc.
©2014 MFMER | slide-146
Research to Practice
Literacy
• Literacy IS in our SLP Scope of Practice
• See ASHA Technical Report
Roles and Responsibilities of SLPs with
Respect to Reading and Writing in Children
and Adolescents
• See ASHA Literacy Gateway
©2014 MFMER | slide-147
Research to Practice
Literacy Risk Factors
• Multiple studies have shown that children with
speech impairment have perform less well than
peers on measures of phonological awareness,
reading, spelling and math
• 20% of children with speech disorders will need
special education services in school
©2014 MFMER | slide-148
Research to Practice
Literacy Risk Factors
• Speech and language problems often occur
together
• As many as 60% of children with language
impairment will have a language-based
learning disability
• Having speech and language impairment
together increases the risk
©2014 MFMER | slide-149
What We Know
• There is overwhelming evidence that early
speech-language disorder is a risk factor for
later literacy problems
• There is evidence that early intervention helps
• Proactive monitoring and intervention will be
especially important for children who have both
speech disorder and language impairment
©2014 MFMER | slide-150
Documenting Progress
©2014 MFMER | slide-151
How do we know our treatment is
working?
• Data collection is important
• You should expect to see some changes within
a few sessions
• Rate of change may be slow at first
• Be conscious of criteria – it matters!
• Is the child’s functional ability to communicate
improving?
• Video recordings can be helpful
©2011
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©2014 MFMER | slide-152
Documenting progress
• P – book
• P – book2
• P – protocol
• P - multisyll
©2014 MFMER | slide-153
3-point scoring
• Used in Strand, Stoeckel & Baas, 2006 and
Baas, et al., 2008
2 = correct production
1 = mostly correct, with error in place,
manner or voicing of 1 consonant sound
in the syllable or phrase
0 = vowel distortion and/or more than one
error of consonant production
See Appendix
©2011
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©2014 MFMER | slide-154
Sample Data
Probe rubric
Name: ______Example________________
Scoring: 2 = accurate production
1 = mostly accurate, with error of place, manner or voicing on one consonant
0 = vowel distortion and/or more than one error of consonant production
Date
Syllable/phrase
Responses in Direct Imitation
10/30
Go home
0
0
1
0
1
Total
Points
2
mommy
1
2
1
1
1
6
11/5
Go home
1
0
1
1
2
5
11/11
mommy
2
2
2
1
2
9
10/31
©2011
©2014 MFMER | slide-155
Sample Data
12
10
8
hi
me
out
all done
6
4
2
0
Time 1
Time 2
Time 3
©2011
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©2014 MFMER | slide-156
Sample Data
12
10
8
6
X
4
hi
me
out
all done
2
0
Time 1
Time 2
Time 3
©2011
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Sample Goal
(Child) will improve motor planning/programming skills
for speech production by increasing accuracy of
production of a functional core vocabulary. Criteria:
cumulative accuracy of 80% for each item.
a. Accuracy in CV, VC, CVC syllable shapes:
(EXAMPLES: me, no, more, mine, hi, up, on, etc)
b. Syllable sequences (EXAMPLES: no more, go
home, time to go, my turn, hi mom, etc.)
©2011
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• Goal is written to expand both sound and syllable
repertoire, with flexibility in the targets used.
• As the child meets criteria for one item from the stimulus
set, it moves to “everyday use”; a new one is inserted from
a list generated with the help of parents and/or teachers.
• Progress is reported in terms of accuracy for each
individual item on the list and as number of stimulus items
achieving criterion.
©2011
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Progress Review example
(Child) has met criterion for “me”, “no”, “up”, “go”,
“my turn”, and “hi mom.”
Current targets:
70% cumulative accuracy for “go home”
60% cumulative accuracy for “sit”, “mine”
40% cumulative accuracy for “computer”,
“Thomas”
©2011
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©2014 MFMER | slide-160
Video
• L cars
• P series early to final
©2014 MFMER | slide-161
Treatment Review
and
Decision-Making
©2011
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©2014 MFMER | slide-162
Treatment Review
• There is no single management procedure or
program that is most appropriate for CAS
• But evidence base is beginning to grow
• Treatment will likely need to be adjusted over
time to address the child’s progress (or lack of
progress)
• Ongoing assessment will help to identify
what issue is primary
©2014 MFMER | slide-163
164
Treatment Review
• We can make use of best available evidence as
rationale for incorporating some of these
techniques:
©2014 MFMER | slide-164
Treatment Review
• Teach movement sequences vs isolated
phonemes
• Use multisensory input (auditory, visual, tactile)
• Incorporate principles of motor learning
• Be intentional in manipulating frequency and
intensity of practice
©2011
©2014 MFMER | slide-165
166
Treatment Review
• Think about range of difficulty in targets
(remember that challenge can facilitate motor
learning)
• Adjust the level of cueing carefully
• Make thoughtful use of commercial materials
• Include caregivers as much as possible
©2014 MFMER | slide-166
Questions?
©2014 MFMER | slide-167
[email protected]
©2011
©2014 MFMER | slide-168