Agenda for Todays Workshop Treatment Approaches, Strategies, - - PDF document

6/6/2019 1 Treatment Approaches, Strategies, And Ideas For Involving Caregivers In Therapy For CAS

Organized by Apraxia Kids Co-sponsored by Rush University Department of Communication Disorders and Sciences 6-15-19 Chicago, IL Presented by:

Mindy Vasilakopoulos PediaProgress Downers Grove, IL Margaret (Dee) Fish Fish Speech Services Northbrook, IL Aubry Cortez PediaProgress Downers Grove, IL

Agenda for Today’s Workshop

• General Introduction to CAS

– Definition and features/characteristics – Overview of treatment considerations

• Overviews of Evidence-Based Treatment Programs

– Dynamic Temporal and Tactile Cueing (DTTC) – Kaufman Speech to Language Program (K-SLP) – Integrated Phonological Awareness Intervention (IPA) – Multisensory Cueing (Various Approaches)

Agenda for Today’s Workshop

• Overviews of Evidence-Based Treatment Programs

(cont’)

– Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT) – Motor Speech Treatment Protocol (MSTP) – Rapid Syllable Transitions Program (ReST) – Tactile Biofeedback (Speech Buddies) – Visual Biofeedback (Ultrasound Biofeedback; Elecropalatography)

Agenda for Today’s Workshop

• Breakout Sessions

– Session 1 Ideas for Involving Caregivers in Therapy

• Overcoming barriers to caregiver involvement
• Teach, Model, Coach, Review
• Case Studies

– Session 2 Evaluation and Differential Diagnosis

• Components of a Thorough Motor Speech Evaluation
• Comparison of CAS, Phonological Impairment, Dysarthria
• Case Studies

Childhood Apraxia of Speech (CAS)

• CAS is a neurological childhood (pediatric) speech sound

disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.

Childhood Apraxia of Speech: Position Statement, ASHA 2007

Three Key Features of CAS

• a.) inconsistent errors on consonants and vowels

in repeated productions of syllables and words

• b.) lengthened and disrupted coarticulatory

transitions between sounds and syllables (sequencing)

• c.) inappropriate prosody, especially in the

realization of lexical or phrasal stress

Childhood Apraxia of Speech: Position Statement, ASHA 2007

6/6/2019 2 Characteristics of CAS

• Limited repertoire of vowels / vowel errors
• Variability of errors
• Vowel errors or distortions
• Struggle or "groping" for articulatory position may be observed
• Pre-rehearsed or modeled utterances easier than volitional, self-

initiated utterances

• Impaired rate/accuracy on diadochokinetic tasks
• Gaps/pauses between syllables (even small gaps)
• Difficulty with prosody including overall slow rate; “choppy” and

monotone speech

• Receptive language skills almost always higher than expressive

www.apraxia-kids.org/apraxia_kids_library/what-is-childhood-apraxia-of-speech/

Qualities of Effective Treatment Programs

• Frequent, shorter therapy sessions 3-5 times per week
• INDIVIDUALIZED - No treatment plan or program should be

the same for different children

• Motor-Programming Approach

– Frequent, intensive practice – Focus on actual skill (accurate speech movement) – Enhanced external sensory input (cognitive, visual, auditory, tactile, and kinesthetic cues) – Types of practice (random vs. blocked) – Appropriate feedback – Vary rate

www.apraxia-kids.org/apraxia_kids_library/general-treatment-principles/

Multisensory Cueing

• Foundation of various treatment approaches
• Should be chosen according to the child's:

Responses Learning style Current level of functioning Patterns of errors

Fish, 2016, p. 133

Multisensory Cueing – Types of Cues

• Visual - Model of the mouth posture
• Auditory - Verbal model
• Tactile - Touch
• Kinesthetic - One's internal sense of movement
• Proprioceptive - Internal sense of how body parts are moving in

space, sense of force/effort of movement and sense of speed of movement

• Metacognitive – Associative cue; Description of the speech

movements

Fish, 2016, pp. 134-135

Kaufman Speech-to-Language Protocol (K-SLP)

• Based on applied behavior analysis (ABA) and applied verbal behavior (AVB)
• Incorporates the principles of motor learning
• Uses phonological processes to simplify words to best approximations

Strategies:

• 1. Define the behavior
• 2. Establish motivation
• 3. Model and cue
• 4. Implement errorless teaching / learning
• 5. Understand shaping
• 6. Mix & vary tasks
• 7. Practice the new skill
• 8. Practice in the child's natural environment

http://www.kidspeech.com/the-kaufman-speech-to-language-protocol/

Dynamic Temporal and Tactile Cueing (DTTC)

• Developed by Edythe Strande, PH.D.
• Appropriate for children 3 yrs. and older with severe speech

sound disorder (SSD), including those who have little or no functional verbal communication, but who can attempt imitation

• A variation of integral stimulation (introduced in the 1950s by

Milisen for articulatory treatment, "listen to me, watch me, do what I do")

• Based on Eight-step Continuum for Treatment of Acquired

Apraxia of Speech (Rosenbeck, Lemme, Ahern, Harris & Wertz, 1973)

https://www.apraxia-kids.org/apraxia_kids_library/integral-stimulation-method-adapted-for-children-as-dttc/

6/6/2019 3

DTTC Hierarchy of Cueing

• 1. Direct imitation
• 2. Simultaneous production with prolonged vowels
• 3. Reduction of vowel length
• 4. Gradual increase of rate to normal
• 5. Direct Imitation
• 6. Reduction of SLPs vocal loudness, eventually miming
• 7. Direct imitation
• 8. One to two second delay imitation
• 9. Spontaneous production

Integrated Phonological Awareness Intervention

• Simultaneously addresses: speech production, phonemic

awareness, and letter-sound association

• Teaches a variety of phonological awareness skills in the

context of articulation therapy, thus increasing efficiency of treatment

– Letter knowledge – Phoneme identity and Phoneme matching – Phoneme blending – Segmenting

https://www.canterbury.ac.nz/media/documents/education-and-health/gail-gillon---phonological-awareness- resources/programmes/preschool/01-Integrated-Phonological-Awareness-Manual-Sept-07.pdf **FREE 49 page resource

Integrated Phonological Awareness Intervention

• 2009 study by McNeill et al. examined use of

IPA Intervention in children with CAS – findings suggest IPA facilitates improved speech production and phonological awareness in some children with CAS

• Appropriate for children with mild – to – moderate CAS

and phonological impairment, preschool and older, who struggle with (or are at risk for) both motor speech control and phonological awareness

PROMPT

• Prompt is used for children with a variety of speech

sound disorders, including children with various types of motor speech involvement (MSI) (dysarthria, CAS, MSI- NOS).

• Incorporates specific tactile/kinesthetic/proprioceptive

cues to facilitate accurate production of phonemes, words, phrases

• Ultimate goal is to develop “the independent, flexible

and coordinated use of all articulators … for efficient speech production” (Hayden, 2004, p. 97)

Dale PS, Hayden DA (2013)

(Rapid Syllable Transitions) ReST

• Used primarily for older children (ages 5+) with mild to

moderate CAS who can sustain attention to structured tabletop work

• Designed for children with CAS to facilitate improved:
• Phoneme accuracy and consistency
• Speed and fluidity of transitions from one syllable to the

next

• Appropriate lexical stress
• Targets used are phonotactically permissible pseudo-

words (CV.CV, CV.CV.CV) with varied stress assignment

Murray E, McCabe P, Ballard KJ. 2015

SAMPLE ReST NONSENSE WORDS

http://sydney.edu.au/health-sciences/rest/

6/6/2019 4 Tactile Biofeedback

• Speech Buddies is used for children struggling to

achieve accurate production of some later developing phonemes

• Provides tactile input to elicit correct lingual

placement for production of the following phonemes “s/z; sh; ch/j; l; r”

• Ultimate goal is to develop increased articulatory

accuracy for 7 later developing phonemes first in isolation and ultimately in connected speech

VISUAL BIOFEEDBACK

• Ultrasound biofeedback
• Electropalatography (SmartPalate technology)

https://completespeech.com/smartpalate/

Ultrasound Biofeedback

• Ultrasound biofeedback is used primarily for older

children age 7+ with persistent speech sound disorders, including CAS

• It provides visual cueing by way of ultrasound

technology to elicit correct tongue placement for production of lingual phonemes

• Ultimate goal is to develop increased phoneme

accuracy and improved overall speech intelligibility.

Preston JL, Brick N, Landi N (2013)

Electropalatography

• The SmartPalate technology is used for grade-school

children through adult who have struggled to achieve certain lingual consonant phonemes

• Designed to:
• Increase tactile awareness of and more accurate

production of phonemes in which there is tongue to palate or lip to lip contact.

• Ultimate goal is to develop increased phoneme

accuracy and improved overall speech intelligibility.

Lundeborg, I., & McAllister, A. (2007)

When a child is diagnosed with childhood apraxia

• f speech, it suggests the child has difficulty with

speech

PRAXIS

• PRAXIS is different than EXECUTION
• PRAXIS is different than trouble learning the

sound system and rules that govern the sound system of a given language

• Children with PD have difficulty developing

phonological representations (phonological mapping) of the sound system of the language

6/6/2019 5

What is PRAXIS?

• PRAXIS involves the ability to conceptualize

(ideation), PLAN, and PROGRAM skilled volitional movement.

• It requires accurate specification of various

spatiotemporal parameters of movement sequences.

PLANNING AND PROGRAMMING SPEECH MOVEMENTS

• Planning – In motor planning, specifications are made related to

placement and manner for articulatory movements, as well as timing of specific movements for each sound and sequence of sounds.

• Programming – In motor programming, specifications are made

related to degree of muscle tone, velocity of movement, force, range of motion, and degree of stability of joints. Apraxia-Kids, Anita van der Merwe https://www.apraxia-kids.org/apraxia_kids_library/speech-motor- learning-in-cas/ retrieved 3-15-19

DISTINGUISING FEATURES

According to the ASHA Ad Hoc 2007 Committee three segmental and suprasegmental features were identified as gaining some consensus as being key characteristics of speech samples:

• Inconsistent errors on consonants and vowels in

repeated productions of syllables or words

• Lengthened and disrupted co-articulatory transitions

between sounds and syllables

• Inappropriate prosody, especially in the realization of

lexical or phrasal stress These characteristics alone don’t warrant a dx of CAS.

MAYO CLINIC SYSTEM TO CLASSIFY CHILDREN W/ CAS

10 signs of CAS – Child must meet criteria for at least 4 signs in at least 3 of 17 speech tasks on the research protocol to be described as CAS

• 1. Vowel distortions
• 6. Intrusive schwa
• 2. Voicing errors
• 7. Increased difficulty w/ multisyllabic

words

• 3. Distorted substitutions

8 Syllable segregation

• 4. Difficulty achieving initial articulatory

configurations or transitory movement gestures

• 9. Slow speech rates and/or

diadochokinetic rates

• 5. Groping
• 10. Equal stress or lexical stress errors

Other Research in Feature Analysis Leading to Differential Diagnosis Murray et al 2015

These 4 measurements on 2 assessment tasks led to 91% diagnostic accuracy against expert diagnosis: 1. Occurrences of Syllable Segregation 2. Reduced accuracy of Lexical Stress Matches 3. Reduced percentage phonemes correct from Multisyllabic Words 4. Reduced articulatory accuracy on diadochokinetic tasks – specifically in repetition of /pətəkə/ Task #1- multisyllabic word production Task #2- diadochokinetic testing as part of thorough oral motor exam. What about inconsistency and groping?

CAS SPEECH-RELATED CHARACTERISTICS

• Initial articulatory configurations
• Articulatory movement sequences/word shapes
• Phonemic challenges: consonants
• Frequent vowel errors/distortions
• Inconsistency

6/6/2019 6 CAS SPEECH-RELATED CHARACTERISTICS

• Complexity
• Gaps between words, syllables and sometimes between

sounds

• Groping/trial & error behavior
• Diadochokinesis (especially, prosodic & timing errors)
• Prosody and Suprasegmentals

CAS SPEECH-RELATED CHARACTERISTICS

• Connected speech
• Early vocalizations/babbling
• Automatic versus volitional productions
• Regression

CAS NON-SPEECH CHARACTERISTICS

• Difficulty with volitional, non-speech oral movements (may
• r may not accompany verbal apraxia)
• Early feeding
• Limb and/or hand praxis
• Receptive and expressive language
• Morphology and syntax
• Attainment of first words
• Literacy/preliteracy

DIFFERENTIAL DIAGNOSIS (Apraxia-kids.org)

CAS DYSARTHRIA PHONOLOGICAL DISORDER ARTICULATORY STRENGTH Not significant Reduce strength; possible paralysis No weakness INVOLUNTARY ORAL MOVEMENT Not impaired Impaired Not impaired INCONSISTENCY Yes Generally consistent Generally consistent VOWELS Often impaired May be impaired Usually good CONSONANT ERRORS O/D/S; Some Initial position

• missions

Primarily distortions O/D/S; Usually FCD PROSODY Often impaired Related to type of dysarthria Generally good VOICE QUALITY/ RESONANCE Usually appropriate; possible resonance differences Often impaired: hoarse, harsh, breathy, hypernasal Appropriate

EVALUATION COMPONENTS

• Complete a thorough Case History
• Take time just to observe and note:

– speech characteristics – language characteristics (R and E) – social/interactive characteristics – ideation in play – fine and gross motor skills; posture

• Oral Motor Examination (including observation
• f structure/function/diadochokinetic skills)

6/6/2019 7 EVALUATION COMPONENTS

• Based on your observations, complete formal and informal

measures to sufficiently tax the motor speech system – Increasing syllable shape complexity (e.g., “top” (CVC); “stopped” (CCVCC) – Increase # of syllables in the word (e.g., miss, _________, __________; hippo, __________; person/________, __________) – Increase phonetic complexity (cocoa/cookie/cozy) – Increase linguistic complexity (phrases/sentences) – Varied syllable or sentence stress (button/balloon; I ate 6 cookies; I ate 6 cookies; I ate 6 cookies)

• Formal assessments may need to be supplemented with

informal tasks

EVALUATION COMPONENTS

• DYNAMIC CUEING is ESSENTIAL!!! It provides

information about:

– beneficial cues for treatment – complexity of cues required – severity – prognosis – development of goals and treatment targets – # of targets to focus on w/in each session – recommendations for # and distribution of treatment minutes

DYNAMIC CUES may include:

• Setting up initial articulatory configuration
• Simultaneous production
• Reduced rate
• Miming
• Backward or forward chaining
• Phonetic placement cues
• Tapping out syllables
• Tactile cues to facilitate phoneme accuracy or

sequencing

ANALYSIS OF FINDINGS

Note any findings related to…

• Groping or trial & error behavior
• Difficulty achieving initial articulatory configuration for

an utterance

• Increased difficulty with increased complexity
• Syllable segmentation/gaps
• Lexical and contrastive stress errors or excessive and

equal stress

• General prosody patterns – rhythmicity,

chunking/pausing (we’ll discuss more later)

• Stimulability and response to cueing

ANALYSIS OF FINDINGS

Note any findings related to…

• Difficulty imitating and sequencing nonspeech motor

movements

• History of difficulty with feeding
• Delayed development of language/vocabulary
• Delayed development of or limited volubility of babbling
• Difficulties with morphology and syntax
• Social/pragmatic language difficulties
• Difficulty with phonological/literacy skill development
• Poor fine and/or gross motor coordination
• Late attainment of motor milestones

6/6/2019 8

POSSIBLE REASONS FOR LIMITED LANGUAGE AND/OR SPEECH INTELLIGIBILITY

Cognitive impairment Receptive and/or expressive language impairment Social language impairment (Including by not limited to Autism) Hearing impairment Other physiological impairment (e.g., cleft palate) Phonological impairment Dysarthria CAS

Case Study #1 - Eli

INITIAL PHONE CONVERSATION WITH MOTHER

• Age: 3 years, 2 months
• Recent audiological exam – normal findings
• Significant History- Frequent ear infections; recent

big leap of progress in speech therapy Current SLP suspects CAS Mother reported most people have trouble understanding him; gets easily frustrated when misunderstood and will throw toys and hit

Case Study #1

Target Word Eli’s Production

daddy “daddy” blue dinosaur “boo di.uh.au” sun, shoe, funny “un” “oo” “unny” bus “bus” pajamas “pa.da.mas” cookie “too.tie” pepperoni “pep.puh.wo.ni” alligator “a.wi.da.do” spoon “poon” Baby eat ice cream “baby ea ice weam” I not see it. “I nah ee ih.”

POSSIBLE REASONS FOR LIMITED LANGUAGE AND/OR SPEECH INTELLIGIBILITY

Cognitive impairment Receptive and/or expressive language impairment Social language impairment Hearing impairment Other physiological impairment (e.g., cleft palate) Phonological impairment Dysarthria CAS

CASE STUDY #2: Molly

Madeline W: age 3.6 years MOTHER REPORTED:

• Significant medical history: bilateral ptosis,

amblyopia, torticollis, plagiocephaly, hip rotation, 2 surgeries to correct ptosis

• Vision corrected with glasses
• Normal audiological findings
• Late attainment of motor and speech milestones
• She has been reading online and believes Madeline

has CAS – SLP agreed

CASE STUDY #2

Target Word Production Target Word Production /a/ /a/ /ʌ/ /ʌ/ /ɔ/ /ɔ/ /o/ /a/ /u/ /ʌ/ /mama/ /mʌ/ /dada/ /dʌ/ /bu bu/ /bʌ/ /beɪbi/ /ma/ /baɪ/ /bʌ/ /daʊn/ /dʌ/ /no/ /mʌ/ /yɛs/ /ʌ/ /go/ /ʌ/ /pʌpi/ /ba ba ba ba/ /baɪ baɪ/ /ba ba ba/

6/6/2019 9

POSSIBLE REASONS FOR LIMITED LANGUAGE AND/OR SPEECH INTELLIGIBILITY

Cognitive impairment Receptive and/or expressive language impairment Social language impairment Hearing impairment Other physiological impairment (e.g., cleft palate) Phonological impairment Dysarthria CAS

Case Study #3 - Max

INITIAL PHONE CONVERSATION WITH MOTHER

• Age: 3 years, 6 months
• GERD resolved by 18 months
• In speech for past 2 years
• Diagnosis Phonological Disorder
• Slow progress
• Shy with strangers and slow to warm up at school
• Highly unintelligible

Target Word Production Target Word Production water /wawa/ /wadʊ/w/m dino /dado/ bike /baɪ/ carrot /gɛ/ eye /aɪən/ blue /bu/ daddy /dadi/ apple /abo/ cup /bup/ see /ji/ shoe /ju/ bus /bʌh/ baby /bɛbi/ cow /gaʊ/ baby cow /bɛ ga/ dino /dado/ CASE STUDY #3

POSSIBLE REASONS FOR LIMITED LANGUAGE AND/OR SPEECH INTELLIGIBILITY

Cognitive impairment Receptive and/or expressive language impairment Social language impairment Hearing impairment Other physiological impairment (e.g., cleft palate) Phonological impairment Dysarthria CAS

FOLLOWING ASSESSMENT, WE MAKE IMPORTANT CLINICAL DECISIONS

• Eligibility (Is this child eligible for speech-language

services?)

• Number of treatment minutes per week
• Distribution of treatment minutes (number/length of

sessions)

• Individual, dyad/small group, larger group (only 1-1 or

combo)

• Syllable shape goals
• Phoneme goals

FOLLOWING ASSESSMENT, WE MAKE IMPORTANT CLINICAL DECISIONS

• Prosody goals
• Language goals
• Feedback: frequency, type, timing
• Beneficial types of cueing
• Possible early target utterances (with emphasis on

functional targets from your great POWER VOCABULARY TARGETS slides)

6/6/2019 10 References

• American Speech-Language-Hearing Association. (2007). Childhood

apraxia of speech [Position Statement]. Available from www.asha.org/policy.

• Fish, M. (2016). Here's How to Treat Childhood Apraxia of Speech,

Second Edition. Plural Publishing. San Diego, CA.

• Gomez, M, McCabe, P, Jakielski, K, & Purcell, A. (2018). Treating

Childhood Apraxis of Speech with the Kaufman Speech to Language Protocol: A Phase I Pilot Study. Language, Speech, and Hearing Services in Schools. 49(3), 524-536

• Mass, E, Gildersleeve-Neumann, C, Jakielski, JK, Stoekel, R,

(2014). Motor-based intervention protocols in treatment of childhood apraxia of speech (CAS). Current Developmental Disorders Reports. 1(3), 196-206.

• Maas E, Robin DA, Austermann Hula SN, Freedman SE, Wulf

G, Ballard KJ, & Schmidt RA. (2008). Principles of motor learning in treatment of motor speech disorders. American Journal of Speech- Language Pathology. 17(3), 277-98.

• McNeill, BC, Gillon, GT, Dodd, B. (2009). Effectiveness of an

integrated phonological awareness approach for children with childhood apraxia of speech (CAS). Sage Journals. 25(3), 341-366.

• Murray, E, McCabe, P, & Ballard, KJ. (2014). A Systematic Review of

Treatment Outcomes for Children With Childhood Apraxia of

• Speech. American Journal of Speech-Language Pathology. 23, 486-

504.

• Rosenbeck, JC, Lemme, ML, Ahern, MB, Harris EH, & Wertz RT.

(1973). A treatment for apraxia of speech in adults. Journal of Speech and Hearing Disorders, 38(4), 462-72.

• Strand, EA, Stoeckel, R, & Baas, B. (2006). Treatment of Severe

Childhood Apraxia of Speech: A Treatment Efficacy Study. Journal

• f Medical Speech-Language Pathology. 14(4), 297-307.
• Dale PS, Hayden DA (2013). Treating speech subsystems in

childhood apraxia of speech with tactual input: the PROMPT

• approach. Am J Speech Lang Pathol 22(4): 644–666. DOI:

10.1044/1058-0360(2013/12-0055).

• Lundeborg, I., & McAllister, A. (2007). Treatment with a

combination of intra-oral sensory stimulation and electropalatography in a child with severe developmental

• dyspraxia. Logopedics Phoniatrics Vocology, 32(2), 71–79.
• Murray E, McCabe P, Ballard KJ. A randomized controlled trial

for children with childhood apraxia of speech comparing rapid syllable transition treatment and the Nuffield Dyspraxia Programme -Third Edition. Journal of Speech, Language, and Hearing Research2015;58(3):669-86. [DOI: 10.1044/2015

• Preston JL, Brick N, Landi N (2013). Ultrasound biofeedback

treatment for persisting childhood apraxia of speech. Am J Speech Lang Pathol 22(4): 627–643. DOI: 10.1044/1058-0360(2013/12- 0139)

• Preston JL, Leece MC, Maas E. Motor-based treatment with and

without ultrasound feedback for residual speech-sound

• errors. International Journal of Language and Communication

Disorders2017;52(1):80-94. [DOI: 10.1111/1460-6984.12259