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Children with Developmental Apraxia of Speech Communication Profiles and Interventions Laura J. Ball, Ph. D. Munroe-Meyer Institute for Genetics and Rehabilitation.

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Presentation on theme: "Children with Developmental Apraxia of Speech Communication Profiles and Interventions Laura J. Ball, Ph. D. Munroe-Meyer Institute for Genetics and Rehabilitation."— Presentation transcript:

1 Children with Developmental Apraxia of Speech Communication Profiles and Interventions Laura J. Ball, Ph. D. Munroe-Meyer Institute for Genetics and Rehabilitation University of Nebraska Medical Center, Omaha

2 Demographics Onset Course Gender Prevalence Aggregation

3 Research Classifications Unitary Entity: isolate one characteristic that differentiates DAS from other childhood speech problems. Syndrome does not require one “necessary and sufficient” dx criterion. Subtypes:behavioral characteristics are associated with dx criteria for each of 2+ subtypes of the disorder.

4 Theoretical Perspective Shriberg, (1997a, 97b, 97c) present a schema for speech production in DAS with linguistic processing stages. 1. Input processes (auditory-temporal, perceptual) 2. Organizational processes ( representational, transformational) 3. Output processes (selection-retrieval, pre- articulatory sequencing) 4. Articulatory execution.

5 DAS: Deficit in Input Processes? Auditory-Temporal & Perceptual input processes are usually proposed from 2 general perspectives. Children with DAS have: 1. Across-the-board deficits in language processes. 2. Specific deficits in either formulation or transformation of appropriate phonological representations.

6 Robin, (1993) noted that children had disordered prosody, suggesting that “impaired temporal perception could impact ability to gain information about durational aspects of prosody and add to the observed prosodic difficulties.”

7 DAS: Deficit in Organizational Processes? Representational & Perceptual Organization Velleman & Strand (1994) implicate representational processing. They suggest that children with DAS “could be seen as impaired in their ability to generate & utilize frames, which would otherwise provide the mechanisms for analyzing, organizing, & utilizing information from their motor, sensory, & linguistic systems for the production of spoken language.”

8 Maassen, Thoonen, & Gabreels (1993): Children with DAS demonstrate a “phonological encoding disorder.”

9 Snow, Marquardt, & Davis (1992): Children with DAS “demonstrate an apparent breakdown in the ability to perceive ‘syllableness’ and access & compare syllable representations with regard to position & structure.”

10 Groenen, Crul, Maassen, & Thoonen (1993): “weaker auditory memory traces” suggest perceptual discrimination tasks have diagnostic value. “The degree of dysfunction in speech production is related to the degree of dysfunction in speech perception.”

11 Transformational Organization Morphophonemic, allophonic & sociolinguistic rules appear to be intact.

12 DAS: Deficit in Output Processes? Pre-articulatory Sequencing (most prevalent) attributes the variability observed in speech output to deficits in pre-articulatory sequencing of the spatio-temporal movements for speech sounds.

13 Selection-Retrieval Phonetic variability involves a lower-level deficit in motor programming, rather than retrieval of phonemic units. Walton & Pollack (1991) “motor theory”: “Although one could argue that there is a phonemic confusion in the speech of these children, one could also argue that their ability to demonstrate these contrasts is lost when their motor systems are taxed or challenged.”

14 DAS is a disorder of movement

15 Diagnostic Features Speech Errors: Differ from errors of children with developmental delay, phonological processes. Resemble errors of adult acquired apraxia (contrast between voluntary and involuntary performance, variability of errors). Differ from dysarthria, which has errors in phonation, resonance, articulation & prosody.

16 DAS impacts all aspects of communication

17 Why do we Communicate? Light (1988) identified four purposes of social communication: 1. expression of wants or needs, 2. transfer of information, 3. social closeness, and 4. social etiquette.

18 Important Aspects 1. DAS as a disorder of movement 2. DAS as a disorder impacting all aspects of communication

19 DAS Defined Typically defined in terms of sound production error patterns, 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.

20 DAS is a disorder of movement

21 Survey of SLPs Participants regional SLP’s treating DAS Profiles children actually in treatment Perspective clinical awareness vs. “pure” research version

22 Profiles

23 DAS & Communication: Characteristics Decreased intelligibility Disordered language Social withdrawal Behavioral aggression Academic failure

24 Important Aspects… gee, notice a pattern here? 1. DAS as a disorder of movement 2. DAS as a disorder impacting all aspects of communication

25 Screening for DAS Address increase in referrals & diagnoses of DAS among preschool population Short administration time Organize, streamline assessment process Increase assessment efficiency Morehouse & Linderman, 2000

26 Screening for Developmental Apraxia of Speech (SDAS) Oral Motor Movements Phoneme Stimulability Intelligibility Checklist of DAS Characteristics Increasing Word Length Multisyllabic Words Across Trials Interpretation & Recommendations Morehouse & Linderman, 2000

27 Assessment of DAS (Strand, 1998) Neuromuscular Muscle strength, tone, & coordination Reflexes Sensory function Structural Function Structures, tissue characteristics, & sensation Range of motion, strength, coordination, speed, & ability to vary muscle tension.

28 Motor Speech Production Simple to complex phonetic sequencing: CV, VC, CVC (vary the vowel) monosyllabic words multisyllabic words phrases sentences of increasing length

29 Assess at Level of Breakdown Examine any vowels NOT heard in spontaneous speech Examine CV/VC combinations, also omitting those heard in spontaneous speech Examine CVC productions, omitting those heard in spontaneous speech same 1st & last phoneme different 1st & last phoneme

30 simultaneous production with examiner direct imitation delayed imitation Examine Words of Increasing Length

31 simultaneous production with examiner direct imitation delayed imitation Examine Multisyllabic Words

32 Respiration Laryngeal function Resonance: Large number hyper- nasal hypo- nasal mixed nasality Physiological functioning for speech production

33 Articulation & Phonology What evaluation procedures would be most appropriate to address the needs of children with DAS? What evaluation procedures would be most appropriate to address the needs of children with motor-based speech disorders?

34 Intelligibility & Comprehensibility What are the most appropriate means of assessing intelligibility in young children? How might you get a measure of a child’s comprehensibility vs. intelligibility?

35 Intelligibility/Comprehensibility Index of Augmented Speech Comprehensibility in Children (I- ASCC) (Dowden, 1997) A non-standardized clinical measure to assess comprehensibility.

36 I-ASCC Hierarchy Present a picture with a verbal cue such as “What is this?” Present a picture and provide contextual cues such as “It’s a food you might eat. What is it?” Present a picture plus an embedded model such as “It’s pizza. Now you say it.”


38 Intelligibility Judge listens to taped utterances without contextual cues and transcribes.

39 Comprehensibility After listening to & judging the entire set of utterances without contextual cues, the listener rewinds the tape, reads a contextual cue and transcribes again.

40 Contextual Cues Something children eat at snack time. Something children use during craft time. Something children eat for lunch. Clothing young girls wear outside. What you see children doing with a book.

41 Language What current methods exist to measure expressive language in unintelligible children? What are the most appropriate assessment procedures for assessing both receptive and expressive language in children with DAS?

42 Clinically, consider of ALL of the following: Movement skills Receptive & expressive language skills Physical structures and functions Comprehensibility Communication repertoires in use

43 Differential Diagnosis Determine which characteristics are most readily apparent. Are there dominant speech characteristics? Dysarthria vs. DAS Fluency disorder vs. DAS Phonological disorder vs. DAS Developmental articulation vs. DAS

44 Research Questions What attributes of overall communication disabilities are found in children with DAS? Do clusters based on communication disabilities exist for children with DAS?

45 Methods N=36 children with DAS Screening: DAS Screening Instrument (Blakeley, 1980) Child Social Interaction Scales (Adapted from Booth-Butterfield and Gould, 1986; Duran, 1992; Wiemann, 1977; Canary and Spitzberg, 1987; McCrosky, 1982; Christophel, 1990; and Burgoon, 1976.)

46 Criteria for Inclusion Committee of 3 DAS experts rated “degree of DAS” A mean score  3, considered DAS

47 Articulation and Phonology Do children with DAS use phonological processes? Examine consistency of productions. Khan-Lewis Phonological Analysis Articulation & prosody Goldman-Fristoe Test of Articulation Consider impact on language skills & reading development

48 Language sample if intelligibility allows Comprehensive receptive & expressive Morphology & syntax Test of Auditory Comprehension of Language (III) (1998) Peabody Picture Vocabulary Test (IIIA/B) Language

49 Communication Social communication skills Behavioral communication repertoires Academic communication skills Social Skills Rating System (Gresham and Elliott, 1990)

50 Assessment Procedures Contributing to DAS Profile Identification

51 Profile Communication Aspects Intelligibility & Comprehensibility Language (receptive & expressive) Social Behavioral Academic

52 Cluster Analysis Measure used to examine large data set and determine if there are patterns of similarity among the variables. Results in “dendrogram” (see diagram) which depicts the total data set and each stage of grouping the most similar data points (or in this case, children with DAS) into clusters.

53 Cluster Analysis Confirmatory measure of profiles previously obtained (Ball & Beukelman, 1998). Classifies sample into smaller number of mutually exclusive groups based on similarity. Variables analyzed simultaneously to discover underlying structure.

54 Significant Discriminant Functions

55 Profile Identification Procedures Discriminant Function Structure Weights Articulation-oriented Function 1 Articulation-.531 DAS.488 Intelligibility.481 MLU.452 PCC.413 Language-oriented Function 2 Parent/behavior Language comprehension.434 Receptive Vocabulary.363 Phonological skills.347

56 Cluster One, n = 12 high # articulation errors high social skill ratings high DAS scores (very DAS) few consistent phonological processes low intelligibility low vocabulary scores high disruptive behaviors low receptive language scores small MLU low PCC

57 Cluster Two, n = 12 high # articulation errors high social skills ratings less DAS many consistent phonological processes low intelligibility high vocabularyscores few disruptive behaviors high receptive language scores high MLU high PCC

58 Cluster Three, n = 1 high # articulation errors many consistent phonological processes more DAS low intelligibility low vocabulary scores less socially interactive many behavioral disruptions low receptive language skills low MLU low PCC

59 Cluster Four, n = 11 low # articulation errors few consistent phonological processes less DAS high intelligibility high vocabulary scores less socially interactive few behavioral disruptions high receptive language scores high MLU high PCC

60 I II IV High Articulation Err; Low Language X X Low Articulation Err; High Language X High Behavior Probs.; Low Language X X Low Behavior Probs.; High Language X Cluster Status on Significant Variables


62 Intervention

63 Motor Learning Theory Motor learning occurs as a result of experience & practice Relevant factors: Precursors to Motor Learning Conditions of Practice Knowledge of Results Effects of Rate

64 Motor Learning: Prepractice The prepractice portion of a therapy session involves: Motivation make the tasks seem important set goals with the child with standard to achieve not just “do the best you can” Focused Attention

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

66 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

67 Establish Reference of Correctness auditory feedback i.e., for /pa/, may have lip closure as correct to begin, then later move to correct articulation

68 Motor Learning: Practice Knowledge of Performance Knowledge of Results summary immediate Repetitive Practice mass distributed

69 Knowledge of Performance (KP) Feedback about the correctness of a particular movement pattern re: accuracy of production. e.g., “I heard you say ….”

70 Knowledge of Results (KR) Feedback about the outcome of a movement pattern re: environmental goal. e.g., “Yes, you got it!” “No, that’s not quite it.”

71 Avoid extraneous activity (speaking, movements by clinician/child) during the period between the response & when you deliver KR, also after KR

72 Summary KR is better than immediate KR, better to wait until several (easier wait 15, difficult wait 3-5) responses are obtained

73 Conditions of Motor Speech Practice (DAS) Repetitive Practice need enough trials/session to allow motor learning to occur & become habituated to automatic use reinforcements that don’t take time develop activities that facilitate repeated opportunities for production of target movement patterns

74 Mass vs. Distributed Practice decision depends on severity and type mass yields quick development of accurate production distributed requires longer time, but get better generalization direct imitation delayed imitation

75 Examine Sentences of Increasing Length direct imitation with repeated attempts

76 Speech Practice for DAS Intensive treatment is required Large number of movement repetitions required (no fewer than 20) Come to neutral position between attempts (rest), do NOT divide into component parts Progress through hierarchy of task difficulty Treat rhythm, stress & intonation to coincide with articulation drills

77 Augmentative and Alternative Communication Children with DAS

78 Integrating AAC and Natural Speech Extent of AAC use depends upon the communication load that can be carried by natural speech. Extent of AAC use will vary from child to child. Extent of AAC use will vary for a child depending on the communication goal.

79 Lindblom Model of Mutuality Rich Information from the acoustic signal (Intelligibility) Poor Poor Signal-Independent Rich Information Lower Comprehensibility Higher Comprehensibility

80 Intelligibility Estimates Mother 85% Grandmother 30% School SLP 30% Classroom teacher 50% AAC Specialist 25-30%

81 AAC Use & Intelligibility of Children with DAS N = 36 children confirmed with DAS M = 6 years, 1 month age M = 44% intelligibility Range of intelligibility from 0 to 97% N = 1 child using AAC at time of evaluation for DAS

82 Use of AAC systems by Children with DAS (Cumley, 1997) Participants were children with severe phonological disorder and/or DAS N = 16 Children 3 yrs, 5 months to 7 yrs, 5 months

83 Procedures DAS children with a range of intelligibility were taught to use an AAC technique Children engaged in play situations Interactions were video recorded and analyzed

84 Research Design ABA Design: 1. No AAC Board Present 2. Treatment Condition with AAC Board Present 3. Post-treatment Condition with AAC Board Present

85 Results Increase comprehensible messages Increased successful communication repairs Children with most severe speech disorders used AAC most frequently

86 AAC use did not decrease the number of speech attempts!!! AAC use reduced the number of gestures. AAC was used primarily to resolve communication breakdowns.

87 Communication Goals Conversation Small talk Information sharing Language learning Participation Education & Recreation Social memberships Establishing & maintaining Wants & Needs

88 Multimodal Considerations Communicative contexts Communicative goals Intent of communication situation Immediate & future communication needs Support development of skills

89 Theme-specific boards Picture/symbol dictionary Remnant books Voice output communication aids Collaborate roles & responsibilities for each partner Establish initiation & repair of breakdowns) Focus on Communicative Competence

90 AAC Strategies Sign Low-tech (situation specific) Portable digitized speech devices (situation specific) Portable general purpose devices

91 AAC Evaluation Why children with DAS are difficult to augment typically ambulatory have developed alternative, often unique communication strategies may have intact cognitive skills language development ongoing may have poor literacy skills

92 AAC Device Specifications Portability Comprehensive system high tech low tech Cover extensive vocabulary demands Minimize sequencing demands Teach sequencing skills Allow & facilitate language development

93 Family Concerns re: DAS Qualitative Research Project Garn-Nunn & Katz, 2000 Obtained postings daily from APRAXIA-KIDS listserve Apparent Themes Diagnosis Treatment Securing Treatment Personal

94 Family Diagnostic Concerns 26% of postings Varying descriptive terms Nature of problem Concomitant problems Importance of Early Diagnosis SLP crucial to success Garn-Nunn & Katz, 2000

95 Family Treatment Concerns 28% of postings Importance of speech motor practice Sign language, AAC facilitate speech early Parents intensively involved with treatment Changing nature of treatment Educational concerns Garn-Nunn & Katz, 2000

96 Family Concerns: Securing Treatment Services 22% of postings Intensive treatment, long period of time Secure different sources of treatment IEP procedures, goals, availability of services Private insurance issues Parent advocacy training, IDEA Garn-Nunn & Katz, 2000

97 Family Personal 17% of postings Success stories, thanks, encouragement Failures, venting Explaining DAS to others & to child Local support groups Garn-Nunn & Katz, 2000

98 Case Study Walt, 10 year 6 month old male Regular 4th grade classroom Intelligibility <50% to unfamiliar listener Diagnosed with DAS in years of traditional articulation- oriented speech therapy Past evaluation, recommendations

99 Assessment Results Language TACL-3 PPVT-III Receptive subtests from CELF-R MLU

100 Articulation/Phonology GFTA KLPA Screening Test for Developmental Apraxia of Speech (Blakeley, 1980) Percent of Consonants Correct Motor Speech Tasks

101 Social Communication Social Skills Rating System(Gresham & Elliott, 1990) (AGS) Child Social Interaction Scale Intelligibility/Comprehensibility I-ASCC

102 AAC Assessment for Walt Examine current communication and communication needs parent & child interview speech evaluation results communication abilities understands symbols for communication emerging literacy skills

103 Physical Status ambulatory, active good fine motor control hearing and vision WNL

104 Walt’s Communication Device Lightweight & portable Durable Extensive vocabulary Support emerging literacy skills Support developing language Allow for novel message generation Good quality voice output for communication in a variety of contexts

105 Walt’s Communication System DynaMyte (DynaVox Systems, Inc) Topic Boards Letter Board Remnant book Natural speech

106 Classroom Recommendations Provide multiple avenues of communication Computer supported literacy options Phonetic based word generation (Intellikeys) Story reading (Living Books, Intellikeys) Story writing (Write:Outloud, CoWriter) Organizational software (Inspiration)

107 Speech Therapy Recommendations Frequent treatment sessions (daily) Brief treatment sessions (15 min) Motor learning concepts stressed knowledge of results knowledge of performance distributed practice Provide tactile, visual, & verbal feedback

108 References Bradford & Dodd (1996). Do all speech-disordered children have motor deficits? Clinical Linguistics and Phonetics, 10(2), Davis, B. (1998a). Differential diagnosis of developmental apraxia. Newsletter: ASHA Special Interest Division 1: Language Learning and Education, 5(2), 4-7. Hayden, D.(1994). Differential diagnosis of motor speech dysfunction in children. Clinics in Communication Disorders, 4(2), Hayden & Square (1999). Verbal Motor Production Assessment for Children (VMPAC). The Psychological Corporation: A Harcourt Assessment Company

109 More References Cumley, G. (1997). Introduction of an augmentative and alternative modality: Effects on the quality and quantity of communication interactions of children with severe phonological disorders. Unpublished Doctoral Dissertation, University of Nebraska-Lincoln. Davis, B., Jakielski, K., & Marquardt, T. (1998). Developmental apraxia of speech: Determiners of differential diagnosis. Clinical Linguistics and Phonetics, 12(1), Dowden, P. (1997). Augmentative and Alternative Communication Decision Making for Children with Severely Unintelligible Speech. AAC, 13(1),

110 More References Hall, P., Jordan, L., & Robin, D. (1993). Developmental apraxia of speech: Theory and clinical practice. Austin, TX: Pro-ed. McNeil, M., Robin, D., & Schmidt, R. (1997). Apraxia of Speech: Definition, differentiation, and treatment. In M. McNeil (Ed.), Clinical management of sensorimotor speech disorders (p. 394). New York: Thieme. Shriberg, L., Austin, D., Lewis, B., McSweeny, J., & Wilson, D. (1997a). The Percentage of Consonants Correct (PCC) metric: Extensions and reliability data. JSLHR, 40(4),

111 More References Shriberg, L., Aram, D., & Kwiatkowski, J. (1997a). Developmental apraxia of speech I: Descriptive and theoretical perspectives. JSLHR, 40(2), Shriberg, L., Aram, D., & Kwiatkowski, J. (1997b). Developmental apraxia of speech II: Toward a diagnostic marker. JSLHR, 40(2), Shriberg, L., Aram, D., & Kwiatkowski, J. (1997c). Developmental apraxia of speech III: A subtype marked by inappropriate stress. JSLHR, 40(2), Strand, E. (1998). Treatment of developmental and acquired apraxia of speech. In D. Beukelman & K. Yorkston (Eds.), Motor speech disorders. Baltimore: Brookes.

112 More References Strand, E. A. (1995). Treatment of motor speech disorders in children. Seminars in Speech and Language, 16(2), Shriberg, L., Austin, D., Lewis, B., McSweeny, J., & Wilson, D. (1997b). The Speech Disorders Classification System (SDCS): Extensions and lifespan reference data. JSLHR, 40(4), Caruso & Strand (1999). Clinical Management of Motor Speech Disorders in Children. NY: Thieme. Beukelman, D., & Mirenda, P. (1998). Augmentative and Alternative Communication. (2nd ed.). Baltimore: Brookes.

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