2 E1 E2 E3 Clinical expertise Best external evidence In our presentation, we will present an overview of 10 caps that were conducted throughout the year on the topic of intervention for childhood apraxia of speech – ie: E1 evidence. We will describe the groups attempt to gather internal evidence from clinical practice or E2.Best internal evidence(from clinical practice)Best internal evidence(from client factors & preferences)(Based on Dollaghan, 2007)EBP in the Workplace by Baker & Kelly (2011) for QLD: SPAA
3 Childhood Apraxia of Speech (CAS) Childhood apraxia of speech (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.ASHA (2007)
4 KEY FEATURES OF CASInconsistent error production on both consonants and vowels across repeated productions of syllables or wordsLengthened and impaired coarticulatory transitions between sounds and syllablesInappropriate prosodyMorgan & Vogel (2009)
5 So, what is the nature of the evidence-base for treatment of CAS?
6 Treatment for CASThere is currently no gold standard treatment approach for treating CASThis is because:“there are currently too few well-controlled studies in this field to enable conclusions to be drawn about the efficacy of treatment for the entire CAS population, and calls for SLPs working in this area to design better studies”(Morgan & Vogel, 2009)
7 SO, WHAT EVIDENCE IS AVAILABLE? Lower level studies, usually based on one or a few children.This year, we have critically appraised 10 studies.An overview of the principles that underscore the treatment approaches helps to understand the nature of the evidence.
8 GENERAL PRINCIPLES (STRAND, 2012) The goal or the focus of the treatment of CAS is to improve the individual’s ability to assemble, retrieve, and execute motor plans for speech. The focus or target of treatment is the movement vs. the sound.Practice should focus on making those movement transitions, in the context of speech.At first, the clinician will provide maximum support by providing visual, tactile and auditory models, fading those cues over timeBecause the goal of treatment is to improve movement accuracy, a number of approaches are grounded in the principles of motor learning
9 PRINCIPLES OF MOTOR LEARNING (PML) (BASED ON MAAS ET AL., 2008) What is Motor Learning?A process of acquiring the capability for producing skilled actionIt occurs as a result of experience and practiceIt is influenced by a variety of factorsThese factors are thought to make a difference in therapy
10 Principles of Motor Learning (PML) (based on Maas et al., 2008) Motor Performance - How the movement isperformed during training, within the sessionMotor Learning - how the movement isperformed at another time (i.e., generalization)Precusors to Motor Learning:Motivation and AttentionPre-PracticeRemembering for CAS to consider:RateProsodyPractice and feedback conditions!
11 PML: Practice Conditions OptionsEvidencePractice amountSmall vs LargeNo systematic evidencePractice distributionMassed vs DistributedPractice variabilityConstant vs VariableLimited evidence for benefit of variable practice in unimpaired speech motor learning ; no evidence for MSDPractice scheduleBlocked vs RandomLimited evidence for random practice, in unimpaired speech motor learning and treatment of AOSAttentional FocusInternal vs ExternalTarget ComplexitySimple vs ComplexLimited evidence for benefit of targeting complex items in treatment of AOSMaas et al (2008)
12 PML: Feedback Conditions OptionsEvidenceFeedback typeKnowledge of Performance (KP) vs Knowledge of Results (KR)No systematic evidenceFeedback frequencyHigh vs Low/Summary-KRSome evidence for benefit of reduced feedback frequency in treatment for AOS and speech motor learning in hypokinetic dysarthriaFeedback timingImmediate vs DelayedSome evidence for delayed feedback in treatment for AOS and hypokinetic dysarthriaMaas et al (2008)
13 Treatment approaches/methods There are a variety of approaches described in the literature, such as:Integral stimulation, and, Dynamic Temporal and Tactile Cueing (DTTC)Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT)Nuffield Centre Dyspraxia Programme (NDP3)Rapid Syllable Transition Treatment (ReST)Melodic Intonation Therapy (MIT)Augmentative devices to facilitate communicationGeneric approaches based on PMLStimulability training program (STP)mCVT (modified core vocabulary training)
14 Brief description of Integral Stimulation and Dynamic Temporal and Tactile Cueing (DTTC)
15 Integral StimulationIntegral Stimulation is an articulation therapy involving imitation, auditory models, and visual modelsDeveloped by Robert Milisen, 1954The child IMITATES utterances modelled by the SP with attention focused on LISTENING while LOOKINGPROSODIC cueing methods such as MIT or contrastive stress are also usedWord stress and the contours of sentences are emphasised early in treatmentFunctional communication is emphasised
16 DYNAMIC TEMPORAL AND TACTILE CUEING (DTTC) “For non-verbal children, with very severe CAS, Edythe Strand uses a variation of Integral Stimulation that she developed, called: Dynamic Temporal & Tactile Cueing for speech motor learning (DTTC)”“DTTC is based on John Rosenbek and colleagues’ “Eight-step Continuum for Treatment of Acquired Apraxia of Speech.”“It allows for a continuous shaping of the movement gesture.”(Bowen, 2012)
17 DYNAMIC TEMPORAL AND TACTILE CUEING (DTTC) “Allows opportunity for the child to take increasing responsibility for assembling, retrieving and executing motor plans with progressively less cueing.”“Sometimes, we begin the therapy process by working in the session and having the parents work at home to establish good visual attention to a person’s face, as well as general imitation skills.”“These are prerequisites for the integral stimulation approach, and for most children can be achieved with a positive reinforcement behaviour modification approach.”Strand (2012)
18 DTTC Procedure (From Bowen, 2012, based on Edyth Strand’s work) Imitation - Direct, immediate imitation of natural speech.Simultaneous production with prolonged vowels (most support)Reduction of vowel lengthGradual increase of rate to normalReduction of therapist’s vocal loudness, eventually mimingDirect imitationIntroduction of a one or two second S-R delay (least support)Spontaneous ProductionKeep in mind: This hierarchy is constantly varying -- after observing the child's response on each trial
19 CAP – Integral Stimulation Strand & Derbertine(2000)The Efficacy of Integral Stimulation Intervention with Developmental Apraxia of SpeechSingle case study design with multiple baselineProvided evidence for the use of Integral Stimulation incorporating a number of basic PML for children with CAS
20 CAP – Dynamic Temporal and Tactile Cueing (DTTC) Baas, Strand, Elmer & Barbaresi (2008)Treatment of Severe Childhood Apraxia of Speech in a 12- Year-Old Male with CHARGE AssociationSingle subject multiple baseline designProvided a low level of evidence for the use of DTTC incorporating some PML to improve the functional verbal communication of children with severe CAS
21 CAP - Dynamic Temporal and Tactile Cueing (DTTC) Strand, Stoeckel & Baas (2006)Treatment of Severe Childhood Apraxia of Speech: A Treatment Efficacy StudySingle subject with multiple baseline design for 4 participantsFrequent treatment using DTTC incorporating the PML resulted in improvements in articulatory accuracy and verbal communication for 3 out of 4 children with severe CAS who had been non-verbal despite previous treatment
22 CAP – Stimulability training program and Modified core vocabulary training Iuzzini & Forrest (2010)Evaluation of a combined treatment approach for childhood apraxia of speechSingle subject multiple baseline design with 4 participantsProvided emerging evidence for the use of STP (stimulability training program) paired with mCVT (modified core vocabulary training) to increase the phonetic inventory and PCC of children with CAS
23 CAP – MIT and Touch-cues Martikainen & Korpilahti (2011)Intervention for childhood apraxia of speech: A single case- studySingle case study multiple baseline designA combination of MIT & Touch-Cue Method(TCM) intervention led to improved vowel and consonant production in a single case. However, further research is required.
24 CAP – Rapid Syllable Transition Treatment (ReST) Ballard, Robin, McCabe & McDonald (2010)A Treatment for Dysprosody in Childhood Apraxia of SpeechSingle subject multiple baseline design for 3 siblingsTargeted treatment using PML was effective in improving the production of SW vs WS stimuli and generalised to untreated stimuli, but minimal changes were seen in production of real words
25 CAP – Practice condition: high or low dose? Edeal & Gildersleeve-Neumann (2011)The Importance of Production Frequency in Therapy for Childhood Apraxia of SpeechSingle subject alternating AB design with 2 participantsFrequent and intense practice of speech targets results in more rapid responses to treatment. Retention and transfer were greater for speech sounds that were practised times per session than for speech sounds that were practised times per session (ie: higher dose was better)
26 CAP - Feedback condition: high vs low frequency feedback? Maas, Butalla & Farinella (2012)Feedback Frequency in Treatment for Childhood Apraxia of SpeechAlternating treatment and multiple baseline single subject design with 4 participantsFindings were mixed - unclear whether low or high frequency feedback is more effective for children with CASProvided support for the efficacy of integral stimulation treatment for children with CAS
27 CAP – Practice condition: Blocked or random? Maas & Farinella (2012)Random versus blocked practice in treatment for childhood apraxia of speechTwo-phase alternating treatment and multiple baseline single subject design with 4 participantsUnclear whether random or blocked practise is more effective for children with CASFindings from nonspeech motor learning literature may not extend to treatment for CASProvided support for the efficacy of integral stimulation treatment for children with CAS
28 CAP - AAC Cumley G. & Swanson, S. (1999) Augmentative and Alternative Communication Options for Children with Developmental Apraxia of Speech: Three Case Studies3 single case studies retrospectively writtenProvided a low level of support for the implementation of high and low tech AAC with children with CAS
29 PARt 2: E3BP Internal Evidence Best external evidenceClinicalexpertiseThis year we also considered how we could apply some of the findings from the literature, particularly the literature on the principles of motor learning.E2E3Best internal evidence(from clinical practice)Best internal evidence(from client factors & preferences)(Based on Dollaghan, 2007)EBP in the Workplace by Baker & Kelly (2011) for QLD: SPAA
30 EBP Phonology E3BP Trial ( still in process) Look at which principles you have been givenSelect two clients with a speech impairment – one for each principleSelect a treatment goal for each client to trialClarify and compare your results with others from your workplaceTake data (including generalisation data)Complete the one page questionnaire
31 EBP Phonology E3BP PML Principles Blocked vs Random presentation of stimuliKP with no delay vs KR with 3 second delayHigh frequency vs Low frequency feedback
32 Why is there not more evidence? Methodological challenges:Lack of a standard definition for CASDifficulties in differential diagnosisLikely significant heterogeneity in symptomatologyChanging symptomatology over timeMaintaining experimental control in real clinical settingsLack of support for large scale studies
33 CONCLUSIONS Treatment for CAS requires: Careful planning by the clinician and familyKnowledge about the various treatment approaches and how they overlapAn understanding of the principles of motor learning and how application of those principles to treatment planning and implementationCaution is warranted in extrapolating from the nonspeech motor learning literature to speech treatment for CAS
34 ReferencesAmerican Speech-Language-Hearing Association. (2007). Childhood Apraxia of Speech [Technical Report]. Available from Baas B.S., Strand E.A., Elmer L.M., Barbaresi, W.J. (2008). Treatment of severe childhood apraxia of speech in a 12-year-old male with CHARGE association. J Med Speech Lang Pathology, Dec; 16(4): Ballard, K.J., Robin, D.A., McCabe. P., & McDonald, J. (2010). A Treatment for Dysprosody in Childhood Apraxia of Speech. Journal of Speech, Language, and Hearing Research. Vol. 53;Bowen, (2012). Dynamic Temporal and Tactile Cueing (DTTC) and Integral Stimulation. Retrieved fromCumley G. & Swanson, S. (1999). Augmentative and Alternative Communication Options for Children with Developmental Apraxia of Speech: Three Case Studies. AAC Augmentative and Alternative Communication (15), Edeal, D.M. & Gildersleeve-Neumann, C.E. (2011). The Importance of Production Frequency in Therapy for Childhood Apraxia of Speech. American Journal of Speech-Language Pathology, May; 20, (95-110).
35 References (cont)Dollaghan, C. A. (2007). The handbook for evidence-based practice in communication disorders. Baltimore: Paul H. Brookes.Iuzzini, J. & Forrest K.(2010). Evaluation of a combined treatment approach for childhood apraxia of speech. Clinical Linguistics & Phonetics; 24(4-5),Maas, E., Butalla, C.E. & Farinella, K.A. (2012) Feedback Frequency in Treatment of Childhood Apraxia of Speech. American Journal of Speech- Language Pathology 21,Maas, E. & Farinella, K. A. (2012). Random versus blocked practice in treatment for Childhood Apraxia of Speech. Journal of Speech, Language and Hearing Research, 55, Maas, E., Robin, D.A., Austermann Hula, S.N., Wulf, G., & Schmidt, R.A. (2008). Principles of Motor Learning in treatment of Motor Speech Disorders. American Journal of Speech-Language Pathology, 17,Martikainen, A. & Korpilahti, P. (2011). Intervention for childhood apraxia of speech: A single-case study. Child Language Teaching and Therapy, 21, 9-20.
36 REFERENCES (CONT)Morgan, A.T. & Vogel, A.P. (2009). A Cochrane review of treatment for childhood apraxia of speech. European Journal of Physical and Rehabilitation Medicine. Mar;45(1):Strand, E. (2012, April 6). Management of CAS [PowerPoint slides]. Brigham Young University, Provo UT.Strand, E., Stoeckel., R., & Baas, B. (2006). Treatment of Severe Childhood Apraxia of Speech: A Treatment Efficacy Study. Journal of Medical Speech Pathology, 14, Strand, E.A.,and Debertine, P.(2000) The efficacy of integral stimulation intervention with developmental apraxia of speech. Journal of Medical Speech Pathology. 8 (4),