Presentation on theme: "Laura K Smith, MA, CCC-SLP Metro Speech-Language Symposium"— Presentation transcript:
1 Importance of Differential Diagnosis and Treatment Approach in Childhood Apraxia of Speech Laura K Smith, MA, CCC-SLPMetro Speech-Language SymposiumLone Tree, CO
2 About me I’m a Denver Native Received my BA from MSCD Received MA from UNC distant learning programCurrently work for DPS and Lowry Speech TherapyLive with my husband and two kidsMy daughter was dx with CAS at 2yrs 11mo
3 Ashlynn’s fourth Birthday First time singing Happy Birthday Song!First time blowing out her candles on her own!
4 Importance of early intervention Importance of early intervention is well documented throughout the literatureImportance of early intervention for CAS requires differential diagnosis. Techniques designed for typical speech and language delays are not effective treatment approaches for CAS.Principles of motor learning theory should drive therapy. (11/6/07 ASHA Leader, Magill 1998, Schmidt 2004).Ancillary learning is NOT affective for this population. I did with this Ashlynn every night. Talk about boys!
5 Speech disorders Speech Sound Disorders Motor Speech Disorders ArticulationPhonological ProcessingMotor Speech DisordersChildhood Apraxia of SpeechDysarthria
6 What is 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 technical report, 2007)Other names: dyspraxia, developmental verbal apraxia, developmental apraxia of speech
7 Definition continued (ASHA, 2007) Three generally agreed upon diagnostic markersinconsistent errors on consonants and vowels in repeated productions of syllables or wordslengthened and disrupted co-articulatory transitions between sounds and syllables (difficulty moving from one sound to the next, or one syllable to the next)inappropriate prosody, especially in the realization of lexical or phrasal stress. (may sound monotone, robotic, and may have a tendency to always stress the first syllable etc.)
8 Other Diagnostic indicators (ASHA, 2007) - little to no babbling as a baby- lack of vowel variation; overuse of schwa- vowel distortion-regression or loss of once produced words- impaired rate/accuracy on diodochokinetic tasks- higher receptive versus expressive language- impaired volitional oral movements (oral apraxia), groping- makes inconsistent sound errors, or may produce target accurately in one context, but not another.Ashlynn cooed and laughed, but never babbled. Had a “go to” word or phrase “a dah” * A note about diodochokinetic rate:
9 Non-speech motor signs Non-speech motor signs of CAS that are most commonly proposed in the literature (some of which are also cited as signs of dysarthria) include the following: general awkwardness or clumsiness, impaired volitional oral movements, mild delays in motor development, mildly low muscle tone, abnormal oro-sensory perception (hyper- or hyposensitivity in the oral area), and oral apraxia (e.g., Davis et al., 1998; McCabe et al., 1998; Shriberg et al., 1997a). The non-speech motor features typically listed for oral apraxia are impaired volitional oral movements (imitated or elicited postures or sequences such as “smile-kiss”) and groping (e.g., Davis et al., 1998; McCabe et al., 1998; Shriberg et al., 1997a).Ashlynn walked on her toes. Difficulty imitating baby signs. No pointing.
10 Motor Speech Examination (Strand 1996, Stoeckel 2005) Examine ability to sequence phonetic sequences in various contexts.CV, VC, and CVC combos using various vowelsMono and multi-syllabic word repetitionsPhrase and sentence repetition increasing sentence length.* Not a lot of commercially available tests on the market for this. One used at my clinic is the Kaufman Speech Praxis Test for Children.
11 Motor speech Exam continued Vary temporal relationship between stimulus and responseSimultaneousImmediate vs. delayed repetitionEvaluate Prosody!A note about prosody and Ashlynn
12 Causes? No known cause to date for all cases Researchers in 1998 discovered a gene that causes CAS called FOXP2. However, only a small percentage of children with CAS had FOXP2 abnormalities.Idiopathic CAS can run in families.It can also be diagnosed in children where there is no family history of CAS.Can be the result of a neurological impairment caused by infection, illness, or injury before or after birth, which may, or may not show up as positive findings on MRI scans.
13 A note about Ashlynn’s characteristics Low muscle tone, open mouth posture, drooled excessively as a baby, even when not teethingArmy crawled at 9 months, walked at 17 months, used whole hand to point, couldn’t imitate signsVery clumsy. Impaired balanceWould forget to masticate during the swallow (choke risk!)Oral apraxia – couldn’t pucker, kiss, or blowCouldn’t imitate baby signs. Had words and lost them.
14 Notice pointy toes, open mouth posture, low tone in the cheeks.
15 Comparison Chart (CASANA advisory board) Verbal ApraxiaSeverePhonological processing disorderInconsistencies in articulation performance–the same word may be produced several different waysErrors include substitutions, omissions, additions and repetitions, frequently includes simplification of word forms. Tendency for omissions in initial position. Tendency to centralize vowels to a “schwaa”Number of errors increases as length of word/phrase increasesConsistent errors that can usually be grouped into categories (fronting, stopping, etc.)Errors may include substitutions, omissions, distortions, etc. Omissions in final position more likely than initial position. Vowel distortions not as common.Errors are generally consistent as length of words/phrases increases
16 Comparison chart continued (CASANA advisory board) Verbal apraxiaSevere Phonological Processing DisorderWell rehearsed, “automatic” speech is easiest to produce, “on demand” speech most difficultReceptive language skills are usually significantly better than expressive skillsRate, rhythm and stress of speech are disrupted, some groping for placement may be notedNo difference in how easily speech is produced based on situationSometimes differences between receptive and expressive language skillsTypically no disruption of rate, rhythm or stress
17 A controversial diagnosis Diagnostic indicators vary in the research from study to study.There is currently no gold standard, that when identified, leaves little doubt that CAS is presentCAS characteristics can overlap with phonological processing characteristicsClinicians in the field have devised their own diagnostic schemasLeads to potential misdiagnosis/over diagnosisStockel 2005: The presence of a motor deficit will necessarily influence the development of phonology and language processes.
18 How early to diagnose A note about age Difference between a “late talker” and CASGenerally speaking, regardless of age, a child can be diagnosed with CAS if they can commit to a full motor speech examination.
19 Why is differential diagnosis important? In a word: TREATMENT!!!Children diagnosed with CAS need a motor based speech approach to therapyTraditional articulation and phonological therapies are not successful for children with CAS (Cycles, minimal pairs, maximum opposition, etc)These approaches are designed to remediate a sound, or sound error patterns.
20 What is a motor based approach to therapy? Focuses on the planning, sequencing, and coordination of muscle movements for the development of intelligible speechIt does NOT include oral motor exercises designed to strengthen the oral/motor musculature, since apraxia is an issue of motor planning, not motor weakness.Motor planning approaches include: integral stimulation (Strand & Debertine, 2000), as well as other commercially available approaches: The K-SLP, PROMPT, and SpeechEZ.Research is ongoing to prove the efficacy of these programs.Integral Stimulation (DTTC) and PROMPT have demonstrated effectiveness in the literature (Strand & Debertine, 2000; Dale & Hayden, 2013)Integral stimulation emphasizes auditory and visual modelsOther programs emphasize tactile and/or gestural cues
21 Motor learning theory (Schmidt 1988, Stoeckel 2005) Three factors relevant to the treatment of motor speech disorder:PrepracticeConditions of practiceKnowledge of results and effects of rate
22 Motor learning continued Pre-practice Inspire motivation Conditions of practice Awareness of goal Frequent practice Repetitive motor drill Mass vs. Distributed Blocked vs RandomizedKnowledge of ResultsGive child frequent information about movement performance
23 Therapy strategies Ancillary learning techniques do NOT work for CAS. Oral motor exercises are NOT reported in any literature to improve CAS. If you want to improve speech, work on speech!Develop a core vocabulary list/book (Hammer 2005, Kaufman 2013)Start with simple syllable shapes and move up the hierarchy incorporating principles of motor learning.
24 Other strategies that work - Stabilize vowelsSuccessive approximations (Kaufman 2013)Built confidence! Follows typical phonology patternsErrorless teaching (Kaufman 2013)Use of some type of visual or tactile cue (Hammer 2013, Kaufman 2013, Stoeckel 2013)Key is consistencyBackward chaining
25 Strategies Continued Don’t forget language! Carrier phrases Pivot phrases (Kaufman 2013)Repetitive booksModeling, recasting, expansion and repetition techniques
26 Case in Point Video Olivia 3.7 Early intervention since 2 years Came with 3 words and maybe 10 word approximations
27 Olivia 4:11 Motor based approach to therapy initiated. Only seen client 1x week for 45 minutesWent from 10 words to over 50 and combining words in her repertoire
28 Resources Apraxia-kids.org http://www.kidspeech.com/ Facebook pagesAPRAXIA KIDS: Every Child Deserves a VoiceApps for Apraxia KidsApraxia BloggersColorado Families Living with Apraxia
29 Bibliography/References American Speech-Language-Hearing Association (2007). The technical report on childhood apraxia of speech.American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech (position statement).Beate, P. (2013) Childhood Apraxia of Speech in Multigenerational Families: Genes and Generations. Childhood Apraxia of Speech Symposium, Denver, CO.Childhood Apraxia of Speech Association of North America. (2005). Key characteristics of childhood apraxia of speech.Dale, P. & Hayden, D. (2013) Treating speech subsystems in Childhood Apraxia of Speech with tactual input: The PROMPT Approach. American Journal of Speech/Language Pathology.Gildersleeve-Neumann, C. (2007, November 06). Treatment for Childhood Apraxia of Speech : A Description of Integral Stimulation and Motor Learning. The ASHA Leader.Hammer, D. (2013) A Multi-Sensory Approach for Childhood Apraxia and Speech Sound Disorders. Metro Speech-Language Symposium, Denver, CO.Jakielski, K. (2013) State of the Art in Childhood Apraxia of Speech Research: A synopsis of the 2013 Childhood Apraxia of Speech Symposium, Denver, CO.Kaufman, N. (2013) The Kaufman Speech to Language Protocol: Effective Strategies for CAS. National Conference on Childhood Apraxia of Speech, Denver, CO.Stoeckel, R. (2005) Childhood Apraxia of Speech: Assessment and Treatment, Aurora, CO.Stoeckel, R. (2013) Dynamic Temporal and Tactile Cueing (DTTC): Why, When, How. National Conference on Childhood Apraxia of Speech, Denver, CO.