1. Childhood Apraxia of Speech: Parent Involvement in Evaluation and Therapy
Brisbane, Australia
June 16, 2007
David W. Hammer, M.A. CCC-SLP
Children’s Hospital Of Pittsburgh, PA USA

2. WWW.APRAXIA-KIDS.ORG “Time to Sing” CD - 2000 “Hope Speaks” DVD - 2005
“Treatment Strategies” DVD
AdHoc Committee Documents
“Taking it Home” DVD

3. WHAT DIAGNOSTIC CHALLENGES FACE US?
Diagnosing toddlers in the 2-3 year-old range
Apraxia is difficult to diagnose if limited sample.
Diagnosis helps parents to ground themselves and eventually complete necessary grieving.
Sometimes it is hard to let go of a diagnosis.
Don’t need neurologist to confirm but follow through with assessment if recommended
“Differential Diagnosis for Childhood Apraxia”
Video Clip -- Ross, age 3-4

4. Differential Diagnosis
Parents often report limited sound play.
Child usually has a limited sound inventory.
Language comprehension abilities are far superior to expressive language skills.
Child does better when he imitates than when he tries to say things on his/her own.
Child has major problems sequencing.
As words or sentences get more complex, precision and clarity break down further
Video Clip -- Anna, age 3-10

5. Differential Diagnosis
Child’s speech reflects unusual stress patterns, poor range of inflection, and frequent pausing
Child’s speech often is inconsistent
Video Clip -- Jacob, age 3
Voiced/Voiceless sound errors occur
“Groping” behaviors are observed
Vowel distortions are very common
Video Clip -- Alex, age 5
12. Sound omissions occur in the first position of words which is unusual

6. ADHOC COMMITTEE’S DEFINITION OF CAS
“Childhood apraxia of speech is a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits.”
“The core impairment…in planning and/or programming…movement sequences results in errors in speech sound production and prosody.”

7. ADHOC COMMITTEE’S 3 CONSENSUS FEATURES
Inconsistent errors on consonants and vowels in repeated productions of syllables or words
Lengthened & disrupted transitions between sounds & syllables
Innappropriate prosody, especially in relation to word and phrase stress

8. Unfortunately, pure apraxia of speech is rare!!!
Video Clip - Mickey, age 6
Video Clip - Anna, age 8-1

9. WHAT DOES MY CAS ASSESSMENT INCLUDE?
For young children, most testing is informal.
Formal test resources are used if needed.
In-depth parent information is obtained.
Other apraxic features are investigated.
Nonspeech oral skills are evaluated.
Video Clip -- Michael, age 4

10. WHAT CAUTIONS DO WE NEED TO CONSIDER?
Concern for misdiagnosing:
Nonverbal child
Dysarthric child
Severe phonologically disordered child
Confounding diagnosis child

11. Severe Phonological Disorder
Comparison of Childhood Apraxia of Speech, Dysarthria and Severe Phonological Disorder
Verbal Apraxia
Dysarthria
Severe Phonological Disorder
No weakness, incoordination or paralysis of speech musculature
Decreased strength & coordination of speech musculature--leads to imprecise speech production, slurring and distortions
No difficulty with involuntary motor control for chewing, swallowing, etc. unless there is also an oral apraxia
Difficulty with involuntary motor control for chewing, swallowing, etc. due to muscle weakness and incoordination
No difficulty with involuntary motor control for chewing and swallowing
 Inconsistencies in articulation performance--the same word may be produced several different ways
 Articulation may be noticeably “different” due to imprecision, but errors generally consistent
 Consistent errors that can usually be grouped into categories (fronting, stopping, etc.)

12. Severe Phonological Disorder
Comparison of Childhood Apraxia of Speech, Dysarthria and Severe Phonological Disorder
Verbal Apraxia
Dysarthria
Severe Phonological Disorder
Errors include substitu- tions, omissions, additions and repetitions, frequently includes simplification of word forms. Tendency for omissions in initial position & to centralize vowels to a “schwa”
Errors are generally distortions
Errors may include substitutions, omissions, distortions, etc. Omissions in final position more likely than initial position. Vowel distortions not as common
Number of errors increases as length of word/phrase increases
May be less precise in connected speech than in single words
Errors are generally consistent as length of words/phrases increases
Well rehearsed, “automatic” speech is easiest to produce, “on demand” speech most difficult
No difference in how easily speech is produced based on situation

13. Severe Phonological Disorder
Comparison of Childhood Apraxia of Speech, Dysarthria and Severe Phonological Disorder
Verbal Apraxia
Dysarthria
Severe Phonological Disorder
Receptive language skills usually significantly better than expressive skills
Typically no significant discrepancy between receptive & expressive
Sometimes differences between receptive and expressive language skills
Rate, rhythm and stress of speech are disrupted, some groping for placement may be noted
Rate, rhythm and stress are disrupted in ways specifically related to the type of dysarthria (spastic, flaccid, etc.)
Typically no disruption of rate, rhythm or stress
Generally good control of pitch and loudness, may have limited inflectional range for speaking
Monotone voice, difficulty controlling pitch and loudness
Good control of pitch and loudness, not limited in inflectional range for speaking
Age-appropriate voice quality
Voice quality may be hoarse, harsh, hypernasal, etc. depending on type of dysarthria
•Compiled by Ruth Stoeckel, M.A., CCC-SLP and David Hammer, M.A., CCC-SLP, members of the Childhood Apraxia of Speech Association Professional Advisory Board

14. WHAT CAN I EXPECT AT THE EVALUATION?
Therapist may say they are unsure, and call it a “working” or “suspected” diagnosis of apraxia, which is difficult sometimes to hear.
Therapist may say haven’t seen many children, and they don’t consider themselves an apraxia “expert” but…
You should be provided resources (Parent- friendly handouts; “Hope Speaks” DVD; Parent group contacts; Website guidance such as “The Family Place--The Start Guide”)

15. WHAT SHOULD WE PREPARE FOR NEXT?
Find a way to be part of the team right away.
Prepare for the “plateau effect” in therapy
Understand “Prognostic Indicators” (usually after therapy begins but may need to address earlier)
Follow through with additional evaluations if recommended by the evaluator
Video Clip -- Sharon Gretz & Dr. Campbell

16. WHAT SHOULD THERAPY LOOK LIKE?
Should start out as individual Tx
Should be tailored to your child’s needs
Should reflect a balance in time spent with your child and time spent with you
Should support your involvement
Video Clip, Doug and Mom
Should be a mix of drill and play activities

17. HOW DO WE PARTNER WITH OUR CHILD’S THERAPIST?
Therapist: Explain changing nature of Tx intensity
Parents: Understand intensity needs may change
Therapist: Ensure parents feel they can help
Parents: Be honest about home practice

18. HOW DO WE PARTNER WITH OUR CHILD’S THERAPIST?
Therapist: Consider eventual dyad/group tx
Parents: Be open to dyad/group therapy options
Therapist: Enable parents to observe sessions
Parents: Understand constraints on this

19. HOW DO WE GET STARTED?
Listen for your child’s expressions/env sounds and let therapist know these.
Understand how to use “starter positions” such as “mm”, “oo” and “ee”.
Video Clip -- Austin, age 4-3
Use sound “names” to make it more fun to prompt verbal speech.

20. Visual and Verbal Cues for Treatment
CONSO-NANTS
NAME of SOUND
VERBAL CUE
OTHER CUES
 “p” sound
 “b” sound
Popping sound
“Where’s your pop?”
“You forgot your pop.”
Fill cheeks up with air and blow out with the sound, feeling wind on hand.
“m” sound 
Humming sound
“Close your mouth and hummmmm…”
Lips together and hum. Touch to feel vibration.
“n” sound 
“NN” sound
“Teeth together and buzz.”
Finger on clenched teeth to feel the vibration.
“t” sound
“d” sound
Tippy sounds
“Use your tippy.”
Index finger to center of spot above upper lip.

21. Visual and Verbal Cues for Treatment
CONSO-NANTS
NAME of SOUND
VERBAL CUE
OTHER CUES
“h” sound
Open mouth windy sound
“Where’s your wind?” “I didn’t feel your wind.”
Open palm of hand up just in front of your mouth to feel wind.
“k” sound
 g” sound
Throaty sounds
“Where’s your throaty?”
Index finger pointed to throat.
“f” sound
“v” sound
Biting lip windy sound
“You forgot to bite your lip.” “You forgot your wind.”
Bite lower lip with upper teeth and blow wind.
Initial “s” sound
Smiley windy sound
“Smile & make some wind.” “Keep those teeth together.”
Smile with teeth together and blow the wind.

22. Visual and Verbal Cues for Treatment
CONSO-NANTS
NAME of SOUND
VERBAL CUE
OTHER CUES
Final sounds
Sticky sounds
“Where’s your sticky?”
For “s” move forearm from left to right starting with an open hand and moving to a closed hand.
“z” sounds
Buzzing windy sound
“Use your buzz.”
Teeth together and blow wind.
“sh” sound
Fat and fluffy sound
“Make it fat and fluffy.”
Lips out and puckered while blowing out.
“ch” sound
 “j” sound
Chomping sound
“I didn’t see those lips moving.” “Work your lips.”
Lips protruding while making chomp sound.

23. Visual and Verbal Cues for Treatment
CONSO-NANTS
NAME of SOUND
VERBAL CUE
OTHER CUES
“l” sound
Tower sound
(Lifty sound)
“Open your mouth – tongue up.” “Touch the spot and drop.”
Mouth open, tongue up behind upper teeth, then lowered.
“r” sound
“RR” sound
“Push up on the sides and move back with your tongue.”
Demonstrate pushing up on sides of tongue in butterfly position.
“w” sound
Sliding sound
“ooo to eee sliding.”
Start out in the ooo position with lips puckered then move to the eee sound.

24. Visual and Verbal Cues for Treatment
CONSO-NANTS
NAME of SOUND
VERBAL CUE
OTHER CUES
“y” sound
Sliding sound
“eee to ooo sliding.”
“sp, st, sk, sn, sl”
sounds and other consonant clusters
Friendly sounds
“You forgot your With a straight friend.” index finger on table, start moving finger from left to right while saying the /s/ sound then end by tapping finger on table when the “friendly” sound is added. Or move forearm with open hand from left to right while saying /s/ sound and point to other sound positions as indicated above.

25. HOW DO WE GET STARTED? Make a core vocabulary book.
- Benefits and Procedures

26. CORE VOCABULARY BOOK - BENEFITS
Organizes a starting vocabulary that facilitates a mutual focus between you, your child’s therapist/s, and other important adults in the child’s life.
Enables the child to sense early success.
Allows you to immediately feel a part of the “team.”
Provides foundation for future AAC device usage if necessary.
Wipe right

27. CORE VOCABULARY BOOK
Use photographs containing pictures of people, toys, objects, and verbs important in the life of the child, as well as words being targeted in therapy.
Photographs are placed in a “Grandma’s Brag Book” with written word at the top (so when child points, word is not covered).
Video Clip -- Luke and Sharon
Fly right

28. VISUAL PROMPTS & TOUCH CUES
Can use cueing program (such as PROMPT) or more eclectic cueing.
Goal is to fade the cues over time as soon as possible
Reduces “yes/no” communication style and replaces it with support for verbal expansion.

29. What are the Advantages of Sign/Picture/AAC Use?
Provides prompt for verbal speech
Likely to increase verbal attempts. Does not lead to less verbal output
Most children’s strengths are visual
Allows child to build language and functional communication while working on speech production

30. What are specific Sign Language Advantages?
Can be held toward face for oral cues
Can be paired with sound prompts
Allows for systematic fading of cues [Sign language cueing hierarchy]

31. What are specific Sign Language Advantages?
Can be held toward face for oral cues
Can be paired with sound prompts
Allows for systematic fading of cues
Can use later to prompt functors (“little words”)

32. Cueing Hierarchy For ASL Use
(1) Sign plus full verbal cue
(2) Sign plus first sound/syllable cue
(3) Sign plus first sound position cue
(4) Sign only

33. When Should We Stop Using Sign Language?
Do NOT stop just because your child:
(1) is not good with fine motor skills
(2) your child starts talking
(3) your child doesn’t like to sign
It is primary a PROMPT for verbal speech!!
If child uses sign to help communicate, great!

34. Try to incorporate Early Literacy Skill building as soon as possible!!
…and make sure both dad and mom read to your child.

35. WHAT ARE THE THERAPY CHALLENGES WE FACE?
To provide a balance between repetitive practice opportunities and activities which are motivating and result in optimal carryover of skills. [Dads and Moms can help with ideas]
Game idea: “Super Sean and Captain Hammer Battle Apraxia”

36. WHAT OTHER THERAPY CHALLENGES ARE THERE?
To support home practice that is productive, maintains high expectations, and does not lead to frustration. [ “Word Bins/Boxes” ]
To help the child with transitions as they move through the education system. [ “All About Me” book]

37. HOW DO WE HELP OUR CHILD ATTEND TO SOUNDS?
Pay attention to your rate of speech and modify if needed (Use “phrased speech” especially if child becomes disfluent).
Provide expanded feedback for your child which assures optimal awareness and taps other “systems” and strengths.
Video Clip -- Tyler, age 3-0

38. HOW CAN WE SUPPORT MULTI-SENSORY TX?
Set up “communication temptations” at home to elicit speech production.
Use a multi-sensory approach as directed by your child’s therapist, with multiple cues that are faded over time toward an oral speech focus.
Stretch across

39. HOW CAN WE SUPPORT MULTI-SENSORY TX?
Your observations and participation are critical to learn how to use/fade cues.
You can learn to use strategies such as “Fill in the blank” for a reluctant talker, word “bins”, and cueing hierarchies.
You can support the use of sign language, PECS, and AAC devices at home.
Peek right

40. TREATMENT SUMMARY FOR PARENTS
Practice activities need to be motivating, repetitive, and multi-sensory in nature
Video Clip -- Sean, age 4-11
Intensity of treatment should be constantly monitored and adjusted accordingly

41. Response Hierarchy to Inaccurate Verbal Attempts
(1) Just look at your child with non-understanding
(2) Say: “You forgot your…” (sticky)
“Where’s the…?” (friend)
“I didn’t hear any…” (wind)
(3) Provide cue at 4 levels in reverse order
1. Sign only
2. Sign plus first sound position
3. Sign plus audible first sound/syllable
4. Sign plus full word

42. HOW CAN WE SUPPORT PROSODY CHANGES?
Play with character voices.
Use songs and rhythms
Use rhyming books, i.e., Shel Silverstein and Dr. Seuss

43. WHAT ARE NON-SPEECH THINGS WE CAN DO?
Keep communication open and honest.
Have high expectations of your child.
Please still find time to be a parent!
Prepare for transition times (“All about me” book to share with others).
Collaborate with therapists/teachers.
Involve all family members.
Video Clips -- Cole, age 3 & family

44. HOW LONG WILL ALL OF THIS TAKE?
Conducted a pilot outcome study
Asked parents to rate on 4-point scale
Looked at ratings of “less than half” to “about three-fourths”
For Phonological-disordered children, required average 29 individual Tx sessions
For Children with Apraxia, required average of 151 sessions

45. HOW CAN WE FIND SUPPORT FOR THIS?
Try to find a parent group in your area.
Ask your child’s therapist who they might recommend that you talk with.
Use the Apraxia-Kids resources as much as you can.
Consider joining the list-serv on apraxia.
Be an advocate for change.
Video Clip -- Sharon & Dr. Campbell

46. Are Issues Different for “Older” Children?
Vocabulary demands increase, so may hear decreased multi-syllabic precision
“Fast speech” reflects a system that can’t handle the increased demands.
See breakdowns when tired (energy)

47. What Other Issues are There for “Older” Children?
Word retrieval deficits become more evident (inefficient storage).
May talk louder because can’t regulate
Novel words and nonsense words are more problematic from a motor planning/programming standpoint.
Video Clip -- Gary, age 8-8

48. What are the Treatment Considerations?
Consider single most prominent factor contributing to clarity breakdowns.
Video Clip -- Zackery, age 8-0
Focus moves to intonation, rate, and stress with less emphasis on speech.
Intensity of treatment is not the same.
Optimal may be dyad or group therapy.

49. What are Other Treatment Considerations?
Teenagers with CAS may keep sentences shorter to meet articulatory demands. Need to build confidence in longer utterances (“phrased speech”).
Therapist should use and you should support “errorless teaching” with 80% success.
Assume progress, but does not mean should remain in therapy--TAKE BREAKS! COULD BE BEST THING FOR THEM.

50. WHAT OUTCOMES CAN WE EXPECT?
Previous Video Clip -- Doug, age 5
Video Clip -- Zachary, age 6
Video Clip -- Alex, age 5
Video Clip -- Cole, age 5
Video Clip -- Austin, age 5
Video Clip -- Luke, age 10
Video Clip -- Jacob, age 8
Video Clip -- Tyler, age 9