1. A Presentation to CSHA Hot Topics
Childhood Apraxia of Speech : Characteristics, Assessment, and Treatment – An Overview
A Presentation to CSHA Hot Topics
Children’s Hospital Central California
October 6, 2015
Don Freed
Department of Communicative Disorders and Deaf Studies
California State University, Fresno
Fresno, CA

2. Definition of Childhood Apraxia of Speech
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, pp 3-4).

3. Assumptions about CAS in this presentation:
It is a separate diagnostic entity from functional articulation disorders (FAD).
It is caused by problems with the motor programming and control of speech muscles.
It is a rare condition (studies suggest between .1% and 4.3% of referred children have CAS).
The research into CAS continues to be incomplete, although progress is being made regarding defining, assessing, and treating this disorder.

4. Characteristics of CAS

5. Characteristics of CAS: Overview
Numerous characteristics have been assigned to CAS.
These characteristics vary quite a lot among children with CAS.
These characteristics also can vary in severity—mild to severe.
Children with CAS can demonstrate co-occurring difficulties in the following areas: nonspeech motor behaviors, speech motor behaviors, prosody, language, phonemic awareness, and literacy (ASHA, 2007).

6. Speech Motor Behaviors—Sequencing Phonemes
Children with CAS may have difficulty putting phonemes into the right order within a word and moving from sound to sound.
For example, /st/ becomes /təs/.
Sometimes they can sequence phonemes accurately in syllables or single words but not in phrases or sentences.
They can demonstrate this problem when doing SMR tasks.
This difficulty can include metathetic errors (reversing phonemes): “Pete” becomes /tip/.

7. Speech Motor Behaviors: Groping and Silent Posturing
These two conditions are often noted in cases of CAS.
Groping occurs when the child actively moves the articulators while trying to find the right placement for a target phoneme.
Silent posturing occurs when the child freezes his or her articulatory movements when trying to find the right placement.
Groping and silent posturing usually are present after children have had their “articulatory awareness” increased by treatment.
Young children with CAS may not demonstrate these two characteristics because they have not had significant amounts of treatment.

8. Speech Motor Behaviors: Inconsistent Errors
These errors can occur when the child is asked to produce the same word over multiple trials (ASHA, 2007).
Inconsistent errors is the most frequently used characteristic of CAS by clinicians to make a diagnosis.
However, Strand did not include inconsistent errors in her 10-point checklist for assessing and diagnosing CAS.
Even more significant was the finding of Murray et al. (2015) that inconsistent errors did not contribute significantly to predicting the diagnosis of CAS.

9. Speech Motor Behaviors: Intelligibility
Often the connected speech of a child with CAS is much less intelligible than would be suggested by that child’s performance on a single-word articulation test.
Imitation of single words and common phrases may be quite intelligible, but long portions of conversational speech may be unintelligible.
Speech intelligibility may be closely related to the severity of the CAS.

10. Speech Motor Behaviors: Severity
Most clinicians describe their clients with CAS as having a severe speech/articulation disorder.
However, CAS actually can present itself as a mild, moderate, or severe disorder.
In cases of mild CAS, it may take a number of sessions spread over several weeks before the clinician can recognize the symptoms of the disorder.

11. Characteristics of CAS: Problems with Prosody
Most researchers say that abnormal prosody is one of the more obvious characteristics of CAS.
Several recent CAS studies have concentrated on dysprosody, and this research has found that difficulty transitioning between syllables is a core problem in this disorder.
In fact, difficulty with transitioning between syllables has been identified as a potentially strong diagnostic marker for this disorder.

12. Types of Speech Errors in CAS
Although all types of errors can occur in CAS (substitutions, omissions, distortions, prolongations, repetitions), research has suggested that some may be more common than others.
Substitution errors typically are the most common over time.
Omission errors may be most common in younger children and then become less evident as the child grows older.
Toward the end of treatment, substitutions may evolve into distortions.
Such a change is not that uncommon with normally developing children, but in cases of CAS, the change from substitution to distortion moves at a much slower pace.

13. Types of Speech Errors in CAS
Regarding manner of production, it is pretty clear that children with CAS have the most difficulty producing fricatives and affricates.
Consonant clusters also are mentioned frequently as being quite difficult.
These reports generally indicate that these children are acquiring these sound classes in about the same sequence as normally developing children.
However, they acquire them at a much slower rate and at an older age, and only after plenty of tx.

14. Types of Speech Errors in CAS
Children with CAS may demonstrate the abnormal prolongation of certain phonemes within a word.
Yoss and Darley (1974) found that prolongations commonly occurred in a variety of contexts: repetitions of CVC words, nonsense words, real words, and words within carrier phrases.
Such prolongations contribute to the prosody errors in CAS.

15. Types of Speech Errors in CAS
Children with CAS may add extra phonemes to a word—applesauce may be produced as “applesocks.”
It is common for these children to add a schwa vowel to the middle of a consonant cluster—block is produced as /bəlak/.
While this is a fairly common addition for most children, it seems to happen much more frequently in CAS and is harder to get rid of in treatment.
These children also can repeat sounds or syllables in words—computer might be produced as “computerer.”

16. Types of Speech Errors in CAS
Researchers also have reported voicing errors in CAS, and they have reported that these errors are hard to assess and to treat.
It is not uncommon to find vowel omissions and substitutions in children with CAS.
These errors may include diphthong reductions (boy produced as /bo/, substitutions of the rhoric vowels, and substitutions between tense and lax vowels (/I/ and /i/).

17. Characteristics of CAS: Nonspeech Motor Behaviors
Children with CAS can demonstrate:
A general overall clumsiness
Mildly slow motor development
Abnormally high or low oral sensitivity
Nonverbal oral apraxia—difficulty imitating or sequencing volitional oral movements not related to speech, such as puckering the lips, wagging the tongue, and licking the lips.

18. Assessment of CAS

19. Assessment of CAS
At the present time, the assessment of CAS relies heavily on the clinical knowledge and the experience of the clinician.
A major problem is the lack of precise diagnostic markers to clearly identify children with CAS. Many of the characteristics of CAS also are found in other conditions.
For example, children with FAD or dysarthria demonstrate many of the problems seen in CAS. Also, there is variability in children with CAS, both in types of errors they produce and in relative severity levels.
There are a number of published tests of CAS currently available; however, they all must be used with caution.
Even new tests for CAS have issues. For example, the recent Dynamic Evaluation of Motor Skills (Strand et al., 2013) has been shown to produce false negatives.

20. Assessment of CAS
Although research into CAS is getting closer to the development of valid and reliable tests, McCauley and Strand said, “In the meantime, however, clinicians are in the position of having no tests that can be considered well developed for use with children with motor speech disorders. Within an evidence-based practice perspective, one is enjoined to find the best evidence (or test) available and to use it along with clinical experience and knowledge of the client. Consequently, clinicians’ knowledge of these disorders and clinical experience with them assume primary importance in determining the quality of decision making” (2008, p. 89).

21. Assessment of CAS
Many clinicians use two sets of diagnostic features in conjunction to help guide their judgment on whether a child presents CAS.
The first is ASHA’s (2007) consensus-based feature list:
Inconsistent errors on consonants and vowels in repeated productions of syllables or words.
Lengthened and disrupted coarticulatory transitions between sounds and syllables.
Inappropriate prosody, especially in the realization of lexical (syllable) or phrasal stress.
ASHA’s criterion is 3 of 3 needed for diagnosis.

22. Assessment of CAS The second is Strand’s 10-point checklist:
Difficulty achieving initial articulatory configurations and transitions into vowels.
Syllable segregation (pausing between syllables)
Lexical stress errors or equal stress
Vowel or consonant distortions including distorted substitutions
Groping (nonspeech)
Intrusive schwa
Voicing errors
Slow rate
Slow DDK rate
Increased difficulty with longer or more phonetically complex words.
Strand’s diagnostic criterion for CAS is 4/10 over three different tasks.

23. Assessment of CAS
Why not just rely on ASHA’s feature list or Strand’s 10-point list for making the diagnosis?
ASHA’s list includes inconsistency of errors, which Murray et al. (2015) found to not contribute significantly to the diagnosis of CAS in their study.
Regarding Strand’s list, Murray et al. (2015) said, “Children need to show evidence of any four of the 10 features on the list, with no differential weighting of any feature. To our knowledge, the sensitivity and specificity of Strand’s checklist has not been tested, and it may not be sufficiently specific, with potential risk of diagnosing negative cases with CAS. The present results show that two participants with clear dysarthria and one with a submucous cleft were diagnosed with CAS [just] using the Strand checklist” (p. 53).

24. Assessment of CAS
Recent research is giving us some direction to follow when assessing for CAS.
Murray, McCabe, Heard, and Ballard (2015) conducted an extensive study into making the differential diagnosis of CAS.
They screened 72 children (ages 4-12) with suspected CAS, 47 of which underwent detailed speech and language assessment.
Twenty-eight children were diagnosed with CAS by the first two authors of the study, based primarily on their clinical experience, but they were also guided by ASHA’s (2007) feature list and Strand’s 10-point checklist.

25. Assessment of CAS
Twenty-four measures were extracted from all the tests administered to the children diagnosed with CAS to determine which measures contributed most to the diagnosis of CAS. Here are the measures:
Inconsistent errors
Inappropriate prosody
Percent vowels correct
Syllable segregation
Intrusive schwa
Voicing errors
Slow speech rate
Increased difficulty with longer words
Distorted coarticulatory transitions
Nonspeech groping
Slow DDK rates 17. Percent consonants correct 18. Percent phonemes correct 19. Oral structure score 20. Oral function score 21. Maximum phonation time 22. Receptive Language Score (CELF) 23. Expressive Language Score (CELF) 24. Vowel or consonant distortions

26. Assessment of CAS
Discriminant function analysis was used to reveal if one or more of the 24 measures could reliably predict the experts’ diagnosis for those 28 children determined to have CAS.
The results showed that combining the results from just four measures reached 91% accuracy when compared to the experts’ opinion.
Moreover, these four measures were obtained from just two assessment tasks used in the study.

27. Assessment of CAS
Percentage of correct lexical stress on a 50-item polysyllable word test (out of total 162 syllables).
Instances of syllable segregation on the same test. This was defined as “noticeable gaps between syllables” as the child said the 50 words.
Percentage of correct phonemes (out of 328 total phonemes) on the same test.
“Puh-Tuh-Kuh” accuracy on two trials on an oral motor exam.

28. Assessment of CAS
The authors created a formula from their data to predict whether a child likely has CAS or not:
Diagnosis = (% lexical stress matches x -.011) + (syllable segregation score x .012) + (% phoneme correct x .007) + (DDK accuracy score x -.003)
Then round the resulting number to 0 decimals.
The result of 1 indicates likely CAS; a score of 0 indicates likely non-CAS.
Here is the calculation for a 4-yo female with severe articulation errors:
Diagnosis = (6 x -.011) + (45 x .012) + (46 x .007) + (77 x -.003)
Diagnosis = (-.066) + (.54) + (.322) + (-.231)
Diagnosis =
Diagnosis = = 1 = CAS likely

29. Treatment of CAS

30. General Comments Regarding Treatment of CAS
In 2007, ASHA summarized their findings on treatment with this statement: “Overall, the principles of motor learning theory and intensity of speech-motor practice appear to be the most often emphasized in an optimal treatment program. These recommendations include the need for distributed practice, in which speech-motor practice is carried out across a variety of activities, settings, and situations, and includes several exemplars per pattern” (p. 56).

31. General Comments Regarding Treatment of CAS
ASHA cautions against using nonspeech oro-motor exercises in the treatment of CAS.
This is because speech requires more flexibility, less automatic rhythmicity, finer coordination, and far lower levels of strength than are used in oro-motor exercises.
They stated their position this way: “ the consensus opinion is nonspeech oro-motor therapy is neither necessary nor sufficient for improved speech production” (p.56).

32. Results of a Systematic Review of CAS Treatment Studies
Murray, McCabe, and Ballard (2014) reviewed 42 single-case experimental studies (23) and descriptive studies (19) that were published in peer-reviewed journals between 1970 to 2012.
There were 13 different treatment approaches used in the 23 experimental studies (e.g., speech motor skills, linguistic skills, AAC).
All experimental studies were Level IIb, which means treatment was systematically applied and control was established using a stable baseline.
The authors examined (a) study quality, (b) treatment procedures, (c) treatment procedures, and (d) certainty of evidence for the 23 experimental studies.
They also used Smith’s (1981) level of certainty process as part of their analysis, which measures whether the findings of a study are suggestive, preponderant, or conclusive.

33. Results of a Systematic Review of CAS Treatment Studies
The authors found three treatment procedures that, “ reached the level of preponderant evidence with promising evidence of efficacy across several participants diagnosed with CAS” (p. 498).
Integral Stimulation/Dynamic Temporal and Tactile Cueing (DTTC)
Rapid Syllable Transition Treatment (ReST)
Integrated Phonological Awareness Intervention
The authors noted that there is no evidence at this time indicating which of these three procedures is the most effective as a treatment for CAS.
Currently, there are no Level III studies of CAS treatment, which would be needed before a procedure could considered to have conclusive evidence of effectiveness.

34. Results of a Systematic Review of CAS Treatment Studies
The authors’ examination of the 42 CAS studies revealed the following common factors in successful treatment programs:
Intensive treatment is needed for positive results. Those providing treatment 2-3 times a week for up to 1 hour each session were most successful.
Most studies used many trials. Sixty trials per session was at the upper end in the reviewed studies. More research is needed to provide estimates of how much therapy is needed for children with CAS.
All therapy in the reviewed studies was done in individual sessions. Forty percent of the studies used home practice as part of the treatment.

35. Results of a Systematic Review of CAS Treatment Studies
Regarding the three CAS treatment procedures with the highest level of evidence, the authors made these recommendations:
No matter which treatment is selected, it should be conducted at least twice a week, incorporating more than 60 trials per session.
DTTC seems to work best for children with severe CAS.
ReST seems to work best for children with mild to moderate CAS between the ages of 7 and 10.
Integrated Phonological Awareness Intervention seems to be best for children with mild to severe CAS between the ages of 4 and 7.

36. DTTC
DTTC is a variation of the integral stimulation (“look at me and listen”) treatment procedure used in adult AOS.
DTTC is different from adult AOS treatment in that it allows continuous shaping of the child’s productions through the constant use and fading of cues.
The clinician facilitates speech by providing models that the child imitates.
Cues are individualized, based on the child’s performance. Cues can be tactile, visual, auditory, and proprioceptive.
The clinician’s supportive cues may change from trial to trial, according to how the child is performing.
Repetitive drill of functional vocabulary words is needed. This promotes generalization to day-to-day communication.

37. DTTC Treatment Sequence
Here are the basic steps of the DTTC procedure:
Begin with a trial of direct imitation.
If this is unsuccessful, the clinician and child say the utterance together--very slowly at first and adding tactile or gestural cues if needed. (It can be helpful to hold the vowels longer at this stage and ensure that the jaw and lip postures are correct.
Continue to practice the utterance, slowly increasing the rate of speech to normal. Do this until the child is easily producing the utterance with the clinician, without any articulatory groping and at a normal rate.

38. DTTC Treatment Sequence
Now the clinician slowly fades his or her simultaneous production by reducing volume to where ultimately there is only silent mouthing of the utterance.
When the child is confident and successful at this level, the clinician again tries direct imitation. The clinician provides a verbal model of the utterance, while ensuring the child is looking closely at the clinician’s face.

39. DTTC Treatment Sequence
The child repeats the utterance. (If needed, the clinician can provide a simultaneous production or silent mouthing of the utterance as the child attempts to repeat. As the clinician’s cues fade, the child keeps saying the utterance in direct imitation.) This adding and fading of auditory, visual, and tactile cues as needed is an essential part of this treatment. The clinician must keep the child successful.

40. DTTC Treatment Sequence
After the child is saying the utterance at a normal rate, with correct articulation and movement, and with varied prosody, the clinician introduces a delay in the child’s response—usually just 1 or 2 seconds between the clinician’s production and the child’s repetition. If the child has trouble, use just enough cueing to make the child successful, and then fade the cues slowly.
Lastly, have the child make correct spontaneous productions of the utterance, reintroducing and fading cues as needed.

41. DTTC
DTTC is only one of two CAS treatment procedures that has been researched by independent research groups.
DTTC studies have shown maintenance of treatment effects and generalization to untrained stimuli.
Murray et al. (2014) reported that DTTC was examined in six Level IIb studies (Baas et al., 2008; Edeal & Gildersleeve-Neumann, 2011; Maas & Farinella, 2012; Mass et al., 2012; Strand & Debertine, 2000; Strand et al., 2006).
The results of these six studies revealed that 11/13 participants with CAS had moderate to large treatment effects, with the judgment of certainty being “preponderant.”
Since the Murray et al. article, an additional Level IIb study by Skelton and Hagopian (2014) showed that DTTC could be successfully combined with randomized variable practice to improve the speech of children with CAS.

42. Rapid Syllable Transitions (ReST) Treatment
Because CAS seems to be a problem of motor control and because disrupted prosody is a key symptom of this disorder, Ballard, Robin, McCabe, and McDonald (2010) developed ReST to improve prosody by enhancing a child’s speech motor abilities.
ReST is based on the principles of motor learning that have been shown to help children and adults learn, maintain, and generalize motor skills.
Overall, the principles of motor learning include extensive practice, presenting stimuli in random order, high levels of task difficulty, and self evaluation of performance.

43. Rapid Syllable Transitions (ReST) Treatment
ReST specifically targets a child’s ability to control relative durations in the production of SW and WS pseudo words while simultaneously producing accurate speech sounds.
The authors state that, “pseudo words are especially appropriate for use in treatment because they are not influenced by previously learned motor plans, or differences in frequency or familiarity across participants” (p. 138). In other words, each attempt at saying one of the target words will be a novel motor learning task for the child with CAS.

44. Rapid Syllable Transitions (ReST) Treatment
ReST incorporates the idea that repeatedly practicing many multisyllable pseudo words encourages a child to concentrate on the transitions between syllables. Such problems with syllable transitions are thought to be central characteristic of CAS and contribute significantly to dysprosody and unintelligibility.
The pseudo words follow all the phonotactic rules of real English words.
Consonants in the pseudo words are individualized for the child: (a) they are phonemes the child can produce accurately at least 10% of the time, (b) they will vary in manner, place, and voice, and (c) do not include vowel-like consonants /y/ or /l/.

45. Rapid Syllable Transitions (ReST) Treatment
Examples of SW pseudo words:
Combol
Condan
Mapet
Mambey
Conol
Examples of WS pseudo words:
Bemade
Adoon
Bediss
Bevade
Apoon

46. Rapid Syllable Transitions (ReST) Treatment
Research has shown that children with CAS show significant improvement in the ability to produce SW and WS lexical stress patterns in both treated and similar untreated exemplars of two-syllable pseudo words.
The effects of treatment are retained up to 4 weeks post-treatment and generalize to similar untrained stimuli.
Treatment effects do generalize to connected, everyday speech.

47. Rapid Syllable Transitions (ReST) Treatment
Each treatment session is divided into a pre-practice phase (10-20 min.) and a practice phase (40-50 min.).
Pre-practice phase:
The two-syllable pseudo words (n = 20) are written on cards (with a pictured alien on it to help the child stay engaged). The clinician says the word, and the child is asked to determine if the word has a SW or WS stress pattern.
Then the clinician says the word, and the child imitates it. The child is given 100% “knowledge of performance” (e.g., detailed feedback on how to improve productions, “Make this part longer, and this part shorter.”) on his or her production of the stress pattern and phonemes in the target words.
Cues are provided such as hand tapping and target length of syllables.
The child is moved to the practice phase when five consecutive correct trials are completed for both SW and WS words.

48. Rapid Syllable Transitions (ReST) Treatment
Practice phase:
The 20 cards are presented to the child one-at-a-time, and the child is asked to either read the word or repeat it after a model from the clinician.
One hundred trials of the child saying the words during each practice phase are recommended.
The child is only given “knowledge of results” feedback during this phase (i.e., correct/incorrect), with a 3-5 second delay between the child’s response and the clinician’s feedback.
Feedback fades from 90% in the beginning of the session to 10% at the end.

49. Rapid Syllable Transitions (ReST) Treatment
Murray et al. (2014) reported that ReST has been examined in one Level IIb study (Ballard, Robin, McCabe, & McDonald, 2010). Note: at least three Level IIb ReST studies have been completed since the 2014 CAS review article, one of which was from an independent research group.
The results of this study revealed that 3/3 participants with CAS had significant treatment effects, with the judgment of certainty being “preponderant.” (The most recent ReST studies also showed improved production of untrained words, maintenance, and generalization to connected speech in most participants.)

50. Integrated Phonological Awareness
This approach simultaneously incorporates speech production practice with phonological awareness tasks, letter knowledge, and phonological cues to enhance the speech of children with CAS.
Its rationale is that children with CAS are likely to have significant written language problems in conjunction with their speech production difficulties.
By addressing both deficits in simultaneous treatment activities, some children with CAS have shown significantly improved speech and writing skills.

51. Integrated Phonological Awareness
This procedure’s intervention attempts to (a) enhance letter knowledge, (b) facilitate phonological awareness at the phoneme level, and (c) improve speech intelligibility.
Each session includes activities that address each of these three goals in an integrated manner.
Treatment should be conducted 2x weekly for 1 hour per session for 6-8 weeks.
Group sessions of up to three children are acceptable. (However, it is ideal if each week contains only one group session and one individual session.)

52. Integrated Phonological Awareness
It is best, but not essential, that the children know the following concepts before beginning treatment: same/different, first/last, beginning/end, slow/quick/ together/apart, and letters, sounds in a word, and a word.
The treatment phases of Integrated Phonological Awareness is divided into five sets of program activities, which can include resources, speech practice, activities, and home practice.

53. Integrated Phonological Awareness
Program Activities:
Letter Knowledge
Aim: to facilitate knowledge of the relationship between a letter, the name of the letter, and the common phoneme associated with the letter.
List of resources: letter cards, speech cards, sound-symbol bingo cards,
Speech practice tasks (quoted from the manual):
“The children should be given opportunities to articulate the phoneme for the letter as often as possible during the game activities. The therapist should frequently reinforce the relationship between the letter, its name, and its sound during the activities. Letters should be selected that are appropriate to the children’s speech goals.

54. Integrated Phonological Awareness
For example: • Children whose speech target goal is s cluster reduction should be introduced to letters from that cluster (e.g. s and t, s and p etc.). • Children whose target speech goal is final consonant deletion should be introduced to the letter that will be used in therapy at the end of the word. • Children whose target speech goal is a substitution error (e.g. velar fronting) should be introduced to the target sound (/k/) and the substituted sound (/t/) within letter knowledge activities to allow for minimal pair therapy targeting the substituted sound.”

55. Integrated Phonological Awareness
Letter Knowledge (continued)
Activities level 1: for children with no or little letter knowledge. Tasks include letter/sound recognition, matching letters by case, and identifying letters at the start of words.
Activities level 2: for children with some knowledge of letter-sound relationships. Tasks include sound/symbol bingo game and letter matching with minimal pairs.
Home activities: suggestions for what parents can do at home to reinforce what is being learned in therapy.

56. Integrated Phonological Awareness
Program Activities (continued)
Phoneme Identity and Phoneme Matching
Aim: to facilitate children’s ability to identify phonemes in words
Resources: munching monkey, crunching crocodile, letter cards, speech target cards, phoneme identity cards
Activities level 1: initial phoneme matching tasks
Activities level 2: once children gain confidence in identifying words that start with a target sound, new activities incorporate a wider range of sounds.
Home activities: Parents are encouraged to perform certain activities and games that help children identify phonemes in words.

57. Integrated Phonological Awareness
Program Activities (continued) Blending Aims: to facilitate children’s ability to blend sounds together at the onset rime level and at the phoneme level (onset = the initial consonant or blend at the beginning of a syllable, rime = the following vowel and any final consonant) Resources: speech target cards, segmentation/blending boards Activities level 1: for children with limited phonological awareness begin blending at the onset-rime level using CV and CVC words Activities level 2: children at this level are required to blend phonemes into whole words Home activities: none recommended

58. Integrated Phonological Awareness
Program Activities (continued)
Segmentation
Aim: to facilitate children’s ability to segment a target speech word at the onset-rime or phoneme level and to identify the correct articulation of target words.
Resources: Segmentation/blending boards, segmentation picture board, speech targets
Activities level 1: teaching a puppet to talk
Activities level 2: segmentation/blending bingo
Home activities: none recommended

59. Integrated Phonological Awareness
Program Activities (continued)
Phoneme Manipulation
Aim: to facilitate children’s ability to hear sound changes in words and to recognize how changing letters in words changes sounds in words.
Resources: speech target words
Activities: Initial sound changes in words and minimal pair sound tasks
Home activities: none recommended

60. Integrated Phonological Awareness
Murray et al. (2014) reported that Integrated Phonological Awareness has been examined in four Level IIb studies (McNeill et al., 2009a; McNeill et al., 2009b; McNeill, 2010; Moriarty & Gillon, 2006).
The results of these four studies revealed that 11/15 participants with CAS had significant treatment effects, with the judgment of certainty being “preponderant.”

61. Integrated Phonological Awareness
All program activities are available in the free, 49-page manual at this webpage:
Free downloads of nearly all treatment materials also can be found on the above webpage.

66. The Prognosis for Children with CAS
These children make slow progress.
Years of treatment is the rule in nearly all cases of CAS.
Children with mild CAS can be expected to acquire normal articulation (with treatment).
Most researchers say children with severe CAS will have ongoing articulation difficulties, even when they are in high school.
Realistically, the person with severe CAS may never obtain completely normal articulation.

67. The Prognosis for Children with CAS
We need to be aware of this guarded prognosis when we are counseling families and other professionals.
We can be optimistic in that with much hard work, the child probably will improve.
But we also need to make families aware that even with the hard work, the outcome may not be 100% perfection.

68. References
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