Clinical Decision-Making in Assessment and Treatment of Childhood Apraxia of Speech Welcome to this course on Differential Diagnosis for Childhood Apraxia.

Clinical Decision-Making in Assessment and Treatment of Childhood Apraxia of Speech
Welcome to this course on Differential Diagnosis for Childhood Apraxia of Speech. My name is Ruth Stoeckel and I am an SLP from Rochester Minnesota. I have had a career-long interest in pediatric motor speech disorders and appreciate the opportunity provided by ASHA to share information about assessment of motor speech disorders. Childhood Apraxia of Speech , which I will refer to as CAS, is a low-incidence disorder. Diagnosis can be challenging. There is potential for both overdiagnosis and underdiagnosis . There are misconceptions on the part of both parents and professionals about who should make the diagnosis. Apraxia is a motor speech disorder. The ASHA Technical Report affirms that SLPs – SLPs with specialized expertise – are the professionals who should be making the diagnosis. As we have improved in diagnosis and begun to monitor long-term outcomes for children with CAS, we know that other professionals will almost always need to be called upon to participate in the child’s treatment due to concerns about co-occurring problems, including learning disorders that may not be evident until school age. Our emphasis today will be on discerning characteristics of a child’s speech sound disorder for differential diagnosis. Ruth Stoeckel, Ph.D., CCC-SLP Mayo Clinic

Disclosures Financial Disclosures:
Compensation from ASHA for online conference Compensation for speaking/teaching from Childhood Apraxia of Speech Association of North America (CASANA) Compensation from Medbridge webinars Nonfinancial Disclosures: Member of the Professional Advisory Board of CASANA

Instructor, Mayo Medical School
Clinical Practice Research

Objectives Based on best available evidence, participants will:
Interpret responses during assessment to support differential diagnosis in children with severe speech sound disorders Describe how dynamic assessment can contribute to assessment of speech sound disorders Compare motor-based versus phonological approaches to treatment Discuss evidence-based interventions for CAS

Connecting Research to Practice: Why?

Why Connect Research to Practice?
Understanding of… the physiology of the speech mechanism interactions of cognitive,linguistic, and motor factors, and effects of treatment factors informs our clinical decision-making during assessment and treatment

Research to Practice: Evidence Based Practice
EBP does not require us to use information only from peer-reviewed studies But we DO need to consider the level of evidence when empirical studies are lacking Instead of asking “Is XYZ an evidence-based practice?” ask “What is the level of evidence for this practice?”

Research to Practice: Resources for Best Available Evidence
ASHA Systematic Reviews Cochrane Data Base Speech Bite ASHA Technical Reports Consultation with experts Current journal articles/reviews

Research to Practice: Assessment
There are interactions among cognitive, linguistic, and motor aspects of development The interactions of these aspects of development change over time (Kent, 2004; Smith & Goffman, 2004; Nip, Green & Marx, 2010)

Speech sound perception skills may be impaired in some children with speech sound disorders (Munson, Edwards, & Beckman, 2005; Preston,) Vowels: Children with CAS have difficulties positioning and sequencing articulators for vowels (timing, nasality, voicing) (Gibbons, 2002) Vowel errors contributed to long term intelligibility problems in 3 children with CAS (Davis, 2003)

Research to Practice: Treatment
There is a growing evidence base that can help to inform decisions about “dosage” (frequency and length of sessions) choice of targets treatment approaches/treatment factors

Research to Practice: Literacy
We know that children with early speech- language problems are at risk for literacy problems As well as less optimal outcomes for academics in general (e.g., Lewis, et al. 2015) A note on terminology Let’s be clear in differentiating Phonological processING from Phonological patterns (processES)

Research to Practice: Personal
Throughout the day, be thinking about: What information you usually gather during assessment and treatment Why you choose specific assessment tools or treatment techniques How you use information to arrive at a diagnosis and to guide treatment When you modify treatment due to progress or lack of progress

ASSESSMENT

Assessment for Severe Childhood Speech Sound Disorders
Simple, right? Mild motor issues? ATTENTION LANGUAGE Dysarthria CAS mixed SENSORY COGNITION EXPERIENCE Phonological Disorder Adapted from Hodge, 2008

What is Childhood Apraxia of Speech (CAS)?
It is a neurologic pediatric speech sound disorder “In which the precision and consistency of movements are impaired in the absence of neuromuscular deficits”

CAS “The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.”

“A child is at increased risk for early and persistent problems in
speech, expressive language, and the phonological foundations for literacy and need for AAC” (ASHA Technical Report, 2007)

CAS CAS can occur in isolation (idiopathic)
CAS can appear to be the primary disorder, with later identification of associated problems, such as reading difficulty but CAS itself is not the “cause” CAS can occur in conjunction with other disorders, such as Genetic disorders Brain injury

Results: Comorbidities

Results of Mayo Study of Children with CAS: Expressive Language Delay

Best Available Evidence
Suggests that many/most children with CAS will have co-occurring problems (e.g,. Lewis, et.al., 2004; Lewis, et al., 2015; Baas, Stoeckel, Kosey 2016) Our focus today will be on the speech disorder

Differentiating Disorders

Phonologic Disorder The primary factor is thought to be linguistic rather than motor Etiology is most often unknown

Childhood Apraxia of Speech (CAS)
The primary factor is thought to be praxis: planning/programming movements No obvious weakness or impaired ability to move articulators Can be acquired (e.g., stroke, TBI) or “developmental.”

Dysarthria Difficulty with execution of movements
Weakness, paralysis, or abnormal tone resulting in decreased range of motion, decreased speed, or impaired movement of the articulators Usually caused by impairment in the central or peripheral nervous system

Assessment Assessment procedures are used to
determine the relative contribution of linguistic (phonology and language) skill cognition speech motor skill assist in planning treatment

ASHA Evidence Map "The best diagnosis method is combined, that is, clinical assessment (observation of the child’s speech) and formal evaluation (with valid and reliable protocols)"

Assess language Consider referrals for assessment in other areas as needed, which may include Neurology – possible seizures or other neuro involvement Developmental Peds – possible developmental or genetic conditions, motor development Neuropsychology/Psychology – cognitive and learning skills

Research to Practice: Assessment of Speech
Assessment should include presentation of targets with hierarchical levels of cuing accommodating a child’s developmental level, and using different levels of complexity Sound patterns Word vs phrase or sentence, and having the child attend to examiner’s face for visual cues (Kent, 2004)

Be conscious of vowel errors Consider assessment of speech perception – phonological processing

Assessment Procedure Develop an individualized assessment plan:
Screen/assess language Examine oral structure and function, speech subsystems Assess speech perception Obtain phonetic/phonemic inventories Assess motor speech skill We’ll talk about each of these in more detail shortly, but let me introduce you to each component here. I can’t emphasize strongly enough that a child’s ability to communicate across multiple modes needs to be considered. We don’t want to be too quick to apply the diagnosis of CAS to children because of “not talking” or to be too hesitant to apply the diagnosis for a child who is actively attempting to communicate while having to rely on very few sounds or words. In addition to an impression about language skills, we want to review physical and structural characteristics that may contribute to the child’s difficulty speaking. Next, we want to carefully assess the child’s speech sound inventory to identify patterns beyond those that may be superficially evident, and look at what the child produces spontaneously versus what they produce in response to an expected target, like a picture on a standardized test, or a modeled production. Given evidence that some children with speech sound disorders have reduced speech perception skills, assessing this area, either initially or early in the therapy process, makes sense both in terms of maximizing teaching effectiveness and also by proactively monitoring this important literacy skill. Finally, assessment for CAS cannot be based on assessment of articulation or phonology alone. There must be a specific attempt to evaluate motor speech skill. I’m going to share a dynamic assessment procedure that can generate data to contribute to differential diagnosis for motor speech impairment versus phonologic impairment.

Assessment: History Birth history Family history
Developmental milestones First words, word combinations Motor milestones Co-existing problems Sensory function issues Seizures, hearing loss, learning issues Feeding history, abnormal reflexes

Assessment: Structure and Function
Structures Range of motion Coordination Strength Ability to vary muscular tension Speed Tissue characteristics

Assessment: Observation of Speech Subsystems
Respiration Articulation Phonation Resonance Prosody

Video Example P S-F

Assessment: Language Consider the child’s speech in the context of their overall ability to communicate Does the child exhibit communicative intent to comment, request, engage in social interaction? to initiate interactions with expected frequency?

Assessment: Formal/Conventional Measures of Language
Informal measures Language sampling Parent report Standardized checklists Standardized tests can provide useful information about the child’s language skills in a structured context. However, there can be misuse of scores as well. A significant discrepancy between receptive and expressive language skills is sometimes cited as a characteristics for differential diagnosis of CAS, and it can be a useful observation for some children. However it is possible for a child have delays in both receptive and expressive language and still have CAS. It is also possible for a child to have no delays in language but a significant delay in speech sound acquisition. For example, a 3-year-old who is using gestures effectively ,and following directions well could potentially score in the “average” range for age on a general language measure like the PLS-5 that allows gestures to be counted toward the expressive score, while that child may be nonverbal, or producing only simple single words with a restricted phonemic repertoire. There is no receptive-expressive discrepancy, but the child ‘s ability to speak is clearly not in line with the estimate of language skill. In cases where there is little or no discrepancy between receptive and expressive skills, a difference between estimated level of language and expectations for speech sound development may be data that contributes to thinking about the possibility of CAS .

Assessment: Language Language Sampling can be done with children who have limited intelligibility (Bingner, Ragsdale & Bustos, 2016) Mean Length of Utterance in words Mean number of syllables per utterance Percentage of comprehensible words

Assessment: Language Formal measures Receptive/expressive vocabulary
General language tests Formal language sample analysis

Assessment: Language Is there a discrepancy between receptive and expressive skills? (not required for CAS dx) Is there a discrepancy between estimated level of language and speech sound development? (e.g., acquiring sign language rapidly but remaining nonverbal) Receptive > Expressive? Language Level > Speech Sound Acquisition?

Assessment: Language in Bilinguals
Disorder will occur in all languages Consider the aspects of normal language acquisition in all languages and the characteristics of communication disorders

Video example P book 1

Assessment: Speech Perception
Informal observations may be sufficient at initial evaluation Formal assessment may be particularly helpful for children approaching school age or already in school Phonological awareness skills are necessary but not sufficient for development of reading skill Assessment of speech perception is not a routine aspect of assessment for many of us, based on reports I have seen for children coming from around the country . Checking for discrimination of sound patterns informally may be sufficient at the time of initial assessment, but more detailed data can be helpful as the child begins therapy, and formal assessment will become more important for children who are at later preschool or school age. It is well established that children with a history of speech problems tend to have more difficulty than peers with phonological awareness tasks. Knowing how important phonological awareness is as a basis for literacy, we need to have this “on our radar”, so to speak.

Assessment: Speech Perception Phonologic Processing
Formal tests such as the CTOPP, TOPA, Wepman, etc. Informal measures such as the Locke task (1980)

Assessment: Speech Perception Phonologic Processing
Evaluate the child’s understanding of phonemic categories and other phonologic awareness skills, which can influence the interaction of speech and vocabulary development, and literacy/academic skills

Assessment: Speech Obtain Phonetic/Phonemic Inventories
There is no single test of articulation or phonology that is a fully adequate measure of a child’s phonetic inventory (Eisenberg, et al., 2010) Tests can be a useful means for quickly probing a range of speech sounds A spontaneous inventory provides additional information for interpreting results and planning treatment Having looked at language and physical characteristics, we need to move into assessment of the child’s speech sound inventory. What sounds can they produce spontaneously? What sounds do they produce in relation to a target? Are there predictable patterns of error? Are there atypical patterns of error noted? As you see on the screen, a study by Eisenberg and colleagues suggested that standardized assessments can be useful for making sure a variety of sounds are probed, but they should not be considered sufficient information to fully understand a child’s speech sound system. Many of the most widely used tests do not include vowel errors in the analysis, a potentially important source of errors for some children with CAS. A child with severe CAS may not be able to complete a standardized assessment, but it can be helpful to see how a child responds to even an abbreviated attempt at picture-naming. The ability to produce a target without an immediate verbal model is one of the things we are probing here. We will be assessing ability to produce a target in imitation of a model as part of the motor speech examination. In addition to the structured assessment, documenting the child’s spontaneous inventory can contribute helpful information to the process. One of the features identified in the early paper on childhood apraxia by Yoss and Darley was difficulty producing words on demand. Documenting sounds the child produces when verbalizing freely will help us to see if they produce a greater number of sounds in that context than in an elicited context. This inventory can help us to identify sounds that were not produced on a formal measure but for which the child might be stimulable when we present stimuli in the motor speech exam, or when we move to treatment.

Assessment:Speech Obtain Phonetic/Phonemic Inventories
Sound system analysis is needed To describe the current phonetic/phontactic inventory To guide decisions regarding intervention approach and stimulus selection To establish a baseline for progress monitoring Once we have collected information about the child’s sound system, we can look for patterns of error that suggest phonological impairment, and to identify atypical errors or patterns of error that signal a more severe phonological disorder aside from or in addition to a possible motor speech impairment. Documenting speech sound inventory carefully at the time of assessment provides a baseline against which to compare data collected at a later time as a way to document progress. The binary decisions – error or no error – that are made on standardized tests will not be sensitive to a child who is making small increments of progress. Comparing how the child’s speech sound inventory is increasing in spontaneous output versus elicited output may provide evidence for improvement towards the target or generalization that isn’t captured when only a few exemplars of a particular target are probed on the standardized measure. Looking at phonotactic structure as a part of this analysis can us insight into whether the child is depending on simple syllable structures versus more complex structures and/or sequences. It can be particularly helpful for children who are verbal, but break down with increased length or complexity of sequences. Most importantly, learning about the child’s current phonetic/phonemic inventories helps us to think about what to probe as part of the motor speech examination.

In order to teach at a syllable level, we have to know the child’s phoneme inventory

Sound System Analysis: A “Sequence” of Speech Sound Development
Early 8 Middle 8 Late 8 m b j n w d p h t k g ŋ f v ʧ ʤ ʃ ɵ ð s z l r Ʒ around 3 years of age around 3-4 years of age The speech sounds are shown here in their specific categories. most between 5 ½ - 8 years of age Think of these ages as “usually acquired by” rather than “wait until this age to teach” Shriberg, 1993; Lof 2004

Sequence of Speech-Sound Development: Vowels
Early: /i/, /u/, /o/, /˄/,/ɑ/ Later: /a/, /ɔ/, / ə/ Later yet: /e ɪ/, / ɪ/, /ɛ/, /ɝ/ (Stoel-Gammon & Herrington, 1990)

Assessment: Speech Phonetic Inventory
What sounds and syllable shapes is the child producing spontaneously? (Helps to identify what the child can build on) Error Inventory How does the child’s sound system map onto adult forms? How do syllable shapes relate to target forms?

Video example P G-F

ACTIVITY Find the production/error analysis form in your packet
Use the word list in your packet to record sound substitutions and omissions in the grey area under the heading “Relational (elicited)” based on the transcribed responses

ACTIVITY Take out the production/error analysis form again
Use transcription of spontaneous output in your packet to identify sounds the child is producing spontaneously in the white columns Is there overlap in the two inventories?

Independent inventory
Relational inventory Both inventories

Assessment: Motor Speech Skill
As with articulation/phonology, there is no single test that is fully adequate to assess motor speech skill (McCauley & Strand, 2008) A checklist approach to assessment is insufficient We have finally reached the “meat” of the assessment protocol, specific assessment of motor speech skill. In 2008, McCauley and Strand reviewed all available standardized measures for assessing speech motor skill. They concluded that there is no single test that should be used as the sole source of information for a diagnosis of CAS. So, what can we do? We can use any of these measures as a means for collecting data and making behavioral observations, while using our own clinical thinking to interpret the findings. I think of the analogy that “you learn to read so you can read to learn.” For any testing we do, but particularly for CAS, it is a similar matter of learning to use tests and other procedures to develop a sense of what is indicative of a motor speech disorder, then as we develop skill, we begin an assessment with a hypothesis about the child’s motor speech skill and what we are looking for, then use the test or other procedures to inform that hypothesis.

From: McCauley & Strand, 2008
DARK BLUE Vowels - included on 7 measures LIGHT BLUE Cs sylls (nonsense stimuli) - 5 measures to varying degrees; 1 measure entirely RED Single words - 4 measures AP, KSPT, STDAS, VDP GREEN Multiple words - 4 measures AP, STDAS, VDP, VMPAC WHITE Connected Speech - ratings - 2 measures AP and VMPAC; 2 others also had connected speech, but clearly as individual items YELLOW DDK From: McCauley & Strand, 2008

Assessment: Motor Speech Skill
A motor speech exam should include presentation of targets with hierarchical levels of cuing To accommodate the child’s developmental level Using different levels of complexity Syllables Syllable sequences of increasing complexity While child attends to examiner’s face for cues In the book, Clinical Management of Childhood Motor Speech Disorders, Edythe Strand suggests that a motor speech exam should include a hierarchy of cues and targets of varied complexity so we can accommodate where the child is at developmentally while providing support to determine the highest level of complexity the child can achieve with help. The child can be encouraged to watch the examiner’s face to take best advantage of multisensory cues. How do we decide on complexity of targets? That’s where the chart we looked at previously can come in handy! I am going to keep in mind that I want to probe syllables or syllable sequences that represent functional vocabulary as much as possible. Using real, useful words can help the child to communicate more effectively as quickly as possible, and that can be motivating for them as well as their caregivers. My process then is to look to the chart we made earlier to considering what is already consistently in the child’s consonant inventory that I can probe with varied vowels or where there are movement patterns -- you can think about place of articulation – that are represented by one or more sounds that could potentially facilitate acquisition of additional sounds. For example, looking at the chart we used earlier, we know that the child has lip closure for bilabials, so it may be a good idea to probe that movement with evaluation of the child’s control of voicing, but maybe go to a final position, again to take advantage of the tendency acoustically to devoice in final position. So “up” as a possible target. Additionally, I can use the chart to see what syllable shapes the child has produced, and consider probing sounds that aren’t in their inventory in a simple or existing syllable shape. The child on the example chart has a good inventory of syllable shapes, but no CVCs represented. So I might try “house” or “done”. What I want to do in putting together an individualized motor speech examination is to decide at what level of complexity to start – simpler syllable shapes for a more severe child, potentially more complex shapes for a more verbal child, taking into consideration the speech sound inventory as well -- and how I will systematically vary the length and complexity while providing support for the child in terms of different types of cues. There is a lot to think about!

Why Use Dynamic Assessment?
It is sensitive to changes that result from the child’s responses to cues  acquisition of a new skill It is different from standardized tests which compare a child’s performance to a normative group Two children with the same standard score on a test may have different levels of severity and different prognosis for change Response to cueing may be more informative about prognosis than total number of errors

It facilitates judgments of severity and prognosis the clinician is providing different levels of support or cuing Observations regarding response to types and levels of cuing facilitate judgments regarding how much cuing will be needed in early therapy to induce improvement in performance how long it may take to achieve initial progress

It takes advantage of what a child can do independently while providing support when needed It is interactive, focusing on the process of acquiring a skill The child’s responses guide the process, allowing for continuous adaptation It follows the process that can be used in treatment On this slide, I usually animate the circle to go around a time or two and reinforce the iterative nature of the dynamic assessment task. The hierarchies of task complexity and level of cuing can be presented to the child in a dynamic framework. Target stimuli are presented to the child, and the child’s response determines what is presented to them next. If the answer is correct, the child is reinforced, and a new target stimulus will be presented. If the child is incorrect, the examiner may present the target again, but with additional cues. We are exploring the child’s ability to produce targets on demand, and their ability to take advantage of the additional cues to achieve success. Response to cues allows us to get a sense of how easily the child can acquire a new skill when provided with the necessary support. We allow the child to “show us what they’ve got” while trying to expand/extend that skill.

Motor Speech Exam Direct Imitation Incorrect Correct Simultaneous
production Continue to add cues as needed to determine if the child can achieve correct production with increasing assistance Mark as correct Slowed rate Add tactile and/or gestural cues Based on Strand, 2004 and Strand, et al., 2013

We are looking for: Estimate of severity Where the breakdown occurs What type of cueing is needed for success A good evaluation provides a starting point for treatment planning

Video Examples J-MSE P-MSE

ACTIVITY Use the production/error analysis form and parent inventory list to come up with words to probe in the motor speech examination. Be sure to consider: Probing for sounds you predict may be stimulable Probing a variety of syllable shapes Probing at least a few syllable sequences Are they functional words that could be used to initiate therapy? Choose one “challenge” word

What are we looking for? ASHA Technical Report (2007) possible markers;: (a) inconsistent errors on consonants and vowels in repeated productions of syllables or words, (b) lengthened and disrupted coarticulatory transitions between sounds and syllables, and (c) inappropriate prosody, especially in the realization of lexical or phrasal stress. Having talked about the “how” of the motor speech examination, we should talk ab it about what it is we are looking for while doing it. As we are presenting our targets and noting behaviors, what specific behaviors are we looking for that suggest motor planning/programming impairment? The respected group of clinicians and researchers who contributed to the ASHA Technical report reviewed existing research studies to identify characteristics for which there was the most evidence. They included a disclaimer that these should not be considered the “gold standard” by which to make a diagnosis, but they provide us with at least a bit of guidance. First, inconsistent errors on vowels and consonants in repeated productions. An example would be a child who is asked to say “mommy”, and upon repeated efforts tries “mama,” “meehee”, “meemeemee.” Lengthened and disrupted coarticulation can be noted in various ways. Some children with CAS will have a tendency to segment within words. For example the child you saw in the video clip separated the onset /g/ from the “oh” in “go.” Some children may separate words within a phrase that would usually be coarticulated, resulting on “choppy” prosody. Still others may have slower than typical transitions, resulting in a labored-sounding production of sequences. The third possible characteristic is disrupted prosody. Parents often report that their child with CAS has difficulty modulating loudness. A large study by Shriberg and colleagues identified a tendency for equal, excess stress. Some children produce targets with misplaced stress, and need to work on using appropriate lexical or sentential stress patterns.

“Importantly, these three features are not proposed to be the necessary and sufficient signs of CAS.” “These and other reported signs change in their relative frequencies of occurrence with task complexity, severity of involvement, and age.”

A fourth candidate characteristic = vowel distortions (e. g
A fourth candidate characteristic = vowel distortions (e.g., Davis, Jacks, & Marquardt 2005) Contribute to ratings of severity of a disorder Are not likely to occur without consonant errors Are less likely to be corrected spontaneously by children with motor speech disorders

Additional Possible Characteristics
Limited early babbling/sound play Better performance on automatic vs volitional speech Restricted sound inventory for age Increased errors with increased phonetic/linguistic complexity Atypical phonological patterns (e.g., initial consonant deletion) Additional characteristics that can contribute to a diagnosis of CAS are listed here. It’s important to recognize that many of these characteristics can overlap with other speech sound disorders, including phonological disorder or dysarthria. At the present time, we don’t have enough information to make a confident diagnosis in a child who is not yet expected to be speaking in words, that is, to identify children based only on their preverbal vocalizations or babble It might be tempting to use these characteristics as a checklist to arrive at a diagnosis. However, the fact is that how these characteristics may be expressed in a particular child will vary depending on their age and developmental level, and it is still incumbent on us as clinicians to make judgments about the child’s presentation with any of these characteristics that can help us discern whether there is a motor planning/programming impairment. Which leads us to discussion of interpreting test results.

Disruption in temporal and spatial relationship of articulators Longer word and sentence durations Difficulty achieving and/or maintaining articulatory postures Disrupted suprasegmentals (rate, pitch, loudness) – can occur with dysarthria as well

Difficulties with sound sequencing Sounds produced correctly in some sequences are produced incorrectly in others. Why? Perhaps due to different motor requirements

Assessment: Sound System Analysis
A child with phonologic disorder will usually have Consistent patterns of error “typical” patterns such as final consonant deletion, fronting, stopping, etc. Intact prosody Vowels intact A child with CAS may have Restricted sound repertoire Poor differentiation of vowels Few/simple syllable shapes Atypical error patterns (e.g., initial consonant deletion, sound preference, epenthesis, voicing errors, etc.)

Comparison Chart This is descriptive, not diagnostic
Chart is also available at Apraxia-Kids.org

Video Examples Hi C w/Edy L DEMSS G A first

Assessment Summary Assessment information is used to:
Determine if there is sufficient evidence to make a diagnosis of CAS Identify the relative contribution of cognitive, linguistic, and motor factors Determine priorities for treatment Plan appropriate treatment strategies To re-iterate, there may be times when a child’s age and/or presentation are so complex that we defer a definitive diagnosis and say there is “suspected CAS”. Parents are inclined to want something definite, but we are serving the best interests of the child and their family by taking a thoughtful approach to diagnosis and talking about how to use assessment information to identify appropriate treatment. When CAS is the primary contribution to the child’s communication disorder, a motor-based approach is recommended. There is no single approach shown to have efficacy for every child with apraxia, but best available evidence suggests that a consistent aspect across the approaches that have been studied is that they incorporate principles of motor learning. Again, the child may have other co-occurring issues, and it may be appropriate to introduce some aspects of phonological treatment and to consciously choose specific sentence forms as targets to support language development. And as motor planning/programming skills improve, attention to these other aspects of the child’s communication may take priority. Providing appropriate treatment involves identifying what is needed for a given child at a given time, and adapting treatment techniques as progress is made.

Intervention

Intervention Options “wait and see” protocols alternative
Kits or programs protocols Apps alternative treatments “wait and see”

Three Main Categories of Intervention for CAS/Severe SSD
Integral stimulation  Emphasizes auditory and visual models DTTC Tactile/gestural  Touch/gestures are emphasized PROMPT Prosodic Emphasizes melody and rhythm as facilitators ReST

Research to Practice: Approaches with Research Evidence
Based on Systematic Reviews Dynamic Temporal and Tactile Cuing (DTTC) -- Integral Stimulation Rapid Syllable Transition (ReST) Biofeedback PROMPT Nuffield Dyspraxia Programme (NDP3) (Murray, McCabe & Ballard, 2014; Maas,Gildersleeve-Neumann, Jakielski & Stoeckel, 2014)

Research to Practice Strongest evidence for DTTC/Integral Stimulation
Small scale studies (Edeal & Gildersleeve-Neumann, 2011; Maas, Butalla & Farinella, 2012; Maas & Farinella, 2011; Maas, et al., 2008; Strand, Stoeckel, & Baas, 2006; current study, Maas & colleagues) .

Research to Practice Randomized, Control Study of ReST and NDP3 (Murray, McCabe & Ballard, 2016) Biofeedback (Ultrasound) (Preston, Brick & Landi, 2013) PROMPT (Grigos, Hayden & Eigen, 2010; Dale & Hayden, 2013)

Typical “dosages” vary for each approach, often determined by convenience rather than empirical guidance for number and length of sessions or duration of intervention Optimal treatment intensity is specific to the intervention(s) being used and to the speech disorder being treated (Kaipa & Peterson,2016)

Research to Practice Nonspeech exercises
Babbling and early nonspeech oral behaviors are not related (e.g., Moore & Ruark, 1996) Movements for eating and speaking are dissociated early in life Speech is not a series of isolated movements (e.g., Nip, Green & Marx, 2010).

Research to Practice Nonspeech Exercises
Evidence-Based Systematic Review recommendations 1) Pursue treatments with established efficacy instead 2) Look to basic research for evidence of a theoretical basis for the unproven treatment 3) Use in clinically-based research McCauley, Strand, Lof, Schooling & Frymark, 2009

Intervention: Research to Practice
Use best available evidence to answer… How do I choose an appropriate treatment approach? How do I choose these goals?

Research to Practice Communication is a priority
For minimally verbal children, you may need to start with imitation, AAC, etc. (DeThorne, et al., 2009) The child needs to understand the task; intent to improve movement (Maas, et al., 2008) Promote early success – the child should be stimulable for targets (Maas, et. al, 2008) Use of functional targets can increase motivation (Strand & Debertine, 2000)

Minimally Verbal Children: Review
Provide access to AAC Minimize pressure to speak Imitate the child Use exaggerated intonation and slowed tempo Augment auditory, visual, tactile and proprioceptive feedback Avoid emphasis on nonspeech-like articulator movements: focus on function (DeThorne, et al., 2009)

Intervention: Phonologic vs Motor
Phonologic Intervention Motor Intervention Emphasizes the sound patterns of language Emphasizes how changes in sound pattern affect meaning Targets are single sounds or sound patterns Coarticulation is not considered critical Emphasizes principles of motor learning; movement vs sounds Emphasizes proprioception and how variations in movement affect output Targets are movement sequences (syllable level or higher) Coarticulation is critical

Functional targets based on movement patterns vs sound patterns:
Tea Key Phonological therapy addresses a systematic pattern of sound contrasts sound changes that relate to meaning CAS treatment emphasizes spatiotemporal parameters – movement patterns where articulators start, where they are moving to, and how those movements are timed to achieve intelligible production of sound sequences. Movement patterns are treated using the principles of motor learning Movement patterns Home My puppy CVC CVCVCV 92

A Treatment Framework: DTTC
Based on Integral Stimulation Allows opportunity for the child to take increasing responsibility for assembling, retrieving and executing motor plans with progressively less cueing Easily accommodates principles of motor learning “Mixed” approach integrates language/phonology with motor practice

Dynamic Temporal and Tactile Cuing (DTTC)
Direct Imitation Incorrect Correct Simultaneous production Practice with varied rate and prosody If incorrect, try miming or go back to simultaneous Slowed rate Delayed repetition Add tactile and/or gestural cues After simultaneous repetitions at normal rate and prosody, probe direct imitation

Treatment is continually adjusted to adapt to changes in the child’s
The child may be working on different stimuli at different levels of the cueing hierarchy The level of cueing is constantly changing within and between sessions, depending on the child’s responses Don’t forget to allow the child adequate processing time for their responses Treatment is continually adjusted to adapt to changes in the child’s speech motor skill

Video example J- stop it sara

Activity Pair up Use the graphic to teach one partner “my puppy”
“student” can decide how to respond Use the graphic to teach second partner “open” “student can decide how to respond

Research to Practice: Intervention
Encourage attention to face for visual cues Incorporate principles of motor learning Teach movement sequences vs isolated phonemes Use multisensory input (auditory, visual, tactile)

Intervention: Research to Practice:
Be conscious of frequency and intensity of practice Think about range of difficulty in stimuli -- challenge can facilitate motor learning Adjust the level of cuing carefully

Research to Practice Communication is the priority

Understanding the Task
Emphasis is on movement versus sounds, however… Communication involves cognitive and linguistic aspects as well as motor skill (Nip, Green & Marx, 2010) Are we teaching strategies appropriate for developmental age and level of motor skill?

Stimulability The child should be able to produce the target with some level of cuing Success can lead to increased motivation/effort If the child is not stimulable, the result may be frustration and distrust

Functional Targets Think about the needs of the “whole child”
Build vocabulary and language as well as speech accuracy Give the child ways to interact with others and with their environment

Structure of Practice/ Principles of Motor Learning
Choices need to be made about: Organization of sessions How many targets to include in treatment, depending on severity and type of motor speech disorder immediate goal (acquisition vs stabilization/transfer) (Maas, et al., 2008)

Distribution: Mass vs. Distributed practice
Mass practice = minimal time between trials or sessions Facilitates acquisition Distributed practice = a greater amount of time between trials or sessions. Important for stabilization and generalization Within a session, mass practice can mean a large number of repetitions of a single target. Distributed practice is fewer repetitions spread throughout the session

Distribution Mass minimal time between trials Distributed
greater amount of time between trials Hi mom Dora Mass minimal time between trials Hi mom Dora Mass vs distributed practice refers to the number of repetitions and amount of time between repetitions. Massed practice is good for acquisition – lots of practice at once Distributed practice is fewer repetitions over more time, good for retention Here’s an example: In this example, the child may start out practicing “hi mom” and “Dora” in mass practice. She is showing increased accuracy for “Dora” with minimal cueing, so the distribution within a session is changed to continue mass practice for “hi mom” but begin to work on “Dora” in distributed practice. 108

Schedule: Blocked vs. Random Practice
Blocked practice means all practice trials of a given stimulus are practiced together before moving on to the next. Facilitates improved performance Random practice means that the order of presentation of the stimuli are randomly mixed up throughout the session. Facilitates retention/motor learning

Scheduling Random Blocked
all practice trials of a given stimulus are practiced together before moving on to the next I do I do Elmo Elmo Movie Movie Home Home Random the order of presentation of the stimuli are randomly mixed up throughout the session I do Home Movie Elmo Elmo I do I do Movie Blocked trials allow for some degree of anticipation, and therefore better performance Random trials force the child to retrieve the motor plan without the benefit of that anticipation, and so reinforce the learning. 110

Variability: Variable vs. Constant practice
Constant practice = working on one specific exemplar of the target, Helpful early in therapy when problem is more severe May facilitate learning relative aspects of movement Variable practice incorporates variations of the target, such as modifying rate, loudness, inflection, etc. or varying context (single word vs phrase , etc.) Helpful to transfer skills later in the therapy process May facilitate learning of absolute aspects of movement

Variability Constant working on one specific exemplar of the target
I want a cookie Variable incorporating variations of the target, such as modifying rate, loudness, pitch, etc. I want a cookie! We know that productions of a target will not be exactly the same from one attempt to the next. Consistency may help the child be accurate in learning a target Variations in rate, loudness, pitch and duration help the child explore the range of what “works” The child may learn from their mistakes as well as their successes. 112

Feedback: Knowledge of results vs knowledge of performance
Knowledge of results: provided after completion of the movement that compares outcome to target (e.g., That was what I want to hear! Those were all right!) Knowledge of performance relates to the nature or quality of the movement gesture (e.g., Close your lips tighter. Close your mouth just a little more) Frequency and timing of feedback is different for children and adults (Sullivan, Kantak, & Burtner, 2008)

I want one X40 My turn X1 Thomas X50 Puppy X40 Hi mom X20 Time to go X5
Mass AND Distributed Mostly random, “blocked” with “my turn” Probably constant AND variable

Conditions of Practice
Need focused attention, even if brief Develop the habit of child looking at clinician’s face Emphasize improving movement rather than sounds Challenge, but don’t frustrate Use activities that generate many opportunities for repetition We want good quality practice; shaping to accuracy

Sessions “There is emerging research support for the need to provide three to five individual sessions per week for children with apraxia as compared to the traditional, less intensive, one to two sessions per week (Hall et al., 1993;Skinder-Meredith, 2001; Strand & Skinder, 1999).” Optimal treatment intensity is specific to the intervention(s) being used and to the speech disorder being treated (Kaipa & Peterson,2016)

Sessions Number of sessions per week should be adjusted based on
Severity of the CAS Child’s ability to participate Family/Educational support Other interventions A child may benefit from some small group work to facilitate development of pragmatic skills

Sessions Length of sessions may depend on
Child’s developmental ability to attend/participate Tasks to accomplish (e.g., time to counsel/educate parent, demonstrate techniques, etc. in addition to intervention with child) Allow time for a high number of repetitions per session (Edeal & Gildersleeve-Neumann, 2011) Clinician preference and therapy style

Targets Target choices should include consideration of how to:
promote early success in therapy promote generalization of learning “use what the child gives you” in terms of phonetic repertoire and syllable shapes improve movement gestures for accurate production of specific vowels and/or consonants encourage good prosody increase effectiveness of verbal communication

How Many Targets? Depends on severity of child’s speech disorder
Increase number (and complexity) as skills improve

Type of Targets Use what the child has in their inventory and consider: Single syllables vs syllable sequences types of syllables/sequences phonetic complexity awareness of general sequence of sound development (e.g., early, middle, late) tring varied syllable shapes (CV, VC, CVC, etc.)

Functional Targets: Consider Speech Needs
Try new sounds in existing syllable shapes Increase sound repertoire Use existing sounds in new syllable shapes Phrases as sequences Increase syllable repertoire Accurate lexical stress Accurate phrasal stress Improve prosody

Video example J- ee-ah B-S book

Functional Targets: Vowels
Vowels are important for intelligibility

Vowels Can be a significant aspect of intelligibility of a syllable
Are primarily of concern in motor speech disorders (CAS, dysarthria) vs phonological disorders Errors are not as likely to spontaneously resolve as consonant errors

Intervention for Vowels
Integrated into overall treatment plan Work for accuracy, not approximations Individualize to child – no set order based on evidence in the literature Choose facilitating contexts, remember coarticulation effects Diphthongs involve movement, good to address early if possible

Facilitating Contexts
High frequency (how often used), low density (how many similar words can be created by changing one phoneme) Alveolars with high front vowels (day, see, say) Labials with central vowels (butt, pet, bet) Velars with high back vowels (go, cool, cook)

Facilitating Contexts
High front vowel in second syllable (mommy, daddy) Voiceless stop/fricative/affricate after a lax vowel (sit, look, nap) Velars and fricatives in final position AVOID voiced plosives in final position Too easy to end up with added schwa (bug-uh)

Building Speech & Quantifying Complexity Toolkit

Functional Targets: Consider Language Needs
Nouns Verbs Conceptual vocabulary Vocabulary Length of utterances Complexity of utterances Grammar/ Syntax Greeting Requesting/directing Commenting Social Interaction

Examples C- out1 C –out2 S – fruit B -- book

Language – model telegraphic utterances or not?
Using grammatical features may facilitate language processing (Bredin-Oja & Fey, 2014) Helps child anticipate upcoming words Grammatical features (e.g. –ing) help the child learn new words We don’t want to reinforce child speaking telegraphically in the long run Typically developing children process spoken language more quickly when grammatically correct than when telegraphic (Fernald & Hurtado, 2006; Fey, Long & Finestack, 2003 )

Don’t forget prosody! She likes village life butter family lives in Toronto. I like village life butter bin life has its advantages. Everything butter purse was recovered. Jim couldn't decide whether to go with butter Larry. The other butter daughter gave her was a rose. She said butter Ernie took it. Butter Lee in the morning it's still dark. Orange pekoe is good, butter bull tea is nice in the winter. Fish live in the ocean butter chins do not.

L – reps J – Luigi/Mario

Target “bins” Current Targets Planned Targets Generalization Mine
Bamber Valley (school) My house Penelope (sister) I want one Time to go Where is it? Lucy (dog) Thomas Sit down I see it Mine Hi mom Daddy Home All done (aw done)

Target “bins” Planned Targets Generalization Current Targets Hi mom
Bamber Valley (school) Penelope (sister) I want one Time to go Where is it? Lucy (dog) Thomas Sit down I see it Mine My house Daddy Thomas All done (aw done) Hi mom home

Target “bins” Generalization Planned Targets Current Targets
Bamber Valley (school) Penelope (sister) Time to go Where is it? David (friend) My socks Sit down I see it I want one My house Where is it? Thomas Lucy (dog) Time to go Sit down (?) mine Hi mom Daddy All done Home/go home

Include Parents When Possible
Participate in sessions (under your direction) Home practice activities See appendix for sample homework

Z - “I want to do 10!” – also J

Eliciting Multiple Repetitions
See appendix for suggestions What tips can you share for eliciting repetitions?

Fit the program to the child, not the child to the program
Why did I choose this treatment approach? Why did I choose these goals? How will I know whether intervention is working?

Research to Practice Alternative Treatments
Know our SLP scope of practice Fish oil, supplements, diet Hippotherapy Listening therapy Craniosacral therapy, massage Etc. ASHA Brochure: Questions About New Products

Research to Practice: AAC
Myth: If a child is allowed to use AAC, they will choose to use that mode instead of talking BUSTED Schlosser & Wendt, 2008; Romski, et al., 2010

Research to Practice: Bilinguals
Bilingual treatment may facilitate greater improvement than English-only treatment in a child with CAS (Gildersleeve-Neumann & Goldstein, 2014). Minimal research on bilingual intervention suggests that we should: Focus on improving communication skills in all languages used in home and community Consider the extent to which each language is used/context Consider CAS severity Be mindful of other factors: cognition,etc.

Research to Practice Literacy
Literacy IS in our SLP Scope of Practice See ASHA Technical Report Roles and Responsibilities of SLPs with Respect to Reading and Writing in Children and Adolescents See ASHA Literacy Gateway

Research to Practice Literacy Risk Factors
Multiple studies have shown that children with speech impairment have perform less well than peers on measures of phonological awareness, reading, spelling and math 20% of children with speech disorders will need special education services in school

Research to Practice Literacy Risk Factors
Speech and language problems often occur together As many as 60% of children with language impairment will have a language-based learning disability Having speech and language impairment together increases the risk

What We Know There is overwhelming evidence that early speech-language disorder is a risk factor for later literacy problems There is evidence that early intervention helps Proactive monitoring and intervention will be especially important for children who have both speech disorder and language impairment

Documenting Progress

How do we know our treatment is working?
Data collection is important You should expect to see some changes within a few sessions Rate of change may be slow at first Be conscious of criteria – it matters! Is the child’s functional ability to communicate improving? Video recordings can be helpful

Documenting progress P – book P – book2 P – protocol P - multisyll

3-point scoring Used in Strand, Stoeckel & Baas, and Baas, et al., 2008 2 = correct production 1 = mostly correct, with error in place, manner or voicing of 1 consonant sound in the syllable or phrase 0 = vowel distortion and/or more than one error of consonant production See Appendix

Sample Data

Sample Goal (Child) will improve motor planning/programming skills for speech production by increasing accuracy of production of a functional core vocabulary. Criteria: cumulative accuracy of 80% for each item. a. Accuracy in CV, VC, CVC syllable shapes: (EXAMPLES: me, no, more, mine, hi, up, on, etc) b. Syllable sequences (EXAMPLES: no more, go home, time to go, my turn, hi mom, etc.)

Goal is written to expand both sound and syllable repertoire, with flexibility in the targets used.
As the child meets criteria for one item from the stimulus set, it moves to “everyday use”; a new one is inserted from a list generated with the help of parents and/or teachers. Progress is reported in terms of accuracy for each individual item on the list and as number of stimulus items achieving criterion.

Progress Review example
(Child) has met criterion for “me”, “no”, “up”, “go”, “my turn”, and “hi mom.” Current targets: 70% cumulative accuracy for “go home” 60% cumulative accuracy for “sit”, “mine” 40% cumulative accuracy for “computer”, “Thomas”

Video L cars P series early to final

Treatment Review and Decision-Making

Treatment Review There is no single management procedure or program that is most appropriate for CAS But evidence base is beginning to grow Treatment will likely need to be adjusted over time to address the child’s progress (or lack of progress) Ongoing assessment will help to identify what issue is primary

Treatment Review We can make use of best available evidence as rationale for incorporating some of these techniques:

Treatment Review Teach movement sequences vs isolated phonemes
Use multisensory input (auditory, visual, tactile) Incorporate principles of motor learning Be intentional in manipulating frequency and intensity of practice

Treatment Review Think about range of difficulty in targets (remember that challenge can facilitate motor learning) Adjust the level of cueing carefully Make thoughtful use of commercial materials Include caregivers as much as possible

Questions?

THANK YOU

Clinical Decision-Making in Assessment and Treatment of Childhood Apraxia of Speech Welcome to this course on Differential Diagnosis for Childhood Apraxia.

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Clinical Decision-Making in Assessment and Treatment of Childhood Apraxia of Speech Welcome to this course on Differential Diagnosis for Childhood Apraxia.

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Presentation on theme: "Clinical Decision-Making in Assessment and Treatment of Childhood Apraxia of Speech Welcome to this course on Differential Diagnosis for Childhood Apraxia."— Presentation transcript:

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