1. Childhood Apraxia of Speech: Evaluation and Therapy Challenges Brisbane, Australia June 15, 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 - 2006 AdHoc Committee Documents - 2007 “Taking it Home” DVD - 2007

3. DIAGNOSTIC CHALLENGES Diagnosing toddlers in the 2-3 year-old range especially difficult Davis-Velleman article addresses this Caution diagnosing if limited sample (data) Use “suspected” or “working diagnosis” Don’t need neurologist to confirm “Differential Diagnosis for Childhood Apraxia”  Video Clip -- Ross, age 3-4

4. Differential Diagnosis 1. Limited early sound play (cartoon)

6. Differential Diagnosis 1. Limited early sound play 2. Sound inventory restrictions 3. Expressive language deficits in contrast to receptive language 4. Imitation superior to volitional skills  Video Clip -- Matt, age 3 5. Sequencing/Movement difficulties 6. Word/ Sentence complexity breakdowns  Video Clip -- Caleb, age 8  Video Clip -- Anna, age 3-10

7. Differential Diagnosis 7. Prosodic deviancies 8. Inconsistency  Video Clip -- Jacob, age 3 9. Voiced/Voiceless sound errors 10. “Groping” behaviors 11. Vowel distortions  Video Clip -- Alex, age 5 12.Sound omissions

8. For young children, most is informal Formal test resources available Get in-depth parent information Investigate other apraxic features Look at nonspeech oral skills Concern for misdiagnosing: Nonverbal child Dysarthric child Severe phonologically disordered child Confounding diagnosis child WHAT DOES MY CAS ASSESSMENT INCLUDE?

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

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

11. Comparison of Childhood Apraxia of Speech, Dysarthria and Severe Phonological Disorder Verbal ApraxiaDysarthriaSevere 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 weakness, incoordination or paralysis of speech musculature 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. Comparison of Childhood Apraxia of Speech, Dysarthria and Severe Phonological Disorder Verbal ApraxiaDysarthriaSevere 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. Comparison of Childhood Apraxia of Speech, Dysarthria and Severe Phonological Disorder Verbal ApraxiaDysarthriaSevere 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 Age-appropriate voice quality

14. THERAPY FOR APRAXIA NO SINGLE PROGRAM WORKS FOR ALL CHILDREN WITH APRAXIA!! MUST INDIVIDUALIZE!!! BE FLEXIBLE AND LOOK FOR SERENDIPITOUS LEARNING OPPORTUNITIES!!!!

15. HOW CAS THERAPY DIFFERS FROM ARTIC/PHONOLOGICAL Motor learning theory should drive our treatment of children with CAS. - precursors to motor learning (trust, motivation, and focused attention) - repetitive and variable practice - mass vs. distributed practice - reinforcement and feedback Therapy must be more intensive, but fade intensity over time. (“fatigue factor”)

16. HOW CAS THERAPY DIFFERS FROM ARTIC/PHONOLOGICAL THERAPY “Developmental” guidelines don’t dictate sound choice. Contrastive/Minimal Pair approach is not suggested at early stages. Increased cueing is needed. May need to teach compensatory placement.  Video Clip, Doug, age 5-6 More intensive parent involvement is essential for optimal progress.

17. HOW DO WE GET STARTED? Build on expressions/env sounds.  Video Clip -- Shane, age 3-6 Use “starter positions” such as “mm”, “oo” and “ee”.  Video Clip -- Austin, age 4-3  Video Clip -- Peter, age 5 Label sounds, but try to incorporate placement/manner cues (chart).

18. Visual and Verbal Cues for Treatment CONSO- NANTS NAME of SOUND VERBAL CUEOTHER 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.

19. Visual and Verbal Cues for Treatment CONSO- NANTS NAME of SOUND VERBAL CUEOTHER CUES “h” soundOpen 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.

20. Visual and Verbal Cues for Treatment CONSO- NANTS NAME of SOUND VERBAL CUEOTHER 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” soundsBuzzing windy sound “Use your buzz.”Teeth together and blow wind. “sh” soundFat 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.

21. Visual and Verbal Cues for Treatment CONSO- NANTS NAME of SOUND VERBAL CUEOTHER CUES “l” soundTower 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” soundSliding sound“ooo to eee sliding.” Start out in the ooo position with lips puckered then move to the eee sound.

22. Visual and Verbal Cues for Treatment CONSO- NANTS NAME of SOUND VERBAL CUEOTHER CUES “y” soundSliding 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.

23. HOW DO WE GET STARTED? Build on expressions/env sounds.  Video Clip -- Shane, age 3-6 Use “starter positions” such as “mm”, “oo” and “ee”.  Video Clip -- Austin, age 4-3  Video Clip -- Peter, age 5 Label sounds, but try to incorporate placement/manner cues (chart). Make a core vocabulary book. - Benefits and Procedures

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

25. 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 placed in a “Grandma’s Brag Book” with written word at the top (so when points does not cover word). Allows for parents to feel part of “team”  Video Clip -- Luke and Sharon

26. Try to incorporate Early Literacy Skill building as soon as possible!!  Video Clip -- Doug, age 6-1  Video Clip -- Austin, age 4-5

27. HOW DO WE INCORPORATE ORAL-MOTOR STRATEGIES? My Definition of OM strategies: “Speech therapy strategies and techniques which draw the child’s attention and effort to the oral musculature/articulators while SIMULTANEOUSLY engaging them in speech production practice”  Video Clips -- Luke, age 3-2

28. I. THERAPY CHALLENGES To provide a balance between repetitive practice opportunities and activities which are motivating and result in optimal carryover/generalization of skills. To make sure that optimal practice of speech sound production is accomplished so that speech motor patterns become more automatic (“drill-play” examples)  Video Clip -- Connor, age 2-11

29. THERAPY IDEAS TO ENHANCE REPETITION & SEQUENCING Do-a-Dot Art activities Hop/Jump over activity Pictures on bowling pins Soccer knock down (pizza tables) Hide and find in sandbox Cave hunt with flashlight Smartie hide for /s/ clusters 3 Little Pigs for reps and /l/ clusters

30. MORE THERAPY IDEAS “Launcher” into boxes “Which is funnier?” for word pairs Pass/kiss for /s/ word pairs Pirate Pop-Up for reps and stress “Bee” figure for unstressed “be” Picture drop for faster sequencing Spin chair with drum for demand Magna Doodle for “th” phrases “Red Roll / Green Roll” for “r” phrases

31. I. THERAPY CHALLENGES To support home practice that is productive, maintains high expectations, and does not lead to frustration (Amy Meredith on success) [ “Word Bin” Demonstration ] To provide expanded feedback assuring optimal awareness while tapping other “systems” and strengths

32. II. ESTABLISHING THERAPY GOALS Keep “functional communication” in the forefront of decision making. Choose consonants/vowels which increase likelihood of early success. May need to teach isolated sounds, but move to sound sequencing as early as possible (blending with “ha”)  Video Clip -- Austin, age 4-3 (“s”)  Video Clip -- Max, age 5-6 (“sh”)

33. II. ESTABLISHING THERAPY GOALS Use “key words” or “key contexts” to build automatic responses for more challenging sound sequences.  Video Clip -- Colin, age 4 Use “starter phrases” to build functional communication ASAP.  Video Clip -- Garrett, age 2-3

34. III. MULTI-SENSORY THERAPY APPROACH Set up “communication temptations” to elicit speech production. Use a multi-sensory approach as deemed necessary, with multiple cues that are faded over time toward an oral speech focus.  Video Clip -- Luke, age 3-2  Video Clips -- Jacob, age 3-6

35. III. MULTI-SENSORY THERAPY APPROACH Work simultaneously on sound production, sound sequencing, and language. Don’t wait for sound/sound sequencing accuracy before focusing on language expansion! Build in suprasegmental features from the start, through the use of songs, character voices, motor activities  Video Clip -- Luke, age 4-4

36. III. MULTI-SENSORY THERAPY APPROACH Encourage parent observations and participation as much as possible. Provide specific, ongoing feedback to parents to support home practice (“Fill in the blank” strategy if reluctant talker; Word “bins”, Cueing hierarchy, etc.) Use sign language, PECS, AAC devices as deemed necessary.

37. Advantages of Sign/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

38. Advantages of Sign Language Can use later to prompt functors (“little words”) Can be held toward face for oral cues Can be paired with visual cues Allows for systematic fading of cues

39. 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

40. VISUAL PROMPTS TOUCH CUES Can use a systematic cueing approach (e.g. PROMPT) or a more eclectic cueing approach  Video Clip -- Tyler, age 3-3

41. VISUAL PROMPTS TOUCH CUES Goal is to fade the cues over time as soon as possible Allows for small increments of success to document in progress notes Eventually, use sign plus visual prompt/touch cue

42. VISUAL PROMPTS TOUCH CUES For some children, pictures facilitate production/sequencing  Video Clip -- Mickey, age 6-4  Video Clip -- Zachary, age 5-0 (AAC device discussion)

43. TREATMENT SUMMARY MUST make activities motivating, repetitive, and easily carried over to the home  Video Clip -- Sean, age 4-11 MUST monitor intensity of treatment and adjust accordingly MUST involve parents and help them to understand how to respond to their child

44. Response Hierarchy to Inaccurate Verbal Attempts (1) Just look at 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 (or full word if no sign)

45. ASSOCIATED AREAS of DEFICIT Self-dialogue in play may be absent. Pragmatic communication may be weak – where dyads can be beneficial.  Video Clip -- Luke and Sean, age 5 after Luke in therapy 2 yrs

46. ASSOCIATED AREAS of DEFICIT Disfluencies may surface, which could indicate system overload. Suprasegmental features are frequently off track (May be one of the most lingering aspects for older children with CAS with stress, timing, volume control residual features)

47. SUPRASEGMENTAL FEATURES – TREATMENT Address throughout therapy Use “backward build-ups” for multi- syllabic words Use activities such as “Build-A- Sentence” for word stress  Video Clip -- Luke, age 5-6 with frog clicker

48. SUPRASEGMENTAL FEATURES – TREATMENT Use motor feedback for stress  Video Clip -- Cole, age 3-6 Use songs and rhythms  Video Clip -- Anna, age 4-0 Use rhyming books, i.e., Shel Silverstein and Dr. Seuss  Video Clip -- Luke, age 5-6

49. 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 so 81% more therapy Find study in “Clinical Management of Motor Speech Disorders” by Caruso and Strand (1999) or on Apraxia-Kids website

50. OUTCOMES  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

51. Issues 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)

52. Issues for “Older” Children Compensatory patterns may emerge.  Video Clip -- Rhonda, age 7-5 Gloss for Reading I am a yellow plastic duck and I am in great danger. Yesterday I was snuggled safe with hundreds of bathtub toys. We were in a crate on a big ship. A storm came. Our crate was washed overboard.

53. Issues 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

54. Treatment for Older Children 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.

55. Treatment for Older Children Teenagers with CAS may keep sentences shorter to meet articulatory demands. Need to build confidence in longer utterances (“phrased speech”). Assume progress, but does not mean should remain in therapy--TAKE BREAKS! COULD BE BEST THING FOR THEM. Use “errorless teaching” with 80% success.

56. Treatment for Older Children Use stopwatch for timing of utterances. Use reading programs that are highly visual (See “Selected Resources”) Videorecord for self-evaluation. Talk about how they feel.