6/6/2019 Agenda for Today’s Workshop Treatment Approaches, Strategies, • General Introduction to CAS And Ideas For Involving Caregivers In – Definition and features/characteristics Therapy For CAS – Overview of treatment considerations Organized by Apraxia Kids • Overviews of Evidence-Based Treatment Programs Co-sponsored by Rush University Department of Communication Disorders and Sciences 6-15-19 Chicago, IL – Dynamic Temporal and Tactile Cueing (DTTC) – Kaufman Speech to Language Program (K-SLP) Presented by: – Integrated Phonological Awareness Intervention (IPA) Aubry Cortez Margaret (Dee) Fish Mindy Vasilakopoulos PediaProgress Fish Speech Services PediaProgress – Multisensory Cueing (Various Approaches) Downers Grove, IL Northbrook, IL Downers Grove, IL Agenda for Today’s Workshop Agenda for Today’s Workshop • Overviews of Evidence-Based Treatment Programs • Breakout Sessions (cont’) – Session 1 Ideas for Involving Caregivers in Therapy – Prompts for Restructuring Oral Muscular Phonetic • Overcoming barriers to caregiver involvement Targets (PROMPT) • Teach, Model, Coach, Review – Motor Speech Treatment Protocol (MSTP) • Case Studies – Rapid Syllable Transitions Program (ReST) – Session 2 Evaluation and Differential Diagnosis – Tactile Biofeedback (Speech Buddies) • Components of a Thorough Motor Speech Evaluation – Visual Biofeedback (Ultrasound Biofeedback; • Comparison of CAS, Phonological Impairment, Dysarthria Elecropalatography) • Case Studies Childhood Apraxia of Speech (CAS) Three Key Features of CAS • 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 • a.) inconsistent errors on consonants and vowels neuromuscular deficits (e.g., abnormal reflexes, abnormal in repeated productions of syllables and words tone). CAS may occur as a result of known neurological • b.) lengthened and disrupted coarticulatory impairment, in association with complex neurobehavioral transitions between sounds and syllables disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in ( sequencing ) planning and/or programming spatiotemporal parameters of • c.) inappropriate prosody , especially in the movement sequences results in errors in speech sound realization of lexical or phrasal stress production and prosody. Childhood Apraxia of Speech: Position Statement, ASHA 2007 Childhood Apraxia of Speech: Position Statement, ASHA 2007 1
6/6/2019 Characteristics of CAS Qualities of Effective Treatment Programs • Frequent, shorter therapy sessions 3-5 times per week • Limited repertoire of vowels / vowel errors • • INDIVIDUALIZED - No treatment plan or program should be Variability of errors the same for different children • Vowel errors or distortions • Motor-Programming Approach • Struggle or "groping" for articulatory position may be observed – Frequent, intensive practice • Pre-rehearsed or modeled utterances easier than volitional, self- – Focus on actual skill (accurate speech movement) initiated utterances – Enhanced external sensory input (cognitive, visual, auditory, • Impaired rate/accuracy on diadochokinetic tasks tactile, and kinesthetic cues) • Gaps/pauses between syllables (even small gaps) – Types of practice (random vs. blocked) • Difficulty with prosody including overall slow rate; “choppy” and – Appropriate feedback monotone speech – Vary rate • Receptive language skills almost always higher than expressive www.apraxia-kids.org/apraxia_kids_library/general-treatment-principles/ www.apraxia-kids.org/apraxia_kids_library/what-is-childhood-apraxia-of-speech/ Multisensory Cueing Multisensory Cueing – Types of Cues • Visual - Model of the mouth posture • Foundation of various treatment approaches • Auditory - Verbal model • Should be chosen according to the child's: • Tactile - Touch • Kinesthetic - One's internal sense of movement Responses • Proprioceptive - Internal sense of how body parts are moving in Learning style space, sense of force/effort of movement and sense of speed of Current level of functioning movement • Metacognitive – Associative cue; Description of the speech Patterns of errors movements Fish, 2016, p. 133 Fish, 2016, pp. 134-135 Kaufman Speech-to-Language Protocol (K-SLP) Dynamic Temporal and Tactile Cueing (DTTC) • Based on applied behavior analysis (ABA) and applied verbal behavior (AVB) • Developed by Edythe Strande, PH.D. • Incorporates the principles of motor learning • Appropriate for children 3 yrs. and older with severe speech • Uses phonological processes to simplify words to best approximations sound disorder (SSD) , including those who have little or no Strategies: functional verbal communication, but who can attempt 1. Define the behavior imitation 2. Establish motivation • A variation of integral stimulation (introduced in the 1950s by 3. Model and cue Milisen for articulatory treatment, "listen to me, watch me, do 4. Implement errorless teaching / learning what I do") 5. Understand shaping • Based on Eight-step Continuum for Treatment of Acquired 6. Mix & vary tasks Apraxia of Speech (Rosenbeck, Lemme, Ahern, Harris & Wertz, 1973) 7. Practice the new skill 8. Practice in the child's natural environment https://www.apraxia-kids.org/apraxia_kids_library/integral-stimulation-method-adapted-for-children-as-dttc/ http://www.kidspeech.com/the-kaufman-speech-to-language-protocol/ 2
6/6/2019 DTTC Hierarchy of Cueing Integrated Phonological Awareness Intervention • Simultaneously addresses : speech production, phonemic 1 . Direct imitation awareness, and letter-sound association 2. Simultaneous production with prolonged vowels • Teaches a variety of phonological awareness skills in the 3. Reduction of vowel length context of articulation therapy, thus increasing efficiency of treatment 4. Gradual increase of rate to normal – Letter knowledge 5. Direct Imitation – Phoneme identity and Phoneme matching 6. Reduction of SLPs vocal loudness, eventually miming – Phoneme blending – Segmenting 7. Direct imitation 8. One to two second delay imitation https://www.canterbury.ac.nz/media/documents/education-and-health/gail-gillon---phonological-awareness- resources/programmes/preschool/01-Integrated-Phonological-Awareness-Manual-Sept-07.pdf 9. Spontaneous production **FREE 49 page resource PROMPT Integrated Phonological Awareness Intervention • 2009 study by McNeill et al. examined use of • Prompt is used for children with a variety of speech IPA Intervention in children with CAS – findings suggest IPA sound disorders , including children with various types of facilitates improved speech production and phonological motor speech involvement (MSI) (dysarthria, CAS, MSI- awareness in some children with CAS NOS). • Incorporates specific tactile/kinesthetic/proprioceptive • Appropriate for children with mild – to – moderate CAS cues to facilitate accurate production of phonemes, and phonological impairment , preschool and older, words, phrases who struggle with (or are at risk for) both motor speech • Ultimate goal is to develop “ the independent, flexible control and phonological awareness and coordinated use of all articulators … for efficient speech production ” (Hayden, 2004, p. 97) Dale PS, Hayden DA (2013) SAMPLE ReST NONSENSE WORDS (Rapid Syllable Transitions) ReST • Used primarily for older children (ages 5+) with mild to moderate CAS who can sustain attention to structured tabletop work • Designed for children with CAS to facilitate improved: • Phoneme accuracy and consistency • Speed and fluidity of transitions from one syllable to the next • Appropriate lexical stress • Targets used are phonotactically permissible pseudo- words (CV.CV, CV.CV.CV) with varied stress assignment Murray E, McCabe P, Ballard KJ. 2015 http://sydney.edu.au/health-sciences/rest/ 3
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