Apraxia Of Speech

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Part I

Introduction Over the years, since the first accounts of the disorder, there has been disagreement over the underlying nature of the disorder. Some have proposed that CAS is linguistic in nature; others have proposed that it is motoric and some have put forth the tenet that it is BOTH linguistic and motoric in nature. However, currently nearly all sources describe the key presenting impairment involved with CAS as some degree of disrupted speech motor control. The reason for this difficulty is still under investigation by speech scientists. Weakness, paresis, or paralysis of the speech musculature does not account for the impaired speech motor skills in CAS. Differences in various theories of speech motor control notwithstanding, it is believed that the level of impairment in the speech processing system occurs somewhere between phonological encoding and the motor execution phase, such as a disruption in motor planning and/or programming. Some believe that children with CAS have difficulty accurately storing or volitionally accessing Speech motor plans and programs and the spatial-temporal specifications within them. To some degree or another, these impairments result in difficulty rapidly and accurately moving between sequences of articulatory configurations that are required for continuous and intelligible speech production. Some researchers posit that children with CAS additionally have disordered sensory-motor related features such as reduced or aberrant proprioception and thus an inability to realize the relationship and spatial position of the articulatory structures to one another. For some of the most severely affected children, even initiating speech movement gestures may prove extraordinarily difficult. There appears to be some consensus and research evidence that children who display these sorts of speech motor impairments also typically have problems in certain aspects of expressive and/or receptive language, even if subtle. There is currently no agreement as to whether these linguistic impairments are central to the disorder or are separate issues that co-occur or are co-morbid. Some

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2 individuals have described CAS as a disorder that changes and unfolds over time.

Childhood Apraxia of Speech The use of the prefix "A" (i.e.: absence) and "dys" (i.e.: partial) attached to the root word praxis may also provide confusion. In most instances, use of either of the terms apraxia or dyspraxia appear to be based on personal preference, one's graduate educational institution, and/or one's geographic location rather than a substantially, meaningful or practical difference. The term apraxia, however, is the choice used nearly exclusively to describe the adult form of the disorder. Praxis, in either case, refers to "skilled movement."

Definitions Praxis: "The generation performance of a to select, plan, Pattern which is

of volitional movement patterns for the particular action, especially the ability organize, and initiate the motor the foundation of praxis" (Ayres 1985).

Spatial-Temporal Coordination • Critical to fluent, adult-rate speech-language production • Dominates the development of speech-motor control over the first six years of life. • Gradual increase in overall execution speed of motor programs over the ages 3-11 years. • Segment durations are conditioned or adapted according to the linguistic content of the utterance (Netsell 1981) Motor sequencing: Ordering the individual gestures that make up the whole motor plan and coordinating them with each other. Includes:  

Determining the order of the elements Figuring out how to get from one to the other (Ayres 1985): transitions

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Apraxia: "A disorder in carrying out or learning complex movements that cannot be accounted for by elementary disturbances of strength, coordination, sensation, comprehension, or attention" (Strub & Black 1981). "..A group of phonological disorders resulting from disruption of central Sensorimotor processes that interfere with motor learning for speech... Paralysis or weakness might be present, but is not sufficient to account for the nature and severity of the observed speech disorder" (Crary 1984). "Viewed as a syndrome...developmental verbal apraxia might be defined as a severe and persistent phonological disorder coupled with an expressive syntactic disorder with variable neurological and articulatory findings." (Aram 1984) Unitary Disorder:  One consistent symptom or set of symptoms is always present Syndrome/Symptom Complex:  A pattern of symptoms, with a common underlying cause, is used for diagnosis  No one symptom alone is adequate to identify the syndrome  Different children may have varying symptoms of the same disorder “a reduced capacity to form systemic mappings [between articulatory movements and their auditory consequences] might underlie the oral motor and early speech learning difficulties in DAS [CAS] and put the child at a disadvantage for the acquisition of the motor aspects of phonology, that is, the phoneme-specific mappings”… “higher level [phonological] knowledge … must be acquired by the child via the problematic speech production and perception skills” (Maassen 2002, pp. 261, 265) Thus, apraxia or dyspraxia is a disorder of: 1. Volitional movement (Dewey et al. 1988, Maassen et al. 2003, Nelson, 1995) 2. Spatial-temporal coordination (Sussman et al. 2000, Nijland et al. 2002)

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4 3. Motor sequencing (Crary & Anderson, 1991) 4. Carrying out or learning complex movements (Crary & Anderson, 1991) 5. Central sensorimotor processes (Crary 1984) 6. Accommodation to context (coarticulation, etc.; Maassen et al. 2001, Nijland et al. 2003, Nijland et al 2002).

Types of Apraxia A person may have one or more types of apraxia at the same time. We describe three types of apraxia: 1. limb 2. oral 3. verbal Limb apraxia: limb apraxia is associated with volitional movements of the arms and legs. The client may be unable to wave good bye or make a fist on command (volitionally) even though the muscular strength and range of motion necessary to complete the tasks are present and the client is able to automatically (non volitionally) perform the tasks. Oral apraxia: The client with oral apraxia may be unable to protrude the tongue or smack the lips volitionally. Oral apraxia is sometime confused with the third type, verbal apraxia since they both involve oral facial muscles but they are not the same. Verbal apraxia: Verbal apraxia is a disorder of motor programming for the production of speech. The client with verbal apraxia has difficulty positioning and sequencing muscles involved in the volitional production of phonemes. Clients may exhibits one, two or three types of apraxia. The Terminology Developmental apraxia of speech Developmental verbal dyspraxia childhood apraxia of speech

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5 Childhood Apraxia of Speech (CAS) is the current preferred terminology to describe the disorder. Other terms still in "use" and from the relatively recent past include "developmental apraxia of speech" and "developmental verbal dyspraxia". Use of the descriptor "developmental", however, unfortunately provides a false implication to other professional groups that the speech difficulties of affected children are akin to "delays" in development; are transient and can be simply outgrown without direct intervention.

Early signs & symptoms: 

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Limited or little babbling as an infant (void of many consonants). First words may not appear at all, pointing and “grunting” may be all that is heard. The child is able to open and close mouth, lick lips, protrude, retract and lateralize tongue while eating, but not when directed to do so. First word approximations occurring beyond the age of 18 months, without developing into understandable simple vocabulary words by age 2. Oral scanning or groping may occur with attempts at speaking. Continuous grunting and pointing beyond age 2. Lack of a significant consonant repertoire: child may only use / b , m , p , t , d , h /. All phonemes (consonants and vowels) may be imitated well in isolation, but any attempts to combine phonemes are unsuccessful. Words may be simplified by deleting consonants or vowels, and/or replacing difficult phonemes (consonants and vowels) with easier ones. Single words may be articulated well, but attempts at further sentence length become unintelligible. Receptive language (comprehension) appears to be better than attempts at expressive language (verbal output). One syllable or word is favored and used to convey all or many words beyond age 2. A word (may be a real word or a nonsensical utterance) is used to convey other words beyond age 2. The child speaks mostly in vowels.

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Verbal preservation: getting “stuck” on a previously uttered word, or bringing oral motor elements from a previous word into the next word uttered. The child has difficulty moving the tongue where they want it to go. “Pop-outs” or automatic words and phrases are spoken clearly, but they cannot be imitated when directed or may not be heard again. Other fine motor problems may be present.

CAS is a “symptom complex”  No one feature is adequate for diagnosis  Symptoms can include motor, linguistic, neurological.  Inconsistency is expected across children and within same child  Symptoms change over time (Lewis et al. 2004;Shriberg et al. 2003)

CAS as a Secondary Diagnosis • Approximately 60% of children on the autism spectrum have motor speech symptoms; about 13% report primarily symptoms of apraxia; 10% primarily dysarthria; remainder mixed (Marili, Andrianopoulos, Velleman & Foreman, 2004) • Symptoms of CAS are common among children with Down syndrome (Kumin & Adams 2000; Rupela & Manjula, in submission)

Key characteristics of CAS When considering characteristics of the disorder, Speech and Language Pathologists need to keep in mind that children with other speech sound disorders share some characteristics from the list. Other characteristics may be more common and contribute more specifically to the differential diagnosis of CAS, distinguishing CAS from the other pediatric speech sound disorders. Additional research is needed to identify a diagnostic marker with an acceptable degree of specificity and sensitivity (i.e.: identifies children with CAS while ruling out those who do not have CAS). Until such research data is available, the list below may be useful for identification of children suspected to have CAS.

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7 Key characteristics: •

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Limited repertoire of vowels; less differentiation between vowel productions; and vowel errors, especially distortions Variability of errors Unusual, idiosyncratic error patterns (sometimes defying transcription!) Errors increase with length or complexity of utterances, such as in multi-syllabic or phonetically challenging words. Depending on level of severity, child may be able to produce accurately the target utterance in one context but is unable to produce the same target accurately in a different context. More difficulty with volitional, self-initiated utterances as compared to over-learned, automatic, or modeled utterances Impaired rate/accuracy on diodochokinetic tasks (Alternating movement accuracy or maximum repetition rate of same sequences such as /pa/, /pa/, /pa/ and multiple phoneme sequences such as /pa/ /ta/ /ka/ ) Disturbances of prosody including overall slow rate; timing deficits in duration of sounds and pauses between and within syllables contributing to the perception of excess and/or equal stress, "choppy" and monotone speech. At some point in time, groping or observable physical struggle for articulatory position may be observed (possibly not present on evaluation, but observable at some point in treatment). May also demonstrate impaired volitional non speech movements (oral apraxia)

Etiology Theories about causes: While there is agreement about the defining characteristics of DAS, it is not known exactly what causes CAS. There are several theories about the cause of CAS including: 1. Some believe that children with CAS have problems producing speech because of auditory deficits, albeit in the presence of normal hearing tests. The belief is that

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8 these deficits adversely affect the child’s ability to detect and/or encode speech sounds from conversational speech. 2. Another theory is that CAS may be caused by a child’s difficulty in learning and building an adult-like language system. 3. Yet another viewpoint is that CAS is caused by problems in a child's organization and sequencing of speech components such as sound, syllables, and melody. The belief is that the child has mentally stored these speech components, but do not possess the skills to consistently organize and sequence the movements of the articulators into words and sentences. To begin with, developmental verbal apraxia is a spectrum disorder. What this means is that there are no definite behaviors that identify its presence. Instead, a child is identified as having apraxia if he/she exhibits a number of characteristics that are believed to be highly indicative of apraxia. Because of this, no two children with apraxia are alike. Additionally, although many hypotheses have been proposed for the etiology (cause) of apraxia, in reality, apraxia has a number of etiologies. Some of them are: genetic predisposition to motor sequencing disorders (family history), problems prenatally or at birth, differences in the rate of development or quality of myelination (covering or sheath for the nerve cells in the brain, which increases dramatically in the preschool years), neurological disorders, developmental delay, etc Finally, there are many features/traits in a child's life that will differ with each child, that have a great deal of influence in terms of the outcome for a child with apraxia.

Demographics: • 86% of kids with CAS have at least one family member w/ speech-language disorders • 59% have at least one affected parent • Higher rates of family history than for other speechsound disorders: suggests genetic basis in at least some cases (Lewis et al. 2003)

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9 FOXP2 (The gene is required during early embryonic development for formation of brain regions associated with speech and language): Translocation on chromosome 7q31 A few individuals (e.g., the “KE” family) with this genetic difference have the symptoms of oral and verbal apraxia. However, they also have oral-facial anomalies and nonverbal deficits. Thus, FOX-P2 may be the cause of some cases of CAS, but certainly not all of them.

Prevalence • Prevalence 1-2 children per thousand (Shriberg et al., 1997a); up to 3-4% of children with speech delay are given this diagnosis (Delaney & Kent, 2004)

Prognosis of Apraxia Factors Which Effect Long-term Outcome in Apraxia: Etiology of the Child's Apraxia Is the cause of the child's oral motor deficits primarily motor, linguistic, or phonological in nature? Because the cause of apraxia varies, so will the prognosis. Two children with similar presenting symptoms initially, may have different outcomes because one child's etiology may allow for new motor skill development more readily than the other child's etiology. The difficulty for the clinician lies in the fact that only rarely do we know the etiology (cause) of a child's apraxia. Family History When other family members have a similar speech history, it is reasonable to conclude that the child's long term outcome may be similar to that family member's (providing, of course, that their etiologies are truly the same). Severity of Apraxia In general, the more severe the child's apraxia, the longer they will need to receive treatment. Presence of Oral as well as Verbal Apraxia Children who exhibit an oral apraxia as well as a verbal apraxia often require treatment longer than those children who exhibit only a verbal apraxia. Overall Health Children whose overall health is good are more accessible 9

10 to learning of all kinds than children who have periods of time when they are less "learning available" because of illness (middle ear infections, upper respiratory infections, etc.). Cognitive Skills Children with measured learning potentials in the average to above average range have a more favorable prognosis than children with cognitive delays. Attention/Ability to Focus Children with attentional issues will often require intervention for longer periods than children with average to above average attentional skills. This is because the SLP can focus on the child's productions rather than on maintaining their attention, and because children with attentional issues tend to have more difficulty monitoring their own speech (which is very important for "carry-over" of skills to the conversational level). Child's Reaction to Their Intelligibility Deficit Children who are seemingly unaware of, or unbothered by the difficulty other people have understanding them often require longer treatment. Ability to Self-Monitor Children who have average to above average abilities to monitor their own speech productions tend to make progress more quickly than children who are unable to "self-monitor" and continue to need the SLP or others to give them feedback regarding their productions. Self-monitoring is an important skill for children with apraxia to learn. This is the process by which they take skills learned in therapy and begin to use them in their spontaneous speech. The only way this can occur is for the child to begin to "hear" his/her own productions and "edit" them. If a child cannot perceive an error, it will be impossible for him/her to correct it. Age at Which Intervention Begins The younger the child is when treatment begins, the better his/her long term prognosis. Appropriateness of Therapy Because children with apraxia are different in terms of the etiology of the apraxia, the therapeutic approach utilized in their treatment needs to be tailored to their individual

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11 needs. A "one-size-fits-all" approach does not work for children with apraxia. Knowledge of the current approaches to the management of apraxia is necessary for the SLP to adjust sessions according to the child's needs. Frequency of Therapy The more frequently the child receives appropriate therapy, the better his/her long term prognosis. Co morbidity The presence of other disorders with apraxia (such as hearing loss, dysarthria, etc.) will generally indicate a poorer prognosis than when apraxia presents as the only disorder/delay for a child. A "pure apraxia," however, is not the norm. When a child is neurologically different in one way, it often means they will exhibit learning/motor/behavior issues in other areas of their development. Additionally, children with apraxia do not have the opportunity to interact with peers and adults in a typical way, and so are at greater risk for developing/exhibiting social, behavioral, language, etc. delays and disorders because of the apraxia. Motivation A child who has a positive response to working with a therapist on increasing his/her speech intelligibility has a better prognosis than the child who is resistant or ambivalent towards his/her therapy. Parent Involvement, Education, Support A parent's knowledge/understanding of their child's apraxia increases their ability to respond in ways that encourage the child's communication skills. They are also much better equipped to advocate in effective ways for the child with other people in the child's life. Parents should be wary of any prognostic statement which is absolute in either direction. It is not possible for a clinician to say with absolute certainty that a child will completely recover; conversely, he/she will not be able to tell you that your child will never talk. To date, there are no definitive studies of the outcome of children with apraxia. This is due to the lack of agreement/identification of this group of children, and

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12 also due to the fact that there are no two children with apraxia who are exactly alike in terms of their apraxic characteristics, so establishing a control group to determine efficacy and results of long-term therapy is very difficult.

Progress and Long Term Outcomes With appropriate early intervention and ongoing support, most children with CAS can improve their speech production skills and develop functional speech. The period of time this outcome requires is individualized and most likely based on the unique characteristics of the child and the level and quality of the intervention provided. Previous literature had cited "slow or little progress" as a "characteristic" of apraxia. Currently it is recognized that while treatment is intensive and extends over a number of years, these children are very capable of making wonderful gains and developing intelligible speech. Progress, is of course, individualized, however unproductive therapy should not go on indefinitely. If the child is not making noticeable and meaningful progress over several months of treatment, the SLP needs to regroup and examine the reason. If a child fails to make significant and adequate progress despite receiving speech therapy intervention, the following questions need addressed: • • •

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Is the diagnosis correct? Is the frequency of therapy adequate for the child's needs? Is the intensity appropriate? For example, is therapy offering the child dozens and dozens of "practice moments" or is the child sitting, listening and not practicing speech much at all? Is the therapy tailored toward motor speech methods and techniques to the extent required for adequate progress? Is the therapeutic environment safe and motivating to this child? Is clinician - child rapport adequate? Are other issues interfering with progress? (i.e., can the child sustain enough attention to participate? Has the child had health related problems? Is the family following through with practice at home or is the child willing to practice at home? Could other diagnoses contribute to lack of adequate progress?) 12

13 If after addressing these issues, progress is still not adequate, ask for consultation from a colleague with more experience with this particular disorder. Some long-term residual issues that may persist even after the child attains intelligibility include sound distortions and prosody deficits (rate, timing, stress, intonation). If these issues are present, therapy strategies can continue to target them. Additionally, speech therapy may need to continue to address linguistic or pragmatic needs presented by some children. A prognosis is, at best, an estimate of how your child's speech skills will improve with therapy. An exact outcome is impossible for any SLP to predict. There are several reasons why a child's treatment outcome is very difficult to predict.

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Part II

Evaluation, Assessment and Diagnosis of Childhood Apraxia of Speech While there are a number of packaged evaluation kits available, many clinicians use common evaluation techniques to assess children with suspected CAS. Young children with CAS can be especially challenging to evaluate and may be non-risk takers with their speech attempts. In some cases, especially with very young children, an extended period of evaluation in order to elicit sufficient speech samples to make diagnosis is warranted. Overall, tasks used in the assessment process in order to differentiate CAS from other speech sound disorders should include: 

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Speech production tasks graded from simple to more complex (from simple syllables to challenging multisyllabic words) The effect of increased length on accuracy (i.e.: me, meet, meeting) The effect of context on speech accuracy (more; more milk, want more) Observation of performance on repeated productions of the same target Documentation of differences between elicited or imitated productions vs. volitional and spontaneous productions An analysis of types of errors, including omissions, distortions and substitutions Observations concerning prosody (stress, intonation, rate) Observations of nonspeech movement sequencing (show me how you bite. Show me how you blow. Bite, then blow)

Common articulation tests alone will not provide the information needed for differential diagnosis, although such tests can provide some information necessary to the process. Additionally, traditional child language tests

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15 can provide helpful information about the child's communication profile but will not provide the type of information necessary to make a differential diagnosis. If clinicians work in settings in which they administer expressive/receptive language testing in order to determine eligibility for services and the clinician suspects the child could have CAS, referral for in depth evaluation of speech production should occur.

Additional Assessment Considerations While the previous assessment and evaluation discussion centered on the speech production difficulties of children with suspected CAS, several other considerations for planning and conducting assessments should be considered. The literature documents co-morbid language related deficits, thus both expressive and receptive language evaluation should be a part of the evaluation process of documenting a complete communication profile for the child with CAS. Narrative language skills should be a part of that battery, as appropriate, given the current functioning of the child. A structural-functional evaluation should be performed as well in order to document any observations of abnormalities in structures, sensation, strength, range, symmetry, etc. For children who are school age or approaching school age, the evaluation of phonemic awareness and early literacy related skills should be included in assessments. A propensity for literacy related deficits in phonemic awareness, reading, spelling and written expression has been substantiated in children with CAS in recent research and should be considered, regardless of the child's current level of speech production capability.

Apraxia Assessment Tools The Verbal Motor Production Assessment for Children (VMPAC) (Deborah Hayden, M.A., CCC-SLP and Paula Square, Ph.D., CCC-SLP) Identify children with motor issues that have negative effects on the development of normal speech motor control. Pinpoint where the child begins to have difficulty, with items arranged from basic to complex. This test leads you

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16 step-by-step through the evaluation; helpful Clinician's Notes provide explanation. The Apraxia Profile (Lori Hickman, M.S., CCC-SLP) Use to assist in the differential diagnosis of developmental verbal apraxia, identify the presence of oral apraxia, and reveal the most problematic oral-motor sequences and movements. Document a child's oral-motor sequencing deficits and establish the level of oral movements and sequences produced successfully. Obtain helpful information to share with parents, teachers, and other professionals. Kaufman Speech Praxis Test(By Nancy Kaufman, M.A., CCC-SLP) the KSPT identifies the level of breakdown in a child's speech so that treatment can be established and improvement tracked. Easy to administer and score, the test measures a child's imitative responses to the clinician, locates where the child's speech system is breaking down, and points to a systematic course of treatment. The Screening Test for Developmental Apraxia of Speech (STDAS-2) Robert Blakeley, Ph.D. The Screening Test for Developmental Apraxia of Speech (STDAS) assists in the differential diagnosis of developmental apraxia of speech. This screening instrument points out the need for additional and more specific speech and neurological evaluation.

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Speech Therapy for Children with CAS While children with CAS have many similarities to one another, they also display frank differences in communication profiles. Thus, this is a heterogeneous population. It will be important for clinicians to determine the contribution of speech motor processing to the child's speech difficulty. Children with a diagnosis of CAS will initially need to work, much of the time, at this level in the system. For children with significant speech motor-planning deficits there should be an assumption that the child, at least for a period of time, will need frequent and intensive individual speech therapy.

Frequency and Intensity One factor that appears to have agreement among experts in speech-motor programming treatment approaches is that early in the therapy process, children with apraxia of speech will need intensive services, most often on an individual basis. A number of factors influence the frequency of therapy, including: • • •

The severity of the child's speech-motor impairment and functional communication disorder The child's age and ability to tolerate therapy The child's willingness to practice with parents/caregivers.

Clinicians are likely to find themselves in the role of an advocate to insure that these children, especially those who are severely impaired, receive the appropriate intensity and frequency of treatment. In the early phases of treatment for children with moderate to severe CAS, appropriate frequency may range from 3 - 5 individual speech therapy sessions per week. As children improve and develop speech motor control over volitional utterances, frequency can be reduced accordingly, as long as they maintain and generalize improvements.

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18 Additionally, intensity refers to actual time spent in individual therapy sessions that provides children with CAS opportunities for numerous repetitions of speech movement targets. In keeping with motor learning theory, many repetitions are required in order for motor skills to become volitional and automatic. Speech therapy needs to provide these children with many, many repetitions and response opportunities of targeted utterances. This response intensiveness is in contrast to treatment approaches in which the child is mainly asked to listen vs. respond or to share response time with multiple other children. By the end of a speech therapy session, no matter the length of the actual session, the child with CAS should have produced dozens and dozens of target utterances. This high degree of intensity for responses is not likely to occur in group therapy settings. Children with apraxia of speech are often described in the professional literature as needing frequent and intensive speech therapy in order to address the motor planning and programming issues which are at the heart of their speech difficulty. In the annexure C there are the most relevant citations available that describe the need for frequency and intensity. When children with apraxia receive appropriate speech therapy they can and do make progress! As their speech becomes more and more intelligible, frequency of services can be adjusted according. Children must be looked at for their individualized needs and circumstances. In addition to their motor planning and programming needs, children with apraxia often have other speech and/or language needs that must also be factored into therapy. Some children may also require training with augmentative communication devices in addition to therapy specifically targeting their speech production. (For supported citation see annexure c)

General Treatment Principles Motor-programming Approach If one understands CAS as a disorder of the speech motor system, then guidance for treatment can be found in understanding motor programming/planning tenets. Again, each child with CAS will have their own individual profile and will have different needs at different points in their development as competent speakers and communicators.

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19 Clinicians will still need to determine what contribution motor speech deficits have in the child's overall speech difficulty as well as address other potential language and communication deficits. Overall, methods that employ a motor programming approach will: • • •

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Provide frequent and intensive practice of speech targets Focus on the actual skill being trained (accurate speech movement) Include enhanced external sensory input (not just auditory, but also visual, tactile, cognitive cues for speech production) Give careful consideration to types of practice (random vs. blocked practice of target items) Provide appropriate feedback (knowledge of results or knowledge of performance

1-Multi-sensory Input for Speech Practice Overall, most treatment methods in the professional literature describe variations of therapeutic multisensory input to the affected child. Use of multisensory strategies may incorporate input that is visual, auditory, proprioceptive and tactile in order to teach the child the movement sequences for speech. It is not yet understood exactly why such “inputs” assist in the articulatory accuracy or “speech motor learning” of children with CAS. One theory is that children with CAS do not benefit from sensory-motor feedback for their speech attempts in the same way as typically developing children do. Perhaps the feedback is faulty, reduced, or otherwise inadequate to provide meaningful assistance to the motor learning process. Essentially then, each speech attempt would be akin to the “first time”, with children with CAS failing to incorporate the sensory results of their speech effort into their next speech attempt. Feedback is an important aspect of motor learning. If a child cannot benefit from or does not receive intrinsic sensory feedback, theoretically it is possible that external or imposed feedback can help facilitate speech production skills. Another possibility is that over time visual or tactile cues may map an association for the child and thus trigger a type of “motor memory” for the articulatory goal. Tactile methods of speech facilitation include methods that provide direct tactile input to the child’s face or 19

20 articulators in order to “cue” them for the correct production. With these sorts of methods, the speechlanguage pathologist may apply pressure or otherwise touch the child’s face, neck, and head, to provide a tactile cue for correct production or speech movement gesture. (See information on the PROMPT therapy method) Visual methods provide visual “cues” as to the shape, placement or movement of the articulators. Hand signs or cues often provide a visual cue. More technologically advanced methods such as electropalatography readouts, various computerized programs such as “Speechviewer” and other forms of biofeedback can also provide the child with visual feedback for speech movement performance. A visual cue may help to elicit an appropriate movement configuration upon a learned association. Asking the child to slow down and to maintain articulatory configurations for a longer duration than is typical provides additional proprioceptive feedback in order for the child to have more opportunity to “feel” the position of the articulators (See information on The Dynamic Temporal and Tactile Cueing for Speech Motor Learning Method - DTTC). In some therapy methods such as the PROMPT and the DTTC methods, the clinician may provide touch to the jaw, face, etc. in order to provide additional proprioceptive input. Enhanced proprioceptive input, theoretically, may help the child benefit and learn from the motor experience and make adjustments to stored motor programs and plans based on such feedback and experience. It is important to note that in all of these sensory modalities, direct and systematic training of articulatory movement sequences receives a high degree of emphasis. While the SLP may be called on to teach isolated phonemes at some point as well, this is not the key emphasis of therapy for children with CAS. Rather, the emphasis is on well-controlled sequences of movement patterns required for accurate production of a continuous string of phonemes (i.e.: continuous speech). Additionally, for children that have a significant deficit in speech motor planning and programming a “minimal pairs” (auditory discrimination) approach is not a primary element of treatment to elicit improved speech motor planning. The reason for this is that the treatment method should match the understanding of the underlying nature of the child’s disorder. If the child’s disorder is motoric (as opposed to linguistic),

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21 then a motor speech approach should be adopted. More linguistically or phonologically based approaches may also have a benefit for some children who ALSO have a linguistic or more traditional auditory perceptual or phonological deficit to their overall profile but such methods do not replace the need for speech motor strategies.

2-Establish Functional Communication Many children with CAS struggle so significantly and are so severely affected that they have difficulty attaining any semblance of a functional vocabulary. Thus, one initial goal for treatment of such children should be to aid in establishing such a vocabulary. A careful inventory of the child's current consonant and vowel inventory may provide a clue as to beginning words (or approximations) that may be possible. Word choices should take into account words and functions that a child would want to communicate.

3-Successive approximations One method of therapy, "successive approximations" may help to establish functional verbal communication. Word approximations are shaped and molded, with the assistance of cuing and input from the SLP, until there is independent accuracy in the word production. By examining how children first learn to speak, we can observe that many of the early vocabulary begins with word approximations such as, baw for ball, or bah for bottle, or even wawa for water. Children with CAS who have performed little babbling or practice as infants, may not be able to change what they hear and understand, into the motor act of speaking those words. By simply offering children with CAS the opportunity to attempt word approximations using the consonants and vowels already in their repertoire, successful attempts at words are achieved, reinforced, and rewarded by the listeners comprehension, and thus their response to the childs needs and desires. Through shaping,

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22 cueing, and fading techniques, children with CAS can gradually move into whole words, phrases and sentences. One can evaluate the consonant and vowel patterns of children by asking them to imitate, moving in a hierarchy from simple to complex vowel and consonant combinations to obtain a profile of the child’s motor-speech proficiency. Then, through practice of this hierarchy of consonant and vowel patterns, the children gain verbal praxis skills for the ultimate goal of successful verbal communication. Beyond the workout of practicing consonant-vowel patterns in real words is the important aspect of functional communication. As soon as the child has any type of an approximation for a word, it should be encouraged and reinforced by the appropriate response of the listener (i.e., giving the child juice for attempting doos or oos for juice). In this approach, however, we do not necessarily wait for the child to use an approximation independently, though that is certainly the optimal goal. We actually assist them with imitation, cues, prompts or any possible way to help them make their best word approximation attempt. We also help to script the children directly into two or three-word combinations almost immediately, even if every word is only approximated, such as in I want .., being scripted as Ah wah This approach encompasses aspects of behavior modification (shaping, cueing, fading) for successful approximations, as well as our knowledge of phonological processes, which are the way young children tend to simplify adult forms of words. Such phonological concepts as final consonant deletion, cluster reduction, vowel neutralization, to name a few processes, are what we rely upon to decide how a word can be simplified based upon typical speech development. Every word can be reduced to its shell (this concept of word shells was introduced by Ms. Carole Goff, M.A., CCC/SLP). For instance, the word bottle, can be broken down like this: bottle bah-do bah-o bah-bah 22

23 bah Choosing the child’s highest successful imitation and reinforcing it (ideally giving the child the bottle), offers them a chance at successful verbal communication rather than only accepting the full word which may not yet be a possibility. This approach also encompasses techniques gleaned from the research and work accomplished by many speech and language pathologists who work with individuals exhibiting acquired apraxia of speech. These techniques include using melody and gestures to take the pressure off of the volitional muscle control system. Occupational therapy/sensory integration techniques of direct stimulation to the oral musculature and using gross-motor activity to propel the entire motor system to activate verbal-motor skills are also valuable to this approach. The Kaufman Speech Praxis Treatment Approach is also becoming highly successful for children with CAS on the spectrum of autism. Dr. Vincent Carbone, Ed.D, BCBA and Ms. Tamara Kasper, MS/CCC-SLP, BCaBA, are currently researching and adapting the KSPT techniques specifically through Applied Verbal Behavior, employing methods from B.F. Skinner (1959) and Sundberg and Partington (1998). The changes for children with autism are largely due to the fact that it can be more difficult to move along the hierarchy of word approximations, as there is more work involved in extinguishing and replacing the first learned word approximation and shaping it toward the ultimate goal of the full word. Dr. Carbone also utilizes the method of stimulus-stimulus pairing to move non-verbal (yet vocal) children into the ability to imitate CV patterns, which prepares them for the KSPT approach. Through the workout, scripting, and ultimately improving word retrieval, grammatical skill development and general formulation skills, children with CAS can become effective verbal communicators.

4-David Hammer's approach Just as communication therapy for children with apraxia of speech presents unique challenges, it certainly is a challenge to present views on treatment in a few paragraphs. There are many complexities involved when we discuss therapy strategies due to the wide range of

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24 children whom we service. These include, but certainly are not limited to,  

  

The maturation level of the child The child's general cognitive abilities Possible dual diagnoses Other deficit areas such as fine motor skills And parent motivation.

When we discuss intervention strategies, we must take into account individual strengths as we develop a multi-sensory, multi-modality communication therapy course of action. For children who have the cognitive capacity to understand picture stimuli, David finds that an essential component to early therapy is the development of a "core vocabulary" book. This involves the inclusion of photographic pictures into a "Grandma's Brag Book" (small photo album). The photos should consist of meaningful people, toys, and objects in the child's life as well as words that contain initially targeted sound sequences. This book often serves as a child's first success at expansion of functional communication interactions with significant others. The use of sign language has proven to enhance vocal output, reduce frustration, and provide differentiation for words that "sound the same" in the early course of treatment. Touch cueing and physical prompting are also critical elements of David’s treatment approach. Each of these techniques is modified to fit the particular needs and tolerance level of the child. An ongoing goal is to fade all cues as soon as possible to allow for the child to develop the oral/verbal movement and sequencing patterns necessary for intelligible speech. Oral-motor work is never done without a sound production goal in mind. Sounds are not taught in isolation for any length of time with almost immediate progression to consonant-vowel or vowel consonant forms. Focus on suprasegmental features (e.g. rhythm, stress, intonation, etc.) should be ongoing from the start of therapy to enable the most naturalistic speech production possible. If we begin intensive individual intervention in the optimal age range, the challenges in therapy are:

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25 (1) To discover ways to motivate toddlers and preschool-age children into repetitive practice of sound sequences while having fun at the same time (2) To let the child seemingly set the stage for the sessions while, at the same time, achieving therapy goals and (3) To make sure that optimal practice of speech sound production is accomplished so that speech motor patterns become more automatic. These are not impossible tasks if we remain creative thinkers, flexible therapists, and great listeners to the children and their parents. David says” I can't stress enough the importance of family involvement (including siblings attending treatment sessions), and close collaboration with all professionals involved in the child's programming. This ensures consistent encouragement and feedback which "nudges" the child with apraxia of speech in the direction of self-motivated speech practice”. Once a core vocabulary has been established, it may be useful to incorporate "carrier phrases", i.e., short sentence constructions in which core vocabulary can be inserted. For example, "I see _____", "Where is _________", "I want ______". Additionally, "power phrases" may be introduced as therapy targets. These are short phrases that may serve high utility to the child ("No way", "Get out", "Me too") and provide the child with functional communication.

5-Systematic and Hierarchical Structure for Early Success Many methods employed for successful speech therapy for children with CAS are both systematic and hierarchical. A strong emphasis is placed on understanding the current level on which the child is successful and then incrementally building and shaping improved articulation accuracy and movement sequencing through systematically altering the phonetic length, articulatory adjustment, contexts, type of external cues and so on. Clinicians need to be careful to insure that children with apraxia have early success in their speech therapy sessions. One way to enhance this probability is to make sure that starting work

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26 is focused at the level at which the child can be successful and then incrementally begin to build new CVC forms, new speech movement patterns, new contexts, etc.

6-Shelley Velleman's approach (for method see annexure B) Key factors to consider in therapy approaches for childhood apraxia of speech:

1. It's a dynamic disorder, and it's far more a disorder of combining elements than of producing the elements themselves. In other words, the main problem is in putting elements together "on line". The person may be able to make a certain consonant sound and a certain vowel sound, but the hard part is putting them together into a syllable. For older/less impaired children, it may be a problem of putting words into sentences or even of making a paragraph out of sentences. With respect to reading, the child may know which letters "say" which sounds, but be unable to blend them together into a word; or the child may recognize a whole ("sight") word but be unable to understand how the letters combine to make that word. 2. Many factors -- especially communication pressure and performance load (meaning + complexity of grammar + difficulty of sounds + difficulty of vocabulary, etc.) -can have an impact on the person's ability to produce certain sounds/words/sentences at a given time. Just because the child said something once does not mean (s)he can say it again, especially if it is important to do so. The more (s)he wants to say it, the harder it will be to do so. This results in the child appearing to be inconsistent, resistant, or even stubborn. There are often language symptoms (about 50% of the time). Researchers disagree whether these are part of the syndrome or not (I think they are), but all agree that they often co-occur with the articulation symptoms. These may be very basic and appear early (e.g., early grammar will be delayed or disordered), or they may not show up until the child is

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27 older. Some children's language symptoms do not appear until they begin to try to use language as a tool (e.g., reading to learn as opposed to learning to read), in 4th or 5th grade. Sometimes reading is affected. 4.

Prosody differences (stress and intonation, especially stress) are a key symptom of the disorder. Many children get to the point where their speech is quite intelligible, yet they still sound different because their stress or intonation patterns are unusual. Usually, speech is slow and choppy. Some children sound quite robotic. 5. There may be other types of apraxia present, including oral apraxia (affecting nonspeech movements of the mouth) or limb apraxia (affecting the hands). Occupational or physical therapists should be involved if so. 6. It's not the same as other phonological delays. The symptoms can be quite complex, and may change suddenly and unpredictably. The child often will not follow the developmental sequences which are listed in textbooks for other children. Therefore, therapy approaches should: 1.

Be dynamic. Movement patterns and building larger elements should be emphasized. Working on producing consonant sounds in isolation, for example, is a bad idea. It may produce quick results, but it will not contribute to intelligible speech. (The only exception to this is consonant sounds which have a meaning, such as "mmm" and "shh".) Syllables should be the basic unit, building up from there. The activities which will actually address the heart of the problem are activities where the oral-motor planning system has to plan how to get from one articulatory position to another. This may begin with repeating simple meaningful syllables (baa-baa-baa, moomoo-moo), moving up to alternating syllables which include either the same consonant or the same vowel (baa - bee baa - bee; bee - D - bee - D). Working on articulatory movement patterns (as in Moving Across Syllables) is also very helpful. 2. Include activities with lower communication pressure, to increase the automaticity of syllables/words already in the child's repertoire (e.g., through singing, book-reading, and other verbal routines), as well as activities with

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28 higher communication pressure. Augmentative/alternative communication (signs or picture boards) can often help in two ways: 1. reduce the communication pressure, so the child actually finds it easier to speak 2. decrease everyone's frustration. Using sign or picture boards does not discourage the child from speaking. It helps. 3. Include monitoring and (if appropriate) treatment of language symptoms. Teach grammatical word endings in an order that is phonologically easiest, even if this doesn't follow developmental order. 4. Address prosody very directly, beginning at a young age. Early activities can include anything with rhythm, pitch, or loudness changes. Music is great! Be sure to vary rhythm, so the child doesn't get locked into one equalstressed rhythm pattern. Older children should be explicitly taught about the importance of prosody in speech, including: •

•

Stress patterns which signal nouns vs. verbs (CONtrast vs. conTRAST), different types of phrases (light HOUSEkeeper vs. LIGHTHOUSE keeper), or sentence meanings (I DIDN'T know vs. I didn't KNOW). Intonation, which signals the type of sentence (yes-no question, with pitch rising at the end, versus statements and wh- questions, with pitch falling at the end) and also the speaker's emotions.

5. Include movement activities (e.g., to music). Co-therapy with occupational or physical therapists is often very helpful. 6. We recommend therapy as intensively and as often as possible. Five short sessions (e.g., 30 minutes) a week is better than two 90-minute sessions. Regression will occur if therapy is discontinued for a long time (e.g., over the summer). At least some of the therapy, on a regular basis (e.g., once a week) must be provided by an ASHA-certified ("CCCSLP"), licensed (in those states with licensure) speech-

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29 language pathologist. Other professionals who work with the child in other sessions must be supervised by the certified person (e.g., meet with her/him weekly to discuss progress and strategies). Most of the therapy (e.g., 2-3 times a week) must be provided individually. If group therapy is provided, it will not help unless the other children in the group have the same diagnosis and are at the same level phonologically. Adequate services cannot be provided in whole-classroom activities. Language stimulation, exposure, etc. may have an impact on some social language skills, but are not sufficient. If you are told,"(S)he'll get it by listening to the other kids", do not believe it. If (s)he could get it through exposure, (s)he'd have it already.

Key components of successful intervention 1-Knowledge of Results - Knowledge of Performance The child with CAS will require "feedback" in order for motor learning to occur. Two types of feedback to consider in treatment are "knowledge of performance" and "knowledge of results." Knowledge of performance refers to feedback provided by the SLP that gives the child specific information on how a movement is performed or correction to the specific movement (i.e., 'your tongue needs to be up more", "build up that air inside with your lips closed tight"). Knowledge of results refers to feedback from the SLP regarding how well the overall speech attempt was performed (i.e., "Yes, you did it!", "That wasn't it, try it again."). Some experts suggest that knowledge of performance is more appropriate in early treatment phases and knowledge of results more appropriate as the child gains some control in their speech motor processing system. Clinicians, however, should give careful attention to feedback and make clinical judgments and evaluation related to the degree of external feedback provided, assessing the child's internal feedback capacity and "self monitoring". The end goal is for the child's system to develop intrinsic feedback and selfmonitoring. There is risk to providing too much or too little external feedback. If too little is provided, the child may fail to make progress because their system is not 29

30 currently providing them with sufficient internal feedback. If too much feedback is provided, the child's system will never be taxed to develop internal feedback loops and will possibly fail to take over the responsibility for independent processing. So, careful attention is warranted to the extent and type of external feedback provided by the clinician. This is a gentle process of providing appropriate feedback and backing off and observing the child's ability to be accurate with volitional speech movement sequences using their own internal system of feedback.

2- Effort, Attention and Motivation: Children with CAS need to exert a great deal of their cognitive and attention resources to the speech task, especially during the early phases of speech therapy as they build volitional control over their speech motor system. SLPs need to assess consistently their environment and the potential distracters for the child that will reduce the child's ability to put forth the necessary attention and intrinsic resources to their speech practice. For example, noise and visual distracters or movement can reduce the child's ability to put forth their greatest allocation of attention to the speech production practice. As children develop their speech motor skills, these issues may become less important. Attention is a key skill for children who require the type of multisensory strategies described for children with apraxia of speech. In particular, for a child to benefit from increased sensory input like visual cueing, they must be able to provide eye contact and attend to the SLP's face when instructed to do so. Children who are unable to give even the most basic level of attention to the SLPs face may need preliminary work to increase their ability to do so in order that they may benefit from an intensive speech motorprogramming based approach. Children with CAS have likely experienced a great deal of failure in their communication attempts. Many either withdraw from communication interactions or develop behaviors related to their frustrating situation. Additionally, many children have experienced a lack of success at previous speech therapy attempts. Thus, the SLP needs to provide special care and concern to actively 30

31 engage such youngsters and insure that they experience early success in therapy - even during the first session. Experienced clinicians pay attention to: • •

•

•

Understanding the child's personality as well as their history of communication failure and success Demonstrate understanding directly to the child by validating their experience and sharing the desire to help speech become easier for them. Remember that each child is different in what motivates them and what interests them. By including such interests in therapy, children may be enticed to participate with more willingness. Work with caregivers to communicate a safe environment for the child and to create trust in the process.

3- Helping child with CAS Various studies conducted with children with limited phonological awareness or poor reading skills point to some suggestions. For instance, a study by Hatcher, Hulme, & Ellis who divided seven year olds who were poor readers into three groups and provided different arrangements of phonological awareness training, reading instruction, or no other training outside of the routine classroom work, found that the only group that made significantly more progress than the control group, was the group that focused on both phonological awareness plus explicit reading strategies. In her article reporting the results of this study, Stackhouse writes, "phonological awareness training alone does not necessarily facilitate literacy development. Literacy development is dependent on children's ability to link their phonological awareness skills to letter knowledge and reading experience." (Stackhouse, 1997, p.162) An earlier study by Bradley and Bryant of 65 children with below average ability on phonological awareness tasks as nonreaders before entering school demonstrated that phonological awareness training needs to be combined with explicit letter knowledge teaching for these children to make actual gains in literacy development. Further, a complete language assessment needs to be done. Such an assessment must not only look at and define the symptoms of the speech, reading, and spelling problems but also the underlying nature of those problems. A full assessment would include: speech, language and oral-motor 31

32 abilities; auditory skills (such as auditory discrimination, memory and organization); rhyme detection and production; syllable and phoneme segmentation; reading comprehension and expression; spelling and awareness of reading and spelling strategies. It is also important to include more difficult items in reading and spelling tests (for instance, multisyllabic words) in order to determine a particular child's difficulty. At the end of a thorough assessment, Stackhouse suggests that: "...having identified through the assessment (a) a profile on speech, language, and reading tests (b) the level and modality of breakdown (c) the severity of the difficulties and their manifestation in 'real life' (d) the coping strategies adopted then remediation can be planned" (Stackhouse, 1985, p.109)

4- The Role of the Speech and Language Pathologist: The literature and studies reviewed for this paper indicate that there needs to be awareness and vigilance to the literacy development of children with spoken language problems, especially those who have apraxia of speech. "There is a danger that as intelligibility reaches an acceptable level, the child is discharged from the speech therapist's care only to be left struggling with residual speech difficulties and related spelling problems," concludes Joy Stackhouse. (Stackhouse, 1985, p.115) While the role of the speech and language pathologist is not to teach reading and spelling per se, Snowling & Stackhouse indicate that, "the role is one of identification and promoting the underlying skills that contribute to literacy development." (Stackhouse, 1997, p.190) It is hoped that by receiving early, intensive communication therapy for apraxia of speech or phonological deficits, these children may, in fact, heighten their phonological awareness and, in part, strengthen a potentially intrinsic weakness. Stackhouse suggests that some possibly relevant tools, techniques and activities include: •

phoneme-grapheme matched cards (cards with pictures that represent sounds)

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33 • • • • •

color coded systems as visual reminders of language structures or of sound groups sound categorization activities using multi-sensory approaches syllable and sound segmentation activities rhyming work explicit teaching of reading and spelling rules

5- Reading instruction Research accumulated over time indicates that many children need explicit teaching using a phonics approach with phonological awareness; sound-letter correspondence and decodable text with kindergartners and first graders. Research appears to indicate that whole language can enhance comprehension and that a balance of comprehension and decoding skills should be focused on but that whole language should not be the only strategy used with nonreaders. This data may be especially important to children with apraxia of speech and residual problems.(see annexure D)

6- Parents Participation: Parents can support the work of speech pathologists and teachers by following through on home activities that are suggested. For young children, these include nursery rhymes and rhyme games; making games with syllable beats in words; drawing attention to the printed word while reading to children; using books with rhymes and word patterns. Most importantly, parents need to be proactive by knowing what is happening in their child's school program. Developing effective communication with teachers and therapists will help promote skill development and also help to identify potential roadblocks at the earliest possible time, before a significant problem has developed.

7- Augmentative and Alternative Communication and Apraxia Augmentative and Alternative Communication (AAC) may be appropriate for children with a diagnosis of CAS. Some children benefit from using sign language for some period

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34 of time when their speech is not yet fully intelligible. There are many benefits to sign language and other AAC forms detailed in other articles on the website, however several benefits include: • • •

•

•

Allows for continued language, vocabulary, literacy and educational development Enables participation in the curriculum Increases likelihood that a familiar listener can "catch" the meaning intended from an unintelligible utterance, thus providing communication motivation for the child Provides another form of sensory input that can be used as paired association method for triggering "speech motor memories" Reduces the communication pressure felt by the child who has experienced a great deal of failure and anxiety in communication attempts, allowing their personal resources to be directed back to the communication process

The use of AAC requires a skilled evaluator and trainer to insure the child's needs and abilities are properly considered. For SLPs who do not feel adequately trained or skilled in AAC methods, evaluation, and treatment, arrange for or request technical assistance. If providing support to an AAC user, SLPs should familiarize themselves with the benefits and current research literature on AAC.

8- Appropriate time to Consider Augmentative and Alternative Communication (AAC) for Children with Apraxia of Speech The American Speech-Language-Hearing Association defines AAC as ... "a set of procedures and processes by which individuals communication skills (i.e., production as well as comprehension) can be maximized for functional and effective communication. In other words, AAC includes any form of communication other than speech that allows the user to communicate in his or her surroundings." Light (1988) identified four primary functions, or purposes, of communication. These include: (1) expression of wants and needs, (2) exchange of information,

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35 (3) social closeness, and (4) social etiquette. Typically-developing children use speech to function within these areas. When speech is not adequate to achieve the child’s communicative purposes, it is necessary for the child to find a way to close any gaps. In terms of expressing wants and needs, AAC is a nice bridge between the need to communicate a message and actually getting your meaning across to another person. Children can use natural gestures, sign language, a communication book, a symbol (picture, photograph, line drawing, etc.), and/or a speechgenerating device to convey their intents. Exchange of information becomes essential in a school setting. The teacher requires that the child interacts within the classroom by asking/answering questions, participating in collaborative learning groups, and using increasingly more complex language. This exchange of information demonstrates to the teacher that the child has achieved levels of knowledge expected at various stages in development. For example, a child that is unable to say an s is going to have a difficult time indicating that he/she has learned the concept of plurals. This same child would easily be able to demonstrate the use of plurals using AAC. As children mature, the requirements to communicate multiply with the opportunities. Social environments become more diverse and filled with more communication partners. Making communication interactions functional and effective takes on greater importance because of the addition of these social influences. There is a chance that families will encounter speechlanguage pathologists who choose to focus on speech, while overlooking overall communication. A focus on speech is not wrong in and of itself. We all want our children to use natural speech. However, everyone on the child’s team (including parents and peers) needs to step back and really look at that child’s ability to communicate functionally within his/her various environments. Focus on what the child is currently able to communicate. Consider, if the progress in therapy is slow, how long are you willing to wait for the child to communicate? Is it ok to go through Kindergarten entirely without talking? First grade? There is a real difference between intelligibility (how understandable a child is using speech alone) and comprehensibility (which take speech into account along with context). Some AAC strategies put context into an

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36 interaction, and that may be sufficient to support the Child’s communication. These strategies might include alphabet (first letter) supplementation, indicating the topic being discussed, indicating a change in topic, etc. An evaluation to determine a particular child’s needs is invaluable to determine the best AAC supports. When discussing AAC, one of the first concerns voiced by parents and caregivers is that use of AAC might prevent the child from talking, or further delay development of natural speech. In response, there is a reference to the excellent Cumley (2001) article included on the Apraxia-KIDSSM web site. His research demonstrated that AAC does not deter a child from using speech to communicate, if and when it is effective for him/her. Moreover, as speech increasingly becomes the primary mode of communication (with development of functional natural speech), AAC tools and strategies will be gradually phased out of the child’s communicative strategies. In fact, the child will phase out use of AAC on his/her own, when speech becomes more effective and efficient.

9-Using Sign Language for Children with Apraxia of Speech Often when someone raises the idea of using sign language for a child with apraxia, parents may experience confusion and even fear. After all, "The child can hear just fine! Why would we use sign language for a hearing child?" Or "But won't using the sign mean my child won't need to talk? Won't it keep him/her from speaking?" Conversely, some parents report that their child's speech language pathologist has told them that the child will rely on sign and thus not learn to speak. This article attempts to address many of these myths about signing. First of all, in our mainstream culture it is true that we see most images of sign language associated with people who are deaf or hard of hearing. However, that doesn't mean that for some children - those with apraxia - that sign cannot help! For children with apraxia the sign can be used to assist and augment their verbal communication, sort of as a bridge to communication while they are learning to speak clearly. The use of signing with children who have apraxia has nothing to do with their ability to hear or

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37 understand the spoken word. Most children with apraxia have very good receptive language skills. Secondly, it is rare that a child's speech output is diminished by using sign language. To the contrary, therapists and parents alike nearly always report a heightened willingness to try new words and say more. Nearly all parents are actually quite relieved when their child starts to use some signs to help with communication. It makes life easier for the child and the parent! For just a few children with apraxia of speech, sign may not be indicated. These children have additional severe motor planning difficulties with their arms and hands, making it extremely difficult for the child to use a fairly consistent manual sign to represent a word. However, it is possible that even these children can benefit from sign if the adult uses the sign as a form of visual cueing (explained in more detail below). And it is not necessary that the child's sign is "perfect," just that they can be fairly consistent with whatever approximation of a sign they can achieve. Reasons for considering Sign & Verbal Attempts: Below are some reasons why we might want to consider using sign and verbal attempts for a child with apraxia: 1. Reduce Frustration: Reduce frustration and have basic needs understood. Children who have access to sign language are at least able to communicate at some level, which usually results in decreased frustration on their part and yours. 2. Symbolic Communication: Sign can be important to young children with little or no speech because it is symbolic communication. They are learning that they can label things and use the signs to communicate. This is important for all children. Those with typically developing speech are doing so with speech attempts - words. Our children with speech apraxia also need a way to do this so that this part of the process of acquiring language is not further delayed. 3.

Expansion of Expressive Speech: For children who have apraxia and who are really struggling to sequence sounds into words, sign can be a mechanism to insure that their 37

38 expressive language development isn't further impeded. Speech production is just that: producing speech. Expressive language is the ability to understand and properly use the rules of the language to construct sentences. So a child with apraxia is at risk, due to the speech production struggle, of also falling seriously behind in expressive language since they have no means to try out and practice how words go together to create meaningful and proper messages. Using sign assists children to keep expanding their expressive language. While they may not be able to speak a word or put two words together, they can still, by using sign, be doing this same thing in a different way. 4. Successful Communication: Children with apraxia who use sign, may also use it as an assist for the listener when accompanied by their vocal attempts. They may be capable of, for example, three word sentences in which each word is an approximation, not properly articulated, and thus the listener may not understand their message. When the child uses sign, along with the vocal attempt, the listener (if they know the signs) can have a better chance of understanding the message and thus, the child is successful at communication. Our children very much need to feel successful in their attempts to use their voice to communicate. If when attempting to use their voice to communicate, no one ever understands, it is not uncommon for them to just stop trying to use their voice. When they are understood (perhaps because they also used sign) they are delighted to realize they were successful and are more likely to keep on trying. 5.

Controls Rate of Speech: when the adult uses sign, and even when the child uses sign, it has the tendency of slowing down the rate of speech for most people (obviously not for interpreters perhaps!). For some children with apraxia, this is very helpful for them to have the additional time to allow for motoric transitions between words, etc. It gives them a better chance, in many cases, of also being able to imitate you. Many adults speak fast and that can have a negative effect on a child with apraxia's ability to imitate you. 6.

Serves as Visual Cues: It is pretty much universally agreed that multisensory input is helpful to children with apraxia of speech. The literature is full of examples of "cues" from various modalities that, when consistently

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39 paired with verbal attempts, can trigger for the child access to the motor plan they need to produce the word, sound, or sound sequence correctly. One very powerful modality for many children with apraxia is visual (thus the term "visual cues"). When the adult is also using sign to "cue" the child, and an association between the visual cue and the word or sound has been made over time, just the sight of the "cue" can help the child produce the correct word. Sometimes a sign for an alphabet letter may be used in conjunction with a location to cue a sound (sign for "K" being held at the throat). As children's speech becomes more intelligible, they almost always drop their use of the signs. However, many parents and therapists will continue to use a sign themselves for the purpose of providing a visual cue for sound or word production when the child is struggling. 7. Kinesthetic Reinforcement: Some people believe that the use of manual sign helps kinesthetic reinforcement of volitional movements and sequencing when accompanying the verbal attempt. Speech-language pathologists who successfully use sign language with children who have apraxia do not have the child using the signs in isolation. Instead, they are encouraging the child to use signs along with verbal attempts. Therapists and parents need to work together in partnership on all aspects of a child's therapy, including the use of manual sign language to augment speech attempts.

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Part III

Working with Families and Caregivers For many reasons, it is in the child's best interest when SLPs are committed to working with and beside parents and caregivers. Creating professional-parent partnerships whenever possible enhances the opportunities for children with CAS. Parents can be valuable "therapy extenders", with proper guidance from the SLP. It is not likely enough to simply spend a minute at the end of a therapy session verbally telling the parent what occurred. It is not likely enough to send home a homework sheet and think it is going to be helpful. As often as possible, parents should observe a significant portion of a speech therapy session so that they can receive direct instruction on how to elicit appropriate speech practice at home. Some therapy settings provide ample space and room for this to occur. For example, settings that have observation rooms with oneway mirror windows are a real bonus for providing parents with the opportunity to view therapy sessions. Creativity may be needed in other settings in which observation is not as simple. Some SLPs use video cameras to periodically record therapy sessions so the parent can view them. Minimally, some parents report taking baby monitors to the therapy room so they can at least hear the treatment session in progress. While having oneself observed is not always comfortable, the real help it can provide to the family hopefully overrides any such discomfort. SLPs need to go beyond verbally reporting the help that parents can provide at home to also modeling it directly. It is through this modeling and direct guidance that parents will learn what their child is capable of producing independently or with cueing and that which the child is not yet capable. As previously explained, the amount of practice will directly influence the child's ability to achieve motor learning for speech. Without practice outside of the 40

41 therapy room, many children will not receive the adequate degree of practice. Thus, if SLPs encounter parents who are not able or unwilling to learn how to practice with their child, a discussion of the ramification on long-term progress is certainly appropriate. Many parents today try to educate themselves on problems affecting their children. Thus, SLPs will encounter parents who may have read more recent information on apraxia in children than the SLP has! It is important to understand that most parents are eager to engage with the SLP as partners in helping the child. It is perfectly fine to acknowledge when the SLP has not had much experience with apraxia; has an equal eagerness to learn about the disorder and its treatment; and express an overall willingness to include the parents as partners. Parents appreciate when the SLP can acknowledge that which they do not know and an expression of willingness to learn and seek training in order to help their child. There may be times when the SLP is concerned that the parent is not, for whatever reason, following through consistently or providing appropriate support to the child at home. During such instances, a meeting without the child presents and outside of scheduled therapy time may need to occur. It is important to sensitively and honestly share concerns for the child's progress with the parent so that realistic understanding exists. The SLP may also need to provide referrals to other appropriate professional resources for specific children. For example, if the SLP suspects that the child has an underlying pervasive disability, disorder, or syndrome it would be important to refer the family to an appropriate developmental pediatrician or pediatric neurologist. Overall, it is in the best interest of the child when the SLP is able to involve the parent or caregiver as a partner in the therapy process. All efforts should lead to that hopeful result.

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Part IV

A Case Study of Childhood Apraxia of Speech Case #1 Jamie, a six year-old boy, moved into town and entered first grade. He was very unintelligible (hard to understand), but seemed to have a lot to say. His teacher said he did well on many of the math papers, but struggled with letters and sounds. Jamie had been receiving speech therapy for the past year and a half in his previous school, but his mother reported little noticeable progress. We did a more complete educational evaluation, including a speech-language assessment. We found that Jamie had some fine-motor weaknesses and sensory integration delays, which were identified by the occupational therapist. The finemotor weaknesses explain why he had such difficulty with such things as gripping his pencil and writing his letters on the line in an appropriate way. The sensory integration difficulties also explained why he was resistant to wearing clothes of different textures, was knocking into walls as he walked, and didn't seem to sense when crumbs were left on his mouth after snack. The occupational therapist ("OT") began therapy once a week in a small group in the therapy room. Later in the year, much of the therapy was done in the class. The special education teacher did a learning disabilities assessment and found there was difficulty in most areas related to sequencing. Jamie could not put pictures of a story sequence in order, repeat words in order, or copy letters in order. His letter-sound understanding ("S" says "sss") was adequate. He could read some memorized words, but could not sound out a new word, even when he knew each 42

43 sound in the word. His math skills appropriate and his attention span education help was initiated, with teacher going into the first grade during Language Arts.

seemed to be age was good. Special the special education class to help Jamie

In terms of the speech-language assessment, I found that Jamie's difficulties were a pretty classic case of "dyspraxia", also known as "Developmental Dyspraxia of Speech" or apraxia. While he had been previously identified as having a severe articulation disorder, the word dyspraxia never appeared in any of his previous evaluation reports. How did I know? Jamie was able to produce nearly all the vowel and consonant sounds in isolation. If I said, "Jamie, say 'ah' (as in *apple*), he could do it. He could say "apple" if he concentrated. He could say "pie". But if I asked him to say "apple pie", this is what I heard: "paboo bie". If I asked him to say it three times, I would get three answers. Another attempt might sound like "pappie bah". There was no consistency. He often produced single words clearly, but fell apart in phrases and conversation. Words with more than one syllable were also much more difficult for him to pronounce. Sounds that were produced in one word (the "s" in "bu*s*") were left off in other places ("s" in the phrase "I *s*ee"). Moreover, his global difficulty with sequencing, fine-motor, and sensory integration was typical for children with dyspraxia. He could tell what he said wasn't sounding right, and was visibly frustrated, but couldn't *sequence* the sounds and syllables to match what I said. This might explain why his previous therapy, which consisted of ear training and traditional articulation therapy (where he worked on one sound at a time in single words) wasn't producing any significant change. He was also getting oral-motor therapy designed to strengthen his muscles. I'm guessing the previous therapist knew his mouth wasn't doing something right. However, when I saw Jamie, his tongue, lips, and other muscles were not weak or lacking control during nonspeech tasks. Perhaps the therapy had done its job, I couldn't tell. While some children with dyspraxia have difficulty with verbal as well as nonverbal oral movements, Jamie did not. He was able to open his mouth, stick out his tongue, and perform a variety of other commands with normal timing and precision. His chewing, drinking and swallowing were normal. His tongue did not

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44 protrude at rest, his jaw did not slide during speech tasks, and he did not drool. Lastly, Jamie's sentence structure (syntax) was fragmented. He said things such as "Morrow I bay di my dend" (Tomorrow I play with my friend) and I noticed some word-retrieval difficulties in conversation and on picture-naming tests. That is, he recognized a word's meaning when he heard it, but could not remember it when asked to name a picture. This too, is not uncommon with dyspraxic children. In terms of therapy, I began a very structured, systematic approach. I incorporated a variety of methods, such as the PROMPT technique(which is represented by Deborah Hayden also described in this study ) and drills which work at the syllable level, then are incorporated into phrases and conversation. Words that were too difficult for Jamie to produce but of high interest, were broken down into easier "versions" so he could at least approximate a consistent way of saying what he wanted. I also began using the Phonemic Synthesis program, which helps children auditorily learn to blend sounds and sequence them. This helps their speech, decoding, spelling, and word retrieval. Initially, individual sounds within a syllable or word were cued with gestures to help Jamie sequence them. As he improved, each word in a phrase was cued. Without a great deal of home practicing, all of my efforts would have been of little benefit. However, Jamie and his mother were diligent and it paid off. By the middle of second grade (a year and a half later), Jamie's speech was significantly improved. By the beginning of fourth grade, he was done with articulation therapy and occupational therapy. However, Jamie still needed some special education support in Language Arts and work on developing his expressive language. As is sometimes the case, Jamie will most likely need some kind of speech and/or special education assistance for awhile. But he is a "normal" boy and looks and sounds like the rest of his friends at this writing. Note: (The above is a case study which is based on several actual children I have seen over the years with the diagnosis of dyspraxia or apraxia. The name is fictitious.)

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45 Patti Hamaguchi has a private pediatric speech therapy practice in Cupertino, California. She has a master's degree in Speech-Language Pathology from the College of New Jersey and holds the CCC (Certificate of Clinical Competency) from ASHA.

Case history # 2 Omer is an 8 years old boy student of academic group in autism institute was brought for the speech and language assessment by her mother with the complain of poor functional language and poor intelligibility. For further evaluation an interview was conducted. Mother reported that his prenatal and post natal birth history was normal. No complication was seen during this period. At the age of 1-1/4 he had seizure. He delayed in his speech and language milestones. He is able to convey his message verbally. But doesn’t initiate to start conversation. For the speech and language evaluations following tests were administered: Oral facial examination: To assess the structural and functional integrity of the oral mechanism oral facial examination was administered. Facial features was symmetrical. Range of motion of opening and closing mouth was normal. Movement of tongue was normal. Pharynx was also in normal condition. In short oral musculatures were intact. Diadochokinetic Syllable Rates: To assess the ability to make rapidly alternating speech movement this test was administered. The score is 10.3 and standard deviation 2.8. The rate of errors were high, he found very difficult this task. Articulation Scale: •

To find the score of sound production, stimulability, intelligibility, oral motor function and adverse affect on educational performance articulation Scale was administered. The total score was fall within the range of 17-24, which is moderate. Errors were inconsistent. He has no difficulty in individual sound 45

46 production. All phonemes (consonants and vowels) were imitated well in isolation, but any attempts to combine phonemes are unsuccessful.Errors increased with length or complexity of utterances, such as in multi-syllabic or phonetically challenging words.

Functional Communication rating scale: His score was 4 in interaction and intention that is severely affected. As mother has already reported he doesn’t initiate for conversation. Findings Omer has difficulty in the production of clusters of vowels and consonants, specially with the CCVCC, and in the complex context. During assessment Omer did not initiate to start conversation and when prompted he gave good response, speech was intelligible in isolation but within sentence structure complex utterances were not intelligible, he exhibited a number of characteristics that are believed to be highly indicative of apraxia. Therapy intervention: So far the initial stage of treatment Omer was recommended for frequent and intensive one on one speech therapy programs with Phonotactic Therapy techniques (see annexure B) PROMPT (Prompts for Restructuring Oral Muscular Targets, also watch video presentation online). Targets were the development of simple CVC syllable production with 90% accuracy. He started to receive 5 days, 30 minutes therapy session. After 40 sessions the results were very positive and mother reported the positive results in his speech. All important components are being considered for successful therapy treatment. He is currently receiving the therapy treatment according to the prescribed schedule and prognosis is very positive.

Note: (the above case study has been taken from Autism Institute Karachi.) 46

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Conclusion: Childhood Apraxia of speech, also known as verbal apraxia or dyspraxia, is a speech disorder in which a child has trouble saying what he or she wants to say correctly and consistently. It is not due to weakness or paralysis of the speech muscles (the muscles of the face, tongue, and lips). The severity of apraxia of speech can range from mild to severe. Developmental apraxia of speech (DAS) occurs in children and is present from birth. It appears to affect more boys than girls. This speech disorder goes by several other names, including developmental verbal apraxia, developmental verbal dyspraxia, articulatory apraxia, and childhood apraxia of speech. DAS is different from what is known as a developmental delay of speech, in which a child follows the "typical" path of speech development but does so more slowly than normal. The cause or causes of DAS are not yet known. Some scientists believe that DAS is a disorder related to a child's overall language development. Others believe it is a neurological disorder that affects the brain's ability to send the proper signals to move the muscles involved in speech. However, brain imaging and other studies have not found evidence of specific brain lesions or differences in brain structure in children with CAS. Children with CAS often have family members who have a history of communication disorders or learning disabilities. This observation and recent research findings suggest that genetic factors may play a role in the disorder. Children with either form of apraxia of speech may have a number of different speech characteristics, or symptoms. One of the most notable symptoms is difficulty putting sounds and syllables together in the correct order to form words. Longer or more complex words are usually harder to say than shorter or simpler words. Children with apraxia of 47

48 speech also tend to make inconsistent mistakes when speaking. For example, they may say a difficult word correctly but then have trouble repeating it, or they may be able to say a particular sound one day and have trouble with the same sound the next day. Children with apraxia of speech often appear to be groping for the right sound or word, and may try saying a word several times before they say it correctly. Another common characteristic of apraxia of speech is the incorrect use of "prosody" -- that is, the varying rhythms, stresses, and inflections of speech that are used to help express meaning. Children with developmental apraxia of speech generally can understand language much better than they are able to use language to express themselves. Some children with the disorder may also have other problems. These can include other speech problems, such as dysarthria; language problems such as poor vocabulary, incorrect grammar, and difficulty in clearly organizing spoken information; problems with reading, writing, spelling, or math; coordination or "motor-skill" problems; and chewing and swallowing difficulties. The severity of both acquired and developmental apraxia of speech varies from person to person. Apraxia can be so mild that a person has trouble with very few speech sounds or only has occasional problems pronouncing words with many syllables. In the most severe cases, a person may not be able to communicate effectively with speech, and may need the help of alternative or additional communication methods. Professionals known as speech-language pathologists play a key role in diagnosing and treating apraxia of speech. There is no single factor or test that can be used to diagnose apraxia. In addition, speech-language experts do not agree about which specific symptoms are part of developmental apraxia. The person making the diagnosis generally looks for the presence of some, or many, of a group of symptoms, including those described above. Ruling out other contributing factors, such as muscle weakness or language-comprehension problems, can also help with the diagnosis. To diagnose developmental apraxia of speech, parents and professionals may need to observe a child's speech over a period of time. In formal testing for both acquired and developmental apraxia, the speech-language pathologist may

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49 ask the person to perform speech tasks such as repeating a particular word several times or repeating a list of words of increasing length (for example, love, loving, lovingly). For acquired apraxia of speech, a speech-language pathologist may also examine a person's ability to converse, read, write, and perform non-speech movements. Children with developmental apraxia of speech will not outgrow the problem on their own. Speech-language therapy is often helpful for these children and for people with acquired apraxia who do not spontaneously recover all of their speech abilities. Speech-language pathologists use different approaches to treat apraxia of speech, and no single approach has been proven to be the most effective. Therapy is tailored to the individual and is designed to treat other speech or language problems that may occur together with apraxia. Each person responds differently to therapy, and some people will make more progress than others. People with apraxia of speech usually need frequent and intensive oneon-one therapy. Support and encouragement from family members and friends are also important. The PROMPT technique presented by Deborah Heydn is useful in the therapy. In severe cases, developmental apraxia of speech may need to use other ways to express themselves. These might include formal or informal sign language, a language notebook with pictures or written words that the person can show to other people, or an electronic communication device such as a portable computer that writes and produces speech. Researchers are searching for the causes of developmental apraxia of speech, including the possible role of abnormalities in the brain or other parts of the nervous system. They are also looking for genetic factors that may play a role in DAS or CAS. Other research on CAS is aimed at identifying more specific criteria and new techniques that can be used to diagnose the disorder and distinguish it from other communication disorders. Research on acquired apraxia of speech includes studies to pinpoint the specific areas of the brain that are involved in the disorder. In addition, researchers are studying the effectiveness of various treatment approaches for acquired and developmental apraxia of speech.

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References Caruso, A.J., and Strand, E. A. (1999) Clinical Management of Motor Speech Disorders in Children. New York: Thieme. Cumley, G. D.; Swanson, S. (1999) Augmentative and alternative communication options for children with developmental apraxia of speech: three case studies. Augmentative and Alternative Communication, vol. 15, no. 2, pp. 110. Davis, B. L.; Velleman, S. L. (2000). Differential Diagnosis and Treatment of Developmental Apraxia of Speech in Infants and Toddlers. Infant Toddler Intervention, 2000, vol. 10, no. 3, pp. 177-192. Forrest. K. (2003) Diagnostic criteria of development apraxia of speech used by clinical speech-language pathologists. American Journal of Speech-Language Pathology, 12(3), pp. 376 - 380. Gibbon, F. Stewart, F., Hardcastle, W.J. and Crampin, L. (1999) Widening access to electropalatography for children with persistent sound system disorders. American Journal of SpeechLanguage Pathology, 8, 319-334. Hammer, D. and Robin, D.A. (2003) "Childhood Apraxia of Speech: Assessment, Treatment & Current Issues", a Hendrix Foundation/CASANA workshop presented in San Diego, CA. Hall, P. K., Jordan, L.S. and Robin, D. A. (1993) Developmental Apraxia of Speech: Theory and Clinical Practice. Austin, TX: ProEd. Lewis BA. Freebairn LA. Hansen AJ. Iyengar SK. Taylor HG. (2004) School-age follow-up of children with childhood apraxia of speech. Language, Speech & Hearing Services in the Schools. 35(2):122-40. Maassen B. (2002). Issues contrasting adult acquired versus developmental apraxia of speech. Semin Speech Lang;23(4):257266.

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51 Maassen, B. (2004) Speech output disorders. In Verhoeven, L. and van Balkom, H. (Eds.) Classification of developmental language disorders. Mahway, NJ: Lawrence Erlbaum Associates. McNeil, M. R. (Ed.). (1997). Clinical management of sensorimotor speech disorders. New York, NY: Theime. Odell K. H.; Shriberg L. D. (2001) Prosody-voice characteristics of children and adults with apraxia of speech. Clinical Linguistics & Phonetics, vol. 15, no. 4, pp. 275-307. Shriberg, L.D. and Campbell, T.F. (Eds.) (2003). Proceedings of the 2002 childhood apraxia of speech research symposium. Carlsbad, CA: The Hendrix Foundation. Shriberg LD. Campbell TF. Karlsson HB. Brown RL. McSweeny JL. Nadler CJ. (2003) A diagnostic marker for childhood apraxia of speech: the lexical stress ratio. Clinical Linguistics & Phonetics. 17(7):549-74. Shriberg LD. Green JR. Campbell TF. McSweeny JL. Scheer AR. (2003) A diagnostic marker for childhood apraxia of speech: the coefficient of variation ratio. Clinical Linguistics & Phonetics. 17(7):575-95. Stackhouse, J. and Wells, B. (1997) Children's speech and literacy difficulties: a psycholinguistic framework. San Diego, CA: Singular. Strand, E. A., and Debertine, P. (2000). The efficacy of integral stimulation intervention with developmental apraxia of speech. Journal of Medical Speech Language Pathology, vol. 8, no. 4, pp. 295-300. Strand, E.A. and Stoeckel, R. (2004) "Differential Diagnosis and Treatment of Childhood Apraxia of Speech", a Hendrix Foundation/CASANA workshop presented in St. Paul, MN. Thoonen G., Maassen B., Gabreels F., Schreuder R. (1999) Validity of maximum performance tasks to diagnose motor speech disorders in children. Clinical Linguistics & Phonetics, vol. 13, no. 1, pp. 1-23. Velleman, S.L. (2003). Childhood apraxia of speech resource guide. Clifton Park, NY: Delmar Learning. Web Reference: http://www.apraxiakids.org/site/apps/nl/content.asp?c=chKMI0PIIsE&b=1071417&ct=1460 307

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52 Recommended: live video lecture on PROMPT Technique by Deborah Heyden must watch it. http://video.google.com/videoplay?docid=2545150313323194177&sourceid=searchfeed

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