Assessment and Treatment of Childhood Apraxia of
2/20/2018
Communication, Movement and Learning Lab
Assessment and Treatment of Childhood Apraxia of Speech Jenya Iuzzini-Seigel, PhD, CCC-SLP Marquette University Communication, Movement and Learning Lab
2/20/2018
3
Learner Outcomes
* List characteristics associated with CAS, which can support differential diagnosis
* Describe and apply principles of motor learning that
Background on CAS
can aid in treatment planning for CAS
* Describe and apply evidence based interventions for CAS
* Create treatment plans for children with CAS with and without comorbidities 2/20/2018
APRAXIA
5
What is childhood apraxia of speech (CAS)?
* Praxis is Greek for doing an action * Apraxia is an inability to perform the action
“Neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes or tone)” (ASHA, 2007)
* May affect oral and/or limb movements as well as speech
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Prevalence of CAS
Differential diagnosis of CAS * No overt physical markers of CAS and although there are
• •
genetic (Centanni et al., 2015; Fisher et al., 1998; Laffin et al., 2012) markers associated with CAS, these are not yet diagnostic * Published tests tend to lack psychometric properties that allow for confident and replicable differential diagnosis alone (McCauley & Strand, 2008) * Much of the published literature lacks operationally defined diagnostic criteria that can be applied clinically
Affects 1-2 children per 1,000 (Shriberg et al., 1997) Higher prevalence in males than females, affecting 2-3 males: 1 female (Hall et al., 1993; Lewis et al., 2004)
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Underlying causes of CAS
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What is the underlying mechanism?
• Idiopathic - No known cause • Syndromic - Result of known neurobiological disorder of genetic or metabolic origin (e.g., galactosemia, velocardiofacial syndrome) • Acquired - Due to intrauterine stroke, birth trauma, infection etc.
* May be due to decreased sensitivity of tongue and palate, or increased neural noise (Terband & Maassen, 2010) * May be due to a difficulty establishing robust motor programs that contain articulatory motor commands for speech sound targets • Could be due to a difficulty learning implicit patterns that affects speech, motor, language, and reading (Cabbage, Iuzzini-Seigel et al., 2018; Iuzzini-Seigel et al., 2017)
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What features characterize CAS? •
Why don’t we have a validated list of features?
Validated list of features does not exist
•
Rare and heterogeneous population!
•
Circularity between experimental variables and those used for group assignment
•
Broad age range included in studies
•
Different diagnostic criteria used across studies
(ASHA, 2007)
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ASHA Features of CAS (Technical Report, 2007)
What do you consider important features of CAS?
• Inconsistent speech errors (how much, how should they be measured?) • Lengthened and disrupted coarticulatory transitions between sounds and syllables • Inappropriate prosody, especially in realization of lexical or phrasal stress
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CAS Features Explained
CAS Features (adapted from Shriberg, Potter, & Strand, 2011) * * * * * * * * * * *
Vowel Error Consonant distortions Voicing errors Equal or excess stress Syllable segregation Difficulty achieving initial articulatory configurations or transitionary movement gestures Intrusive schwa Slow rate Increased difficulty with multisyllabic words Disturbed resonance Groping 2/20/2018
Operational definitions (Iuzzini-Seigel, Hogan & Green, 2017) •
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Operational definitions
Vowel Error: A vowel production error in which the vowel is substituted for another phoneme OR in which the vowel is recognizable as a specific phoneme but it is not produced exactly correctly (e.g., not a prototypical production, may sound like it’s in between two vowels). It is not
•
Stress errors: An error in which the appropriate stress is not produced correctly. For example: conDUCT vs. CONduct have different stress patterns. It is considered an error if the stress is inappropriately equalized across syllables, or on the wrong syllable.
•
Syllable segregation: Brief or lengthy pause between syllables which is not appropriate.
•
Difficulty achieving initial articulatory configurations or transitionary movement gestures: Initiation of utterance or initial speech sound may be difficult for child to produce and may sound lengthened or uncoordinated. Also, child may evidence lengthened or disrupted coarticulatory gestures or movement transitions from one sound to the next.
considered an error if the vowel is substituted with another phoneme that is consistent with an adult-like model (e.g., /hɑt dag/ /hɑt dɔg/)
•
•
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Consonant Distortion: A consonant production error in which a speech sound is recognizable as a specific phoneme but it is not produced exactly correctly (e.g., an /s/ that is produced with lateralization or dentalization).
Voicing errors: A sound is produced as its voicing cognate (e.g., a /p/ that is produced as a /b/). In addition, this could also describe productions which appear to be in between voicing categories (e.g., blurring of voicing boundaries).
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Operational definitions •
Intrusive schwa (e.g., in clusters): A schwa is added in between consonants. For example, it may be inserted in between the consonants in a cluster (e.g., /blu/ becomes /bəlu/). This NOT considered a "vowel error".
•
Slow rate: Speech rate is not typical. It is slower during production of part (e.g., zzziiiiiiper/zipper) or the whole word (e.g., tooommmmaaatoooo/tomato).
•
Increased difficulty with multisyllabic words: The participant has a disproportionately increased number of errors as the number of syllables increases (as compared to words with fewer syllables).
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Operational definitions
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•
Resonance or nasality disturbance: Sounds either hyponasal: not enough airflow out of nose/"stuffy" OR hypernasal: too much airflow out of nose for non-nasal phonemes (e.g., plosives).
•
Groping: Prevocalic (silent) articulatory searching prior to onset of phonation, possibly in an effort to improve the accuracy of the production. You need to see the child to assess this feature.
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Listen! What do you see and hear?
What did you hear and see? 2/20/2018
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What did you see and hear? * * * * * * *
Vowel errors Voicing errors Distortions Inconsistency Slow rate Glottal stops Groping
How should I measure inconsistency? How much inconsistency is too much?
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Token-to-token inconsistency
Measuring Word Inconsistency
* Inconsistency of a word or phrase across multiple productions (e.g., Dodd et al., 2006; Iuzzini-Seigel, Hogan, & Green, 2017) * Pros: Maintains context, quick to score (i.e., same or different) * Cons: Does not quantify intra-item inconsistency, may mask severity or improvement, does not inform phonemic treatment targets, may require additional phonemic analysis
*
Cons: Does not quantify intra-item inconsistency, may mask severity or improvement, does not inform phonemic treatment targets, may require additional phonemic analysis
* Example: ✳
“elephant”
*
/ɛpədɑn/, /ɛdæn/, /ʌpfæn/
•
Measuring Phrasal Inconsistency in school-aged children ( Iuzzini-Seigel et al, 2017)
2.
If child scores higher than 40%, their test should be rescored without items that are inconsistent due to alternations between accurate productions and developmentally appropriate errors (e.g., gliding in a 4 y.o.)
Inconsistency is task dependent!
Have child say “Buy Bobby a Puppy” five times
Token-to-token inconsistency (%)
1.
DEAP contains 25 single syllable and multisyllabic items that are repeated 3x each Items are scored as “same” or “different” If more than 40% of items are “different,” child is considered inconsistent
* •
Compare trials
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CAS
SD
(Iuzzini-S eigel, Hogan, & G reen, 2 0 1 7 )
TD
60 50
40 30 20 10 0
3.
Monosyllabic RW
If child produced any inconsistencies across trials, they are considered inconsistent.
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Multisyllabic RW
Phrase level
Task
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How much inconsistency is too much? Token-to-token inconsistency * ≥ 40% on DEAP * ≥ 0% on 5 reps of “Buy bobby a puppy”
How do I pick an assessment task?
* Ensure that task is challenging for children with CAS but simple for children with speech delay or phonological disorder ✳
For school-aged children, 5 repetitions of “Buy Bobby a puppy” is effective
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Do children need to evidence all features to warrant a diagnosis of CAS? •
How often and in how many contexts should a child demonstrate these features to warrant a CAS diagnosis?
Why or why not?
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Many articles suggest that speech should be assessed in three contexts
2.
In a school-aged child at least 4 or more features should be evidenced in each context to warrant a diagnosis of CAS
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Differential diagnosis
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Differential diagnosis
• Speech battery and speech sample (Dodd et al., 2006; Iuzzini-Seigel,
GFTA Standard Score
Hogan & Green, 2017; Strand et al., 2013),
• Assess articulatory and prosodic accuracy, inconsistency, types of
• • • •
errors, other features
≥ 85 WNL
Oral mechanism assessment Language and literacy testing Family history Does child have any other suspected deficits?
NON-CAS SSD WIS < 40% BBP = 0% Consistent Few CAS features
• Fine or gross motor issues? • Psychosocial issues?
Structural-functional motor speech exam
< 85 NWNL
CAS WIS ≥ 40-50% BBP > 0% Inconsistent Several CAS features
Other co-occurring considerations
* Range of motion * Can tongue elevate to alveolar ridge, protrude between teeth?
* Speed * Does tongue move with rapidity needed for speech? * Strength * Does child have adequate tongue strength and lip seal? * Muscular tension * Can child vary tension and relaxation of muscles * Coordination * Can child alternate oral movements and rapid alternating oral
•
Oral-motor apraxia and/or dysarthria
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Comorbid language disorder (Lewis et al., 2004; Zuk, Iuzzini-Seigel et al., 2018)
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Comorbid fine and gross motor disorders (Gretz, 2013)
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Comorbid reading disorder (Lewis et al., 2004; Cabbage, Iuzzini-Seigel, et al., 2018)
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Delayed babbling (Highman et al., 2008)
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Speech perception deficits, when language impairment is also present (Zuk, Iuzzini-Seigel, Cabbage, Green, & Hogan, 2018)
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In pairs, differentially diagnose child and determine factors you will consider in treatment planning. Case 1, male Age = 56 months Normal receptive language (SS = 96) and IQ (SS = 105) Low expressive language (SS = 63) Poor fine and gross abilities based on standardized testing
Using Praat freeware to listen and look
* Praat is free acoustical software * Can be used to record and playback audio * Can be used to facilitate transcription of challenging speech samples
Multisyllabic words
* Can be used to analyze speech and voice recordings (frequency, voice onset time among voice measures)
Language sample Goldman Fristoe Test of Articulation-3
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Praat Instructions * * * * * * * * *
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Download Praat Open Praat (run) Record new sound file of your student Open sound file View and Edit Highlight your target word and zoom in (ctrl ‘n’) Press tab to play (repeat as many times as needed) Measure voice onset time to look at voicing errors Record sample at beginning of therapy and then monitor change throughout (look for emergence of covert contrasts to see if you are on the right track!)
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Factors to consider during treatment planning
Treatment
Does the goal increase the functionality of the child’s communication in important contexts? * Does it expand speaker/listener strategies? * Does it extend modes of communication?
Does it increase child’s intelligibility? * By increasing consistency and focusing on core vocab?
Does it diminish unexpected errors that decrease intelligibility and attract negative attention? * By targeting articulatory and prosodic errors
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Broad Effects of CAS and other SSDs
(WHO ICF; Murray &
Possible Targets for Treatment
Iuzzini-Seigel, 2017)
Language/Cognition Oral Language • Receptive and expressive language • Semantics, syntax, morphology, pragmatics
* Body functions and structure = Breakdown in speech production and reduced intelligibility
* Activity = Reduced communicative competence * Participation = Lack of peer acceptance, reduced
Speech Production Phonology
Functional Outcomes Increase intelligibility
Increased consistency
Increase peer acceptance and decrease bullying
Increased accuracy
Written language Phonemic expansion • Phonological awareness • Reading/writing/ Prosody spelling
access to curriculum
Increase language comprehension
Increase expressive language organization and comprehensibility Increase literacy and writing abilities
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Eliciting speech-like vocalizations
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Principles of motor learning (Maas et al., 2008)
* Provide access to AAC (e.g., device, low-tech, signing)
* Motor Performance
* Will promote language learning and vocalization can still be encouraged
* Minimize pressure to speak
* Accuracy of a motor behavior during acquisition (e.g.,
* Avoid direct requests for imitation, model and encourage turn-taking
during therapy)
instead
* Gloss the child’s productions to show you understand and
* Motor Learning
achieve clarity
* Retention or generalization of learned behavior * Relatively permanent changes
* Increase auditory, visual, tactile and proprioceptive feedback * Use exaggerated intonation and slowed tempo to enlist right hemisphere (Kouri & Winn, 2006)
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Practice
Distributed vs. Massed Practice
Practice
* Distributed practice – Four 15 minute sessions * Massed – One 60 minute session
Practice makes permanent! Ideally we would aim for: 1. A high number of trials per session (100+) 2. At least 2-3 sessions/week (up to 60 minute sessions) 3. Use of home practice if family is able
* Opportunities to forget and then recall information will help to promote learning
* Sleep also improves learning
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Practice (Edeal & Gildersleeve-Neumann, 2011; Skelton, 2014; Wong, 2013)
Feedback * Feedback Type: * Knowledge of Performance (i.e., specific feedback about trials) and high frequency
* Blocked practice should result in better acquisition/performance
feedback helps acquisition
* Knowledge of Results (i.e., summative feedback about several trials) and less frequent
* (e.g., working on skill A for 15 trials before moving to Skill B) * Random practice should result in better learning and generalization * (e.g., the order of stimuli are mixed up throughout the session)
feedback helps learning and generalization
* KP = “That sounded like an /th/ rather than an /s/. I saw your tongue sticking out that time. Let’s try again with your tongue back behind your teeth.”
* KR = “Two of those were right” or “Great job!”
* Start with blocked and then progress to random practice
Variability of Stimuli *
*
Practice Variability * Constant practice (same target in same context) may improve motor performance * Variable practice (different target in different contexts) may improve learning Clinically? * When beginning work on a sound target, syllable shape, phrase, stress pattern, etc., use a small stimulus set for high performance. * one sound in one syllable position (e.g., /s+V/ in “see, say”) * For motor learning/retention, increase stimulus set size, target multiple sounds in multiple positions in multiple words (e.g., initial and final /s, z/) * Vary rate, intonation, loudness to provide different contexts
Ways to select targets
* Sounds * Words * Syllable shapes * Stress patterns * Utterances or sentences * Can embed words with specific phonemes or syllable
Complexity * Training of more complex targets will facilitate learning of less complex behaviors without needing to train them directly * Phonological (Dinnsen, Chin, & Elbert, 1992; Gierut, 2001, 2005) * (e.g. Treatment of an unknown target will promote learning to known and unknown targets) ✳
Treatment of an affricate will imply learning of fricatives-> treatment of fricatives will imply learning of stops
* Motor * Training of a complex motor movements (e.g., production of an affricate or fricative) will generalize to less complex movements (e.g., production of a stop)
Selecting sounds (Shriberg & Kwiatkowski, 1994)
* Early: /p, b, m, n, d, w, j, h/ * Middle /t, k, g, f, v, ʧ, ʤ, ŋ/ * Late /r, l, s, z, ʃ, ʒ, θ, ð/
shapes etc. * Can alter prosody to alter meaning, or change from statement to question * (e.g., Sally went to the store, Sally went to the store?)
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Target selection: syllable shapes Syllable Shape
Examples
CV C1VC1V VC C1VC1 C1VC2 C1VC2V CCV
Do, me, go Mommy, baby Up, on Mom, dad Mop, cat, hop Money, happy Snow, ski, blow
Target selection: prosodic pattern
* Vary words based on stress patterns (Ballard et al., 2010) * * * *
STRONG-weak Teddy, candy, Monday, Lego weak-STRONG Balloon, remote Weak-STRONG-weak Potato, banana, piano STRONG-weak-weak Domino, telephone, hamburger
* Embed these words into sentences with varying prosody
Stimulability
Stimulability training
* Historically used to supplement articulation testing (Travis, 1931; Milisen, 1954)
* More recently used as the basis of treatment protocols (Miccio & Elbert, 1996; Powell & Miccio, 1996)
* Targets are trained using sound production paired with gestures
* Stimulable sounds are likely to emerge without direct intervention (Powell, Elbert, & Dinnsen, 1991) 2/20/2018
Perception training
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Original Core Vocabulary Treatment
* If child is not stimulable, perceptual training may facilitate
* Increased consistency in children with inconsistent speech
* You can provide computer-based training where the child has to
* No phonemic inventory expansion * Highly functional words are selected by family, client, and
stimulability and accurate production (Rvachew et al., 1999)
determine whether they heard the correct sound or not by pointing to a picture of the target word (e.g., a sheep) or a picture of an “X”
* You can provide the child with numerous exemplars of a target
produced by all different talkers, to broaden and strengthen their perception of a phoneme
disorder or CAS (Crosbie, Holm, & Dodd, 2005) teacher
* Goal is child’s best, but not necessarily error-free, production * Participants may require phonological treatment afterwards (Dodd & Bradford, 2000)
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Modified Core vocab + Stimulability treatment (Iuzzini & Forrest, 2010)
Results: Change to accuracy
▪ Stimulability targets presented in C or CV context for 5-10
80
minutes at the start of each session ▪
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Each stimulability target was presented with an associated gesture 60
▪ ▪
▪
Percent Consonants Correct (%)
▪ Modified Core Vocabulary Treatment One or two complex phonological target(s) are selected for each subject based on pre-treatment inventory Parents generate a list of 30 words that included the treatment sound(s) in any word position and then 5-10 are treated at a time New stimuli were introduced once the child achieved criterion (18/20 correct) on existing treatment words
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40
Pre-treatment Post-treatment
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20
▪ Can also develop core sentences which will target accuracy and
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prosody
0 P1
Integral Stimulation/Dynamic Temporal & Tactile Cueing (Strand & Debertine, 2000; Strand et al., 2006)
P2
P3 Participants
P4
Average
Structure of DTTC (Strand & Skinder, 1999)
* Emphasize sequences of sounds, a word or phrase,
Direct Imitation
not just a single sound * “Listen to me, watch me, do what I do“ * Increase complexity:
Correct Continue with Direct Imitation and Gradually Increase Rate
Incorrect Simultaneous Production
• Start with simple syllables (ma, ba, da), progress to harder words Incorrect Slow rate and add tactile cues
(mom, bob, dad, hi), then progress to phrases (e.g., “hi mom”)
Correct Continue until no artic errors, normal rate and prosody
Incorrect Add mime or go back to direct imitation
* Within one level of complexity, fade cues (max → min) • Direct imitation, delayed imitation, visual cue • Vary prosody
After many trials with no effort, go back to direct imitation
Correct Continue varying rate and prosody until no artic errors, normal rate and prosody
Add delay. If correct, add longer delay up to 3 sec.
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Integral Stimulation/DTTC
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Integral Stimulation/DTTC
Verbal/Tactile cues
*
https://www.youtube.com/watch?v=sq7vFWLqodM (start at 2:46)
Simultaneous productions Mime
Vary Rate & Prosody
Direct imitation Delayed Imitation
Elicited Production
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Integrated Phonological Awareness Approach
(Lewis et
Phonological Awareness Intervention
al., 2004; Moriarty et al., 2006; Stackhouse & Snowling, 1992)
* Three areas are targeted simultaneously
(Moriarty et al. 2006)
* Three 45 minute sessions/week for 3 weeks * Activities include
* Phonological awareness * Grapheme to phoneme correspondence (word attack
* * * *
skills) * Speech sound production
* Aims to increase phonological processing and
Identification of phonemes in isolation Identification of initial and final phonemes in words Phoneme segmentation and phoneme blending Phoneme manipulation with letter (grapheme) blocks
* During these games, colored blocks that represent individual phonemes/graphemes are used
phonological awareness
* If sound production error occurs, blocks are used to identify the error and prompt correction
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Rapid Syllable Transition Treatment (ReST) (Ballard et al., 2010; McCabe et al., 2010)
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ReST Treatment (McCabe et al., 2017)
* Grounded in theory of motor control and learning * Intensive practice of multisyllabic nonwords (e.g., toobiger) to *
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http://sydney.edu.au/health-sciences/rest/
produce increased speech sound accuracy, and improved coarticulation and prosody First, stimuli and accurate production are trained during prepractice period
* Feedback is given after every trial
* Next, accurate production is trained during the “practice period” where principles of motor learning guide feedback schedule (KR is given for 50% of trials, e.g., right/wrong) 2/20/2018
PROMPT (Prompts for Restructuring Oral Muscular Phonetic Targets, Square-Storer & Chumpelik Hayden, 1989)
* Teaching motor programming skills by imposing target positions * * * *
and sequences of movements Clinician provides physical input about place, manner of production, degree and direction of jaw and tongue movement, and segment and syllable durations Research has been limited but is now starting to emerge Has been used in various clinical populations including children and adults with apraxia, children with autism https://www.youtube.com/watch?v=NaS9MeDU0CE
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Biofeedback treatment
The process of becoming aware of physiological functions using instruments that provide information about the physiology, with a goal of being able to manipulate them at will Provides “Knowledge of Performance” In speech therapy, biofeedback may include:
Mirrors, webcams Decibel meter Electropalatography Spectrograms Ultrasound
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Ultrasound biofeedback (Preston et al., 2013, 2014)
Spectrograms
* Ultrasound uses high frequency sound waves to
* Can be used to promote . . . * * * * *
generate an image * It does not use radiation and is considered safe * The device is USB powered and plugs into a PC (laptop can be used) * It can be used in the context of motor learning therapy to promote increased accuracy and precision of articulatory targets * 200 trials per session * http://www.haskins.yale.edu/uvf/
Nonspeech oral motor exercises
Oral motor exercises have not been shown to benefit speech in children with speech sound disorders (Forrest & Iuzzini, 2008)
* If you want to improve speech, work on speech * Training a “part” of a movement does not carryover
* Nonspeech Oral Motor Exercises: Any technique that does not
*
*
require the child to produce a speech sound but is used to influence the development of speaking abilities Examples * Horns, Straws, Lollipops, Gum, Tongue Pops
to the whole
* Speech requires coordination of multiple subsystems (phonatory, respiratory, articulatory)
* By spending time training nonspeech oral motor
Proposed Purposes: * Improve oral motor strength * Improve oral motor coordination * Improve speech
Other considerations
loudness prosody voiced-voiceless differentiation articulation sound differentiation
exercises, you are taking time away from training actual speech production * Limited time window for maximal gains– how will you maximize the child’s potential and gains?
CASE STUDIES Form groups of 3-4 people.
* How might CAS impact the family? * How would comorbid deficits impact the child and family? * Emotional strain * Time and financial strain
Work together to create an assessment and treatment plan
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Case study 2:
* * * * * * * *
Case study 3: * Child is 6 years old, with a history of otitis media and mildly
Age = 5;2 (years; months) How many CAS features do you hear? GFTA SS =
Communication, Movement and Learning Lab
Assessment and Treatment of Childhood Apraxia of Speech Jenya Iuzzini-Seigel, PhD, CCC-SLP Marquette University Communication, Movement and Learning Lab
2/20/2018
3
Learner Outcomes
* List characteristics associated with CAS, which can support differential diagnosis
* Describe and apply principles of motor learning that
Background on CAS
can aid in treatment planning for CAS
* Describe and apply evidence based interventions for CAS
* Create treatment plans for children with CAS with and without comorbidities 2/20/2018
APRAXIA
5
What is childhood apraxia of speech (CAS)?
* Praxis is Greek for doing an action * Apraxia is an inability to perform the action
“Neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes or tone)” (ASHA, 2007)
* May affect oral and/or limb movements as well as speech
2/20/2018
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Prevalence of CAS
Differential diagnosis of CAS * No overt physical markers of CAS and although there are
• •
genetic (Centanni et al., 2015; Fisher et al., 1998; Laffin et al., 2012) markers associated with CAS, these are not yet diagnostic * Published tests tend to lack psychometric properties that allow for confident and replicable differential diagnosis alone (McCauley & Strand, 2008) * Much of the published literature lacks operationally defined diagnostic criteria that can be applied clinically
Affects 1-2 children per 1,000 (Shriberg et al., 1997) Higher prevalence in males than females, affecting 2-3 males: 1 female (Hall et al., 1993; Lewis et al., 2004)
2/20/2018
Underlying causes of CAS
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What is the underlying mechanism?
• Idiopathic - No known cause • Syndromic - Result of known neurobiological disorder of genetic or metabolic origin (e.g., galactosemia, velocardiofacial syndrome) • Acquired - Due to intrauterine stroke, birth trauma, infection etc.
* May be due to decreased sensitivity of tongue and palate, or increased neural noise (Terband & Maassen, 2010) * May be due to a difficulty establishing robust motor programs that contain articulatory motor commands for speech sound targets • Could be due to a difficulty learning implicit patterns that affects speech, motor, language, and reading (Cabbage, Iuzzini-Seigel et al., 2018; Iuzzini-Seigel et al., 2017)
2/20/2018
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What features characterize CAS? •
Why don’t we have a validated list of features?
Validated list of features does not exist
•
Rare and heterogeneous population!
•
Circularity between experimental variables and those used for group assignment
•
Broad age range included in studies
•
Different diagnostic criteria used across studies
(ASHA, 2007)
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ASHA Features of CAS (Technical Report, 2007)
What do you consider important features of CAS?
• Inconsistent speech errors (how much, how should they be measured?) • Lengthened and disrupted coarticulatory transitions between sounds and syllables • Inappropriate prosody, especially in realization of lexical or phrasal stress
2/20/2018
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CAS Features Explained
CAS Features (adapted from Shriberg, Potter, & Strand, 2011) * * * * * * * * * * *
Vowel Error Consonant distortions Voicing errors Equal or excess stress Syllable segregation Difficulty achieving initial articulatory configurations or transitionary movement gestures Intrusive schwa Slow rate Increased difficulty with multisyllabic words Disturbed resonance Groping 2/20/2018
Operational definitions (Iuzzini-Seigel, Hogan & Green, 2017) •
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Operational definitions
Vowel Error: A vowel production error in which the vowel is substituted for another phoneme OR in which the vowel is recognizable as a specific phoneme but it is not produced exactly correctly (e.g., not a prototypical production, may sound like it’s in between two vowels). It is not
•
Stress errors: An error in which the appropriate stress is not produced correctly. For example: conDUCT vs. CONduct have different stress patterns. It is considered an error if the stress is inappropriately equalized across syllables, or on the wrong syllable.
•
Syllable segregation: Brief or lengthy pause between syllables which is not appropriate.
•
Difficulty achieving initial articulatory configurations or transitionary movement gestures: Initiation of utterance or initial speech sound may be difficult for child to produce and may sound lengthened or uncoordinated. Also, child may evidence lengthened or disrupted coarticulatory gestures or movement transitions from one sound to the next.
considered an error if the vowel is substituted with another phoneme that is consistent with an adult-like model (e.g., /hɑt dag/ /hɑt dɔg/)
•
•
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Consonant Distortion: A consonant production error in which a speech sound is recognizable as a specific phoneme but it is not produced exactly correctly (e.g., an /s/ that is produced with lateralization or dentalization).
Voicing errors: A sound is produced as its voicing cognate (e.g., a /p/ that is produced as a /b/). In addition, this could also describe productions which appear to be in between voicing categories (e.g., blurring of voicing boundaries).
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Operational definitions •
Intrusive schwa (e.g., in clusters): A schwa is added in between consonants. For example, it may be inserted in between the consonants in a cluster (e.g., /blu/ becomes /bəlu/). This NOT considered a "vowel error".
•
Slow rate: Speech rate is not typical. It is slower during production of part (e.g., zzziiiiiiper/zipper) or the whole word (e.g., tooommmmaaatoooo/tomato).
•
Increased difficulty with multisyllabic words: The participant has a disproportionately increased number of errors as the number of syllables increases (as compared to words with fewer syllables).
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Operational definitions
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•
Resonance or nasality disturbance: Sounds either hyponasal: not enough airflow out of nose/"stuffy" OR hypernasal: too much airflow out of nose for non-nasal phonemes (e.g., plosives).
•
Groping: Prevocalic (silent) articulatory searching prior to onset of phonation, possibly in an effort to improve the accuracy of the production. You need to see the child to assess this feature.
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Listen! What do you see and hear?
What did you hear and see? 2/20/2018
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What did you see and hear? * * * * * * *
Vowel errors Voicing errors Distortions Inconsistency Slow rate Glottal stops Groping
How should I measure inconsistency? How much inconsistency is too much?
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Token-to-token inconsistency
Measuring Word Inconsistency
* Inconsistency of a word or phrase across multiple productions (e.g., Dodd et al., 2006; Iuzzini-Seigel, Hogan, & Green, 2017) * Pros: Maintains context, quick to score (i.e., same or different) * Cons: Does not quantify intra-item inconsistency, may mask severity or improvement, does not inform phonemic treatment targets, may require additional phonemic analysis
*
Cons: Does not quantify intra-item inconsistency, may mask severity or improvement, does not inform phonemic treatment targets, may require additional phonemic analysis
* Example: ✳
“elephant”
*
/ɛpədɑn/, /ɛdæn/, /ʌpfæn/
•
Measuring Phrasal Inconsistency in school-aged children ( Iuzzini-Seigel et al, 2017)
2.
If child scores higher than 40%, their test should be rescored without items that are inconsistent due to alternations between accurate productions and developmentally appropriate errors (e.g., gliding in a 4 y.o.)
Inconsistency is task dependent!
Have child say “Buy Bobby a Puppy” five times
Token-to-token inconsistency (%)
1.
DEAP contains 25 single syllable and multisyllabic items that are repeated 3x each Items are scored as “same” or “different” If more than 40% of items are “different,” child is considered inconsistent
* •
Compare trials
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CAS
SD
(Iuzzini-S eigel, Hogan, & G reen, 2 0 1 7 )
TD
60 50
40 30 20 10 0
3.
Monosyllabic RW
If child produced any inconsistencies across trials, they are considered inconsistent.
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Multisyllabic RW
Phrase level
Task
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How much inconsistency is too much? Token-to-token inconsistency * ≥ 40% on DEAP * ≥ 0% on 5 reps of “Buy bobby a puppy”
How do I pick an assessment task?
* Ensure that task is challenging for children with CAS but simple for children with speech delay or phonological disorder ✳
For school-aged children, 5 repetitions of “Buy Bobby a puppy” is effective
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Do children need to evidence all features to warrant a diagnosis of CAS? •
How often and in how many contexts should a child demonstrate these features to warrant a CAS diagnosis?
Why or why not?
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1.
Many articles suggest that speech should be assessed in three contexts
2.
In a school-aged child at least 4 or more features should be evidenced in each context to warrant a diagnosis of CAS
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Differential diagnosis
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Differential diagnosis
• Speech battery and speech sample (Dodd et al., 2006; Iuzzini-Seigel,
GFTA Standard Score
Hogan & Green, 2017; Strand et al., 2013),
• Assess articulatory and prosodic accuracy, inconsistency, types of
• • • •
errors, other features
≥ 85 WNL
Oral mechanism assessment Language and literacy testing Family history Does child have any other suspected deficits?
NON-CAS SSD WIS < 40% BBP = 0% Consistent Few CAS features
• Fine or gross motor issues? • Psychosocial issues?
Structural-functional motor speech exam
< 85 NWNL
CAS WIS ≥ 40-50% BBP > 0% Inconsistent Several CAS features
Other co-occurring considerations
* Range of motion * Can tongue elevate to alveolar ridge, protrude between teeth?
* Speed * Does tongue move with rapidity needed for speech? * Strength * Does child have adequate tongue strength and lip seal? * Muscular tension * Can child vary tension and relaxation of muscles * Coordination * Can child alternate oral movements and rapid alternating oral
•
Oral-motor apraxia and/or dysarthria
•
Comorbid language disorder (Lewis et al., 2004; Zuk, Iuzzini-Seigel et al., 2018)
•
Comorbid fine and gross motor disorders (Gretz, 2013)
•
Comorbid reading disorder (Lewis et al., 2004; Cabbage, Iuzzini-Seigel, et al., 2018)
•
Delayed babbling (Highman et al., 2008)
•
Speech perception deficits, when language impairment is also present (Zuk, Iuzzini-Seigel, Cabbage, Green, & Hogan, 2018)
movements 2/20/2018
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In pairs, differentially diagnose child and determine factors you will consider in treatment planning. Case 1, male Age = 56 months Normal receptive language (SS = 96) and IQ (SS = 105) Low expressive language (SS = 63) Poor fine and gross abilities based on standardized testing
Using Praat freeware to listen and look
* Praat is free acoustical software * Can be used to record and playback audio * Can be used to facilitate transcription of challenging speech samples
Multisyllabic words
* Can be used to analyze speech and voice recordings (frequency, voice onset time among voice measures)
Language sample Goldman Fristoe Test of Articulation-3
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Praat Instructions * * * * * * * * *
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Download Praat Open Praat (run) Record new sound file of your student Open sound file View and Edit Highlight your target word and zoom in (ctrl ‘n’) Press tab to play (repeat as many times as needed) Measure voice onset time to look at voicing errors Record sample at beginning of therapy and then monitor change throughout (look for emergence of covert contrasts to see if you are on the right track!)
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Factors to consider during treatment planning
Treatment
Does the goal increase the functionality of the child’s communication in important contexts? * Does it expand speaker/listener strategies? * Does it extend modes of communication?
Does it increase child’s intelligibility? * By increasing consistency and focusing on core vocab?
Does it diminish unexpected errors that decrease intelligibility and attract negative attention? * By targeting articulatory and prosodic errors
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Broad Effects of CAS and other SSDs
(WHO ICF; Murray &
Possible Targets for Treatment
Iuzzini-Seigel, 2017)
Language/Cognition Oral Language • Receptive and expressive language • Semantics, syntax, morphology, pragmatics
* Body functions and structure = Breakdown in speech production and reduced intelligibility
* Activity = Reduced communicative competence * Participation = Lack of peer acceptance, reduced
Speech Production Phonology
Functional Outcomes Increase intelligibility
Increased consistency
Increase peer acceptance and decrease bullying
Increased accuracy
Written language Phonemic expansion • Phonological awareness • Reading/writing/ Prosody spelling
access to curriculum
Increase language comprehension
Increase expressive language organization and comprehensibility Increase literacy and writing abilities
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Eliciting speech-like vocalizations
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Principles of motor learning (Maas et al., 2008)
* Provide access to AAC (e.g., device, low-tech, signing)
* Motor Performance
* Will promote language learning and vocalization can still be encouraged
* Minimize pressure to speak
* Accuracy of a motor behavior during acquisition (e.g.,
* Avoid direct requests for imitation, model and encourage turn-taking
during therapy)
instead
* Gloss the child’s productions to show you understand and
* Motor Learning
achieve clarity
* Retention or generalization of learned behavior * Relatively permanent changes
* Increase auditory, visual, tactile and proprioceptive feedback * Use exaggerated intonation and slowed tempo to enlist right hemisphere (Kouri & Winn, 2006)
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Practice
Distributed vs. Massed Practice
Practice
* Distributed practice – Four 15 minute sessions * Massed – One 60 minute session
Practice makes permanent! Ideally we would aim for: 1. A high number of trials per session (100+) 2. At least 2-3 sessions/week (up to 60 minute sessions) 3. Use of home practice if family is able
* Opportunities to forget and then recall information will help to promote learning
* Sleep also improves learning
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Practice (Edeal & Gildersleeve-Neumann, 2011; Skelton, 2014; Wong, 2013)
Feedback * Feedback Type: * Knowledge of Performance (i.e., specific feedback about trials) and high frequency
* Blocked practice should result in better acquisition/performance
feedback helps acquisition
* Knowledge of Results (i.e., summative feedback about several trials) and less frequent
* (e.g., working on skill A for 15 trials before moving to Skill B) * Random practice should result in better learning and generalization * (e.g., the order of stimuli are mixed up throughout the session)
feedback helps learning and generalization
* KP = “That sounded like an /th/ rather than an /s/. I saw your tongue sticking out that time. Let’s try again with your tongue back behind your teeth.”
* KR = “Two of those were right” or “Great job!”
* Start with blocked and then progress to random practice
Variability of Stimuli *
*
Practice Variability * Constant practice (same target in same context) may improve motor performance * Variable practice (different target in different contexts) may improve learning Clinically? * When beginning work on a sound target, syllable shape, phrase, stress pattern, etc., use a small stimulus set for high performance. * one sound in one syllable position (e.g., /s+V/ in “see, say”) * For motor learning/retention, increase stimulus set size, target multiple sounds in multiple positions in multiple words (e.g., initial and final /s, z/) * Vary rate, intonation, loudness to provide different contexts
Ways to select targets
* Sounds * Words * Syllable shapes * Stress patterns * Utterances or sentences * Can embed words with specific phonemes or syllable
Complexity * Training of more complex targets will facilitate learning of less complex behaviors without needing to train them directly * Phonological (Dinnsen, Chin, & Elbert, 1992; Gierut, 2001, 2005) * (e.g. Treatment of an unknown target will promote learning to known and unknown targets) ✳
Treatment of an affricate will imply learning of fricatives-> treatment of fricatives will imply learning of stops
* Motor * Training of a complex motor movements (e.g., production of an affricate or fricative) will generalize to less complex movements (e.g., production of a stop)
Selecting sounds (Shriberg & Kwiatkowski, 1994)
* Early: /p, b, m, n, d, w, j, h/ * Middle /t, k, g, f, v, ʧ, ʤ, ŋ/ * Late /r, l, s, z, ʃ, ʒ, θ, ð/
shapes etc. * Can alter prosody to alter meaning, or change from statement to question * (e.g., Sally went to the store, Sally went to the store?)
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Target selection: syllable shapes Syllable Shape
Examples
CV C1VC1V VC C1VC1 C1VC2 C1VC2V CCV
Do, me, go Mommy, baby Up, on Mom, dad Mop, cat, hop Money, happy Snow, ski, blow
Target selection: prosodic pattern
* Vary words based on stress patterns (Ballard et al., 2010) * * * *
STRONG-weak Teddy, candy, Monday, Lego weak-STRONG Balloon, remote Weak-STRONG-weak Potato, banana, piano STRONG-weak-weak Domino, telephone, hamburger
* Embed these words into sentences with varying prosody
Stimulability
Stimulability training
* Historically used to supplement articulation testing (Travis, 1931; Milisen, 1954)
* More recently used as the basis of treatment protocols (Miccio & Elbert, 1996; Powell & Miccio, 1996)
* Targets are trained using sound production paired with gestures
* Stimulable sounds are likely to emerge without direct intervention (Powell, Elbert, & Dinnsen, 1991) 2/20/2018
Perception training
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Original Core Vocabulary Treatment
* If child is not stimulable, perceptual training may facilitate
* Increased consistency in children with inconsistent speech
* You can provide computer-based training where the child has to
* No phonemic inventory expansion * Highly functional words are selected by family, client, and
stimulability and accurate production (Rvachew et al., 1999)
determine whether they heard the correct sound or not by pointing to a picture of the target word (e.g., a sheep) or a picture of an “X”
* You can provide the child with numerous exemplars of a target
produced by all different talkers, to broaden and strengthen their perception of a phoneme
disorder or CAS (Crosbie, Holm, & Dodd, 2005) teacher
* Goal is child’s best, but not necessarily error-free, production * Participants may require phonological treatment afterwards (Dodd & Bradford, 2000)
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Modified Core vocab + Stimulability treatment (Iuzzini & Forrest, 2010)
Results: Change to accuracy
▪ Stimulability targets presented in C or CV context for 5-10
80
minutes at the start of each session ▪
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Each stimulability target was presented with an associated gesture 60
▪ ▪
▪
Percent Consonants Correct (%)
▪ Modified Core Vocabulary Treatment One or two complex phonological target(s) are selected for each subject based on pre-treatment inventory Parents generate a list of 30 words that included the treatment sound(s) in any word position and then 5-10 are treated at a time New stimuli were introduced once the child achieved criterion (18/20 correct) on existing treatment words
50
40
Pre-treatment Post-treatment
30
20
▪ Can also develop core sentences which will target accuracy and
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prosody
0 P1
Integral Stimulation/Dynamic Temporal & Tactile Cueing (Strand & Debertine, 2000; Strand et al., 2006)
P2
P3 Participants
P4
Average
Structure of DTTC (Strand & Skinder, 1999)
* Emphasize sequences of sounds, a word or phrase,
Direct Imitation
not just a single sound * “Listen to me, watch me, do what I do“ * Increase complexity:
Correct Continue with Direct Imitation and Gradually Increase Rate
Incorrect Simultaneous Production
• Start with simple syllables (ma, ba, da), progress to harder words Incorrect Slow rate and add tactile cues
(mom, bob, dad, hi), then progress to phrases (e.g., “hi mom”)
Correct Continue until no artic errors, normal rate and prosody
Incorrect Add mime or go back to direct imitation
* Within one level of complexity, fade cues (max → min) • Direct imitation, delayed imitation, visual cue • Vary prosody
After many trials with no effort, go back to direct imitation
Correct Continue varying rate and prosody until no artic errors, normal rate and prosody
Add delay. If correct, add longer delay up to 3 sec.
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Integral Stimulation/DTTC
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Integral Stimulation/DTTC
Verbal/Tactile cues
*
https://www.youtube.com/watch?v=sq7vFWLqodM (start at 2:46)
Simultaneous productions Mime
Vary Rate & Prosody
Direct imitation Delayed Imitation
Elicited Production
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Integrated Phonological Awareness Approach
(Lewis et
Phonological Awareness Intervention
al., 2004; Moriarty et al., 2006; Stackhouse & Snowling, 1992)
* Three areas are targeted simultaneously
(Moriarty et al. 2006)
* Three 45 minute sessions/week for 3 weeks * Activities include
* Phonological awareness * Grapheme to phoneme correspondence (word attack
* * * *
skills) * Speech sound production
* Aims to increase phonological processing and
Identification of phonemes in isolation Identification of initial and final phonemes in words Phoneme segmentation and phoneme blending Phoneme manipulation with letter (grapheme) blocks
* During these games, colored blocks that represent individual phonemes/graphemes are used
phonological awareness
* If sound production error occurs, blocks are used to identify the error and prompt correction
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Rapid Syllable Transition Treatment (ReST) (Ballard et al., 2010; McCabe et al., 2010)
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ReST Treatment (McCabe et al., 2017)
* Grounded in theory of motor control and learning * Intensive practice of multisyllabic nonwords (e.g., toobiger) to *
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http://sydney.edu.au/health-sciences/rest/
produce increased speech sound accuracy, and improved coarticulation and prosody First, stimuli and accurate production are trained during prepractice period
* Feedback is given after every trial
* Next, accurate production is trained during the “practice period” where principles of motor learning guide feedback schedule (KR is given for 50% of trials, e.g., right/wrong) 2/20/2018
PROMPT (Prompts for Restructuring Oral Muscular Phonetic Targets, Square-Storer & Chumpelik Hayden, 1989)
* Teaching motor programming skills by imposing target positions * * * *
and sequences of movements Clinician provides physical input about place, manner of production, degree and direction of jaw and tongue movement, and segment and syllable durations Research has been limited but is now starting to emerge Has been used in various clinical populations including children and adults with apraxia, children with autism https://www.youtube.com/watch?v=NaS9MeDU0CE
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Biofeedback treatment
The process of becoming aware of physiological functions using instruments that provide information about the physiology, with a goal of being able to manipulate them at will Provides “Knowledge of Performance” In speech therapy, biofeedback may include:
Mirrors, webcams Decibel meter Electropalatography Spectrograms Ultrasound
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Ultrasound biofeedback (Preston et al., 2013, 2014)
Spectrograms
* Ultrasound uses high frequency sound waves to
* Can be used to promote . . . * * * * *
generate an image * It does not use radiation and is considered safe * The device is USB powered and plugs into a PC (laptop can be used) * It can be used in the context of motor learning therapy to promote increased accuracy and precision of articulatory targets * 200 trials per session * http://www.haskins.yale.edu/uvf/
Nonspeech oral motor exercises
Oral motor exercises have not been shown to benefit speech in children with speech sound disorders (Forrest & Iuzzini, 2008)
* If you want to improve speech, work on speech * Training a “part” of a movement does not carryover
* Nonspeech Oral Motor Exercises: Any technique that does not
*
*
require the child to produce a speech sound but is used to influence the development of speaking abilities Examples * Horns, Straws, Lollipops, Gum, Tongue Pops
to the whole
* Speech requires coordination of multiple subsystems (phonatory, respiratory, articulatory)
* By spending time training nonspeech oral motor
Proposed Purposes: * Improve oral motor strength * Improve oral motor coordination * Improve speech
Other considerations
loudness prosody voiced-voiceless differentiation articulation sound differentiation
exercises, you are taking time away from training actual speech production * Limited time window for maximal gains– how will you maximize the child’s potential and gains?
CASE STUDIES Form groups of 3-4 people.
* How might CAS impact the family? * How would comorbid deficits impact the child and family? * Emotional strain * Time and financial strain
Work together to create an assessment and treatment plan
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Case study 2:
* * * * * * * *
Case study 3: * Child is 6 years old, with a history of otitis media and mildly
Age = 5;2 (years; months) How many CAS features do you hear? GFTA SS =
