Childhood Apraxia of Speech Treatment

CHILDHOOD APRAXIA OF SPEECH
FOCUS ON TREATMENT

ISHA ANNUAL CONFERENCE
February 13, 2009

Presented by:
Margaret Fish, M.S., CCC‐SLP

DEFINITION OF CAS

“… a neurological childhood (pediatric) 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,
abnormal tone). CAS may occur as a result of known neurological impairment, in association with complex
neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The
core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in
errors in speech sound production and prosody.”

ASHA Ad Hoc Committee on Apraxia of Speech in Children

CHARACTERISTICS HAVING GREATEST PROMISE FOR
SENSITIVITY AND SPECIFICITY FOR IDENTIFICATION OF CAS

Sensitivity – Characteristic is observed in most kids with CAS
Specificity – Characteristic is not observed in most kids without CAS

Inconsistent errors in production of consonants and vowels with repeated productions of syllables and
words;
Lengthened and disrupted coarticulatory transitions between sounds and syllables;
Inappropriate prosody, especially in the realization of lexical or phrasal stress.
ASHA Ad Hoc Committee on Apraxia of Speech in Children

ADDITIONAL CHARACTERISTICS OF CAS

 Presence of vowel distortions
 Limited consonant and vowel repertoire
 Use of simple syllable shapes
 Greater difficulty as word length or phrase length increase
 Connected speech more unintelligible than single‐word articulation test might suggest
 Poor diadochokinesis
 Limited production of complex word shapes
 Slow development of Speech‐Language Pathology Services limited speech intelligibility
 Limited babbling during infancy
 Groping, struggling to speak
 Possible soft palate involvement
 Receptive language (typically) exceeds receptive language
 Regression or loss of sounds or words

EVALUATION

ESSENTIAL ELEMENTS OF A MOTOR SPEECH EXAM
 Produce words imitatively and spontaneously
 Produce words with increasingly complex syllable shapes
 Repeat test items more than once
 Execute non‐vocal oral movement
 Produce phrases and sentences
 Produce challenging words with the benefit of cueing (visual/auditory/tactile/proprioceptive)
Note the following:
 Weakly produced phonemes
 Groping
 Resonance differences
 Prosody differences (intonation, stress)
 Rate and volume
FORMAL ASSESSMENT INSTRUMENTS
KSPT ‐ Kaufman Speech Praxis Test for Children (Kaufman)
VMPAC – Verbal Motor Production Assessment for Children (Hayden and Square)

2009 ISHA Annual Conference, February 1215, 2009
Childhood Apraxia of Speech: Focus on Treatment, Margaret Fish, M.S., CCC‐SLP . . . . . 2
TREATMENT FOR
CHILDHOOD APRAXIA OF SPEECH
TREATMENT CONSIDERATIONS

Principles of Motor Learning
 Shorter, More Frequent Sessions

 Focus on Phoneme Sequencing – Not Just Sounds

 Encourage Repeated Practice to Build Muscle Memory

 Provide Optimal Reinforcement

Other Treatment Considerations
 Facilitate Speech Praxis Using Multimodal Cues
 Focus on Vowels
 Facilitate Word Approximation as Necessary
 Move Quickly to Phrases and Sentences
 Choose Vocabulary Carefully
 Enhance Motivation
 Address Speech Prosody
 Consider Purpose of Oral Motor Activities
 Consider Relative Contribution of Motor Speech
 Address Current and “Future” Literacy Needs
1. NUMBER OF SESSIONS PER WEEK AND LENGTH OF SESSIONS
Motor Learning Research indicates:
• Motor skills are acquired more quickly (in terms of total hours spent within practice sessions) when
shorter, frequent sessions are used.
• Motor skill accuracy is better when shorter, frequent practice sessions are implemented.
• Retention of motor skills is higher for individuals receiving shorter, frequent practice sessions.
Therefore…
When possible, incorporate a treatment schedule of shorter, frequent sessions for kids with CAS.
Ex: Rather than 2, 45 min. sessions/week, schedule 3 or 4‐ 30 minute sessions
2. FOCUS ON PHONEME SEQUENCING, NOT JUST SOUNDS
Whole practice is more effective for teaching movement patterns when the component parts of the movement
are highly related
Parts practice is more effective in teaching a movement pattern in which the component parts are less related
Therefore…
•Since speech movements are highly related to one another and phoneme production is highly dependent on the
phonemes surrounding it (due to coarticulation), whole practice is preferable to parts practice.
Suggestions:
•Begin at least at the syllable level (CV or VC);
•Move to phrase level as quickly as possible;
•Make the words meaningful;
•If CV or VC is too challenging try:
‐ adjusting the temporal aspects of the word
‐ adding multimodal cues
‐ using isolated phonemes that denote meaning – many of which are fun, silly or emotionally charged.
PHONEME SEQUENCE HIERARCHY

 C (m, s, z, sh, ch)**

 CV (boy, hi, no, go, moo)
 VC (up, on, in, off, out, ape)
 CV‐CV with reduplication (mama, baba, wawa, moo‐moo, boo‐boo)
 CV‐CV with same C but varied V (mommy, daddy, puppy, cookie, turtle)
 CV‐CV with varied C and V (bunny, dino, potty, hippo, table)
 CVC with assimilation (pop, pup, mom, cake, mop, five)
 CVC without assimilation (cup, pin, bake, fish)
 CV‐CV‐CV (banana, tomato, potato, bicycle)
 CV‐CVC (button, chicken, magic, finish)
 CVC‐CVC (popcorn, cupcake, basket, picnic, football)
 Blends (spoon, jump, splash, jumps)
 Multisyllables (motorcycle, alligator, refrigerator, Cinderella, hippopotamus)
3. ENCOURAGE REPETITION TO BUILD MUSCLE MEMORY
Mass practice (practicing fewer things many times) leads to better accuracy during initial
learning of motor skill BUT inhibits carryover
Distributed practice (practicing numerous things fewer times) leads to better
carryover/habituation BUT increases time to develop a new skill
Therefore …
•When teaching new movement patterns, mass practice is recommended
•When trying to habituate skills, distributed practice is recommended
Materials and Activities to Promote Repeated Practice
•Echo microphone •Colored blocks
•Puzzles •Large blocks
•Sound puzzles •Markers/crayons/paper
•String beads/pop beads •Dot Articulation (Super duper, Inc)
•Farm toy •Stickers/stamps
•Cash register toy •Familiar characters and accessories
•Cars, trucks and ramps •Dollhouse and family characters
•Train track and trains •Big truck, airplane
•Mr. Potato Head/Mr. Potato Head Pals •Tool toys
Games for Repetitive Practice (Purchased) – Games should be:
 Quick
 Fun
 Used either as:
o Reinforcer
o Selected vocabulary
Sample games:
Pop‐Up Pirate Barnyard Bingo
Cariboo Lucky Ducks
Crocodile Dentist Milk and Cookies
Don’t Spill the Beans Silly Faces
Silly Six Pins Colorforms
Lego Creator Memory Games
Mousetrap Lotto Games
Animal Buddies Holiday& Seasonal Gameboards for
Speech and Language (Super Duper, Inc.)

Quick and Simple Games:

Bowling/Soccer bowling Earn it now – make it later
Basketball Large number dice
Long jump Large number spinner
Picture hop Magnet chips
Animal walk Double dice roll
Treasure hunt 100
Mailman Go Fish
Block designs Memory
Tall tower Simon Says
Dominoes Letter Path
Stickers & Stamps Louder/softer/other variations
Progressive drawing Hidden puzzle pieces
4. PROVIDE OPTIMAL REINFORCEMENT

Types of Feedback:

 Extrinsic Feedback – Sensory information provided by an outside source. Motor Learning Research
indicates Extrinsic Feedback is necessary to acquire NEW skills
o Knowledge of Performance
o Knowledge of Results
 Intrinsic Feedback – Sensory information within the learner. Motor Learning Research indicates
Intrinsic Feedback is necessary for CARRYOVER of skills
o Auditory
o Proprioceptive
o Tactile

Principles of Reinforcement When Teaching a New Motor Skill

 Provide frequent feedback
 Provide immediate feedback
 Provide KNOWLEDGE OF PERFORMANCE
o Tell what was not correct about the movement
o Tell what should be done differently
 Limit the amount of information provided
 Don’t overload

Principles for Development of Intrinsic Feedback

 Fade extrinsic feedback progressively
 Begin to use intermittent reinforcement
 Move to providing KNOWLEDGE OF RESULTS
 Begin to delay feedback
5. FACILITATE SPEECH PRAXIS USING MULTIMODAL CUES

Specific Cueing Techniques (Visual, Auditory, Tactile/Proprioceptive)

 PROMPT (Prompts for Restructuring Oral Muscular Phonetic
Targets)
 DTTC – Dynamic Temporal and Tactile Cueing (Edythe Strand and
colleagues)
 Variation of rate
 Choral Speaking (simultaneous production)
 Hand motions/positions
 Tapping/clapping out phonemes and syllables
 Blocks or paper/felt squares to denote number of syllables or
words
 Written letters and words
 Sound names
 Verbal descriptions and specific feedback (knowledge of
performance)
 Mouth Pictures
 Visual – looking at self in mirror or looking at therapists face
 Pictures to denote syllables or phonemes
MULTISENSORY CUEING TECHNIQUES
Cueing Technique Visual Auditory Tactile
Dynamic Temporal and Tactile Cueing X X X
Rate Variations X
Choral Speaking/Simultaneous X X
Production
Direct Imitation (I say it; you say it) X X
Watching Clinician X X
Mime X
Mirror X
Hand Motions/Gestures X
Written Letters/Words X
Tapping/Clapping Out Syllables X X
Blocks/Paper Squares to Denote # of X
Sounds/Syllables/Words
Sound Names X
Verbal Descriptions of How to Produce X
Sounds
Pictures to Denote Separate Syllables X
Mouth Pictures X
PROMPT® X X X
Touch Cues X


**Adapted from Clinical Management of Motor Speech Disorders in Children. Caruso, A
and Strand E.

6. VOWELS
VOWEL DIAGRAM

TONGUE POSITION
Front Central Back

High Mid
MANDIBLE HEIGHT

Low
7. PROGRESSIVE APPROXIMATIONS

Sample Approximation Sequence
For the Word “Dinosaur”

• “dah no”
• “di no”
• “di no so”
• “di no saur”
Practice Approximations
8. PHRASES AND SENTENCES
Sample Carrier Phrase Corresponding Language Activity
It’s a ___________ “Feely box” – place hand inside box, feel what’s inside and tell
what it is
_________ in/on/up Animal characters going on a school bus.
TV toy characters climb up mountain.
I got a ___________ Go Fish game or Memory game – tell what you got when you
turn over a pictures
I found a _____________ I Spy – using a flashlight, find “hidden” toys
Big/little ___________ Jack‐o‐lantern picture
(color word) ___________ Potato head
I have (a) _________ Describe clothing or physical characteristics of self and other
person
You have (a) __________
I want (a) _________ Tell what piece you need to complete a sticker picture, block
structure, or craft project
I want (a) _______ _______
(number word) ________ Counting books
_________ go Animals, characters or toy people going down slide or moving in
vehicle
More ____________ Bubbles
Do you have a _________? Go Fish game
Bye‐bye ___________ Putting toys away
9. CONSIDERATIONS WHEN CHOOSING VOCABULARY
When choosing target words, take into consideration:
 Phoneme repertoire
 Syllable shapes
 Planes of movement
 Child’s interests
 Family routines
 School routines
CASE EXAMPLES
CHILD A
Age 3 years, 6 months
Consonants /b, m, d, n/
Vowels /o, oo, ah, uh/
Syllable shapes – CV, CVCV reduplicated
Interests – vehicle toys, balls, farm animals
Consistency – “bah”, “mah” are consistent. Other combinations achieved using multisensory cues
CHILD B
Age 7 years, 10 months
Consonants /p, b, m, w, t, d, n, h, f, s/
Vowels /all, though diphthongs can be difficult at rapid rate
Syllable Shapes – all except blends, thou inconsistent
Interests – action heroes, soccer, basketball
Consistency ‐ difficulty with multisyllabic words. Omits medial consonants (even at CV‐CVC) unless rate is
significantly reduced.
LESSON PLAN WORKSHEET – Child A
Name____________________ Date________
Syllable Phoneme(s) Vocabulary; Activities;
Shape(s)
C and V Phrase Structures Materials

LESSON PLAN WORKSHEET – Child B
Name____________________ Date________
Syllable Phoneme(s) Vocabulary; Activities;
Shape(s)
C and V Phrase Structures Materials

RESOURCES FOR PICTURES

• Moving Across Syllables
• Kaufman Speech Praxis Treatment Kits
• Word Flips™
• Picture Express
• Becoming Verbal and Intelligible
• Boardmaker™
• Google™ Images
10. ENHANCING MOTIVATION
MOTIVATION DEVELOPS WHEN CHILDREN:
• Know they are successful
o Use clear and concrete reinforcement
o Use powerful and pragmatic vocabulary
o When choosing targets, taking into account
 Phoneme repertoire
 Syllable shapes
 Planes of movement
o Utilize progressive approximations when necessary
• Understand the power of language
• Understand how the motor system will affect their ability to communicate
• Are having fun
11. STRESS AND INTONATION
Children with CAS frequently demonstrate inappropriate stress patterns ‐ excessive equal stress is common
• Teach exclamations using over exaggeration
• Count and stop
• Emphasize key words expressing high levels of emotional content
• Questions vs. declaratives
• Statement‐Question‐Response
• Changing meaning of sentence based on which word is stressed
• Syllable stress

12. CONSIDERATIONS FOR ORAL MOTOR ACTIVITIES IN CAS
1. Time
2. Purpose
3. Research
13. RELATIVE CONTRIBUTIONS
1. Language – comprehension, narrative language, grammar, vocabulary, pragmatics, MLU
2. Social – reciprocity, Interaction, emotional regulation, play
3. Dysarthria – speaking rate, muscle weakness, articulatory precision
4. Phonology – phonological processes
14. LITERACY CONSIDERATIONS
Within the context of treatment, help children to:
 Recognize that words begin or end with the same sounds
 Segment words into individual sounds
 Blend individual syllables or sounds
 Recognize rhyme patterns
Do this by:
 Using written letters as sound cues
 Writing target words on practice cards
 Highlighting specific sounds, syllables, words
o Make the sound/syllable/word larger
o Use different color
o Underline
 Focus attention to the # of sounds/syllables/words
 Sort target words by
o Beginning sounds
o Ending sounds
o Number of syllables
o Ending syllables
o Vowels
TREATMENT CONSIDERATIONS FOR CHILDREN WITH
LITTLE OR NO LANGUAGE

 Cast a wide net
 Reinforce vocalizations
 Give meaning to vocalizations
 Get imitation going
 Choose toys that reinforce early sound effects and simple exclamations
 Imitate Child’s movements/sounds
 Emphasize key words
 Use small vocabulary set
 Choose activities with vocabulary containing
 Model slow, exaggerated articulation
 Use amplification tools
 Use motion
 Use music
 Use repetitive books and counting books
 Describe what child is doing with the speech motor system from the start
 Use consistent terminology
Simple books to establish use of sound effects, single words and two
word phrases
•Moo, Baa, La La La – Sandra Boynton
•Blue Hat Green Hat – Sandra Boynton
•Spot Books – Eric Hill
•Old Macdonald Had a Farm – various authors
•Who Says That – Arnold L. Shapiro
•Brown Bear Brown Bear What Do You See – Bill Martin
•Open The Barn Door – Christopher Santoro
•Baby Bop’s Toys – Kimberly Kearns and Marie O’Brien
•Mommy and Me – Neil Ricklen
•Kiss the Boo‐Boo – Sue Tarsky
•Five Little Ducks – Raffi
•Here Are My Hands ‐ Bill Martin Jr. and John Archambault
•Five Little Monkeys Jumping on the Bed – Eileen Christelow
•Five Little Monkeys Sitting in a Tree – Eileen Christelow
•Freight Train – Donald Crews
•Are You My Mother? – P.D. Eastman
•Who’s Hat – Margaret Miller
•Who’s Shoe – Margaret Miller
•Mary Wore Her Red Dress and Henry Wore His Green Sneakers – Merle Peek
•City Sounds – Craig Brown
•Animal Sounds – Aureleuo Battaglia
Books to promote increased sentence length, morphological markers,
and specific phonemes
•The Three Bears – Byron Barton
•The Little Red Hen – various authors
•The Three Little Pigs – various authors
•Mr. Gumpy’s Motor Car – John Burningham
•Mr. Gumpy’s Outing – John Burningham
•Andrew’s Bath – David McPhail
•The Very Hungry Caterpillar – Eric Carle
•The Very Busy Spider – Eric Carle
•The Mitten – Jan Brett
•Owl Babies – Martin Waddell
•Dear Zoo – Rod Campbell
•The Three Little Pigs – James Marshall (and other authors)
•It Looked Like Spilt Milk – Charles Shaw
•Who’s Toes Are Those – Joyce Elias and Cathy Strum
•King Bidgood’s in the Bathtub – Audrey Wood
•A Pile of Pigs – Judith Zoss Enderle and Stephanie Gordan Tessler
•Guess Where You’re Going, Guess What You’ll Do? – A.F. Bauman
•I Wish I Could Fly – Ron Maris
•Here Comes a Bus – Harriet Ziefert
•I Went Walking – Sue Williams
•A Giraffe and a Half – Shel Silverstein
•Four Fur Feet – Margaret Wise Brown
•“Slowly, Slowly, Slowly,” said the Sloth – Eric Carle
•When Sheep Sleep – Laura Numeroff
•Here Comes a Bus – Harriet Ziefert
•A Pile of Pigs – Judith Zoss Enderle and Stephanie Gordan Tessler
Songs to promote speech for children with Apraxia
•Apples and Bananas – vowel variety
•Baby Bumblebee – animal sounds, simple word production
•Down by the Bay – rhyming, simple word production, vowel variety
•Five Little Ducks – counting, simple word production through sentence completion
•Five Little Monkeys Jumping on the Bed – counting, simple word production through
sentence completion
•Head, Shoulders, Knees and Toes – simple word production, vowel variety
•I Caught a Fish Alive – counting, simple word production through sentence completion
•If You’re Happy and You Know It – vocal and non‐vocal imitation
•John Jacob Jingleheimer Schmidt – complex word production
London Bridge is Falling Down j‐ simple word production through sentence completion
•Old Macdonald had a Farm – animal sounds and vowel variety
•One, Two, Buckle My Shoe – simple word production, counting
•Pat‐a‐Cake – simple word production (esp. bilabials)
•Pop goes the Weasel – simple word production, non‐vocal imitation
•Ring Around the Rosy – simple word production
•Row, Row, Row, Your Boat – simple word production, early developing vowels /o, i/
•The Alphabet Song – vowel variety, production of CV and VC combinations
•The Wheels on the Bus – simple word production
•The Itsy Bitsy Spider – simple word production through sentence completion
•This is the Way We . . . – vocal and non‐vocal imitation, simple word production
•Twinkle, Twinkle Little Star – simple word production
• Wibbely Wobbely Woo – complex word production
CHILDHOOD APRAXIA BIBLIOGRAPHY
Professional Books, Articles, Videos and Websites:
American Speech‐Language‐Hearing Association. (2007). Childhood Apraxia of Speech [Technical
Report]. Available from www.asha.org/policy

Apraxia Kids Retrieved September 8 , 2007, World Wide Web: http://www.apraxia‐kids.org

Caruso, A. and Strand, E. Clinical Management of Motor Speech Disorders in Children. New York, NY:
Thieme, (1999)

Dynamic Remediation Strategies for Children with DVA, Video and Handbook. Rockville, Maryland:
ASHA (1998)

Gildersleeve‐Neumann, C. Treatment for Childhood Apraxia of Speech: A Description of Integral
Stimulation and Motor Learning, The ASHA Leader, November 6, 2007

Hall, P., A Letter to the Parent(s) of a Child with Developmental Apraxia of Speech, Language Speech,
and Hearing Services in the Schools, Vol. 31, 169‐172, (April 2000)

Kilmas, N., Differential Diagnosis of Articulatory Impairment. Advance for SpeechLanguage
Pathologists and Audiologists, Vol. 11, (June, 2001)

Lewis, B and Ekelman, B., Literacy Problems Associated with Childhood Apraxia of Speech.
Perspectives on Language, Learning and Education, Vol. 14, 10‐17 (October, 2007)

Magill, R. A., Motor Learning and Control: Concepts and Applications, Seventh Edition. New York, NY:
McGraw‐Hill (2004)

Marshalla, P., Becoming Verbal with Developmental Apraxia. Kirkland, WA, Marshalla Speech and
Language (2001)

McCauley, R. and Strand, E., A Review of Standardized Tests of Nonverbal Oral and Speech Motor
Performance in Children. American Journal of SpeechLanguage Pathology, Vol. 17, 81‐91 (February
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Phonetics: The Sounds of English and Spanish – The University of Iowa Retrieved September 8 ,
2007, World Wide Web: http://www.uiowa.edu/~acadtech/phonetics/about.html

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Approach, Third Edition. Champaign, IL: Human Kinetics (2004)

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Theoretical Perspectives. Journal of Speech, Language, and Hearing Research, Vol. 40, (April, 1997)

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Diagnostic Marker. Journal of Speech, Language, and Hearing Research, Vol. 40 (April, 1997)

Shriberg, L., Aram, D., and Kwiatkowski, J., Developmental Apraxia of Speech: III. A Subtype Marked
by Inappropriate Stress. Journal of Speech, Language, and Hearing Research, Vol. 40 (April, 1997)

Strand, E. and McCauley, R., Differential Diagnosis of Severe Speech Impairment in Young Children.
The ASHA Leader, Vol 13(10), 10‐13 (2008)

Strand, E., Treatment of Motor Speech Disorders in Children. Seminars in Speech and Language, Vol.
16 (1995)

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on Childhood Apraxia of Speech, Anaheim, CA, July 12‐14, 2007

The Prompt Institute Retrieved September 8, 2007, World Wide Web: http://promptinstitute.com

Velleman, S., Childhood Apraxia of Speech: Resource Guide. Clifton Park, NY: Delmar Learning (2003)

Tests, Workbooks and Other Therapy Materials

Barty, N., and Bellamy D. Picture Express, Comox, BC, Canada: Picture Express Software (1998)

Dauer, K., Irwin, S. and Schippits, S., Becoming Verbal and Intelligible: A Functional Motor
Programming Approach for Children with Developmental Verbal Apraxia, Austin, TX: Pro‐Ed,
(1996)

Drake, M. Just for Kids ‐ Apraxia, East Moline, IL: LinguiSystems, Inc. (1999)

Frimmer, B. Totally Terrific Arctic Tongue Twisters, Greenville, SC: Super Duper Publications

Granger, R., Word Flips TM for Learning Intelligible Production of Speech, Greenville, SC: Super
Duper Publications (2005)

Hayden, D. and Square, P., Verbal Motor Production Assessment for Children, The Psychological
Corporation, (1999)

Kaufman, N. Kaufman Speech Praxis Test for Children, West Bloomfield, Michigan: Northern Speech
Services, (1996)

Kaufman, N. Kaufman Speech Praxis Treatment Kit for Children ‐ Basic Level and Kaufman Speech
Praxis Treatment Kit for Children ‐ Advanced Level. West Bloomfield, MI: Northern Speech
Services, (1998)

Kaufman, N, The Kaufman Speech Praxis Workout Book. West Bloomfield, MI: Northern Speech
Services, (2005)

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Sequences San Antonio, TX: Communication Skill Builders, A division of Psychological Corp., (1990)

O’Bryan, B., Sound Reps Workout: A Total Fitness Program for Articulation Strengthening.
Youngtown, AZ: ECL Publications (1996)

Strode, R. and Chamberlain, C., The Source for childhood Apraxia of Speech. East Moline, IL:
LinguiSystems, Inc., (2006)

Strode, R. and Chamberlain, C. Easy Does It for Apraxia and Motor Planning, East Moline, IL:
LinguiSystems, Inc., (1993)

Strode, R. and Chamberlain, C. Easy Does It for Apraxia ‐ Preschool, East Moline, IL: LinguiSystems,
Inc., (1994)

Webber, M and Webber S., 168 Seasonal & Holiday Open‐Ended Artic Worksheets. Greenville, SC:
Super Duper Publications (1998)


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