1. Peter Flipsen Jr., Ph.D., S-LP(C), CCC-SLP Idaho State University flippete@isu.edu 2013 Utah State Convention Park City, UT

2.  Part 1 – Definitions / Differential Diagnosis  Part 2 – Goal Selection / Treatment Principles / Specific Treatment Suggestions 2013 Utah State Convention Park City, UT

4.  ASHA’s current preferred term.  Known by many labels including: ◦ Developmental Apraxia of Speech ◦ Developmental Dyspraxia ◦ Developmental Verbal Dyspraxia ◦ Childhood Verbal Apraxia 2013 Utah State Convention Park City, UT

5.  Type of Speech Sound Disorder (SSD) ◦ Broad category that includes any difficulty with output of speech sounds and includes:  articulation (phonetic) disorders, and  phonological (phonemic) disorders 2013 Utah State Convention Park City, UT

6.  Considerable controversy until recently.  Does it even exist?  What causes it?  How do we define it?  How do we distinguish it from other childhood speech disorders?  Is intervention different from what we do with other SSDs? 2013 Utah State Convention Park City, UT

7.  To help resolve the controversy, ASHA convened an expert panel and they developed: ◦ CAS Position Statement (2007) ◦ CAS Technical Report (2007)  Available at the ASHA website 2013 Utah State Convention Park City, UT

8.  ASHA (2007) expert panel did an extensive literature review and evaluation of that literature and concluded (among other things) that: YES, IT EXISTS! 2013 Utah State Convention Park City, UT

9.  Prevalence (how common?): ◦ No large population studies yet available.  Current best estimate = 0.1–0.2% of the general population (Shriberg, Aram, & Kwiatkowski, 1997). ◦ Probably translates to no more than 1-2% of the average SLP caseload.  One large study showed 3-4% of the caseload at a large urban hospital (Delaney & Kent, 2004). ◦ 516 cases out of 12-15,000 children with SSD 2013 Utah State Convention Park City, UT

10.  Prevalence estimates probably seem low but …  Recent increases in diagnoses, especially in the last decade.  Actual increase in cases? ◦ Greater survival rates of high-risk infants?  May also be due to: ◦ Legislative changes ◦ Funding issues ◦ Inconsistency of definitions 2013 Utah State Convention Park City, UT

11.  “ Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). CAS occurs 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 2007 position statement. 2013 Utah State Convention Park City, UT

12.  Neurological impairment.  No single source. ASHA (2007) expert panel suggested three broad routes: ◦ 1. May be idiopathic. 2. Result of known neurological impairment  Specific nervous system damage?  Specific events or disease processes known to cause neurological insult? ◦ 3. Co-occurring with some complex neurobehavioral disorders 2013 Utah State Convention Park City, UT

13. ◦ Autism – CAS in1% of cases?? ◦ Chromosome Translocations ◦ Coffin-Siris syndrome (7q32–34 deletion) ◦ Down syndrome (Trisomy 21) ◦ Rolandic Epilepsy ◦ Fragile X syndrome (FMR1) – CAS in up to 40% of cases?? ◦ Joubert syndrome (CEP290; AHI1) ◦ Galactosemia – CAS in 40-60% of cases?? ◦ Rett syndrome (MeCP2) ◦ Russell-Silver syndrome (FOXP2) ◦ Velocardiofacial syndrome ◦ (22q11.2 deletion) ◦ Williams-Beuren locus duplication (7q11.23) 2013 Utah State Convention Park City, UT

14.  80% of cases are male.  Nuclear family aggregation ◦ CAS and other SSDs often “run” in families  Has been associated with mutations of the FOXP2 gene ◦ Based on findings from different studies using different labs. ◦ Not all individuals with CAS have this mutation however.  May accompany some genetic syndromes 2013 Utah State Convention Park City, UT

15.  Problem in planning or programming the movement sequences for speech.  In the absence of neuromuscular deficits (i.e., tone and reflexes not necessarily impaired) ◦ But may have co-existing dysarthria  In the absence of problems with planning for “non-speech” activities such as chewing and swallowing. ◦ But may have co-existing oral apraxia 2013 Utah State Convention Park City, UT

17.  Speech often (though not always) normalized by adulthood. ◦ Because of Tx? In spite of Tx?  Often slow to respond to therapy ◦ Not a clear diagnostic sign however ◦ Could simply mean we’ve erred on the diagnosis and have been applying the wrong treatment 2013 Utah State Convention Park City, UT

18.  Both assumed to represent problems with programming and/or planning for speech.  AOS involves damage to an intact speech and language system.  CAS occurs before speech and language system has been fully developed. ◦ May affect the DEVELOPMENT of the higher levels of speech and language (Maasen, 2002). ◦ No “automatic” speech yet – often spared in AOS 2013 Utah State Convention Park City, UT

19.  Emerging literature suggests the following MAY be unique to CAS: ◦ 1. Inconsistent output on repeated attempts at the same words  May include vowel errors, especially atypical errors ◦ 2. Disrupted and lengthened transitions  Difficulty with articulatory sequencing  Problems more apparent as words get longer  Breaks between consonants and vowels ◦ 3. Disordered prosody  Excessive equal stress?  Monotone?  Possible problems controlling rate, nasality, pitch, loudness? 2013 Utah State Convention Park City, UT

20.  1. sound used correctly in some word positions but not others? ◦ Not unique to CAS; could just be incomplete learning.  2. sound used correctly in some words but not in others? ◦ Not unique to CAS; could be “fossilized” forms.  3. multiple attempts at the same word yield different outputs? ◦ Consistent with planning difficulties of CAS 2013 Utah State Convention Park City, UT

21.  Delayed speech onset  Limited vocal output  Reduced intelligibility  Limited phonetic inventory ◦ Likely reliance on early sounds  Limited syllable shape inventory (V, CV, VC, CVC, etc.)  Tendency to rely on gestures over vocal communication 2013 Utah State Convention Park City, UT

22.  Persistence of speech problem well into the school years?  Difficulties with expressive language? ◦ Look like they may have co-existing language impairments (Lewis et al., 2004). ◦ Suggests planning problem extends beyond speech (Ball et al., 2002)  Difficulties with the phonological foundations of written language? ◦ ASHA, 2007 2013 Utah State Convention Park City, UT

23.  According to the ASHA expert panel (ASHA, 2007): ◦ “It is the certified speech-language pathologist who is responsible for making the primary diagnosis of CAS, for designing and implementing the individualized and intensive speech-language treatment programs needed to make optimum improvement, and for closely monitoring progress.” 2013 Utah State Convention Park City, UT

24.  1. Separating CAS from other SSDs  2. Separating CAS from possibly co-existing dysarthria and/or oral apraxia  3. CAS signs likely vary with: ◦ Age ◦ Severity ◦ Particular task being used 2013 Utah State Convention Park City, UT

25.  Several published procedures available:  NOTE: All were developed before the release of the ASHA position statement. Each uses their own definition of CAS. Test / ProcedureAge Range 1. Apraxia Profile (Hickman, 2000)3;0 – 13;11 2. Kaufman Speech Praxis Test (Kaufman, 1995)2;0 – 6;0 3. Screening Test for Developmental Apraxia of Speech-2 (Blakely, 2001)4;0 – 7;11 4. Verbal Dyspraxia Profile (Jelm, 2001)None listed 5. Verbal Motor Production Assessment for Children (Hayden & Square, 1999) 3;0 – 12;11 2013 Utah State Convention Park City, UT

26.  Need to gather fairly typical data:  Case history ◦ Family background, oral motor history, speech and language milestones  Single word artic test  Oral facial exam – include DDK tasks  Conversational speech sample – transcribe  Language comprehension testing  Phonological awareness testing 2013 Utah State Convention Park City, UT

27.  Often see limited vocal output  Limited variety of consonants and vowels  May see single sounds used as words  Need speech output or at least attempts at speech to make a diagnosis! ◦ means diagnosis before age 3 years is very difficult.  Non-speech problems (drooling, dysphagia) may only indicate co-existing oral apraxia. 2013 Utah State Convention Park City, UT

28.  1. Inconsistency – a few options ◦ Conversational speech  Record sample and look for consistency in attempts at words produced multiple times. ◦ Single word Artic tests  Administer whole test once  Repeat later in the session (twice completely)  Record productions and look at consistency 2013 Utah State Convention Park City, UT

29.  Assess using the consistency subtest of the Diagnostic Evaluation of Articulation and Phonology (DEAP). ◦ 25 words attempted once (do some other activity), say 25 words again (do some other activity), say 25 words again. ◦ If >40% of the words are produced inconsistently = criterion for “inconsistent”. 2013 Utah State Convention Park City, UT

30.  2. Problems with transitions  DDK procedures ◦ Focus on consistency and accuracy (not speed) ◦ May not have difficulty with AMR tasks (same place of artic; puh,puh, puh; tuh, tuh, tuh) ◦ More likely to see problems with SMR tasks (place of artic changes; puh, tuh,tuh; puh, tuh, kuh) ◦ Problems with both may signal co-existing dysarthria 2013 Utah State Convention Park City, UT

31.  Suggest testing at normal rate (no need for a stopwatch).  1. Children with CAS have sequencing problems at normal rate.  2. Several studies suggest motor planning is different at fast rate vs. normal rate. 2013 Utah State Convention Park City, UT

32.  2. Transitions?  Problems with multisyllabic words and/or as words get progressively longer? ◦ Probably only useful for children over 6 years ◦ ham – hammer – hammering ◦ hope – hopeful – hopefully ◦ hand – handle – handily ◦ wide – widen – widening 2013 Utah State Convention Park City, UT

33.  3. Prosody  Evaluate conversational speech ◦ Listen for inappropriate use of stress on multisyllabic words ◦ Listen for inappropriate use of pitch and intonation ◦ Listen for inconsistent rate or loudness  Overall slower rate may indicate co-existing dysarthria ◦ Inconsistent nasality? ◦ Need to evaluate at least 25-30 utterances to get a valid sample. 2013 Utah State Convention Park City, UT

34.  Case history ◦ Look for “neurological events” that might suggest neurological damage – not always there. ◦ Look for family history of any speech or language impairments – not always there. ◦ Look for (past and current) problems with feeding, chewing, swallowing, and/or drooling.  Would suggest possible co-existing oral apraxia 2013 Utah State Convention Park City, UT

35.  Use conversational speech to establish: ◦ 1. Overall intelligibility (% words understood)  Need to measure it directly ◦ 2. Syllable shape inventory  Ignore accuracy here; any consonant counts as C, any vowel counts as V ◦ ◦ 3. Phonetic inventory  Any sound that shows up counts regardless of whether it matches the target 2013 Utah State Convention Park City, UT

37.  Still quite speculative since we’re still trying to sort out how to do the diagnosis. ◦ Most current suggestions were proposed before the ASHA position statement appeared.

38.  Three broad general strategies: ◦ 1. Improve functional communication – so many of these children have such reduced output and/or reduced intelligibility. ◦ 2. Focus on the core impairment – use the definition to identify and select specific goals. ◦ 3. Treat the emerging features 2013 Utah State Convention Park City, UT

39.  Some suggestions(not mutually exclusive):  A. Consider the use of sign language  May not be an option if “limb apraxia” is also present (may be co-morbid).  Limited audience?

40.  B. Consider an AAC system – usually an easier option than sign language. ◦ Big barrier = parent concerns that “they will become dependent on it” and never speak.  No evidence this is the case.  Evidence actually suggests the opposite.  Devices demonstrate the power of effective communication, but they are slow.  Provides motivation to practice speech which is much faster. 2013 Utah State Convention Park City, UT

41.  C. Consider a Core Vocabulary Approach ◦ Not originally intended for CAS. ◦ Designed by Barbara Dodd and her colleagues for their “Inconsistent Phonological Disorder” category. ◦ Children who demonstrate inconsistent use of unusual phonological patterns (processes).  Goal is to increase consistency which is one of features that is emerging as possibly unique to CAS. ◦ Would seem appropriate to try it.

42.  Long-term goal = produce at least 70 words consistently. ◦ Not necessarily correct but at least predictable.  Assumes that once this goal is reached, consistency will generalize to other words.  Requires significant family involvement. ◦ Consult with family, teachers and the child and select about 50-70 “functionally powerful” words for the child. ◦ Words attempted often and meaningful specifically to them.

43.  Each week randomly select 10 of these words and drill heavily. Goal is to get a consistent production. ◦ Ideally get fully correct production  May have to accept a close approximation or developmentally appropriate errors.  As long as it is consistent, it will be easier to understand. ◦ Make sure everyone knows what the words are and what the acceptable form is (if not fully correct).

44.  At beginning of each week have child produce entire list 3 times.  Consistently correct words can be dropped.  Select a new random set of 10 from the remaining words and drill these.

45.  The core issue is a problem with planning  Neither strict motor approach nor a strict linguistic approach would seem appropriate. ◦ Using either of these might account for much of the slow progress in therapy seen with these children.

46.  Teach planning.  Learning to plan means being regularly faced with a new goal. ◦ Need to present multiple targets in random order to reduce predictability.  Include several levels of complexity. ◦ We probably can’t assume generalization across levels.  Focus on speech. ◦ Non-speech movements not likely of much value unless there is a co-morbid oral apraxia.

47.  Keep the steps small. ◦ Likely need to teach both new sounds and new syllable shapes. ◦ If we introduce a new sound, practice it in a syllable shape they can already produce. ◦ If we introduce a new syllable shape, practice is using sounds they can already produce.

48.  Probably need direct work above the word level.  Keep the vocabulary and syntax at or (preferably) below the child’s developmental level. ◦ There are several studies showing trade-offs between speech accuracy and syntactic complexity in SSD. ◦ Simpler vocabulary and syntax minimizes the “planning burden” they have to deal with.  We normally plan speech at the phrase or clause level.

49.  When working above the word level, be sure to incorporate work on prosody. ◦ Work on different rates, different lexical stresses, and different intonation patterns. ◦ May start with stock repetitive structures and then expand to newly generated utterances. ◦ Focusing on planning does really mean you are using principles of motor learning.

50.  A. inconsistency – Core vocabulary approach?  B. transitions – teaching planning can help here.  C. prosody – especially focus on use of stress. Can incorporate with other work or focus separately. ◦ N-V pair drill  Content-content; rebel-rebel; contract-contract ◦ Practice both trochaic (SW) and iambic (WS) words ◦ Contrastive stress drills  The girl sat on the big chair.  Who sat on the big chair?  She sat where?  Which chair did she sit it?

51.  Study looking at the treatment of lexical stress in CAS  Focus is on treating lexical stress issues.

52.  Incorporated Principles of Motor Learning.  Single subject design (n=3)  Treated stress using 4 syllable nonsense words of varying complexity with both SW and WS stress patterns (see appendix, p. 1245). ◦ Checked for generalization to both less complex 3 syllable forms (same vowels) and more complex 4 syllable forms. Look at generalization to both words and nonsense words.  Measured outcomes using both perceptual judgments and acoustic analysis. ◦ Recall stress is signaled by loudness, duration, and pitch.

53.  Three participants (M: 10;10, F: 9;2, M: 7;8) all from the same family. ◦ All had history of severe speech sound problems. ◦ Demonstrated 3 emerging features of CAS as agreed by first three authors. ◦ No signs of dysarthria (i.e., no weakness or low tone). ◦ No intellectual concerns. Normal language skills. ◦ All had rec’d traditional artic therapy. No previous work on prosody.

54.  4 one-hour sessions per week for 3 weeks.  Followed principles of motor learning.  Stimuli practiced (read aloud) in structured carrier phrases. ◦ All stimuli could be produced correctly but were done so with limited stress differences across syllables. ◦ 10-12 trials for each of the 10 target stimuli. ◦ 100-120 trials per session. ◦ No models, only feedback on correctness. ◦ 100% feedback on first trial reduced to 10% by last trial.

55.  All three showed improvements in use of SW and WS patterns in the training stimuli based on perceptual judgments. ◦ 0-80%, 0-76%, 0-38% correct respectively.  All three were able to show contrast between the stress patterns using differences in duration. ◦ Least contrast for participant 3.  Results not as clear for pitch or loudness differences.  Some generalization by all three to untreated less complex forms.  Limited generalization to more complex forms.

56.  Effects were maintained after 4 weeks of no treatment for 2/3 participants (older ones). ◦ Youngest participant (least effect) was also the most severely involved.  Appears that prosody is a separate problem from speech sound accuracy.  Prosody impairments can be successfully remediated.

57.  Now called “Dynamic Temporal and Tactile Cueing” (DTTC) when used with children. ◦ “… emphasizes the shaping of movement gestures for speech production and the continued practice of those gestures in the context of speech. Shaping occurs initially through the use of simultaneous production. The utterances are practiced slowly and simultaneously at first to facilitate movement accuracy. The clinician helps the child achieve the correct jaw and lip positions for the initial articulatory configuration, has the child stay in that position for a few moments to maximize proprioceptive processing, and then simultaneously produces the utterance slowly with the child, utilizing tactile and gestural cues as needed. As the child produces the movement gesture with increased accuracy, the clinician slowly increases the rate of movement toward normal.”  p. 298, Strand, Stoekel, and Baas, 2006

58.  Some emerging case study findings suggest this approach may work for CAS. ◦ Strand and Skindner, 1999 ◦ Strand and Debertine, 2000 ◦ Strand et al., 2006 ◦ Edeal and Gildersleeve-Neumann, 2011  Studies all invoke “Principles of Motor Learning” as part of the process.

59.  Touch cuing – clinician teaches an association between touching a certain part of the face and certain sounds. ◦ See handout. ◦ Clinician then touches each part of the face in sequence to stimulate child to produce the sequence of sounds. ◦ No formal evidence.  PROMPT – weak evidence base, but ??  Melodic Intonation Therapy – typically thought of as an adult intervention ◦ Teach speech through sing-song like productions that may help integrate prosody and speech. ◦ No formal evidence.

60.  American Speech-Language-Hearing Association. (2007). Childhood Apraxia of Speech [Position Statement].  American Speech-Language-Hearing Association. (2007). Childhood Apraxia of Speech [Technical Report].  Ball, L. J., Bernthal, J. E., & Beukelman, D. R. (2002). Profiling communication characteristics of children with developmental apraxia of speech. Journal of Medical Speech-Language Pathology, 10, 221-229.  Ballard, K.J., Robin, D.A., McCabe, P., & McDonald, J. (2010). A treatment for dysprosody in childhood apraxia of speech. Journal of Speech, Language, and Hearing Research, 53, 1227-1245.  Blakeley, R. W. (2001). Screening Test for Developmental Apraxia of Speech – Second Edition. Austin, TX: Pro-Ed.  Delaney, A. L., & Kent, R. D. (2004, November). Developmental profiles of children diagnosed with apraxia of speech. Poster session presented at the annual convention of the American-Speech-Language-Hearing Association, Philadelphia.  Dodd, B., Hua, Z., Crosbie, S., Holm, A., & Ozanne, A. (2006). Diagnostic Evaluation of Articulation and Phonology. San Antonio, TX: The Psychological Corporation.  Edeal, D.M., & Gildersleeve-Neumann, C.E. (2011). The importance of production frequency in therapy for childhood apraxia of speech. American Journal of Speech-Language Pathology, 20, 95-110  Hayden, D., & Square, P. (1999). Verbal Motor Production Assessment for Children. San Antonio, TX: The Psychological Corporation.  Hickman, L. (1997). Apraxia Profile. San Antonio, TX: The Psychological Corporation.  Jelm, J. M. (2001). Verbal Dyspraxia Profile. DeKalb, IL: Janelle Publications.  Kaufman, N. R. (1995). Kaufman Speech Praxis Test for Children. Detroit, MI: Wayne State University Press.  Lewis, B. A., Freebairn, L. A., Hansen, A. J., Iyengar, S. K., & Taylor, H. G. (2004). Schoolage follow-up of children with childhood apraxia of speech. Language, Speech, and Hearing Services in Schools, 35, 122-140.  Maassen, B. (2002). Issues contrasting adult acquired versus developmental apraxia of speech. Seminars in Speech and Language, 23, 257-266.  Shriberg, L. D., Aram, D. M., & Kwiatkowski, J. (1997). Developmental apraxia of speech: I. Descriptive and theoretical perspectives. Journal of Speech, Language, and Hearing Research, 40, 273-285.  Strand, E. A., & Debertine, P. (2000). The efficacy of integral stimulation intervention with developmental apraxia of speech. Journal of Medical Speech-Language Pathology, 8, 295–300.  Strand, E. A., & Skinder, A. (1999). Treatment of developmental apraxia of speech: Integral stimulation methods. In A. J. Caruso & E. A. Strand (Eds.), Clinical management of motor speech disorders in children (pp. 145–185). New York, NY: Thieme.  Strand, E. A., Stoeckel, R., & Baas, B. (2006). Treatment of severe childhood apraxia of speech: A treatment efficacy study. Journal of Medical Speech-Language Pathology, 14, 297–307. 2013 Utah State Convention Park City, UT