1. Childhood Apraxia Defined Typically defined in terms of sound production error patterns, but actually a disorder of movement. Difficulty is noted with purposeful voluntary movements for speech, creating an inability to sequence speech movements in the absence of paralysis. (Caruso & Strand, 1998)

2. Demographics Onset – Impaired from birth Course – Often long course of tx Gender – 3 male: 1 female Prevalence – Unknown (1:1000) Aggregation – FoxP2 gene autosomal dominant (KE family) – Some familial transmission

3. CAS & Impact on Overall Communication Decreased intelligibility Disordered language Social withdrawal Behavioral aggression Academic failure

4. CAS & Impact on Overall Communication Decreased intelligibility Disordered language Social withdrawal Behavioral aggression Academic failure

5. CAS Clinical Indicators Reduced phonemic repertoire (esp. consonants, simple word & syllable shapes Prosodic abnormalities (timing) Vowel errors not affected by length of utterance Variability, sequencing difficulties Difficulty achieving & maintaining articulatory configurations (artic overshoot) Use simple syllable shapes Difficulty completing a movement gesture for a phoneme easily produced in a simple context but not in a longer context (underspecified motor plan)

6. Differential Diagnosis CAS vs. Speech Delay – Differs from errors of children with developmental delay in that does not follow developmental sequences (later sounds come in earlier, etc.) CAS vs. Phonological Processes – Differs from errors of children with phonological processes in contrast between voluntary & involuntary performance, error variability CAS vs. Dysarthria – Differs from dysarthria, which has errors in phonation, resonance, articulation & prosody related to weakness, paralysis

7. Movement For CAS, re-conceptualize the way you think about articulation and phonology  Move away from thinking about sounds  Don’t think about processes  Movements are the focus

8. Motor Learning Theory Motor learning occurs as a result of experience & practice 1.Pre-practice skills 2.Conditions of Practice

9. Pre-practice to Establish Motor Learning Pre-practice portion of a therapy session involves – Focused attention – Motivation – General idea of task – Observational learning

10. Focused Attention “ability to focus cognitive, perceptual, sensory & activity toward the skill he/she is attempting to learn” – need intent to learn – limit extraneous stimuli – stimuli that limit cognitive, linguistic, phonetic load will enhance child’s ability to focus attention – child must look at & listen to clinician – novelty: change position, vary volume, etc

11. Motivation consider desire to talk vs. years of failure talking make the tasks important, useful set goals with the child set a reasonable standard to achieve provide early success reduce frustration

12. General Idea of Task – understand task clearly – ways they will learn – keep instructions simple; focus on 1-2 important aspects of movement. – DO NOT OVERINSTRUCT

13. Observational Learning – modeling & demonstration with pictures, videotapes, and live demos – show the child the movements a few times covering all stimuli being targeted in the session – be wary of verbal instructions

14. Establish Reference of Correctness – that child understands – use auditory feedback – i.e., for /pa/, may accept lip closure as correct to begin, later move to correct articulatory production

15. Repetitive Practice Intensive treatment (best if 5 days/week) Large # of movement repetitions (no less than 40), enough trials/session to allow motor learning to become automatic use reinforcements that don’t take time Activities should facilitate repeated opportunities for production of target movement patterns

16. Mass vs. Distributed Practice – Mass = less frequent, longer sessions – Distributed = frequent, short sessions – decision depends on severity and type – mass yields quick development of accurate production – distributed requires longer time, but get better generalization

17. Knowledge of Performance Feedback about the correctness of a particular movement pattern regarding accuracy of production. – I heard you say …. – I saw you…placement cues

18. Rate & Prosody Considerations Come to neutral position btwn attempts (rest), do NOT divide into components – Breaking up words will cause the child to learn that motor pattern and not the coarticulated one Move through hierarchy of task difficulty Treat rhythm, stress & intonation with/as a component of articulation drills

19. Hierarchy of Response/Cued Support – simultaneous production with examiner – direct imitation – delayed imitation (gradually increase delay time) – spontaneous

20. Intervention Strategy Work on vowels when working on whole word transitions (e.g., C  V, V  C, C  V  C), don’t address vowels or consonants alone Work on consonants when working on whole word or phrase transitions (e.g., no isolated consonants) Kids can always say something, they may only have 1-2 sound combos that they use as words, but can start there Take what they say in conversation that makes sense & examine the GFTA correct productions to determine correct transitions in the child’s speech

21. Play & Success Beginning sessions Set up play situation (find out likes; ~5 different activities, books, toys, basket of activities: they choose) allow child to be in charge, set up situation where they don’t think they are working, but rather just interjecting speech into play

22. Move into new movements Take the correct transitions in their repertoire & ask them to directly imitate words they can say Get successes 1 st ! (e.g., mom, ma, mama) Get several delayed imitative productions of the same sound sequence (e.g., “can you say 5 of them?”) When introduce new, start where need to with either simultaneous  direct imitation  delayed imitation

23. Reinforce Lots of Utterances Attempt to get as many productions of each movement as possible during the session (min 40-50) Ignore error productions Make a big deal out of successful productions Make the session fun & successful to the child so that they are excited to return for the next session Give parents feedback,

24. Base List SLP learns what child is able to say & getting imitations of these Prior to the 2 nd session, SLP creates cards with Boardmaker pictures for items on the base list Base list is of sound combinations/ words the child can produce (observed during 1 st session) Continue with play activities from 1 st session while introducing the base list combinations ( e.g., uh-oh, mama, baby, oh-no, boo, baa, moo, me, my, bye)

25. Direct Imitation Have the child attempt productions following direct imitation on all of the base list items to evaluate continued success If child is unable to successfully produce one item, that card is pulled from the list for that session Begin to combine the words/sequences that the child can say and attempt to get direct imitations of the combinations

26. Break Down & New Next, 1 of the following occurs… 1.Produce new word not on base list. 2.Breaks down and has “had enough” for that session. 3.SLP probes for new words during play/activities

27. Produce new word (not on base list) – immediately reinforce verbally – word is added to the base list – introduce into later activities/sessions

28. SLP probes for new words (during play/activities) – Combine consonants the child can produce with different vowels to create VC, CV, CVC, VCV combinations – Provide auditory, visual, and/or placement cues for the child. – Attempt to get direct imitation

29. Conditions of Practice – Reference for correct – Repetitive practice mass vs. distributed random vs. blocked – Knowledge of performance – Knowledge of results immediate vs. summary – Rate & prosody – Stimulus/response complexity

30. Combinations Continue as in Session 2. Begin to combine 2 of their base words together, attempting to keep one of the words consistent (either 1 st or 2 nd ) & go through the base list In this way, create silly sentences, laughing to make it playful – Moo bye – Moo bee – Bee moo Bee bye Bye moo Bye bee

31. Rudimentary Carrier Phrases Begin to introduce rudimentary carrier phrases. – My… – Oh no… – I…

32. Carrier Phrases = Coarticulation Introduce lengthier carrier phrases, thinking about coarticulation Generally, when combining 2 base words together, this is not as much an issue When using carrier phrases, think about conversational speech & make it sound natural » I need a (I nee da)… » I want a (I wanna)… » I have to (I hafta)… » I’ve got to (I gotta)… » Hop up (Hah pup)… » Come here (kuh mere)…

33. Generalization Books Create a book that pairs carrier phrases with the sound sequences (words) from their base list – “Hop up mommy” – “Hop up bug” – “Hop up puppy” Use Boardmaker pictures so the child can “read” the book and initiate spontaneous utterances

34. Functional Communication As intelligibility increases, SLP begins working on most functional communication in conversational interactions (also  motivation) – Best friends, teacher, sibling names – Baseball terminology if participating in that activity (extracurricular activity terms) – Pets

35. As intelligibility improves… May appear to have language delays (scores) due to the impairment in speech (become more apparent) May use simplified speech productions (of a younger developmental age) because that is where they find the most success with artic. Clean up – Sequences in grammatical structures -ed endings Plurals Verb tense – The “holes” (e.g., sequences not solid in conversation)

36. Documenting Progress Accuracy on base word list (cumulative %) Add words to base list, % accuracy Accuracy of base words in a carrier phrase Intelligibility of spontaneous speech Decreased frustration (e.g., ↓“meltdowns”, ↓ episodes of anger, ↓ aggression, ↓ crying) Parents report ↓ frustration, others notice child ↑ understood & ↑ verbal ↑ test scores on retesting