A MULTI-MODAL APPROACH TO CHILDHOOD APPRAXIA OF SPEECH

1. A MULTI-MODAL APPROACH TO CHILDHOOD APPRAXIA OF SPEECH PRESENTED BY Debra Lauharn MA, OTR Christin Dowd MA, CCC-SLP

2. Childhood Apraxia of Speech (CAS) • Liepmann (1900) first used the term apraxia to describe a movement disorder in which a person has difficulty with the accurate production of volitional movement patterns in the absence of other neuromuscular anomalies. • Marshalla (1997) defined apraxia in speech as a nonlinguistic sensorimotor disorder of articulation characterized by impaired capacity to program the position of muscle movements. * There is no connection to cognitive or linguistic comprehension problems

3. The American Speech Language Hearing Association (ASHA) defines CAS as: A neurological pediatric 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). It may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders or as an idiopathic neurogenic speech sound disorder.

4. Ebert (2009) includes 4 core elements of APRAXIA: • It is not associated with a cognitive impairment • It is not associated with neuromuscular deficits • It is a neurological disorder • It interferes with the ability to sequence sounds for speech on command * children with CAS will have a history of being quiet, while a child with a language delay has a typical babbling history

5. Childhood Apraxia of Speech (CAS) is characterized as a motor speech disorder and is often defined as an inability to perform voluntary specific motor actions, on command or demonstration, consistently on all occasions, in the absence of any neurophysiological or neuromuscular disability (Brian, 1965). *OT’s & PT’s would refer to motor planning difficulties as dyspraxia

6. It can be difficult to diagnose CAS, and many clinicians agree that it is wise to use the term “suspected childhood apraxia of speech” when working with non-verbal children. • Clinicians rely on a list of signs and symptoms to validate other differential communication disorders, and speech pathologist must consider: language delay/linguistic, suspected apraxia/motor planning, dysarthria and ASD. • The difference between ASD & CAS is the intact receptive language skills and pragmatic skills. • Dysarthria is a weakness in the speech muscles. • Children with a motor delay make more consistent and rapid progress.

7. Children with CAS are unable to sequence the motor production for speech sounds, and the sequencing errors are disruptions in the production of the correct ordering of speech sounds or syllables. • Children with CAS are often reported to have co-existing conditions such as oral apraxia, muscle hypotonia, sensory integration dysfunction, and limb apraxia (Ebert 2009). * Children with apraxia have a “soft/chubby cheek” look to the face, and usually have behaviors

8. Jean Ayers, OTR, uses the developmental pyramid to discuss the hierarchy of development

9. Jean Ayres (1979)discussed the hierarchy of development as progressing from gross motor; using the large muscles of the body, to fine motor; using the arms and hands, to the most intricate of all fine motor skills; speech articulation. • Ayres reports that it is not uncommon to find that a child with CAS also demonstrates deficits in sensory processing, and is a result of poor organization of tactle, vestibular and/or proprioceptive sensations. • Since motor planning is the first step in learning and acquiring skills; the child with apraxia usually has a shortage of motor planning skills.

10. Sensory processing is the ability to filter and organize all of the senses of the body so that an individual can move, think and behave normally. Touch receptors in the skin, the pressure receptors in the muscles and joints, and the vestibular or movement centers in the brain all work together to let the body know where it is in space and gives us body awareness. • Apraxia or poor motor planning results in a slow processing, or a lack of integration in the touch receptors and muscles of the body, and can result in poor body awareness and movement deficits from the tips of our fingers and toes to the oral structures of the mouth (Ayers & Marshalla).

11. Therapy • A MULTI-MODAL intervention approach to Childhood Apraxia of Speech (CAS) targets gross motor skills, fine motor skills, oral motor awareness, verbal production and parent participation as a single intervention. • The MULTI-MODAL approach is an eclectic approach incorporating occupational and speech therapy treatment methods and is based on research and trial and error. • Chris and Deb story

12. Gross Motor • Developmentally, we move before we learn other skills (ie. use utensils, speak). • Gross motor room activities are used to potentially create thicker mylenization and faster synapses leading to enhanced neuron firing to create “highways” for higher levels. • Observations of poor gross motor skills have been linked to children with language problems (Owen & McKinlay, 1997) • 3 planes of movement: we are 3 dimensional creatures and move in the sagittal, frontal and transverse planes. • Sagittal: pathways move back to front across motor cortex; walking, jumping back & forth, running *facilitates the brains ability to put thoughts into action and place words on a page. • Frontal: pathways move side to side across the corpus callosum (crossing midline); stepping sideways, skating *strengthens visual fields needed for eye tracking in reading. • Tansverse: pathways move bottom to top in the brain; twisting, jumping up & down, roll, spinning *for spatial awareness that is used to organize letters into a word, words on a page, and math concepts.

13. Gross Motor *************Show motor room video***** • Motor room must haves: swings, trampoline, rolling down a ramp • Motor room extras: slide, scooter and ramp with soft blocks, roller coaster, scooter and hoop, therapy ball, tunnels, step over brackets, steps without railing, balance beams * Disinfectant wipes!!

14. Oral Motor Awareness • Children with apraxia need to have oral-motor awareness in order to find and use their articulators during imitation and on command in order to make and copy speech sounds. • A device called the Z-vibe dispenses a low vibration to calm, organize, and bring awareness to the oral cavity and articulators. • The Z-vibe can be used to encourage the developmental movement patterns of the tongue (lateralization, tongue tip directionality) and overall muscle strengthening of the oral structures (lips, cheeks). ***********show Z vibe with spoon and attachments w/book • *******video of Z vibe***************

15. Oral Motor Awareness (cont’d) • Orton-Gillingham uses finger cues with sounds and letters. This system is a multi modal approach to for reading. It is great to use cues for sound production • LiPS (Lindamood Phonemic Sequencing) is also a multimodal approach for reading. This program talks about how a phoneme looks, feels and sounds. We use this approach in cuing the sounds we are using. • Lip poppers • Tongue tappers • Nose sounds • Lip coolers • Tongue scrapers

16. Verbal Production • Nancy Kaufman (1995) & identified that children who are developing typically have vocabularies that begin with babbling and progress to word approximations (ie. Wawa for water) and then progress using simple consonants and vowels. • Kaufman developed the Successive approximation Approach where a method of shaping word approximations toward target productions that are moved directly into functional expressive vocabulary. • Cari Ebert (2009) measures progress by documenting a child’s increase in spontaneous vocalizations, and ability to produce consonant and vowel sounds in isolation as well as in combination. • We use both approaches as well as the child’s ability to begin scripting to request, and increasing mean length of utterance in a language sample during play time. • We believe you get more language output with movement. • We have cue cards for consonant vowel combinations based on the Kaufman principals. These cards are also used in art projects, books, as well as given to the parents to use at home for practice. • *******show video********************

17. Fine Motor Skills • Music provides sensory stimulation and multi-sensory learning by involving hearing, seeing, feeling, touching, and moving. • Imitation of simple arm and hand movements coupled with music and singing develop into finger play (ie. Twinkle little star, build a house). • Music and rhythm make learning fun, less stressful, and improves social interaction. • Rothstein (2010) reported that singing or chanting rhythmically makes learning easier for children as the body is naturally compelled to move to music. • Orton-Gillingham concludes: “students learn 2x as much 2x as fast when body movement is involved”. • Young children exposed to music have an advantage in higher thinking skills, and helps children repeat words which increases speech and language skills. *deep pressure, vibration and music/rhythm all go to the same centers in the brain to help calm and organize the CNS.

18. Fine Motor (cont’d) • Children with neurological or developmental delays such as CAS may have difficulty with fine motor movements (Blanc, 2004). • Simple, age appropriate art projects improve muscle tone, arm/hand strength, and finger isolation as well as integrate touch and other sensory processing skills. • Ayres and Mailoux (1981) highlight the importance of the speech and language pathologist along with the occupational therapist in the development of speech and language skills. • The OTR can provide the influence of fine motor as well as sensory integration to language development. **************show video*********************

19. Parent/Caregiver Participation • When the therapist provides activities, models strategies and has the caregiver participate during intervention it is beneficial to the child’s progress and success. • Continuous repetition in multiple functional environments result in generalization and an increase in success for carryover and maintenance (Pennington et al. 2009) • Caregivers learn to provide cueing and hand over hand (HOH) assistance to the child to improve participation and to allow the child to “feel” the correct motor pattern. • When caregivers learn and carryover the speech targets into the natural environment it not only provides more repetition and acquisition of motor skills, but let’s the caregiver know that they are an integral part of the team. • It also provides opportunity to establish consistent behavioral strategies in therapy and at home.

20. REFERENCES American Speech-Language-Hearing Association. (2007). Childhood Apraxia of Speech[Position Statement]. Retrieved from American Speech-L anguage-Hearing Association: www.asha.org/policy Ayres, A. (1979). Sensory integrationand the subjects. Los Angelos, CA: Western Psychological Services. Ebert, C. (2010). Suspected apraxia and early intervention. Cross Country Education Inc. Toledo. Hanschu, B. (2003). Evaluation and treatment of sensory processing disorders: From perspective of the ready approach. Developmental Concepts. Phoenix, AZ. Kaufman, N. R. (1998, 2001). The Kaufman Speech-Praxis Treatment Kit 1 - Basic Level. Gaylord, MI: Northern Speech and National Rehabilitation Services. Kaufman, N. R. (1995). The successive approximation method of intervention for children with apraxia of speech. Retrieved from www.apraxia- kids.org. Liepmann, H. (1900). Das krankheitsbild der apraxie (motorischen asymbolie) auf grundeines falles von einseiteger apraxie. Monatsshrift fur Psychiatrie und Neurologie, 8, 15-40. Lindamood, P. C. (1998). The lindamood phoneme sequencing program for reading, spelling and speech LiPS teacher's manual for the classroom and clinic third edition. Austin, TX: Pro.ed an International Publisher. Mailloux, A. A. (1981). Influences of sensory integration procedures on language development. The American Journal of Occupational Intervention , 35, 383-390. Marshalla, P. (n.d.). The non-verbal apraxic subject: Speech-language techniques. Kalamazoo, MI: Marshalla Speech and Language. Orton, S. (1937). Reading, writing, and speech problems in children. New york: W. W. Norton. Stoeckel, R. (2010). The importance of parent involvement in the speech intervention process for children with apraxia. Retrieved January 5, 2010, from Apraxia-kids: http://www.apraxia-kids.org