Childhood Apraxia of Speech

1. Childhood Apraxia of Speech Information from the Conference by: Margaret Fish MS,CCC-SLP

2. Definition of Childhood Apraxia of Speech • “A neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of a neuromuscular deficit (e.g., abnormal reflexes, abnormal tone).” • In simple terms it is a disorder of motor planning.

3. Characteristics • Inconsistent errors in production of consonants and vowels with repeated productions of syllables and words. • Lengthened and disrupted co-articulatory transitions between sounds and syllables • Inappropriate prosody (not always, sometimes their prosody is the best thing they have going for them) • Connected speech more unintelligible than expected given phoneme repertoire of results of single-word articulation test.

4. Characteristics (continued) • Limited vocalizations/babbling during infancy. (“very easy baby, was so quite”) • Automatic speech (counting, singing, etc) better than volitional productions. • Groping or silent posturing • Regression (loss of sounds and words) • Poor diadochokinetic rates (pa-ta-ka), accuracy, and rhythm. • Difficulty producing volitional oral movements • Possible feeding difficulties during infancy (unrelated to significant muscle tone weakness)

5. Characteristics (continued) • Receptive language (typically) exceeds expressive language • Late in attaining first words • At risk for literacy difficulty

6. Essential elements of motor speech exam • Provide opportunities for child to: • Produce words imitatively and spontaneously • Produce words with increasingly complex syllable shapes • Repeat test items 3-4 times (not necessarily sequentially) • Execute non-vocal oral movements • Produce phrases and sentences • Produce challenging words with the benefit of cueing (visual/tactile/proprioceptive)

7. Formal assesment Instruments • KSPT- Kaufman Speech Praxis Test for Children (Kaufman) • VMPAC- Verbal Motor Production Assessment for Children (Hayden and Square) • The Apraxia Profile (Hickman)

8. Treatment Considerations • Focus on Phoneme Sequencing • Provide Opportunities for repetitive practice • Provide the appropriate intensity of service • Select vocabulary thoughtfully (functional vocabulary) • Incorporate multisensory cues and feedback • Focus on vowels • Address prosody early on in treatment • Incorporate phonetic modifications as necessary • Move quickly to phrases and sentences • Facilitate carryover

9. Motor Learning Theory • When teaching new movement patterns mass practice is recommended. (Hi mom, hi mom, hi mom) • When trying to habituate skills, distributed practice is recommended. (I got ball, give me, roll down, got it)

10. Increasing Practice Opportunites • Divide activities into three phases • Set-up the activity • Complete the activity • Review the activity (mailman activity example)

11. Materials and activities to promote repeated practice • Echo microphone • Puzzles • Sound Puzzles • String beads or pop beads • Fisher Price Farm • Fisher Price cash register • Cars, trucks and ramps • Train track and trains • Mr. Potato Head • Marble works • Books and songs

12. Materials and activities to promote repeated practice • Books and songs (The big book of exclamations) • Bubbles • Zoo animals • Playdough and accessories • Wind up toys • Games (my turn, your turn, #’s, colors, teach vocabulary so they can play with friends) • Familiar characters with accessories • Dollhouse with family characters

13. Quick games for repetitive practice • Pop-up pirate • Cariboo • Crocodile dentist • Don’t spill the beans • Silly six pins • Lego creator • Mousetrap • Animal buddies • Barnyard bingo • Lucky ducks • Milk and cookies • Silly faces • Colorforms • Memory games • Lotto games • Holiday and seasonal game boards (super duper)

14. Activities for children who enjoy movements • Bowling • Basketball • Long jump: put pictures of words on floor and jump over them. Add a new word each time. (“ I jumped over a ____”, “ I jumped over a ___and ___and ____) • Picture hop • Treasure hunt • Mailman

15. Activities for creative children • Block designs • Tall tower • Dominoes • Stickers • Progressive drawing (guess what I’m drawing) • Earn it now-make it later crafts

16. Miscellaneous Activities • Go fish • Memory • Simon says • Louder/softer (say word louder or softer) • Hidden puzzle pieces (hide under target words)

17. Intensity of service • Motor learning research suggests that motor skills are: • Acquired more quickly • Attained more accurately • And are better retained With shorter, more frequent sessions ***She said in a perfect world a minimum of 3-5, 20-30 minute sessions a week is ideal.***

18. Multisensory Cueing • Specific cueing techniques • Rate variations • Choral speaking (simultaneous production) • Direct or delayed imitation • Mirror • Mime (take away your voice) • Hand motions/positions (Pam’s place on youtube) • Written letters and words • Tapping/clapping out syllables • Syllable manipulatives • Sound names • Phoneme placement cues • Mouth pictures

19. Pam’s Place- Vowels (find on youtube)

20. Visual syllable words May Toe Toe

21. moo Vee

22. Give a lot of feedback • When teaching a NEW motor skill: • Provide frequent feedback • Provide immediate feedback • Provide knowledge of performance • Tell what was not correct about the movement • Tell what should be done differently next time *Limit the amount of information provided- don’t overload*

23. Feedback continued • Progressively fade extrinsic feedback • Provide intermittent reinforcement and feedback • Begin to provide extrinsic feedback in form of knowledge of results (was the target correct or incorrect) • Begin to delay feedback as skill level increases

24. Phonetic modifications • Four ways to modify targets: • 1. Choose simpler words • “Nana” for grandma • “Uh huh” for yes 2. Teach alternate articulatory placement (e.g. dental placement for alveolors) 3. Consider normal phonological patterns (Kaufman) • Syllable reduction, reduplication, cluster reduction, final consonant deletion, liquid gliding, or vowelization 4. Vowel simplification (e.g. pure vowels for dipthongs) • This gives children power and a function vocabulary • Honoring the modifications increases vocabulary

25. Kaufman’s Successive Approximations • “Day no” • “di no” • “di no so” • “di no saur”

26. Facilitation generalization • Increase practice opportunities • Increase flexibility by using many phoneme contexts • Reduce cueing • Increase rate • Reduce pausing between syllables/words • Change feedback from descriptive (knowledge of performance) to correct/incorrect (knowledge of result) • Choose functional vocabulary • Enlist help of family/teachers

27. Extra info that I thought was cool but didn’t really pertain to apraxia much… • Teach children to ask appropriate follow-up questions discretely: • Use question cue cards • Limited choices of cue cards “I’m feeling kind of sad today” Where? Why?

28. Conversations • Integrating the three basic conversation extenders through discrete practice: • What type of conversation extender is the student predominantly using? • Who is doing the most talking? • Use chipper chat tokens, each person has their own color. Put token on card when they do it. Ask a question Make a comment Tell something about you or someone you know

29. The conversation train • Colored strips or small trains, one color for each person in the conversation • Lay strips side by side for each conversational turn • Include “talk over” or interruption strip • Include “off topic” card Talk over card Off topic card