Childhood Apraxia of Speech

CHILDHOOD APRAXIA OF SPEECHInformation from the Conference by:Margaret Fish MS,CCC-SLP

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.

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.

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)

CHARACTERISTICS (CONTINUED) Receptive language (typically) exceeds

expressive language Late in attaining first words At risk for literacy difficulty

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)

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)

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

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)

INCREASING PRACTICE OPPORTUNITES Divide activities into three phases

Set-up the activity Complete the activity Review the activity

(mailman activity example)

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

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

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)

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

ACTIVITIES FOR CREATIVE CHILDREN Block designs Tall tower Dominoes Stickers Progressive drawing (guess what I’m

drawing) Earn it now-make it later crafts

MISCELLANEOUS ACTIVITIES Go fish Memory Simon says Louder/softer (say word louder or softer) Hidden puzzle pieces (hide under target

words)

INTENSITY OF SERVICE Motor learning research suggests that motor

skills are: Acquired more quickly Attained more accurately And are better retainedWith shorter, more frequent

sessions

***She said in a perfect world a minimum of 3-5, 20-30 minute sessions a week is ideal.***

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

PAM’S PLACE- VOWELS (FIND ON YOUTUBE)

VISUAL SYLLABLE WORDS

Toe May Toe

moo Vee

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*

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

PHONETIC MODIFICATIONS Four ways to modify targets: 1. Choose simpler words

“Nana” for grandma “Uh huh” for yes2. 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

KAUFMAN’S SUCCESSIVE APPROXIMATIONS “Day no” “di no” “di no so” “di no saur”

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

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?

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

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