Childhood Apraxia DefinedTypically 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)

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

CAS & Impact on Overall Communication

Decreased intelligibilityDisordered languageSocial withdrawalBehavioral aggressionAcademic failure

CAS & Impact on Overall Communication

Decreased intelligibilityDisordered languageSocial withdrawalBehavioral aggressionAcademic failure

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)

Differential DiagnosisCAS 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

Movement

For CAS, re-conceptualize the way you think about articulation and phonology

Move away from thinking about soundsDon’t think about processesMovements are the focus

Motor Learning Theory

Motor learning occurs as a result of experience & practice

1. Pre-practice skills2. Conditions of Practice

Pre-practice to Establish Motor Learning

Pre-practice portion of a therapy session involves

–Focused attention–Motivation–General idea of task–Observational learning

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

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

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

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

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

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

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

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

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

Hierarchy of Response/Cued Support

–simultaneous production with examiner

–direct imitation–delayed imitation (gradually increase

delay time)–spontaneous

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

Play & SuccessBeginning 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

Move into new movements• Take the correct transitions in their repertoire &

ask them to directly imitate words they can say • Get successes 1st! (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

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,

Base List • SLP learns what child is able to say & getting

imitations of these• Prior to the 2nd 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 1st session)• Continue with play activities from 1st session while

introducing the base list combinations (e.g., uh-oh, mama, baby, oh-no, boo, baa, moo, me, my, bye)

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

Break Down & NewNext, 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

Produce new word (not on base list)

– immediately reinforce verbally– word is added to the base list – introduce into later

activities/sessions

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

Conditions of Practice

– Reference for correct– Repetitive practice

mass vs. distributedrandom vs. blocked

– Knowledge of performance– Knowledge of results

immediate vs. summary– Rate & prosody– Stimulus/response complexity

Combinations• Continue as in Session 2.• Begin to combine 2 of their base words together,

attempting to keep one of the words consistent (either 1st or 2nd) & 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

Rudimentary Carrier Phrases

Begin to introduce rudimentary carrier phrases.– My…– Oh no… – I…

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)…

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

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)

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