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Overview
• Childhood apraxia of speech
• Two studies
1. Intervention and follow-up study (McNeill,
Gillon & Dodd, 2009, 2010).
2. Prospective evaluation of features of
childhood apraxia of speech (McNeill, in
progress)
Childhood Apraxia of Speech:
Evidence of phonological
awareness treatment
effectiveness
Brigid McNeill
Gail Gillon
Barbara Dodd
Rationale
• Deficits in CAS are not limited to speech
– Persistent reading and spelling difficulties (Lewis et al., 2004; Stackhouse and Snowling, 1992)
– Poor phonological awareness skills (Marion et al., 1993; Marquardt et al., 2002, McNeill et al., 2009)
– Reading and spelling may be more affected than other developmental speech-language disorders
(Lewis et al., 2004; 2012)
Rationale
• Possible to integrate speech, phonological
awareness and letter knowledge goals in
children with speech disorder (Gillon, 2000, 2002, 2005)
• Pilot study: 3 children aged 6-7 years with
CAS (Moriarty & Gillon, 2006)
Aim
• Evaluate the effectiveness of an integrated
intervention for children with CAS that
simultaneously targets
– Speech sound production
– Phoneme awareness
– Letter-sound knowledge
Diagnostic Model (Ozanne, 2005)
Phonological planning
Phonetic programming
Motor execution
Characteristics
Inconsistent speech errors
Vowel and consonant errors
Atypical speech errors
Articulatory groping
High number of consonant
omissions
Atypical oro-motor function
Participant Selection Process
SLTs trained across NZ
44 children with sCAS (4 – 7 yrs) assessed
CAS
n = 12
3 females, 9 males
Inconsistent SD (ISD)
n = 12
3 females, 9 males
Participants
• CAS Inclusionary criteria • Moderate-severe speech disorder
• Non-developmental speech errors
• Atypical oro-motor function
• Inconsistent speech production (DEAP)
• PPVT SS within 1.5 sd of the mean
• 12 children with CAS (3f, 9m)
• 12 children with TD (3f, 9m)
Speech Data (single word) Age (yrs; months) PCC Participant
1
2
3
4
5
6
7
8
9
10
11
12
4;3
4;3
4;5
4;5
4;7
5;0
5;4
6;6
7;3
7;3
7;6
7;8
14%
19%
53%
55%
42%
25%
54%
76%
70%
58%
71%
81%
% of Group within Normal Limits
0
10
20
30
40
50
60
70
80
90
100
PA LK Burt
Perc
en
tag
e o
f g
rou
p w
ith
in n
orm
al
lim
its
CAS
ISD
TD
Study Design
• Multiple single-subject and comparative
group design
Baseline
repeated
measures
2 weeks
Intervention
block 1:
6 weeks
Intervention
break:
6 weeks
Intervention
block 2:
6 weeks
Post
repeated
measures
2 weeks
Pre-test Post-test
Repeated Measures (for each target speech error pattern)
Speech
Production
Probes
10 trained
words
5 untrained
words
Phoneme
Awareness
Probes
Control
Language
Probe
Pre-Post Measures (Group)
• PCC, PVC: single word articulation
• Spontaneous connected speech
• Inconsistency %
• Standardized phonological awareness
• Letter-sound knowledge
• Decoding
– Real word, non-word
• Informal spelling test
Integrated PA Intervention
Phoneme Awareness
Speech
Production
Letter-sound
knowledge
Intervention
• Targeted speech production practice within PA
activities
• Using phonological cues and graphemes to
prompt speech production
Phoneme Identity
k c
star king
Phoneme Segmentation Bingo
“sleep”
Activity: Manipulation with letters
t o p
s m k
b r l a e i
Prompt Speech with Letters
• Level 1
• When you say “top”, I can‟t hear the
/s/ sound at the start
• Try and say stop again with a /s/
sound at the start
s t o p
“top”
Prompt Speech with Letters
• Level 2 (more support)
– Child: “top”: Prompt as per level 1
– Child: “top”
– “let‟s make it easier to say – copy me”
– Work at building the sounds closer together
s t o p
Results: Single-Subject Example
0
10
20
30
40
50
60
70
80
90
100
Probes
% p
ho
ne
me
s c
orr
ect
Trained
Untrain
ed
Billy: S-cluster production speech probes
Results: Single-Subject Example
Billy: S-cluster production PA probes
0
10
20
30
40
50
60
70
80
90
100
Probes
% p
honem
es c
orr
ect
Trained
Untrained
Repeated Measures Summary
• Speech – 10/12 participants: improvement in trained and
untrained speech targets • 1 school aged participant: improvement in trained target 1 only
• 1 preschool participant: no improvement
• Phoneme awareness – 9/12 participants: improvement in trained and untrained
• 1 school aged participant: trained improvement only
• 2 preschool participants: trained improvement only
Speech Generalization
0 2 4 6 8 10 12
Target 1
Target 2
No of participants who generalized speech target
Group Results
0
2
4
6
8
10
PA* Letter* Real reading Non-word
reading*
Spelling*
Co
mp
ara
tiv
e C
ha
ng
e
CAS Typical
* Significant difference * Significant difference, p < .05
Item Pre (6;6) Post (6;11)
rain
kangaroo
girl
shark
dinosaur
teeth
fish
chips
bridge
cake
*Items not directly trained in intervention
r ran
cau kangwoo
jo gol
c shak
danc dinshor
tc tef
fohpne fish
thedhcl
qanenelc
ddenlce
tis
bish
kak
Longer term results
• 6 month follow-up assessment
– PA, decoding, spelling, letter knowledge
• Children with CAS able to maintain gains
– Did not continue accelerated growth
TOPA
0
2
4
6
8
10
12
14
16
18
20
PRE POST FOLLOWUP
RA
W S
CO
RE
CAS
TYPICAL
Phonological Awareness (TOPA)
Non-Word Reading
0
10
20
30
40
50
60
70
80
PRE POST FOLLOWUP
Perc
en
t P
ho
nem
es C
orr
ect
CAS
TYPICAL
Conclusions
• Integrated method effective and efficient
for most participants
• Gains could not be explained by general
maturation
• Generalization to reading and spelling
• Transfer to connected speech immediately
post-intervention for some participants
Clinical Implications
• Important to assess PA and other early literacy abilities in CAS – Receptive tasks where possible
• Possible to target PA and reading/spelling without compromising speech gains – May require ongoing support to continue accelerated
development
• Important to target spoken and written language in CAS
A longitudinal examination of inconsistent speech production errors in
children with severe speech disorder
Brigid McNeill, PhD
Outline
• Brief introduction to inconsistent speech errors
• Overview of entire longitudinal project
• Study: Focus on inconsistent speech over time
• Time for questions
Inconsistency
• Inconsistency of phoneme based on word position –
• Inconsistency of phoneme based on lexical item – dilk, mummy
• Inconsistency across multiple productions of the same word
/efənt/ /elfənt/, /elfʌs/
A cross-section sample (n=409) of children aged 3;0 – 6;11 showed that inconsistency rates of 10-13% Younger children more variable In typical development, variation tends to involve alteration between correct and immature form (e.g., rabbit-wabbit)
Token to Token Inconsistency in Typical Development
Holm, Crosbie & Dodd, 2007
Token to Token Inconsistency in Developmental Speech Disorder
Dodd, 2005
Differential Diagnostic Features
Inconsistent
• Token-token
• Not other forms of variability
Coarticulatory transition
• Prolonged sounds
• Prolonged pauses between sounds
Prosody
• Phrasal
• Sentential
ASHA, 2007
Differential Diagnostic Features
• BUT…..
– „not proposed to be necessary and sufficient
signs of CAS…‟
– Features will change over time
– Lack of validation
– „A consensus starting point‟
CAS
(n = 12)
Inconsistent
(n = 12)
Typical
(n = 12)
Age (months) 68.5 (17.0) 61.2 (8.1) 73.4 (15)
PPVT 90.4 (8.1) 97.8 (9.5) 97.2 (8)
PCC 51.6% (22.5) 52.5% (19.0) 97.6%** (2)
Whole-word
Inconsistency
(DEAP)
59% (17.7)
57.0% (13.4)
2%** (4)
Oro-motor 14.0** (4.2) 27.3 (2.4)
** significant difference at 0.001 level McNeill, Gillon and Dodd, 2009
Mean performance on the TOPA (standard score)
0
10
20
30
40
50
60
70
80
90
100
TOPA
sta
nd
ard
sco
re
CAS
Incon
Typical
**
** significant difference at 0.001 level
Percent in each group performing within/above normal limits
0
20
40
60
80
100
120
PA Letter Reading
CAS
Incon
Typical
Childhood Apraxia of Speech
Inclusion criteria
Describe group
Identify diagnostic features
Study Overview
• Children aged 4;6 – 7
– Exhibit at least 1 of the 3 potential diagnostic characteristics
– Followed over time: 5 assessments over 2 years
– Explore characteristics over time
– Look at association between diagnostic characteristics and other parts of the linguistic profile
Recruitment N = 55 40 children with inconsistent speech disorder (34) • Two have left the study • Four: profiles not suited to being grouped 15 children (coarticulation and/or prosodic features without inconsistent speech) Overall attrition: 3 children
Longitudinal examination of
inconsistent speech errors.
Brigid McNeill, PhD
College of Education
University of Canterbury
Research Questions
• How does the speech (severity and inconsistency) of children with ISD change over time?
• What predicts chronic inconsistent speech production over time?
• What are the differences between children with ‘chronic’ and ‘transient’ inconsistent speech errors
Participants
• N = 34 (27 males, 7 females) aged 5;0-7;10
Variable Mean (sd) Age 68.9 (9.4)
TONI 101.3 (9.8)
PPVT 92.9 (11.2)
Inconsistency 56% (12.1)
PCC 53.6% (21.0)
PVC 86.1 (19.8)
Oromotor 10 below normal limits
Measures
• DEAP (Phonology + Inconsistency)
• Oro-motor (VMPAC)
• Connected speech (intelligibility, prosody, expressive language)
• Receptive language
• Phonological Awareness
• Word reading, decoding and passage comprehension
• Spelling
/kæɳgəru/
/tæwu/
/kæɳgəru/
Male, aged 7;6
/gʌk/
/dʌ/
/gak/
Male, aged 7;6
Inconsistency ‘diagnosis’ over time
0
20
40
60
80
100
120
Time 1 Time 2 Time 3 Time 4
0
10
20
30
40
50
60
70
80
90
100
Time 1 Time 2 Time 3 Time 4
Change in Speech Over Time
PCC PVC Incon
*
* *
*
What predicts inconsistency over time?
• DV: Change in inconsistency % (taking into account inconsistency at time 1)
• Regression analysis:
– Step 1: Age (insignificant, p =0.556
– Step 2: PCC (time 1)*, p =0.042; PVC (time 1) p =0.103,
– Step 3: Oro-motor (time 1), p = 0.706
– Step 4: PPVT* (p = 0.016), TONI (p = 0.321)
Chronic versus Transient Inconsistents Chronic
(n = 21)
Transient
(n = 13)
Age (months) 69.7 (10.7) 67.6 (6.99)
PPVT 89.0 (9.3) 99.2 (11.5)
TONI 98.0 (8.0) 106.5 (10.5)
PCC Change 0.66 (0.65) 0.44 (0.34)
PVC Change* 0.14 (0.25) 0.02 (0.03)
Oro-motor* 64 (8.3) 82 (9.2)
Inconsistency (Time 1) 60.6 (11.6) 48.6 (9.1)
Chronic versus Transient Inconsistents
Chronic
(n = 21)
Transient
(n = 13)
Phonological Awareness 84.7 (14.2) 94.5 (15.9)
Word Reading 94.0 (14.5) 107.7 (13.8)
Decoding 88.2 (12.7) 103.8 (13.7)
Passage comprehension 91.1 (13.8) 106.3 (15.2)
Spelling* 78.8 (7.6) 91.8 (17.7)
Conclusions
• Inconsistent speech errors are relatively stable over time
• Chronic use of inconsistent speech errors appears to be associated with oromotor skills and vowel production
– 2 other forwarded markers of CAS
• Chronic use of inconsistent speech errors impacts literacy development
Future Steps
• Dig further into the data – Models predicting inconsistent speech production
– Subgroups of inconsistency. • substitutions (e.g. any fricative will do) are less of a
marker of severity than changes in syllable structure/number of syllables or single phoneme favouritism (e.g., /v/ at the start of every word)
• Association between inconsistent speech and other forwarded markers of CAS (ASHA, 2007)
