Treating Childhood Apraxia of Speech Preschool and more severe children
Professor Tricia McCabe PhD CPSP
The University of Sydney
27th June 2018
@tricmc#apraxia
DisclosuresTricia• is employed by The University of Sydney;• works as a Speech Pathologist in private practice for Cate Madill Voice
and Speech;• is an unpaid member of the Professional Advisory Council of
Apraxia – Kids PLL;• is a certified practicing member of Speech Pathology Australia;• has been an Accreditor of university degrees for SPA;• is an unpaid member of the Professional Standards Advisory
Committee of SPA.
The ReST website was funded by a philanthropic grant from the Ian Potter Foundation.
Tricia has no other financial or nonfinancial relationships to disclose.
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Overview
• Definition and differential diagnosis of CAS.
• The nature of CAS as a motor programming and planning disorder should lead to treatment decisions.
• Recognise CAS treatments which are both evidence based and effective.
• Explore Dynamic Temporal and Tactile Cueing, Nuffield Dyspraxia Programme, use of AAC in CAS and other treatments for severe speech disorder in CAS.
• Understand the importance of developing speech and language concomitantly in children with CAS.
Definition of CAS
Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech 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). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder.
The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.
ASHA Technical Report (2007)
http://www.asha.org/docs/html/TR2007-00278.html
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ASHA consensus core features of CAS
• Inconsistent errors on consonants & vowels nb definitions of consistent
• Disruptions to co‐articulatory transitions– movement between syllables and/ or sounds
• Inappropriate prosody‐ especially in the realization of lexical or phrasal stress
THESE ARE THE DIAGNOSTIC MINIMUM FOR CAS
ASHA 2007
Comparison of ASHA & Shriberg
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ASHA CAS Technical Report Criteria (ASHA, 2007)
Dx: all 3 met
Inconsistency
Difficulty transitioning between sounds and syllables
Inappropriate lexical or phrasal stress
10 point checklist (Shriberg, Potter & Strand, 2009)Dx: at least 4/10 met (over 3 tasks per criterion)
N/A
1. Difficulty with initial and transitory movements
2. Syllable segregation
3. Equal or lexical stress errors
4. Distorted substitutions
5. Groping (non-speech)
6. Intrusive schwa
7. Voicing errors
8. Slow rate
9. Slow diadokinetic (DDK) rate
10. Increased difficulty with polysyllable words
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Ozanne and colleagues
CAS = Inconsistent deviant speech disorder with speech motor impairment
– Dodd’s definition of inconsistent (see DEAP)
– Deviant means not developmental
– Motor impairment is difficulty with DDK tasks
Ozanne, A. (2005). The speech of children with developmental apraxia of speech. In B.Dodd Differential diagnosis and treatment of children with speech. London, Whurr.
Inconsistency vs. Variability
Consistency
• Phonemic (as per DEAP)
• Phonetic (as per Iuzzini‐Seigel et al)
• Word list repeated (eg DEAP)
• Words repeated (eg Apraxia Battery)
• Deviant vs. developmental errors
Variability
• Across tasks, linguistic complexity etc
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Questionable features
• Speech groping.
• Slow rate of improvement in therapy.
(these two are possibly iatrogenic)
• clumsiness.
Babies and Infants
• Fewer vocalisations but babbling seems to be similar in structure
• Fewer consonants or used less frequently
• Delayed emergence of vowels
• Age appropriate syllable shape inventory with fewer productions
• Limited change over time
NB NO evidence of not talking or not attempting to communicate
Baker, E., (2018). Toddler Polysyllable Test 3 (TPOT3). Sydney, Australia: AuthorGathercole et al (1994). The children's test of nonword repetition: A test of phonological working memory. Memory, 2(2), 103‐127. doi:10.1080/09658219408258940Gozzard, H., Baker, E., & McCabe, P. (2006). Children’s productions of polysyllables. ACQuiring Knowledge in Speech, Language and Hearing, 8(3), 113‐116.Stokes, S. F., & Klee, T. (2009). The diagnostic accuracy of a new test of early nonword repetition for differentiating late talking and typically developing children. Journal of Speech, Language, and Hearing Research, 52(4), 872+.
My motor speech disorders assessment
• Case history and hearing
• Connected speech – book or play
• SW – Polysyllables if possible
• Consistency
• OMA
• Probes for specific concerns
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Dynamic assessment
• Dynamic Evaluation of Motor Speech Skills (DEMSS ; Strand, McCauley, Weigand, Stoeckel, & Baas, 2013)
• This tool is designed for use with severe and complex speech sound disorders in young children and provides a structured approach to evaluating speech potential.
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Strand et al 2013
Questions to help with diagnosis
• Phonological analysis. Is there an observable pattern?
• Is the child consistent?
• Does the child have motor impairments? DDK?
• Are there timing errors or problems with syllable transitions?
• Are there deviant speech errors?
• Does the child have any OTHER recognised condition which could explain your results eg cerebral palsy, hearing impairment etc.
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In my private practice…
• 2nd opinion assessments usually turn out to be something else
– Resonance
– Phonology + Voice
– Phonology + resonance (+ voice)
– Voice + Phonology + Stutter
What about CAS + Phonology?
• A: Treat the Phonology first!!
When you hear hoof beats …
… think horses NOT zebras
The simplest explanation is usually the best
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Principles of Motor Learning (and Neuroplasticity)
Principles of Motor Learning
Movement memories are implicit*
‐ require attention,
‐ depend on repetition, and
‐ tend to be modality and context specific.
Speech is one of the most complex movement sequences we do!* (and only in the brain).
• General motor plan – for multiple motor goals eg the idea of /k/
• Specifies spatial and temporal aspects of motor movement eg the specific [k] in [kɪs] (kiss)
van der Merwe, 2009
Motor Planning makes/ uses a General Motor Plan (GMP)
A single GMP can be used in many situations
e.g. tennis swing can be hard or soft
(but not used for squash)
e.g. /k/
• “kiss” & “sick”
What happens when …
‐ you mislearn a plan? ‐ or can’t store one in the first place?
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Motor programming…
• Specification of – Muscle tone
– Movement velocity (rate)
– Strength of movement
– Range of movement
– Mechanical stiffness of joints
• Considers motor equivalence – multiple ways to obtain same acoustic goal = sounds!
• Known as “parameterisation”
Motor sensory circuitsSpeech motor cortex (SMA)
Frontal lobe
Cranial nervesSpeech motor cortex (SMA)
Cranial nerves Muscles & nerves of vocal tract & respiration
Programming(coordination, timing)
Cerebellum,subcortex
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BOTH planning and programming
are needed to learna new motor skill
Motor learning
“the process of acquiring (and retaining) the capability for producing skilled actions”Schmidt & Lee, 2011
Acquisition
Short‐term performance
Acquisition
Short‐term performance
Learning
Generalisation & retention
Learning
Generalisation & retention
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Motor learning
• Acquisition = only in the session
• Learning = transfer, generalisation, retention
• Pre‐practice (teaching) aims for acquisition
• Practice (training) aims for retention
Principles of motor learning (PML)
Pre‐practice (teaching)
• Massed (blocked) practice
• Low rate of practice
• Feedback on technique
• Feedback 100%
• Low target complexity
• Until the patient demonstrates
acquisition
Practice
• Randomised practice
• Distributed practice
• High rate of practice
• Feedback on outcome
• Feedback – timing, random, not 100%
• Target complexity
Maas et al, 2008; McIlwaine, Madill & McCabe, 2010
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What is an internal reference of correctness? And why is it important
Pre‐practice = acquisition
AIM: Develop an internal reference of correctness (know what is required)
Practice = learning
AIM: be able to independently use the skill
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Acquisition vs. learning
• Treatment which is low intensity, easy targets with high frequency knowledge of performance feedback leads to acquisition – an in‐the‐session change
• Treatment which is high intensity, hard targets with low frequency knowledge or results feedback leads to long term change in behaviour – i.e. learning
Applies to all motor learning. Requires resilient clinicians
Important Expectation!
Use of these principles in therapy may result in slower acquisition (process of learning), but long‐term gains (learning) will be substantial.
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When do you apply the PML?
In any disorder with a motor component – both adults and kids
– Articulation
– Apraxia
– Accent
– Dysarthria
– Stuttering
– Voice
– Dysphagia
– Hand writing
Good treatments for motor speech disorders will:
• Use the principles of motor learning
• Give feedback on what you hear not what you see (beware the McGurk effect)
• Teach “core” words
• Include variety
• Include drill based games/ activities
• Work on speech ! (nb no evidence that nsomeworks)
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Evidence based treatments for preschoolerswith CAS
Hierarchy of evidenceLevel Description
IaWell‐designed meta‐analysis of >1 randomized
controlled trial
Ib Well‐designed randomized controlled study
IIa Well‐designed controlled study without randomization
IIb Well‐designed quasi‐experimental study
III Well‐designed non‐experimental studies, i.e.,
correlational and case studies
IV Expert committee report, consensus conference,
opinion of respected authorities
Levels of evidence for treatment efficacy, from ASHA (2004)
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Q: What to do when the evidence
• isn’t there?
• doesn’t match your patient?
• is low quality?
A: Science!
• a single case experimental design approach to treatment
• informed consent
• data– baseline
– treatment
– control
– generalisation
• Clear and agreed review and exit points
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Evaluating treatments Leve
l Description
Ia Well‐designed meta‐analysis of >1 randomized controlled
trial
Ib Well‐designed randomized controlled study
IIa Well‐designed controlled study without randomization
IIb Well‐designed quasi‐experimental study
III Well‐designed non‐experimental studies, i.e., correlational
and case studies
IV Expert committee report, consensus conference, opinion of
respected authorities
Levels of evidence for treatment efficacy, from ASHA (2004)
Modified from Thomas, D. (2017) Rapid Syllable Transition treatment for childhood apraxia of speech: exploring treatment efficacy in three service delivery contexts . Umpublished PhD thesis. The University of Sydney
Maas, E., Gildersleeve‐Neumann, C. E., Jakielski, K. J., & Stoeckel, R. (2014). Motor‐Based Intervention Protocols in Treatment of Childhood Apraxia of Speech (CAS). Current Developmental Disorders Reports, 1 197.
How to choose a therapy technique...
Treat what you see !
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Non speech oral tasks
No evidence in paediatric or adult literature that training non‐speech oral tasks will improve speech
To improve speech – work on speech (PML)
e.g., Lof, 2008; Strand & McCauley, 2009
How to choose a therapy technique... (factors to consider)
• age of the child• severity of the SPEECH disorder.• principles of motor learning• likely duration of therapy.• previous approaches used with the child.• naturalness of outcome especially prosody.• family commitment.• time available• need for AAC (PECS, sign etc) & LANGUAGE development• other impairments.• be clear: when to move on to another treatment
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So what are the evidence based treatments for younger and more severe children with childhood
apraxia of speech?
Three with best evidence
• Nuffield Dyspraxia Programme ‐NDP3
• Dynamic Tactile and Temporal Cueing ‐DTTC
• AAC
Older or less severe
• ReST
• IPA
• Biofeedback
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Nuffield Dyspraxia Programme
• frequently used by Australian SLPs (Gomez 2018)
• RCT evidence = 4 sessions per week for 3 weeks
• manual recommends 3‐4 sessions per week
• need to target 3 goals simultaneously – each session.
• Use ‘Treatment Planning and Progression’ checklist in the programme
• Do not do NSOME (we through it out)
• Chose 3 areas to work on simultaneously• Work on new sounds in old structures/ words
• E.g. New sounds as single sounds
• Work on known sounds in new words
• E.g. If child can say ‘m’ and ‘f’ and ‘h’ and ‘b’ put them in one syllable CV words
• E.g. ‘more’, ‘far’, ‘hi’ and ‘boo’
• Can work on prosody, resonance, pitch or other suprasegmentalsas needed
• Then specific sounds/ words for each goal
Nuffield Program (NDP3) goals
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NDP3 speech hierarchy:
(Williams & Stephens, 2004 section 4 pg 74.)
Level 1: early consonants, vowels and CV words (e.g. More)
Level 2: 1 and 2 syllable words
Level 3: later developing sounds, 2 and 3 syllable words, clusters some phrases
Level 4: last developing sounds, any word gaps, sentences and conversation
Nuffield Program (NDP3)
• Drill play
• Symbolic representation of sounds
• Repeated and alternating– Sounds, Syllables & Words
• Pre‐developed games, handouts & pictographs
• NDP3 Speech Builder program
• Risks: Poor Prosody; poor goal setting by habit
Williams, P. and Stephens, H. (eds) (2004) Nuffield Centre Dyspraxia Programme 3rd edition. Windsor, UK: The Miracle Factory
LEVEL OF EVIDENCE One RCT Murray, McCabe & Ballard 2015, one repeated single caseNew research – eNuffield
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If correct:• Ask the child to repeat the word/ stimuli 3 x
If incorrect – teaching includes…• Verbal instructions• Pictured sounds/ words/ sentences• Modelling• Articulation cues – teeth together for ‘s’• Cued articulation – hand signs to signal sounds – tactile • Visual cues – ladders for voice volume or pitch,
articulograms
NDP3 teaching strategies
A word about ReST
• Rapid Syllable Transition Treatment – the other treatment in the RCT
• For children aged 4 and over
• Nonsense words
• Risks: Child, clinician and parent need to be resilient; nonsense words
• More info in next webinar
• www.sydney.edu.au/health‐sciences/rest
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Dynamic Temporal and Tactile Cueing“listen to me, watch me, do what I do”
•shaping speech motor skill
•start where the child has success
•choose functional sounds or words
•uses touch cueing, simultaneous productions, immediate and then delayed imitation
• aims for errorless learning
• always teach words as a whole movement
• starts with face to face (very close)
• Hint for touch cueing – start on arm, ask permission, move up slowly..
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Dynamic Temporal & Tactile Cueing (DTTC)
•repetitive and distributed practice•high rate of feedback on both performance and result
•all studies have multiple sessions per week•new work shows maybe able to train parents, definitely can train tutors/therapy aides
•move on to other treatments •Risks: all evidence is intensive
LEVEL OF EVIDENCE: Multiple single cases with a range of children incl developmental disability
(look up Dr Edy Strand DTTC for demonstration video)
AAC• “with the AAC systems she would attempt to repair
conversation, had clearer speech and a decrease in frustration levels”
• “resulted in an increased mean length of utterance (MLU), more novel utterances and better maintenance and repair of conversation”
• improves speech confidence and resilience• improves language output• not used when no longer needed• Risks: Parent or child rejection
LEVEL OF EVIDENCE: Multiple repeated single cases of various levels
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AAC evidence in CAS Aided AAC modelling with
picture symbols
Binger et al., (2011)
Binger et al., (2008)
Binger & Light (2007)
Speech generating devices Bornman et al., (2001)
Harris, Doyle et al., (1996)
Luke (2016)
Partners in Augmentative
Communication Training
Culp (1989)
Integrated multimodal
intervention
King et al., (2013)
Eclectic (signing,
communication board, and
various speech approaches)
Watson & Leahy (1995)
Tierney et al., (2016)
Cumley & Swanson (1999)
from Thomas, D. (2017) Rapid Syllable Transition treatment for childhood apraxia of speech: exploring treatment efficacy in three service delivery contexts . Umpublished PhD thesis. The University of Sydney
EVIDENCE – 1 single case experiemental design study of 2 children, 1 improved.
Gomez, McCabe, Jakielski & Purcell (2018)
PROMPT
• Prompts are sensori‐motor cues which may be used to signal place, manner, duration, voicing, and tension for phonemes, words or phrases
• Tactile‐kinaesthetic articulatory cues on the jaw, face and under the chin, that “help to develop or restructure speech production output
• Risks: poor prosody; cost to clinician
LEVEL OF EVIDENCE: One single case report (all other journal articles do not contain DATA)
Dale & Hayden (2013).
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Concomitant development of speech and language
Motor Linguistic
Children with multiple diagnoses
• Treat the phonology first
• Language leads speech
• DTTC has been shown to work with kids with developmental disabilities
• Referral to Cleft clinic for VPI asap
• CAS then Stuttering then CAS… (no evidence yet for this)
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What difficulties do children with CAS have in therapy ?
• Progress can be very slow.
• Practice can be boring.
• Frustration.
• Poor prosody can be iatrogenic.
• Poor generalisation.
• Poor self monitoring and self awareness.
What to tell parents
• Don’t believe everything you read on the web.• Intensity is important
• Plan to participate in the treatment process• Some sessions just don't work well, that is ok.• Be careful about learned helplessness (yours and your child’s)
• Don't expect overnight success• Get second opinions if you want• Know your legal rights eg NDIS.
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SummaryTreatments for younger/
more severe kids
• Issues:– Concomitant language development
– Phonological development
– Getting started
• Nuffield (Williams 2011)
• DTTC (Strand et al various)
Childhood Apraxia of Speech treatment requires practice, frequency & good diagnosis!
No shortcuts available!
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Current recruiting kids aged 3‐6
For more information, client specific questions (with parent consent) or to
