Childhood Apraxia of Speech: Parent Involvement in Evaluation and Therapy

1. Childhood Apraxia of Speech: Parent Involvement in Evaluation and Therapy Brisbane, Australia June 16, 2007 David W. Hammer, M.A. CCC-SLP Children’s Hospital Of Pittsburgh, PA USA

2. WWW.APRAXIA-KIDS.ORG • “Time to Sing” CD - 2000 • “Hope Speaks” DVD - 2005 • “Treatment Strategies” DVD - 2006 • AdHoc Committee Documents - 2007 • “Taking it Home” DVD - 2007

3. WHAT DIAGNOSTIC CHALLENGES FACE US? • Diagnosing toddlers in the 2-3 year-old range • Apraxia is difficult to diagnose if limited sample. • Diagnosis helps parents to ground themselves and eventually complete necessary grieving. • Sometimes it is hard to let go of a diagnosis. • Don’t need neurologist to confirm but follow through with assessment if recommended • “Differential Diagnosis for Childhood Apraxia” • Video Clip -- Ross, age 3-4

4. Parents often report limited sound play. Child usually has a limited sound inventory. Language comprehension abilities are far superior to expressive language skills. Child does better when he imitates than when he tries to say things on his/her own. Child has major problems sequencing. As words or sentences get more complex, precision and clarity break down further Video Clip -- Anna, age 3-10 Differential Diagnosis

5. Child’s speech reflects unusual stress patterns, poor range of inflection, and frequent pausing Child’s speech often is inconsistent Video Clip -- Jacob, age 3 Voiced/Voiceless sound errors occur “Groping” behaviors are observed Vowel distortions are very common Video Clip -- Alex, age 5 12.Sound omissions occur in the first position of words which is unusual Differential Diagnosis

6. ADHOC COMMITTEE’S DEFINITION OF CAS “Childhood apraxia of speech is a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits.” “The core impairment…in planning and/or programming…movement sequences results in errors in speech sound production and prosody.”

7. ADHOC COMMITTEE’S 3 CONSENSUS FEATURES • Inconsistent errors on consonants and vowels in repeated productions of syllables or words • Lengthened & disrupted transitions between sounds & syllables • Innappropriate prosody, especially in relation to word and phrase stress

8. Unfortunately, pure apraxia of speech is rare!!! Video Clip - Mickey, age 6 Video Clip - Anna, age 8-1

9. WHAT DOES MY CAS ASSESSMENT INCLUDE? • For young children, most testing is informal. • Formal test resources are used if needed. • In-depth parent information is obtained. • Other apraxic features are investigated. • Nonspeech oral skills are evaluated. • Video Clip -- Michael, age 4

10. WHAT CAUTIONS DO WE NEED TO CONSIDER? • Concern for misdiagnosing: Nonverbal child Dysarthric child Severe phonologically disordered child Confounding diagnosis child

11. Comparison of Childhood Apraxia of Speech, Dysarthria and Severe Phonological Disorder

12. Comparison of Childhood Apraxia of Speech, Dysarthria and Severe Phonological Disorder

13. Comparison of Childhood Apraxia of Speech, Dysarthria and Severe Phonological Disorder

14. WHAT CAN I EXPECT AT THE EVALUATION? • Therapist may say they are unsure, and call it a “working” or “suspected” diagnosis of apraxia, which is difficult sometimes to hear. • Therapist may say haven’t seen many children, and they don’t consider themselves an apraxia “expert” but… • You should be provided resources (Parent-friendly handouts; “Hope Speaks” DVD; Parent group contacts; Website guidance such as “The Family Place--The Start Guide”)

15. WHAT SHOULD WE PREPARE FOR NEXT? • Find a way to be part of the team right away. • Prepare for the “plateau effect” in therapy • Understand “Prognostic Indicators” (usually after therapy begins but may need to address earlier) • Follow through with additional evaluations if recommended by the evaluator • Video Clip -- Sharon Gretz & Dr. Campbell

16. WHAT SHOULD THERAPY LOOK LIKE? • Should start out as individual Tx • Should be tailored to your child’s needs • Should reflect a balance in time spent with your child and time spent with you • Should support your involvement • Video Clip, Doug and Mom • Should be a mix of drill and play activities

17. HOW DO WE PARTNER WITH OUR CHILD’S THERAPIST? • Therapist: Explain changing nature of Tx intensity • Parents: Understand intensity needs may change • Therapist: Ensure parents feel they can help • Parents: Be honest about home practice

18. HOW DO WE PARTNER WITH OUR CHILD’S THERAPIST? • Therapist: Consider eventual dyad/group tx • Parents: Be open to dyad/group therapy options • Therapist: Enable parents to observe sessions • Parents: Understand constraints on this

19. HOW DO WE GET STARTED? • Listen for your child’s expressions/env sounds and let therapist know these. • Understand how to use “starter positions” such as “mm”, “oo” and “ee”. • Video Clip -- Austin, age 4-3 • Use sound “names” to make it more fun to prompt verbal speech.

20. Visual and Verbal Cues for Treatment

21. Visual and Verbal Cues for Treatment

22. Visual and Verbal Cues for Treatment

23. Visual and Verbal Cues for Treatment

24. Visual and Verbal Cues for Treatment

25. HOW DO WE GET STARTED? • Make a core vocabulary book. - Benefits and Procedures

26. CORE VOCABULARY BOOK- BENEFITS • Organizes a starting vocabulary that facilitates a mutual focus between you, your child’s therapist/s, and other important adults in the child’s life. • Enables the child to sense early success. • Allows you to immediately feel a part of the “team.” • Provides foundation for future AAC device usage if necessary.

27. CORE VOCABULARYBOOK • Use photographs containing pictures of people, toys, objects, and verbs important in the life of the child, as well as words being targeted in therapy. • Photographs are placed in a “Grandma’s Brag Book” with written word at the top (so when child points, word is not covered). • Video Clip -- Luke and Sharon

28. VISUAL PROMPTS & TOUCH CUES • Can use cueing program (such as PROMPT) or more eclectic cueing. • Goal is to fade the cues over time as soon as possible • Reduces “yes/no” communication style and replaces it with support for verbal expansion.

29. What are the Advantages of Sign/Picture/AAC Use? • Provides prompt for verbal speech • Likely to increase verbal attempts. Does not lead to less verbal output • Most children’s strengths are visual • Allows child to build language and functional communication while working on speech production

30. What are specific Sign Language Advantages? • Can be held toward face for oral cues • Can be paired with sound prompts • Allows for systematic fading of cues [Sign language cueing hierarchy]

31. What are specific Sign Language Advantages? • Can be held toward face for oral cues • Can be paired with sound prompts • Allows for systematic fading of cues • Can use later to prompt functors (“little words”)

32. Cueing Hierarchy For ASL Use • (1) Sign plus full verbal cue • (2) Sign plus first sound/syllable cue • (3) Sign plus first sound position cue • (4) Sign only

33. When Should We Stop Using Sign Language? • Do NOT stop just because your child: (1) is not good with fine motor skills (2) your child starts talking (3) your child doesn’t like to sign It is primary a PROMPT for verbal speech!! If child uses sign to help communicate, great!

34. Try to incorporate Early Literacy Skill building as soon as possible!! …and make sure both dad and mom read to your child.

35. WHAT ARE THE THERAPY CHALLENGES WE FACE? • To provide a balance between repetitive practice opportunities and activities which are motivating and result in optimal carryover of skills. [Dads and Moms can help with ideas] • Game idea: “Super Sean and Captain Hammer Battle Apraxia”

36. WHAT OTHER THERAPY CHALLENGES ARE THERE? • To support home practice that is productive, maintains high expectations, and does not lead to frustration. [ “Word Bins/Boxes” ] • To help the child with transitions as they move through the education system. [ “All About Me” book]

37. HOW DO WE HELP OUR CHILD ATTEND TO SOUNDS? • Pay attention to your rate of speech and modify if needed (Use “phrased speech” especially if child becomes disfluent). • Provide expanded feedback for your child which assures optimal awareness and taps other “systems” and strengths. • Video Clip -- Tyler, age 3-0

38. HOW CAN WE SUPPORT MULTI-SENSORY TX? • Set up “communication temptations” at home to elicit speech production. • Use a multi-sensory approach as directed by your child’s therapist, with multiple cues that are faded over time toward an oral speech focus.

39. HOW CAN WE SUPPORT MULTI-SENSORY TX? • Your observations and participation are critical to learn how to use/fade cues. • You can learn to use strategies such as “Fill in the blank” for a reluctant talker, word “bins”, and cueing hierarchies. • You can support the use of sign language, PECS, and AAC devices at home.

40. TREATMENT SUMMARY FOR PARENTS • Practice activities need to be motivating, repetitive, and multi-sensory in nature • Video Clip -- Sean, age 4-11 • Intensity of treatment should be constantly monitored and adjusted accordingly

41. Response Hierarchy to Inaccurate Verbal Attempts • (1) Just look at your child with non-understanding • (2) Say: “You forgot your…” (sticky) “Where’s the…?” (friend) “I didn’t hear any…” (wind) • (3) Provide cue at 4 levels in reverse order 1. Sign only 2. Sign plus first sound position 3. Sign plus audible first sound/syllable 4. Sign plus full word

42. HOW CAN WE SUPPORT PROSODY CHANGES? • Play with character voices. • Use songs and rhythms • Use rhyming books, i.e., Shel Silverstein and Dr. Seuss

43. WHAT ARE NON-SPEECH THINGS WE CAN DO? • Keep communication open and honest. • Have high expectations of your child. • Please still find time to be a parent! • Prepare for transition times (“All about me” book to share with others). • Collaborate with therapists/teachers. • Involve all family members. • Video Clips -- Cole, age 3 & family

44. HOW LONG WILL ALL OF THIS TAKE? • Conducted a pilot outcome study • Asked parents to rate on 4-point scale • Looked at ratings of “less than half” to “about three-fourths” • For Phonological-disordered children, required average 29 individual Tx sessions • For Children with Apraxia, required average of 151 sessions

45. HOW CAN WE FIND SUPPORT FOR THIS? • Try to find a parent group in your area. • Ask your child’s therapist who they might recommend that you talk with. • Use the Apraxia-Kids resources as much as you can. • Consider joining the list-serv on apraxia. • Be an advocate for change. • Video Clip -- Sharon & Dr. Campbell

46. Are Issues Different for “Older” Children? • Vocabulary demands increase, so may hear decreased multi-syllabic precision • “Fast speech” reflects a system that can’t handle the increased demands. • See breakdowns when tired (energy)

47. What Other Issues are There for “Older” Children? • Word retrieval deficits become more evident (inefficient storage). • May talk louder because can’t regulate • Novel words and nonsense words are more problematic from a motor planning/programming standpoint. • Video Clip -- Gary, age 8-8

48. What are the Treatment Considerations? • Consider single most prominent factor contributing to clarity breakdowns. • Video Clip -- Zackery, age 8-0 • Focus moves to intonation, rate, and stress with less emphasis on speech. • Intensity of treatment is not the same. • Optimal may be dyad or group therapy.

49. What are Other Treatment Considerations? • Teenagers with CAS may keep sentences shorter to meet articulatory demands. Need to build confidence in longer utterances (“phrased speech”). • Therapist should use and you should support “errorless teaching” with 80% success. • Assume progress, but does not mean should remain in therapy--TAKE BREAKS! COULD BE BEST THING FOR THEM.

50. WHAT OUTCOMES CAN WE EXPECT? • Previous Video Clip -- Doug, age 5 • Video Clip -- Zachary, age 6 • Video Clip -- Alex, age 5 • Video Clip -- Cole, age 5 • Video Clip -- Austin, age 5 • Video Clip -- Luke, age 10 • Video Clip -- Jacob, age 8 • Video Clip -- Tyler, age 9