Childhood Apraxia Defined

1. Childhood Apraxia Defined Typically 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)

2. 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

3. CAS & Impact on Overall Communication Decreased intelligibility Disordered language Social withdrawal Behavioral aggression Academic failure

4. CAS & Impact on Overall Communication Decreased intelligibility Disordered language Social withdrawal Behavioral aggression Academic failure

5. 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)

6. Differential Diagnosis CAS 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

7. Movement For CAS, re-conceptualize the way you think about articulation and phonology • Move away from thinking about sounds • Don’t think about processes • Movements are the focus

8. Motor Learning Theory Motor learning occurs as a result of experience & practice • Pre-practice skills • Conditions of Practice

9. Pre-practice to Establish Motor Learning Pre-practice portion of a therapy session involves • Focused attention • Motivation • General idea of task • Observational learning

10. 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

11. 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

12. General Idea of Task • understand task clearly • ways they will learn • keep instructions simple; focuson 1-2 important aspects of movement. • DO NOT OVERINSTRUCT

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Hierarchy of Response/Cued Support • simultaneous production with examiner • direct imitation • delayed imitation (gradually increase delay time) • spontaneous

20. 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

21. 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

22. 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

23. 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,

24. 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)

25. 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

26. Break Down & NewNext, 1 of the following occurs… • Produce new word not on base list. • Breaks down and has “had enough” for that session. • SLP probes for new words during play/activities

27. Produce new word (not on base list) • immediately reinforce verbally • word is added to the base list • introduce into later activities/sessions

28. 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

29. Conditions of Practice • Reference for correct • Repetitive practice mass vs. distributed random vs. blocked • Knowledge of performance • Knowledge of results immediate vs. summary • Rate & prosody • Stimulus/response complexity

30. 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

31. Rudimentary Carrier Phrases Begin to introduce rudimentary carrier phrases. • My… • Oh no… • I…

32. 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)…

33. 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

34. 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)

35. 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