ISHA Apraxia Presentation Feb 2010 Krantz

8/3/2019 ISHA Apraxia Presentation Feb 2010 Krantz

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Childhood Apraxia of Speech(CAS)

SpeechSound

Disorders

PhonologicalDisorders

ChildhoodApraxia of

Speech

Dysarthria

ReducedIntelligibility

CAS

DysarthriaPhonological

Disorder

Childhood Apraxia of Speech (CAS) is aneurological speech sound disorder thatinvolves a child’s difficulty planning and/or

programming purposeful voluntarymovements for speech in the absence ofneuromuscular deficits (abnormal tone,abnormal reflexes).

ASHA, 2007



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No weakness, incoordination or paralysis ofspeech musculature

No difficulty with involuntary motor control;chewing, swallowing

Inconsistencies in articulation performance

Errors-tendency for omissions in the initialposition.

Number of errors increases as length of word/phrase increases

Fewer vowels and less vowel differentiation

“On-demand speech” is most difficult toproduce; Well rehearsed “automatic speech”;”

Rate, rhythm, and stress are disrupted

May have limited inflectional range whenspeaking

Good control of Pitch, Loudness

non-verbal oral motorproblems

weaknessor

paralysis

Dysarthria

difficultiesplanning andprogramming

skilled volitionalmovement

non-verbal oralApraxia

(blowing,kissing)

INFANTS and TODDLERS

• Gaps in consonant or vowelrepertoire, little variety

• Marginal babble, without true

consonants• Incomplete syllables• Has only one movement

pattern

• Groping/lack of flexibility• Limited or stereotyped

intonation patterns

OLDER CHILDREN

• Limited consonants andphonetic inventory

• Use of simple syllable shapes

• Frequent omission errors• Increased errors on longersequences

• Groping/lack of willingnessto imitate

• Variability• Altered suprasegmental

characteristics



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A disorder in carrying out or learning complex movements that cannot be accountedfor by elementary disturbance of strength,coordination, sensation, comprehension, orattention

(Strub & Black, 1981)

This is what we know…

We need to broaden ourfocus …..

We need to consider the

whole child in ourdiagnosis and treatmentof children with speechand language disorders

Apraxia

DownSyndrome

AutismSensory

ProcessingDisorder

Decreased intelligibility with increased length ofutterance

Inconsistency of speech errors

Decreased ability to perform voluntary tasks ascompared to automatic tasks

Difficulty sequencing oral movements andspeech sounds

(Kumin & Adams,2000)

Co- occur with oral motor skill difficulty Motor templates needed for speech which are

typically developed through vocal play are notbeing developed?

Speech perception (processing) and speechproduction centers of the brain are notcommunicating well in individuals with DownSyndrome?

Children with Down syndrome who have beengiven diagnosis of Apraxia begin speaking at alater age, mean age of five years.



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Impairments in the use of nonverbal behaviors Difficulties with Joint Attention

Delay in or lack of spoken language and gestures

Lack of communicative vocalizations withconsonants prior to 24 months (Wetherby &Woods,2002)

Lack of speech or gestures in subset of childrenwith Autism may be related to issues other thansocial-cognitive abilities (Prizant)

• Sensory experiences include touch, movement, bodyawareness, sight ,sound and the pull of gravity.

• Sensory processing is the child’s ability to process sensoryinformation from the proprioceptive, vestibular, tactile,

auditory, visual, gustatory, and olfactory s ystems in concertwith their ability to maintain regulation

• Sensory integration is the ability to effectively perceive(process) , interpret and and react to sensation from theenvironment

• We are able to sustain regulation by being able t o react tosensation appropriately and efficiently



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ImitationOrganization of

facialexpression ,gesture,

sounds , words

Social-emotional

Development

Ideationinteractions based on

imitation +selfgenerated ideas

Exploration andmovement

possibilities;

Communicating newideas

LanguagePlan and organize

and activity (pairingmovement and

words)

Language describestheir goals andlanguage fororganization

• ActivityPatterns

• Behaviors

• SensoryDefensiveness• Attention andRegulation

Difficulties with:

Calming,overreaction,

communicativeintent ,arousal,

Modulation ofemotions.

“fight or flight,tactile, auditory,visual vestibulardefensiveness,

rigidity, tantrums

Increased activity orlow activity levels.

Emotional andsocial development

Poor self concept,aggressive,withdrawal,

inflexible, difficultyw/transitions

Difficulty initiating play ideas

Difficulty sequencing actions

Difficulty adapting to novel situations

Poor persistence

Need for sameness

Difficulty generalizing learned behaviors to

new situations

Osten, Cawn (2005)

Treatment must depend on:

The child’s neurological maturity andmotor skills to be able to IMITATE andPRODUCE oral motor movements forspeech sounds (Velleman, 2003).



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Cognitive planning and motor execution arenecessary for success of the speech movement.

Speech movement is unlike any other motortasks

Speech requires rapid and continuous decisionmaking prior to and during speaking

Integral stimulation

Approaches in which tactile cues as well asgestural cues are used

Prosodic cueing methods which emphasizemore prosody and incorporate morelinguistic components.

Combination of the above

Integral Therapy Method

Treatment that requires the child to imitateutterances modeled by the clinician.

Attention is focused both on the auditory model aswell as the visual attention to the clinician’s face

Easiest way of saying words until they haveincreased motor-speech coordination

Children are taught the “shell of words”

Begins with word approximations andsystematically refines and reinforcesproductions toward whole target words andphrases

PROMPT- Prompts for Reconstructing OralMuscular Phonetic Targets (Haden, 2006).

Movement in the context of speech production

A tactually grounded, sensori-motor, cognitive-linguisticassessment and treatment approach for speechproduction disorders

PROMPT intends to: 1) provide stabilization andincreased sensory feedback to the speech system; 2)a dynamic process of training the system how toaccommodate different and continuously varying “states”of each utterance

Cawn,SLP(2006)

Keep the following in mind:



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Intent to communicate whether verbally or non-verbally must be present before speech andlanguage intervention can begin

Cognitive, language, social and motor skills arelearned through interactive relationships

B e h a v i o r R e g u l a t i o n Behavior Regulation

(least social):Communicative actsthat regulate another’sbehavior

Request Object/action

Protest object/action

S o c i a l I n t e r a c t i o n Social Interaction

(quasi-social):Communication actsused to direct another’sattention to oneself forsocial purposes.

Request social routine

Request comfort

Call

Greet

Show off

Request permission

J o i n t A t t e n t i o n Joint Attention (most

social):

Acts used to directanother attention forpurpose of sharingfocus on an entity orevent.

Comments on object/action

Request information

Provide informationabout past or futureevents.

Wetherby/Prizant,1993

• Physiological

• Processing

• Cognitive

• Motor

• Social Emotional

TREATMENT

Intentionality

Regulation

Non-verbal gestures

Neuromuscular integrity

Sensory processing

sensory-motor

auditory processing/language

Look at individual differences

Where does the process start? Affect

Joint Attention

Non-verbal and pre-linguistic sounds that arecommunicative

Changes in prosody and rhythm

Repetition (play, motor movements andverbalization)



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1. Increase a reciprocal flow of interaction usingwords and gestures.

2. Improve breath support (phonatory control) forconnected speech production while supportingpostural stability.

3. Increase the complexity of movement patternsin sounds; sequencing of sounds for productionof words( CVC sequences, marking syllables)

CHRISTIAN

1. To facilitate shared attention and expand reciprocalinteractions

2. Improve postural support for speech production3. To demonstrate speech motor control in on a single plane of

movement for use in functional communication. 4. Sustain clear phonation with symmetrical jaw movement for

3-5 seconds. 5. Sustain airflow without phonation for 3-5 seconds starting

from neutral jaw position. 6. Demonstrate beginning jaw gradation changes with voicing7. Integrate mandibular and labial-facial movements with jaw

gradation (/b, m, a,/) for the production of functional CV andVC syllables'.

8.

Produce CV and VC syllables integrating bilabial movementswith jaw gradation adding devoiced sounds

To demonstrate speech motor control integrating threeplanes of movement (vertical, horizontal, and lateral)for use in communication within structured/unstructured activities.

Demonstrate control of manner and timing for phrasesthat contain prosodic meaning

Comprehends location and temporal relationships suchas behind, in back of, in front of, before and after in avariety of different contexts. (Receptive language goal)



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Flexibility on the part of the therapist Changes in the therapy situation can cause changes

in performance

System fatigue -therapy should be augmented byroutines; group activities and contextual rhythmic,multimodal or other types of support

Sequencing ability in the area of play-children withspeech motor planning challenges may showparallel difficulties in planning sequencedhierarchical play routines. Pair play with sounds.

Coordinating therapy or co-treatment.

HOLDEN

Holden came to us at 3 years, 3 months of age Speech characteristics

Limited syllable shape repertoire

Preference for using /d/ rather than velar and bilabial consonants

Omission of medial and fi nal consonants

Marked final consonants with /s/ or / ∫/

Vowel distortions

Language characteristics

Extremely limited MLU

Delayed syntax development

Word-retrieval difficulties

Other individual differences

Limited ideation around play (immature play)

Limited gestural system

Separation difficulties– especially in the face of tasks he perceived asdifficult

Therapy goals : Speech (medial and final consonants, articulatory

transitions, expanding syllable-shape repertoire)

Language -increase MLU, add grammatical markers,increase vocabulary

Ideation/Play (initially play was “hide and find” typeinteraction and simple “monster” themes)

Individual Differences guided the therapy process Separation difficulties, anxiety around speech,

regulation difficulties

Relationship developed around communicativeinteractions in less structured tasks. Integrated more

structured tasks as H. became available.

Increased trust /confidence

Progress in all goalareas – speech,language, play

Increasedregulation / overall

organization

Increased availabilityfor more structured

work

Increasedintelligibility and

more successful socialinteractions

Relationship is

central therapeutic

strategy

Introduction ofKaufman Cards ,direct imitation,

tactile cuing

ISHA Apraxia Presentation Feb 2010 Krantz

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