What to do when they’re Two! Assessment & Treatment of ...

“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA

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What to do when they’re Two!Assessment & Treatment of children between the ages

of two and three with suspected CAS

Marnie Millington, MS CCC-SLP

CASANA Recognized for Advanced Training and Clinical Expertise in Childhood Apraxia of Speech

ASHA Non-Financial Disclosure

Marnie Millington, MS, CCC-SLP, is co-owner of Children’s Speech & Feeding Therapy, a private practice in Needham, Massachusetts.

• Disclosure: Millington is a graduate of CASANA’s Intensive Training Institute on CAS and was provided a stipend for this webinar. There are no other relevant financial or non-financial relationships to disclose.


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Recording Policy

The use of cameras, audio recording devices, and/or video recording devices, including cell phones, is prohibited during CASANA webinars.

Participants found audio or video recording any portion of the will be asked to cease immediately.

Learning Outcomes

Learning Objectives:

• Participants will be able to discuss typical speech and language development in children between the ages of two to three.

• Participants will be able to explain how to determine whether speech or language deficits are the primary contributor to a child’s overall communication disorder.

• Participants will be able to demonstrate knowledge and use of therapy techniques that are grounded in motor learning.

• Participants will learn about new research highlighting potential early signs of CAS.


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Is it CAS?

• Difficult to test

• Errors can mirror common features of CAS

• Possible delay or lack of speech-motor experience can look like CAS

What do we do?

EVALUATE

• Behavior

• Representational & symbolic play

• Language comprehension & Expression

• Speech: vocal play & word approximation/words


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What do we do?

INVENTORY & PRIORITIZE

• Identify all relevant deficits

• Prioritize them in order of relative contribution

• Create a treatment plan with home and direct intervention components

What else to consider?

Consider all areas of need & all communication modalities

• Referral to other professionals

• Consider non-verbal & verbal communication


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Between the ages of two and three

Where did they come from?

BEFORE THEY WERE 2…

• Turn-taking interactions

• Babble: Reduplicated to Variegated

• Jargon: babble + prosody

• Expressive vocabulary of approximately 200 words

• Two to four word combinations


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What do two to three year olds look like?

Hearing & Understanding Talking

• Understands differences in meaning (e.g., “go-stop,” “big-little”)

• Follows a two-step request (e.g., “Get the ball and throw it to Daddy”)

• Listens to and enjoys hearing stories for longer periods of time

• Has a word for almost anything• Uses two and three word

combinations to talk• Is understood by familiar

listeners most of the time• Often asks for or directs

attention to objects by naming them

• Asks Why?• May stutter on words or sounds

Two to Three Years. (n.d.). Retrieved November 21, 2015, fromhttp://www.asha.org/public/speech/development/23/

Speech development from 2 to 3…


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What does the speech of 2 to 3 year olds sound like?

• Phonetic classes expand & increase in frequency: velars, fricatives & affricates

• Consonant clusters emerge between 30-36 months, first in final positions

• Unstressed syllables are produced

• Many types of word shapes: VC, CVC, CVCVC, CVCC, CCVC, etc!

Vowel development 15-36 months(Donegan, 2002; Pollock& Berni, 2003)

Children’s vowel inventories grow from 4-12 vowels

• Early lax vowels are represented prior to 18 months /8/, /1/, /4/,/7/

• By 18 months, tense and point vowels emerge /3/,/o/,/i/, /u/, /0/

• Vowels in stressed syllables develop before unstressed syllables

• Non-rhotic vowels increase from mean accuracy of 92- 94% Increase in intelligibility to 97% at three


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Prosodic Development between birth and 3years

• Mark affect

• Contrastive stress emerges with word combinations

• Differ stress vs. unstressed syllables (Smith, 1978)

• Produce weak syllables in initial position

• Differentiate between two stressed syllables (Kehoe & Stoel-Gammon, 1997) 36 months 97%

Is anyone looking into red flags?

Until recently, this question was driven by parent report…

Overby & Caspari (2015)


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Early speech development in children with CAS

• Viewed home videos of children between the ages of 0 -24 months

• Looked at volubility, place, manner and syllable shape


Significantly fewer

• Resonant vocalizations

• Different places & manners of articulation

• Syllable Shapes


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Fewer

• Fricatives

• Voiceless phones

• Glottal phones

• Closed syllable shapes

Regression in vowel volubility

How do you test a 2 year old?

Photo credit: Dave Engeldow


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D= Direct I= Indirect S=Standardized N= Non-Standardized

*= in this population

Behavior Pretend Play

Language Comprehension

Expressive Language

Speech Related Factors

Observe SymbolicPlay Test (D/S)

Peabody Picture Vocabulary Test-4 (D/S) 2;6+

Expressive One WordVocabulary Test (D/S)

Goldman-Fristoe Test of Articulation-3 (D/S)

Structural-FunctionalExam/Snack (D/N

Attention Westby Play Scales (D/N)

Question Probe (D/N) IndependentAnalysis (D/N)

Regulation Direction Probe (D/N) Language Sample (D/N)

RelationalAnalysis (D/N)

Motivation Reynell Developmental Language Scales (D/S)

Motor-Speech Exam (D/N)

Receptive-Expressive Emergent Language Scale-3 (I/S)

Parent report(I/N)

MacArthur CDI (I/N*)

What measures should be used when CASs?

Standardized Non-Standardized

Goldman Fristoe Test of Articulation-3 Independent Analysis

Relational Analysis

Structural-Functional Exam/Snack

Motor-Speech Exam


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Nate

Independent or phonetic analysis of the child’s speech

What vowels are produced:• Monophthongs• Diphthongs• Note: place & rounded vs. unrounded• Are these fully resonant?

What consonants are produced:• Place• Manner• Voicing

What phonotactic structures are present?


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Independent or phonetic analysis of Nate’s speech

What vowels are produced• Monophthongs: /i,q,1,0/ • Diphthongs /08,97/• Note: place & rounded vs. unrounded: front, mid, back,

rounded and unrounded• Are these fully resonant? Not consistently

What consonants are produced: /w,b,m,d/ • Place: labial & alveolar• Manner: oral & nasal stops & continuants• Voicing: voiced onlyWhat phonotactic Structures are present? V, CV, VCV, CVCV

Relational or phonemic analysis of the child’s speech

• Compare the child’s speech to language peer/adult models

• What errors and error patterns are present?

• What prosodic skills are present?


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Motor-Speech Exam

• Non-standardized task used to identify whether the child presents with Childhood Apraxia of Speech

• Review of formal measures designed to assess children’s motor speech skills revealed weaknesses in reliability; only VMPAC demonstrated validity (McCauley & Strand, 2008 )

• Strand & colleagues working on the DEMSS (Strand et al, 2012)

Motor-Speech Exam

• Based on integral stimulation Milisen (1954)

• Speech stimuli are presented for the child to model

• Hierarchical format: Vowels, single syllable words, two syllable words, to three

• Words can begin in isolation and later be embedded into sentences


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Motor-Speech Exam

• The child is asked to imitate the adult’s models over several successive trials

• The adult provide more support/ cues to determine whether the child improves

• The adult fades the cues to examine if the child’s production deteriorates

Motor-Speech Exam

• Transcribe the child’s responses

• Analyze for the key features of CAS by using ASHA position statement & the Mayo list of CAS characteristics


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Mayo List of characteristics of CAS(diagnosed if four or more observed across two

different tasks)

1 Vowel distortions 2 Distorted substitutions 3 Difficulty w/initial articulatory configurations or

transitionary movement gestures 4 Lexical or phrasal stress errors 5 Syllable or word segregation 6 Groping 7 Intrusive schwa 8 Voicing errors 9 Slow speech rate and/or slow DDK 10 Increased difficulty with multi-syllabic words

Motor-Speech Exam


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Motor-Speech Exam

Structural Functional Exam

• Non-standardized task

• Examines neuromuscular status

• Cranial nerve function

• Assesses the parameters of non-speech, oral motor function

• Results help to confirm/rule out the diagnosis of congenital/ acquired dysarthria


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What do you do when the Structural-Functional Exam goes down in flames?

What do you do when the Structural-Functional Exam goes down in flames?


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Nate assessment results

Hx: early history consistent with motor speech disorder

Behavior: low frustration tolerance, good selective and sustained attention, reducedeye contact for speech tasks

Play: lack of sequenced play

Language Comprehension: WNL

Expressive Language: single sign repertoire of over 50, no combinations, verbal repertoire of six word approximations

Speech: limited repertoire of vowels, consonants, and syllable shapes, distorted and not fully resonant,

MS: distorted substitutions, voicing errors, increase with complexity “Mama” to “ma-ee”

SF/Snack: non-speech oral motor skills 8-12 month levelS

Triage: crucial questions

What is the relative contribution of the child’s speech difficulties to his or her overall communication disorder?


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Triage: crucial questions

What is the underlying nature of the child’s speech disorder: linguistic or motoric?

What will we do with all this information if the child is under 3?

• We will place them on a watch for CAS by labeling with CASs

• We will design and implement therapy to address the errors and areas of need

• We will include choices in treatment that are supported by the motor learning literature


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Treatment

• Increase intervention intensity

• Create functional objectives

• Establish the foundation behaviors

• Educate parents

Speech Treatment

What does intense intervention mean?

• # sessions per week

• # trials per session

• Time is spent with the child talking


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Treatment

Speech:

• Core Vocabulary

• Increase ability/accuracy

Language:

• AAC

Speech Technique

• Integral Stimulation

• DTTC


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Successful Treatment!

Photo by Justin Griner

Attention to the clinician’s face


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Start together

Practice Words

Photo: Kyle Court


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Say the word together

Prosodic Contour


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Speech Treatment

Other supports to improve success

• Temporal cue

• Tactile cue

• Progressive approximation/intelligible error

Speech Treatment

How do we use the motor learning literature to help?

New goals Older goals

(low accuracy) (higher accuracy)

Mass practice Distributed

Consistent practice Variable

Consistent/rapid FB Inconsistent/delay

Accuracy Accuracy/Natural outcome


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Speech Treatment

Speech Treatment


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Speech Treatment

Measuring success


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Speech Treatment

The Whole Picture


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Questions?

What to do when they’re Two! Assessment & Treatment of ...

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