Childhood Apraxia of Speech (CAS) Or Not Part 2: How to Treat

Childhood Apraxia of Speech (CAS) Or Not Part 2: How to Treat

SCSHA 2018

Childhood Apraxia of Speech (CAS) or Not Part 2: How to Treat

Laura Moorer, M.A., ; Kimberly Mory, M.A., ; Melissa Stockholm, M.Ed.,

We are all employed by Texas Woman’s University and we have no relevant financial or nonfinancial relationships to disclose.

The goal for treatment is for the child to acquire voluntary, accurate, and consistent control of the speech articulators so that phonemes and phoneme sequences are produced accurately and consistently when the child wants to do so.

For CAS – stress the sequences of movements (movement gestures) and development of the “memory” of patterns

  1. Motor learning occurs as a result of experience and practice and it is influenced by factors such as:
  1. Precursors to motor learning
  2. Motivation
  3. Understanding of the task
  4. Focused attention on the movement
  5. Pre-practice
  1. Conditions of practice
  2. Repetitive motor drill – quality and quantity
  3. Mass Practice – practice for longer periods of time with less frequency (Ex: 45 mins/2x/week; 3-5 targets)
  4. Fewer targets with more repetitions, more appropriate for acquisition, mod- severe cases
  5. Distributed Practice – practice sessions for shorter periods of time but with increased frequency (Ex: 20 mins./4x/week; 6+ targets)
  6. More targets so practice is spread out; for generalization, less severe cases
  • Blocked practice- Target is practiced for a # of times (in a block), then the clinician moves to the next target
  • Good to facilitate acquisition
  • Leads to better accuracy
  • Better for more severe cases
  • EX: Initial /b/ in CV combinations (my, my, my, my, my)
  • Random practice
  • Stimuli are practiced one at a time and are all mixed up
  • Enhances retention and better generalization
  • A variety of movement patterns is practiced in random order from trial to trial
  • Ex: Initial plosives in CV combinations (bye, go, two, key, do, pa)
  1. Feedback
  2. Frequency, Timing, Type
  3. Knowledge of Performance vs Knowledge of Results
  4. Intrinsic Feedback versus Extrinsic Feedback
  5. Summary Feedback versus Bandwidth Feedback
  6. Delayed Feedback – for self monitoring
  1. Rate
  • A slower rate facilitates habituation of articulatory movement while allowing variability in practice.
  • Varying rate and prosody are effective tools during repetitive drill
  1. Target Selection

ATo maximize potential speech outcomes, it is important to consider the child’s:

  • Current speech abilities
  • Speech sounds vowels and consonants
  • Syllable shapes CVC and CVCV for English
  • What phonemes to begin with?
  • IF needed - vowels to improve intelligibility including /e, /i/,/o/, and /ae/ initially. Vowels are difficult as you can’t readily teach tongue placement and relatively few techniques are available for teaching vowels.
  • Early developing consonants as they are easier to produce and many first words use those sounds.
  • Overriding rule of thumb according to Davis and Velleman (2000) is as follows:
  • New Phonemes + Established Word Shape= Potential Targets
  • New Word Shapes + Established Phonemes= Potential Targets
  • Language skills
  • Meaningful, functional, words and phrases
  • Decrease Homonyms
  • Semantic Relations
  • Make sure words represent a wide range of parts of speech
  • Grammatical Morphemes
  • For greater opportunities for sentence expansion
  • Cognitive-Linguistic Age
  • When choosing vocabulary, consider the age and/or cognitive abilities of the child. It is very important to consider the social implications when selecting targets for treatment.
  • Environmental Factors
  • Motivational factors
  • Socialization factors
  • Choose targets for Tommy
  1. Multi-Sensory Cueing
  1. Multi-sensory cues – be careful of providing too much at one time; use strengths of the child; use visual, auditory, tactile/kinesthetic/proprioceptive, and metacognitive cues.
  • It is very dynamic – a series of adding and fading cues as the child needs.
  • Visual Cues
  • Mirror
  • Watch me
  • Mime
  • Auditory
  • Slow Rate
  • Forward Chaining - /t/, tre/, /tren/
  • Backward Chaining - /en/, /ren/, /tren/
  • Visual and Auditory
  • Simultaneous Production: “Say it with me”
  • Direct Imitation
  • Delayed Imitation - My turn, wait, your turn
  • Tactile
  • Oral motor placement and awareness
  • Metacognitive and Visual cues includes:
  • Graphic
  • Hand cues for voice, manner, or place
  • Tapping/clapping syllables
  • Blocks/Chips
  • Metaphors – place, manner, and voicing
  • Humming sound
  • Biting windy sound
  • Phonetic Placement cues
  • “Put your tongue between your teeth”
  • “Can use ultrasound biofeedback for older children”
  1. Integral Stimulation

See Flow Chart

  1. Treatment
  2. The child needs to be successful (producing the words correctly) but challenged (working on new skills).
  3. If the child is struggling:
  • Slow down
  • Break into small chunks but always pull together
  • Increase cuing
  • Block practice

  1. How do we ensure success:
  • Control targets
  • Scaffolding cues
  • Scaffolding hierarchy
  • Intensity of services
  • Lots of practice
  • Distribute practice
  • Fun and motivating
  • Functional
  1. How do we build in the ability to generalize?
  • Random or distributed practice
  • Vary context
  • Vary motoric or linguistic complexity
  • Encourage self-monitoring
  1. Other Areas
  1. Social Language
  2. Prosody - Need to build in from very beginning
  3. Practice vowels and simple shapes with different prosody
  • Stress - Stressed vs weak syllable shapes and sentences
  • Juncture – Pauses in sentences
  • Tone of Voice - Rate, pitch, rhythm, intensity to express mood, sarcasm, ask a question
  1. Literacy – Phonemic and Phonological development
  1. Resources
  2. ASHA Practice Portal for CAS
  3. ASHA Technical Report for CAS
  4. Childhood Apraxia of Speech Association of North America
  5. Fish, Margaret (2015) Here’s How to Treat Childhood Apraxia of Speech 2nd Ed. Plural Publishing, San Diego, CA.
  6. Gildersleeve-Neumann, E. (2007) Treatment of Childhood Apraxia of Speech: A Description of Integral Stimulation and Motor Learning. Ahsa Leader, November.
  7. Murray, E, McCabe, P, and Ballard, KJ. (2014) A systematic review of treatment outcomes for children with Childhood Apraxia of Speech. American Journal of Speech-Language Pathology. Vol 23 pp 486-504 August

List of Suggested Repetitive Books

  • Boynton, S.- Red Hat, Yellow Hat
  • Brown, M.- Goodnight Moon (Board Book)
  • Campbell, R.- Dear Zoo: A Lift The Flap Book (Dear Zoo)
  • Carle, E.- Have You Seen My Cat?
  • Carle, E. - 1, 2, 3 to the Zoo
  • Carlstrom, N.W.- Jesse Bear, What Will You Wear? (Jesse Bear)
  • Cartwright, S.- Who’s Making That Mess? (Usborne Lift-the-Flap Book)
  • Christelow, E.- Five Little Monkeys Jumping on the Bed (Board Book)
  • Eastman, P.D.- Are You My Mother?
  • Ernst, L.C.- Up to Ten and Down Again
  • Guarino, D.- Is Your Mama A Llama?
  • Kalan, R.- Jump, Frog, Jump!
  • Pereira, L. & Solomon, M. - Oh! A Bubble…
  • Shaw, C.B.- It Looked Like Spilt Milk
  • West, C.- “Buzz, Buzz, Buzz” Went Bumblebee
  • West, C.- I Don’t Care! Said the Bear
  • Williams, S - I Went Walking
  • Williams, L - The Little Old Lady Who Was Not Afraid of Anything
  • Wood, A.- The Napping House

All books are hyperlinked to a website for that book.

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