Week 15

what type of speech sound disorder is apraxia?

motor speech disorder

apraxia of speech

deficits in motor planning or motor programming

• brain has trouble telling or coordinating muscles how and when to move to make sounds

what phase of speech production in communication is apraxia?

phase 3: motor planning and programming

phase 3: motor planning and programming task

specify movement parameters

• range of motion 

• strength

• speed

• direction

• degree of muscle contraction

phase 3: motor planning and programming impairment domain

motor speech (apraxia)

phase 1: ideation task

communicative intent

phase 1: ideation impairment domain

cognitive

phase 2: language task

• word retrieval

• phonological mapping

• syntactic formation

phase 2: language impairment domain

language

phase 4: motor execution task

execution of movement to have acoustic output

phase 4: motor execution impairment domain

motor speech (dysarthria)

• weak muscle tone

CAS formal definition

a neurological childhood SSD in which the precision and consistency of movements underlying speech are impaired

hallmarkers of CAS

impairment in planning or programming spatiotemporal movement parameters of movement sequences

• errors in articulation

• errors in prosody

what does CAS often co-occur with?

expressive language impairment

CAS cause

usually unknown/idiopathic

continuous movement is required for….

the act of speaking

end goal when working with CAS

continuous movement

continuous movement

speech is produced as specific sequences of movement that are not discrete but blend from one gesture to another

• ex: no stopping or pauses of the movement during the syllable production

characteristics present in CAS but not discriminative 

• limited consonant and vowel repertoire 

• use of simple syllable shapes 

• SODA errors

  • poor standard scores on artic tests

• poor intelligibility

children with functional SSD may also have these characteristics

discriminative characteristics in CAS

• difficulty moving from one articulatory configuration to another when the child attempts the continuous movement across syllables

• groping and/or trial and error behavior, especially when they are trying to imitate

• distortions of intended vowels

• intrusive schwa occurs in word final and within word positions

• prosodic errors

  • lexical stress errors

  • equal stress

• inconsistent voicing errors

to be classified with CAS, how many characteristics need to be observed?

at least 4 of the 10 listed signs

how to differentially diagnose CAS from inconsistent error patterns?

inconsistent error pattern characteristics are key

• normal movement parameters, no groping

• speech rate and prosody are good

childhood dysarthria results from…

damage to the nervous system

etiologies associated with dysarthria

• cerebral palsy

• brain tumros

• TBI

• down syndrome

dysarthria characteristics

• decreased respiratory support

• weak articulatory contacts

• strained voice due to decreased respiratory support

In some children with dysarthria, CAS or other speech disorders may ________

co-occur

CAS assessment protocol

1. history review

2. testing

   1. speech samples from free/structured play

   2. artic or phonology test

   3. oral-mech exam

   4. oral non-verbal apraxia exam

   5. dynamic motor speech exam

other SSDs will not show deficits in which exams?

oral non-verbal apraxia exam and dynamic motor speech exam

when do you use a oral non-verbal apraxia exam?

only if groping is present during the oral-mech exam

why is a dynamic motor speech exam the most important tool in CAS assessment?

helps make further judgements regarding the presence and severity of CAS markers 

dynamic motor speech exam identifies…

• what type of cues elicit successful imitations

• speech errors that occur in spontaneous speech

DEMSS criterion-referenced assessment

• facilitate, confirm, or rule out a diagnosis of CAS

• estimate the severity of a child’s disorder

• inform the development of treatment goals

• decide on the most effective methods of cueing during treatment

DEMSS scoring

obtain component scores for 4 parameters:

1. vowel accuracy

2. prosodic accuracy

3. overall artic accuracy

   1. entire word must be accurate

4. consistency

use the PML to determine

• how we will organize practice

• how we will provide type and amount of feedback

• cueing strategies

goal of CAS treatment

to improve an individual’s ability to assemble, retrieve, and execute motor plans for speech

focus of CAS treatment

continuous movement

• achieving artic configurations and transitioning into and out of these configurations

• “making movements in the context of speech”

“making movements in the context of speech” changes _________

everything

• goal writing

• conditions of practice

• stimuli/target words

• feedback

• treatment techniques

conditions of practice

schedule shorter frequent sessions

• ex. 5x week, 20-30min

maximize the # of practice trials per session (high amount)

• use of reinforcers that take very little time (ex. quick turn games)

• new ways to keep their interest w/o taking them away from the task

• use reinforcers that keep the child’s attention to the clinician’s face

stimuli/target words

whatever you choose, you need to keep movement in mind

• various lengths and phonetic complexity

  • ex. a variety of syllable shapes

• crafted around vowels in error

• important and functional words/phrases in classroom and at home

CAS treatment techniques

a combination of:

• artic techniques for phonetic placement and movement

• strategies focusing on speech rate and prosody

• multisensory cueing strategies

also consider:

• AAC devices to facilitate functional communication

phonetic placement and movement

adressing both consonant errors AND vowel distortions in CAS

vowels are often distorted due to…

• increased or decreased jaw opening

  • openness

• lips that are too rounded or too retracted

  • movement

T/F: speech rate strategies involves modifying the use of rate within a session

true

speech rate strategies

1. start very slowly at first

   • child learns to hold the initial artic position longer than they usually do

1. gradually increase speech rate with continued practice trials

   • until the child is producing the movement accurately at a normal rate with a normal prosody

the use of slower rate and staying in the initial configuration helped maximize ___________

proprioception

• perception or awareness of the position and movement of the body 

prosodic strategies

1. work on prosody very early, eliminating syllable segmentation

2. work on establishing correct lexical as well as phrasal stress early in treatment

3. varying to help the child establish flexibility in their motor planning and programming

1. work on prosody very early, eliminating syllable segmentation

smooth movement without pauses during syllables

2. work on establishing correct lexical as well as phrasal stress early in treatment

phrasal stress

• “Bob hit the ball”

• “Who hit the ball?” “BOB hit the ball”

• “Did Bob kick the ball?” “Bob HIT the ball”

• “Did Bob hit the truck?” “Bob hit the BALL”

lexical stress

• “BA-by” vs. “BA-BY”

3. varying to help the child establish flexibility in their motor planning and programming

excited voice vs. question voice vs. alien voice vs. happy voice

Dynamic Temporal and Tactile Cueing (DTTC)

integral stimulation technique that involves watching, listening, and imitating a model to practice speech movements

DTTC hierarchy

DTTC goal

shaping movement gestures or transitions for speech production and the continued practice of those gestures in the context of speech

DTTC prerequisites 

• able to focus attention to the SLP’s face for at least a few minutes at a time

• able to at least attempt direct imitation

DTTC key idea

the use of a specific hierarchy of temporal delay in each block of practice

DTTC rationale

providing max support at first, and then the child takes the increasing responsibility for assembling, retrieving, and executing motor plans with progressively less cueing

• learning → generalizing

at each level of the DTTC hierarchy 

• start slowly, and move toward normal rate

• provide variability in practice 

• provide multisensory cues as needed 

  • fade ASAP

• provide KP feedback at first, then move to KR feedback

DTTC main takeaway

before moving to the next level of the hierarchy, the child needs to show accurate movement at normal rate, speak in varied prosody, and show no effortful production

K-SLP

• motor programming approach

  • speech is broken down into smaller units (C, V, syllables, words)

  • built back up into the target behavior

• adds/fades cues as needed

• target vocab is reinforced to give a child a functional vocab

NDP3

• motor programming approach

  • building from core units of speech (phonemes) and simple syllables

• phonological skills are incorporated through use of minimal pairs

ReST

• PML approach 

• stimuli

  • repetitions of varied sequences of real or nonsense syllables

• intensive practice

  • producing multisyllabic pseudo-words to improve speech sound production

PROMPT

• sensory treatment approach

• uses tactile-kinesthetic-proprioceptive cues

• supports and shapes movements of the oral articulators