Pediatric MSD Final Exam

What is involved in the act of speaking?

Respiratory Support

Sound source (VF)

Resonance

Constriction of air stream (Artic)

Motor Speech Disorder

deficit in planning/execution of speech production

2 types of MSD

dysarthria and apraxia

Dysarthria

challenges in execution of speech production (neuromuscular)

Childhood Apraxia of Speech (CAS)

challenges in planning for speech productions (Neuro)

What ages does Pediatric MSD serve?

18 months-21 yo

(but can be addressed earlier if appropriate)

Settings for Pediatric MSD

Public Schools

Private Schools

Home Health

Acute Care

ECI

Inpatient Rehab

Private practice

University clinic

Congenital

MSD that may have an impact on ongoing development of language including phonology (born with it)

Acquired

event occurs after birth, causes a change in motor planning/execution function of speech

Congenital Causes MSD

hypotonia of unknown origin

genetic syndromes

cerebral palsy

- Intellectual Disability

-ASD

-Language Disorder

-CP (cerebral Palsy)

cerebral palsy (CP)

condition characterized by lack of muscle control and partial paralysis, caused by a brain defect or lesion present at birth or shortly after

non-progressive motor disorder stemming from insult to CNS

Cerebral Palsy Cause

hypoxia

periventricular hemorrhage

intraventricular hemorrhage

Mechanical birth trauma

intrauterine infection

-Premies, chromosomal abnormalities, unidentified perinatal complications

acquired cases examples

TBI

Shaken Baby Syndrome

Anoxia

Meningitis

Brain Tumor

CP diagnosed after

Strength

contraction of muscle fibers (associated with movement)

UPM communicates with LMN

LMN innervate muscles, and contract muscle fibers

Weakness

reduced ability to produce force

-damage to UMN and LMN (can cause hyper/hypotonia)

-can disrupt speech and range of movement

-LOW TONE DOES NOT EQUAL WEAKNESS

-often accompanies dysarthria

Tone

• partial contraction of muscle fibers at rest and in response to passive stretch

• Dmg to LMN and UPM can result in hypo/hypertonia

• lesions may affect tone, causing rigidity/variable tone

Hypotonia

reduced resistance to passive stretch

-Flaccid Dysarthria

Hypertonia

increased resistance to passive stretch

-Spastic Dysarthria

3 Subspecialties of Motor Behavior

motor development

motor learning

motor control

Motor development

change in motor control and behavior through interaction of maturation and experience

motor learning

set of internal processes associated with practice/experience leading to relatively permanent change in capability for responding

motor control

execution of processes that lead to skilled voluntary movement

Principles of Motor Learning

process of acquiring skills to perform a specific movement (skilled action)

-influenced by: motivation, attn, feedback

Schema

memory representations

Schema theory

relationship between conditions, motor commands, sensory consequences

-based on past actions We update schema

ex: I have motor schema to turn handle when I see a door knob

Recall

remember past schema and calculate with current situation to use appropriate parameters of movement

Recognition

predict sensory consequences if the goal is achieved

-system evaluates by comparing condition to actual

Schema Theory and Motor Planning

speech production involves CONSTANT STREAM of info to and from the brain

-specific sequences of continuous movement

-brain defines parameters of movement for each muscle group

Speech Input Steps

1. sensory (auditory, visual, tactile)

2. Perception

3. Output (Linguistic)

Movement Output

1. motor planning/programming

2. retrieval/activation of motor plans

3. execution of movement

Disordered Principles of Motor Learning

-FEEDBACK IS REALLY IMPORTANT

-prov external feedback to build motor schema

-in MSD, damage may lead to not detecting errors --> incorrect schema

-if you get taught to hold a tennis racket wrong you will keep holding it wrong until you get external feedback

Motor Learning VS Performance

1. Acquisition (Practice)

2. Retention (Performance)

3. TRANSFER !!! (Generalization)

- generalize skill to other things, we can't teach every speech movement, they need to generalize speech sounds

Distinguishing between practice and transfer

performance changes during practice

-performance doenst predict retention/transfer

-the primary goal of treatment is to maximize generalization !!

Types of MSD

Apraxia, Dysarthria, Stuttering

Differential Diagnosis

Must do comprehensive assessment to determine bases of MSD

• consider concomitant issues

• diagnoses may be mild to severe in intelligibility

• don’t assume only one diagnosis because they present as severe

Phonological Processing Disorder

-PATTERNS of errors

-substitutions

-omissions

-additions

-distortions

NOT A MOTOR SPEECH DISORDER !!!!

-errors are predictable!

Treatment: Phonological Processing Disorder

training of elimination of phonological process

-cycles approach

-complexity approach

-metaphon

-multiple phoneme approach

processes are relatively consistent

Childhood Apraxia of Speech (CAS)

motor speech disorder caused by disturbance in motor planning or programming of sequential movement for volitional speech production

-not a medical diagnosis (type of speech sound disorder)

Why does CAS occur?

unknown etiology

-possibly Neuro or genetic

-issues with gait/coordination

-doesnt matter the cause, bc we treat the motor planning challenges

Disturbances in CAS

Artic

Rate

Prosody

also Literacy Issues

Rhythm of Speech

(doenst involve subsystems)

-occurs ABSENT of muscle weakness

Is CAS over diagnosed?

YES!

because of lack of consistency in characteristics, no standardized assessment

-similar errors in other SSD

-lack of agreed diagnostic criteria

-limited sound production in kids

-severe unintelligibility leads to CAS when they could be Phono

Issues of Prognosis

• frequently occurs with expressive language disorder and other concomitant diagnosis

• long-term course with minimal lack of progress

• continual ongoing artic issues and literacy issues

Praxis

the ability to conceptualize, plan, program skilled volitional movement

Praxis of Speech (Typical)

speech is a continuous movment

-no stopping/starting in the middle of a syllable

-muscles are selected for a specific time, speed, direction, force etc

Praxis Deficits CAS

difficulty with

-motor planning areas of cortex

-proprioceptive info (awareness of body position)

(brain uses that to tell articulators where there and where to go)

Praxis Deficits (Non-Speech)

-Volitional Movements (kissing, blowing, lip smacking)

-May or may not co-occur with CAS, but if child has Oral Apraxia CAS chances go up

CAS Paradigm SHIFT!

not addressing phonemes!!

-addressinG MOVEMENT

Co-articulation

the articulation of 2 or more speech sounds together, so that one influences the other

-"Toys" → the voiced "oy" turns the "s" into a voiced "z"

-"Cat" → voiceless "t' in cats causes "s" to be voiceless

Syllable Segregation

occurs within a word when the movement from one syllable to another is disrupted and speech may sound halting or dysfluent

segmental

division between soundSs, syllables, and words

suprasegmental

stress, tone, and duration in the syllable or word for a continuous speech sequence

top 3 segmental and suprasegmental errors in CAS

1. inconsistent errors (on consonants and vowels in repeated productions)

2. Lengthened and disrupted coarticulatory transitions between sounds and syllables

3. innapropriate prosody,, especially in lexical or phrasal stress

CAS: Vowel and Consonant Distortions

Not consistent substitutions, the target vowel just isnt quite right

CAS: Inconsistent Voicing errors

Difficult for listener to distinguish if the sound is voiced or voiceless

CAS: Prosodic Errors

Equal stress and segmentation

-each syllable it's own segment

-robotic sounding

CAS: Awkward/imprecise movement transitions

Moving from one articulatory configuration to the next (may see pauses)

CAS: Groping and/or trial and error behaviors

Usually seen in elicited responses (but not spontaneous productions)

CAS Artic: Omissions

/do/ for dog

May be secondary to child trying to make the word easier to produce motorically

CAS Artic: Substitions

/gat/ for cat

Substitutions usually involve substituting an easier phoneme for a more difficult one

CAS Artic: Distortions

/shun/ for sun

Distortions may occur bc child is groping and unable to determine appropriate placements; vowel distortions heard

CAS Artic: Additions

/balak/ for black

Additions may occur to compensate for movement error for complex sounds

-intrusive schwa

CAS Artic: Complex Sound Errors

Fricatives (f, th), affricates (ch, j), and consonant blends are often errored to motor complexity of manner of placement

CAS Artic: Metathetic Errors

problems in correct sequencing of sounds in a syllable or syllables in a word

/dab/ for bad

/maks/ for mask

/chor pak/ for pork chop

/ship/ for fish

CAS Artic: Voicing/Devoicing Errors

/tog/ for dog

Can occur at word and convo level and can be considered sound substitutions

CAS Artic: Vowel Errors

/bol/ for ball

CAS: Oral Motor Errors (Oral Apraxia)

-Diff imitating oral motor movements

-Frequent groping for movmeent

-Trial and error movmnt behavior

-Difficulty following oral commands for oral motor movements

-Difficulty maintaining articulatory postures

CAS Prosody Errors

-children with CAS segment speech and talk syllable by syllable

-slower rate

-monotone

-innapropriate inflections at word level

-long pauses

-impaired production of lexical stress

CAS Prosody Differential Diagnosis

-prosody is a core marker of CAS!

-inconsistency and long co-articulatory transitions = NOT DIAGNOSTIC marker

Dysarthria

MSD resulting from impaired neuromuscular control of speech mechanism itself

-planning intact!! actual muscles not intact

Childhood Dysarthria Considerations

site of lesion based on adult brains

child and adult Brains are DIFFERENT!!

Point of lesion: Flaccid

LMN

Point of lesion: Spastic

UMN (most dysarthrias are spastic)

Point of lesion: Extrapyramidal

Hyper/Hypokinetic

Point of lesion: Cerebellar

Ataxic

Point of lesion: Mixed

mix of UMN and LMN damage

Dysarthria: CN involvement

6/12 CN we use for speech

Speech and Motor Processing Systems

1. respiratory

2. phonatory

3. resonance

4. articulatory muscle system

Dysarthria: Respiratory Impact

1. Significantly reduced respiratory reserve (vital capacity)

2. Insufficient intraoral air pressure (can't hear them well)

Respiration Speech Deficit = Poor Volume

Dysarthria: VP Impact

1. Inconsistent/Uncoordinated velopharyngeal function/closure

Leads to Velopharyngeal-Emissions (VPI)

Velopharyngeal Speech Deficits = Hypo/Hypernasality (Resonance Issues)

Dysarthria: Oral Artic Impact

(Because of muscle strength and tone issues)

-Alveolars

-Voiceless Phonemes more misarticulated than voiced (/s/ more distorted than /z/)

-Velars (lim tongue mobility)

-Distortion of fricatives and affricatives

-Errors predictable “within the manner of production:

Final Consonant errors more common than initial consonant

Dysarthria: Phonation Impact

-Breathy or Harsh

-Prosody Errors at Phrase/Sentence level

-Monotonous Pitch

-OR Unequal and Equal Stress issues at word, phrase, sentence level

-Loudness issues

Spastic Dysarthria: Respiration

decreased loudness, grunts, shallow inhalation

Spastic Dysarthria: Phonation

Strain/Strangled quality, harsh, monotone, low pitch with breaks

Spastic Dysarthria: Artic

slow, labored, imprecise

Spastic Dysarthria: Resonance

hypernasal, emissions (not always)

Spastic Dysarthria: Prosody

excess and equal stress, short phrases

Flaccid Dysarthria: Respiration

decreased pressure, shallow, decreased control of exhalation, audible inhalation

Flaccid Dysarthria: Phonation

breathy or harsh, decreased pitch and loudness variation

Flaccid Dysarthria: Artic

slow, labored, imprecise

Flaccid Dysarthria Resonance

hypernasal, emissions (velopharyngeal closure too floppy)

Flaccid Dysarthria

Weakness, Paralysis, HYPOtonia, HYPOflexia, Atrophy

-too little muscle fiber contraction causing decrease in muscle tone

Ex: Down, Tumor, Muscular Dystrophy

Spastic Dysarthria

Weakness, Paresis, Hypertonicity

Mixed Dysarthria

Weakness, slow movement, limited ROM

Mixed Dysarthria:Respiration

expiratory grunt, audible inhalation

Mixed Dysarthria: Phonation

harsh, strain/strangled quality, low pitch, breathy

Mixed Dysarthria: Artic

: imprecise, vowel distortions

Mixed Dysarthria: Resonance

hypernasal

Mixed Dysarthria: Prosody

slow, short phrases, monotone

Hyperkinetic Dysarthria - chorea(quick)

Quick involuntary movements, jerks, chorea

Res - sudden forced inhal/exhale

phon - harsh, monopitch, excess loudness

artic - imprecise consonants

resonance - hypernasal

pros - prolonged intervals/sounds, variable rate

EX: Tourettes

Hyperkinetic Dysarthria - dystonia (slow)

involuntary movements - hypertonia, writing

• res: audible inspiration

• phon: strain, harsh, voice tremor

• artic: imprecise consonant, distorted vowels

• res: hypernasal

• pros: inappropriate silences, prolongations