Childhood Apraxia of Speech:
Evaluation and Therapy
Challenges
Brisbane, Australia
June 15, 2007
David W. Hammer, M.A. CCC-SLP
Children’s Hospital Of Pittsburgh, PA USA
 WWW.APRAXIA-KIDS.ORG

“Time to Sing” CD - 2000

“Hope Speaks” DVD - 2005

“Treatment Strategies” DVD - 2006

AdHoc Committee Documents - 2007

“Taking it Home” DVD - 2007
DIAGNOSTIC CHALLENGES
 Diagnosing toddlers in the 2-3 year-old range
especially difficult
• Davis-Velleman article addresses this
• Caution diagnosing if limited sample (data)
• Use “suspected” or “working diagnosis”
 Don’t need neurologist to confirm
 “Differential Diagnosis for Childhood Apraxia”
Video Clip -- Ross, age 3-4
Differential Diagnosis
1. Limited early sound play (cartoon)
Differential Diagnosis
1. Limited early sound play
2. Sound inventory restrictions
3. Expressive language deficits in contrast to
receptive language
4. Imitation superior to volitional skills
 Video Clip -- Matt, age 3
5. Sequencing/Movement difficulties
6. Word/ Sentence complexity breakdowns
 Video Clip -- Caleb, age 8
 Video Clip -- Anna, age 3-10
Differential Diagnosis
7.
8.
Prosodic deviancies
Inconsistency
 Video Clip -- Jacob, age 3
9. Voiced/Voiceless sound errors
10. “Groping” behaviors
11. Vowel distortions
 Video Clip -- Alex, age 5
12.
Sound omissions
WHAT DOES MY CAS
ASSESSMENT INCLUDE?






For young children, most is informal
Formal test resources available
Get in-depth parent information
Investigate other apraxic features
Look at nonspeech oral skills
Concern for misdiagnosing:
Nonverbal child
Dysarthric child
Severe phonologically disordered child
Confounding diagnosis child
ADHOC COMMITTEE’S
3 CONSENSUS FEATURES

Inconsistent errors on consonants and
vowels in repeated productions of
syllables or words

Lengthened & disrupted coarticulatory
transitions between sounds & syllables

Innappropriate prosody, especially in
relation to lexical or phrasal stress
Unfortunately, pure
apraxia of speech is
rare!!!
Video
Clip - Mickey, age 6
Video Clip - Anna, age 8-1
Comparison of Childhood Apraxia of Speech,
Dysarthria and Severe Phonological Disorder
Verbal Apraxia
Dysarthria
Severe Phonological
Disorder
No weakness,
incoordination or paralysis
of speech musculature
Decreased strength &
coordination of speech
musculature--leads to
imprecise speech
production, slurring and
distortions
No weakness,
incoordination or paralysis
of speech musculature
No difficulty with
involuntary motor control
for chewing, swallowing,
etc. unless there is also an
oral apraxia
Difficulty with involuntary
motor control for chewing,
swallowing, etc. due to
muscle weakness and
incoordination
No difficulty with
involuntary motor control
for chewing and
swallowing
Inconsistencies in
articulation performance-the same word may be
produced several different
ways
Articulation may be
noticeably “different” due
to imprecision, but errors
generally consistent
Consistent errors that can
usually be grouped into
categories (fronting,
stopping, etc.)
Comparison of Childhood Apraxia of Speech,
Dysarthria and Severe Phonological Disorder
Verbal Apraxia
Dysarthria
Severe Phonological
Disorder
Errors include substituErrors are generally
tions, omissions, additions distortions
and repetitions, frequently
includes simplification of
word forms. Tendency for
omissions in initial position
& to centralize vowels to a
“schwa”
Errors may include
substitutions, omissions,
distortions, etc. Omissions
in final position more likely
than initial position. Vowel
distortions not as common
Number of errors
increases as length of
word/phrase increases
May be less precise in
connected speech than in
single words
Errors are generally
consistent as length of
words/phrases increases
Well rehearsed,
“automatic” speech is
easiest to produce, “on
demand” speech most
difficult
No difference in how
easily speech is produced
based on situation
No difference in how
easily speech is produced
based on situation
Comparison of Childhood Apraxia of Speech,
Dysarthria and Severe Phonological Disorder
Verbal Apraxia
Dysarthria
Severe Phonological
Disorder
Receptive language skills
usually significantly better
than expressive skills
Typically no significant
discrepancy between
receptive & expressive
Sometimes differences
between receptive and
expressive language skills
Rate, rhythm and stress of
speech are disrupted,
some groping for
placement may be noted
Rate, rhythm and stress
are disrupted in ways
specifically related to the
type of dysarthria (spastic,
flaccid, etc.)
Typically no disruption of
rate, rhythm or stress
Generally good control of
pitch and loudness, may
have limited inflectional
range for speaking
Monotone voice, difficulty
controlling pitch and
loudness
Good control of pitch and
loudness, not limited in
inflectional range for
speaking
Age-appropriate voice
quality
Voice quality may be
Age-appropriate voice
hoarse, harsh, hypernasal, quality
etc. depending on type of
dysarthria
THERAPY FOR APRAXIA
NO SINGLE PROGRAM WORKS
FOR ALL CHILDREN WITH
APRAXIA!!
MUST INDIVIDUALIZE!!!
BE FLEXIBLE AND LOOK FOR
SERENDIPITOUS LEARNING
OPPORTUNITIES!!!!
HOW CAS THERAPY DIFFERS
FROM ARTIC/PHONOLOGICAL
•
Motor learning theory should drive our
treatment of children with CAS.
- precursors to motor learning (trust,
motivation, and focused attention)
- repetitive and variable practice
- mass vs. distributed practice
- reinforcement and feedback
•
Therapy must be more intensive, but fade
intensity over time. (“fatigue factor”)
HOW CAS THERAPY DIFFERS
FROM ARTIC/PHONOLOGICAL
THERAPY
•
•
•
•
“Developmental” guidelines don’t dictate
sound choice.
Contrastive/Minimal Pair approach is not
suggested at early stages.
Increased cueing is needed.
May need to teach compensatory placement.
Video Clip, Doug, age 5-6
•
More intensive parent involvement is
essential for optimal progress.
HOW DO WE GET STARTED?
• Build on expressions/env sounds.
 Video Clip -- Shane, age 3-6
• Use “starter positions”
such as “mm”, “oo” and “ee”.
Video Clip -- Austin, age 4-3
Video Clip -- Peter, age 5
• Label sounds, but try to incorporate
placement/manner cues (chart).
Visual and Verbal Cues for Treatment
CONSONANTS
NAME of
SOUND
VERBAL CUE
OTHER CUES
“p” sound
“b” sound
Popping
sound
“Where’s your
pop?”
“You forgot your
pop.”
Fill cheeks up with
air and blow out
with the sound,
feeling wind on
hand.
“m” sound
Humming
sound
“Close your
mouth and
hummmmm…”
Lips together and
hum. Touch to feel
vibration.
“n” sound
“NN” sound
“Teeth together
and buzz.”
Finger on clenched
teeth to feel the
vibration.
“t” sound
“d” sound
Tippy sounds “Use your tippy.” Index finger to
center of spot
above upper lip.
Visual and Verbal Cues for Treatment
CONSONANTS
NAME of
SOUND
VERBAL CUE
OTHER CUES
“h” sound
Open mouth
windy sound
“Where’s your
wind?” “I didn’t
feel your wind.”
Open palm of
hand up just in
front of your mouth
to feel wind.
“k” sound
g” sound
Throaty
sounds
“Where’s your
throaty?”
Index finger
pointed to throat.
“f” sound
“v” sound
Biting lip
windy sound
“You forgot to
bite your lip.”
“You forgot your
wind.”
Bite lower lip with
upper teeth and
blow wind.
Initial “s”
sound
Smiley windy
sound
“Smile & make
some wind.”
“Keep those
teeth together.”
Smile with teeth
together and blow
the wind.
Visual and Verbal Cues for Treatment
CONSONANTS
NAME of
SOUND
VERBAL CUE
“Where’s your
sticky?”
OTHER CUES
For “s” move
forearm from left
to right starting
with an open hand
and moving to a
closed hand.
Final
sounds
Sticky sounds
“z” sounds
Buzzing windy “Use your buzz.” Teeth together and
sound
blow wind.
“sh” sound
Fat and fluffy
sound
“Make it fat and
fluffy.”
Lips out and
puckered while
blowing out.
“ch” sound
“j” sound
Chomping
sound
“I didn’t see
those lips
moving.” “Work
your lips.”
Lips protruding
while making
chomp sound.
Visual and Verbal Cues for Treatment
CONSONANTS
NAME of
SOUND
VERBAL CUE
OTHER CUES
“l” sound
Tower sound
(Lifty sound)
“Open your
mouth – tongue
up.” “Touch the
spot and drop.”
Mouth open,
tongue up behind
upper teeth, then
lowered.
“r” sound
“RR” sound
“Push up on the
sides and move
back with your
tongue.”
Demonstrate
pushing up on
sides of tongue in
butterfly position.
“w” sound
Sliding sound
“ooo to eee
sliding.”
Start out in the
ooo position with
lips puckered then
move to the eee
sound.
Visual and Verbal Cues for Treatment
CONSONANTS
NAME of
SOUND
VERBAL CUE
OTHER CUES
“y” sound
Sliding sound
“eee to ooo
sliding.”
“eee to ooo
sliding.”
“sp, st, sk,
sn, sl”
sounds and
other
consonant
clusters
Friendly
sounds
“You forgot your With a straight
friend.”
index finger on
table, start moving
finger from left to right while saying
the /s/ sound then end by tapping
finger on table when the “friendly”
sound is added. Or move forearm
with open hand from left to right
while saying /s/ sound and point to
other sound positions as indicated
above.
HOW DO WE GET STARTED?
•
Build on expressions/env sounds.
 Video Clip -- Shane, age 3-6
•
Use “starter positions”
such as “mm”, “oo” and “ee”.
Video Clip -- Austin, age 4-3
Video Clip -- Peter, age 5
•
•
Label sounds, but try to incorporate
placement/manner cues (chart).
Make a core vocabulary book.
- Benefits and Procedures
CORE VOCABULARY BOOK
- BENEFITS
•
•
•
•
Organizes a starting vocabulary that
facilitates a mutual focus between
therapists, parents, and other important
adults in the child’s life.
Enables the child to sense early success.
Allows parents/caregivers to immediately
feel a part of the “team.”
Provides foundation for future AAC
device usage if necessary.
CORE VOCABULARY BOOK
•
•
•
Use photographs containing pictures of
people, toys, objects, and verbs important
in the life of the child, as well as words
being targeted in therapy.
Photographs placed in a “Grandma’s Brag
Book” with written word at the top (so
when points does not cover word).
Allows for parents to feel part of “team”
Video Clip -- Luke and Sharon
Try to incorporate Early
Literacy Skill building as
soon as possible!!

Video Clip -- Doug, age 6-1
 Video Clip -- Austin, age 4-5
HOW DO WE INCORPORATE
ORAL-MOTOR STRATEGIES?
• My Definition of OM strategies:
“Speech therapy strategies and
techniques which draw the child’s
attention and effort to the oral
musculature/articulators while
SIMULTANEOUSLY engaging
them in speech production
practice”
 Video Clips -- Luke, age 3-2
I. THERAPY CHALLENGES
• To provide a balance between repetitive
practice opportunities and activities which
are motivating and result in optimal
carryover/generalization of skills.
• To make sure that optimal practice
of speech sound production is
accomplished so that speech
motor patterns become more
automatic (“drill-play” examples)
Video Clip -- Connor, age 2-11
THERAPY IDEAS TO ENHANCE
REPETITION & SEQUENCING

Do-a-Dot Art activities
 Hop/Jump over activity
 Pictures on bowling pins
 Soccer knock down (pizza tables)
 Hide and find in sandbox
 Cave hunt with flashlight
 Smartie hide for /s/ clusters
 3 Little Pigs for reps and /l/ clusters
MORE THERAPY IDEAS
“Launcher” into boxes
 “Which is funnier?” for word pairs
 Pass/kiss for /s/ word pairs
 Pirate Pop-Up for reps and stress
 “Bee” figure for unstressed “be”
 Picture drop for faster sequencing
 Spin chair with drum for demand
 Magna Doodle for “th” phrases
 “Red Roll / Green Roll” for “r” phrases

I. THERAPY CHALLENGES
•
To support home practice that is
productive, maintains high expectations,
and does not lead to frustration (Amy
Meredith on success)
[ “Word Bin” Demonstration ]
•
To provide expanded feedback
assuring optimal awareness while
tapping other “systems” and strengths
•
•
•
II. ESTABLISHING
THERAPY GOALS
Keep “functional communication” in the
forefront of decision making.
Choose consonants/vowels which
increase likelihood of early success.
May need to teach isolated sounds, but
move to sound sequencing as early as
possible (blending with “ha”)
 Video Clip -- Austin, age 4-3 (“s”)
 Video Clip -- Max, age 5-6 (“sh”)
II. ESTABLISHING
THERAPY GOALS
•
•
Use “key words” or “key contexts” to
build automatic responses for more
challenging sound sequences.
 Video Clip -- Colin, age 4
Use “starter phrases” to build
functional communication ASAP.
Video Clip -- Garrett, age 2-3
III. MULTI-SENSORY
THERAPY APPROACH
•
•
Set up “communication temptations” to
elicit speech production.
Use a multi-sensory approach as
deemed necessary, with multiple cues
that are faded over time toward an oral
speech focus.
Video Clip -- Luke, age 3-2
Video Clips -- Jacob, age 3-6
III. MULTI-SENSORY
THERAPY APPROACH
•
•
Work simultaneously on sound
production, sound sequencing, and
language. Don’t wait for sound/sound
sequencing accuracy before focusing
on language expansion!
Build in suprasegmental features from
the start, through the use of songs,
character voices, motor activities

Video Clip -- Luke, age 4-4
III. MULTI-SENSORY
THERAPY APPROACH
•
•
•
Encourage parent observations and
participation as much as possible.
Provide specific, ongoing feedback to
parents to support home practice (“Fill in
the blank” strategy if reluctant talker;
Word “bins”, Cueing hierarchy, etc.)
Use sign language, PECS, AAC devices as
deemed necessary.
Advantages of Sign/AAC Use

Provides prompt for verbal speech

Likely to increase verbal attempts. Does not
lead to less verbal output

Most children’s strengths are visual

Allows child to build language and functional
communication while working on speech
production
Advantages of Sign Language

Can use later to prompt functors (“little
words”)

Can be held toward face for oral cues

Can be paired with visual cues

Allows for systematic fading of cues
Cueing Hierarchy For ASL Use

(1) Sign plus full verbal cue

(2) Sign plus first sound/syllable cue

(3) Sign plus first sound position cue

(4) Sign only
VISUAL PROMPTS
TOUCH CUES
•
Can use a systematic cueing
approach (e.g. PROMPT) or a
more eclectic cueing approach
Video Clip -- Tyler, age 3-3
VISUAL PROMPTS
TOUCH CUES
•
•
•
Goal is to fade the cues over time
as soon as possible
Allows for small increments of
success to document in progress
notes
Eventually, use sign plus visual
prompt/touch cue
VISUAL PROMPTS
TOUCH CUES
•
For some children, pictures
facilitate production/sequencing
Video Clip -- Mickey, age 6-4
Video Clip -- Zachary, age 5-0
(AAC device discussion)
TREATMENT SUMMARY

MUST make activities motivating, repetitive,
and easily carried over to the home
Video Clip -- Sean, age 4-11

MUST monitor intensity of treatment and
adjust accordingly

MUST involve parents and help them to
understand how to respond to their child
Response Hierarchy to
Inaccurate Verbal Attempts

(1) Just look at child with non-understanding

(2) Say:
“You forgot your…” (sticky)
“Where’s the…?” (friend)
“I didn’t hear any…” (wind)
 (3) Provide cue at 4 levels in reverse order
1. Sign only
2. Sign plus first sound position
3. Sign plus audible first sound/syllable
4. Sign plus full word (or full word if no sign)
ASSOCIATED AREAS
of DEFICIT
•
•
Self-dialogue in play may be
absent.
Pragmatic communication may be
weak – where dyads can be
beneficial.
Video Clip -- Luke and Sean,
age 5 after Luke in therapy 2 yrs
ASSOCIATED AREAS
of DEFICIT
•
•
Disfluencies may surface, which could
indicate system overload.
Suprasegmental features are frequently
off track (May be one of the most
lingering aspects for older children with
CAS with stress, timing, volume control
residual features)
SUPRASEGMENTAL
FEATURES – TREATMENT
•
•
•
Address throughout therapy
Use “backward build-ups” for multisyllabic words
Use activities such as “Build-ASentence” for word stress
Video Clip -- Luke, age 5-6
with frog clicker
SUPRASEGMENTAL
FEATURES – TREATMENT
•
Use motor feedback for stress
Video Clip -- Cole, age 3-6
•
Use songs and rhythms
Video Clip -- Anna, age 4-0
•
Use rhyming books, i.e.,
Shel Silverstein and Dr. Seuss
Video Clip -- Luke, age 5-6
PILOT OUTCOME STUDY
•
•
•
•
•
Asked parents to rate on 4-point scale
Looked at ratings of “less than half” to “about
three-fourths”
For Phonological-disordered children,
required average 29 individual Tx sessions
For Children with Apraxia, required average
of 151 sessions so 81% more therapy
Find study in “Clinical Management of Motor
Speech Disorders” by Caruso and Strand
(1999) or on Apraxia-Kids website
OUTCOMES
 Previous
Video Clip -- Doug, age 5
 Video Clip -- Zachary, age 6
 Video Clip -- Alex, age 5
 Video Clip -- Cole, age 5
 Video Clip -- Austin, age 5
 Video Clip -- Luke, age 10
 Video Clip -- Jacob, age 8
 Video Clip -- Tyler, age 9
Issues for “Older” Children
•
Vocabulary demands increase, so may hear
decreased multi-syllabic precision
•
“Fast speech” reflects a system that can’t
handle the increased demands.
•
See breakdowns when tired (energy)
Issues for “Older” Children
•
Compensatory patterns may emerge.
Video Clip -- Rhonda, age 7-5
Gloss for Reading
I am a yellow plastic duck and I am in great danger.
Yesterday I was snuggled safe with hundreds of bathtub toys.
We were in a crate on a big ship.
A storm came. Our crate was washed overboard.
Issues for “Older” Children
•
Word retrieval deficits become more evident
(inefficient storage).
•
May talk louder because can’t regulate
•
Novel words and nonsense words are more
problematic from a motor planning/programming
standpoint.
Video Clip -- Gary, age 8-8
Treatment for Older Children
•
Consider single most prominent factor
contributing to clarity breakdowns.

Video Clip -- Zackery, age 8-0
•
Focus moves to intonation, rate, and stress
with less emphasis on speech.
•
Intensity of treatment is not the same.
•
Optimal may be dyad or group therapy.
Treatment for Older Children
•
Teenagers with CAS may keep sentences shorter to
meet articulatory demands. Need to build confidence
in longer utterances (“phrased speech”).
•
Assume progress, but does not mean should remain
in therapy--TAKE BREAKS! COULD BE BEST
THING FOR THEM.
•
Use “errorless teaching” with 80% success.
Treatment for Older Children
•
Use stopwatch for timing of utterances.
•
Use reading programs that are highly visual
(See “Selected Resources”)
•
Videorecord for self-evaluation.
•
Talk about how they feel.
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CAS: Assessment, Treatment & Current Issues