suspected apraxia and early intervention · pdf file• may have inconsistent...

Suspected Apraxia and Early Intervention

Contact Information

Cari Ebert, M.S., CCC‐SLPSummit Speech Therapy, LLC403 S. Huntington DriveGreenwood, MO 64034

[email protected]

Go Iowa Hawkeyes!!

Whitney & Allyson

AJ has autism and apraxia

Why Are We Here Today?

There is very little information in the literature regarding assessment and treatment of very young children with suspected childhood apraxia of speech.

The purpose of this course is to provide participants with clinically relevant strategies and therapeutic activities for young children under age 5 with suspected apraxia.

Who’s in the Audience?

• Educators/Developmental Therapists• Speech‐Language Pathologists/Assistants• Physical Therapists/PTAs• Occupational Therapists/COTAs• Service Coordinators/Case Managers• Nurses/Nurse Practitioners• Pediatricians

Who Benefits from this Seminar?

• This seminar is NOT just for speech‐language pathologists! Anyone who works with very young, pre‐verbal children will benefit from the information provided today.

• Interprofessional collaboration is a critical component of early intervention.

• In early intervention we strive to treat the whole child, and this can best be accomplished by working together as a team!

Interprofessional Collaboration

• Regardless of our individual discipline (PT,OT, SLP, Educator) we all need to understand strategies for assessing and treating young children who struggle learning to talk.

• We want professional cross‐pollination. This is achieved by attending seminars outside our discipline and through joint therapy visits.

• Talking does not start at the mouth! Many of the skills OT and PT address are indirectly related to learning to talk.

Defining Apraxia

Helping Families and Other Professionals Make Sense of an

Abstract Concept

General Definition of Apraxia

“Apraxia is a neurological disorder characterized by the inability to perform learned movements on command, even though the command is understood and there is a willingness to perform the movement. Both the desire and the capacity to move are present, but the person cannot execute the act.”

Web MD

What Does Apraxia Feel Like?

Hands On Activity to experience apraxia(demonstration)

Use this activity to help family members and other professionals understand what it feels

like to be apraxic!

Types of Apraxia

• Limb Apraxia: Also referred to as dyspraxia. Refers to the inability to make precise movements with the fingers, arms or legs on command.

• Oral Apraxia: Refers to the inability to coordinate and carry out oral/facial movements on command.

• Verbal Apraxia: Refers to the inability to coordinate & sequence sounds necessary for speech on command.

Types of Apraxia

• A child may present with characteristics of just one type of apraxia, a combination of two types of apraxia, or a child may present with characteristics of all three types of apraxia.

• Apraxia may be the primary diagnosis or it may be a secondary diagnosis.

‐Approximately 60% of children on the autism spectrum have motor speech symptoms (Marili, Andrianopoulos,Velleman & Foreman, 2004)

‐Symptoms of CAS are common among children with Down Syndrome (Kumin & Adams, 2000)

2 Types of Verbal/Speech Apraxia

Childhood Apraxia = neurologic dysfunction and/or neurologic immaturity/has never

developed the skill/born with this condition/no infarct evident on brain scans

Acquired Apraxia of Speech (AOS) = brain damage/loss of existing speech/evidence of

damage revealed by CAT scan or MRI/rehabilitative

Habilitative vs. Rehabilitative

• Habilitative services are designed to develop new skills and maximize function. Childhood Apraxia

• Rehabilitative services help recover skills that have been lost or impaired. Acquired Apraxia of Speech

• The Patient Protection and Affordable Care Act of 2010 (PPACA) outlines “essential health benefits” and specifically includes habilitative and rehabilitative services as medically necessary.

ASHA 2007

Etiologies of Childhood Apraxia

According to ASHA, apraxia of speech occurs in children in 3 clinical contexts:

1. associated with known neurological etiologies (intrauterine stroke, infections, trauma)

2. as a primary or secondary sign in children with complex neurobehavioral disorders (genetic, metabolic)

3. may occur as an idiopathic neurogenic speech sound disorder when it is not associated with any known neurological or complex neurobehavioral disorder

Verbal Apraxia

Verbal apraxia has experienced somewhat of an identity crisis. The term “verbal apraxia” was borrowed from the adult neurogenic population following a stroke or other brain injury (i.e. acquired apraxia) and in an effort to make it relate to children it has been referred to by numerous names in the literature including: developmental apraxia of speech, developmental verbal dyspraxia, speech apraxia, childhood verbal apraxia, articulatory apraxia…

ASHA’s Position

The American Speech & Hearing Association’s position is that Childhood Apraxia of Speech(CAS) is the preferred term for verbal apraxia

in children.

‐ASHA Technical Report 2007

“Developmental”

• The word developmental as interpreted by the reimbursement world indicates that apraxia is something children can grow out of and therefore can and should be serviced solely in an educational environment (i.e. NOT medically necessary).

• The word developmental is a red flag word and we should avoid using it in our documentation.

ASHA’s Definition

“Childhood apraxia of speech (CAS) is a neurological childhood speech sound disorder

in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits…the core impairment in planning results in errors in speech sound production and prosody.”

ASHA 2007

Nancy Kaufman’s Definition

“Difficulty executing and/or coordinating/sequencing the oral motor movements necessary to produce and combine consonants and vowels to form syllables, words, phrases and sentences on

volitional control.”

Nancy Kaufman, M.A., CCC‐SLP

1891 Definition

“Defects of articulation in children of good mental capacity…associated neither with

mechanical conditions of the mouth, nor with disease of the articulatory apparatus, but

most certainly dependent on some fault in the central nervous system.”

W.B. Hadden, Medical Doctor , 1891

4 Key Components of CAS

CAS is a neurological speech sound disorder (not a developmental delay ‐ child won’t outgrow it)

CAS interferes with the ability to coordinate & sequence sounds necessary for speech on command

CAS isn’t (in its purest sense) associated with cognitive deficits

CAS isn’t associated with neuromuscular deficits

Explanation for Families

Avoid being too clinical…don’t frighten them with a long, complex definition. Instead, explain what you suspect is going on.

“Your child seems to have some motor planning difficulties. He knows what he wants to say, but he can’t get the message from his brain to his mouth. His brain says speak but his mouth isn’t responding.”

Resources for Families

• If families are eager for more information about apraxia, encourage them to read The Late Talker by Marilyn C. Agin or Speaking of Apraxia: A Parents’ Guide to Childhood Apraxia of Speech by Leslie Lindsay.

• Helpful websites for professionals & families:

www.apraxia‐kids.org (CASANA)www.cherabfoundation.orgwww.kidspeech.com

Birth – 3 Programs

Eligibility Issues

State Eligibility Requirements for Part C of IDEA

• Under Part C of IDEA, states must provide services to any child under 3 years of age who needs early intervention services.

• While all 50 states participate in the Part C program, each state has its own criteria used to determine eligibility.

• Visit www.ectacenter.org (Early Childhood Technical Assistance Center) for rules and regulations regarding Part C of IDEA.

Eligibility Issues in Birth – 3 Programs

• Toddlers with suspected CAS may not qualify for early intervention services in some states. WHY?

• While expressive language is extremely delayed, receptive language is often intact or above average. Thus, the percentage of delay may not meet certain eligibility requirements.

• In essence, these kids are being “penalized” for being typical in every other area of development.

Eligibility Issues in Birth – 3 Programs

• CAS is just a label for a speech sound disorder. It does not carry any special “weight” with it –especially in early intervention.

• The standardized tests administered in EI assess language development more heavily than speech development.

• If cognitive skills are intact and receptive language skills are strong, it can be very difficult to qualify a young child with suspected CAS.

Eligibility Issues

• Kids with suspected CAS usually communicate quite well – they just don’t do it verbally.

• We must advocate for these kids because using the “wait and see” approach can be detrimental.

• We all need to do our part to educate those who work with young children about the importance of early intervention for toddlers with suspected CAS.

Eligibility Issues

• Children with suspected CAS will likely not make statistically significant progress on their own because this is a neurological disorder that requires intervention.

• Our job in early intervention is to build new neural pathways or fix existing ones and teach these children HOW to talk.

Because most of brain development occurs prior to age 3, the earlier we treat these kids, the better their

prognosis becomes.

Early Brain Development

Babies are born with 100 billion neurons. Prior to age 3 the young brain must establish and reinforce connections between neurons. These connections are formed when impulses are sent and received between neurons. Axons send the messages and dendrites receive them. These connections form synapses. During the first 3 years of life the number of neurons stay the same but the number of synapses increases. (www.classbrain.com article 30)

The Brain is Not Complete at Birth!

• Synaptic connections are created at a rapid rate through age three

• By age three, 85% of the core structures of the brain are formed

• Synapses = wiring• While synapses are developing, the brain builds the

potential to learn • Repetition of appropriate interactions will help the brain

reinforce existing synaptic connections & make new ones

(www.wccf.org , www.zerotothree.org, www.classbrain.com article 30)

This is why we believe so stronglyin the power of

EARLY INTERVENTION!!&

This is why the “wait & see” approach doesn’t pay off!

Assessment

Practical Strategies for Assessing Pre‐verbal Children

Pre‐Verbal vs. Non‐Verbal

• Pre‐verbal: use this term to describe young children who are not yet talking. It is anticipated that these children will become verbal with therapy.

• Non‐verbal: use this term to describe older children who are not verbal. It is not likely that these children will become verbal, even with therapy.

Formal vs. Informal Assessment

• Formal vs. Informal Assessment Tools –quantitative vs. qualitative.

• Formal/standardized language tests designed for the birth – 3 population do not assess the integrity of the motor planning system.

• In order to administer a standardized apraxia test, the child must have verbal imitation skills.

Informal Assessment

Informal assessments are a MUST to begin identifying characteristics of suspected CAS in pre‐verbal children because we can’t rely on standardized tests at this very young age.

“There is not a simple checklist of symptoms that can be applied to every child – but rather a large cluster of symptoms may indicate or suggest that apraxia will eventually be diagnosed.” Agin, 2004

Characteristics of Pre‐Verbal Children with Suspected CAS

Pre‐linguistic stages of speech/language development:• History of being an unusually quiet baby – limited

cooing and babbling – often described as “such a good baby” or “serious baby”

• May not have gone through typical oral exploration phase as a baby

• Late to say first word• Limited repertoire of consonant & vowel sounds• Receptive language intact & often above average


Early stages of speech development:• Essentially non‐verbal• Vowel errors are common • Overuse of neutral vowel sounds “uh, eh, ah”• Inability to spontaneously simplify words• Limited or absent verbal imitation skills• Limited syllable & word shapes• Speech appears effortful (posturing/groping)• Use of one syllable for all words (Madison video)

Use of 1 Syllable


Early stages of speech development (cont’d):• Speech sound errors are not typical • May add vowel sound to end of words (“up”

produced as “up‐uh” or “more” produced as “mor‐ee”)

• History of saying a word or phrase clearly one time and never repeating it

• Voicing errors may occur(/b/ for /p/) • May have inconsistent hypernasality


Early stages of speech development (cont’d):• Highly inconsistent speech productions• Significant difficulty sequencing sounds – may

pause between sounds (m – e)• Does not add new words to expressive vocabulary

on a regular basis – may even lose words• Inappropriate prosody/melody of speech impaired• If toddler does say some words, they are often

social words and not power words (hi, bye, mama, please)


Associated characteristics :• May have poor eye contact & miss key information from speakers on how they move their jaw, lips & tongue

• Toddler may actually remain silent for entire therapy session (challenging for therapist!!)

• May dislike watching self in a mirror• Receptive language skills are greater than expressive language skills/large gap between the two


Associated characteristics (cont’d):• Elaborate gesturing skills and a strong desire to communicate

• May be silent during play time – even during high energy activities

• Response to intervention is slow

Assessment

3‐5 Year Old Verbal Children with Suspected CAS

Formal Assessment Tools

Once the child is verbal, a standardized test can be administered to accurately diagnose CAS

Available standardized tests:‐Kaufman Speech Praxis Test for Children (2‐5 years)‐Verbal Motor Production Assessment for Children (3‐12 years)‐The Apraxia Profile (3‐13 years)‐Moving Across Syllables/Test of Syllable Sequencing Skills (Pre‐K

to 5th grade)‐Screening Test for Developmental Apraxia of Speech ‐2

(4‐12 yrs)

Formal Assessment Tools

Standardized articulation tests alone will NOT provide adequate information regarding the integrity of the child’s motor planning system.

Receptive & expressive language skills should be formally assessed, but they alone will NOT provide adequate information regarding the integrity of the motor planning system.

Characteristics of 3‐5 Year Olds with CAS

• May have acquired some later developing sounds while missing earlier developing sounds = atypical development

**Acquisition of speech sounds**vowels are mastered by age 3consonants are acquired in this order:

p, m, h, n, w, b, k, g, d, t, ng, f, y, r, l, s, ch, sh, z, j, v, th, zh


• Highly inconsistent speech productions/ unpredictable speech patterns

• Vowel errors are prevalent

• May reverse sounds or syllables (“kitchen” produced as “chicken” or “sock” produced as “kos”)

• Still relies on gestures to facilitate communication

• Inconsistent progress/lack of progress at times


• Adds sounds or syllables to words

• Difficulty producing multi‐syllabic words (“butterfly, watermelon”)

• May correctly say a difficult word once, but unable to repeat it

• Receptive language skills still superior to expressive language skills


• May be able to correctly articulate single words, but as utterance length increases, overall speech intelligibility decreases

• Backing and initial consonant deletion may be prevalent (*these are rare in neuro‐typical kids with phonological impairment & more difficult to fix in therapy)

• Inconsistent productions on repeated trials of same utterance


• “Trial and error” articulation may be used as child searches/gropes for the correct articulatory position

• Limited success talking with new people or in new situations/increased pressure results in decreased success with verbal output

• Assimilation errors may still be prevalent (“kite” produced as “tite” or “duck” produced as “guck”) –have to help child learn to feel the movement from front to back or back to front


• Inability to maintain correct production of a sound or syllable in context of the actual word – movement between sounds causes replacement or deletion (child can say “no” and child can say “uh” but child is unable to say “Noah”)

• May continue to produce “telegraphic” speech & omit little grammatical words such as the, and, a, etc.

• Expressive language may be impaired (grammatical errors, problems with word order, pronoun errors)

)


• Prosodic differences continue to be an issue (primarily with lexical stress – example: say the words “October” and “octopus” and notice where the lexical stress falls for each word)

• May have poor phonological & phonemic awareness skills (rhyming, sound segmentation, sound blending, beginning & ending sounds) – precursors to reading

• Academic issues related to spelling, reading & writing may become evident as child with CAS gets older

Academic Difficulties & CAS

• “A child who demonstrates communication delays as a toddler and during preschool is at greater risk for later language‐based learning disabilities.” Agin 2004

• “The speech processing system is not only the basis for speech and language development but also the foundation for literacy development; ‘written language’ being an extension of ‘spoken language’.”

Stackhouse www.apraxia‐kids.org

Academic Difficulties & CAS

“Between 40% and 75% of children who have trouble with language development present with reading difficulties later in life.” (Aram, 1989, Bashir, 1992)

“Children with unintelligible speech have problems hearing individual sounds in words and later have trouble making the association between those sounds and the written symbols they need for reading.” (Schraeder, 2009 ADVANCE)

Co‐Existing Conditions

Co‐Existing Conditions

A child with suspected Childhood Apraxia of Speech may have co‐existing conditions including:

Oral ApraxiaOral‐motor weakness/DysarthriaHypotoniaSensory Processing DisorderLimb Apraxia

Informal Assessment

Informal Assessment

1. List child’s overall use of intentional vocalizations and verbalizations.

Vocalizing refers to the act of turning the voice on and does not imply the use of true words.

Verbalizing refers to the act of talking and implies the use of true, meaningful words or word approximations.

Differentiate between the two – many children are vocal but not yet verbal!

IFSP Outcome Examples

• Vocal Outcome: Jay will engage in vocal play/make more sounds when playing alone and with his caregivers, 5 days in one week, at home and at daycare.

• Verbal Outcome: Jay will say approximations of his family members’ names (mama, dada, bubba, papa, nana) to greet, label or call for them, 4 days, over 2 consecutive weeks.

IFSP OutcomesDocumentation Guidelines

1. Outcomes must be family‐centered (reflects the family’s priorities)

2. Outcomes must be functional (support development in one of the 5 domains and considered critical for child’s participation in daily activities)

3. Outcomes must be observable and measurable (how well or how often the activity must be performed and necessary criterion)

Informal Assessment

2. Assess child’s desire to communicate and use of gestures to express self.

Does the child use an elaborate gesturing system to convey information to others?

Does the child have a strong desire to communicate and interact with others? (This helps us with differential diagnosis/helps rule out autism)

Informal Assessment

3. Determine which consonant are produced spontaneously and which sounds can be elicited in isolation.

m, b, p, t, d, n, h, k, g, f, v, s, z, l, r, w, y, sh, ch, j, voiceless th, voiced th

Make note if these sounds are produced randomly and sporadically or produced frequently and consistently.

Informal Assessment

4. Assess child’s ability to produce a wide variety of vowel sounds.

Vowels serve as the foundation for the words we speak & determine how intelligible a child’s speech is.

The human ear is able to interpret a child’s speech when the consonants are produced incorrectly, but it is much more challenging to interpret a child’s speech when there are vowel errors.

Interpret the following utterances. Which ones are most intelligible? Why?

Child 1: “I wa too‐tee”Child 2: “I wa kah‐kah”

Child 1: “I wa mo”Child 2: “I wa ma”

Informal Assessment

Crisp, clear vowel sounds lead to increased speech intelligibility.

So why do most articulation tests only assess consonant sounds?

There are more than a dozen vowel sounds in the English language – some are simple and some are complex.

Informal Assessment

Simple, lax vowels:“ee” as in me“I” as in sit“eh” as in yes“a” as in bag“aw” as in ball“ah” as in watch“u” as in put“oo” as in boo“uh” as in up

Complex, tense vowels:“eye” as In bye“ow” as in out“ou” as in no“oy” as in boy“ay” as in day

(these vowels are called diphthongs)

Informal Assessment

5. Assess child’s ability to co‐articulate a variety of consonant and vowel combinations.

We want “bay ‐ bee ‐ buy ‐ bo ‐ boo” not just “buh.”

6. Assess child’s ability to imitate animal sounds, vehicle sounds, exclamations and other sound effects during play time, making note of prosodic features.

Informal Assessment

7. Assess child’s use of syllable shapes.

Young children with suspected CAS may reduce words to one syllable to make the motor plan as simple as possible.

V, CV, and VC are the most common syllable shapes used by young children with suspected CAS.

Informal Assessment

3 levels of syllableness to assess early on:

1. Reduplication

baba dada boo boo mama

2. 2 syllable words with same consonant, changing vowels:mommy puppy daddy baby

3. 2 syllable words with changing consonant & changing vowels:

monkey panda dino hippo

Informal Assessment

8. List spontaneous use of words/word approximations produced by child, making note of how frequently and consistently they are produced.

9. Assess child’s ability to imitate single words/single word approximations.

10.Make note if child watches speaker’s mouth for visual cues.

11. Determine if speech production errors are consistent or inconsistent across different trials.

Informal Assessment

12. Assess motor imitation skills of actions during play time & during songs and finger plays.

13. Determine if any co‐existing conditions are present.(oral apraxia, limb apraxia, hypotonia, dysarthria, sensory processing difficulties)

14. Make note if oral groping, silent posturing or trial and error articulation are present during attempts to talk. Is talking effortful for child?

15. Assess child’s ability to sustain phonation.

Informal Assessment

16. Assess receptive language skills. Compare receptive and expressive language skills emphasizing significance of the large gap.

17. Make a statement about how the communication impairment is impacting the family’s interactions with their child.

18. Comment on how the communication impairment affects the child (has tantrums, withdraws from social situations, is passive, gets frustrated, etc).

Diagnosis

Making a Diagnosis in Children Under Age 3

Who Diagnoses CAS?

• CAS is a speech sound disorder, therefore, it is diagnosed by a speech‐language pathologist.

• There should be supporting documentation by a pediatrician or pediatric neurologist to support the neurological component of CAS.

• We should document the atypical development and explain how this differs from a developmental articulation disorder.

Should We Diagnose CAS In Children Under Age 3?

• Typically, we should not give a firm diagnosis of CAS prior to age 3.

• Why not? There are two main reasons.

‐First, there is still a lot of brain development occurring prior to age 3.

‐Second, we cannot formally diagnose CAS untilthe child is verbal (in early intervention, most of ourkids are pre‐verbal). Remember, CAS is a speech disorder, not a language disorder!

Making a Diagnosis

“The complexity of diagnosis in young children under age 3 is that the child must be able to participate sufficiently in the assessment. Unless the child can attempt to imitate

utterances that vary in length and phonetic complexity it is very difficult to make a

definitive diagnosis.”Strand, 2003

Making a Diagnosis

“There is no definitive blood test or brain scan that can lead to a clinical diagnosis of apraxia. We have to rely, therefore, on a list of signs and symptoms to help us zero in on the

disorder.”Agin, 2004

Making a Diagnosis

• Once the child is verbal enough to participate in a formal evaluation using a standardized testing tool, it becomes easier to give an accurate diagnosis of CAS.

• Until that time, we report the characteristics, signs and symptoms of the motor planning difficulties and state that we are suspecting CAS as the cause for the lag in expressive language & speech development.

Making a Diagnosis

That’s why we use the term suspectedchildhood apraxia of speech when working with very young, pre‐verbal

children.

Misdiagnosing CAS

• Research has shown that many children with a diagnosis of CAS have been incorrectly diagnosed. (Davis, Jakielski, & Marquardt 1998, ASHA 2007)

• Why is this occurring? – Diagnosing too young– Diagnosing speech disorder in children w/o speech– Professional other than SLP making the diagnosis– Lack of specific guidelines regarding when it’s “ok” to make the diagnosis

Why is it so Difficult to Diagnose Childhood Apraxia of Speech?

Question:

Why is it so difficult to correctly diagnose CAS and so easy to misdiagnose it?

Answer:

Because many of the characteristics overlap with other disorders; there is no blood test or genetic screening tool by which to make the diagnosis (Agin, 2004); CAS may be a secondary diagnosis instead of the primary diagnosis; and symptoms may change over time (Lewis et al. 2004)

Continuum of Speech Sound Disorders

What looks like CAS in a two year old may not look like CAS when the child is older…once

apraxic not always apraxic!

CAS Phonologic Artic

It’s a miracle we speak at all!

• CAS is a MOTOR disorder – and speech is the most finely tuned motor act we perform

• Speech = coordination of respiration, phonation, articulation and resonation

• “Given this complexity, even mild motor difficulties are enough to disrupt speech development.” Jennejahn & Turner 2008

Important Key Points Related to Diagnosing CAS

• CAS is a speech disorder; not a language disorder• A diagnosis of CAS cannot be given until the child is VERBAL

• Key diagnostic features of CAS:– Strong desire to talk– Effort associated with talking– Difficulty coarticulating/sequencing sounds & syllables– Inconsistent errors on vowels and consonants– Prosodic abnormalities

Demographics/Prevalence

• 86% of kids with CAS have at least 1 family member with speech‐language disorders & 59% of kids with CAS have at least 1 affected parent (Velleman, 2006)

• This means there is a strong heritability factor(Agin, 2004)

• Prevalence: estimated to be about 5% of children with speech sound disorders present with CAS

(Delaney & Kent, 2004; apraxia‐kids.org; Strand, 2010)

Prevalence of CAS

• ASHA reports that “as with several other complex neurobehavioral disorders (e.g. autism, ADHD), the prevalence of CAS has reportedly increased substantially during the past decade.”

• Why? Is it a true increase? Or are we misdiagnosing/over‐diagnosing?

• Do you have more children with motor planning difficulties on your caseload currently than you did 5 years ago? 10 years ago? 15 years ago?

Differential Diagnosis


Differential diagnosis is the process of “ruling out” some disorders to ensure proper treatment

A diagnostic work‐up and ongoing diagnostic therapy are crucial steps of the therapeutic process

So, as professionals we must be comfortable with and skilled at diagnostic therapy in order to make a differential diagnosis by identifying specific characteristics to validate our diagnosis of suspected CAS in young children

Suspected CAS or Autism?

Some young children with childhood apraxia of speech may be mis‐diagnosed as having an autism spectrum disorder because there are 4 primary overlapping symptoms that commonly occur in both disorders including:

1. being essentially non‐verbal/pre‐verbal2. having social deficits3. having sensory issues4. having poor eye contact

Differential DiagnosisSuspected CAS vs. Autism Spectrum Disorder

Suspected CAS• Intact receptive language

skills• Communicates wants and

needs effectively – just not verbally

• Strong desire to interact with others

• Exhibits typical play skills (presence of limb apraxia may interfere w/play skills)

Autism Spectrum Disorder• Impaired receptive

language skills• Does not communicate

effectively either verbally or non‐verbally

• Limited desire to interact with other people

• Exhibits atypical, absent or aberrant play skills


Suspected CAS• Eye contact is typically good

until the pressure to talk is placed on them

• Limited speech production attempts because child anticipates failure based on past talking experiences and is therefore NOT a communication risk‐taker

• May have sensory issues

Autism Spectrum Disorder• Eye contact is consistently

poor • Limited speech production

because child lacks understanding that words have power/inappropriate speech production (use of echolalia & scripted phrases)

• Likely has sensory issues


Regarding sensory processing disorder… it is important to remember that while most kids with autism have sensory processing disorder, not all kids with sensory processing disorder have autism!

Differential DiagnosisSuspected CAS vs. Dysarthria

“Dysarthria manifests as disrupted or distorted oral communication due to paralysis, weakness, abnormal tone, or incoordination of the muscles used in speech. Symptoms may include slurred speech, weak or imprecise articulatory contacts, weak respiratory support, low volume, incoordination of the respiratory stream, and hypernasality.”

Strand & McCauley 2008


Suspected CAS• Difficulty planning the

movements necessary to produce and combine speech sounds – often a lack of consonants and vowels

• Difficulty with motor PLANNING

• Not associated with neuromuscular weakness

Dysarthria• Difficulty in the actual

production of speech sounds – distortion of consonants and vowels

• Difficulty with motor EXECUTION

• Characterized by muscle weakness


Suspected CAS• No difficulty with

involuntary motor control for eating (unless there is also oral apraxia)

• Inconsistent speech errors• Receptive language better

than expressive language

Dysarthria• Difficulty with involuntary

motor control for eating due to muscle weakness and incoordination

• Articulation is imprecise, distorted, slurred ‐ but errors are fairly consistent

• No significant difference between receptive & expressive language skills


Suspected CAS• Prosody is disrupted – rate,

rhythm , inflection patterns & stress impaired – better control of pitch and loudness

• Voice quality is intact

Dysarthria• Monotone voice is common

‐ difficulty controlling pitch and loudness levels

• Voice quality may be impaired depending on type of dysarthria (spastic, flaccid, etc.) – voice may be hoarse, harsh, hypernasal, breathy


Kids with CAS don’t have strength issues, they have movement issues. “We don’t need strongarticulators, we need agile articulators.” Dr. Lof 2007

Speech production requires rapid & accurate alternating movements of the articulators (i.e. speed & agility)

Diadochokinetic Rate (measures how accurately person can produce a series of rapid alternating sounds)


• Both CAS and Dysarthria will result in poor speech intelligibility ‐ determining the etiology of the unintelligible speech will guide our treatment methods

• CAS and Dysarthria can co‐exist so some kids on our caseloads won’t fit into a nice categorical box

Differential DiagnosisSuspected CAS vs. Phonological Disorder

• A phonological disorder involves patterns of sound errors

• Common phonological processes young children use:‐final consonant deletion ‐deaffrication‐cluster reduction ‐stopping‐syllable reduction ‐assimilation‐gliding ‐fronting

• Atypical phonological processes include backing and initial consonant deletion


• “Children with a phonological disorder consistently make the same sound substitutions and, when given auditory and visual cues, are able to imitate correct sounds or words.” Agin 2004

• As toddlers become more verbal we may begin to see evidence of speech simplification patterns such as velar fronting or final consonant deletion that may point towards a phonological disorder as opposed to a motor planning disorder


Suspected CAS• Limited number of vowels &

diphthongs produced• Inconsistent /unpredictable

speech errors• Effortful speech• Impaired prosody• “On demand” speech most

difficult / “automatic” speech is easiest

Phonological Disorder• Typically no issues with

vowel productions• Consistent patterns of

errors that can be grouped into categories

• Speech is not effortful• Prosody is intact• No difference in how easily

speech is produced based on the situation

Differential DiagnosisSuspected CAS vs. Expressive Language Delay

• While children develop skills at different ages, the most important factor is that the milestones are achieved in a typical or sequential manner.

• Milestones may be achieved late, but if they are acquired in the correct developmental sequence, the child is likely exhibiting a delay. Delay = child follows a typical path of development, it just takes longer.

• If the developmental sequence is atypical then the child is more likely exhibiting a disorder (scattered skills, splinter skills).


Suspected CAS• Makes slow, inconsistent

progress• Noticeable difficulty with

the production of vowel sounds

• Limited or atypical babbling history

Expressive Language Delay• Makes more rapid,

consistent progress (If child presents with receptive language delay as well, progress with expressive language will be slower)

• Typically no difficulty with vowel sounds

• More typical babbling history


Suspected CAS• Limited phonemic

repertoire• Presents with a disruption

in the normal sequence of development – “atypical development”

• May have disordered prosody

Expressive Language Delay• Wider variety of speech

sounds in repertoire• Mild lag in development ‐

speaks like a child who is chronologically younger

• Typically no issues with prosody


When assessing very young pre‐verbal children, SLPs should be differentially diagnosing between the following:

‐language delay (linguistic)‐suspected childhood apraxia of speech (motor planning)‐dysarthria (motor execution/muscular)‐autism (communicative intent)

Once the child becomes more verbal we will also have to differentially diagnose between CAS and phonological disorder

Therapy

The Journey from Non‐verbal to Verbal Communication

FREQUENCY & DURATION OF SERVICES IN EI

Frequency & Duration of Services in Early Intervention

• Service delivery is far different in birth to three programs than in any other setting therapists work

• While a diagnosis of CAS warrants shorter, more frequent therapy sessions in older kids, this does not translate to early intervention – quantity does not equate to quality when working with the birth to three population

• This can lead to controversy b/c the literature states that kids with CAS need intensive one‐on‐one sessions 3‐5 times per week

Frequency & Duration

• However, this guideline was not designed with toddlers in mind

• Our youngest clients cannot be persuaded to change their schedule to match ours

• The selected therapy time may not be a “good” time for the child

• In early intervention the focus is on the family• IFSP – Individualized FAMILY Service Plan – should revolve around the needs & priorities of the family, not just the developmental needs of the child

PURPOSE OF EARLY INTERVENTION

Family Participation

• Our primary job in early intervention is not to teach the child how to talk, walk, use a spoon, etc. – our primary job in early intervention is to teach the family how to teach their child how to talk, walk, use a spoon, etc.

• In order for early intervention to be effective, it must be integrated into the family’s daily routine – the professional is not available to be with the child every day, therefore the caregiver must step into the primary provider role

Support‐Based Services Model

Caregiver Competence &Confidence

Professional Support Child Outcomes

by R.A. McWilliam – Vanderbilt Center for Child Development

Therapy and Intervention

• Understanding and being able to explain the difference between therapy and intervention to families is crucial when working with the birth to three population.

Therapy is the time spent in direct contact with the child each week. Provided by the therapist.

Intervention is what occurs the rest of the time between therapy sessions. Provided by family.

Therapy and Intervention

• Specific, relevant suggestions should be made that allow the family to incorporate strategies into their daily activities (during bath time, meal time, riding in the car, when reading books, when watching t.v., etc).

• So…let’s talk about those therapeutic strategies and activities that will help families help their child learn HOW to talk!

Fun and Effective Therapy Without Drill Work

Fun & Effective Therapy

Young children learn best through play that is relevant and meaningful to their life – not

through direct instruction, flash cards or drill work!

Be sure to educate parents and caregivers on the power of play in the development of

young children.

No More Drill Work!

Gather common objects of target words and use in lieu of flashcards when working with young children.

Collect small toys, dollhouse items, play food, puzzle pieces, empty food boxes, stuffed animals, Mr. Potato Head pieces, photos, etc.

Turn drill work into play time using these common objects – young children love to manipulate objects –Put in, Dump out and Do it again is the premise of toddler play.

Sound Bags

Create Sound Bags of common objects for different speech targets in lieu of flashcards.

Reduplication Bag:

Target Sounds: “moo moo, hoo hoo, teet teet, neigh neigh,ho ho, waa waa, boo boo, choo choo, woo woo, beep beep,pee pee, wa wa, ba ba, mama, dada, papa, nana”

Objects: cow, owl, bird, horse, Santa, baby, band‐aid, train,fire truck, car, potty, water, bottle, mom, dad, grandpa,grandma, banana

Reduplication Sound BagBa‐ba, Beep‐beep, Neigh‐neigh, Choo‐choo, Papa, Moo moo, Boo‐boo, Ho‐ho

Sound Bags

CVC Sound Bag:

Target Words: “boat, ball, bat, bus, bone, bug, bed, dog, moon, milk, map, mom, pig, pot, pan, pup, top”

2 Syllable/CVCV Bag with changing vowels:

Target Words “dino, pony, bunny, honey, money, potty, Woody, Minnie, Mickey, monkey, hippo, Elmo, daddy, mommy, table, turtle, bubble, teddy, penny, tuna, panda, candy, candle, puppy, happy, baby”

CVCV Sound BagPony – Potty – Minnie – Monkey –Woody – Dino – Table – Hippo

Sound Bags

“a” sound bagTarget words: cat, hat, bat, van, can, pan, track, black, ant, bath, bag, flag, hand, map”

“oo” sound bag

Target words: “shoe, boo, Blue, moo, Pooh, glue, choo choo, two, boo boo, blue, roo”

“oo” Sound Bagshoe – boo – Blue – moo – Pooh – glue –choo choo – two‐ boo boo – blue – roo

Look for Fun Containers/Recepticles

Identify some unique ways to present the objects from your sound bags

– Ned the fabric head– Mailbox– Pillowcase– Bucket– Pin toy

What’s in Ned’s Head?

Mailbox

Bucket

Pin Toy

Therapy Goals & Activities

For Use with Very Young, Pre‐Verbal Children and Their Families

Motor Planning TherapyCritical Components

1. Use of auditory bombardment – pairing a word with a predictable action or activity in an intended repetitive manner.

2. Opportunity without pressure – need to create opportunities to talk but without any pressure to do so – this helps to establish trust between adult and child – avoid instructing child to say specific words (say dog, say cow, say ball…)

ELICITING MULTIPLE REPETITIONS

Eliciting Multiple Repetitions

• One of the most important strategies we must focus on early on in the therapeutic process is repetition of target sounds and words (w/o drill work). This is contextually based auditory bombardment.

• In order to design activities to elicit multiple repetitions, we must select activities that have multiple, identical pieces or parts. # of available pieces = potential # of repetitions!

Suggestions for Eliciting Multiple Repetitions (drill work!)

1. When looking at counting picture books, count objects on the page repeating the object name instead of rote counting “1‐2‐3‐4‐5.”

2. When walking up/down the stairs, say “up‐up” or “down‐down” instead of counting each stair.

3. Use predictable books with repeating phrases and have the child fill in the same word each time. For example, “Brown bear, brown bear what do you ________?”

Suggestions for Eliciting Multiple Repetitions (cont’d)

4. Identify one person in family photos and repeat their name over and over while pointing to the pictures (“mama‐mama‐mama”).

5. Use Velcro play food saying “cut” each time the child cuts with the toy knife.

6. Use muffin tins to elicit 12 repetitions of the target word. Have child place a bouncy ball in each opening saying “ball” each time.

Velcro Food

Muffin Tin

Mini or Super Size?

1 Syllable Word “duck”

2 Syllable Word “happy”


7. Line up play‐dough balls saying “poke” as you poke each ball.

8. Throw small balls into a basketball hoop or laundry basket saying “ball” each time.

9. Race small cars through a wrapping paper tube saying “whee” or “car” each time.

10.Hammer golf tees into Styrofoam saying “boom boom.”


11.Race cars across the table repeating “Ready, set…go!”

12.Touch child’s toes one at a time saying “toe” each time.

13.Stack blocks saying “up” each time a block is placed.

14.Anything that pops ‐ bubbles, Moo Popper, bubble wrap, poppers saying “pop‐pop‐pop.”


15.Roll balls down a slide saying “whee.”

16.Stamp magnet pieces on Magnadoodle saying “dot‐dot‐dot” repeatedly.

17.Find all the doors in the house/classroom knocking on each one saying “knock‐knock.”

18. Say “bye‐bye” repeatedly as you put blocks into a tub.


19. Make band‐aid art by sticking a variety of band‐aids on a piece of paper saying “boo‐boo” each time.

20. Have toy animals walk, eat and sleep repeating key words “walk‐walk‐walk,” “eat‐eat‐eat” & “night‐night.”

Other Games with Multiple Identical Pieces…

Ideas for therapy with older kids – in the therapy room

• Mighty Monkey Pegs• Connect 4 (regular size & mini for fine motor)• Pop‐Up Pirate

Mighty Monkey Pegs

Connect 4

Pop‐Up Pirate

Resources for Great Therapy Toys

• www.beyondplay.com• www.toystogrowon.com• www.therapyshoppe.com• www.learningresources.com• www.fatbraintoys.com

THERAPY GOALS

The A.M.E. Approach to Early InterventionAssess –Model – Explain

First, assess the child’s stimulability with each activity (lots of diagnostic therapy with these kiddos).

Second, model how to implement each activity to elicit the desired target behavior (for caregivers).

Third, explain the purpose of each activity & make suggestions to caregiver on how to incorporate them into their daily routines.

Goal 1 Establish Eye Contact

• If child avoids watching the speaker’s mouth this must be addressed early on in the therapeutic process.

• Encourage speakers to hold desired items next to their mouth to elicit eye contact from the child.

• Use over‐exaggerated facial expressions and an animated voice to increase eye contact from child. The gasp can also be very effective.

Eye Contact (cont’d)

• Sit face to face with child during play time.

• Seat child higher than adult to naturally elicit eye contact.

• Read books with child facing adult.

• Use a mirror to encourage eye contact – suggest a door mirror hung horizontally on the wall at the child’s eye level. Sit side by side and make funny faces in the mirror.

Natural Eye Contact

Door Mirror (hung horizontally)

Chenille Kraft Speech Mirror$10.99 each at www.quill.com

Eye Contact (cont’d)

• Wait for eye contact before reinforcing child with desired item – then praise by saying “good looking!”

• Decreased eye contact is likely due to increased pressure to speak – so remove that pressure and eye contact will improve. Opportunity without pressure!

• This is NOT a talking goal!

Goal 2Establish Motor Imitation Skills

• Why do we care? Because motor imitation skills precede verbal imitation skills.

• Explain the purpose and relevance of working on gross motor and fine motor imitation skills – child needs to imitate what we do in order to teach him how to talk.

• This is indirectly related to learning to talk.

• This is NOT a talking goal!

Motor Imitation Skills (cont’d)

Suggested motor imitation targets:

Clap hands Stomp feetBlow a kiss WaveBang blocks Knock on doorFly a toy plane Stick out tongueKnock blocks down Push toy carA‐choo game Make toy animals walkStir with a spoon Gestures/signs Pound a hammer Put on a hatRoll a ball Pat a baby doll

Achoo Video Clip


• Songs and finger plays can be valuable tools for developing motor imitation skills.

• Early on, the focus is on the actions. • Use gentle hand‐over‐hand assistance to help the child be successful with the actions.

• Preferred songs and finger plays can be highly motivating for young children.

• Promotes fun adult‐child interactions and encourages imitation skills.


Suggested songs and finger plays:

Teddy Bear, Teddy BearRow, Row, Row Your Boat (with additional verses)Wheels on the Bus/Animals on the BusIf You’re Happy & You Know ItBaby BumblebeeTwinkle Twinkle Little StarItsy Bitsy SpiderHead, Tummy, Knees & Toes5 Little Monkeys Jumping on the Bed

Teddy Bear

Teddy Bear Teddy Bear Turn AroundTeddy Bear Teddy Bear Touch the GroundTeddy Bear Teddy Bear Show Your ShoeTeddy Bear Teddy Bear That Will Do

Teddy Bear Teddy Bear Go UpstairsTeddy Bear Teddy Bear Say Your PrayersTeddy Bear Teddy Bear Turn Off the LightTeddy Bear Teddy Bear Say Good‐Night

Teddy Bear Video Clip

IFSP Outcome Example

• Alexis will imitate five or more actions when singing her favorite songs/finger plays with her caregivers 3 days, in 2 consecutive weeks.

Goal 3 Vocalizing

• We need to help silent toddlers find their voice.• Encourage caregivers/teachers to reinforce any vocalizations produced by the child.

• Take turns vocalizing into an empty bucket, echo microphone or megaphone.

• Have child say “ahhh” while playing with a toy doctor kit and flashlight.

• Other verses to Row Row Row Your Boat (to elicit scream & roar).

Additional Verses to Row Your Boat

Row, row, row your boat

Down the jungle streamIf you meet a crocodile don’t forget to scream!

AAAHHHHHHHHHH!!

Row, row, row your boatGently back to shoreIf you meet a lion

Don’t forget to roar! ROOOOAAARRR!

Goal 4Establish Sound Effects

• Sound effects are a fun and effective way to:

‐elicit intentional sounds‐transition from pre‐speech to speech sounds‐develop vocal imitation skills‐practice moving articulators‐develop prosody (the melody of speech) ‐transition from automatic to voluntary sounds

• Focus on: (a) non‐speech movements & sounds, (b) animal sounds, (c) vehicle sounds, (d) exclamations & (e) other sounds effects during play time

A. Non‐Speech Movements & Sounds

open mouth (use puppets with big mouths) click tongue

blow raspberries‘Indian’ sound

smack lips togetherblalling sound blow kisses

make funny faces in a mirrorstick tongue out

Puppets


• Oscar will engage in vocal play by imitating 5 different non‐speech movements and sounds when playing with his caregivers, 4 days in 1 week.

This is a great outcome for that silent child who rarely turns his voice on.

B. Animal Sounds

oo‐oo‐ah‐ah (monkey) baak baak (chicken)roaarr (lion/dinosaur) tweet tweet (bird)*pant/woof (dog) baa baa (sheep)meow (cat) hoo hoo (owl)*bubble sound (fish) sssssss (snake)moo (cow) quack quack (duck)neigh (horse) oink (pig)trumpeting (elephant) bzzzzzz (bee)giraffe (tongue wag) seal (arrpppp)

Toy animals

First Animal Sounds

Which animal sounds do we introduce first to non‐verbal children?

1. Fish2. Dog3. Giraffe

WHY?

C. Vehicle Sounds

Siren (police car, fire truck)Vroom, brmmmm (car sounds)Beep beepHonk honkChoo chooAirplane sound

Pair sounds with actions during play time Be playful & animated

D. Exclamations!

These words have distinctive pitch patterns and a strong emotional component:

Whee! Ta daa!Boom! Boo!Uh‐oh! Yuck!Yeah! Wow!Oops! Whoa!Oh no! Ow!Oh man! No no!Pee‐u! I did it!

E. Other Sound Effects

Drinking/slurping soundTick tock (clock)A‐choo (sneezing sound)Waah (crying sound)Shhhhhh (quiet sound)Mmm/num num (eating sound)SniffingUhhhhhh (grunting sound)Coughing, sighing, giggling


• Lupita will produce 10 different sound effects (animal sounds, vehicle sounds, exclamations) when looking at books with her caregivers, 3 days in 1 week.

Goal 5Establish Speech Sounds in Isolation

• This is not appropriate for kids who are already verbal – but it is a crucial step when working with pre‐verbal kids. **This goal is NOT supported in the literature**

• Need to teach child how to use his jaw, lips and tongue to make speech sounds ‐ Focus on eliciting new movements with the articulators.

• “Alphabet Soup” is a successful activity for eliciting speech sounds in isolation.

Speech Sounds in Isolation (cont’d)

Alphabet Soup Activity (toddler articulation test)

• Toddlers love to put in, dump out and do it again• Gather refrigerator magnet letters and a container with a lid –

cut an opening in the lid so the letters will easily fit into the container (don’t use the letters “Q” or “X”)

• Dump all the letters into your lap, take one letter, hold it next to your mouth and say the speech sound (NOT letter name), pause and allow opportunity for a response

• Allow the child to put the letter into the container• Repeat with other letters as long as child is interested

Alphabet Soup

Vowels

“The difficulty getting from one spatial target to another is exacerbated by vowels, because their articulatory targets are configurations rather than contacts. Diphthongs are even more challenging in this respect.”

(Velleman, 2006)

Speech Sounds in Isolation

** IMPORTANT NOTE** The biggest difference between therapy with a pre‐verbal child and therapy with a child who is already talking to some degree is that we often MUST start with isolated phoneme training (the building blocks for speech) with the pre‐verbal child. In a verbal

child with CAS we would always focus on sequencing sounds together as opposed to sounds in isolation.

With a pre‐verbal child there is no place else to start!

Goal 6 Establish Syllable Shapes

• Move rapidly from speech sounds in isolation to simple syllable shapes – speech sequences vs. individual sounds.

• We want “bay‐bee‐buy‐bow‐boo” not just “buh.”

• Do not inadvertently reinforce overuse of the neutral vowel (ex: “bu‐bu‐ball or “du‐du‐down”).

• Repeat the vowel sound before saying the word to establish correct vowel sounds (ex: “ow ‐ down”).

Syllable Shapes (cont’d)

• Being shaping single word approximations with consonants and vowels that the child has success with.

• Speech Steps and Word Flips are two programs available that focus on consonant vowel combinations. These materials can be adapted for use with very young children.

• Both products are available through www.superduperinc.com

Speech Steps

Word Flips

Word Flips – changing vowels

Word Flips – changing consonants

Word Flips – Changing vowel & consonants

Goal 7Establish Syllableness (while moving language forward)

• Reduplicated utterances (mama, dada, papa)

• Two syllable words with same consonant and changing vowel (puppy, baby, daddy, mommy)

• Two syllable words with changing consonant and vowel (monkey, happy, dino, hippo, potty)

• 2 word phrases

• 3 word phrases

Address Speech AND Language

• We must always work on speech AND language with these kids.

• We must move language forward even though speech production skills remain significantly delayed.

• If we don’t move language forward until the child has perfectly produced single words, the child could be in kindergarten & still at the single word level.

Syllableness + Language Hierarchy Target word “mommy”

LanguageSpeech

ma hi ma I want ma

mama hi mama I want mama

ma—mee hi ma—mee I want ma—mee

mommy hi mommy I want mommy

Goal 8Establish Functional Core Vocabulary

• Will not be the same for each child.

• Family should help identify core vocabulary words.

• Core vocabulary of words should not be chosen based on word shape (e.g. CV, CVC), but rather based on how functional they are.

• Early functional core vocabulary words include: child’s name, “mama/dada,” siblings’ names, pets’ names, friends’ names, favorite foods, favorite toys, & other power words (e.g. no, mine, help).

Establish Functional Core Vocabulary

• Print 4x6 pictures of core vocabulary words and keep them in a small photo album ($1 at Wal‐Mart). Add pictures as they become relevant. Or create a core vocabulary box of objects to play with during therapy time.

• Teach child how to say approximations of these core vocabulary words during direct therapy time & show parents how to do this.

Establish Core Vocabulary (cont’d)

• Picture This… is a CD of real photos that can be used to create core vocabulary cards for families.

• Picture This… can be purchased through www.beyondplay.com and it can print labels in English, Spanish, German, Italian or French.

IFSP Outcome Examples

• Zachary will say an approximation of his name when asked “What’s your name?” during story time at the library, 3 consecutive weeks in a row.

• Michael will wave and say “bye‐bye” when his dad leaves for work 4 mornings per week, for 2 consecutive weeks.

Bilingual Core Vocabulary Books

• Creating core vocabulary books can be helpful when working with bilingual families.

• Using the small photo albums, we can create bilingual books by placing the same photo on adjacent pages and using the English label on one side and the Spanish (or other language) label on the adjacent side.

Educating Caregivers

Knowledge is Power!

Language vs. Speech

• Language is the context of what is spoken, written, read or communicated via gestures. Receptive language is what we comprehend; expressive language is the message we convey.

• Speech refers to the sounds and words we speak. Speech requires the coordination of more than 70 muscles and body parts. Speech is one form of expressive language.

Voiced vs. Voiceless Sounds

Voiced Sounds• b• d• g• v• th (as in “this”) • z• j (as in “jump”)• zh (as in “measure”)

• r. w. y, l, m, n, ng• All vowel sounds

Voiceless Sounds• p• t• k• f• th (as in “thanks”)• s• ch (as in “chair”)• sh (as in “shoe”)• h

(sounds with an arrow indicate cognates)

Speech Simplification

• Explain this strategy to parents and caregivers.• Be sure to help them understand how speech simplification is different from baby talk.

• We are teaching these kids to talk the same way typically developing children learn to talk.

Examples: water bluebutterfly

Incorporate Multi‐Modality Cueing Techniques

• Auditory cues are not enough for kiddos with suspected apraxia. Just hearing the words is not facilitating speech development.

• These kids will respond best to a multi‐modality/multi‐sensory cueing approach.

• Incorporate movement and touch into your therapy activities.

• Provide opportunities without pressure.• Remember…talking doesn’t start at the mouth!

Multi‐Modality Cueing (cont’d)

Be specific when teaching speech sounds:

• Tell the child what to do with his articulators (“bounce your lips”)

• Show him what to do with his jaw, lips and tongue (posture your articulators/mouth the sound or word)

• Pair sounds with movement & touch• Offer pictorial cues (show picture of popcorn for /p/)• Provide prosodic cues (say target sound or word louder and with more emphasis; use animated voice)

Multi‐Modality Cueing (cont’d)

• There are different types of specific cueing techniques available. One is called PROMPT.

• PROMPT (Prompts for Restructuring Oral muscular Phonetic Targets) is a multidimensional approach to speech production disorders (visit website at www.promptinstitute.com for more information)

• PROMPT does not “fit” into the early intervention model b/c it’s something the therapist does to the child.

Non‐Verbal Communication Systems

Sign Language & Picture Communication

To Sign or Not To Sign

• Should we use sign language when working with kids with suspected apraxia?

• Sign language can be a useful tool to establish functional communication skills.

• However, if the child is already communicating quite effectively, sign language may not be necessary.

• If the child has limb apraxia/limited motor imitation skills sign language may be difficult to learn.

To Sign or Not To Sign

If a family chooses to use sign, provide them with the guidance, support & tools, but don’t spend a lot of direct therapy time teaching the child to sign.

To Sign or Not To SignIf you decide to use sign language:

Goal is to provide the child with a consistent way to communicate wants and needs until he is ABLE to talk.

Always say the word as you use the sign – we are using sign language as a bridge to verbal communication.

Follow the child’s lead and be flexible – if the child develops his own sign go with it – there is no right or wrong way to sign b/c we are not using a formal sign system – sign is being used to bridge the gap from non‐verbal to verbal communication.

Use gentle hand over hand assistance to help the child be successful with learning new signs.

Sign Language (cont’d)

Begin to fade signs once the child starts pairing with verbal approximations of the desired words.

Initially child will use the sign by itself, next he will pair a sound with the sign, then he will pair the sign with the actual word and use them as equal partners, then he will drop the sign and use the word only.

This is how we transition children from being non‐verbal to verbal communications.

Fading is the most important step of sign language! Teach functional, concrete signs and avoid vague signs. In

other words, one sign = one item.

Sign Language (cont’d)

“More” is the most vague, useless single sign for toddlers and yet it is the most commonly taught sign.

Signing “more”

• The best context to teach the sign “more” is by giving a choice when the child’s behavior indicates he may be finished with an activity.

“Are you all done or do you want more?”

Picture Communication

• Sign language always has to be interpreted by somebody…so a picture communication system might be an easier way to allow the child a functional way to communicate basic wants and needs.

• Deciding whether to use signs or pictures often depends on how many different caregivers the child is with AND the child’s motor imitation skills.

• Use real photos when working with very young children.


• Carlos will use signs, pictures and/or single words to communicate what he wants to play during center time at daycare, 3 days per week, for a period of 4 weeks.

Prognosis

When Parents Ask About Their Child’s Future

Prognosis

“Prognosis means how the child might be expected to do in the future if he or she receives proper treatment. The answer to this question is that outcomes vary, however, children with apraxia can and do improve!”

Sharon Gretz, 2003

When Families Ask About Prognosis

We need to be honest and tell families that progress is often slow ‐ that learning to talk is a marathon not a sprint. There is no “fast fix.”

Remember, that slow progress adversely affects parents’ confidence in the therapy process.

Duration of therapy for a toddler with suspected apraxia is likely to be 3+ years.

Child with CAS is at risk for reading, spelling & writing difficulties as oral language problems often precede written language problems.

What Affects Prognosis for Becoming Verbal?

• Severity • Cognitive skills • Child’s personality/temperament• Age at which therapy was initiated• Co‐existing conditions• Motivation – does child enjoy therapy?• Appropriateness of the therapy• Family involvement

Prognosis

• It is important to remember that CAS is a dynamic speech disorder that changes over time.

• What looks like CAS in a 2 year old may no longer look like CAS in a 4 year old.

• Continuum of speech sound disorders:

CAS Phonologic Residual ArticImpairment Errors

Prognosis (cont’d)

“We need to remember that classifications or labels may change over time with neural maturation and appropriate treatment. For example, children with CAS often progress to the point at which speech characteristics are more appropriately labeled phonologic impairment or residual articulation errors.”

Strand & McCauley, 2008

Case Studies

Case Study 1Gabrielle – age 22 months

• Birth history unremarkable• Started receiving OT & PT before age 6 months• Started receiving speech‐language therapy at age 13 months

• Does not clap or bring hands to midline• No consistent babbling • Is silent most of the time• Whines with a manipulative purpose• Does not use gestures to communicate

Gabrielle

• Started walking at age 16 months• Excessive mouthing of toys starting at age 18 months• Limited purposeful play with toys• Extremely chubby cheeks (at 13 months and still at 22 months)

• Good joint attention• Difficulty with motor imitation skills• No success with sign language • Has difficulty with activities that require two hands

Gabrielle

• Produces only neutral vowel sound• Occasionally makes “dududu” sound; no bilabial sounds

• Limited facial expressions• Is silent much of the time• Follows 1 step commands• No distal point established until age 20 months• Strong desire to interact with others• Skill acquisition rate is slow

Gabrielle

• Did not start crawling until after her 2nd birthday• Has an awkward gait• Cannot move a ride on toy with her own feet• Has responded favorably to a simple picture communication system

How do we categorize Gabrielle?

Dysarthria?Suspected Childhood Apraxia of Speech?

Expressive Language Delay?Autism Spectrum Disorder?Global Developmental Delay?

Case Study 2Wyatt

• EI evaluation at age 25 months• Birth history unremarkable• Passed newborn hearing screening/no hearing concerns

• Developmental milestones, with the exception of speech were met on schedule

• Said first true word at age 15 months• Limited phonemic repertoire• Starting to become highly frustrated

Wyatt

• Says 7 different single words including “hi, bye, up, ball, me, mommy, daddy”

• Not adding new words to expressive vocabulary• No verbal imitation skills• Per parents, he understands everything• Produces an atypical nasal airflow sound as a replacement for words he is unable to say

• Pairs this nasal airflow sound with gestures to communicate wants and needs

Wyatt

• Did not qualify for early intervention program b/c he did not have a 50% delay overall

• Did one month of private speech therapy with focus on family education and training

• Able to elicit many single words by simplifying words, pausing and giving articulatory placement prompts

• Showed family how to be a good speech model (primarily got parents to stop saying “SAY…”)

• Both parents were present at every therapy session

Wyatt

• Wyatt had excellent attention and time on task• Appropriate play skills• Within one month he was using new words both in imitation and spontaneously and starting to combine 2 words together

• Once he learned to verbally imitate, the atypical nasal airflow sound “went away”

How do we categorize Wyatt?



Case Study 3Jill

• EI evaluation completed at age 18 months• Birth history unremarkable• Developmental milestones with the exception of speech were met on time

• Limited cooing and babbling as a baby• Communicates wants and needs by pointing, grunting and pulling on adult

• Says only “mama” and “dada” but not regularly• Produces mostly neutral vowel sounds

Jill

• No verbal imitation skills• Silent child – rarely vocalizes even during high energy activities

• Did not qualify for EI services based on 50% delay, but got her services based on professional opinion

• Therapy started with helping Jill find her voice • Within first month‐able to elicit some speech sounds in isolation & within 2 months she was starting to imitate some simple single word approximations

Jill

• Lots of groping & silent posturing when attempting to talk

• Significant difficulty learning to produce lip rounding vowels “o” and “oo”

• Able to follow 2 step commands• Difficulty co‐articulating consonants and vowels • Very slow and inconsistent progress • Difficulty learning to whisper and yell on command• Excellent eye contact and joint attention

How do we categorize Jill?



Case Study 4Drake

• EI evaluation completed at age 23 months• Birth history unremarkable• HX of frequent ear infections with 2 sets of PE tubes placed

• Passed hearing eval after tubes placed• Motor milestones: sat up at 8 months; crawled at 11 months; walked at 16 months

• Just recently started babbling• Says “no, dada & mama/nana”

Drake

• Father was reportedly a “late talker”• Qualified with a 50% delay in overall communication• Started with speech/language therapy & OT• Had some challenging behaviors which were interfering with his development (i.e. throwing, hitting, biting and avoiding any interaction in which demands were placed upon him)

• Thus, behavior therapy was brought on board• Lack of motor and verbal imitation skills

Drake

• Resists hand over hand assistance so sign language was not an option

• Does not consistently follow 1 step commands• Does not point to pictures on command• Has said words, but loses them rapidly• Uses others as a tool to get needs met (i.e. puts mom’s hand on the doorknob when he wants to go outside)

• Very slow progress

Drake

• Limited joint attention, short time on task• After behavior therapy started, he began showing a little more compliance and motor imitation skills began to improve

• Vowel errors• Effortful speech• Began to elicit speech sounds in isolation which led to single word approximations (i.e. “o‐puh” for “open” and “pu‐duh” for “panda”)

How do we categorize Drake?



Case Study 5Noah

• Age 2 years, 11 months• Birth history unremarkable• No hearing concerns• Frequently has a wet chin and has days when he drools excessively

• Significant difficulty with lingual lateralization• Generalized oral weakness• Adorable chubby cheeks• Poor overall speech intelligibility

Noah

• Unable to blow without spitting• Omits medial consonant in two syllable words• Slushy speech• Receptive and expressive language skills within average range per PLS‐4

• Talks in 3 ‐ 4 word sentences but words are often mumbled and therefore difficult to understand

How do we categorize Noah?



Categorizing Kids on Your Caseload

Your Case Study

• Speech characteristics:

• Co‐existing conditions:

• Probable diagnosis:

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