TREATMENT APPROACHES: CHILDHOOD APRAXIA

OF SPEECH (CAS)

NSW EBP PHONOLOGY GROUP

Leaders: Elise Baker & Bronwyn Carrigg

Presenters: Louise Petersen & Lauren Hamill

Best external evidence

Best internal evidence(from client factors & preferences)

Best internal evidence(from clinical practice)

Clinical expertise

E1

E2 E3

(Based on Dollaghan, 2007)

CHILDHOOD APRAXIA OF SPEECH (CAS)

Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder, in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g. abnormal reflexes, abnormal tone). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.

ASHA (2007)

KEY FEATURES OF CAS

Inconsistent error production on both consonants and vowels across repeated productions of syllables or words

Lengthened and impaired coarticulatory transitions between sounds and syllables

Inappropriate prosody

Morgan & Vogel (2009)

So, what is the nature of the evidence-base for treatment of CAS?

TREATMENT FOR CAS

There is currently no gold standard treatment approach for treating CAS

This is because: “there are currently too few well-controlled studies in this field to enable conclusions to be drawn about the efficacy of treatment for the entire CAS population, and calls for SLPs working in this area to design better studies”

(Morgan & Vogel, 2009)

SO, WHAT EVIDENCE IS AVAILABLE?

Lower level studies, usually based on one or a few children.

This year, we have critically appraised 10 studies.

An overview of the principles that underscore the treatment approaches helps to understand the nature of the evidence.

GENERAL PRINCIPLES (STRAND, 2012)

The goal or the focus of the treatment of CAS is to improve the individual’s ability to assemble, retrieve, and execute motor plans for speech. The focus or target of treatment is the movement vs. the sound.

Practice should focus on making those movement transitions, in the context of speech.

At first, the clinician will provide maximum support by providing visual, tactile and auditory models, fading those cues over time

Because the goal of treatment is to improve movement accuracy, a number of approaches are grounded in the principles of motor learning

PRINCIPLES OF MOTOR LEARNING (PML) (BASED ON MAAS ET AL., 2008)

What is Motor Learning?

A process of acquiring the capability for producing skilled action

It occurs as a result of experience and practice

It is influenced by a variety of factors

These factors are thought to make a difference in therapy

PRINCIPLES OF MOTOR LEARNING (PML) (BASED ON MAAS ET AL., 2008)

Motor Performance - How the movement isperformed during training, within the session

Motor Learning - how the movement isperformed at another time (i.e., generalization)

Precusors to Motor Learning: Motivation and Attention Pre-Practice

Remembering for CAS to consider: Rate Prosody

Practice and feedback conditions!

PML: PRACTICE CONDITIONS

Condition Options Evidence

Practice amount Small vs Large No systematic evidence

Practice distribution

Massed vs Distributed

No systematic evidence

Practice variability Constant vs Variable

Limited evidence for benefit of variable practice in unimpaired speech motor learning ; no evidence for MSD

Practice schedule Blocked vs Random

Limited evidence for random practice, in unimpaired speech motor learning and treatment of AOS

Attentional Focus Internal vs External No systematic evidence

Target Complexity Simple vs Complex Limited evidence for benefit of targeting complex items in treatment of AOS

Maas et al (2008)

PML: FEEDBACK CONDITIONS

Condition Options Evidence

Feedback type Knowledge of Performance (KP) vs Knowledge of Results (KR)

No systematic evidence

Feedback frequency High vs Low/Summary-KR

Some evidence for benefit of reduced feedback frequency in treatment for AOS and speech motor learning in hypokinetic dysarthria

Feedback timing Immediate vs Delayed Some evidence for delayed feedback in treatment for AOS and hypokinetic dysarthria

Maas et al (2008)

TREATMENT APPROACHES/METHODS

There are a variety of approaches described in the literature, such as:

Integral stimulation, and, Dynamic Temporal and Tactile Cueing (DTTC)

Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT)

Nuffield Centre Dyspraxia Programme (NDP3) Rapid Syllable Transition Treatment (ReST) Melodic Intonation Therapy (MIT) Augmentative devices to facilitate communication Generic approaches based on PML Stimulability training program (STP) mCVT (modified core vocabulary training)

BRIEF DESCRIPTION OF INTEGRAL STIMULATION AND DYNAMIC TEMPORAL AND TACTILE CUEING (DTTC)

Integral Stimulation Integral Stimulation is an articulation therapy

involving imitation, auditory models, and visual models

Developed by Robert Milisen, 1954

The child IMITATES utterances modelled by the SP with attention focused on LISTENING while LOOKING

PROSODIC cueing methods such as MIT or contrastive stress are also used

Word stress and the contours of sentences are emphasised early in treatment

Functional communication is emphasised

DYNAMIC TEMPORAL AND TACTILE CUEING (DTTC)

“For non-verbal children, with very severe CAS, Edythe Strand uses a variation of Integral Stimulation

that she developed, called: Dynamic Temporal & Tactile Cueing for speech motor learning (DTTC)”

“DTTC is based on John Rosenbek and colleagues’ 1973 “Eight-step Continuum for Treatment of Acquired

Apraxia of Speech.”

“It allows for a continuous shaping of the movement gesture.”

(Bowen, 2012)

DYNAMIC TEMPORAL AND TACTILE CUEING (DTTC)

“Allows opportunity for the child to take increasing responsibility for assembling, retrieving and executing

motor plans with progressively less cueing.”

“Sometimes, we begin the therapy process by working in the session and having the parents work at home to establish good visual attention to a person’s face, as

well as general imitation skills.”

“These are prerequisites for the integral stimulation approach, and for most children can be achieved with

a positive reinforcement behaviour modification approach.”

Strand (2012)

DTTC Procedure(From Bowen, 2012, based on Edyth Strand’s work)

1. Imitation - Direct, immediate imitation of natural speech.

2. Simultaneous production with prolonged vowels (most support)

3. Reduction of vowel length

4. Gradual increase of rate to normal

5. Reduction of therapist’s vocal loudness, eventually miming

6. Direct imitation

7. Introduction of a one or two second S-R delay (least support)

8. Spontaneous Production

Keep in mind: This hierarchy is constantly varying -- after observing the child's response on each trial

CAP – Integral Stimulation

Strand & Derbertine(2000)

The Efficacy of Integral Stimulation Intervention with Developmental Apraxia of Speech

Single case study design with multiple baseline

Provided evidence for the use of Integral Stimulation incorporating a number of basic PML for children with CAS

CAP – Dynamic Temporal and Tactile Cueing (DTTC)

Baas, Strand, Elmer & Barbaresi (2008)

Treatment of Severe Childhood Apraxia of Speech in a 12-Year-Old Male with CHARGE Association

Single subject multiple baseline design

Provided a low level of evidence for the use of DTTC incorporating some PML to improve the functional verbal communication of children with severe CAS

CAP - Dynamic Temporal and Tactile Cueing (DTTC)

Strand, Stoeckel & Baas (2006)

Treatment of Severe Childhood Apraxia of Speech: A Treatment Efficacy Study

Single subject with multiple baseline design for 4 participants

Frequent treatment using DTTC incorporating the PML resulted in improvements in articulatory accuracy and verbal communication for 3 out of 4 children with severe CAS who had been non-verbal despite previous treatment

CAP – Stimulability training program and Modified core vocabulary training

Iuzzini & Forrest (2010)

Evaluation of a combined treatment approach for childhood apraxia of speech

Single subject multiple baseline design with 4 participants

Provided emerging evidence for the use of STP (stimulability training program) paired with mCVT (modified core vocabulary training) to increase the phonetic inventory and PCC of children with CAS

CAP – MIT and Touch-cues

Martikainen & Korpilahti (2011)

Intervention for childhood apraxia of speech: A single case-study

Single case study multiple baseline design

A combination of MIT & Touch-Cue Method(TCM) intervention led to improved vowel and consonant production in a single case. However, further research is required.

CAP – Rapid Syllable Transition Treatment (ReST)

Ballard, Robin, McCabe & McDonald (2010)

A Treatment for Dysprosody in Childhood Apraxia of Speech

Single subject multiple baseline design for 3 siblings

Targeted treatment using PML was effective in improving the production of SW vs WS stimuli and generalised to untreated stimuli, but minimal changes were seen in production of real words

CAP – Practice condition:

high or low dose?

Edeal & Gildersleeve-Neumann (2011)

The Importance of Production Frequency in Therapy for Childhood Apraxia of Speech

Single subject alternating AB design with 2 participants

Frequent and intense practice of speech targets results in more rapid responses to treatment. Retention and transfer were greater for speech sounds that were practised 100-150 times per session than for speech sounds that were practised 30-40 times per session (ie: higher dose was better)

CAP - Feedback condition: high vs low frequency feedback?

Maas, Butalla & Farinella (2012)

Feedback Frequency in Treatment for Childhood Apraxia of Speech

Alternating treatment and multiple baseline single subject design with 4 participants

Findings were mixed - unclear whether low or high frequency feedback is more effective for children with CAS

Provided support for the efficacy of integral stimulation treatment for children with CAS

CAP – Practice condition:

Blocked or random?Maas & Farinella (2012)

Random versus blocked practice in treatment for childhood apraxia of speech

Two-phase alternating treatment and multiple baseline single subject design with 4 participants

Unclear whether random or blocked practise is more effective for children with CAS

Findings from nonspeech motor learning literature may not extend to treatment for CAS

Provided support for the efficacy of integral stimulation treatment for children with CAS

CAP - AAC

Cumley G. & Swanson, S. (1999)

Augmentative and Alternative Communication Options for Children with Developmental Apraxia of Speech: Three Case Studies

3 single case studies retrospectively written

Provided a low level of support for the implementation of high and low tech AAC with children with CAS

Best external evidence

Best internal evidence(from client factors & preferences)

Best internal evidence(from clinical practice)

Clinical expertise

E1

E2 E3

(Based on Dollaghan, 2007)

PART 2: E3BPINTERNAL EVIDENCE

EBP PHONOLOGY E3BP TRIAL( STILL IN PROCESS)

1. Look at which principles you have been given

2. Select two clients with a speech impairment – one for each principle

3. Select a treatment goal for each client to trial

4. Clarify and compare your results with others from your workplace

5. Take data (including generalisation data)6. Complete the one page questionnaire

EBP PHONOLOGY E3BP PML PRINCIPLES

1. Blocked vs Random presentation of stimuli

2. KP with no delay vs KR with 3 second delay

3. High frequency vs Low frequency feedback

WHY IS THERE NOT MORE EVIDENCE?

Methodological challenges: Lack of a standard definition for CAS Difficulties in differential diagnosis Likely significant heterogeneity in symptomatology Changing symptomatology over time

Maintaining experimental control in real clinical settings

Lack of support for large scale studies

CONCLUSIONS

Treatment for CAS requires:

Careful planning by the clinician and family

Knowledge about the various treatment approaches and how they overlap

An understanding of the principles of motor learning and how application of those principles to treatment planning and implementation

Caution is warranted in extrapolating from the nonspeech motor learning literature to speech treatment for CAS

REFERENCES

American Speech-Language-Hearing Association. (2007). Childhood Apraxia of Speech [Technical Report]. Available from www.asha.org/policy.

 Baas B.S., Strand E.A., Elmer L.M., Barbaresi, W.J. (2008). Treatment of severe childhood apraxia of speech in a 12-year-old male with CHARGE association. J Med Speech Lang Pathology, Dec; 16(4): 181-90.

 Ballard, K.J., Robin, D.A., McCabe. P., & McDonald, J. (2010). A Treatment for Dysprosody in Childhood Apraxia of Speech. Journal of Speech, Language, and Hearing Research. Vol. 53; 1227-1245.

Bowen, (2012). Dynamic Temporal and Tactile Cueing (DTTC) and Integral Stimulation. Retrieved from http://speech-language-therapy.com

Cumley G. & Swanson, S. (1999). Augmentative and Alternative Communication Options for Children with Developmental Apraxia of Speech: Three Case Studies. AAC Augmentative and Alternative Communication (15), 110-125.

 Edeal, D.M. & Gildersleeve-Neumann, C.E. (2011). The Importance of Production Frequency in Therapy for Childhood Apraxia of Speech. American Journal of Speech-Language Pathology, May; 20, (95-110).

REFERENCES (CONT)

Dollaghan, C. A. (2007). The handbook for evidence-based practice in communication disorders. Baltimore: Paul H. Brookes.

Iuzzini, J. & Forrest K.(2010). Evaluation of a combined treatment approach for childhood apraxia of speech. Clinical Linguistics & Phonetics; 24(4-5), 335-345.

Maas, E., Butalla, C.E. & Farinella, K.A. (2012) Feedback Frequency in Treatment of Childhood Apraxia of Speech. American Journal of Speech-Language Pathology 21, 239-257.

Maas, E. & Farinella, K. A. (2012). Random versus blocked practice in treatment for Childhood Apraxia of Speech. Journal of Speech, Language and Hearing Research, 55, 561-578.

 Maas, E., Robin, D.A., Austermann Hula, S.N., Wulf, G., & Schmidt, R.A. (2008). Principles of Motor Learning in treatment of Motor Speech Disorders. American Journal of Speech-Language Pathology, 17, 277-298.

Martikainen, A. & Korpilahti, P. (2011). Intervention for childhood apraxia of speech: A single-case study. Child Language Teaching and Therapy, 21, 9-20.

REFERENCES (CONT) Morgan, A.T. & Vogel, A.P. (2009). A Cochrane review of treatment

for childhood apraxia of speech. European Journal of Physical and Rehabilitation Medicine. Mar;45(1):103-10.

Strand, E. (2012, April 6). Management of CAS [PowerPoint slides]. Brigham Young University, Provo UT.

Strand, E., Stoeckel., R., & Baas, B. (2006). Treatment of Severe Childhood Apraxia of Speech: A Treatment Efficacy Study. Journal of Medical Speech Pathology, 14, 297-307.

 Strand, E.A.,and Debertine, P.(2000) The efficacy of integral stimulation intervention with developmental apraxia of speech. Journal of Medical Speech Pathology. 8 (4), 295-300.