Childhood+Apraxia+of+Speech

==**Childhood Apraxia of Speech **=

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What is Childhood Apraxia of Speech?
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Childhood Apraxia of Speech (CAS) is a motor speech disorder. Children with CAS have problems saying sounds, syllables, and words. This is not because of muscle weakness or paralysis; rather, the brain has problems planning to move the body parts (lips, jaw, tongue) needed for speech. As a result, the child knows what he or she wants to say, but his/her brain has difficulty coordinating the muscle movements necessary to say those words. This motor planning impairment results in errors in speech sound production and prosody. In most cases, the cause is unknown. However, some possible causes of CAS include genetic disorders/syndromes, stroke, or brain injury. It is important to note that while CAS may be referred to as "developmental apraxia," it is not a disorder that children simply "outgrow". With CAS, children do not follow typical patterns and will not make progress without treatment. There is no cure, but with appropriate, intensive intervention, significant progress can be made.

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==**How is Childhood Apraxia of Speech Diagnosed?** ==

A certified Speech Language Pathologist with knowledge and experience with Childhood Apraxia of Speech conducts an evaluation, which assesses the child's **oral-motor abilities**, **melody of speech**, and **speech sound development.** In addition, the SLP may examine the child's receptive and expressive language skills and literacy skills to see if there are co-existing problems in these areas.
 * An Oral-Motor Assessment Involves: **
 * Checking for signs of weakness or low muscle tone in the lips, jaw, and tongue, called dysarthria. Children with CAS typically do **not** have weakness, but checking for it will help the SLP differentiate between a diagnosis of CAS and dysarthria.
 * Seeing how well the child can coordinate the movement of the mouth by having him or her imitate non-speech actions. For example, asking the child to move his or her tongue from side to side, to smile, to frown, and to pucker their lips.
 * Evaluating the coordination and sequencing of muscle movements for speech while the child performs tasks such as the diadochokinetic rate, which requires the child to repeat strings of sounds (e.g., puh-tuh-kuh) as fast as possible. This provides information about a person's ability to make rapid speech movements using different parts of the oral cavity, for example /p/ is produced at the front of the oral cavity and /k/ is produced at the back of the oral cavity.
 * A Melody of Speech (Intonation) Assessment Involves:**
 * Listening to the child to make sure that he or she is able to appropriately stress syllables in words and words in sentences.
 * Determining whether the child can use pitch and pauses to mark different types of sentences (e.g., questions vs. statements) and to mark off different portions of the sentence (e.g., to pause between phrases, not in the middle of them).
 * A Speech Sound Assessment Involves:**
 * Evaluating both vowel and consonant sounds.
 * Checking how well the child says individual sounds and sound combinations (syllables and word shapes).
 * Determining how well others can understand the child when they use single words, phrases, and conversational speech.

**Formal Testing:**
__**Screening:**__ **The Screening Test for Developmental Apraxia of Speech – Second Edition (STDAS-2)** The Screening Test for Developmental Apraxia of Speech - Second Edition (STDAS2), developed by Robert Blakeley, Ph.D., identifies children ages 4 through 12 who have both atypical speech-&-language problems and associated oral performance. These two key factors render children suspect for developmental apraxia of speech. The STDAS2 has four subtests. The first subtest, expressive language discrepancy, is a required prescreening task. For this subtest, the difference between expressive and receptive language age is calculated. Continued administration of the remainder of the screening test is recommended only in cases where the expressive language age is 6 months or more below the receptive language age. The other three subtests, prosody, verbal sequencing, and articulation, are core subtests. In the prosody subtest, the examiner rates a child’s prosody in the production of three imitated sentences as normal or deviant based on observations of ‘deviance in rate, phonemic spacing, inflection or stress’. In the verbal sequencing subtest, the examiner slowly models up to five imitated trials for 10 sequences, ranging from a CVCVC to a triplet of CVCVCVs, and the client imitates. These productions are rated as 1 if the entire sequence in correctly produced, and 0 if any errors in production are made. In the articulation subtest, the examiner elicits imitations of words designed to assess the correct versus incorrect production of each 24 consonant phonemes in initial, medial, and final position. Data collected from the subtests is compared against data of normally developing children, children with developmental apraxia of speech, and children with a variety of other speech and language difficulties.

__**Diagnosing:**__ ** The Kaufman Speech Praxis Test for Children ** **(KSPT)** This test was developed by Nancy Kaufman, M.A., CCC-SLP in 1995. The age ra nge for this test is 2;0 to 5;11. KSPT identifies the level of breakdown in a child’s ability to speak so that treatment can be establishedand improvement tracked. This test is easy to administer and score, and takes about 5-15 minutes to administer. The test helps to measure a child’s imitative responses to the clinician, locates where the child’s speech system is breaking down, and points to a systematic course of treatment. Items in the test are organized from simple to complex motor-speech movements, using meaningful words whenever possible. The test includes an imitative, stimulus/response format that can be administered easily without pictorial stimulation. It includes normative information related to the “normal” speaking population of children and the “disordered” population. A diagnostic rating scale assists in delineating severity levels on a continuum. The test is presented in four parts of increasing difficulty and administration is dependent on the individual's level of functioning. The KSPT is norm-referenced and the standardized items provide a raw score, a standard score, and a percentile ranking for each part of the test, where 100 is mean and 85-115 is the range of average. __ Test parts __ Part 1: Oral Movement Part 2: Simple motor-speech movements Part 3: Complex motor-speech movements Part 4: Spontaneous Length

**The Apraxia Profile**[[image:4152FGD0KVL._SL500_AA300_.jpg width="189" height="189" align="right" caption="Courtesy of Google Images"]]
The Apraxia Profile was developed in 1997 by Lori Hickman, M.S., CCC-SLP. This test assists in evaluating a child’s oral motor sequencing deficits and establishing the level of oral movements and sequences he or she produces successfully. It also makes it easy to document a child’s progress over time and provides helpful information to share with parents, teachers, and other professionals. This test takes 25-35 minutes to administer and is appropriate for children ages 3-13.

** Verbal Motor **** Production Assessment for Children ** **(VMPAC)**
The Verbal Moto r Production Assessment for Children was developed by Deborah Hayden, M.A., CCC-SLP and Paula Square, Ph.D., CCC SLP in 1999. It is appropriate for children ages 3-12 years. This test identifies children with motor issues that have negative effects on the development of normal speech motor control. It pinpoints where the child begins to have difficulty, with items arranged from ba sic to complex. This test leads you step-b y-step through the 30 minute evaluation and there are helpful clinician's notes provide explanation as well. In addition, there is a training video that demonstrates administration and scoring. The VMPAC assess three main areas—Global Motor Control, Focal Oral-motor Control, and Sequencing—and two supplemental areas—Connected Speech and Language Control and Speech Characteristics.

==What Theoretical Approaches Guide Treatment of Childhood Apraxia of Speech? ==

Specific treatments can help develop a child's speech who has Apraxia. These approaches should be done as often as possible for the most successful outcomes. Treatment can be not only done with the clinician at site but also at home during play and daily activities the child is familar with.


 * Approach Defined More Specifically- The Oral Motor Approach:** This approach is practicing the movements for speech sounds. Childhood Apraxia of Speech is a motor speech disorder, and this is because the brain has trouble planning to move the oral motor parts, not because the muscles around the mouth are weak. Working on practicing the movement for speech sounds helps to train the brain in order to help the brain better learn how the sounds and syllables should be made. While working on motor skills the mouth is being trained to produce sounds it is normally not used to producing. Although there is no cure for Childhood Apraxia of Speech, with oral motor approach techniques, it can help with the improvement of speech. In oral motor therapy, the clinician works from the bottom up, beginning with oral postures and movements that include pursing, blowing, sucking, chewing, tongue protrusion, tongue lateralisation, tongue elevation, humming, and lip and jaw manoeuvres. Strength, agility, precision, co-ordination and awareness of oral movements are targeted through a series of systematic exercises, including straws, horns and bite-blocks or comparatively inexpensive, and easily obtainable equipment such as pipes, balls, bubbles, candles, plastic tubing and familiar toys that a family might already own. Also, the consumption of food with challenging textures and drinking thick shakes through straws, large, small and curly may be presented as part of the therapy. Oromotor exercises are advised to help the child develop accurate and rapid movements of all areas of the speech apparatus in preparation for coordinating these movements in the production of speech sounds.



**Visual cues**:(providing a hand cue that your child can see such as Cued Speech) **Shaping approaches** which deconstruct and construct words (e.g. the Kaufman Praxis Treatment Kit) break words down to the level of complexity that your child can say, moving the word immediately into functional expressive vocabulary use, and then building the word up through shaping procedures. For example, your child can say na, but cannot say banana. You would show the child banana many times, having him say na, and then building up to nana, and finally to banana. If his name is Jordan, he might start out by using /da/ when giving his name, then building to /oda/, then odan, then ordan, then Jordan.
 * Oral motor approach** (practicing the movements for speech sounds)

**Cognitive: linguistic approaches** Children learn how to make sounds and learn rules determining where the sounds and sound sequences are used.

**Sensory: motor approaches** Motor learning principles are used to help the child to accurately, consistently and automatically make speech movements, sounds and sound sequences.

**Linguistic: motor approaches (multi-sensory approaches)** These comprise a combination of linguistic approaches and motor programming approaches.

**Cueing Approaches** These treatment approaches include specific sensory, gestural, visual and imagery techniques, and are used in combination with one of the previous approaches.

techniques use a variety of sensory cues to help the child hear, see feel and/or understand the target speech movement gestures being requested of them as they practice words or phrases
 * Multi-sensory cueing**

Approaches use a well-defined and structured heirarchy of speech targets and require the child to imitate utterances (syllables, words, or phrases) modeled by the clinician in a “look, listen, do what I do” approach. In this approach, the child’s auditory attention is focused on listening to the words, and his visual attention is focused on looking at the clinician’s face. Over time as the child’s skills improve, the clinician varies the timing of the child’s repetition and then ultimately works toward the child’s self-initiated correct production of speech targets.
 * Integral stimulation **

Shaping techniques use speech productions that the child is currently capable of producing and then, through various forms of feedback and practice, attempts to shape the child's movement gestures into closer and closer approximations of the target word.
 * Progressive approximation **

Approaches use touch or manipulation of the head, face, lips and jaw during speech production so that the child can better “feel” and over time remember how to move their articulators correctly in order to produce the speech movements. Assistance is often provided at first and then faded as the child obtains independence at making the movements gestures for speech.
 * Tactile facilitation **

Uses rhythm and melody to provide timing or rhythmic structure within which speech movements can be achieved.
 * Prosodic facilitation **

of Treatment and Expected Outcomes?
<span style="font-family: Arial,Helvetica,sans-serif; margin: 0in 0in 10pt;">Childhood Apraxia of Speech (CAS) is a progressive disorder that with enough therapy and proper intervention, significant improvements can be made. With appropriate early intervention and ongoing support (from families, professionals, and other appropriate individuals) most children with CAS can improve their speech production skills and develop functional speech. The period of time this outcome requires is individualized and most likely based on the unique characteristics of the child and the level and quality of the intervention provided. Also, most clinicians have agreed that the treatment approach that is chosen will also determine the efficiency of intervention. Currently it is recognized that while treatment is intensive and extends over a number of years, these children are very capable of making wonderful gains and developing intelligible speech. If this does not occur, the SLP needs to make an adjustmen to therapy central to the child.



<span style="font-family: Arial,Helvetica,sans-serif; margin: 0in 0in 10pt;">Treatment goals for such children have sometimes focused on facilitation of overall communication, with some studies using Alternative and Augmentative Communication (AAC). From the perspective of the World Health Organization's (WHO) //International Classification of Impairments, Disabilities, and Handicaps// and //International Classification of Functioning, Disability, and Health//, interventions designed to directly improve overall communicative functioning may indirectly improve a child's ability to function within relevant social and educational contexts. Most treatment research has focused directly on improving speech production, using several approaches that are consistent with the prevalent views, reviewed previously, of CAS as a motor speech disorder. CAS treatment approaches were divided into four categories: linguistic approaches, motor-programming approaches, combinations of linguistic and motor-programming approaches, and approaches using specific sensory and gestural cueing techniques.

<span style="font-family: Arial,Helvetica,sans-serif; margin: 0in 0in 10pt;">Another way to ensure that the period of time for therapy will improve CAS in a client is the consistency of therapy sessions. Research shows the children with CAS have more success when they receive frequent (3-5 times per week) and intensive treatment. Children seen alone for treatment tend to do better than children seen in groups. According to Margaret Edwards "Early stages of treatment need to be carried out on a one-to-one basis for it is only in this way that the patient can learn to develop his own particular strengths and adopt compensatory measures for weaknesses" (Disorders of Articulation, Aspects of Dysarthria and Verbal Apraxia 1984). It is difficult for a child to progress over time if the SLP is not focusing on their specific characteristics of apraxia.

<span style="font-family: Arial,Helvetica,sans-serif; margin: 0in 0in 10pt;">Factors that can affect the length of therapy include: etiology of the child’s apraxia, family history, overall health, severity of apraxia, attention/ability to focus, appropriateness of therapy, age at which intervention begins, cognitive skills, ability to self-monitor, frequency of therapy, motivation, and outside support from family, teachers, and other professionals. Parents should be wary of any prognostic statement which is absolute in either direction. It is not possible for a clinician to say with absolute certainty that a child will completely recover; conversely, he/she will not be able to tell you that your child will never talk.

<span style="font-family: Arial,Helvetica,sans-serif; margin: 0in 0in 10pt;">However, a child will not advance as well if he or she is not practicing speech aside from therapy. CAS is a disorder of coordination of the muscles, not strength. Visual and tactile cues can assist in therapy improvement. Examples of visual cues could be sitting in front of a mirror practicing sounds while watching the way the mouth moves, as well as auditory feedback. With this multi-sensory feedback, the child can more readily repeat syllables, words, sentences and longer utterances to improve muscle coordination and sequencing for speech. Support from the family, as well as working on speech with the child at home will help move therapy along quite well. A child cannot improve if they are only coming to therapy once or twice a week and going back home to produce incorrect speech sounds. All of this will assure optimal therapy. One of the most important things for the family to remember is that treatment of apraxia of speech takes time and commitment. Children with CAS need a supportive environment that helps them feel successful with communication.

<span style="font-family: Arial,Helvetica,sans-serif; margin: 0in 0in 10pt;">To date, there are no definitive studies of the outcome of children with apraxia. This is due to the lack of agreement/identification of this group of children, and also due to the fact that there are no two children with apraxia who are exactly alike in terms of their apraxic characteristics.


 * <span style="font-family: Arial,Helvetica,sans-serif; margin: 0in 0in 10pt;">Example of Long-Term Objective: **

<span style="font-family: Arial,Helvetica,sans-serif; margin: 0in 0in 10pt;">- The child will develop and improve their speech production in order to produce functional speech and effectively communicate with peers.


 * <span style="font-family: Arial,Helvetica,sans-serif; margin: 0in 0in 10pt;">Example of Behavioral Objective: **

- The child will say sounds in all word positions in response to pictures with 85% accuracy as well as produce conversational speech with 75-80% accuracy.

==<span style="background-color: #f9cdf6; color: #ff00ff; font-family: 'Comic Sans MS',cursive; font-size: 200%; margin: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 5px;">**What Kinds of Techniques/Activities** == ==<span style="background-color: #f9cdf6; color: #ff00ff; font-family: 'Comic Sans MS',cursive; font-size: 200%; margin: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 5px;">**Might be Observed in a Typical Treatment Session?** ==

<span style="font-family: Arial,Helvetica,sans-serif;">﻿Therapy is not a quick fix for childhood apraxia of speech. Therapy will eventually help most children with CAS become competent speakers. However, this can often take at least two years or much longer. Different approaches are used with children with CAS than children with other articulation difficulties or language disorders. Techniques used to treat CAS are based on principles of motor learning. Children with Childhood Apraxia of Speech require an extremely high amount of intensive therapy that is begun early on an individual basis.

<span style="font-family: Tahoma,Geneva,sans-serif;">1. **Stress sequence of speech movements**- <span style="font-family: Arial,Helvetica,sans-serif;">The main focus of speech therapy for CAS is on speech movement sequences. Children with CAS struggle with planning and programming movement sequences. Treatment should focus on supporting the child's ability to produce increasingly complex articulatory sequences, rather than individual phonemes. The clinician works on sequencing speech sounds together that are produced in different parts of the oral cavity. The "memory" for each speech movement and the sequencing of speech movements is very important. Articulation "memory" should be based on internalized information that relates the sounds that are heard to their specific motor patterns. The clinician will begin at the syllable level (Consonant Vowel or Vowel Consonant). If these sequences are too difficult, the clinician will increase the amount of multi-sensory cueing and also reduce the rate of production. A way to increase the demand for memory retention is by interrupting the child between requests for response sequences.

<span style="font-family: Tahoma,Geneva,sans-serif;">2. **Reduce rate of production**- <span style="font-family: Arial,Helvetica,sans-serif;">Rate of production can have a huge impact on motor learning. When the child uses a slower production rate, the child is able to plan and program the articulatory movement sequences more accurately. If the motor plan for a target sound/utterance is accomplished at a slower rate, then a gradual increase in rate should be begun.

<span style="font-family: Tahoma,Geneva,sans-serif;">3. **Work on the vowels**- <span style="font-family: Arial,Helvetica,sans-serif;">Treatment addresses vowel accuracy and helps children establish a complete vowel inventory. It is common for a child with severe CAS to only have the neutral vowel sound, for example "uh" in "cup".

<span style="font-family: Tahoma,Geneva,sans-serif; font-size: small;"> <span style="font-family: Tahoma,Geneva,sans-serif;">4. **Multi-sensory cueing** **techniques**- <span style="font-family: Arial,Helvetica,sans-serif;">Multisensory input appears helpful to many children with suspected CAS. Use a variety of sensory cues to help the child hear, see, feel, <span style="font-family: Arial,Helvetica,sans-serif;">and/or understand the target speech movement gestures being requested of them as they practice words or phrases. Looking in a mirror while producing the target sounds will help the child to see how he/she is moving the articulators. Getting feedback from a number of senses, such as tactile "touch" cues and visual cues, for example, watching him/herself in the mirror, as well as auditory feedback, is often helpful. With this multi-sensory feedback, the child can more readily repeat syllables, words, sentences and longer utterances to improve muscle coordination and sequencing for speech. Increased sensory feedback for control of movements and movement sequences.

<span style="font-family: Tahoma,Geneva,sans-serif;"><span style="font-family: Tahoma,Geneva,sans-serif;">5. **Many repetitions of speech movements are required in drill-oriented sessions**. <span style="font-family: Arial,Helvetica,sans-serif;">A high degree of repetition to develop and establish motor plans is required for effective CAS treatment. Three to ten repetitions of each stimulus are usually used. Stimuli range from CV utterances to multisyllabic words. Each set of repetitions is interrupted by the client returning to a neutral or resting position to reduce perservative behavior.

<span style="font-family: Tahoma,Geneva,sans-serif;">6. **Manipulation of prosodic features**- <span style="font-family: Arial,Helvetica,sans-serif;">Rhythm, intonation, stress, and rate manipulation should be integrated into the therapy program from the beginning. The areas that specifically need to be targeted should be revealed by the diagnostic data. However, there are some children who do not seem capable of manipulating articulatory and prododic features at the same time. If this is the case, articulatory goals are established first, and prosody added later to articulation tasks that are easy to the client.

<span style="font-family: Tahoma,Geneva,sans-serif;">7. **Progressive approximation** **and shaping techniques** - <span style="font-family: Arial,Helvetica,sans-serif;">Use speech productions that children are currently <span style="font-family: Arial,Helvetica,sans-serif;">capable of producing and then, through various forms of feedback and practice, attempt to shape the child’s movement gestures into closer approximations of the target word.

<span style="background-color: #f9cdf6; color: #ff00ff; font-family: 'Comic Sans MS',cursive; font-size: 200%;">Activ﻿ities Done Inside and Outside of Therapy

 * <span style="font-family: Arial,Helvetica,sans-serif;">Practice making combinations of sounds. Children with CAS need to practice "sequencing" sounds. For example, if the child can say "bye," practice by saying bye to the toys that are put away; "bye bee," "bye ball," "bye pooh," "bye book." Begin with sounds that are easy for the child, whether they be speech sounds, animal sounds, or environmental sounds (for example: beep, beep).
 * <span style="font-family: Arial,Helvetica,sans-serif;">Play with whistles, blow toys, bubbles, and musical instruments. Practice blowing in and out can often help improve a child's coordination and control of the respiratory movements necessary for speech.

<span style="background-color: #f9cdf6; color: #ff00ff; font-family: 'Comic Sans MS',cursive; font-size: 200%;">**Personal Observations:**

 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 120%;">An activity we observed during therapy for CAS was an “I Spy” game. The clinician taped small picture cards on the wall around the room. The client was asked to get up and pick a card and say “I see a ” and name the object on the card. The goal of this activity was to work on sequence of speech movements.


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12pt;">While observing therapy, the clinician and client played a Bingo game. They took turns picking picture cards from a pile and naming them as they were chosen. During this activity, all of the pictures ended in the phoneme /f/. The client practiced moving his articulators from a vowel sound to the labio-dental position for the /f/ sound.


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12pt;">In a hospital setting, a clinician worked on oral motor exercises utilizing a popsicle. First the clinician asked the client to stick out her tongue, touch the sides of her lips with her tongue, and move her tongue up and down while projected from her mouth. The client showed great difficulty with these exercises. Then the clinician asked the client to pretend she was licking a popsicle, again she could not project her tongue out of the oral cavity. Yet, when given an actual popsicle, the client was able to project her tongue forward out of the cavity.


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12pt;">During therapy, the client and the clinician worked on conversational speech by the client describing his school vacation. The clinician aided the client in moving his articulators the appropriate way in order to produce effective functional speech and at the same time, correcting initial and final consonant deletion.

<span style="font-family: Arial,Helvetica,sans-serif;">

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