Childhood Apraxia Defined. Typically defined in terms of sound production error patterns, but actually a disorder of movement . - PowerPoint PPT Presentation
Childhood Apraxia Defined
Childhood Apraxia DefinedTypically defined in terms of sound production error patterns, but actually a disorder of movement. Difficulty is noted with purposeful voluntary movements for speech, creating an inability to sequence speech movements in the absence of paralysis. (Caruso & Strand, 1998)1The articulation aspect of CAS is motor in nature. It is a disorder of MOVEMENT, not in actual sound production. So as SLPs it may be a difficult concept. We are very used to thinking in terms of individual sound production. With these children, we need to focus on the process of movements required. The reason there is so much irregularity in the childs speech is that they dont get the sound sequences. Look at production of similar movements with lots of drill.
DemographicsOnsetImpaired from birthCourseOften long course of txGender3 male: 1 femalePrevalenceUnknown (1:1000)Aggregation FoxP2 gene autosomal dominant (KE family)Some familial transmission2Onset: From birth, see impairments in development of movements for speech production.Course: Often long, arduous treatments. Question if because slps didnt know appropriate interventions, or if just difficult to treat.Gender: Male to female: 3 to 1 For dissertation, had 19% female (or approximately 5 to 1)Prevalence: Generally one in one thousand, not really known. Aggregation: Genetic studies show some familial transmission with certain disorders (Renpenning syndrome, Sotos syndrome? etc.)
CAS & Impact on Overall CommunicationDecreased intelligibilityDisordered languageSocial withdrawalBehavioral aggressionAcademic failure3These characteristics have been commonly cited in the research literature and within the books directed at CAS. CAS & Impact on Overall CommunicationDecreased intelligibilityDisordered languageSocial withdrawalBehavioral aggressionAcademic failure4These characteristics have been commonly cited in the research literature and within the books directed at CAS. CAS Clinical IndicatorsReduced phonemic repertoire (esp. consonants, simple word & syllable shapesProsodic abnormalities (timing)Vowel errors not affected by length of utteranceVariability, sequencing difficultiesDifficulty achieving & maintaining articulatory configurations (artic overshoot)Use simple syllable shapesDifficulty completing a movement gesture for a phoneme easily produced in a simple context but not in a longer context (underspecified motor plan)Differential DiagnosisCAS vs. Speech DelayDiffers from errors of children with developmental delay in that does not follow developmental sequences (later sounds come in earlier, etc.)CAS vs. Phonological ProcessesDiffers from errors of children with phonological processes in contrast between voluntary & involuntary performance, error variabilityCAS vs. DysarthriaDiffers from dysarthria, which has errors in phonation, resonance, articulation & prosody related to weakness, paralysis6MovementFor CAS, re-conceptualize the way you think about articulation and phonology
Move away from thinking about soundsDont think about processesMovements are the focus7Lack consistent error production seen with developmental delay. Not result of immature sound productions, but actual motoric impairment. Dysarthria will also exhibit consistent errors, with some physical signs of weakness, paralysis, etc.
CAS is a disorder of movement.
Motor Learning TheoryMotor learning occurs as a result of experience & practice
Pre-practice skillsConditions of Practice8Pre-practice to Establish Motor LearningPre-practice portion of a therapy session involvesFocused attentionMotivationGeneral idea of taskObservational learningFocused Attentionability to focus cognitive, perceptual, sensory & activity toward the skill he/she is attempting to learnneed intent to learnlimit extraneous stimulistimuli that limit cognitive, linguistic, phonetic load will enhance childs ability to focus attentionchild must look at & listen to cliniciannovelty: change position, vary volume, etc10Motivationconsider desire to talk vs. years of failure talkingmake the tasks important, usefulset goals with the child set a reasonable standard to achieveprovide early successreduce frustration General Idea of Taskunderstand task clearlyways they will learnkeep instructions simple; focus on 1-2 important aspects of movement. DO NOT OVERINSTRUCT12Observational Learningmodeling & demonstration with pictures, videotapes, and live demosshow the child the movements a few times covering all stimuli being targeted in the sessionbe wary of verbal instructionsEstablish Reference of Correctnessthat child understandsuse auditory feedbacki.e., for /pa/, may accept lip closure as correct to begin, later move to correct articulatory productionRepetitive PracticeIntensive treatment (best if 5 days/week)Large # of movement repetitions (no less than 40), enough trials/session to allow motor learning to become automaticuse reinforcements that dont take timeActivities should facilitate repeated opportunities for production of target movement patterns Mass vs. Distributed PracticeMass = less frequent, longer sessionsDistributed = frequent, short sessions
decision depends on severity and type mass yields quick development of accurate productiondistributed requires longer time, but get better generalization16Knowledge of PerformanceFeedback about the correctness of a particular movement pattern regarding accuracy of production.
I heard you say .I saw youplacement cuesRate & Prosody ConsiderationsCome to neutral position btwn attempts (rest), do NOT divide into componentsBreaking up words will cause the child to learn that motor pattern and not the coarticulated oneMove through hierarchy of task difficultyTreat rhythm, stress & intonation with/as a component of articulation drills18Hierarchy of Response/Cued Supportsimultaneous production with examinerdirect imitationdelayed imitation (gradually increase delay time)spontaneous 19Intervention StrategyWork on vowels when working on whole word transitions (e.g., C V, V C, C V C), dont address vowels or consonants aloneWork on consonants when working on whole word or phrase transitions (e.g., no isolated consonants)Kids can always say something, they may only have 1-2 sound combos that they use as words, but can start thereTake what they say in conversation that makes sense & examine the GFTA correct productions to determine correct transitions in the childs speechPlay & SuccessBeginning sessionsSet up play situation (find out likes; ~5 different activities, books, toys, basket of activities: they choose) allow child to be in charge, set up situation where they dont think they are working, but rather just interjecting speech into play Move into new movementsTake the correct transitions in their repertoire & ask them to directly imitate words they can say Get successes 1st! (e.g., mom, ma, mama)Get several delayed imitative productions of the same sound sequence (e.g., can you say 5 of them?)When introduce new, start where need to with either simultaneous direct imitation delayed imitationReinforce Lots of UtterancesAttempt to get as many productions of each movement as possible during the session (min 40-50)Ignore error productionsMake a big deal out of successful productions Make the session fun & successful to the child so that they are excited to return for the next sessionGive parents feedback, Base List SLP learns what child is able to say & getting imitations of thesePrior to the 2nd session, SLP creates cards with Boardmaker pictures for items on the base list Base list is of sound combinations/ words the child can produce (observed during 1st session)Continue with play activities from 1st session while introducing the base list combinations (e.g., uh-oh, mama, baby, oh-no, boo, baa, moo, me, my, bye)Direct ImitationHave the child attempt productions following direct imitation on all of the base list items to evaluate continued successIf child is unable to successfully produce one item, that card is pulled from the list for that sessionBegin to combine the words/sequences that the child can say and attempt to get direct imitations of the combinationsBreak Down & NewNext, 1 of the following occursProduce new word not on base list. Breaks down and has had enough for that session. SLP probes for new words during play/activities Produce new word (not on base list)immediately reinforce verballyword is added to the base list introduce into later activities/sessionsSLP probes for new words (during play/activities)Combine consonants the child can produce with different vowels to create VC, CV, CVC, VCV combinationsProvide auditory, visual, and/or placement cues for the child. Attempt to get direct imitationConditions of PracticeReference for correctRepetitive practicemass vs. distributedrandom vs. blockedKnowledge of performanceKnowledge of resultsimmediate vs. summaryRate & prosodyStimulus/response complexityCombinationsContinue as in Session 2.Begin to combine 2 of their base words together, attempting to keep one of the words consistent (either 1st or 2nd) & go through the base listIn this way, create silly sentences, laughing to make it playfulMoo byeMoo beeBee moo
Bee bye Bye moo Bye beeRudimentary Carrier PhrasesBegin to introduce rudimentary carrier phrases.MyOh no ICarrier Phrases = CoarticulationIntroduce lengthier carrier phrases, thinking about coarticulationGenerally, when combining 2 base words together, this is not as much an issueWhen using carrier phrases, think about conversational speech & make it sound naturalI need a (I nee da)I want a (I wanna)I have to (I hafta)Ive got to (I gotta)Hop up (Hah pup)Come here (kuh mere)Generalization BooksCreate a book that pairs carrier phrases with the sound sequences (words) from their base listHop up mommyHop u