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R e b e c c a J . M c C a u l e y, P h . D . P ro f e s s o r
D e p a r t m e n t o f S p e e c h a n d H e a r i n g S c i e n c e T h e O h i o S t a t e U n i v e r s i t y
CAS Intervention: Principles
Guiding Treatment and Evidence Based Approaches
P r e s e n t e d t o t h e I n d i a n a S p e e c h , L a n g u a g e , a n d H e a r i n g
A s s o c i a t i o n A p r i l 4 , 2 0 1 3
Purpose
� Review aspects of the nature of deficits in CAS that necessitate comprehensive approaches to intervention
� Introduce intervention approaches that target ¡ The core planning/programming deficit ¡ Reduced phonetic inventory/unintelligibility ¡ Specific problem areas associated with CAS: Vowels, prosody,
consistency
� Identify intervention strategies that can help increase language skills and communicative effectiveness
Organization of this talk
1. Background on the basic problem and range of problems associated with CAS
2. Treatments aimed at the core deficit in motor planning and programming for speech
3. Treatments for addressing the basic problems of reduced phonetic inventory and poor intelligibility
4. Treatment approaches for special problems 5. Treatment considerations for the BIG picture
Background on the core problem and the range of deficits
Language and communication
challlenges
Overall speech sound problem
Core deficit
Nature of the Deficit
l “a neurological childhood (pediatric) speech sound disorder,
l in which the precision and consistency of movements underlying speech are impaired
l in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). . . .
Definition of CAS (ASHA, 2007)
Three contexts in which it occurs
� Idiopathic – unknown cause � Syndromic – In association with complex
neurobiological disorders of a genetic or metabolic nature, e.g., Down syndrome, Fragile X, galactosemia, autism
� Acquired – In association with an acquired neurogological condition, e.g., intrauterine stroke, infection, trauma
(ASHA, 2007)
Defining/discriminative characteristics
� Inconsistent errors on consonants and vowels in repeated productions of syllables and words
� Lengthened and disrupted coarticulatory transitions between sounds and syllables
� Inappropriate prosody, especially in the realization of lexical or phrasal stress
(ASHA, 2007, p. 2)
“The core impairment in planning and/or programming spatio-temporal
parameters of movement sequences results in errors in speech sound production
and prosody.”
(ASHA, 2007, P. 2)
Getting from level of impairment to planning treatment
Cognitive
Linguistic
Motor Planning and Programming
Motor Execution
“dog” Step 1. Lift velum to close off nose Step 2. Put tongue behind teeth…è Muscles 1, 2, and 3, get ready…then Muscles 2 and 4, you’ll come next….
/da/
Hey, I’d like to talk about that cute animal
Stages in Speech Production
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Levels of Impairment
Cognitive
Linguistic
Motor Planning and Programming
Motor Execution
Phonological Impairment
CAS
Dysarthria
Impairment-Based Treatment Strategies
Cognitive
Linguistic
Motor Planning and Programming
Motor Execution
Phonological approaches addressing linguistic and functional use
Motor learning principles with special attention to motor planning and timing
Motor learning principles with special attention to physiology (e.g., weakness)
Treatment of the core deficit
1. Principles of motor learning (Maas, Robin, Hula, Freedman, Wulf, Ballard & Schmidt, 2008)
2. Dynamic Temporal and Tactile Cueing (Strand & Skinder, 1999)
3. Prompts for restructuring oral muscular phonetic targets (PROMPT©; Hayden et al., 2010)
� Recommendations from the motor learning & motor speech disorders literature (e.g., Maas, Robin, Hula, Freedman, Wulf, Ballard & Schmidt, 2008)
(1) Provide many practice opportunities (i.e., trials or carefully organized repetitions) // other skilled motor practice
“Practica hace al maestro” “Practice makes perfect .”
Principles of motor learning (2) Use distributed versus massed practice (schedule lots of sessions), especially initially
• Probably the single most common recommendation re: CAS
• // Development of difficult motor skills of any kind and difficult cognitive tasks of any kind
• and difficult cognitive tasks of any kind –“thou shalt not cram for tests”
Let’s do a thought experiment, comparing the following mathematical tasks:
(3) Initially, block trials of like stimuli; later, randomize trials
21/3 21/3 21/3 12/2 12/2 12/2 32/4 32/4 Versus
21/3 12/2 32/4 12/2 21/3 32/4 12/2 32/4 !
(4) Initially begin with a small stimulus set (5) Use facilitators
Choral/simultaneous production Tactile cues Slowed rate, that is then normalized and finally varied
Additional recommendations
1. An articulatory approach designed to facilitate lots of movement practice
2. Uses imitations that increase in length and complexity beginning at level where success is expected
3. Cueing strategies include slowing rate, simultaneous production, and tactile/gestural cues
formerly Integral Stimulation (Rosenbek et al, 1973; Strand & Skinder, 1999; Strand, Stoeckel, & Baas, 2006)
Dynamic Temporal and Tactile Cueing (DTTC)
(Strand & Skinder, 1999)
4. Uses an increasing time delay between model and the child’s production is an important feature
5. Relatively well supported through single case experimental designs (e.g., Strand, Stoekel, & Baas, 2006)
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Structure of DTTC (Strand & Skinder, 1999)
Slow rateAdd tactile cues
Incorrect
After many trialswith no effort,
go back to direct imitaion
Continue until: No artic. errorNormal rate &
prosody
Correct
IncorrectSTIMULTANEOUS
PRODUCTION
Add mime and/orgo back to
simultaneous
Incorrect
IncorrectShorten delay orBack up to Direct
Imitation
CorrectAdd delay up
3 secods
Add Delay
Continue,varying rate & prosody
until: no artic. error,normal rate & prosody
Correct
CorrectContinue with direct imitation;
gradually increase rate
DIRECT IMITATION Video Clip of DTTC
PROMPT © : Prompts for restructuring oral muscular phonetic targets
� Emphasis on tactile/gestural cues designed to guide practice for motor production
� Specific cues (prompts) involve touching the face and neck to signal
÷ Articulatory position & manner of production for individual sounds
÷ The nature of the movement gesture required given contextual affects
� Uses meaningful words and phrases � http://www.promptinstitute.com/index2.html
(Hayden et al., 2010)
Example of Two Consonant Prompts
� For /p/, first and second fingers hold lips closed/pull out; Jaw height 1; Nasal/laryngeal not specified; Mouth contact 1,2; Timing Hold; Pressure(tension) Firm
� For /b/, first and second fingers hold lips closed; Jaw height 1; Nasal laryngeal 9; Mouth contact 1,2; Timing Fast; Pressure (tension) Moderate
(Chumpelik [Hayden], 1984)
Increasing research on the PROMPT
� For example, Sally Rogers, Deb Hayden at al (2006) “Teaching young nonverbal children with Autism useful speech: A pilot study of the Denver Model and PROMPT interventions
� 10 nonverbal children with ASD given 12 one-hour sessions and daily 1 hour parent home interventions
� 8 of the 10 developed 5 or more novel functional words and spoke multiple times per hour after therapy
� Better responders = children with mild to moderate ASD, better motor imitation and emerging joint attention
Video Clip from Deb Hayden
Treatments for unintelligibility and reduced phonetic inventory
1. Thoughts on managing the child who will not imitate
2. Stimulability intervention 3. Modified core vocabulary and
stimulability (Iuzzini & Forrest) 4. Modified cycles approach
Management of unintelligible and young children
� Regardless of etiology, certain core elements need to be represented in the plan that address problems in speech, language, and communication
� Improve speech production/linguistic use of sounds � Improve language skills (vocabulary) � Improving communicative success
(comprehensibility/quality of interactions/life)
When “Simon says” doesn’t work
� Authors’ strategy: Identify strategies for use with this population that have at least some research support (Level 2 = at least 1 experimental or quasi-experimental design on a relevant population)
DeThorne, Johnson, Walder,& Mahurin-Smith (2009)
Alternatives to imitation
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Population of interest: Children who won’t imitate
¡ Are more often encountered in early intervention settings (EI) for children < 3 years of age
¡ Diagnoses will often be lacking, but may ultimately relate to the Autism Spectrum Disorders, or if SSD to SSD – Psychosocial involvement
¡ Often encourage clinicians to pursue nonverbal oral motor exercises (for which there is very, very little research evidence & equally little theoretical grounding in physiology, especially neurophysiology)
Evidence-based strategies for eliciting speech-like vocalizations
¡ AAC is now viewed as helping language learning, not just providing a different modality
¡ If a nonvocal AAC strategy (e.g., sign) is used, voice/vocalization can be encouraged to increase speech output
¡ If a device with vocal output is used, modeling is increased
1. Provide access to augmentative and alternative communication
� Why? Negative effects of anxiety on motor performance
� Avoid direct requests for imitation, model instead and encourage turn-taking ¡ Divert attention away from
speaking to having fun—using a puppet,
¡ Simultaneous productions ¡ Follow the child’s lead
¡ Reduces production demands because the form is familiar and may ultimately be shaped toward a more adult like form
¡ In normal development, imitation of the child builds imitation by the child and allows the adult to assign meaning to a child’s perhaps nonlinguistic vocalization ¡ Child: ba ¡ Adult: —oh, ball!”
2. Minimize pressure to speak
3. Imitate the child
¡ Rationale: Making speech more music like may enlists the right hemisphere
¡ Improved prosody --> improved intelligibility
¡ Evidence – primarily a single subject design and a nonsense word learning task (Kouri & Winn, 2006) showed greater imitations occurring in a sung vs. spoken task
¡ Strategies, especially for introducing 2 word utterances, (e.g., light on, all done)
¡ Rationale: Role of sensory feedback is greatest early in learning and later is reduced
¡ A focus on on movement may be helpful if sensory problems
¡ Methods of augmenting feedback ¡ Tactile – tactile cues//
Prompt Strand’s methods ¡ Auditory –
¡ slight amplification ¡ PVC pipe ¡ Echo microphone
4. Use exaggerated intonation and slowed tempo
5. Augment auditory, visual, tactile and proprioceptive feedback
� Nonspeech movements of the articulators involve different parts of the brain than speech movements à therefore, this won’t help speech!
� Only use nonspeech activities in a limited way and when the child is not imitating speech sounds;
� Nonspeech activities that are used should be as close to speech movements as possible and transitioned to speech as quickly as possible
6. Avoid emphasis on nonspeech-like articulator movements
Other strategies - needing more research
� Use of carrier phrases � Pairing vocalizations with analogous cross-
modality movements – for example pairing fricative with widening/narrowing arm gesture
� Encouraging vocal play � Incorporating metaphoric devices to solidify
speech sound knowledge and establish a linguistic concept that is associated with movement
� EXAMPLE: /s/ the snake sound
Stimulability Treatment
� Child is presented with a cast of characters, a set of colored drawings, and a set of gestures paired with target phonemes
� Imitation of sounds in isolation is encouraged, but not demanded
� Examples ¡ /s/ - Silly Snake “slinkily move finger up arm” ¡ theta - Thinking Thumb “tap thumb on chin” ¡ /p/ - Putt putt Pig “hands move in a skating motion” ¡ /m/ - Munchie Mouse “Push lips together and rub
tummy”
(Miccio & Elbert, 1996 Miccio & Williams, 2010)
Session Organization
v Elicit 1/3 of stimulability probe (5 min)
v Review of characters and their sounds (5 min)
v Activity I: Go fish (10 min)
v Activity II: Guess my card (10 min)
v Activity III: Spinner game (10 min)
v Elicit 1/3 of stimulability probe (5 min)
Video Clip from Miccio & Williams (2010)
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Combined approach using stimulability and core vocabulary § Stimulability (ST) + modified Core Vocabulary
approach (mCVT) § Feedback – First immediate & continuous, then
variable (every 3 trials on average) § Structure of sessions
§ Stimulability Treatment - 10 min. § Modified Core Vocabulary Treatment - 45 min. § Both components used imitation then spontaneous
(Iuzzini & Forrest, 2010)
More on each component
§ Stimulability Treatment § Used nonstimulable sounds § Taken off the list once 90% correct production;
then that sound cued in the mCVT § mCVT
§ Used 30 words containing target sound(s) – meaningful and commonly used by the child (names, family, action words, etc).
§ Target sounds – Used at least once IMF
Iuzinni & Forrest findings (2010)
§ Four children were studied using single subject designs
§ 20 treatment sessions over 10 weeks § Sets of 30 words per child chosen to include at least
one complex phoneme and included words selected by the family
§ Mean gains in PCC (% consonants correct) = 20; Mean gains in phonetic inventory = 5 sounds
The Cycles approach
§ Auditory stimulation (formerly “bombardment”) § Production practice opportunities for a given
phonological pattern (e.g., final consonants) for a small number of words
§ Cueing allowed, but generalization is expected; in part because words are chosen that are emerging in production
(Hodson & Paden, 1991; Prezas & Hodson, 2010)
Adaptations to the Cycles approach to facilitate motor learning
§ Increase number of trials § Use a smaller set of words (a relatively small set is
already recommended) § Carefully arrange timing between model and the
child’s attempt and modify over time (lengthen if successful)
§ Use other facilitators § Slowed rate § Tactile and gestural cues
(McCauley & Strand, 1999)
Treatments for the special symptoms associated with CAS
1. Prosody 2. Vowels 3. Inconsistency in
error patterns
l Suprasegmental characteristics of speech, including § phrasing, § rate, and § stress
l Frequently assessment is quite subjective; however, better methods are emerging (e.g., PEP-C – Peppe, experimental)
1. Prosody Prosody as a special problem in CAS
§ Shriberg, Aram & Kwiatkowski identified a subgroup of children with CAS for whom excessive/equal/misplaced stress was a chief characteristic
§ What are you most likely to see? Equal-excessive stress (Shriberg, Aram, & Kwiatkowski, 1997)
§ Sometimes thought to be a response to treatment, rather than an intrinsic aspect of CAS
Don’t contribute to the problem!
1. Avoid prolonged use of abnormal stress patterns, e,g., TI GER for “tiger” instead of Ti ger
2. Vary prosodic features, e.g., pitch and loudness as soon as articulation is okay
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For lexical stress § Represent syllables with blocks
§ and stressed syllables with a different color than unstressed syllables
§ Work on stress identification § rhiNOcerous
§ Use backward chaining of multisyllabic words § bik-->A-bic-->syLLAbic--> tisyLLAbic--
multisyLLAbic
Other suggestions for treating prosody
Velleman (1998, 2002)
Child example with Shelley Velleman
¡ Work on identification of stressed word in a sentence (beginning with exaggerated emphasis)
¡ Use blocks as for lexical stress and consider backward chaining for phrases & sentences
¡ Practice contrasting stress in words/phrases with contrastive stress (e.g., blackBOARD vs BLACKboard)
For Sentential/Phrasal Stress
¡ Practice responding to different wh- questions that elicit different stress: e.g., Who ate the bread? What did the rat eat? What did the rat do to the bread?
¡ Carry over to reading, then conversation
More for sentential and phrasal stress Child example with Shelley
Velleman 2. Vowels - Reasons to treat vowels…
§ Spontaneous or consonant-treatment- related improvement does not always occur
§ Contribution to intelligibility due to high frequency of occurrence in English
Gibbon & Beck, 2002; Gibbon, et al,, 1992; Hall, Jordan& Robin, 1993; Pollock & Hall 1991: Stoel-Gammon, 1990
More reasons to consider addressing vowels
§ Developmentally early § Child’s problems may be
perceived as a foreign accent § Vowel errors may not be as
uncommon as once thought
Gibbon & Beck, 2002; Gibbon, et al,, 1992; Hall, Jordan& Robin, 1993; Pollock & Hall 1991: Stoel-Gammon, 1990
Difficulties in targeting vowels
l No clearcut phonetic placement
l Limited treatment literature
l Harder perceptual judgments than for Cs
l Poorer understanding of vowel development
1. Begin with stimulable vowels 2. Auditory bombardment 3. Treat one vowel at a time 4. Consider facilitators such as
÷ Choral production ÷ PROMPT ÷ Cued Speech
Techniques for vowel errors!
(Gibbon & Beck, 2002; Hall et al., 1993)
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5. Follow a traditional hierarchy of activities, beginning with detection, discrimination through production in more difficult contexts
6. Minimal pair therapy (after successful production)
Visual aids illustrating vowel contrasts
� Shapes ¡ e.g., rounded vs. unrounded
� Movement ¡ Monophthongs vs. diphthongs (truck
standing still vs. moving) � Color
¡ All vowels; back vowels; front vowels, etc � Computer programs
¡ IBM Speechviewer includes 2 and 4-phoneme contrasts (calls attention to neutralizations)
(Gibbon & Beck, 2002; Hall et al., 1993)!
Emerging technique
� Sonography – Bernhardt, et al.
� University of British Columbia
� Transverse image
l Similarity of word production across repetitions
l Related to older concept of stimulability yet now emphasis is on word, not single sound, integrity
3. Consistency Core Vocabulary for SSDs
� Developed by Barbara Dodd et al. for use with children identified as showing Inconsistent speech sound disorders
� Concept – Stabilization of current representations prior to attempts to increase contrasts
� Evidence shows that it is more effective than an approach designed to increase contrasts
(Dodd et al., 2010) Video clip for the Core Vocabulary Approach
Core vocabulary: An informal implementation
• Identify a small set (3 to 10) of highly useful words
• Work to obtain “best possible” production
• Familiarize conversational partners with these so that the child is encouraged to use them
Benefits: improved intelligibility as well as practice of emerging sounds
THE BIG PICTURE * Language and literacy * Overall communicative effectiveness
Language and communication
challlenges
Overall speech sound problem
Core deficit
Components in a comprehensive assessment Language /Cognition
Speech Phonology to
Movement
Functional outcomes
Oral language • receptive/expressive • semantics/syntax/
morphology/ pragmatics
Written language • Phonological
awareness/ • Reading/writing/
spelling
Other possible domains of interest • Attention • Memory • Cognition • Speech perception
Phonetic repertoire development Vowels Consonants Reduction in inconsistent errors Improved syllable structures and prosody
Intelligibility Comprehensibilty Literacy
63
A tempting focus
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Components in a comprehensive assessment Language /Cognition
Speech Phonology to
Movement
Functional outcomes
Oral language • receptive/expressive • semantics/syntax/
morphology/ pragmatics
Written language • Phonological
awareness/ • Reading/writing/
spelling
Other possible domains of interest • Attention • Memory • Cognition • Speech perception
Phonetic repertoire development Vowels Consonants Reduction in inconsistent errors Improved syllable structures and prosody
Intelligibility Comprehensibilty Literacy
64
Addressing literacy issues in CAS
While not always present, they often will be, with special difficulties in ¡ sound symbol correspondence, ¡ sound blending ¡ and sound segmentation
Stackhouse & Snowling describe two such children as being different from other dyslexic children; as being deviant rather than delayed in acquiring the alphabetic principle
Therefore, phonological awareness may need to play an early and persisting role in overall treatment
Stackhouse & Snowling, 1992
Possible considerations
� Phonological awareness interventions designed for children with SSDs ¡ Gail Gillon ¡ Anne Hesketh
� Metaphonological interventions ¡ Anne Tyler ¡ Hoffman & Norris
-
Working on Literacy Skills
� Address phonological awareness, but consider other language weaknesses that can contribute to reading difficulties (Hoffman & Norris, 2006)
� Suggestions from a case study (Tempest & Parkinson, 1994)
¡ Work on sight vocabulary, if child’s visual memory skills are strong, using rebuses
¡ Have the child learn words then put read in stories created using known words
¡ Make use of tactile, visual, and auditory cues in word learning ÷ Go to youtube to see Jan Norris and phonic faces
¡ Address speech needs with Metaphon type treatment, which includes phonological awareness activities (also like Gail Gillon’s approaches)
Hoffman & Norris, 2006;Tempest & Parkinson, 1994"
How to view the larger impact of CAS – the ICF and ICF-Youth of the World Health Organization
Broader effects of CAS
� Body functions and structure èBreakdown in speech production and Reduced intelligibility
� Activity à Reduced communicative competence
� Participation à Lack of peer acceptance; reduced access to teachers/information in classroom
è can serve as inspiration for thinking about broader approaches to treatment
ICF and ICF-Youth of the World Health Organization –
Thinking about the ICF for more comprehensive treatment
Functional Limitation – Breakdown in speech production and intelligibility
à What can you change that affects intelligibility in addition to child’s speech?
Ø Room acoustics?
Ø Listener hearing?
Limitations on activities à what can change to improve
communication in context Ø AAC strategies? Ø Increase use of gestures?!
Limitation on Participation Lack of peer acceptance; reduced access to teachers/information in classroom § Consider peer & teacher
education by you/ by the child with CAS;
§ Consider attention to issues related to bullying
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Last Group Exercise
� Read over the 2 case Discuss your initial ideas for planning treatment in a small group with people sitting near you who are focused on the same child, including the following topics: ¡ Initial goals ¡ Scheduling ¡ Special factors to consider
Mary – 3 years old
3 year old, very quiet, with a history of otitis media and mildly impaired receptive language Consonants � Initial: b, d, m, n, w, (j), (z),"ch” � Medial: (b), (d), (p), (n), (w), (j), "ch" � Final: glottal stop, p, (m), n, (f), (s), ("sh") Vowels i, I, o, ae, a, and schwa Syllable shapes
¡ V “I” [ai], “hi” [ai] ¡ CV “toe” [to], “dog” [da] ¡ CVC “dog” [dad]
Word Shapes � Monosyllables: V, CV “I” [ai], “toe” [to] � Bisyllabic: CVCV, CVCV “mama” [mama], “bubbles” [babab]
Justin – Age 9
� Diagnosed with CAS at age 4, treated with DTTC, then a traditional approach to address residual errors
� Current problems ¡ Residual errors affecting rhotic vowels and fricatives (especially s/z) ¡ Prosodic abnormalities, especially, in multisyllabic words ¡ Problems in phonological awareness, reading, and spelling ¡ ADHD diagnosis ¡ Social difficulties due to teasing by a new student who calls attention
to Justin’s speech differences and his general clumsiness
The hope is that by beginning at the core, but considering the whole, we will have better outcomes for children with CAS!
Language and communication
challlenges
Overall speech sound problem
Core deficit
� deThome, L.S., Johnson, C.J.., Walder, L., & Mahurin-Smith, J. (2008). When “Simon Says” doesn’t work: Alternatives to imitation for facilitating early speech development. American Journal of Speech-Language Pathology, 18, 133-145.
� Dodd, B. (1995). Procedures for classification of subgroups of speech disorder. In B. Dodd (Ed.), Differential diagnosis and treatment of children with speech disorders (pp. 49-64). San Diego, CA: Singular.
� Highman, C. Hennessey, N., Sherwood, M. & Leitao, S. (2008). Retrospective parent report of early vocal behaviours in children with suspected Childhood Apraxia of Speech (sCAS). Child Language Teaching and Therapy, 24, 285-306.
� in childhood apraxia of speech. International Journal of Language and Communication Disorders, 44, 175-192. � Miccio, A.W., & Elbert, M. (1996). Enhancing stimulability: A treatment program. Journal of Communication Disorders, 29,
335-351. � Chumpelik [Hayden], D. (1984). The prompt system of therapy: Theoretical framework and applications for developmental apraxia
of speech. Seminars in Speech and Language, 5, 139-156. � Gibbon, F., & Beck, J.M. (2002). Therapy for abnormal vowels in children with phonological impairment. In M.J. Ball & F.E.
Gibbon (Eds.) Vowel disorders (pp. 217-248). Boston: Butterworth-Heinemann. � Gillon, G. (2006). Phonological awareness intervention: A preventive framework for preschool children with specific speech and
language impairments. In R. McCauley & M. Fey (Eds.), Treatment of language disorders in children (pp. 279-308). Baltimore: Paul Brookes.
� Hayden, D. & Square, P. (1994). Motor speech treatment hierarchy: A systems approach. Clinics in Communication Disorders, 4, (3): 162-174
� Hoffman, P., & Norris, J. (2006) Visual approaches to literacy. In R. McCauley & M. Fey (Eds.) Treatment of language disorders in children (pp. 347-382). Baltimore: Paul Brookes.
� McCauley, R. & Fey, M. (2006). Treatment of language disorders in children. Balitmore: Paul Brookes. � Rosenbek, J. C., Lemme, M., Ahern, M., Harris, E., & Wertz, R.T. (1973). A treatment for apraxia of speech in adults. Journal of
Speech and Hearing Disorders, 38, 462-472. � Stackhouse, J., & Snowling, M. (1992). Barriers to Literacy Development in Two Cases of Developmental Verbal Dyspraxia,
Cognitive Neuropsychology, 9(4), 273-299. � Strand, E.A. & Skinder, A. (1999). Treatment for motor speech disorders in children: Integral stimulation methods. In A. Caruso & E.
Strand (Eds.), Clinical management of motor speech disorders in children (pp. 109-148). New York, NY: Thieme Medical Publishers. � Strand E., Stoekel, R., Baas, B. (2006). Treatment of severe childhood apraxia of speech: A treatment efficacy study. Journal of
Medical Speech-Language Pathology, 14, 297-307. � Velleman, S.L. (1998). Lexical stress errors in Developmental Verbal Dyspraxia: The problem and some possible solutions. Special
Interest Division #1 Language Learning and Education newsletter, 5 (2), 12-16. � Williams, A.L., McLeod, S., & McCauley, R.J. (Eds., 2010). Interventions for speech sound disorders in children. Baltimore: Paul
Brookes Publishers.
Selected References
Contact information [email protected]
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