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“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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What to do when they’re Two!Assessment & Treatment of children between the ages
of two and three with suspected CAS
Marnie Millington, MS CCC-SLP
CASANA Recognized for Advanced Training and Clinical Expertise in Childhood Apraxia of Speech
ASHA Non-Financial Disclosure
Marnie Millington, MS, CCC-SLP, is co-owner of Children’s Speech & Feeding Therapy, a private practice in Needham, Massachusetts.
• Disclosure: Millington is a graduate of CASANA’s Intensive Training Institute on CAS and was provided a stipend for this webinar. There are no other relevant financial or non-financial relationships to disclose.
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Recording Policy
The use of cameras, audio recording devices, and/or video recording devices, including cell phones, is prohibited during CASANA webinars.
Participants found audio or video recording any portion of the will be asked to cease immediately.
Learning Outcomes
Learning Objectives:
• Participants will be able to discuss typical speech and language development in children between the ages of two to three.
• Participants will be able to explain how to determine whether speech or language deficits are the primary contributor to a child’s overall communication disorder.
• Participants will be able to demonstrate knowledge and use of therapy techniques that are grounded in motor learning.
• Participants will learn about new research highlighting potential early signs of CAS.
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Is it CAS?
• Difficult to test
• Errors can mirror common features of CAS
• Possible delay or lack of speech-motor experience can look like CAS
What do we do?
EVALUATE
• Behavior
• Representational & symbolic play
• Language comprehension & Expression
• Speech: vocal play & word approximation/words
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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What do we do?
INVENTORY & PRIORITIZE
• Identify all relevant deficits
• Prioritize them in order of relative contribution
• Create a treatment plan with home and direct intervention components
What else to consider?
Consider all areas of need & all communication modalities
• Referral to other professionals
• Consider non-verbal & verbal communication
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Between the ages of two and three
Where did they come from?
BEFORE THEY WERE 2…
• Turn-taking interactions
• Babble: Reduplicated to Variegated
• Jargon: babble + prosody
• Expressive vocabulary of approximately 200 words
• Two to four word combinations
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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What do two to three year olds look like?
Hearing & Understanding Talking
• Understands differences in meaning (e.g., “go-stop,” “big-little”)
• Follows a two-step request (e.g., “Get the ball and throw it to Daddy”)
• Listens to and enjoys hearing stories for longer periods of time
• Has a word for almost anything• Uses two and three word
combinations to talk• Is understood by familiar
listeners most of the time• Often asks for or directs
attention to objects by naming them
• Asks Why?• May stutter on words or sounds
Two to Three Years. (n.d.). Retrieved November 21, 2015, fromhttp://www.asha.org/public/speech/development/23/
Speech development from 2 to 3…
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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What does the speech of 2 to 3 year olds sound like?
• Phonetic classes expand & increase in frequency: velars, fricatives & affricates
• Consonant clusters emerge between 30-36 months, first in final positions
• Unstressed syllables are produced
• Many types of word shapes: VC, CVC, CVCVC, CVCC, CCVC, etc!
Vowel development 15-36 months(Donegan, 2002; Pollock& Berni, 2003)
Children’s vowel inventories grow from 4-12 vowels
• Early lax vowels are represented prior to 18 months /8/, /1/, /4/,/7/
• By 18 months, tense and point vowels emerge /3/,/o/,/i/, /u/, /0/
• Vowels in stressed syllables develop before unstressed syllables
• Non-rhotic vowels increase from mean accuracy of 92- 94% Increase in intelligibility to 97% at three
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Prosodic Development between birth and 3years
• Mark affect
• Contrastive stress emerges with word combinations
• Differ stress vs. unstressed syllables (Smith, 1978)
• Produce weak syllables in initial position
• Differentiate between two stressed syllables (Kehoe & Stoel-Gammon, 1997) 36 months 97%
Is anyone looking into red flags?
Until recently, this question was driven by parent report…
Overby & Caspari (2015)
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Early speech development in children with CAS
• Viewed home videos of children between the ages of 0 -24 months
• Looked at volubility, place, manner and syllable shape
Early speech development in children with CAS
Significantly fewer
• Resonant vocalizations
• Different places & manners of articulation
• Syllable Shapes
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Early speech development in children with CAS
Fewer
• Fricatives
• Voiceless phones
• Glottal phones
• Closed syllable shapes
Regression in vowel volubility
How do you test a 2 year old?
Photo credit: Dave Engeldow
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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D= Direct I= Indirect S=Standardized N= Non-Standardized
*= in this population
Behavior Pretend Play
Language Comprehension
Expressive Language
Speech Related Factors
Observe SymbolicPlay Test (D/S)
Peabody Picture Vocabulary Test-4 (D/S) 2;6+
Expressive One WordVocabulary Test (D/S)
Goldman-Fristoe Test of Articulation-3 (D/S)
Structural-FunctionalExam/Snack (D/N
Attention Westby Play Scales (D/N)
Question Probe (D/N) IndependentAnalysis (D/N)
Regulation Direction Probe (D/N) Language Sample (D/N)
RelationalAnalysis (D/N)
Motivation Reynell Developmental Language Scales (D/S)
Motor-Speech Exam (D/N)
Receptive-Expressive Emergent Language Scale-3 (I/S)
Parent report(I/N)
MacArthur CDI (I/N*)
What measures should be used when CASs?
Standardized Non-Standardized
Goldman Fristoe Test of Articulation-3 Independent Analysis
Relational Analysis
Structural-Functional Exam/Snack
Motor-Speech Exam
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Nate
Independent or phonetic analysis of the child’s speech
What vowels are produced:• Monophthongs• Diphthongs• Note: place & rounded vs. unrounded• Are these fully resonant?
What consonants are produced:• Place• Manner• Voicing
What phonotactic structures are present?
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Independent or phonetic analysis of Nate’s speech
What vowels are produced• Monophthongs: /i,q,1,0/ • Diphthongs /08,97/• Note: place & rounded vs. unrounded: front, mid, back,
rounded and unrounded• Are these fully resonant? Not consistently
What consonants are produced: /w,b,m,d/ • Place: labial & alveolar• Manner: oral & nasal stops & continuants• Voicing: voiced onlyWhat phonotactic Structures are present? V, CV, VCV, CVCV
Relational or phonemic analysis of the child’s speech
• Compare the child’s speech to language peer/adult models
• What errors and error patterns are present?
• What prosodic skills are present?
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Motor-Speech Exam
• Non-standardized task used to identify whether the child presents with Childhood Apraxia of Speech
• Review of formal measures designed to assess children’s motor speech skills revealed weaknesses in reliability; only VMPAC demonstrated validity (McCauley & Strand, 2008 )
• Strand & colleagues working on the DEMSS (Strand et al, 2012)
Motor-Speech Exam
• Based on integral stimulation Milisen (1954)
• Speech stimuli are presented for the child to model
• Hierarchical format: Vowels, single syllable words, two syllable words, to three
• Words can begin in isolation and later be embedded into sentences
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Motor-Speech Exam
• The child is asked to imitate the adult’s models over several successive trials
• The adult provide more support/ cues to determine whether the child improves
• The adult fades the cues to examine if the child’s production deteriorates
Motor-Speech Exam
• Transcribe the child’s responses
• Analyze for the key features of CAS by using ASHA position statement & the Mayo list of CAS characteristics
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Mayo List of characteristics of CAS(diagnosed if four or more observed across two
different tasks)
1 Vowel distortions 2 Distorted substitutions 3 Difficulty w/initial articulatory configurations or
transitionary movement gestures 4 Lexical or phrasal stress errors 5 Syllable or word segregation 6 Groping 7 Intrusive schwa 8 Voicing errors 9 Slow speech rate and/or slow DDK 10 Increased difficulty with multi-syllabic words
Motor-Speech Exam
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Motor-Speech Exam
Structural Functional Exam
• Non-standardized task
• Examines neuromuscular status
• Cranial nerve function
• Assesses the parameters of non-speech, oral motor function
• Results help to confirm/rule out the diagnosis of congenital/ acquired dysarthria
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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What do you do when the Structural-Functional Exam goes down in flames?
What do you do when the Structural-Functional Exam goes down in flames?
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Nate assessment results
Hx: early history consistent with motor speech disorder
Behavior: low frustration tolerance, good selective and sustained attention, reducedeye contact for speech tasks
Play: lack of sequenced play
Language Comprehension: WNL
Expressive Language: single sign repertoire of over 50, no combinations, verbal repertoire of six word approximations
Speech: limited repertoire of vowels, consonants, and syllable shapes, distorted and not fully resonant,
MS: distorted substitutions, voicing errors, increase with complexity “Mama” to “ma-ee”
SF/Snack: non-speech oral motor skills 8-12 month levelS
Triage: crucial questions
What is the relative contribution of the child’s speech difficulties to his or her overall communication disorder?
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Triage: crucial questions
What is the underlying nature of the child’s speech disorder: linguistic or motoric?
What will we do with all this information if the child is under 3?
• We will place them on a watch for CAS by labeling with CASs
• We will design and implement therapy to address the errors and areas of need
• We will include choices in treatment that are supported by the motor learning literature
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Treatment
• Increase intervention intensity
• Create functional objectives
• Establish the foundation behaviors
• Educate parents
Speech Treatment
What does intense intervention mean?
• # sessions per week
• # trials per session
• Time is spent with the child talking
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Treatment
Speech:
• Core Vocabulary
• Increase ability/accuracy
Language:
• AAC
Speech Technique
• Integral Stimulation
• DTTC
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Successful Treatment!
Photo by Justin Griner
Attention to the clinician’s face
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Start together
Practice Words
Photo: Kyle Court
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Say the word together
Prosodic Contour
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Speech Treatment
Other supports to improve success
• Temporal cue
• Tactile cue
• Progressive approximation/intelligible error
Speech Treatment
How do we use the motor learning literature to help?
New goals Older goals
(low accuracy) (higher accuracy)
Mass practice Distributed
Consistent practice Variable
Consistent/rapid FB Inconsistent/delay
Accuracy Accuracy/Natural outcome
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Speech Treatment
Speech Treatment
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Speech Treatment
Measuring success
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Speech Treatment
The Whole Picture
“What To Do When They’re Two: Assessment and Treatment of Young Children with Suspected Childhood Apraxia of Speech,” Presented by: Marnie Millington, MS, CCC‐SLP, February, 2016, Sponsored by: CASANA
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Questions?