ASHA Slides by nvbc7n893



                           Peter Flipsen Jr., Ph.D., CCC-SLP
                                           Idaho State University
                                                         Dr. Christina Gildersleeve-Neumann
            Christina Gildersleeve-Neumann, Ph.D., CCC-SLP
                                         Portland State University

                                                                     Resulting in
                                                                     ◦ Inconsistency in productions of
                                                                     ◦ Sequencing
                                                                     ◦ Generalization

Increasing phonetic inventory                                             Two primary goals
◦ Establish new consonants, vowels, and/or word                          1. Establish consistent interpersonal communication.
  shapes                                                                          Watch for behaviorally acceptable attempts to communicate
◦ Expand place, expand manner, or both                                            Respond appropriately to any mode of communication
◦ Small steps                                                            2. Establish consistent use of oral communication.
   Sounds they have, use in more complex word shape                               Increase vocalizations of any sort
                                                                                  Start with sounds already in repertoire
   Add a new word shape using sounds they have                                        Eventually expand sound repertoire
Decreasing errors                                                                     Eventually expand complexity
◦ Consonants                                                              Focus
◦ Vowels                                                                 ◦ Build movement sequences
◦ Word shapes                                                            ◦ Increase variety of phonemes & word shapes
Improving suprasegmentals                                                ◦ Worry less about segmental accuracy
                                                                     (Davis & Velleman, 2001)


   For very young and/or very severe children,     Consider what phonetic context to put new
   consider using:                                 sounds in
   ◦ Consonants: /p, b, t, d, m, n, w, j/
                                                    ◦ Consonant + Vowel combinations based on basic
      Add new place or manner as appropriate          movement patterns:
      Small steps, not baby steps                      bilabial C + neutral V (mama, buhbuh for bottle)
         Not just voicing contrast
                                                       alveolar C + front V (daddy, see)
                                                       velar C + back V (go, cook, caw)
   ◦ Vowels: /i, Ǻ, e, ǫ, ǩ, a, æ/
   ◦ Word shapes: CV, CVCV, CVC

                                                 Facilitation of overall communication
                                                 Likely includes
                                                 ◦ Intense speech sound treatment
                                                 ◦ Augmented or alternative communication to
                                                   increase language development

Support for need of 3-5 sessions per week of
intense treatment when severity of involvement    Difficulty planning purposeful speech
high                                              movements
Individual rather than group therapy              ◦ Work on sounds in syllables & words, not in
Naturalistic environment                            isolation
◦ Support carryover and generalization            Movement must be specific to speech,
AAC devices may be used to increase functional    not haphazard
                                                  Neuromuscular system intact
Non-speech oral motor therapy not necessary
nor sufficient for improved speech
ASHA, 2007


                                                        Articulatory (Motor-based)
                                                        ◦ Focus on speech output through articulatory practice
Children with CAS needing more individual therapy       ◦ Types
                                                           Integral stimulation, touch cues, PROMPT*, etc.
than non-CAS speech sound disorder (SSD) to                 Prompts for Restructuring Oral Muscular Phonetic Targets
receive same functional treatment outcome               Prosodic
◦ Average cost of treating CAS 5x that of SSD           ◦ Focus on suprasegmentals to increase speech production
                                                        ◦ Types
                                                           Melodic intonation therapy, Suprasegmental, etc
Campbell (1999)                                         Gestural
                                                        ◦ sign language, home signs, etc.
                                                        Augmented Communication System


                                                           Focusing on speech production, increasing
    Use articulatory approach                              accuracy and use of articulators
                                                           ◦ Increase motor planning for speech by practicing speech
    Guide treatment based on child’s entry-level
    skills.                                                ◦ Hierarchical approach – simpler to more complex motor
                                                             planning tasks
    Choose highly functional words and phrases             ◦ Greater emphasis on movement sequences and syllabic
                                                             integrity than individual sounds
    Involve child and parents in decisions
    Build complexity                                       ◦ Application of cognitive motor learning principles
    ◦ Take what they have and use it in a new way          Consider:
        New sounds in familiar word shapes                 ◦ Multimodal inputs to build speech movement patterns
        New word shapes with familiar sounds                    Tactile, auditory, visual cues
                                                                Internal & External Feedback

Integral Stimulation
Dynamic Temporal and Tactile Cueing
Kaufman’s Shaping Word Approximations
Hammer’s Multi-sensory Approaches


                                                                           Discrete movements
                                                                           ◦ Brief action,
                                                                           ◦ Well-defined beginning and end
                                                                           ◦ Examples:
Occurs after Practice & Experience                                             Hitting a ball, snapping fingers.
                                                                               Single syllable
◦ With skill you’re attempting to learn                                    Continuous
Leading to                                                                 ◦ Action unfolds without beginning and end
                                                                           ◦ Repetitive
◦ Relatively permanent changes in the                                      ◦ Examples:
                                                                               Walking, riding a bike, babbling
  capability for responding                                                Serial
                                                                           ◦ Composed of many discrete movements
                                                                           ◦ Order is crucial
                                                                           ◦ Often learned in pieces, but also need to master the whole
                                                                           ◦ Examples:
                                                                               Gymnastics routine

◦ Predictable & stable environmental state                                If I want to effect learning of a new skill,
◦ Little decision-making in matching movement to environment
◦ In learning closed skill, individual strives for increased              ◦ How can I make sure that my therapy maximizes
  consistency.                                                              practice conditions?
◦ Examples:
    Lap swimming, playing with a ball alone, gymnastics routine, indoor

◦ Unpredictability, instability of environment
◦ Movement in motion
◦ Can’t prepare in advance
◦ In learning open skill, learner must increase diversification of
  movement to meet situational demands
◦ Examples:
    Skiing, playing a ball game against unknown opponents.
Schmidt & Lee, 2005

                                                                          Energizing Effects
                                                                          ◦ Interest, Motivation
Performance                                                               Guidance Effects
◦ Production accuracy within a session                                    ◦ Feedback as crutch
**Learning **                                                             Degrading Effects
◦ Retention and generalization across sessions                            ◦ Boredom, Fatigue
◦ Ability to use new skill in new environments                            Randomization
                                                                          ◦ Temporarily lower performance


Delay testing                                         1.   Precursors to motor learning
 ◦ Ensure enough time so transfer effects gone        2.   Conditions of practice
Transfer Test                                         3.   Knowledge of results
 ◦ Give new test, observe topic in new environment
    Probe data
                                                      4.   Influence of rate.

◦ Child-Specific                                           Initially
   Motivation                                              ◦ Repetitive motor drill
   Focused attention                                            Learn motor skill through practice
   Age                                                          Quality of practice important
   Support                                                        Focused attention, scheduling, feedback
◦ Therapist                                                Progressing Towards
   Prepractice                                             ◦ More natural settings
     Teach how articulators move to produce a sound        ◦ More natural targets
     Talk about movement without actually doing it
        visualization of movement
        direct observation of modeling movement

     Mass to Distributed Practice                            ◦ Shorter more frequent sessions
      ◦ Mass                                                     Phone calls
                                                                 Outside class
         Practice for longer periods of time
                                                             Aid of others (When Performance Skills Strong)
      ◦ Distributed                                          ◦ Working with other professionals
         Practice for shorter times                          ◦ Homework
            More frequently and/or                               Ask me…
                                                                 In car
            Longer time period
                                                                 Split between members
      ◦ Mass: Better performance in session                      Bedtime books
      ◦ Distributed: Better generalization                       Bath time, play routine
                                                                 Speech buddy
                                                                 Leaving phone messages
                                                                 Homework calendar


    Blocked                                                     ◦ Can always anticipate what is coming next
    ◦ Practice same target repeatedly within one                Random
      block of time
                                                                ◦ Change mental & physical activity from task to task
    **Random                                                    ◦ Two Hypotheses
    ◦ Practice multiple targets throughout a                       Elaboration
      block of time                                                  When practice random order, forces client to discriminate
                                                                     between tasks, developing more elaborate representations
                                                                     In random, forget solution that just happened, forces task
                                                                     Contribute to memory strength
                                                                Want to force learning into situation that requires
                                                                new generation of answer

                                                            Summary Feedback
Types of Feedback                                           Reduced feedback frequency
◦ Knowledge of Results
                                                            Bandwidth Feedback
   Provide comments about production accuracy
◦ Knowledge of Performance                                  Delayed feedback
   Specific information on actual production                ◦ Instantaneous feedback stops client’s evaluation
   Suggest how to do movements                                process

Need both for cognitive motor learning

A slow model
◦ will facilitate accuracy of child’s speech in imitation
Having child slow own productions
◦ will increase accuracy
◦ more planning time                                        Use cueing and feedback to increase output
◦ more feedback time


Articulatory                                          Example of Hierarchy
                                                         Watch & listen with maximal cueing. Simultaneous
Intense                                                  production
                                                         Clinician model, client repeat/clinician mouth
“Watch me & listen”                                      Clinician model, client immediately repeat with cues
By any means necessary                                   Clinician model, client repeat, no cues.
◦ Tactile, kinesthetic, visual, auditory, prosodic,      Delayed repetition (1-5 second delay)
                                                         Reading with delay
Originally for adults                                    Question response
◦ Recent adaptation for children: Dynamic Temporal       Role-playing or games.
  and Tactile Cueing
 (Strand, Stoeckel, & Bass, 2006).

Cues                                                    Build speech patterns
Level                                                   ◦ Use a drill-type treatment approach (or drill play),
                                                          but vary
◦ May need a lot one day, few the next
                                                            # of cues provided in a session
◦ If break down, go back to maximal cues, then
                                                            Types of cues presented
  attempt again with minimal cues
                                                        ◦ Work towards more natural, more random

Importance of multiple productions for
(Elbert, 1991; Edeal & Gildersleeve-Neumann, 2009)           Introduce early self-monitoring skills for self
                                                             correction early on
                                                             ◦ Think motor learning more than motor performance.
Multiple opportunities in developmentally-
appropriate play or drill activities
Repetition of sound patterns in a variety of
meaningful contexts
Use repetitious play routines, books, etc.


Communicative intent                                                          Utilize articulatory approaches
Primary disorder is in motor planning, motor                                  ◦ Focus on production
execution                                                                     ◦ Improve speech through intense speech practice
                                                                              ◦ Apply principles of cognitive motor learning
Core difficulty not cognitive or language-
                                                                                  (Maas, et al, 2008)
                                                                              ◦ Use most effective cueing strategies
◦ May supplement treatment for primary disorder
                                                                                  Integral Stimulation, DTTC, Touch Cues, Prompt
  with treatment for CAS
                                                                              ◦ Continually re-evaluate treatment approach and
                                                                                  Be willing to change

American Speech-Language-Hearing Association. (2007). Childhood Apraxia       Elbert, M., Powell, T., Schwartzlander, P. (1991). Toward a
of Speech [Position Statement].                                               technology of generalization: How many exemplars are sufficient?
American Speech-Language-Hearing Association. (2007). Childhood Apraxia       Journal of Speech & Hearing Research, 34, 81-87.
of Speech [Technical Report].
                                                                              Maas, E., Robin, D. A., Hula, S. N. A., Freedman, S. N., Wulf, G.,
Campbell, T. F. (1999). Functional treatment outcomes in young children       Ballard, K. J., Schmidt, R. A. (2008). Principles of motor learning in
with motor speech disorders. In A. Caruso & E. Strand (Eds.), Clinical
                                                                              treatment of motor speech disorders. American Journal of Speech-
management of motor speech disorders in children (pp. 385–396). New York:
Thieme Medical.                                                               Language Pathology. 17, 277-298.
Davis, B.L., & Velleman, S. (2001). Differential diagnosis and treatment of   Schmidt, R. A., & Lee, T. D. (2005). Motor control and Learning: A
developmental apraxia of speech in infants and toddlers. Infant-Toddler       behavioral emphasis (4th edition). Champaign, IL: Human Kinetics.
Intervention, 10, 177-192.                                                    Strand, E. A., Stoeckel, R. & Baas, R. (2006). Treatment of severe
Edeal, D. M. & Gildersleeve-Neumann, C. E. (2009). The importance of          childhood apraxia of speech: A treatment efficacy study. Journal of
production frequency in therapy for childhood apraxia of speech. Manuscript   Medical Speech-Language Pathology, 14, 297-307.
in revision.


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