Treatment Principles of Childhood Apraxia of Speech

 

As it is understood, Childhood Apraxia of Speech/Developmental Verbal Dyspraxia  is a motor speech disorder, therefore, the principles of motor speech therapy would apply. However, it is more complex than this as there are often other issues that require treatment. Idiopathic Childhood Apraxia of speech persists throughout childhood, and into adulthood. Without adequate treatment it would thus affect a child’s ability to communicate socially and essentially, as well as affect literacy, language and learning due to its impact on phonological awareness and other factors. This can have a significant impact in the overall quality of a child’s life, as well as their academic success and social interactions.

Treatment therefore has to be individualized, and focuses around the goals of improving intelligibility, language and general communication. Literacy goals are also incorporated into treatment by Speech-Language Pathologists. Because it is a motor speech disorder, treatment revolves around frequent, repetitive practice to achieve speech targets. This means that parents have to commit to being directly involved in their child’s treatment process. From collecting paperwork, to planning the logistics of attending many costly speech therapy sessions per week over the course of years sometimes, parent commitment and understanding is essential to giving children with Apraxia the essential gift of speech. Often times families have to make changes to schedules, working hours and other factors to incorporate speech therapy as a way of life for the first few years of treatment. The payoff of this investment is enormous and cannot be quantified of course.

It is important that your child be assessed by a team.  In Alberta, this would include of course, the Speech-Language Pathologist who can initially be accessed through Public Health for a child with speech delay. Your family physician can refer to an audiologist, (a hearing test should be done to rule out a hearing disorder) pediatrician if your child has other conditions, and in the school system your child will have access to Occupational Therapy, Physical Therapy and other Allied Health Professionals. The Speech-Language Pathologist is the main health care professional responsible for the delivery of treatment for CAS. In Alberta, Private Speech therapy is a non insured service. However, most insurance plans do subsidize a portion of Speech Therapy costs. Initial assessment and treatment in the preschool years done at Public Health is insured by Alberta Health Services, and parents do not have to cover the cost of the initial assessment and treatment that occurs. The amount of treatment received through Public Health would vary depending on Services available.

Parents will come to understand that they are the “speech models” of their children, and therefore should try their utmost to provide appropriate speech modelling for children with apraxia. Sometimes this can bring a huge sense of self awareness to parents individually. Providing opportunities for practice at home and on the go is essential. Speech-Language Pathologists will often provide this sense of support for parents, building confidence in them, and providing a framework for adequate practice techniques to be worked on at home and on the go.

Since children with CAS generally make little or slow progress with conventional language based treatment, it has become the “Standard of Practice” to use a motor based approach in the treatment of CAS. However, even within this framework, the programs that incorporate motor learning principles have not been extensively studied. There have only been a few if only a couple of actual Randomized Control Trials comparing different treatment approaches. Other single study designs have only had a few participants, and many have yielded conflicting results. However, we could say, still, the “Gold Standard” of treating CAS involves using these motor based principles which involve a combination of selecting appropriate targets, repetitive practice, and providing feedback.

A treatment regimen that has found to be effective in the treatment of CAS is the use of multimodal “cues” such as auditory, visual, gestural and tactile-kinesthetic-proprioreceptive (TKP) cues. Treatment programs that incorporate this approach are discussed below.  In addition to helping the child join different sounds together to form words (Phoneme Sequencing) other aspects of speech such as Prosody (smoothness of speech),  Rate, Tone and vocabulary are worked on by the Speech-Language Pathologist.  Repetitive Practice, Intense Treatment, Multisensory Cues and Feedback, and choosing the right words that are appropriate to helping the child function in his or her home and social and academic setting are the fundamentals of Speech Therapy for Childhood Apraxia of Speech.  Below are the treatment protocols in brief.

Integral Stimulation Approaches such as DTTC (Dynamic Temporal and Tactile Cueing), which is used for treating motor speech disorders such as CAS, involves auditory, tactile and visual cuing incorporating the principles of motor learning, including imitation (“Watch me, listen, and do what I do”) to model speech. It is hierarchical, in that it builds up from easy speech targets to more complex ones, and the supports are reduced as the child becomes more accurate independently. This method helps build sound patterns for new utterances into the child’s memory using repetition and reduced cuing with practice. Read More about DTTC. Integral Stimulation approaches such as DTTC have the most research supporting their effectiveness in children with CAS, with multiple single case studies showing success.

ReSt or Rapid Syllable Transition is another motor based approach that uses the concept of repeatedly practicing non words, thus helping a child to transition between syllables, as this is thought to be a core problem in CAS. This system uses the general principles of Motor Speech Therapy ie. Repeated practice trials, the variable practice of complex targets, and reducing feedback, and is suggested to be used for the older child who has mild to moderate speech motor impairment.

A third approach used extensively in Australia and the United Kingdom is the Nuffield Dyspraxia Programme, Third Edition (NDP3), which is a bottom-up approach that builds a child’s repertoire of sounds from single sounds, to syllables and then syllable sequences, using various motor approaches such as frequent feedback and blocked practice. It includes phonological awareness skills, and working on phrasal stress. NDP3 is generally appropriate for children between 4-12 with mild to severe CAS. There has only been one recent randomized control trial which compared ReSt to NDP3 and showed that both treatments are effective in treating CAS, however ReST seemed to show a stronger maintenance of gains, thought to be due to the aspects of motor learning that it targeted vs NDP3.

PROMPT: This stands for Physically Restructuring Oral Muscular Phonetic Targets and is a treatment that has been used for CAS for a number of years, though there are few published studies about its’ efficacy for CAS. It integrates cognitive, language, motor and sensory aspects of communication to help kids form and shape the movements of the oral articulators (muscles of speech). The studies published to show that PROMPT can work for kids with CAS were small in sample size, and done by researchers affiliated with the PROMPT Institute.

Kaufman Speech to Language Protocol (2009) principles stress the importance of proper modelling so that children can always hear the correct words or sounds they have to imitate. It uses multimodal cues and goes through a six step program building on having the child acquire vowels and consonants that are missing, and building a repertoire of functional words that the child can use in his or her daily interactions, followed by building expressive language and building a home program. These principles are incorporated into various programs.

In summary, the principles of motor learning include repetition, cuing, feedback and frequent practice, and focus on aspects such as acquisition of sounds, making the movements from one sound to another, using this knowledge to make sounds that become words, then short sentences that are relevant to the child, and thus building accurate speech sounds and language.  Additionally, SLP’s work on prosody and rate and other aspects to develop clear and smooth speech, as well as building language along the way.  Home practice and support is essential. Once learned, the child builds on what he or she knows and more complex targets can be taught. A knowledgeable, experienced and personable Speech-Language Pathologist will incorporate all of these principles into sessions with activities that are fun and engaging for the child, thus successful treatment can become a reality.

The largest resource on the web is CASANA’s website: Apraxiakids.org

Apraxia-KIDS.org/What makes Speech Therapy Different for Children with Apraxia?

Apraxia-KIDS.org/Frequency/Intensity of Treatment

Apraxia-KIDS.org/General Treatment Principles

Information about the types of treatments available can also be found here. Asha.org/Treatment

References:
Asha.org/policy 2007b
E. Maas, C.E. Gildersleeve-Neumann,K.J.Jakielski,R. Stoeckel (April 2014),Motor-Based Intervention Protocols in Treatment of Childhood Apraxia of Speech (CAS), Springer International Publishing, Switzerland.
Edwin Maas,Christine E. Butalla, Kimberly A. Farinella(2012) Feedback Frequency in Treatment for Childhood Apraxia Of Speech. American Journal of Speech-Language Pathology, Vol 21, 239-257 August 2012, ASHA.
Philip S. Dale, Deborah A. Hayden (2012) Treating Speech Subsystems in Childhood Apraxia of Speech with Tactual Input: The PROMPT Approach, American Journal of Speech-Language Pathology, 644-661 2013
Elizabeth Murray, Patricia McCabe and Kirrie J. Ballard A Randomized Controlled Trial for Children with Childhood Apraxia of Speech Comparing Rapid Syllable Transition Treatment and the Nueffield Dyspraxia Program-Third Edition,(2014) Journal of Speech, Language and Hearing Research, Vol 58, 669-686, June 2015.
Elizabeth Murray, Patricia McCabe and Kirrie J. Ballard A Systematic Review of Treatment Outcomes for Children with Childhood Apraxia of Speech (2013) American Journal of Speech-Language Pathology, Vol 23, 486-504, August 2014
Strand, E., Stoeckel R., Baas, B.,Treatment of Severe Childhood Apraxia of Speech, A Treatment Efficacy Study, December 2006.
Here’s How to Treat Childhood Apraxia of Speech, Margaret Fish, Chapter 11