Literature Review

Neuromotor Speech Disorder: Childhood Apraxia of Speech (CAS)

Other disorder: Autism Spectrum Disorder (ASD)

Treatment: PROMPT (PROMPT© stands for Prompts for Restructuring Oral Muscular

Phonetic Targets. It is a tactile-kinesthetic approach to speech therapy, which means

that the speech-language pathologist uses touch cues on the client's face (vocal folds,

jaw, lips, tongue), to support and shape correct movement of these articulators.)

AAC: PECS (PECS is a type of Augmentative and Alternative Communication that uses

visual symbols to teach the learner to communicate with parents, carers, teachers and

peers. The aim is to teach intentional, functional communication and to allow users to

communicate their wants and needs.)

Please include Autism information as well as CAS information below.

Sections to be completed:

Intervention

Intervention Method- CAS and Autism

Motor Speech Treatment Hierarchy

Augmentative and Alternative Communication

Interprofessional Practice (include AAC)

Cultural Humility

Top of the License

Sample from another group on CAS from last year.

Intervention

Intervention Method

When looking at intervention for apraxia of speech, Darley (1975) states that the goal is to help

the patient relearn the motor sequences they need in order to produce phonemes accurately.

There are six principles that are essential in managing apraxia of speech. However, not all

patients are candidates for treatment when it comes to apraxia of speech. This may be the case

when the patient’s impairments are so severe that functional speech production is merely

impossible. In these specific cases, the patient will not benefit from treatment.

Patients and families need to understand the characteristics of apraxia of speech and the rationale

for treatment tasks. Meaning, the family of the patient needs to understand the nature of this

disorder, receive counseling, and understand what the treatment process entails. Most treatment

programs begin with repetitive and intensive drill work. In order for patients to appropriately

re-learn all the motor movements necessary to produce phonemes, they need constant repetition.

Treatment should be sequenced in a way where the patient maintains a high success rate. The

patients need to start off with easy activities in order for them to feel motivated, then slowly

progress to more difficult activities. It is vital that the patient should learn how to monitor their

own speech. With appropriate treatment and feedback from the clinician, the patient should be

able to monitor and correct their errors in order to learn what is and isn't appropriate. Teaching

the patient to become aware of their sound errors will help them learn to self-correct. Lastly,

treatment should focus on functional communication. Clinicians should ensure patients are able

to communicate their wants and needs appropriately. Therefore, helping them produce

meaningful words as promptly as possible is important (Freed, 2020).

Motor Speech Treatment Hierarchy

Dynamic Temporal and Tactile Cueing (DTTC) for speech motor learning is a method that

incorporates principles of motor learning and is used with children who struggle and are

unsuccessful with articulatory imitation. DTTC allows for continuous shaping of the movement

gestures, with the goal of improving motor planning (Bowen, 2011). According to Strand (2020),

the overall goal of the DTTC is to improve the patient’s efficiency of neural processing for the

development and refinement of sensorimotor planning and programming. DTTC is based on

integral stimulation (“look at me, listen to me, say what I say”) and involves intensive drill on a

core vocabulary (Maas & Farinella, 2012). This integrated stimulation involves the manipulation

of imitation, cues, speech rate, and the timing of models and imitation (Skelton & Hagopian,

2014). The steps in DTTC are as follows:

1. Imitation – In its implementation, DTTC begins with direct, immediate imitation of

natural speech.

2. Simultaneous production of prolonged vowels (most clinician support) – If the child

cannot imitate, the therapist makes the task easier and more ‘supported’ by introducing

simultaneous production. The clinician says the utterance at normal volume with child,

very slowly with touch or gesture cues as required. The utterance is slowed by sustaining

the vowel and not by undue emphasis on the onset consonant. This usually helps the child

to imitate while allowing the clinician to run a ‘visual check’ of jaw and lip postures.

3. Reduction of vowel length – The rate of stimuli production is increased (vowel length

is reduced) to sound more natural.

4. Gradual increase of rate to normal – Practice continues at this level to the point where

the child synchronizes effortlessly with the therapist at normal rate, with normal

movement gestures, and without silent posturing.

5. Reduction of therapist’s vocal loudness, eventually miming – Using delicate timing,

the therapist is then in a position to reduce volume eventually reaching a point where the

therapist is producing a mime (mouthing the utterance) as the child actually says it aloud.

Because of the intellectual closeness within the dyad this can be a tricky point in therapy,

and some children will dutifully follow exactly what the adult is doing so that the two are

miming at each other! This is obviously not the goal, and children may need explicit

instruction to keep their voice ‘turned on’ even though the adult’s is ‘off’. The gesture

and touch cues may still be needed at this point, and will be necessary in the next step, the

integral stimulation method proper.

6. Direct Imitation - The clinician ensures that the child is comfortable with moving to

this harder level in which the child watches the adult’s face while an auditory model is

provided. The child attempts to repeat the model and if successful does so many times. If

unsuccessful, the therapist may backtrack to the simultaneous level or silent

mouthing/miming level described above. Eventually all miming is faded completely, and

the child directly imitates and ‘repeats’ targets numerous times before the final step is

introduced.

7. Introduction of a one or two second S-R delay (least support) - Once the child is

directly imitating the therapist’s model with normal rate, prosody he or she can vary, and

appropriate articulatory gestures, the therapist inserts a new requirement: a one to two

second delay before the child imitates, so that the child produces a very slightly delayed

response (1- to 2- seconds delay). To facilitate this for the children who find the delay

difficult and want to ‘jump in’, miming while the child produces the delayed response is

often helpful.

8. Spontaneous production - Finally, the therapist elicits the spontaneous utterances,

for example, by asking the child questions (‘What is this called?’), using cloze tasks

(‘Twinkle, twinkle ___ ___’), sentence completion (‘Mother elephant is big, her baby is

____’) (Bowen, 2011).

Augmentative and Alternative Communication

According to American Speech-Language-Hearing Association, augmentative and alternative

communication includes all the different ways in which we share our ideas and feelings without

actually talking. When you augment something, you are adding to it, therefore, augmentative

communication is when you add something to your speech (e.g. pictures, sign language, facial

expressions, a letter board, etc.). These tools can assist you with making your message clearer for

your communication partner. Alternative communication refers to needing a different way to

communicate. This could be because your speech is not understood by others or because you are

not able to speak (Hartmann, 2020).

AAC can refer to many different tools, systems, devices or strategies that are designed to assist

or replace verbal speech. Each and every single one of us uses different forms of AAC every day.

These include writing, drawing, facial expressions, or even the use of gestures instead of talking.

Individuals who have difficulties with speech and language may rely on AAC to help them

communicate. Some individuals may use AAC at all times, others may only use AAC in specific

scenarios (American Speech-Language-Hearing Association).

There are many different reasons why someone may not be able to communicate using speech.

They may have a developmental disability that has affected the development of their speech, or

they may have an acquired disorder that has affected their ability to speak. Different people with

a variety of communication difficulties, speech impediments, or disorders may benefit from

using AAC (Lingraphica, 2020).

There are different types of AAC devices – unaided systems and aided systems. It is common for

people who use AAC to use a combination of AAC types when communicating. Unaided

systems do not require anything other than your own physical body. These include facial

expressions, body language, gestures, and some sign vocabulary. With unaided communication,

an individual relies on their own body to convey messages to listeners. Aided systems use some

sort of device or tool in addition to the body. Aided systems can be broken down into basic and

high-tech. A basic aided system could be a pen and paper or using a picture board to point to.

High-tech aided devices refer to using a computer or tablet to touch letters or pictures in order

for that device to speak for the individual (American Speech-Language-Hearing Association).

The implementation of augmentative and alternative communication can be used to provide the

patient with an opportunity to practice repetitive production. The purpose of AAC is to “enable

those with highly limited verbal expression competencies to communicate efficiently to varying

communication partners and to participate in a variety of social situations and everyday

activities” (Lüke, 2016). Recent advances in technology have provided clinicians more options

than ever before to support a child’s acquisition of language using speech generating

augmentative and alternative communication systems (Barton-Hulsey et al., 2017). Evidence

shows that augmented input for improving communication skills in people with developmental

disabilities and CAS is promising (Zangari, 2018). The AAC being recommended for this case

study is Proloquo2Go. Proloquo2Go is an innovative application developed by AssistiveWare

that provides user friendly support for users, as well as all members within the interdisciplinary

team, in order to implement AAC best practices. AssistiveWare was founded in 2000 and is a

leading pioneer in the field of augmentative and alternative communication, developing assistive

technology software for iOS and macOS. Proloquo2Go was released in 2009 as the first

full-featured augmentative and alternative communication application for iOS. This is an AAC

application that can be used as a daily communication tool and aiding in building language skills.

This application was designed to promote growth of communication skills, as well as foster

language development through research-based vocabularies. This is one of the few AAC

applications that is designed to support all users, from beginner to advanced, and is available in

English, Spanish, French, and Dutch (AssistiveWare).

Interprofessional Practice

Children who use aided AAC receive their primary language input from the spoken language of

those around them; however, their primary form of expression is through the use of their AAC

system, which can sometimes create asymmetry in the language context. This asymmetry can be

reduced by aided augmented input, enhancing development of their expressive vocabulary,

morphology, and syntax (Allen et al., 2017). AAC strategies have shown to help with specific

aspects of communication with children with CAS, such as “repair of communication

breakdowns, topic initiation, message length, and complexity” (Oommen & McCarthy, 2015).

This is why it is important to have an interdisciplinary team that is working collaboratively to

develop a treatment plan for the patient, and is implementing the proper use of the AAC device.

Interdisciplinary team members will include the patient’s family members, Speech-Language

Pathologist, Occupational Therapist, Physical Therapist, psychologist, and teacher.

AssistiveWare offers on-demand training videos with their AAC specialists, which will allow for

proper training of Proloquo2Go application for all members of the interdisciplinary team

(AssistiveWare).

Cultural Humility

In 1998, Tervalon described cultural humility as a “lifelong process of self-reflection,

self-critique and commitment to understanding and respecting different points of view, and

engaging with others humbly, authentically and from a place of learning” (Tervalon, et. al, 1998).

Cultural humility is a concept that provides a way to work with people from different cultures.

When developing an intervention plan, a clinician must not only be mindful of the patient’s

strengths and weaknesses within the scope of Speech-Language Pathology, but the culture,

religion, and background that the patient comes from. For example, certain cultural groups hold

differing views regarding the use of eye contact in communication (Shipley & McAfee, 2016).

When treating apraxia of speech, eye contact is important in order for the patient to receive the

clinician’s visual cues, especially when implementing a treatment strategy that focuses on

feedback. A clinician must acknowledge a patient’s differences and be willing to adjust the

intervention in order to provide a therapy that is both culturally sensitive and addresses the

patient’s areas of weakness; only then will the patient have the best prognosis for

rehabilitation/habilitation.

Top of the License

Top of the license principles reflect a health care worker’s true value and effectiveness by

maximizing the time they spend delivering services they are uniquely qualified to provide and

collaborating with other professionals/individuals to provide services in the most cost-effective

manner (McNeilly, 2018). The intervention will reflect TOL principles because a fully licensed

Speech-Language Pathologist will take the time to formulate and execute an intervention that is

individualized to the specific patient. The treating Speech-Language Pathologist will recommend

the setting, frequency, and duration of therapy, as well as collaborate with the family and other

professionals seen by the patient in order to work on self-management and generalization of

skills outside of the therapeutic setting. In this way, the Speech-Language Pathologist is

maximizing outcomes by contributing to the whole team. Treating the impairment alone may not

lead to functional improvement or be meaningful to the patient. Overall, the Speech-Language

Pathologist will provide services that are ethical, and only engage in patient care activities that

require their level of expertise and skill (McNeilly, 2018).