Childhood Apraxia of Speech: Disclosure The K-SLP · PDF fileactivities, people/pet’s...

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K-SLP Methods & Behavioral Strategies to Build Successful Vocal CommunicationNancy R. Kaufman, MA, CCC-SLP

GO SSLP Best Practices ConferenceAtlanta, GA – March 9, 2018

NancyR.Kaufman,M.A.,CCC/SLPKaufmanChildren’sCenterforSpeech,Language,

Sensory-Motor,AndSocialConnections,Inc.WestBloomfield,Michigan48322

Phone(248)737-3430• [email protected]

ChildhoodApraxiaofSpeech:TheK-SLPMethods&BehavioralStrategiestoBuildSuccessful

VocalCommunicationTheKaufmanChildren’sCenterforSpeech,Language,Sensory-Motor,&SocialConnections,Inc.isownedandoperatedbyNancyKaufman,MA,CCC-SLP.NancyhasdevelopedaspeechpraxistreatmentprogramknownastheKaufmanSpeechtoLanguageProtocol(K-SLP).SheistheauthoroftheK-SLPTreatmentKitsforChildren,theK-SLPWorkoutBook,theKaufmanMuttFamilyTotalLanguageBuilder,theK-SLPInstructionalDVD,andtheKaufmanSpeechPraxisTest.Nancyistheco-author,withTamaraS.Kasper,MS,CCC-SLP,BCBA,oftheK&KSigntoTalkNouns&Verbsprogram.Shebenefitsfromthesalesoftheseproducts,publishedbyNorthernSpeechServices.

Disclosure

TheKaufmanSpeechtoLanguageProtocolAmethodofpracticingsyllableshapegestures

andwordapproximationstowardtargetvocabularytobemoveddirectlyinto

functionalexpressivelanguage.

Typicaldevelopingtoddlerswhoarejustlearningtospeakrarelybegintospeakusingwholewords.Forexample,thewordbottle mightbeproducedinthissequence:

ba

baba

bado

bottle

Childrenwhostruggletospeakdonotgothroughthisprocessormaybestuckonapproximationsmuchlowerthantheircapability.

Continuouslyaskingthemtorepeatwholewordsissettingthemupforfailure!

Thehelpschildrenwhostruggletocombineconsonantsandvowelsto:

• Practice combining the consonantsandvowelswithintheirrepertoiretoformsyllableshapesofVV,CV,VC,CVCV,CV1CV2,CVC,C1V1C2V2,etc.usingrealwords.

• Practice simplenounstospontaneouslynamethem,developingvocabulary,andtoeventuallyaddaverbforatwo-wordutterance(eatapple).

• Practice functionalrequests(mands):on,off,out,open,come,go,watch,don’t,help,etc.

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The helpschildrenwhostruggletocombineconsonantsandvowelsto:

• Practice successiveapproximationstoward“favorites”andhigh-frequencywordsforrequestingandcommenting.

• Practice pivot(carrier)phrasestoimplementforexpressivelanguageformulation.

• Practice buildingsyntax,morphology,andgeneralexpressiveformulationtosociallanguagedevelopment.

Thewasestablishedwithrootsin…

• Appliedbehavioranalysis(ABA),andinparticularappliedverbalbehavior(AVB)

• Phonology/phonologicalprocesses• Acquiredapraxiaofspeech(literatureandresearch)especiallytheuseofmelodyandgesturestofacilitatecommunication

• Sensoryintegrationandpraxis• Currentneuroscience• Currentresearchinchildhoodapraxiaofspeech,especiallyprinciplesofmotorlearning

• ThoughABAisknowntoteachskillstothosewithautismspectrumdisorders,ithasafar-reachingcapacitytoteachanyskills/behaviors.

• The behavior terminABAisoftenassociatedwithextinguishingnegativebehaviorsthatcanbeinterferingtothelearningandsocialprocess.

AppliedVerbalBehavior&the

• However,ABAprinciplesareexcellentandhighlyresearchedteachingstrategiestoestablishorimproveuponbehaviors.

• Inthiscase,thebehaviorswewishtoestablishorimproveuponarethatofspeech-motorandexpressivelanguage (andlanguageprocessing/receptivelanguage).

• Appliedverbalbehavior(AVB)wouldbeamorespecificapproach,especiallywhenteachingthebehaviorofcommunication.


Hereisanewbookonthisverysubject!

AppliedVerbalBehavior&theWhyShouldSLPsLearnthePrinciplesofBehaviorismandHowtoApplyThem?

Direct excerpt from Behavioral Principles in Communicative Disorders: Applications to Assessment and Treatment (Maul, Findlay, Adams)

Speech-language pathologists (SLPs) are in the business of changing communicative behaviors in the clients they serve. SLPs seek to establish new communicative behaviors in their clients, rehabilitate communicative behaviors that may have been lost, strengthen and maintain existing behaviors, and, often simultaneously, decrease communicative behaviors that are undesirable.

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WhyShouldSLPsLearnthePrinciplesofBehaviorismandHowtoApplyThem?

...The well researched principles of behaviorism, therefore, are highly relevant to the field of speech-language pathology because it is a science that has resulted in an evidence-based, systematic set of methods applied to modify the behaviors of others.

• AsSLPs,wewouldneedanadditionalmaster’sdegreetofullyunderstandAVB,withmanyhoursofsupervisedinstruction.Thoughthiswouldbeawonderfulidea,itwouldnotbefeasibleformostofus.

• Therefore,ageneralunderstandingofsometeachingstrategiesofABA,andspecificallyverbalbehavior(AVB)wouldhelpustobebetterclinicians.

• Hereare8AVBteachingstrategiestoimplementforCAS(orotherspeechandlanguagebehaviors).


1. Pairing&establishingmotivation2. Definingthebehavior&datacollection3. Implementingshapingtechniques4. Errorlessteaching5. Implementingandfadingcues6. Differentialreinforcementanderrorcorrection7. Practiceschedulesforthenewbehavior8. Practicingnewskillsinthenatural

environment(coachingparents)

8TeachingStrategies 1• Weshouldneverunderestimatethepowerofmotivation!

• Determinethechild’shighlypreferred toys,activities,themes,characters,places(orfoods/drinksifunmotivatedbytheothers),andhavethemreadilyavailable.

• Afavoriteslistcanbeobtainedfromparentsandcaregivers.

• Ifthechildhasunusualinterests,roundtheseup(examples:surgicalgloves,eyeglasses,phones).

Pairing&EstablishingMotivation

TeachingStrategy

• Pairyourselfwiththechild’shighlypreferreditemsandactivitiesbybeing“theGiverofGoodThings.”

• Givethoseitemsorprovidethoseactivitiesfreely withoutexpectationofperformance.

• Graduallybegintoaskforasimpleperformancetask,suchasagross-motorimitation,orplacingapuzzleinoneavailableopening.

• Ifthechildunderstandsthetaskofimitation,attempttogainsimplegross-motormovementsorsimplevowels/consonants.

PairYourself

• Pairthechild’shighlypreferreditemsandactivitieswiththerapymaterialsorstimulusitems

• Whentheycomeout,sodotheirfavorites

PairItems&Activities

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Whenthereisanabsenceofimitationskills,consider:

• RapidMotorImitationAntecedentTraining

• SigntoTalk(Kasper&Kaufman)

• TamaraKasper’se-course,“ProgressiveandSystematicSpeechandLanguageTrainingforchildrenontheAutismSpectrum”(northernspeech.com)providesthespecificsaboutimplementingtheK-SLPwithspecialpopulationslikeASD.

• Definethebehaviortobeestablished,improvedupon,orextinguishedandreplaced.

• InCAS,theinitialbehavioristhatofspeech-motorplanningandprogrammingandeventuallyexpressivelanguagedevelopment.

• Thisisdonethroughtestingandobservation.

DefiningtheBehaviorTeachingStrategy2

DefinitionofCASpertheAmericanSpeechLanguageHearingAssociation’s(ASHA)AdHocCommitteeonChildhoodApraxiaofSpeech(2007):Childhoodapraxiaofspeech(CAS)isaneurologicalchildhood(pediatric)speechsounddisorderinwhichtheprecisionandconsistencyofmovementsunderlyingspeechareimpairedintheabsenceofneuromusculardeficits(e.g.,abnormalreflexes,abnormaltone).CASmayoccurasaresultofknownneurologicalimpairment,inassociationwithcomplexneurobehavioraldisordersofknownorunknownorigin,orasanidiopathicneurogenicspeechsounddisorder.Thecoreimpairmentinplanningand/orprogrammingspatiotemporalparametersofmovementsequencesresultsinerrorsinspeechsoundproductionandprosody.

Childhoodapraxiaofspeechcan andoftendoesco-existwithotherspeechandlanguagechallenges.Weneedtoconsiderthenatureoftheprimary interferingfactortosuccessfulvocallanguagedevelopment.

Signs&SymptomsofApraxiaofSpeechSource:CASANA/Apraxia-Kids.org

• Limitedrepertoireofvowels;lessdifferentiationbetweenvowelproductions;andvowelerrors,especiallydistortions.

• Variabilityoferrors(inconsistenterrorsonrepeatedtrials).

• Unusual,idiosyncraticerrorpatterns(sometimesdefyingtranscription).

• Errorsincreasewithlengthorcomplexityofutterances,suchasinmulti-syllabicorphoneticallychallengingwords.


• Dependingonlevelofseverity,achildmaybeabletoaccuratelyproducethetargetutteranceinonecontextbutisunabletoproducethesametargetaccuratelyinadifferentcontext.

• Moredifficultywithvolitional,self-initiatedutterancesascomparedtoover-learned,automatic,ormodeledutterances.

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• Impairedrate/accuracyondiadochokinetictasks(alternatingmovementaccuracyormaximumrepetitionrateofsamesequencessuchas/pa/,/pa/,/pa/andmultiplephonemesequencessuchas“puhtuh kuh”)“DifferentialDiagnosisofChildrenwithSuspectedChildhoodApraxiaofSpeech.”(Murray,McCabe,Heard,&Ballard,2015)


• Disturbancesofprosodyincludingoverallslowrate;timingdeficitsindurationofsoundsandpausesbetweenandwithinsyllablescontributingtotheperceptionofexcessand/orequalstress,“choppy”andmonotonespeech.

• Atsomepointintime,gropingorobservablephysicalstruggleforarticulatorypositionmaybeobserved(possiblynotpresentonevaluation,butobservableatsomepointintreatment).

• Mayalsodemonstrateimpairedvolitionalnon-speechmovements(oralapraxia).


Nancy’sobservation:Verbalmotorperseveration:getting“stuck”onapreviouslyutteredword,anautomaticoroverusedword,orbringingspeech-motorelementsfromapreviouswordintothenextworduttered.


OthercharacteristicsthatmaydescribechildrenwithCAS,butarelesslikelytocontributetoadifferentialdiagnosisinclude:

• Poorspeechintelligibility• Delayedonsetofspeech• Limitedbabblingasaninfant• Restrictedsoundinventory• Lossofapparentlypreviouslyspokenwords

EarlyspeechsoundcharacteristicsofCAS:“Volubility,consonant,andsyllablecharacteristicsininfantsandtoddlerslaterdiagnosedwithchildhoodapraxiaofspeech:Apilotstudy.”(Overby &Caspari,2015).

• TheKaufmanSpeechPraxisTest(K-SPT)(WayneStateUniversityPress,1995)isatestthatprovidesuswithinformationaboutwhatvowels,consonants,andsyllableshapesarewithinthechild’srepertoire,andifcoreCAScharacteristicsareobservedinthechild’sresponses.

• Observation wouldprovideuswithspeechandlanguagebehaviorsthatmaybeidiosyncraticorhabituatedthatwouldneedtobeextinguishedandreplaced.

TheKaufmanSpeechPraxisTest

UsingtheKaufmanSpeechPraxisTestforChildren(KSPT),wecandetermineatwhatlevelachild’sspeech-motorskillsarecompromised,andwecantargetthoselevelsintreatment.

TheKSPThierarchyincludesthefollowing:

I.Grossoral-motormovements

TheKaufmanSpeechPraxisTest

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II.SimpleLevel

1. Isolatedvowels– / a,E,�,I,Ã,u,i/

2. Voweltovowelmovement–/aI,oU,eI,aU,�I/(diphthongs)

3. CSimple– /m,b,p,t,d,n,h/

4. CVCV(reduplicatedsyllables)–mama,papa,dada

5. VCV– opa,ah-po,oh-bow

6. CV– da,me,bay,do

7. CV1CV2(repetitiveconsonantswithvowelchange)– mommy,daddy,puppy

8. CVC (assimilatedinitialandfinalconsonants)–pop,mom,bib

9. CVCCVC (initialandfinalconsonantinclusion)–man,home

10. C1V1C2V2(simplebisyllabics)–happy,tummy,bunny

11. CVCVCV(simplepolysyllabics)–banana,potato,tomato

III.ComplexLevel

ComplexC–/k,g,f,s,z,l,r,w,v,j,S,tS,dZ,P,D/

CVCCVC – complexinitialandfinalconsonantinclusion

Complexbisyllabics– candle,chicken,machine

Consonantblends– / r ,s ,l /

fàb (t,dàk,g)andbàf (k,gàt,d)words(alveolartovelarandvelartoalveolar)

Lengthandcomplexitywords:win,window,windowsill

IV.SpontaneousLengthandComplexity

Alex:Evaluation(age3.11)

• Grossoralmovementintact.• Awareofmoisturearoundmouth.• “Mommy”verbalperseveration(gettingstuckonanautomaticword)

• Deliberateproduction(evidenceofearlyprosodyissues).• NeedsbombardmentcuesforsimpleCVforaccuracy.• Overgeneralizationof“y”endingswhenaskedtoimitateCVCVsyllableshapes(baby,puppy,mommy,daddy).*Thisiswhyitisimportanttomixandvaryourtasks.

• Oralgropingtomaintainpositioning.• Voicingerrors.

Alex:Summary

• Canproduce/E/and/i/butcannotcombineintodiphthong/eI/asin“day.”

• VCVassimilation.

• Disintegrationwithextendedsyllabiclength.

• Receptivelanguagemoreadvancedthanexpressive.

• Stimulable forreducingcuestooralpostures.

• Distortedvowelsinconnectedspeech.

• Appearstobeawareofhiserrors.

Alex:Summary

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Tommy:KSPTEvaluation(age4.10)

• Grossoralmotorskillsaregenerallyintact

• Additions(initialconsonantspriortosomeisolatedvowels,addinga/t/,/d/,/h/

• Diphthongreductions/�I/asinboy

• Canproducesimpleconsonantsaccurately(tensevowelsareaccurate,justhaveprevocalicadditions)butstrugglestocombinethesemovements

• Vowelinaccuraciesincontext

Tommy:Summary

• Devoicing/b//z/• Voicinginitial/t/• Deletionofinitialconsonants• Deletionfinalconsonants(inconsistent)• Deletionmedialconsonants• Replacementsofmedialandfinalconsonants• Someinitial/h/wordsintact• Narrowrepertoireofcomplexconsonantsinisolation• Inaccuracyofcomplexconsonants

Tommy:Summary

• Inconsistencyonrepeatedtrials• Hassomeautowordsintact• Verbalmotorperseveration(getsstuckonapreviouslysuccessfulword,"hot/hop“)

• Difficultywithsyllablelength(evenwithCVCV)• Unintelligiblelengthofutterance• Unusualphonologicalprocesses(devoicing,nasalreplacements,initialconsonantdeletion)

• Receptivelanguagesuperiortohisspeech-motorandexpressivelanguageskills

Tommy:Summary

Speech-MotorBehaviors1. Syllableshapes(singlewordsfromK-SLPKit1)

NeedsallsyllableshapesfromCVCVtosimplemultisyllabics.

2. Namecommonnounswithbestapproximationstothetargetadultwordforms.

3. Favoriteslist:bestapproximationstowardtargetadultwordforms.

4. High-frequencywordstobeestablished.5. Producesimplemanding(requesting)words:

in,on,off,up,open,help,come,go,don’t,etc.

Tommy’sBehaviorstoEstablish,ImproveUpon,orExtinguish

ExpressiveLanguageBehaviors1. Usetheabovesinglewordsfunctionally.2. Learnpivotwordsandphrases(tobediscussed).3. Namethefunctionofobjectswithtwoandthree-

wordcombinations(subject-verb-object)4. Nameactionwithtwoandthree-word

combinations(S-V-O)5. Re-scripthisspontaneouscommunicative

attempts6. Moveaheadongrammaticalskillacquisition.

Tommy’sBehaviorstoEstablish,ImproveUpon,orExtinguish

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Tommy:Progress&CoachingMom Amber:Evaluation(age3.3)

Amber:Summary

• Struggle(headnodding)oninitiationofutterances.• Oralgroping,movementinsidetheoralcavity.• /n/in“no”asanautomaticbutunabletoproduce/n/ inothercontexts.

• CVCVbestskilleventhoughshehasCs&Vs,can’tcombine.

• Unintelligibleattemptsatspeaking.• Initialconsonantdeletionandfinalconsonantdeletion.

• Distractible,needstobeinmovement.• Needsvisualcuesforsuccess.

Amber:Progress(age3.6)

• Childrenwhocanproduceconsonantsandvowelsbutstruggletocombinethem.

• Childrenwhostruggletomaintainarticulatoryaccuracywhencombiningconsonantsandvowelsinconnectedspeech.

• Childrenwhounderstandthetaskandcanimitatevocal/verbalbehavior.

Candidatesforthe

1. Determinewhichvowels,consonantsandsyllableshapegestures thechildhasinhis/herrepertoireviatheKaufmanSpeechPraxisTestforChildren.

2. Establishfirstwords(consideringevaluationfindings),andbeginworkingonsyllableshapegestures,andcommonnouns,simplifyingthemotorplansifnecessary.

3. Establishalist offunctionalmands(requests)suchas,on,off,open,out,up,down,andhelp,includingalistoffavoritefoods,drinks,toys,activities,people/pet’snamesplaces,andhigh-frequencywords,establishingbestapproximationsforrequestingandcommenting.

SixStepsofthe

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4. Helpthechildtocombinewordsthroughpivotwordsand(carrier)phrases,aswellastelegraphiclanguagestructures,toincludescriptingfunctionallanguage.Moveaheadonexpressivelanguage(combiningwords),andbackuponspeech-motor(clarity).

5. Refineandintegratecomplexconsonantsandsyllableshapegestures.Continuetobuildexpressivelanguagebyaddinginsyntaxandmorphology.

6. Establishahomeprogram.

SixStepsofthe 3• Shapingisamethodoftrainingabehaviorbywhichsuccessiveapproximationstowardatargetbehaviorarereinforced(PsychologyEncyclopedia).

• Understandingthebasicsofshaping,wecannarrowdownthebehaviorofspeechintocomponentparts(simplifythebehaviorormotorplan)andbuilditbackupbyusingcues,fadingcues,andimplementingreinforcementstrategically.

Shaping(B.F.Skinner)TeachingStrategy

Wecanimplementnaturalphonologicalprocesses tohelpchildrensimplifymotorplanswithbestapproximations…

Aphonologicalprocessisdefinedasasimplifyingdevice.Itisthewaythatadultphonologyissimplified,eitherlinguisticallyormotorically,basedontheprincipaloftheleastphysiologicaleffort.(Weiner,1979)

HowDoWeSimplifytheMotorPlansofWords?

AsSLPswecansimplifywordsfortemporaryfunctionallanguagebyteachingnaturalphonologicalprocesses

• Childrenwhostruggletospeakmaynotfollownaturalphonologicalprocessestosimplifytheirownspeakingattempts.

• Achildmaysimplifythemotorplanofawordmuchlowerthantheirmotoriccapability.

• Ifonlyacceptingthechild’s approximation,theywon’tprogresstowardtargetwords.

• ExposuretogoodspeechandlanguagerolemodelsisnotenoughtohelpthechildwithCAStosucceed.

• Speechmustbepracticedtobemastered.(Strand,2005;Maas,2008)

TheSLPcanimplementphonologicalprocessesasamethodofsimplifyingthemotorplanofwordsonamotorbasisclosertotheadultformofthewordgainingcloserapproximationsjustshortoffailuretosuccessfullyimitate.

ShapingWordApproximationsClinicalImplications

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Eachwordtaughtcanbesimplifiedbyreducingclusters,deletingfinalconsonants,voicingdevoicedconsonants...(naturalphonologicalprocessesemployedabovethelevelofthechild’sbestapproximationconsideringstimulability andcoarticulation).Wecancontinuetoassistthechildrentowardtheadultformofthewordasweprogressintherapy.

ShapingWordApproximationsClinicalImplications Theultimategoalistheabilityto

producewordsperfectly.

Teachingsuccessiveapproximationsofwordsisonly implementedwhenthechildisnotstimulable toaccuratelyproduceconsonants,vowels,orsyllableswithinwordsthatareimportanttothechild’scommunication.

SuccessiveapproximationsarerootedinthebehavioralprocessofSHAPING,originalprinciplesofB.F.Skinnerfromthe50’sand60’s(Skinner,1957).

TeachingSuccessiveApproximationstoSimplifytheMotorPlansofWords

• Whenchildrenareunabletoaccuratelyproduceasign,weoftenteachthemanapproximationasatemporarycommunication.Thisshouldholdtrueforspeechaswell.

• ThinkabouthowANYmotorskillistaught,suchashowtoplaytennisorshootabasket.Smallstepsarepracticeduntiltheycanbecoordinatedintotheentireskill.

• Thechildislikelycapableofabetterorcloserapproximationofawordthantheirownsimplification.

WhyTeachApproximations?(Ratherthantosimplyacceptthechild’sattempt)

• Approximationsgivethechildtheopportunitytouseawordtheywouldotherwisemaynothaveattempted.

• Thechildmaynotbestimulablefortheaccuracyofavowel,consonant,orsyllable,nomatterwhattechniqueswehaveimplement-ed.Wethereforecannotaffordtowaituntilthechildisstimulableforproductionofadifficultphonemetothenworkonwordsthatcontainthem,especiallyforhighlypreferreditemandactivityvocabulary.

Wordapproximationsaretemporaryandfunctional.Asthechildprogressesthroughtherapy,lesserapproximations(motorplans)arereplacedwithhigherapproximationsandultimatelyperfectionofwords.

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Anywordcanbebrokendownintoalevelthatachildcanimitate

Nancy = complextwo-syllableword

Nan-tee = stoppingthe/s/

Nan-dee = stoppingthe/s/(andvoicing)Nae-nee = repetitiveconsonantswith

vowelchange

Nae-nae = reduplication

Nah-nah = vowelneutralization

Nae = syllabicreduction

spaghettiss-puh-geh-ti(segmentingsyllables)

puh-geh-tee(blendreduction)

puh-deh-tee(fronting)

buh-deh-dee(voicing)

__deh-dee(syllabicreduction)

Wecanuseourknowledgeofphonologicalprocessestohelpchildrenwithapraxiaofspeechsimplifywordsintobestapproximations:

Finalconsonantdeletion bafor ballInitialconsonantdeletion ine for mineMaynotbeanaturalprocessbutstillmayservetobethebestapproximation

Medialconsonantdeletion buh-ee for bunny

Clusterreduction top for stop

Reduplication wawa for water

Deaffrication ticken for chickenVowelneutralization nem for name

Stopping tum for thumb

Devoicing bik for big

Fronting tootie for cookie

Voicing doo for too

*Donotteachbacking,asitisnotanaturalprocess.

Example:

water = complexbisyllabicwa-tuh = simplebisyllabic

wa-duh = voicingandvowelneutralization

wa-wa = reduplication

wa = singlesyllable(CV)

oo-awoo-aw = simplifythemovementwithinadiphthong

Teachingwordapproximationsorsimplifyingthemotorplanhelpschildrenwhostruggletospeaktopracticefirstwordswithoutfailure.Thegoalistocontinuouslymoveapproximationstoward perfection.

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Compensatoryplacements(simplifications)forisolatedconsonantsofwhichtheyarenotstimulable

• /t,d,n,l/dentalizetheseconsonants(tonguebetweenteeth)asamoregross-motorandvisibleproduction

• /p,t,k,s/orothervoicelessconsonantsfollowedbyvowels,allowerroneousvoicing/t/=/d//p/=/b//k/=/g//s/=/z/etc.

• /k,g/(initialandmedial)replacewith/t,d/frontingcut=tut

• /l/(initialandmedial)replacewith/w/or/j/look=wook

• /l/(final)replacewith/ou/asinbubbo/bubble

/� r/(final)replacewith/�/asinwatuh/water (vocalization)/S/replacewith/s/ shoe = soo (deaffrication)/tS/replacewith/t/ chair = tair (deaffrication)/dZ/replacewith/d/ jump = dump (deaffrication)/s/replacewith/t/or/d/ soup = toup (stopping)/z/replacewith/d/or/s/ zoo = doo (stopping)

= soo/f/replacewith/p/ fun = pun (labialization)/v/replacewith/b/ very = bery (labialization)

Oncethechildisstimulable foreachvowelandconsonant,extinguish thecompensatoryplacementandreplacewiththeaccurate phonemes.

• Segmentawayfinalconsonantsifinfluencinganerrorontheinitialconsonant.Thisshouldbedonewithoutavocalbreak,ifpossible.Prolongthevowelorusemelodytoavoidthevocalbreak.

• Avoidtheadditionofaschwa vowel,postfinalconsonant.

• Afteremphasizingsyllablestocorrecterrors(makingthemlouder),ensurethatappropriatestresspatternsarethenpracticed.(happyforacquisitiontohappyforretention)

MoreTipsinChoosingSuccessiveWordApproximationsTowardTargetVocabulary

• Continuetofocusuponconsonants,vowels,andsyllableshapesthatareinerrorbyreplacinglesserapproximationswithhigherapproximationstowardperfection.

• Implementingcues,andfadingcues,aswellaserrorlessteachingmethods(cueingbeforefailure)areparamounttotheK-SLPmethods.

EvaluationandTreatmentofChildhoodApraxiaofSpeech– availableintwoformats:• E-course(northernspeech.com)• K-SLPInstructionalDVD(kidspeech.com/dvd)

EightBehavioralTeachingStrategiesForTreatingChildhoodApraxiaOfSpeech(e-course,northernspeech.com)

LearnMore

TheApplicationoftheK-SLPforCAS&ASD

• “Apraxiaofspeechinchildrenandadolescents:Applicationsofneurosciencetodifferentialdiagnosisandintervention.”(Burns,2011)

• “Effectoftutor-modeledsuccessiveapproximationsversustutor-modeledadultformstoimprovetopographyoftacts.”(Eldridge,Kasper&Goodwin,2006)

• “EfficacyoftheKaufmanApproachinIncreasingSpeechOutputwithaLow-VerbalChildwithAutismSpectrumDisorder.”(Holbrook&Pelayo,2013)

• “Improvingthespeechproductionofchildrenwithautism.”(Sweeney-Kerwin,Carbone,etal,2006)

• “Improvingvocalverbalbehaviorviatutor-modeledsuccessiveapproximations.”(Kasper&Goodwin,2003)

Evidence-BasedPractice

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TheApplicationoftheK-SLPforCAS&ASD

• “Increasingthevocalresponsesofchildrenwithautismanddevelopmentaldisabilitiesusingmanualsignmandtrainingandpromptdelay.”(Carboneetal,2010)

• “IntensiveCASsummerprogram:Boostorbust?”(Nancarrow,Kaufman,&Ficker,2013)

• “Shapingwordapproximationsforspeechintelligibility:Effectonlanguage.”(Nancarrow,Kaufman,&Burns,2009)

• “Treatingchildhoodapraxiaofspeech:EvaluatingtheKaufmanSpeechtoLanguageProtocol.”(Gomez,etal,2016)

Evidence-BasedPractice KaufmanSpeechtoLanguageProtocolTreatmentKitsforChildren:BasicLevel(kit1)andAdvanceLevel(kit2)

• TheK-SLPkitsprovideuswithstimuluspictureswhicharepracticedthroughsuccessiveapproximationstowardperfecttargetvocabulary.

• Kit1followsthesimplesyllableshapeswiththeearliestandeasiestconsonant-vowelcombinations.Itincludes/m,b,p,t,d,n,h,w/withvowelstoformsimplesyllableshapeswhichconstitutewholewords.

• Kit2helpswithmorecomplexconsonantandvowelcombinations andtoworkmorespecificallyonphonemesynthesis(consonantsthatareproducedaccuratelyinisolationthroughreplacedordeletedinconnectedspeech).

Thebacksofthecardsareonlysuggestions.Therearemanywaystosimplifywords,dependinguponthechild’sconsonantsandvowels.TheseshouldbepracticedwiththeguidanceofanSLP.

ballba-llbaw

wateroo-aterwa-tuhwawaaw-tuh

wa

• TheK-SLPkitsandSigntoTalkpicturesarejustone easywaytoprovidestimulusitemsrapidlyforpractice!

• Yes!Objectsandnaturalenvironmenttrainingareultimatelyhowtopracticeandretainfunctionalskills.

• But,picturesareinitiallymoreeasilyaccessibleandallowustochoosestimulusitemsefficiently.

AbouttheUseoftheK-SLPKitPictures… • Inadditiontotheuseofpicturesinitially,thereisalwaystheelementofplay,andthewordsassociatedwiththereinforcingtoysandactivities!

• TheapproximationsonthebacksofK-SLPkitsareonlymeanttobesuggestions andfollowtypicalphonologicaldevelopment.

• Approximationsaredeterminedonthebasisofwhatvowelsandconsonantsarewithinachild’srepertoire.

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• Theyaresimplifications ofthemotorplansofwordsorcompensatoryplacementsfordifficultphonemes.

• Ifyouareonlyusingthekitpicturesduringasession,youarenot implementingtheK-SLPthewayitisintended!

• ParentsandcaregiversshouldnotbeusingkitpicturesforhomepracticeunlesstheyareadvisedbytheirSLPastobestapproximationsandcuesforthatparticularchild,and thatthepicturesarepairedwithahighlypreferredtoyoractivity!

• TheK-SLPkitpicturesarejustoneofthefivelistsofsinglewordstopractice.

• Simultaneously,alongwithKit1syllableshapes,othersinglewordsarefocusedupon.

1. Simplesyllableshapes2. Simplecommonnouns3. Simplemands(requestingwords)4. Favorites5. High-frequencywords

GettingStarted:Single-WordLists

Syllableshapesforspeech-motorcoordination/planning(Kit1)CVCV,CV,VCV,CV1CV2,C1V1C2V2,etc.Forthosewithalimitedvowelandconsonantrepertoire.Makealistofthevowelsandconsonantsatthetopofyourpage.Pullthemdownintosimplewords.Havevisualreferencesofthewords.

List1:SyllableShapesPracticeWordsIftheyonlyhaveah,uh,eh,m,b,t,n,wecanestablishwordssuchas:mama

baba

nana=banana

mop

knot

knob

ten

ton

net

on

Exampleofachild’slimitedrepertoire:

Commonnounsofdifferentcategoriesthatlendthemselvestotheabilitytothennametheirfunction.

bubbles(blow) apple(eat)water(drink) ball(throw,kick,bounce)shoes(puton,wear) bike(ride)

List2:SimpleCommonNouns

Functionalwordswhichservetomanipulatetheenvironment.Thesecanbepairedwithagesture.Theyareoftenreferredtoas“powerwords.”

openonoffinouteat

updownyesnodon’tcatch

herethere/dehthis/disthat/datgodraw

comemamadadawatchlookread

List3:FunctionalMandingWords

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Veryoften,thefirstwordsorsignsSLPsandparentstendtoteachare:• more• want• please• help• (all)done• again

Althoughtheseareinitially effective,theybegintolosetheirpower.

Wordsthatbecomelesseffectivesingle-wordmands(requests)ifoverdone

• more

• want

• please

• help• alldone

• again

Unless theyareapivotwordinatwo-wordphrase.Why?

**Oncethesewordsaretaught,theremaybelessmotivationtolearnadditionalvocabulary

***Thechildmayonlylearnthatwhenusingthesesinglewords,goodthingswillprobablyhappen

Listoffavoritefoods,drinks,toys,activities,places,peopleandpetsnames,andfavoritecharacters.

Ifcolors,letters,ornumbersareofhighinterest,addthemtothefavoriteslist.

Thisiswheresimplificationofwordsismostnecessary

List4:FavoritesforMandingWords

Thesearewordsthatareoftensaidbutdon’tfittheothercategories,suchas:

please get byethankyou have awesomesee hi wow

Descriptivewordssuchas:colors,numbers,sizeandshape

Smalllinkingwordssuchasarticlesorauxiliaryverbssuchas:

a,an,the,is,to,are,was

List5:High-FrequencyWords

ListenerResponding(LR)=ReceptiveLanguageShowmeanapple.Showmesomethingweeat.Showmethestemoftheapple.Showmeafruit.

Echoic=VocalimitationSayapple.

Tact=LabelNamethis:apple.

TeachSingleWordsAcrossAllOperants Mand=RequestSayingthewordtogainaccesstoit.

Intraverbal=Fill-ins,answeringquestionsSomethingweeatisan____.Whatisthefruitthatgrowsontrees?

LiteracyWhichwordsaysapple?(pointresponse)Whatdoesthiswordsay?(apple)

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TreatmentTipsforEstablishingFirstWordsVocabulary

a. Gettheconsonantvowelpatternsthechildhasspontaneously,uponimitation.

b. Maketheconsonantsorvowelsmoregross-motorandvisible byexaggeratingthem–dentalizing/t,d,n.,l/orgutteral,openmouthed/k/

c. UsethepicturesinKit1forestablishingeasysyllableshapegesturesandforbestwordapproximationstothenbecomeavisualreferentforeventualspontaneousnaming.

d. Useconsonantsand/orvowelsthatarealreadyinthechild’srepertoire toformearlyvocabulary.

e. Reduplication isanearlyprocessandalsodoesnotincludefinalconsonants.Ifthechildonlyproducesasinglesyllable,bombardwithmorethantwo,andtheymightproducetwo:

mama dada papamoomoo baabaa hoohoo

booboo byebye wawa

nono

f. Finalconsonantsaredifficult.Choosewordsthatdonothavefinalconsonants:

(CVpatternsfromKit1):

me hi bye dough

two bee tea pea

no new now

CVCV,VCV,CV1CV2 andC1V1C2V2 alsodonothavefinalconsonants.Wecanachieveagreatdealofprogressbeforeevenmovingtowardfinalconsonantinclusion.

g. Initialconsonantsmaybedifficult,sochoosewordswithoutthem:

(VCofKit1):

up on in outoat eat ouch arm

h. Assimilation isaneasysimplificationofmanyCVCortwo-syllablewordswithbilabialtobilabialortipalveolartotipalveolar,sochoosewordslike:

pop mom bib dadpup toot mop mapboom mob tin tanknot dot den teddypuppy peppy dirty nuttywhoa wow

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i. Itiseasiertovoiceintheinitialandmedialpositionsandtodevoiceinthefinalposition.Sochoosewordsthatstartwith/b,d,g/ andendwith/p,t,k/ (wheninKit1)

j. Tense vowels and diphthongs are difficultespecially if the child cannot produce /i/ as ineat or /u/ as in boo. We can neutralize thesevowels in a word to help the child produce aword approximation.

Tensevowels: Canbereplacedwith:/u/ asinboo /U/ asinbook/i/ asineat /I/ asinbit

Diphthongs: Canbereplacedwith:/oU/ asinoat /Ã/ asinnut/aI/ asinhigh /A/ asinhot/eI/ asinday /E/ asinbet/�I/ asinboy /�/ asinbought/j/ asinyesand /i/ plusnextvowelinword/w/ asinwant /u/ plusnextvowelinword

k. Considerco-articulation

/t,d/co-articulatebestwith/i/asinteaordeep.

/k,g/co-articulatebestwithneutralvowelssuchas/Ã,«/asincup,come,gum,andgutor/A/asincob,cot,orgob.

/m,p,b/co-articulatebestwith/Ã,«/ or/A/

l. Voiced,nasalcontinuants maybetheeasiestinitialconsonantstotargetastheycanbeprolongedbeforethevowel.

/m/

/n/

m. Tohelpwithinitialconsonantinclusion,keeptheinitialconsonantpairedwiththevowel,prolongthevowelandsegmentawaythefinalconsonantbyjustalittlebit.

ifboot=doot,tryboo-t

n. Ifboththeinitialandfinalconsonantarevoicelessconsonantssuchas/p,t,k/, practicethemwithoutthevowelinthemiddle.

Baeden:FirstWords

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Baeden:Progress(age2.9)

Hereisayoungchild(age2years,3months)whohascharacteristicsofCASbutnoformaldiagnosis.

ThegoalofstartingtheK-SLPistogainimitationofvowels,consonants,orsyllableshapes,andmakeitfunwhilecontinuingtoevaluateforCAS.

*Asyoucansee,nopicturesarenecessary.

Video:Knox’sFirstWords

Knox:FirstWords Hannah:Favorites

1. Imitationpluscues(auditory,visual,andtactilecuesifnecessary)

2. Imitationonlywithminimalcues(visualonly)

3. Spontaneouswithminimalcues(visualonly,suchasoralposturalorgestural)

4. Spontaneous

FourLevelsofChartingSyllableShapeGoals

Example:Thechildwillbeabletoproducesimplebisyllabicsinsuchwordsashappy,bunny,tuna,with(90%)accuracy.

Subgoals:a. Uponimitationwithcuesb. Uponimitationwithminimalcues(visualonly)c. Spontaneouslywithminimalcues(visualonly)d. Spontaneously

SettingIndividualEducationPlanning(IEP)Goals

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James:FirstWords(age2.10)

James:SimpleBisyllabics(age3.5) James:GroupScripting

James:ExpressiveLanguage(age3.8) James:Progress(age5.3)

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James:Progress(age8) James:Progress(age11)

4• Errorlessteaching(orerrorlesslearning)isamethodofcueingbeforefailure.

• Errorlessteachingisatechniquethathelpschildrentoemitsuccessfulresponsesonagivengoal.Thereisanimmediatepromptorcuethatpreventsthechildfromemittingamistakeorerror,andthushelpsthemtopracticecorrectresponsesratherthanerrors.

• Childrenwillbemoreinclinedtocooperatewitherrorlessteaching.

ErrorlessTeaching/LearningTeachingStrategy

Whileestablishinga“core”vocabulary,cueswillbenecessarytoremindthechildofanewmotorsequenceforeachword(picture).Useasmanycuesasnecessaryforthechildtoreachhis/herbestwordapproximation(orwholeword),thenreduceeachcuesystematicallyuntilthechildcannamethepicturesspontaneouslyormandfortheirfavorites,usingtheirbestwordapproximationorwholetargetword.

1. Explanationcues“biteyourlipandblow”(for/f/)“openyourmouth”(for/k/ and/g/)

5 ImplementCuesTeachingStrategy

2.Visual/tactilephonetichandcuesforVOWELS(onoraroundtheclinician’sownmouth)

Visual/tactilephonetichandcuesforVOWELS(onoraroundtheclinician’sownmouth)

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Visual/tactilephonetichandcuesforSIMPLECONSONANTS(onoraroundtheclinician’sownmouth)

3.Visual/tactilephonetichandcuesforSIMPLECONSONANTS(onoraroundtheclinician’sownmouth)

For/k/:Placeyourthumbunderneathyourchinandmakethemotionofpushingup(asinpushingupunderthetongue)withanopenmouthposition.

For/g/:Cupyourhandjustunderyourchinaroundtheneck.

For/S/:Placeyourindexfingeracrossthelipsverticallytomakethe“bequiet”signal(shhhh)orpinchthelateralportionofthelipstogether(forcingthelipstopucker).

For /tS/:Placethethumb,forefinger,andmiddlefingerabovetheupperlip.

For/dZ/:Placethethumb,middlefinger,andforefingerbelowthelowerlip.

For/s/:Putteethtogetherandshowthemwithopenedlipswhilemakingtheletter/s/intheair.

Forvoicing:Placeyourhandonyourthroat(asin“feeling”thevibrationofthevocalfolds).

Youcanalwayscreateyourownhandsignalsaslongastheyareconsistentforthechild.

(Carahaly,Speech-EZ)

4. ConcurrentcuesSaythewordtogetherwiththechild.

5. OralposturalcuesPlacingyourownarticulatorsvisiblyfortheinitial,medial,orfinalconsonantwithoutvoicing.

6. FirstconsonantorsyllablecuesSay,whisper,ororalposturethefirstconsonantorsyllableofawordorsubsequentwordsinaphrasesentence.

7. Contextualcues“Fillins”tosongs,books,andrhymes.

Fillintheblank:“Idrivethe_______.”“Thewheelsonthe________.”“Twinkletwinkle,little________.”

8. TouchcuesPhysicallytouchingyourbodyorthechild’sbodyforsyllabicemphasis(kneetoknee,handtohand,etc.)

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9. Alternatenamingforverbalmotormemory(breakingperseveration)Using2newwordapproximationsandhavingthechildnamethem,alternatingbetweenoneandanother.Often,thewordsmaybesimilar,andtriggersperseveration.Alternatingnamingbetweenthemwithcuesmayhelp,i.e.butter andbunny.

10. Pivotsyllables

ny:bunny,money,honey,Barney,Winnie,Ernie,beanie

ter:water,batter,meter,matter,Peter,butter

dle=/do/:puddle,needle,noodle,poodle,beetle

ble:bubble,marble,table,hobble,pebble

dy:muddy,body,Daddy,handy,candy,Heidi,Paddy

ty:potty,party,beauty,nutty,putty,Betty

*ty canbepronounceddy

11. Signlanguage/gesturalcuesUsesignsoruniversalgestures(Rosenbek,1984)SigntoTalkisawaytobridgesignlanguagetovocalcommunication(Kasper&Kaufman,2009)

12. WrittencuesHighlightingerrorssochildcanreadcues.

13. Answer-firstcuesGivetheanswerfirst.“Lookatherpainting.Whatisshedoing?”

14. DeletionofvowelinmonosyllabicwordsMovingfromtheinitialconsonantdirectlytothefinalconsonantwithoutthevowel,thenaddingthevowelbackin.

15. Backwardchainingontwoandthree-syllablewordsor“chunking”syllablesImitatingthelastvowelorconsonant-vowelofaword,andmovingbackwardorforwardlittlebylittle.

cookie bananaee nanakee ba-nanauh-keecookie

16. PictoralcuesRealpicturesorpictureswhichrepresentconsonants,i.e.clock =t-t-tEasyDoesItForApraxia(Strode&Chamberlain,1994)

17. IntensityPresentingthetarget(errored)syllablelouderinintensitythantheothersyllable.

18. MelodyUsingpitchvariationora“singsong”qualitytothestimulustargetword.MelodicIntonationTherapy(Sparks&Helm,1978)

19.AuditorycontrastcuesExample:pottyChildsays,teeteeClinicianshouldaskthechildtoproducetheirerroragainonimitation:Say,“teetee.”Nowtellthechildtosaypottywhileemphasizingthefirstsyllablelouderandwithadifferentpitchtodrawchild’sattentiontothesyllableinerror.

20.AuditorybombardmentcuesSaythesyllableinerrorthreetimes

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21. WhispercuesWhisperthewordwhilethechildisattemptingit.

22. Automatic/familiarcontextasabridge(usingacontextalreadyinthechild’srepertoire)Ifthechildcannotsaytheworddown,havehimsay,dada (orawordthatstartswith/d/thatiseasilyintheirrepertoire)thenhavehimsay,down.

23. Phonicscues(sounds/letterassociation)ShowthealphabetletterofwhichthechildhasbeentaughttheassociatedphonicsExample:ShowtheletterSandthechildknowstosay,sss.

24. VisualhandcuesCanbeimplementedforarticlesandauxiliaryverbs.Examples:a,the,to,is

25. BreakingupdiphthongsintocomponentpartsExamples: bikewouldbebah-eek

namewouldbeneh-eemhomewouldbeho-oomhousewouldbeha-ooseboywouldbebaw-ee

(Avoidmakingavocalbreakbykeepingvoicingongoing)

26. TalkTools™(Rosenfeld-Johnson,TalkTools.com)

27. PROMPTsystem(Hayden)

28. Speech-EZ(Carahaly)

29. EasyDoesItforApraxiaandMotorPlanning(Strode&Chamberlain)

• Cuesareessentialforinitialsupport,but…THEYNEEDTOBEFADED.

• Theverylastutteranceachievedshouldbethechild’sbestapproximationorwholewordproducedwiththemostminimalcuesnecessary,ideallywithnocuesatall…spontaneousproductions!Andtheyshouldberepeatedafewtimesaswell.

FadingCues

1. Concurrent:Saythewholewordorphrasewiththechild.

2. Whisper:Whisperthewholewordorphrasewiththechild.

3. Provideoralposturalcueswithgestures.

4. Providegesturesonly.

5. Say,“useyourwords.”

ExamplesofFadingCues Emma:FirstWords(age4)

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Emma:FadingOutMelodyforNamingSkills

Emma:Summary

1. Emmawasseatedatthetableforstructuralnaming.

2. ShethencontinuedinourABAprogramtolearnmorerequestinginthenaturalenvironment(andreceptivelanguageaswell)

3. Result:HandingabooktoDadandrequesting,readbook.

Group:ScriptingThroughMusic

Theincredibleprogressyouseeisduetotheteameffortbetweenmyselfandeachchild’sSLPs,parents,familymembers,andcaregivers…aswellasthechild’shardwork!

TreatmentisaCollaborativeEffort!

Olivia:TheK-SLPApproach(age6) Olivia:Progress(age8)

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Jason:Bisyllabic&ExpressiveLanguage

AsdefinedbyAmyMeredith,PhD.CCC-SLP(apraxia-kids.org)

“Prosodyreferstointonation,stresspattern,loudnessvariations,pausing,andrhythm.Weexpressprosodymainlybyvaryingpitch,loudness,andduration.Wealsomayusegreaterarticulatoryforcetoemphasizeawordorphrase…”

• IntheK-SLPandanyCAStherapy,secondsyllablesorfinalsoundsoftenneedtobeemphasized.

Prosody

• InJason’scase,hewasmakingerrorsonsecondsyllables.

• Oncehewasabletoproducethesimplebisyllabicssuchas,muddy,table,happy, itwouldbeimportanttothenchangetheemphasistothefirstsyllablewhereitbelongs.

• Sooncehecouldsaytummy,Ishouldhavegonebackandhadhimproducethosewordswiththepropersyllablestress,tummy

• Asyoucanseeonhisprogressvideo,hisprosodyissuesarereduced,thoughcouldbeimproved.

Jason:Syntax&Morphology/Progress

Jordan:DownSyndrome(age7.4) 6

• Howreinforcementisprovidedalsofollowstheprinciplesofmotorlearning(Skinner,1957;Cooper,Heron&Heward,2007;Maas2008)

• Havethechild’shighlypreferredtoysandactivitiesavailableandreadytouse.

• Thesemightincludeless-ordinaryitemstogather(surgicalgloves,eyeglasses,phones,stimulatingitems).

DifferentialReinforcementAndErrorCorrection

TeachingStrategy

DifferentialReinforcement

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• Thechild’shighlypreferredtoysandactivitiesmightincludeaneaselforpainting,playdough,trampoline,spraybottles,swing,slime,shavingcream,tobeusedforreinforcement.

• Thesemightalsoincludefoods(suppliedbyparentsduetodietsandallergies)

• Praisemaybeallthechildneeds,butagain,let’snotunderestimatethepoweroftangiblereinforcement!

• Foryoungchildren,feedbackmaybeabouthowmuchorhowlittlereinforcementisoffered.

• Forexample,smalleramountsoffoodforsmallerattemptsatthetask,largerforcloserattemptsorforgainingthetargetinfull.

• Forolderchildren,feedbackwouldbemoreexplanationastowhatwaspositiveornegativeregardingtheirattempt,andhowtoimproveuponthedesiredtargetresponse.

• Childmakesanerror(noreinforcement)

• Providecuesandsupportforsuccessfulutterance(giveasmallamountofreinforcementforthatutterance)

• Askagain,withfadedcuesthatwilllikelyresultinthedesiredutterance(givemorereinforcement)

• Gaintheutteranceoneortwomoretimes(givefullreinforcement)

Makethereinforcementreflectthelevelofindependence

ErrorCorrection Josie:FirstWords&UnusualReinforcers(age4)

Josie:Progress(age7)

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Movingintowordcombinationstovaryinwithspeechtasksandpreparingforfunctionalpractice.

CombiningWords • CombiningwordsforfunctionalexpressivelanguageisanothergoaloftheK-SLP.Expressivelanguagetaskscanbemixedinwithspeech-motortasks.

• Helpthechildtocombinewordsthroughpivotwordsandphrases,aswellastelegraphiclanguagestructures,toincludescriptingfunctionallanguage.

• Moveaheadonexpressivelanguage(combiningwords),andbackuponspeech-motor(clarity)

Oncethechildhassomeconsistentwordapproximations,addwordsforatwo-wordphrase,suchaspivotwords(wordswhichremainconstant):my______open______help______want______no______on______tie______

move______more______hi______bye______red______big______hold______

draw/paint______tickle______push______take______wash______don’t______eat_______

*Addaperson’snamebeforeorafterthephrasetoengagethem.Mommyopen.

PivotWords

Iwant__________.

Ineed__________.

Iwantto__________.

Can(may)Ihave______?

Letme__________.

Putaway__________.

Puton__________.

Takeoff__________.

Pickup__________.

Watchme__________.

Drawa_________.

Ticklemy_________.

Come________withme.

CanIhavea_________?

Whereisthe_________?

ScriptFunctionalLanguagewithThree-WordPivotPhrases(ormore)

Sam:PivotPhrases

*withNicoleDevens,CarruthCenterHouston,TX

Sam:Progress

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Namingfunctionofobjects(S-V-O)Foreachconsistentwordapproximationorwholeword,ask…“whatdoyoudowitha…ball?”Helpthechildtorespond“Ithrowball.”Thismayevenbe“/A//to//b�/,”eachwordbeinganapproximation.

*Forsomechildrenwithautismspectrumdisorderswewouldnotworkonnamingfunctionbecauseitwouldnotnecessarilybeabridgetotheuseofthisstructure.

TelegraphicNamingofFunction&Action Hannah:S-V-ONamingFunction

Namingaction(S-V-O)

Presentanactionverbpictureandaskthechild“whatistheboydoing?”Patterntheresponse“boyeatapple.”Thismayhavetobe“/b�/ /i/ /Apo/,”eachwordbeinganapproximation.

*Age-appropriatesyntaxandmorphologywillbebuilt-inlater(pronouns,functionwords).

TelegraphicNamingofFunction&Action Kai:S-V-OAction

Braden:S-V-OPuzzle(age4.9) Alexine:RescriptingPivotPhrases(age3)

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Alexine:Progress(age10)

“Girlpaintwater” “Boycutpaper”

K&KSigntoTalk– northernspeech.com

Presentasimple3-5picturesequencestory.AssistthechildwithanS-V-Oresponseforeach:

“Paddywakeup” “Paddygopotty”“Paddywashhands” “Paddybrushteeth”“Paddyputonclothes” “Paddyeatfood”

• Again,eachwordoftheS-V-Opatternmaystillhavetobeanapproximation.

• Moveaheadonexpressivelanguagewhilealwaysworkingonextinguishinglowerapproximationsandreplacingwithhigherapproximationstowardperfectarticulation.

SimpleSequenceStoriesforS-V-OStructures

KaufmanSpeechtoLanguageProtocolWorkoutBook

KaufmanSpeechtoLanguageProtocolWorkoutBook

Example:Thechildturnsthedoorknobandisunabletoopenthedoor.

Say: “Doyouwantmetoopenthedoor?”(usetheanswerwordswithinyourquestion)

GetbestapproximationforyesSay:“Tellmeyouwanttoopenthedoor.”Helpthechildtosay:“opuh do”or “Iwao-puh”or “o-puhpeez”or “o”(opendoor)(Iwantopen)(openplease)(open)*Eventuallyfadecues

ScriptingFunctionalLanguage

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Avoid askingopen-endedquestionssuchas:Whatdoyouwant?Whatdoyouwanttodo?Whathappened?Canyouuseyourwords?

HelpfulTipsforScriptingLanguage

Instead…

• Trytoanticipatewhatyourchildmightliketosayandputtheanswerin yourquestion:Doyouwanttogooutside?Tellmeyouwanttogooutside (thechildhearstheanswertwice).

• Helpthechildtoproducebestapproximationsandwordcombinationsfortheanswer.

HelpfulTipsforScriptingLanguage

Ethan:Rescripting Lizzie:SyllableShapes

Lizzie:Scripting Refinementandintegration(backuponspecificphonemesynthesis)

Begintobackuponspecificphonemesynthesis,wordinitial,medial,orfinal.Onceanewphonemeisproducedsuccessfullyinsynthesisatthewordlevel,youwillextinguishatemporaryphonemeorapproximationwiththisnewcorrectpattern.

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Jason:Syntax&Morphology/Progress Tessa:SequenceStories

Inadvanceofthegame,knowhisgoals:• Final/s,z/inplurals,auxiliaryverbs(is,was)

andpossessivepronouns(his,hers),andininitialandfinalwordpositions(house,see)

• Velartoalveolarwords(got,get)• Initial/f/(found)

Alexander:TargetingSpeech&ExpressiveLanguageGoalswiththe“What’sinYourDoghouse?”TherapyTool

Alexander:TargetingSpeech&ExpressiveLanguageGoalswiththe“What’sinYourDoghouse?”TherapyTool

Try:

• RapidMotorImitationAntecedentTraining(Tsiouri,Paul,Simmons,Lewis,2012)

• SigntoTalk(Kasper&Kaufman,2009,2012)

WhatAboutChildrenWhoAreNotYetVocalCommunicators?

• RootedintheprinciplesofABA,butextensiveapplicationswithspeech-languagepathology

• RapidMotorImitationAntecedent(Tsiouri,Paul,Simmons,Lewis,2012)

• Focusesonestablishingstrongmotorimitationskills (rapid,fluentandgeneralized)toimproveattending,respondingandbehavioralmomentumtogetchildimitatingsoundsand/orwordstorequestpreferreditems

RapidMotorImitationTraining

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Sophie:RapidMotorImitationtoVocalImitation

Sophie:VocalImitation

Sophie:MandGo

Thefollowingisabrief,summarizeddescription.SigntoTalk takesagreatdealofexpertiseandtechniqueandisbestdonewithinanABAverbalbehaviorprogramwiththeguidanceofanSLP.

ThereisafullmanualwiththeK&KSigntoTalkkits.

SigntoTalk(Kasper&Kaufman,2009,2012)

Amethodtobridgesignlanguagetovocal/verbalcommunication(especiallyinASD)

1. Followthechild’sleadanddiscovertheirhighlypreferreditemsandactivities.

2. Whilethechildisshowingmotivationfortheitemoractivity,playfullyblockthemfromobtainingit,andhelptoshapetheirhandstomakethesignforit.

3. Saythewordfortheobjectoractivitythreetimes(inanaturalvoice).

SigntoTalk(Kasper&Kaufman,2009,2012) 4. Deliverasmallquantityoftheitem(ifpossible)orallowforshortaccesstotheactivity.

5. Thismayhavetobedonemanytimesuntilyourhandsarecomingtowardthechildtohelpthemtosignandtheyproducethesignwithouthelp.

6. Wewouldthenprovidemoreoftheitemoractivity(i.e.abiggerchunkofcookieormoretimetojumponthetrampoline).

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7. Eventually,ifthechildneverattemptsthewordtheyhaveheardpairedwiththesign,stopreinforcingthesignonly– thechildmustvocalizewiththesign.

8. Shapethevocalizationtowardthewordthroughsuccessiveapproximations.

9. Ifthechilddoesnotvocalize,attemptRapidMotorImitationAntecedentTraining.

Kasper,T.&Kaufman,N.(kits2009,app2012).K&KSigntoTalk:ShapingVerbalLanguageforIndividualswithAutismandOtherDevelopmentalChallenges.Gaylord,MI:NorthernSpeechServices.

Somechildrenstruggletoproduceisolatedvowelsandconsonants.Acombinationofthefollowingmaybehelpful:

• OralPlacementTherapy(OPT)(ToincludeReneeRoyHill’sApraxiaShapes)

• Tactilecues(PROMPT)

• KaufmanSpeechtoLanguageProtocol(K-SLP)

• First,signlanguagewastaughtsohecouldrequesthighlypreferreditemsandactivities(Kasper&Kaufman,2009).

• Togainisolatedvowelsandconsonants,TalkTools™wereused.Thesearetoolsusedinsidetheoralcavitytoprovidetactile/proprioceptivecues.

üMickeyMouseearsusedfor/m/.ü Apraxiatactiletubefor/ou/asin“no”and

smalleronefor/u/asin“boot”(ReneeRoyHill)ü Bitestickswereusedfor/i/asin“eat.”

• TheseTalkTools™werethenfadedsothatthephonemeswereperformedwithnoassistance.

EstablishingFirstWordswithaMinimallyVocalChildwithASD TalkTools™for/m/and/i/

BiteSticksFadedfor/i/&TactileTubefor/oU/

EchoictoTactTransfer(ImitationtoNaming)

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PromptedMand(RequesttoReadBook)

PromptedTact(LabelingHisOwnActionWalkBaby)

Jayden:SigntoTalk Jayden:SigntoTalk

Jayden:VocalSkillProgress

• K&KSigntoTalk:ShapingVerbalLanguageforIndividualswithAutismandOtherDevelopmentalChallenges.(Kasper&Kaufman,2009,2011)

• ProgressiveandSystematicSpeechandLanguageTrainingforChildrenontheAutismSpectrum.(Kasper,2015)

• ASystematicApproachtoTeachingSpeechtoNon-VocalIndividualswithAutism(Roy-Hill&Solomon)

• RapidMotorImitationAntecedent(Tsiouri,Paul,Simmons,Lewis,2012)

MoreInformation…

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7• Understandhowtoprovidefeedbackforretentiontooccurforthosewhounderstandlanguage.

• Mixandvarytaskstoavoidactuallyteachingovergeneralization.

• Understandtheprinciplesofmotorlearning.

PracticeSchedulesTeachingStrategy

Principlesofmotorlearningteachushowtoprovidefeedbacksothat:

• Thechildprogressesrapidlyintheacquisitionstageoflearning.

• Thechildretainsthenewmotor(speech)skills.

Moreonmotorlearningprinciples:

“Demystifyingtheprinciplesofmotorlearninginspeechtherapy.”(Maas,2013- webinar)

“Principlesofmotorlearningintreatmentofmotorspeechdisorders.“(Maas,2008)

The&MotorLearningPrinciples

• Providingtimely,powerful,andstrategicreinforcementorfeedbackisimportantwhenattemptingtochangeanygivenbehavior.ThisisacoreprincipleofABA.

• Feedback involvesprovidinglearnerswithinformationabouttheirresponses.

• Reinforcement affectsthetendencytomakeaspecificresponseagain.Usereinforcementespeciallyifthechilddoesnoteasilyunderstandlanguage(highlypreferredtoysoractivities/motivators).

Itisimportanttomovefromblockedpracticetomixingandvaryingtaskstoavoidteaching overgeneralization!

• Blockedpracticeiswhenalearnerperformsasingleskillrepetitiously.

• Randompracticeisworkingonanumberofdifficultskillsincombinationwitheachother…“Soone’scognitivesystemmustadapt,rethink,andsolvetheproblemofchoosingandexecutingappropriatemotorpatterns.”(Dr.AllisonBelger,athleteandPhDclinicalpsychologist)

Afterblockedpractice,randomizethepractice:

• MixtheorderofonesectionofKitpictures(shufflethedeckJ )

• VaryinanothersectionofKitpictures(shufflethedeckstogether)

• Varyinotherexpressivelanguagetasks

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GenerallyforACQUISITION•Morefrequenttrials•Morefrequentreinforcement(mayhavetoreinforceforeachutterance)

•Keepstimulusitemsinpredictableandconsistentorder(easytargets)withsmallincrementstowarddifferenttargets•Provideasmanycues/supportsasnecessaryforsuccess.

GenerallyforRETENTION• Movetolessfrequenttrials(moretimeinbetween)

• Lessfrequentreinforcement(moreresponsesbeforereinforcement)

• Mixandvarystimulusitems(lessordered,morerandom,unpredictable,mixeasyanddifficult)

• Minimaltonocues/support

Gainingasmuchrepetitiononagoalaspossiblefollowscurrentneuroscienceonneuroplasticity.

Neuroplasticityisthebrain'samazingcapacitytochangeandadapt.Itreferstothephysiologicalchangesinthebrainthathappenastheresultofourinteractionswithourenvironment.Fromthetimethebrainbeginstodevelopinuterountilthedaywedie,theconnectionsamongthecellsinourbrainsreorganizeinresponsetoourchangingneeds.Thisdynamicprocessallowsustolearnfromandadapttodifferentexperiences.Huttenlocher(2002),Lomber&Eggermont(2006),Kadis,etal(2013),Sowell,etal(2004)

Neuroplasticity

• Repetition iskeyforCAS.

• Gain asmanyresponsesaspossibleinaplayfulwaywithstrategicreinforcementforretentionskills.Edeal,Gildersleeve-Neumann,2011Strand,2005Burns&Kaufman,2013

8• NET=NaturalEnvironmentTeaching

• Beawareoftheskillareasthathavebeenfocuseduponinstructure.

• Listsomeofthecorevocabularysinglewords,syllableshapewords,specificphonemesynthesisgoals,pivotphrases,andcues.

• Practicethesethroughplay.

NaturalEnvironmentTraining:PracticingNewSkillsintheNaturalEnvironment&CoachingParents

TeachingStrategy

Kiara:SeaWorldToy

• Personalizednotebooks/binders,iPadapps

• TheKaufmanSpeechtoLanguageProtocolWorkoutBook(canbeduplicated)

• TheK-SLPMuttFamilyPracticePuzzle

• Scriptfunctionalsingle-wordmands(requests)orpivotphrases

• Canusepictures,books,magnetics

• Andreal-lifeexperiences

HomeProgramSuggestions

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• Canuserealphotostotellastoryaboutachild’sexperiences,example:goingtothezoo.(“Pictello”iPadappworkswellforthis.)

• iPadapps(seeapraxia-kids.org)

HomeProgramSuggestions

• Startwithmakingcomments

• Askquestionswiththeanswerembedded

• Scriptorre-scriptwithcuesandfadingcues

• Slidebackandforthbetweencommenting(andbeingquiet)toquestions

• Befun,silly,andabsurd

CoachingParents&CaregiversThroughPlay

• Noteinadvance:speech&languagegoals.Makenotesandfocusonthesewithallowingothererrorsgounnoticed.

• Establishpatterns:are/not,will/won’t,do/don’t,can/can’t,does/doesn’tor,why/because

• Possessives:Sheiswearingherdress.Heiseatinghiscake.

Oncechildrenareabletofirstberesponders,thentousevocallanguagefunctionally(pivotphrases),stopaskingquestionsandsimplymakestatementsand…wait.Maybe thebunnywantstohop.Iwonderifthezebraishungry.Look,thislionisnapping.Wow,thiscatislicking thebowl!Hey,therearenohippos.Or,makeanabsurdcommentlike:Iwonderwhatwouldhappenif thedogclimbedonthetable.

*Thechildwillnowenjoyopportunitiestocreatelanguageandtochimeinspontaneously!

Jayden&Parents Whenwecananticipatewhatachildistryingtoconvey(throughtheirnon-verbalorunintelligibleattempts):

• Helpthemtosayitwiththeirbestsingle-wordapproximations,phrases,orfullsentences!

• Don’tforgettofadeyourcues,orthechildrenwillsimplywaitforeachwordandnotmoveaheadtowardspontaneousspeechandlanguageskills!

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Pivotphrasenarrativescanbedoneusingreal-lifeactivities!

• Gettingreadyforschool

• Gettingreadyforbed• Settingorclearingthetable

• Takingouttoys,playingwiththem,andputtingthemaway

• Goinggroceryshoppingandalsobackathome:takingeachitemoutofthebagandputtingaway

• Games

• Playground

• School

• Holidays

• Birthdayparties

• …andmore!

ScripttheLanguageof:

• Allfamilymemberscanplaytogether,promotingturntakingandgoodsportsmanship.

• Scriptingthelanguageofgames.

• Practicingthe/g/ingo andthe/n/inno.

• Vowelaccuracy.

• Scriptingnegatives.

Sanders&theLanguageofGames Sanders:KSPTEvaluation

Sanders:WithFamily Sanders:Progress

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CommonTherapyMistakes• Continuouslyandtirelesslyworkingonvocalimitationwhenitisunsuccessful(tryrapidmotorimitationantecedenttrainingorsignlanguageasabridge).

• Not pairingyourselfwithpleasurabletoysandactivities.

• BringingoutKitpictureswithoutpairingthemwithpleasurabletoysandactivities.

• Usingtoysandmaterialsthatarenotpreferredbythechild(buttheSLPsureenjoysthem)!

• Notprovidingpleasurablemotivatorsforchildrenwhoareusuallycompliantwithoutthem(orforolderchildren)whocouldalluseamotivator!

• Notprovidingtimelyreinforcementforthosewhomayneedamotivatoraftereachresponse.

• Havingthechildpracticerandomwordsthatarenotwithinthelistsofsyllableshapes,functionalwords,orlistoffavorites.

• Accepting thechild'sapproximationandmovingontoanotherwordwithoutattemptingtogainabetterapproximation,withcontinuouspractice.

CommonTherapyMistakes

• StickingonlywithKitpicturesandnotmovingaheadonotherpertinentvocabularylistsorfunctionalexpressivelanguage.

• Givingfullimitationandcuesandnotmovingthemastepfurther togainingthelastresponsetobeasspontaneousaspossible,withcontinuouspractice.

• Forgettingtofadecuesorscriptingeachandeverywordwithoutfadingtoinitialconsonantcues,whispers,oralposturesorgestures.

• Addingaschwa"uh"afterafinalconsonant.


• Forgettingtomodelcorrectly,butwhenhelpingthechildtorespond,gainingthebestapproximation.

• Promotingovergeneralizationduetolackofmixingorvaryingtasks.

• Notgainingenoughresponseswithinasessionforcarryovertotakeplace.

• Waiting forthechildtohaveperfectarticulationofasignificantnumberofsinglewordsbefore assistingthemtocombinetwoandthree-wordphrases.

CommonTherapyMistakes• Scriptingtoomanywords(orhighlevelsofsyntaxandmorphology)beforethechildisready.

• Segmentinginitialconsonants.Shouldkeepthempaired(glued)tothevowelifpossible.


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Andrea:Pre(age3) Andrea:Progress(age13)

Drew:Pre(age3) Drew:Progress(age4)

Drew:Progress(age10) Stephen:Pre(age3)

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Stephen:Post(age18)

PraxisRequiresPractice

Nancy’sFavoritesK-SLPKits1and2,WorkoutBook,MuttFamilyPracticePuzzle,K&KSigntoTalk,

Nancy’sFavorites• InadditiontotheK-SLPmaterials:

• Trainsetswithmanylarge,easypieces

• Windups,smallandlarge

• Push-downorpull-backtoysthatshootforward

• Largeslidewithabucketreadytocatchitems

• Means-endscausalitytoys

Nancy’sFavorites• Binofcharacters(stuffedanimalspreferred):• Winnie,Barney,Minnie,BugsBunny,Ernie(nypivotsyllables)

• SesameStreet,FindingNemo,ToyStory,Frozen,andPawPatrolcharacters

• Familycharactersofdifferentethnicgroups• Animals,oceancharacters

Nancy’sFavorites• Toyhouseholdfurnitureandplaygroundequipment(slide,swing,chairs,tables,beds,potty,cars,etc)

• Bookswithoutwords,orwithasimplesequencestory

• Musicaltoysthatonlyplayforabriefmoment• Magnetics,Colorformsorreusablestickers

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Nancy’sFavorites• Stim Toys.(Koosh balls,wandsthatspin,squishytoys,playdough,lightups,fidgets)

• Blocks

• Simpleboardgames

• DVDplayerwithremote

• Puzzlesthat“talk”

• iPad• Balltoys

• AmericanSpeech-Language-HearingAssociation.(2007).Childhoodapraxiaofspeech(positionstatement).asha.org/policy

• Barbera,M.L.,&Rasmussen,T.(2007). TheVerbalBehaviorApproach:HowtoTeachChildrenwithAutismandRelatedDisorders.London:JessicaKingsleyPublishers.

• Burns,M.&Kaufman,N.(2013).BridgingneurosciencetoclinicalskillsinCASandotherspeechsounddisorders.PresentedattheAmericanSpeech-Language-HearingConvention,ChicagoIL.

• Carahaly,Lynn.TheSpeech-EZApraxiaProgram.speech-ez.com

• Carbone,V.J.,Sweeney-Kerwin,E.J.,Attanasio,V.,Kasper,T.Increasingthevocalresponsesofchildrenwithautismanddevelopmentaldisabilitiesusingmanualsignmandtrainingandpromptdelay.JournalofAppliedBehaviorAnalysis,43, 4,705-9.

• Caspari,S.&Overby,M.(2012).Earlyphoneticandphonologicalcharacteristicsofchildhoodapraxiaofspeech.PresentedattheAmericanSpeech-Language-HearingAssociationNationalConvention,Atlanta,GA.,SanDiego,CA.

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