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Taking Advantage of All Those Teachable Moments
Speech Therapy at Home for Young Children with CAS
Angela Muis, BA
Elaine Dolgin-Lieberman, MA,CCC- SLP
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Disclosure-
Angela Muis
Apraxia Kids Canadian Ambassador
Chair of a team actively building a national resource organization for Canadian families
Speech-Language Pathologist Assistant / Communication Disorders Assistant
Private Reading Instructor
Parent of a wonderful boy with resolved apraxia
Angela does not have any financial relationships to disclose
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Disclosure-
Elaine Dolgin - Lieberman
Member of Apraxia Kids Professional Advisory Council (PAC)
Graduate of the CAS Intensive Training 2011, Recognized by Apraxia Kids for Advanced Training and Clinical Expertise in Childhood Apraxia of Speech
Professional Lecturer in the Graduate Speech and Hearing Department at Mercy College in Dobbs Ferry, NY, teaching an annual class on Childhood Apraxia of Speech.
Clinician in private practice with a primary interest in working with children with motor speech disorders.
Elaine does not have any financial relationships to disclose
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
SPEECH PRACTICE AT HOME IS BENEFICIAL
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Higher production frequency = faster target acquisition
(Edeal & Gildersleeve-Neumann 2011)
Children with CAS benefit from lots of practice
(Murray, McCabe & Ballard, 2014)
More Practice is Better
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
“The need for multiple repetitions to develop motor skills to an automatic level is well established and forms a basis for treatment of CAS. Given the number of hours per day a child spends with family versus therapist, opportunities for practice are multiplied when parents encourage speech practice outside of therapy sessions.
Extending therapy targets into the child’s home environment promotes motor learning that goes beyond acquisition of motor skills.”
- Ruth Stoeckel
Practice at home facilitates carryover and generalization
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
“Many children with childhood apraxia of speech need frequent therapy. Sometimes that’s not possible. At that point it becomes especially important that practice happen at home.”
- Edythe Strand
Practice at home is especially important
when children cannot access
appropriate speech therapy
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Home practice can be a special time for children and their caregivers
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
SPEECH PRACTICE AT HOME IS A PARTNERSHIP BETWEEN PARENT AND SLP
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
“Parents and caregivers are critical to success for children with apraxia of speech. Parents should look to their child’s SLP as a coach, tutor and guide so that the practice they encourage at home is appropriate for their child’s current ability level. ”
- Apraxia Kids
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
PARENTS ENGAGING IN
SPEECH PRACTICE AT HOME NEED
TO KNOW
●What are my child’s goals?
●What specific targets should we work on?
●How many targets should we work on?
●What activities can we do to encourage practice?
●What cueing strategies are available?
●How should I provide feedback to my child?
●What if I am trying and it’s not working?
● What should I do when my child’s speech is not understood?
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
PARENTS ENGAGING IN
SPEECH PRACTICE AT HOME NEED
TO KNOW
●Am I doing this well?
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
A LAUNCHING POINT FOR
PARENTS
“It’s important that, as a parent, you feel comfortable in helping your child with that practice.
Knowing what to listen for, knowing how to help or cue the child if they’re having some problems, having the ability to observe some of the speech pathology sessions is important and it’s really okay to ask your speech pathologist if that can happen.”
- Edythe Strand
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
AN SLP SUPPORTING
HOME PRACTICE NEEDS TO
KNOW
●What is this family’s capacity for home practice?
●What are the parents’ expectations?
●How much support does the parent need to be successful?
●What type of skill development and encouragement does this parent need to best support their child?
●Is the parent experiencing success using skills that are taught to them?
●How are things going with practice at home?
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
A LAUNCHING POINT FOR POINT FOR
SLPs
“Especially at the beginning, when they have the least experience, I find that parents benefit most when they clearly understand their role as active “agents” of their child’s learning and are provided with materials and clear models for how to engage the child in appropriate learning activities, as well as lots of support and encouragement when trying these out. Once they experience some success and gain confidence in their abilities, the need for this level of support decreases.”
- Megan Hodge
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Caregiver as the “agent” of change
It can be challenging to add the new role of being an agent of change for a child with apraxia to the role of parent.
It’s normal for parents to find that adding speech therapy and home practice to an already busy life isdifficult...
because it is.
How am I going to pull this
off?
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Parents may find that a dedicated, structured time for speech therapy at home is needed when a child is working on new skill acquisition or while the parent is getting the hang of a new skill, like cueing or providing feedback to their child.
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Schedule it!
❑ Day planner❑ Calendar ❑ Apps❑ Email to SLP❑ Fill a Jar❑ Visual schedule❑ On the fridge
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Along with structured time working on skill acquisition, parents/caregivers can layer speech practice for that skill onto activities that are already a part of daily life.
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
A naturalistic treatment environment is important for facilitating generalization and carryover of skills, and
home practice is essential for helping the child make optimal progress.”
- ASHA’s Childhood Apraxia of Speech Practice Portal
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
When parents are provided with clear and manageable home practice recommendations, children have an opportunity to practice more frequently and to extend their speech skills across a wider range of settings. This extra practice across settings can help facilitate carryover and generalization of new speech skills.”
- Margaret Fish
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
TeachableMoments
These are real-life opportunities that can happen at any time and any place or be created to help your child practice their speech targets in a natural setting.
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
What are my child’s goals?
How often should we practice?
What specific targets should we
work on?
How many targets should we work on
at one time?
What activities can I do with my child
to encourage these targets?
What therapy and cueing strategies
are available?
How should I provide feedback
to my child?
What if I am trying and it’s not working?
What should I do when my child’s
speech is not understood?
QUESTIONS TO CONSIDER
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
TOOLS AND ACTIVITIES
TOOLS that families can use to take advantage of “Teachable Moments” as they occur in real life.
Creative ACTIVITIES that families can provide that will help the child improve speech accuracy and prosody (rhythm/music of speech) in a natural setting and help them generalize their speech targets in a natural setting.
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
PUTTING TOOLS IN YOUR TOOL BOX
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
What are my child’s goals ?
Look at the Whole Child
What type of help can we provide to Improve your
child’s speech Intelligibility to allow your child to
Indicate their needs
Convey important
information
Interact socially with their peers.
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
What Are My Child’s Targets
Identify words/phrases that are important to your child, can be used for
social interaction, and occur often!
Identify syllable shapes in my child’s repertoire and increase syllable repertoire
Identify sounds in your child’s sound repertoire and increase sound repertoire
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Powerful Early Targets
CV: Go, No, Me, Hi, Bye
VC: Up, Eat
VCV: I do, I go
CVC: mine, nope, yum, yuck
CVCV: mommy, daddy, baby, gimme (give me), no more, bye ma, Go now
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
How Many Targets Should We Work On At One Time?
The more severe the apraxia, the fewer the targets – can even be one target.
The less severe the apraxia, the more targets your child can handle.
Each target should be practiced three to five times during structured activities.
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
How Often Should We Practice?
The more often you practice,
The sooner the child will learn and acquire new targets.
The more consistently your child with retain/retrieve these new targets.
The more likely your child will generalize targets words throughout a variety of settings,
The more likely your child will generalize to untaught words.
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Structured Activities and Teachable Moments
•When doing structured work, try five minutes twice a day. Consider scheduling this practice at specific set time.
•Parents can layer speech practice onto activities that are already a part of daily life.
•Teachable Moments occur ALL DAY LONG.
Take Advantage!
What Therapy and Cueing
Strategies are recommended specifically for
children with CAS
Review the Evidence – Principles of Motor Learning is a treatment that is recommended for child with impaired speech motor planning and programming (Maas, 2008).
Both DTTC (Strand, 1999, Maas, 2008, Strand 2019) and ReST (McCabe, Murray, Thomas, Bejani, and Ballard) have the strongest evidence and are based on the PML.
Add many practice amounts for a child who is less verbal and distribute these repetitions (e.g., read a book and add in the target) for a child who is becoming increasingly verbal.
Make the practice variable – vary your prosody, rate of speech, intensity.
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Cueing Strategies
Start with “Watch Me” to fire up Mirror Neurons
Provide a verbal model - give the sound a name and explain how the child should move his/her articulators. (Hammer, 2014)
Add a visual cue – Fran Santore’s Sounds in Motion or Lynn Carahaly’s Speech EZ cues
If needed, provide a tactile-kinesthetic- proprioceptive cue – Deborah Hayden’s PROMPT.Most Recent evidence (2020) supports effectiveness with severe Speech Motor Disorders, although not specifically CAS
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
REPETITION, REPETITION, REPETITION, REPETITION
Murray, McCabe & Ballard (2014) reported that studies on approaches for CAS typically involved 60 to 120 trials per session (high frequency of repetition), whereas studies on approaches for phonological disorders typically involved 10 to 30 trials per session.
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
How Should I Provide Feedback to My Child?
When a child does not produce the target correctly, blame the muscles, not the child.
The less verbal, the more direct feedback is necessary.
KP: Let your child know how to move their muscles. You closed your lips and made your popping sound when you said “up” (along with a visual cue).
KR: “That was very good!” or “That wasn’t quite right, Let’s try that again?”
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Self - Esteem
Our most important “job” is to love and support our children and increase their self-esteem by helping them be successful in their speech.
At no time should home practice or feedback be painful for your child.
Praise your child’s correct attempts, but acknowledge all their efforts. **
By taking advantage of Teachable Moments, you take away the “work” in “homework” and allow the child the opportunity to practice in the natural setting.
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
What Should I
Do When I
Don’t
Understand
my
Child’s
Speech?
How many times have you pretended to understand your child’s production?
There are times when you may not understand what your child is saying.
Honor the words that you were able to understand.
Repeat back closely as possible and say, “I heard you say…., but I am not sure what “….....” means, Can you show me, or maybe you mean...”
**
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
What if I Am Trying and It
Isn’t Working?
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Start Where Your Child Is!!
Honor all vocalizations and engage in reciprocal vocalizations.
If you child says “baba,” associate it with communication (e.g., “bye bye”).
Let the child know how the sound was made.
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Start Prosody Early
Model language with exaggerated intonation and slowed tempo.
Extend the duration of vowels on the stressed syllable and use a shorter duration on weak syllable. HAAA ppe “happy”
Use lots of intonation in your voice “More?”
Produce targets with different pitches “Let’s say it like an elephant, say it like a
mouse.”
Produce with varying intensities “Whisper, Loud, Angry, Happy”
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________
PA.
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
BE A GOOD MODEL
Use
Use a slower rate of speech.
Think “Mr. Rogers.”
Give
Give time to process,
Add pauses and
Increase the melody of your speech.
Allow
Allow time for your child to formulate their response.
Encourage
Encourage your child to look at your face as a strategy to excite “mirror neurons.”You can model “please” (CCVC) and “thank you (CVCCCV),” but don’t ask for it back!
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
SPEECH MODELS TO AVOID
● Avoid overemphasis of the final sounds of words to reduce the risk of schwa insertion.
● Avoid breaking up words unnaturally
● Avoid Using Equal Syllable Stress
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
TEACHABLE MOMENTS
ACTIVITIES
Children may not want to look at pictures when they are home! But there are many fun ways to get practice in!
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
TEACHABLE MOMENTS
❏ Play!!!!❏ Book Sharing❏ photo books / core vocabulary books.
(start with pictures of family)❏ Bathtime❏ Shopping cart – Food Shopping❏ Taking a walk❏ Kitchen – hang target words for the week❏ Car Rides❏ FaceTime with parent!!!
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Bath time
Face to Face
Captive Audience
Targets:“up”“down”“oh no”“wet,” “bubbles”
- captive audience- “up, p, up, up... Oh oh!”
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
PlaygroundPlayground
Face to face
Lots of movement to make your Targets “variable”
Targets: “Up!” “More!” “Down!”“Whee!”
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Grocery ShoppingGrocery
Shopping
Face to face
Captive audience
“In!”/ “Out!”“Yes!” / “No!”
Target words everywhere!
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Baking
Targets:“cup”“more”“yum”“my turn”“in”
Pro tip: measure out cup measures by teaspoons to increase reps!
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Pool / lake / river / pondSwimming
Targets“Go!" “In!“Go in!”“I go”
3 reps then jump in!
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
PLAY is so important!
● Cognition
● Language development
● Turn taking and imitation – allows for speech imitation
● Joint attention – allows the child to watch me and excite the mirror neurons
● Social Engagement
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Play and Target Practice
Play is fun and provides the opportunity to practice the target words/phrases in a natural setting.
Identify the target word that you are working on prior to play.
Use toys with multiple pieces to allow for numerous opportunities to practice the targets.
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Toys, based on the Westby, Symbolic Play Scale(2000)
Pre-symbolic Level I: 8 to 17 months
• Toys that a child can pull
• Hammer- Pound and Roll
• Toy Telephone
• Blocks
• Balls
• Bowling Game
• Turning knobs, levers, buttons
• Nesting Boxes
• Person in car
• Putting objects into the dump truck and then dump it out
Early Symbolic 17 to 24 months
Farm animal
Grooming kit
Doll and bathtub
Kitchen Set
Dolls
Potato Head
Fisher Price Piggy Bank
Symbolic - 2 to 3 years
Doll House
Doctor Kit
Shopping Cart and Cash register
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Toys based on the Westby, Symbolic Play Scale
Symbolic Play – 3 to 4 years
Represents observed events, i.e., events in which child was not an active participant
Firehouse and Firemen
Pirate Ship and Pirates
Castles and Knights
Police Station and Policemen
Spaceship and Astronauts
Circus
Legos
Zoo
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
For Older Preschool ChildrenREPETITIVE games
• Select games that support your child’s target word/phrase
• Consider games with short turns to allow for quick turn-over
•More turns = more opportunities to repeat your child’s speech targets
• Don’t forget Prosody! Makes the game that more exciting!
• Ask that all players repeat the speech targets
•Modify the rules to allow for success Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Games and Targets
Snail Race (colors) CV- go, two, yea VC / VCV- CVC- red, win, CVCV, yellow, hooray CVCVC+
Pop the Pip(numbers)
More, two Eat, in, out Pop, pig, yum, one, big
Purple, cookie, burger, belly
More cookies
Pop Up Pirate(colors)
Me, Up, oh no! Red, pop , yikes Yellow, Pirate,
Don’t Break the Ice (lots of repetition when putting the ice cubes in)
Ice, icy Hit, wait, hammer Fall down
Honey Bee Tree Bee, two, four In, out, oh no Down, five, buzz
Greedy Gorilla(food)
In, I do Yum, yuck, rice, milk, juice
Yummy, yucky, water
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
FAVORITE GAMES AND TOYS!
❏ Domino Train❏ Funny Bunny❏ Pengoloo❏ Dough Smash❏ Bingo Dabbers❏ Uh Oh Hippo❏ Pop-Up Pirate
❑ Seek and Find with a Flashlight
❑ World’s Smallest Hot Wheels
❑ Baa Baa Bubbles❑ I Spy -Dig In❑ Melissa & Doug
Puppy School
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
“The impaired development of speech has disrupted the development of reading, spelling and writing skills (e.g. learning letter-sound relationships for deciphering new words.” -Murray and McCabe (2014)
Focus on phonological awareness as early as two!
❏ Sound-letter association - YouTube Phonics Song
❏ Rhyming Books
Read two Books Every Evening
❏ One book for the target sound and ❏ One book for prosody (Dave Hammer)
CAS and Language /
Literacy
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Storytime
“Hug” by Jez Alborough
“Beep Beep” & “Choo Choo” by Petr Horácek
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Repetitive Books
Book Title, Author Target Word
More Spaghetti I Say, Rita Goldman Gellman
CV - More, CVCV - Minnie
Moo!, David LaRochelle CV- MOO! With Varying Prosody
If You Give a Mouse a Cookie, Laura Joffe Numeroff
CVC – need, want
Brown Bear, Brown Bear, Eric Carle CV – See, Me, VCCV – at me
The Very Hungry Caterpillar, Eric Carle VC- Eat, Ate
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Apraxia Specific Apps Speech Stickers
Simply Speech Therapy for Apraxia (NACD)• Syllable Words• Words
Apraxia Picture Cards (Linguisystems) – Lite and full version
Apps Listed on Apraxia-Kids.org
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Apps to Practice Target Words
Toca Boca Doctor
Peek – A- Boo Barn
My Play Home
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
The Importance of Parent Involvement
Parents are the experts who know what works for your child.
SLP’s are the experts who know how to teach communication.
Together we can work to maximize your child’s communication.
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Where to Access
Support
SLP
Your SLP can be your BIGGEST ally!
Education
Apraxia Kids webinars
National Conference sessions
Articles on the Apraxia Kids Website
Books
Family & Friends
spouse
siblings
grandparents
friends
anyone you trust who wants to help
You can find home practice specific education in the resources below.
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP
Thank you!!!
Angela Muis and Elaine Dolgin Lieberman, MA,CCC-SLP