The Do’s and Don’ts of CAS Therapy

“The Do’s and Don’ts of Therapy for Childhood Apraxia of Speech,” Presented by: Sue Caspari, MA, CCC‐SLP, January 26, 2016, Sponsored by: CASANA

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The Do’s and Don’ts of CAS TherapySUE CASPARI, MA, CCC/SLP

JANUARY 26, 2016

Sue Caspari, MA, CCC-SLP, works in private practice in the Philadelphia, PA area.

Disclosure: Ms. Caspari is a member of the Professional Advisory Board of theChildhood Apraxia of Speech Association of North America. She receives nocompensation as a member of CASANA’s Professional Advisory Board, but willreceive compensation for this presentation. There are no other relevantfinancial or non-financial relationships to disclose.

ASHA DISCLOSURE INFORMATION

Overview of Session

Motor AspectsSpeech is a complex motor task

CAS is motor speech disorder

Motor principles suggested for treatment

Do’s and Don’tsBased on motor understanding

Discussion of CasesIdentify Do’s and Don’ts


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Speech is a complex motor task

Personality

Functions:PersuadeComment Request…

MeaningEmotions

Grammar

…and also always a motor task

Sounds

Syllables



Many muscles and body parts move in a coordinated way during speech (Thelen, 1991)


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Speech movements are very fast (Caruso & Strand, 1999)


Speech movements must be very precise(Borden, 1984)

CAS is a motor-based speech disorder


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Cognition• Ideas

Language

• Word Retrieval• Phonological Mapping• Syntactic Framing

Motor Speech

• Planning• Programming• Execution


(Caruso & Strand, 1999)

Cognition• Ideas

Language

• Word Retrieval• Phonological Mapping• Syntactic Framing

Motor Speech

• Planning• Programming• Execution


Ø(Caruso & Strand, 1999)

Motor-based speech disorder (CAS) may benefit from amotor-based therapy


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Principles of Motor Learning

Principles of motor learning Practice guidelines from a vast body of research on how we motor-

learn non-speech motor tasks

Tell us that practice helps us learn a motor task

AND that certain ways we practice will facilitate motor learning better than other ways we practice…


Principle Retention

Practice amount Large

Motivation High

Understand task Understand what is being asked of you and why

Task specificity What you practice is what you learn

Optimum challenge level Not too hard, not too easy

(Schmidt & Lee, 2005, Maas, et. al, 2008)

Motor Performance Motor

LearningAcquisition

Retention




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Principle Acquisition Retention

Practice Distribution Mass Distributed

Practice Variability Constant context Varied context

Practice Schedule Blocked, predictable order Random unpredictable order

Feedback Type Knowledge of performance Knowledge of results

Feedback Frequency Often, immediate Inconsistent, delayed

Rate Slow Normal, varied

Attention and Focus Internal External

Adapted from Ruth Stoeckel, Ph.D.


Motor-based CAS therapy

So, because CAS is a motor-speech disorder,

And the principles of motor learning tell us how to practice to improve a motor skill (at least in other parts of the body)

It is theorized that motor-based interventions – that employ these principles of motor learning - will improve speech in children with CAS (even though a lot of speech-related research has not yet been done)


Research on typical speakers uphold the principles of motor learning

Limited research on voice/speech impaired speakers – mixed results regarding principles CAS speakers – 3 parameters studied: practice amount, practice

schedule, feedback frequency


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CAS Study #1 – practice amount (Edeal & Gildersleeve-Neumann, 2011) 30-40 practice trials per session = moderate frequency

100-150 practice trials per session = high frequency

Both practice frequency conditions produced gains Results: High frequency produced greater motor learning – retention

and transfer


CAS Study #2 – practice schedule (Maas & Farinella, 2012)

CAS Study #3 – frequency of feedback (Maas et al 2012) Mixed results (Maas, et al, 2014)

Inconsistent results may relate to complexity of speech motor control

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Maas et al, 2014 reviewed evidence bases for 5 motor-based interventions that are used with children with CAS PROMPT

Rapid Syllable Transition (ReST)

Nuffield Dyspraxia Programme, 3rd Edition (NDP3)

Biofeedback treatment

Integral stimulation – Dynamic Temporal and Tactile Cueing (DTTC)


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PROMPT Must be trained to use

Recommended by authors for children with speech disorders including CAS

Little published research to support claims of effectiveness for children with CAS Most studies done explicitly excluded children with CAS

Studies done without experimental control measures so cannot attribute gains to treatment

Studies conducted by research group affiliated with PROMPT


Rapid Syllable Transition (ReST) Repeated productions of multi-syllabic non-words – surrogate for novel

vocabulary Focuses on principles of motor learning that facilitate retention

Large practice amount random practice schedule variable practice reduced feedback frequency

May be best for older CAS children with mild-moderate impairment Relatively strong evidence base for CAS treatment

Has fewer studies than integral stimulation, but one study is RCT – higher level of evidence

All studies done by one research group

Motor-based therapy for CAS

Nuffield Dyspraxia Programme, 3rd Edition (NDP3) Commercially available – used frequently in UK and Australia

Begins with single sounds – then syllables – then syllable sequences

Marketed for 4-12 year olds with mild-severe motor speech disorders (including CAS)

Uses principles of motor learning that facilitate performance Frequent feedback

Blocked practice trials

Few studies One RCT completed by an independent group of researchers showed gains

Two unpublished studies


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Biofeedback treatment Uses visual feedback of speech movements

Electropalatography – tongue to palate movements

Ultrasound – tongue movements

May be best for older children

No studies yet on “acoustic spectral” biofeedback


Integral Stimulation including DTTC Imitation – repetitive intensive drill - of increasingly longer real words and

phrases (functional vocabulary used as targets)

Incorporates principles of motor learning – all acquisition and motor learning strategies

Targeted to young, severely impaired children with CAS

Has strongest evidence base for use with children with CAS 6 studies

3 independent labs

Integral stimulation type speech therapy –involves imitation (“watch me, listen, and do what I do”)

Principle Retention

Practice amount

Large

Motivation High

Understandtask

Understand what is being asked of you and why


Optimumchallenge level

Not too hard, not too easy

DTTC


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Integral stimulation type speech therapy – involves imitation (“watch me, listen, and do what I do”)

This means: Direct type of therapy (not

indirect)

Child understands what is being asked and why They need to know they are

working on “movements” vs. sounds

DTTC

Target utterances are real words/phrases that are functional and meaningful to the individual child

Principle Retention

Practice amount

Large

Motivation High

Understandtask





DTTC

Target utterances are real words/phrases that are functional and meaningful to the individual child

This means Ask teachers and parents to

generate laundry list of motivating, functional words and phrases

DTTC


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Targets utterances are carefully selected to meet criteria for optimum challenge level in terms of sounds, syllable length and phonotactic complexity/structure

Principle Retention

Practice amount

Large

Motivation High

Understandtask





DTTC

Targets utterances are carefully selected to meet criteria for optimum challenge level in terms of sounds, syllable length and phonotactic structure

This means: Select from the laundry list, targets that

meet parameters for optimum challenge level Phonetic inventory

Sounds the child already can produce

Sounds the child is stimulable for

Sounds that are early developing and highly visible – see handout

Syllable shape

Phonotactic complexity

Consider place, manner and voicing features

DTTC

Repetitive intensive drill of functional vocabulary is a key aspect and is intended to increase generalization of motor patterns to functional communicative settings

Principle Retention

Practice amount

Large

Motivation High

Understandtask





“Danny”“Danny”“Danny”“Danny”“Danny”

DTTC


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Repetitive intensive drill of functional vocabulary is a key aspect and is intended to increase generalization of motor patterns to functional communicative settings

This means: Relatively small set of targets at any one

time so you can get more practice trials of each one 4-6 targets early in treatment or for severe

disorders

10-15 targets later in treatment or for more mild disorders

Activities in therapy session have to allow for lots of practice, and reinforcers should be quick

“Danny”“Danny”“Danny”“Danny”“Danny”

DTTC

The child is encouraged to watch the clinician’s mouth when she model’s a target , especially when first working on a target, to facilitate attention and focus to the speech movement gestures


Practice Distribution

Mass Distributed

Practice Variability

Consistent context, consistent prosody, pitch, rate

Varied context, varied prosody, pitch, rate

Practice Schedule

Blocked, predictable order

Random unpredictable order

Feedback Type Knowledge of performance

Knowledge of results

Feedback Frequency

Often, immediate Inconsistent, delayed


Attention and Focus

Internal External

DTTC

The child is encouraged to watch the clinician’s mouth when she model’s a target , especially when first working on a target, to facilitate attention and focus to the speech movement gestures



Mass Distributed




Practice Schedule





Feedback Frequency



Attention and Focus

Internal External

DTTC


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The child is encouraged to imitate a slower speech rate at first and as motor planning improves, the rate is slowly increased to conversational rates



Mass Distributed




Practice Schedule





Feedback Frequency



Attention and Focus

Internal External

DTTC

The child is encouraged to imitate a slower speech rate at first and as motor planning improves, the rate is slowly increased to conversational rates

This means: Clinician’s model is slow, but not

too slow at first Try to maintain

coarticulation/fluency of entire movement gesture – do not break into parts or segment

DTTC

Practice schedule, and variability are adjusted throughout progression of each target in order to facilitate motor learning



Mass Distributed




Practice Schedule





Feedback Frequency



Attention and Focus

Internal External

SammySammySammySammyHi momHi momHi mom

VS.

SammyHi momI do itHi momI do itSammySammy

DTTC


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Practice schedule, and variability are adjusted throughout progression of each target in order to facilitate motor learning

This means: Blocked, constant practice at

beginning of treatment, or for severe disorders

Random, varied practice as targets become mastered later in treatment, or for milder disorders

SammySammySammySammyHi momHi momHi mom

VS.

SammyHi momI do itHi momI do itSammySammy

DTTC

Accurate movement gestures during speech are shaped through multimodal cueing techniques (visual, verbal, tactile cues)

The cues change from trial to trial based on the errors the child makes

Feedback is systematically altered to facilitate motor learning (knowledge of performance vs knowledge of results)



Mass Distributed




Practice Schedule





Feedback Frequency



Attention and Focus

Internal External

DTTC

Accurate movement gestures during speech are shaped through multimodal cueing techniques (visual, verbal, tactile cues)

The cues change from trial to trial based on the errors the child makes

Feedback is systematically altered to facilitate motor learning (knowledge of performance vs knowledge of results)

This means: Listen to child’s attempt

Identify error

Provide cue based on error At first be specific – consider movement-based

words for verbal cues

Later be more general

Increase amount or intensity of cues as needed to achieve accurate movement (verbal, gestural, tactile) – do not want to practice incorrect movement gestures

DTTC


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Cues are gradually faded and the time from presentation of the model to the child’s response is lengthened as the child progresses to support independence



Mass Distributed




Practice Schedule





Feedback Frequency



Attention and Focus

Internal External

Therapist: Say ‘Hi mom’

---- PAUSE ----

Child: “Hi mom”

DTTC

Cues are gradually faded and the time from presentation of the model to the child’s response is lengthened as the child progresses to support independence

This means: Increase time between clinician

model and child’s production attempt

Fade cues systematically to enable child to hold onto accurate productions Frequency of cues/feedback

Timing of feedbackTherapist: Say ‘Hi mom’

---- PAUSE ----

Child: “Hi mom”

DTTC

Distribute practice over time, environments and contexts



Mass Distributed




Practice Schedule





Feedback Frequency



Attention and Focus

Internal External

DTTC


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Distribute practice over time, environments and contexts

This means: Frequent (3-5X/wk) short (30 min)

sessions to allow for mass and distributed practice of targets over time within sessions

Target utterances are sent home and into the classroom for practice as they achieve mastery within speech sessions

DTTC


Summary of research review (Maas, et al, 2014) Principles of motor learning provide a useful framework for exploring

optimal intervention conditions Motor-based therapy approaches have been found to produce gains

in speech production abilities in children with CAS At time of publication, DTTC had strongest evidence base for use with

children with CAS


Across DTTC treatment studies, the greatest gains occurred when (Maas et al, 2014):

Targets were functional

Treatment was frequent

Production frequency was highest

Motivation was highest


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Across studies: Ingredients that are likely to contribute to speech improvements in children with CAS (Maas, et al, 2014) High amount of practice

Relatively small set of therapy targets – allows for more practice trials of each

Provision of knowledge of performance vs. knowledge of results feedback

Use of alternative feedback modalities (visual, tactile, etc…)

Homework component – distributed practice


Consider each individual child when making decisions on treatment approach (Maas, et al, 2014) Not all children respond to given practice condition manipulation in the

same way Age

Severity

Language and cognitive status

Concomitant disorders

Motivation

Prognosis

Top 10Do’s and Don’ts of CAS TherapyBECAUSE IT’S MOTOR-BASED!


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Top 10Do’s and Don’ts of CAS Therapy

DO Consider using a smaller set of

targets at any one time, especially in the early stages of therapy Maximize practice trials of each

target

DON’T Use too large of a set of practice

words Each one may not get enough

practice trials to show progress

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DO Carefully select target utterances

based on movement parameters -so that they are at an optimum challenge level for the child Sounds the child can produce and

ones that are stimulable

Syllable length that is achievable

Phonotactic complexity that is achievable

DON’T Select target utterances based

solely on specific consonant sounds in the words

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DO Increase length and complexity of

target utterances by using longer words and phrases over time as the child’s motor system improves

DON’T Only use simple words as your

target utterances without regard to increasing length and complexity over time

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DO Obtain maximum practice trials of

each target (perfect practice makes perfect) Select activities and reinforcers

that facilitate lots of practice

DON’T Disregard practice amount or get

a minimal amount of practice trials of each target

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DO Encourage natural coarticulated

speech during practice trials Task specificity – what you

practice is what you learn -facilitates motor learning of natural-sounding speech

DON’T Encourage the child to over-

enunciate consonant sounds and/or segment (put pauses between) sounds within words or words within phrases during practice trials Segmenting is one of the very

things we are often trying to help the child NOT do (negative practice)

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DO Consider altering the type of

feedback provided during acquisition vs retention phases Utilize knowledge of performance

during the acquisition phase

Utilize knowledge of results feedback during the retention phase

DON’T Just use knowledge of

performance feedback regardless of whether or not you are in the acquisition phase or retention phase

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DO Consider using multi-modality

feedback (verbal, visual, gestural, and tactile) to help the child know how to make adjustments in their production attempts.

DON’T Only use verbal cues to help the

child know how to make adjustments in their production attempts.

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DO Consider distributing practice,

especially as a targets approach mastery, across different environments, across time, and across people in order to facilitate motor learning/retention Homework

In-class carryover

DON’T Provide all practice in the speech

therapy session rather than at home or in other environments.

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DO Measure accuracy based on all

aspects of movement gestures during speech including: Consonant accuracy

Vowel accuracy

Correct sequencing of sounds

Coarticulation

Prosody/stress

DON’T Measure accuracy based only on

articulatory placement or production of consonant sounds in words

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DO Consider more frequent, shorter

sessions (3-5, half-hour sessions) Distributes practice more

DON’T Use longer, less frequent sessions

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CAS therapy – goal is to improve movement gestures in speech Want the child to be able to produce the fluent, coordinated speech

movements needed for increasingly longer and more motorically/phonotactically complex syllable shapes

MOVEMENT-BASED goal, not SOUND-based

Motor-based CAS therapyBIG IDEA

Summary


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Flute lesson Using a few target songs Carefully selected in terms of

difficulty

With the GOAL of being able to help the child become more adept at coordinating the movements of respiration, finger /lip/tongue movements required to produce fluent music

CAS Speech lesson Using a few target utterances Carefully selected in terms of

difficulty

With the GOAL of being able to help the child become more adept at coordinating the movements of respiration, phonation and articulation required to produce fluent speech

Summary

Case Examples

Case #1 – Do’s? Don’ts?

Maddie is 3 year-old female with CAS Phonetic inventory /m, n, b, d, h, uh, ae, u, o/ Motor speech system breaking down at simplest 1-syllable level

Plan – seen 4x/week for 30 min each for individual therapy Goal: Coordinate speech movements to produce 1-2 syllable words with

80% cumulative accuracy (accuracy = consonants, vowels, # syllables, prosody, sequencing, coarticulation without segmenting)

Targets: Maddie, mommy, daddy, potty, no, uh-huh, eat, more, sit, help Practice schedule: blocked (AA, BB, CC, DD, etc) Practice amount: 2 trials of each of 10 targets within 30 minute session (total

20 trials) Feedback: verbal only – provide general outcome oriented feedback only Therapy strategies: backward chain 2-syllable words (pull out second

syllable and practice it first, then blend 2 syllables together)


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Case #2 – Do’s? Don’ts?

Sam is a 4 year old male with CAS Phonetic inventory /m, b, n, d, t, sh, w, h, uh, ae, E, u/ Motor speech system breaking down at the 2 syllable level

Plan – seen 1x/week at preschool for 1 hour Goal: produce /s/ in initial position with 80% accuracy Targets: Sue, Sam, sis, slow, sit Practice schedule: blocked (AA, BB, CC, DD, EE, etc.) to start and then

move to random once approaching mastery Practice amount: 10X each before moving to next, rotate through practice

schedule to obtain as many trials as possible within session Feedback/cues: multimodality Therapy strategies: emphasize each sound precisely, including plosing on all

plosives and vowels even within unstressed syllables – make it accurate!

Discussion/Questions

References

Borden, G.J., & Harris, K.S. (1984). Speech Science Primer: Physiology, Acoustics, and Perception of Speech. Baltimore: Williams and Wilkins.

Caruso, A., & Strand, E. A. (Eds.). (1999). Clinical management of motor speech disorders in children. New York: Thieme Medical.

Edeal DM, Gildersleeve-Neumann CE. (2011). The Importance of Production Frequency in Therapy for Childhood Apraxia of Speech. American Journal of Speech-Language Pathology, 20,95-110.


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References

Maas, E, Butalla CE, Farinella KA, Feedback frequency in treatment for childhood apraxia of speech. Am J Speech Lang Pathol. 2012;21:239-57.

Maas E, Farinella KA. Random versus blocked practice in treatment for childhood apraxia of speech. J Speech Lang Hear Res. 2012;55:561-78.

Maas, E., Gildersleeve-Neumann, C. E., Jakielski, K. J., & Stoeckel, R. (2014) Motor-based intervention protocols in treatment of childhood apraxia of speech (CAS). Current Developmental Disorders Reports, 1 (3).

Maas E, Robin DA, Austermann Hula SN, Freedman SE, Wulf G, Ballard KJ, Schmidt RA. (2008). Principles of Motor Learning in Treatment of Motor Speech Disorders. American Journal of Speech-Language Pathology,17, 277–298.

References

Schmidt, R. A. & Lee, T. D. (2005). Motor Control and Learning A Behavioral Emphasis. – 4 ed. Champaign, IL: Human Kinetics Books.

SPAN (2015). Speech Production and Articulation Knowledge Group, University of Southern California. Joy Nash trapped in the MRI Machine. Retrieved March 5, 2015 from: https://www.youtube.com/watch?v=0-aEN2xHBCc

Thelen, E. (1991). Motor Aspects of emergent speech: A dynamic approach. Hillsdale, NJ England: Lawrence Erlbaum Associates.

Yorkston, KM, Beukelman, DR, Strand EA, Hakel, M. (2010). Management of Motor Speech Disorders in Children and Adults –Third Edition. Texas: Pro-Ed.

The Do’s and Don’ts of CAS Therapy

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