DOCUMENT 7
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Research Request – Childhood Speech Apraxia
Brief
Best practice treatment of childhood speech apraxia
Date
09/10/2020
Requester
Wendy
s47F - pers (Assistan
t Director TAB)
Researcher
Janes47F - personal priva (Research Team Leader)
Contents
What is childhood speech apraxia? ........................................................................................................ 2
Treatment Approaches ........................................................................................................................... 2
Motor Programming Approaches ....................................................................................................... 2
•
Dynamic Temporal and Tactile Cueing (DTTC) ........................................................................ 3
•
Nuffield Dyspraxia Program (NDP3®) ...................................................................................... 3
•
Rapid Syllable Transitions (ReST) ............................................................................................ 3
Linguistic Approaches ......................................................................................................................... 3
•
The Cycles approach ............................................................................................................... 3
•
Integrated Phonological Awareness (IPA) ............................................................................... 4
Prosodic Facilitation ............................................................................................................................ 4
Augmentative and Alternative Communication (AAC) ....................................................................... 4
Reference List .......................................................................................................................................... 5
Please note:
The research and literature reviews collated by our TAB Research Team are not to be shared
external to the Branch. These are for internal TAB use only and are intended to assist our advisors
with their reasonable and necessary decision making.
Delegates have access to a wide variety of comprehensive guidance material. If Delegates require
further information on access or planning matters they are to call the TAPS line for advice.
The Research Team are unable to ensure that the information listed below provides an accurate &
up-to-date snapshot of these matters
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What is childhood speech apraxia?
Childhood apraxia of speech (CAS) is a developmental disorder of speech motor planning and/or
programming. It is a rare condition, affecting only 0.1% of the general population. 1 The consensus
based core features of CAS include: 2
1) Inconsistent errors on consonants and vowels in repeated productions of syllables or words
2) Lengthened and disrupted co-articulatory transitions between sounds and syllables
3) Inappropriate prosody, especially in the realisation of verbal or linguistic stress
The long term functioning of people with CAS is largely unreported. Available longitudinal research
suggests that CAS is a persistent disorder that requires therapy. Children with CAS are at risk for
literacy, academic, social and vocational difficulties. 1
Treatment Approaches
Treatment selection depends on factors such as the severity of the disorder and the communication
needs of the child. Because symptoms typically vary both from child to child and within the same
child with age, 3, 4 multiple approaches may be appropriate at a given time or over time. The most
common approaches include motor programming, linguistic, prosodic facilitation and augmentative
and alternative communication (AAC). 5
At present, treatment approaches’ for CAS have not been investigated using high quality randomised
controlled trials (RCTs). A Cochrane Systematic review 1 was only able to locate one RCT which
comparted two motor programming approaches’ (Nuffield Dyspraxia Programme-3 and the Rapid
Syllable Transitions Treatment). 6 Both approaches demonstrated improvement at one month post
treatment for accuracy of production on treated words, speech production consistency and accuracy
of connected speech. An earlier systematic review which included non-RCTs concluded that Dynamic
Temporal and Tactile Cueing has the strongest evidence base, with replicated evidence of efficacy
from several well-controlled single-case experimental design studies from different independent
research group. 7
A brief overview conducted by the American Speech-Language-Hearing Association (ASHA) of
common motor programming (best evidence to date), linguistic, prosodic facilitation and AAC
approaches is provided below. 5
Motor Programming Approaches
Motor programming approaches are based on motor programming/planning principles. These
approaches:
• provide frequent and intensive practice of speech targets;
• focus on accurate speech movement;
• include external sensory input for speech production (e.g., auditory, visual, tactile, and
cognitive cues);
• carefully consider the conditions of practice (e.g., random vs. blocked practice of targets);
and
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• provide appropriate types and schedules of feedback regarding performance (Maas et al.,
Examples of motor programming approaches include the following:
• Dynamic Temporal and Tactile Cueing (DTTC) is an integral stimulation ("look,
listen, do what I do") method that uses a cueing hierarchy (auditory, visual, and tactile) and
systematically decreases supports as the child achieves success at each level of the cueing
hierarchy. 8, 9 Movement gestures are shaped, beginning with direct imitation, moving to
simultaneous production with tactile or gestural cues if direct imitation was unsuccessful,
and then fading the simultaneous cue and again moving to direct imitation. The key element
of this approach is that the clinician is constantly adding or fading auditory, visual, and
tactile cues as needed after each practice trial. It is suggested for very young children with
severe CAS.
• Nuffield Dyspraxia Program (NDP3®) is a motor skills learning approach that
emphasizes motor programming skills and focuses on speech output. It is described as a
"bottom-up" approach in which the aim is to "build" accurate speech from core units of
single speech sounds (phonemes) and simple syllables. New motor programs are established
using cues and feedback and through frequent practice and repetitive sequencing exercises.
Phonological skills are incorporated into the treatment approach through the use of minimal
word pairs. 10
• Rapid Syllable Transitions (ReST)
is a method that involves repetition of varied
sequences of real or nonsense syllables to train motor planning flexibility. 11, 12 It uses
intensive practice in producing multisyllabic, phonotactically permissible pseudo-words to
improve accuracy of speech sound production, rapid and fluent transitioning from one
sound or syllable to the next, and control of syllable stress within words. Pseudo-words are
used to allow the development and practice of new speech patterns without interference
from existing error speech patterns. 13, 14
Linguistic Approaches
Linguistic approaches for treating CAS emphasize linguistic and phonological components of speech
as well as flexible, functional communication. 11 These approaches focus on speech function. They
target speech sounds and groups of sounds with similar patterns of error in an effort to help the
child internalize phonological rules. It is important to note that linguistic approaches to CAS are
intended as a complement to motor approaches, not as a replacement for them.
Examples of linguistic approaches include the following:
• The Cycles approach is a linguistic approach that targets phonological pattern errors. 15
It is designed for children whose speech is highly unintelligible and who have extensive
omissions, some substitutions, and a restricted use of consonants. The goal is to increase
intelligibility within a short period of time. Treatment is scheduled in cycles ranging from 5
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to 16 weeks. During each cycle, the SLP targets one or more phonological patterns. After
each cycle is completed, another cycle begins that targets one or more different
phonological patterns. Recycling of phonological patterns continues until the targeted
patterns are present in the child’s spontaneous speech. 16 The goal is to approximate the
gradual typical phonological development process. There is no predetermined level of
mastery of phonemes or phoneme patterns within each cycle; cycles are used to stimulate
the emergence of a specific sound or pattern, not produce mastery of it.
• Integrated Phonological Awareness (IPA) is designed to simultaneously facilitate
phonological awareness, letter–sound knowledge, and speech production in preschool and
young school-age children with speech and language impairment. Specific approaches to
facilitate the development of phonological awareness include (a) developing knowledge that
positively influences phonological awareness development (e.g., teaching nursery rhymes
and focusing on sound properties of spoken language) and (b) integrating phonological
awareness activities into treatment sessions (e.g., phoneme awareness and letter game
activities). 17, 18
Prosodic Facilitation
Prosodic facilitation
treatment methods use intonation patterns (melody, rhythm, and stress) to
improve functional speech production.
Melodic intonation therapy (MIT) 19 is a prosodic facilitation
approach that uses singing, rhythmic speech, and rhythmic hand tapping to train functional phrases
and sentences. Using these techniques, the clinician guides the individual through a gradual
progression of steps that increase the length of utterances, decrease dependence on the clinician,
and decrease reliance on intonation. 20
Augmentative and Alternative Communication (AAC)
AAC involves supplementing or replacing natural speech or writing with aided symbols (e.g., picture
communication, line drawings, Blissymbols, speech-generating devices, and tangible objects) or
unaided symbols (e.g., manual signs, gestures, and finger spelling). 5 Whereas aided symbols require
some type of transmission device, production of unaided symbols requires only body movements.
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Reference List
1. Morgan AT, Murray E, Liégeois FJ. Interventions for childhood apraxia of speech. Cochrane
Database of Systematic Reviews. 2018(5).
2. American Speech-Language-Hearing Association (ASHA). Technical Report. Childhood
Apraxia of Speech: Ad Hoc Committee on Apraxia of Speech in Children.
www.asha.org/policy/TR2007-00278/. Accessed October 9, 2020.
3. Lewis BA, Freebairn LA, Hansen AJ, Iyengar SK, Taylor HG. School-age follow-up of children
with childhood apraxia of speech. Language, speech, and hearing services in schools. 2004.
4. Shriberg LD, Campbell TF, Karlsson HB, Brown RL, McSweeny JL, Nadler CJ. A diagnostic
marker for childhood apraxia of speech: The lexical stress ratio. Clinical Linguistics &
Phonetics. 2003 Oct 1;17(7):549-74.
5. American Speech-Language-Hearing Association. Childhood Apraxia of Speech. (2020).
Retrived from
https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935338§ion=Reference
s. Access October 9, 2020.
6. Murray E, McCabe P, Ballard KJ. A randomized controlled trial for children with childhood
apraxia of speech comparing rapid syllable transition treatment and the Nuffield Dyspraxia
Programme–Third Edition. Journal of Speech, Language, and Hearing Research. 2015
Jun;58(3):669-86.
7. Maas E, Gildersleeve-Neumann CE, Jakielski KJ, Stoeckel R. Motor-based intervention
protocols in treatment of childhood apraxia of speech (CAS). Current developmental
disorders reports. 2014 Sep 1;1(3):197-206.
8. Strand EA, Debertine P. The efficacy of integral stimulation intervention with developmental
apraxia of speech. Journal of Medical Speech-Language Pathology. 2000 Jan 1;8(4):295-300.
9. Strand EA, Stoeckel R, Baas B. Treatment of severe childhood apraxia of speech: A treatment
efficacy study. Journal of Medical Speech-Language Pathology. 2006 Dec 1;14(4):297-308.
10. Williams, P., & Stephens, H. The Nuffield Center Dyspraxia Programme. In A. L. Williams, S.
McLeod, & R. J. McCauley (Eds.),
Interventions for speech sound disorders in children (pp.
159
–178). (2010) Baltimore, MD: Brookes.
11. Velleman, S. L.
Childhood apraxia of speech: Resource guide. (2003). New York, NY:
Thomson.
12. Velleman, S. L., & Strand, K. Developmental verbal dyspraxia. In J. E. Bernthal & N. W.
Bankson (Eds.),
Child phonology: Characteristics, assessment, and intervention with special
populations (pp. 110–139). (1994). New York, NY: Thieme.
13. McCabe, P., Macdonald-D’Silva, A. G., van Rees, L. J., Ballard, K. J., & Arciuli, J.
Orthographically sensitive treatment for dysprosody in children with childhood apraxia of
speech using ReST intervention. (2014).
Developmental Neurorehabilitation, 17, 137–146.
14. McCabe, P., Murray, E., Thomas, D., & Evans, P.
Clinician manual for Rapid Syllable Transition
Treatment (ReST). (2017). Camperdown, Victoria, Australia: The University of Sydney.
15. Hodson, B. Phonological remediation: A cycles approach. In N. A. Creaghead, P. W. Newman,
& W. Secord (Eds.),
Assessment and remediation of articulatory and phonological
disorders (pp. 323–334). (1989). Columbus, Ohio: Merrill.
16. Hodson, B.
Evaluating and enhancing children’s phonological systems: Research and theory
to practice. (2010). Wichita, KS: PhonoComp.
17. McNeill, B. C., Gillon G. T., & Dodd B. Effectiveness of an integrated phonological awareness
approach for children with childhood apraxia of speech (CAS). (2009).
Child Language and
Teaching Therapy, 25, 341–366.
18. McNeill, B. C., Gillon, G. T., & Dodd, B. The longer term effects of an integrated phonological
awareness intervention for children with childhood apraxia of speech. (2010)
Asia Pacific
Journal of Speech, Language and Hearing, 13, 145–161.
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19. Albert, M., Sparks, R., & Helm, N. Melodic intonation therapy for aphasia. (1973).
Archives of
Neurology, 29
, 130–131.
20. Martin VC, Kubitz KR, Maher LM. Melodic intonation therapy. Perspectives on
Neurophysiology and Neurogenic Speech and Language Disorders. 2001 Oct;11(3):33-7.
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