My name is Marissa Mitchel, and I'm happy to be talking to you today about pediatric motor speech disorders, diagnosis and treatment. Before I begin, I just want to mention that I have no relevant financial or non-financial relationships to any of the products or services that I talk about. So I will be talking about some manualized treatment approaches, as well as some technology, but I have no relationships with any of those companies. So today I hope to answer the following questions. These are oftentimes questions that parents will ask me when they first get a diagnosis. So what are motor speech disorders, what causes them, how are they diagnosed, what therapies and treatments work, and, at least equally important, what doesn't work, and what do we know about long-term outcomes? So what do we know about prognosis? So first, what are motor speech disorders? Before I can really talk about what motor speech disorders are, I really have to talk about how speech happens. Now, this will be a very simplified version of how speech happens, but it is important to consider when we think about motor speech disorders. When most of us talk, we don't really think about what we're doing, but it's a really complex process. So before we even open our mouths, the first thing that happens is we have to decide to communicate and then we have to formulate our message. This is called the cognitive linguistic stage. Next is transcoding. That's where we have to plan and program the sequence of motor movements that are required to produce sounds. After that, we actually have to execute or carry out the motor plan, and we do this by coordinating our articulators. So these are the lips, tongue, jaw, soft palate, and respiratory system that typically are all working in concert to produce speech. And lastly, there's sensory feedback. So after we produce a message, we have to process what we've just done. So auditory, we ask ourselves how did it sound? And then, proprioception is where we think to ourselves, how did it feel? That sensory feedback is really crucial in that we then fine tune what our next message is going to sound like. So for the purposes of talking about motor speech disorders, the two phases of speech production that are going to be most important would be transcoding, so the planning and programming, and then execution of the motor plan. So we can define motor speech disorders as speech sound disorders, or problems with articulation, that's caused by deficits in either motor planning and programming or execution. There are three main types of motor speech disorders, Childhood apraxia of speech, dysarthria, and then a broader category called speech motor delay or motor speech disorder not otherwise specified. This is a broad category that includes children who might not fit neatly into either an apraxia or dysarthria diagnosis, but they have some features of both. Motor speech disorders can be developmental, so they can occur from birth or from the perinatal period or they can be acquired later on in life. They're also variable in severity, so some children present with very mild probleMs. They might not have much changes to their functional communication skills, whereas other children present with severe motor speech disorders and really have trouble producing words in a verbal manner. It's important we consider that motor speech disorders are part of a much larger umbrella of pediatric speech sound disorders. Much more commonly are children who have trouble with that initial cognitive, linguistic stage. They have trouble formulating their message and knowing when to use one sound over another. Kids who have trouble with this oftentimes present with what's called a phonological or articulation disorder, and these are by far the most common pediatric sound disorders. On the other end of the spectrum, a child might not have any problems with motor planning or motor execution, but rather they might have an anatomic or sensory issue that makes speech difficult. These might be children who have a severe lip or tongue tie, a cleft palate, or even a hearing impairment, where they can't actually hear what they're trying to produce. How common are motor speech disorders? The short answer is not very common at all, so it's really challenging to get a good idea of general population prevalence, but the best information I could find was from a study, a recent study from a few years ago, among children ages four to eight, where these researchers estimated that both apraxia and dysarthria occur in approximately 1 in 1,000 children. Speech motor delay, which is the broader category, is a little bit more common, approximately four in 1,000 children. But it's important to keep in mind that certain clinical populations present with motor speech disorders much more commonly So kids with complex neuro-developmental disorders, like intellectual disability, global developmental delay, or autism oftentimes present with motor speech problems, and individuals who have certain genetic conditions. We know that they’'re predisposed for certain motor speech problems. If we take a look at children who present simply with speech delay, if we were to follow those children over time, only about 18% of them would actually meet criteria for some type of motor speech disorder. So even among children with speech problems, motor speech disorders are relatively rare. The other thing to keep in mind is that most kids who present with apraxia and dysarthria present with several different co-occurring diagnoses. It's very uncommon for a child to present just with a motor speech disorders and nothing else. Most commonly we see kids who also present with expressive language impairment and sometimes receptive language troubles, difficulty with comprehension as well. Other common comorbidities include things that implicate the motor system which is probably not a surprise as motor speech disorders are impacting motor speech, motor planning and motor programming. So things like gross motor delay early in life, developmental coordination disorder, which is also referred to as dyspraxia, or on the far end of the spectrum, the more severe end, we might have a child who presents with cerebral palsy. Other common diagnoses include intellectual disability, autism, and epilepsy. So first I'll talk about childhood apraxia of speech. This is defined by the American Speech Language and Hearing Association as a neurological childhood speech sound disorder in which the precision and consistency of movements of underlying speech are impaired in the absence of neuromuscular deficits. And, that last part is important, in the absence of neuromuscular deficits, because if there are neuromuscular problems, the child is more likely to present with dysarthria. The core impairment in apraxia, on the other hand, is in the planning and programming stage, where children have difficulty with the spatiotemporal parameters of movement sequences, and this results in errors in speech sound production and prosody. So in short, we can think of it as a complex higher order motor system deficit in motor planning and programming. Praxis, the root praxis, is a Latin root that actually means planned movement, and so children with apraxia have specific trouble with planning their movements. A quick note about terminology because this can get a little bit tricky, childhood apraxia of speech is the commonly accepted diagnostic term nowadays, but until relatively recently in the US it was referred to as developmental apraxia of speech. Developmental was substituted with childhood for a couple of reasons, mainly because development has the connotation that it might simply be a delay, that a child simply grows out of it with maturation, and we know that to not be the case. Children with childhood apraxia of speech need direct and intensive intervention to make reasonable progress. Another term that you'll oftentimes see is something called dyspraxia, and this is still how apraxia of speech is commonly referred to in the UK and in parts of Europe. In the United States, however, we most often refer to it as apraxia. These all refer to the same thing. There's no gold standard test that will tell you whether or not a child has apraxia, and in fact, it can be really challenging to make that differential diagnosis. The consensus among motor speech disorder experts, however, are that there are three features that are most commonly seen, and are therefore diagnostic of apraxia. The first one is inconsistent errors on repeated productions of syllables or words. This is also referred to as token-to-token variability, and that refers not just to inconsistent speech production between words, but it actually refers to inconsistent speech production of the same word on repeated attempts. So on one occasion the child might come out with the word sounding totally fine, and the next time they struggle with that very same word. Secondly, we oftentimes see lengthened and disrupted co- articulatory transitions between sounds. So that's where kids with apraxia really struggle. It's with actually moving from the motor sequences required to produce one sound to another. And so oftentimes their speech might sound choppy. They might insert some pauses in between syllables or in between words, and this results in unusual prosody and abnormal stress patterns. So a child, even if they're able to produce the sounds correctly in the word that they're saying, a child with apraxia might actually sound robotic or not quite right. So taking the word banana for instance, they might put the stress on the wrong syllable and instead say banana. Some additional features, but these are less diagnostic that are oftentimes seen, are that kids have a limited repertoire of vowels and vowel distortions. So most children who present with run of the mill phonological and articulation disorders, even if they're really severe in nature, they oftentimes produce the vowels correctly, but where they struggle is with consonants. This isn't the case with apraxia. Many kids with apraxia do struggle with vowels, in addition to consonants. They oftentimes present with unusual or idiosyncratic error patterns. Speech therapists who work with kids with apraxia often complain that they're not able to take a good language transcript simply because the errors that they produce are so unusual in nature that there is no way to write them on paper. Kids often have a slow rate of speech with some observable, physical groping where the child might employ trial and error to figure out where they're supposed to place their tongue or their lips or their jaw, so you can actually see the child physical struggle. They oftentimes produce increased errors on longer, complex utterances compared to simpler utterances. They oftentimes have better articulation of automatic or over learned utterances, so things like thank you or counting to 10 might sound fine because the child has over learned them to the point that they become automatic. Another thing we oftentimes hear from parents is that when the child was younger they presented with limited babbling. Kids with apraxia were oftentimes described as quiet infants. And lastly, kids with sever apraxia oftentimes also present with co-occurring oral apraxia, this results in feeding problems, so trouble with swallowing, trouble with chewing. On the more severe end of the spectrum, some kids actually will need a feeding tube. So we spoke about dysarthria, and now I'm going to discuss the second major diagnosis within the motor speech disorder umbrella, and this is dysarthria. And, if you recall, dysarthria occurs at the level of motor execution. It's a motor speech disorders that's caused by weakness, paralysis, or incoordination of the muscles that are used to produce speech. It's often associated with either low muscle tone, which can be referred to as hypotonia, or increased tone, which is referred to as hypertonia or spasticity. It typically results, regardless, in what we would hear as slurred or imprecise speech. And dysarthria is unique among speech sound disorders in that it can impact any or all speech processes, so not just articulation, but also respiration. So perhaps the child doesn't have sufficient breath control resonance, so oftentimes kids with dysarthria have trouble moving air through the speech mechanism and it might escape inappropriately through the nose and prosody as well. There are several different types of pediatric dysarthria, spastic dysarthria typically refers to those children who present with hypertonia or increased muscle tone. Ataxic dysarthria, the child's tone would actually be OK, but they have trouble coordinating their movements. Hyperkinetic dysarthria refers to children who have extra movements that they are not able to control. So we sometimes see this in pediatric Huntington's disease or kids who have other types of chorea or movement disorders. And mixed dysarthria is essentially a combination of features from several of the other types. The main features of dysarthria vary widely depending on what type of dysarthria the child is presenting with, but in general, the kid will present with a slow speaking rate. Their vocal quality might sound breathy as is the case in flaccid dysarthria, or it can even be harsh, hoarse, or strained, which is more often the case with spastic dysarthria. Regardless, they almost always present with imprecise and slurred speech. Most sounds are distortions, which is in contrast the substitutions or deletions which are more common with kids with apraxia. Sound errors are often consistent. So if you recall, one of the hallmark features of apraxia is inconsistent production of the same word. Kids with dysarthria do not typically exhibit this. Their sound errors are oftentimes consistent between words, as well as within words. They oftentimes have difficult regulating pitch and loudness, and children might present with resonance problems. So as I mentioned before, kids with flaccid dysarthria might have a nasally sounding voice because they have trouble with the muscles that are required to close off that passageway to the nose. What causes motor speech disorders? There are three main groups that we can kind of consider. The first would be children who present with an acquired neurological impairment. The second group would be children who have complex neurodevelopmental disorders that are the result from either genetic or metabolic conditions, and the last group are those individuals whose motor speech disorders can be considered idiopathic. So neurological impairment, I'm referring here to any type of infection, illness, or injury or trauma to the brain, so this could be caused by stroke, it could be caused by traumatic brain injury, and these insults could occur before, during, or after birth. These kids will typically present with an abnormal MRI or brain scan, and in these cases are more likely to result in dysarthria compared to apraxia because it's often associated with a broader neuromotor dysfunction. So kids who have a abnormal MRI very rarely present with a isolated speech problem. The second group of children are kids with complex neurodevelopmental disorders, who might present with some type of genetic or metabolic condition. Some of the more commonly seen genetic conditions that we know are associated with motor speech disorders are Fragile X, Down syndrome, Galactosemia, 22q11.2 deletion syndrome, also referred to as Velocardiofacial syndrome. And the last group of individuals, I think, are of particular interest to this group here today, and that's SETBP1-related disorder. So there was a recent study that came out within the last year that indicated that up to 80% of kids in their study presented with childhood apraxia of speech. So this seems to be one of the core features of SETBP1-related disorder. And, if we look at the broader group of children with apraxia, we're beginning to find that more and more kids do have some type of a positive genetic finding. One study that came out last year showed that approximately 1/3 of their apraxia cohort, when they had genetic testing, had some type of positive or pathogenic finding that occurred in multiple different genes. There's no one specific gene that kids are consistently presenting with, but we do know that genetic testing might at some point in the future be indicated with a child with apraxia or dysarthria. However, the third, and very clearly, largest group of kids who have a motor speech disorder are those with idiopathic cases. And, idiopathic essentially means that the cause is unknown. So these are kids that might have genetic testing, but don't present with any identifiable genetic etiology. If they have a MRI, it typically comes back looking completely normal, and so these are children who we don't really know what caused their motor speech disorder, but we oftentimes can assume that it's the result of multiple different genetic and environmental factors. How are motor speech disorders diagnosed? So first, the most qualified professional to diagnose a motor speech disorder is a licensed speech language pathologist, preferably one who has some type of a background of additional training in motor speech disorders. Certainly other professionals such as neurologists and developmental pediatricians are an important part of the care team, especially since most kids who are presenting with motor speech problems have other types of common neurodevelopmental issues. And there are certain considerations that we always want to think about when we're making a diagnosis. The first one is that a differential diagnosis is, really, very difficult if not impossible in children that are younger than 3 years. There are several reasons for this, but the most important reason is that most kids presenting with speech delay at that point really have very limited verbal speech. And so we know that a child needs to have a sufficient amount of speech, preferably phrase level or sentence level, or at least attempting to produce longer utterances in order for the speech therapist to get enough information to make a reliable diagnosis. So in those kids who present as nonverbal or minimally verbal, we might suspect a motor speech disorder, but we wouldn't really be able to reliably make that diagnosis. And lastly, I think I mentioned before, there's no gold standard test for apraxia or other motor speech disorders. It would be a lot easier if there were, but typically the evaluation has to consider many different things, and it really is a diagnosis of exclusion. I think this chart summarizes well what some of the challenges are in making a differential diagnosis. There really isn't any given feature that we always see in any one of these conditions. So oftentimes when a child presents with extremely poor speech intelligibility, meaning they're very hard to understand, there's an assumption that they must be presenting with a motor speech disorder of some type. But in reality, there are many children who have had severe phonological or articulation problems that have very poor speech intelligibility. And so this alone is not really a good diagnostic indicator that the child has a motor speech problem. Some of the other features that we've already talked about, things like abnormality in muscle tone, inconsistent errors, vowel distortions, these are things that typically can occur in more than one speech sound disorder, and so it's important to consider all of these things as part of the comprehensive evaluation. Elements of a motor speech evaluation always include a good caregiver interview, and the reason for this is the parent or the caregiver is with the child more than anybody else, so they can provide really good insight about what that child's speech production looks like across environments. When I see a child in a clinic, beforehand I always do a comprehensive review of any previous multidisciplinary testing which might be through school or might be through private outpatient clinics. I also take a look at the medical and birth history to see if there's anything there that might impact the neuromuscular system. Next I'll do a structural and functional examination. I take a look at the oral mechanisms, so those are the articulators that I mentioned before, things like the tongue, the teeth, the jaw, both the structure as well as their movement and their function to make sure all that looks OK. I look at the respiratory function of the child. I mentioned before the kids with dysarthria oftentimes present with really poor breath control, and this can impact their voice quality as well as articulation. I'll oftentimes have the child try to sustain phonation, so essentially try to make a sound for a long period of time. Kids with motor speech disorders and especially with dysarthria really struggle with this because they have an inefficient speech mechanism, and they won't be able to sustain the same sound very long. And lastly, look at velopharyngeal function, which is essentially how the velopharynx works. Is the child able to make the movements that are required to close off the speech mechanisms so that the air flows appropriately through the mouth rather than escape through the nose? Next, I will always administer or at least I attempt to administer some type of standardized assessment. Even if the focus and the concern really is on speech sound production, I will always give tests looking at both receptive and expressive language skills because we know that most kids who have a motor speech disorders will present with some type of language disorder as well. Some of this might be direct testing. For younger kids, some of it might simply be standardized caregiver report measure where the caregiver has a list of either sounds or words that they report their child can do. Next, and equally important, would be non-standardized assessments. So these are assessments that give me really important qualitative information about how the child produces speech, but it might not give me a standard score, something that I can compare to a larger group of children. Dynamic testing would include some type of evaluation procedure where the child is giving incremental levels of support to figure out what support is necessary for the child to be able to produce certain sounds or certain words. One example of a test like this is would be the Dynamic Evaluation of Motor Speech Skill. Clinical observation and language sample transcription are often used hand in hand, where I'll look at the error patterns that a child produces as they're doing some particular task. Once the motor speech disorder is diagnosed, the next question is, how do we treat it? Some considerations are that speech therapy should be provided by a licensed and certified SLP, particularly one who feels comfortable and might have some additional training in motor speech disorders. Just like there is no gold standard test for apraxia or dysarthria, there's also really no gold standard or one-size-fits-all treatment. What we want to do is take into account that specific child's age, their developmental level, their ability to attend, as well as the severity of the disorder. Evidence-based decision-making is a really important part of that process, so before the speech language pathologist decides on what type of treatment is appropriate, they really should be considering the research evidence. They want to take into account the levels of evidence, so for instance, expert opinions or single case studies certainly don't hold as much weight as a randomized control trial or a systematic review of the literature. And I do want to make the note that most manualized and marketed approaches that are on the market right now have limited research support, so just because something is packaged in a great way and it has a website and they might do trainings, it doesn't necessarily mean that there is a lot of research support for that particular method. There are two main treatment approaches, and these are not mutually exclusive. And in fact, for the most part, I tend to use them both at the same time. The first would be direct speech therapy that has a goal in improving speech intelligibility. So this is looking specifically at the child's speech production, and it's utilizing motor learning principles. The second main treatment approach would be improving functional communication through the use of augmentative and alternative communication, as well as compensatory strategies. So looking for direct speech therapy with a goal of improving intelligibility, even though there are many different ways that you can get at the same goal, we do know that all of these marketed approaches have certain effective components. Most of them will utilize the principles of motor learning. So if you take a look at the picture here, this is a person who is learning how to play the piano, and if you have any type of personal experience learning how to play an instrument or learning how to practice a new sport or hobby that requires motor movement, you probably recognize that you have to have a lot of practice. And there's the old adage that practice makes perfect, and it’'s the same thing for our kids who have apraxia or dysarthria. Therapy should be frequent. A good rule of thumb is that it should occur at least three to five times a week, and it should also be intense. So intensity refers to the amount of actual practice that the child is getting within a single session. For that reason, I usually recommend that at least some therapy is provided individually because it's more effective and more intensive than group therapy. Another principle of motor learning would be multi-sensory cuing. So to take the piano analogy again, when you're first learning how to play your scales, you might actually have some type of a color coded system on the keys, or you might actually write out the notes directly on the keys. So this would be a visual cue that helps tell you where you should be placing your fingers, and it's the same thing when you're dealing with a child who has a motor speech problem. You might use several different sensory modalities to cue the child as to where their lips or their jaw or their tongue should be at any given time. Another important component is to provide direct and immediate feedback. So oftentimes kids, particularly children who have trouble with motor planning, they might not get the feedback that a typical child would when they're trying to execute a speech plan, and so it's important for the speech therapist early on to give direct and immediate feedback so they know whether or not something sounds or feels correct. One focus of therapy should also be on rhythm and prosodic facilitation, and that's one way that this differs from typical speech sound therapy, which usually has an isolated focus on speech sound production. Kids with apraxia, in particular, and dysarthria often have difficulty with prosody, and so this has to be targeted directly. And lastly, progressive approximation and shaping are strategies in which we might break down a word into it's component parts and practice each small and simple component part, and then slowly add to it over time so that the child can eventually produce more complex utterances. With all of these things in mind, there are some manualized treatment approaches that have a reasonable amount of research evidence. The strongest research evidence around the Rapid Syllables Transition treatment, or ReST, and this is targeting children who are ages 4 to 12 with either apraxia or ataxic dysarthria. There's the Nuffield Dyspraxia Programme, which you can probably tell is based in the UK since they use that term dyspraxia. This is targeting ages 3 to 7 with all types of severe speech sound disorders, which include dyspraxia and dysarthria. The Dynamic Temporal and Tactile Cueing system, or DTTC, is aimed at young children who have moderate to severe apraxia. All of these three are looking at those principles of motor learning that we had recently discussed. The last one is a little bit different, the Integrated Phonological Awareness Training Program isn't really a motor learning approach. It's looking more specifically at the level of phonology, so that cognitive linguistic level. However, there is some research support that shows it can be effective in treating kids with apraxia as well. So we're discussing the direct speech therapy with a goal of improving speech intelligibility, but the second main focus of therapy for a child who has either severe apraxia or dysarthria would be the use of Augmentative and Alternative Communication, or AAC. AAC refers to all tools and strategies that are used to supplement or replace speech when it's not sufficient to meet a person's daily needs, and this can include sign language. It can include letter board, or even pencil and paper, or it could be high tech and look like something like a iPhone or a tablet-based device. There are two broad categories of AAC, unaided and aided. Unaided refers to strategies that utilize the user's own body. These are things like facial expressions, vocalization, gesture, and sign language. Aided AAC, on the other hand, refers to some type of tool, whether that's something with a battery or plugged in, or something that's low tech. So we can think of aided AAC as part of a continuum. On the one side we have low tech strategies, these can include pencil and paper, alphabet boards, picture books, things like the Picture Exchange Communication System, or PECS. If we move up the ladder, then you get to mid-tech strategies. These are things that oftentimes allow you to record either one or several simple messages, but they're not dynamic in nature. And at the high tech end of the spectrum, we have what's called dynamic display speech generating devices. These can either be dedicated devices, or they can be off the shelf technology like the iPad or other tablets with some type of a communication app. There are certain considerations when we're implementing AAC. The first is that the AAC assessment should be conducted by the SLP, but certainly with input from family, teachers, therapists, and doctors. Another important point is that there are no prerequisite skills that are required by the child. In years past, it was thought that children weren't ready for AAC if they weren't able to follow directions or attend, and in reality what's important is that you match that individual piece of technology with the unique skills and needs of the child. Verbal children can also use AAC to supplement their speech, so many children who have motor speech impairment might present with phrase level or even conversational speech. However, they might be really hard to understand for people who don't know them well. And in these situations, they can still benefit from AAC to supplement the speech that they do have. AAC is not just for kids who are nonverbal or minimally verbal. And lastly, it's also important to understand that using AAC will not prevent or discourage a child from learning how to talk. I think sometimes parents or school teams are concerned that by introducing AAC, kids will use it as a crutch and then they're not going to be motivated to produce verbal speech. The good news is we have quite a few studies, some of which are listed here, that shows that that's simply not the case. And in fact, in some situations, employing AAC might actually accelerate speech production. So we talked about some of the things that do work, but what doesn't work? Well, we know that certain methods have been discredited, and some can even be harmful. So if you type in, particularly apraxia, into Google, you're going to see a lot of different companies that are trying sell vitamins and supplements, things like megadoses of Vitamin E or Omega 3 fatty acids, fish oils. Unfortunately, there's just not a lot of research that shows that this is effective. And in fact, it might actually be dangerous. A lot of these things are not actually regulated by the FDA. You're not really sure what you're giving your child, and so at this time I really can't recommend them. Additionally, non-speech oral motor therapy has been found to be ineffective for kids with motor speech impairment. Non-speech oral motor therapy refers to things like blowing through straws, blowing through whistles, using chewy tubes, or things that are purported to strengthen the musculature that's required for speech. But really what we know through research, the only thing that works for kids who have motor speech disorders is practicing speech itself. The last two things are facilitated communication and the rapid prompting method. These two things can look a little bit like AAC, but rather than having the child produce their own message, what we found over time is that the facilitator is helping them produce the message for them. So authorship comes into question, and so for these reasons the American Speech Language and Hearing Association has taken a strong stance that they do no recommend using either of those strategies with children who require AAC. And lastly, what do we know about long-term outcomes with kids who have motor speech impairments? There are specific child, child-specific considerations, and these are things that are unique to that individual child, so it makes more sense to take prognosis on a child-by-child basis, then lump all kids with motor speech disorders into the same category to look at prognosis. So the first consideration seems pretty obvious, but I'll mention it anyway, it's severity. So clearly a child who is presenting with a milder apraxia or dysarthria is likely to have a better long-term prognosis than a child who presents with very severe apraxia or dysarthria. Another thing that we want to take a look at are a child's cooccurring or co-morbid diagnoses. So children who have a co-morbid intellectual disability or a behavioral problem might prevent them from making the most out of speech therapy. So the child's ability to attend or to follow directions might make it so that they make slower progress in therapy over time. Next, self awareness and motivation certainly play a role. So some children who have apraxia or dysarthria might have very limited self-awareness that their speech can be a challenge for others to understand. On the one hand, this is a blessing in that kid's tend to not get very frustrated with their speech, but on the other hand these kids often have a low motivation to actually change their speech to make it easier for them to understand. And for that reason, they might make slower progress in therapy. And lastly, when I'm talking to parents in counseling about what I expect from them in the future, I always say that one of the best indicators for an ultimate prognosis is what progress they make initially in therapy. So when I see kids for their initial evaluation where they might get that diagnosis or apraxia or dysarthria and a parent asks me what they can expect 5 years down the road, I always say I would much rather see them back in 6 months or in a year, once they have the right supports to see what what kind of progress they make. Because we know the kids who make good progress over time and we have several data points that we can follow them over time, we'll get a better idea of ultimately what their trajectory is and where they'll end up. So we're talking about childspecific considerations, and these things by and large are things that are individual to the child and really there's not much we can do to change those. However, what we do have control over oftentimes are these treatment specific considerations. The first is a child's age at the onset of speech therapy, so we know that kids who get speech therapy earlier in life oftentimes have better luck, long-term outcomes. We also know the frequency and intensity of speech therapy makes a huge difference. So kids who have more frequent and intense speech therapy tend to make better progress than kids who tend to get speech therapy one or two times a month. In addition to that, we're looking at appropriateness of therapy and the use of evidence-based interventions, and so a speech therapy that instead of looking at simple speech sound production that might take a phonological approach, might not be as appropriate as those that employ those principles of motor learning that we discussed earlier. And lastly, and this is huge for kids who have motor speech disorders, family support and carryover are key. So a speech therapist can only physically be with the child at most a couple of hours a week. But the family is with the child all the time, and so they're a really important part of the treatment team who can work on home practice activities and carryover activities when the child is not currently in speech. So prognosis, these are the main takeaway points, and there's a picture here of a crystal ball, and I oftentimes tell families that I wish I had a crystal ball, and I could predict the future and tell where your individual child could be in 5 or 10 years, but there are some things that we know are typically the case. The first is that many, but certainly not all, children with motor speech disorders do go on to become proficient verbal communicators, and some children in adulthood are able to achieve what we would consider to be normal speech. So there's a subset of children who maybe when they're tired or fatigued or they have a new word that they're unfamiliar with, they might have a little bit of challenges with articulation, but for the most part become totally conversational and the average person wouldn't be able to tell that their speech sounds any different. However, there are some children who will have persistent motor planning deficits, even into adulthood. We know for any child that frequent and intensive speech therapy is necessary, so motor speech disorders aren't like a simple speech delay where we can assume that a child is going to simply mature and outgrow it over time. We do know that kids with motor speech disorders do require direct speech therapy. And lastly, it's important to consider their prognosis depends on the characteristics of that individual child. And so it's important when you're prognosticating that you're taking a look at that individual child's strengths and needs, as well as their progress in speech therapy over time. So I hope you found that helpful. I've enjoyed talking to you today, and I do have a list of references and resources that you might find helpful, and we will try to find a way to get those to any families who would like a list of them, if you would want to do some additional reading on your end. Thank you very much. >> We will begin shortly. Welcome everyone to the diagnosis and what is speech disorders Q&A. I am enjoying here today with speech therapist Marissa Mitchell. We are excited to get started with the Q&A session to address your questions. You should be able to see and hear me on your screen, although I will not be able to see or hear you. We welcome you to ask questions in the Q&A box. Avoid including personal health information in your questions for your own privacy. We apologize if we do not get your questions we will try to cover as many as possible. Since there are many genetic groups represented, it might be difficult to answer specific questions. Let's start the Q&A discussion and hear from you all. Let's begin with our first general question. Most people have a hard time understanding my child's speech. Is there an age where speech is so unintelligible it is unlikely to progress further? >> That's a really good question, and a difficult one to answer. There is no, to my knowledge, research study that shows us there is a cutoff age for speech intelligibility at which point a child will not make more progress. I think the best prognostic indicator is the child's rate of change over time. Even if you have an older child but they have not been in therapy that long, the chances of them greatly improving their speech are probably still pretty good with the right support. On the other hand, if you have a child in speech therapy for a long time and you look at their progress and maybe over the last few years you have seen a bit of a plateau, I would not give up on speech therapy. At that point it might be time to either try to increase the intensity or try a different approach. Whether that is with a new therapist or a new program, something. It is telling you what is going on is probably not working very well. The short answer is there is no age cutoff for intelligibility in my personal experience I have found, or in research. We want to look at that individual child's progress over a specific period of time. >> Let's go ahead and go to the next question. My child was doing the prompt approach. I live in Canada. That type of therapy seems to be the one we mostly use. Should I look for alternative options? >> It depends on how well your child is responding to it. I did not mention prompt therapy directly in my presentation because there is not a lot of evidence to show it is effective. That does not mean it isn't utilizing principles of motor learning which I talked about in the presentation. It does utilize a lot of the same principles. It is not just one of the better studied marketed approaches. If you feel like they are making good progress in speech therapy, I think that is probably the most important indicator what is going on is helping them. I would say if it does not seem to be working, you might want to consider some other evidence-based options. >> Thank you. Is there a recommendation or method of treatment beyond teenage that has successful treatment? >> Beyond school age. To make sure I'm understanding the question specific therapies for adult participants potentially? >> Older individuals. >> There are not any approaches I'm aware of that have a lot of support for development of motor speech disorders in older individuals. I suspect the same techniques that work in a pediatric population would also work for an adult population. There is an entire other set of literature in the areas of acquired motor speech disorders. Individuals and adulthood who had strokes or dementia or some type of generative process that is impacting their motor speech production. There are certainly programs specific to adults. Those are typically more focused on acquired neurological issues. When it comes to development of motor speech disorders, which is what I was talking about today, I suspect the same approaches that work for children would likely work for all the results as well. -- older adults as well. >> This question might be about younger kids. You mentioned in your presentation there needs to be a sufficient amount of verbal speech. Without a diagnosis it might be challenging to access these approaches. How can you try these approaches you cannot get an apraxia diagnosis? >> That is a challenge. I often see kids that are minimally verbal or nonverbal. Certainly we might suspect a motor speech disorders simply based on their history or the fact they have not made progress in therapy. Maybe they have other common comorbid risk factors. Things like motor impairment. Maybe they required babies or they have feeding impairments. I will often times right, reports it is a rule out diagnosis or susceptible -- sysuspected as their skills develop. There is no harm in beginning some type of motor speech impairment program. That usually involves more intensive therapy. I usually tell families early intervention is providing speech one hour a week. One hour might be sufficient but in the case of a child where I suspect apraxia I will likely recommend breaking it into multiple pieces. I would rather the child get three 20-minute intensive sessions versus one block of an hour. When it comes to motor planning more frequent practice is often the better approach. In these situations I would say there isn't harm in trying some motor speech techniques in therapy with a young child if a motor speech disorder is suspected, even if it is not confirmed. >> Great. Is there evidence that using improved speech production? Any particular type? >> There is no evidence I'm aware of that any type of musical program or music therapy improves speech production. I know sometimes individual children might do well with music therapy when it comes to attempting to communicate or perhaps they find it motivating. It is a good way to motivate them to participate in therapy. When it comes to improving speech intelligibility, there is no evidence using music has any type of an effect on the child's speech intelligibility. The thing that works for improving speech is speech. It is practice with actual speech targets. >> How do you find an SLP trained in the DDC approaches? >> Good question. I know on www.asha.org, there is a section for searching individuals, searching licensed SLPs in your area and often times they will list specific areas of expertise they have or interests. Sometimes you can find individuals through that. I often times think the best thing you could do is if you have a child who has an apraxia or other motor speech diagnosis is simply to ask the speech therapist at their comfort level is using a variety of techniques. Most therapists out there now -- know what they know when what they don't. I have referred individuals who I don't feel countable treating if they are with feeding concerns. I know that is not really my area of expertise. Having an open dialogue with your speech therapist is probably the best way to go. Certainly if they don't feel comfortable trying new technique, they might have a colleague they know of who can refer me to. >> A question about accessing services. What suggestions do you have for pure givers in navigating insurance or costs of frequent therapy is inhibited? >> That's a challenge for many kids who present with neurodevelopmental disabilities. Not just children with motor speech impairment. It has been my experience that when a child does have a motor speech diagnosis, sometimes their particular insurance plan is more likely to cover speech therapy simple because of the diagnostic code used, which is a neurological code rather than a development of code which many insurance companies have as an exclusion of what they will cover. It boils down to what your individual insurance plan does do. You certainly could contact your insurance company directly. Often times you can be assigned a case manager where they can make exceptions on a case-by-case basis when it comes to your individual child. The other thing you might want to do is take a look at therapies through school, therapies through early intervention. It should be provided free of cost to your child. That is the first place I would look and make sure your child's individualized education plan has enough speech therapy written into it. That would be the first thing I would recommend. If you are looking specifically at private outpatient options, that will vary based on what particular insurance you have. Another good option is taking a look at local university clinics. If you are lucky enough to live by a university that has a good communication disorders program, frequently graduate students will provide therapies. There are on-campus clinics. They are often much less expensive. They usually have a sliding scale for individuals who don't have any insurance. That would be another option as well. >> Great. What tools or verbal or visual prompts would you recommend for students who have a hard time communicating? Students using three or forward utterances but poor vocabulary skills? >> It depends on what your individual child is working on and what their goals are. In the case of a child who had some verbal speech but maybe it is hard to understand or they are not able to elaborate on their short sentences, I see a role for alternative munication in those situations. Potentially a speech generating device or even pictures. That would be specifically if there are communication breakdowns where the partners are not understanding what the child is trying to say. You can sub limit what they are doing. It is not a replacement of the speech they have but it will improve their functional communication skills in the classroom. >> Thank you for that. The next question is from a family that is trilingual. They have a child with a significant speech delay. Asking if they should reduce the number of languages spoken at home to make it easier or keep using multiple native languages very much naturally? >> That's a great question. Research supports children being raised in a bilingual environment. There is no studies that indicate exposing a child to multiple languages will hinder their land which progress or their speech progress. There is quite a bit of research showing learning another language and being fluent in more than one language has a lot of cognitive benefits for the child as well. I think if you have a child with apraxia or a significantly was disorder, I don't think I would recommend only speaking in one language to the child. What I recommend to families is that you should be using whatever language you are the most comfortable using. Whatever your home language is, that is what you should be using when talking to the child. The most important thing is they are getting a really good model. You want to make sure you are speaking to your child in whatever language you feel is your strongest. >> Thank you. You mentioned speech and feeding can be a problem together. Does that require different kinds of therapy? >> Absolutely. But does require different types of therapy. I mentioned nonspeech oral motor movements or exercises. Things like blowing through whistles or chewing on chewy tubes. There is not a lot of evidence that is helpful for speech production. There may be exercises that would be helpful with feeding therapies specifically. If you have a child who has muscle weakness where they are drooling a lot or having trouble closing their mouth while chewing, they might benefit from certain mouth exercises. There are some specific techniques for children who have swallowing troubles. If they are having trouble coordinating the motor movements for properly forming g and swallowing, there are exercises for those children as well. I recommend if a child presents with a motor speech disorder and a co-occurring feeding disorder that they get a comprehensive video fluoroscopic swallow study to make sure they are not aspirating food and are safe when eating. You have to pay attention to what types of textures the child might save. That is its own area of expertise. I would recommend seeking a comprehensive feeding team evaluation if your child has trouble with feeding. >> Thank you. My child is able to produce a wide array of words. We are working on phrasing and forming sentences. Often times the format of the sentence is jumbled. You might say me wait and set up I am waiting. What are your suggestions. >> What you're describing is very common, not just among children with apraxia. What you're are describing child having difficulty with expressive language production. Specifically more faux syntax. Knowing what order to put words in and what verb endings and other types of grammatical markers to use to make sure they are making sense. The type of therapy I would recommend for those kids is the same as I would for any child presenting with an expressive language impairment. It is not unique to children with apraxia, although certainly if a child has difficulty producing certain sounds and words, that will impact their grammar skills. Those two things need to be targeted in a hand by hand -- hand in hand fashion. I do think there are specific language elicitation techniques that would be unique to a motor speech disorder. Any techniques the speech therapist is using with other children with expressive leg was disorder would be effective with your child as well. >> Thank you. The next question is, is it a good idea to move the school start date or hold them back to your together more time to catch up on Ling which development? >> We often times are asked that question in the clinic. Certainly among children who present with a wide range of learning difficulties, not just motor speech disorders. This is a very personal decision for each family. It depends on your individual child. I tell families that there is no one-size-fits-all approach. Some children might benefit from going to school even if they still have a significant speech impairment. Some children, particularly children who currently have access to very intensive at good intervention, it might be reasonable to wait a year as long as you have them in the appropriate supports. What I would hesitate to do would be to recommend across-the-board holding your child back with the assumption that in a year there speech shall be a significantly better point. Especially if they're not currently able to access intensive services. The level of services children get once they begin kindergarten is much higher than the level of services they are able to get when they are in preschool. This is not always the case. It depends on your individual specific situation. >> Thank you. Should my child have an MRI if they have a motor speech disorder? >> I mentioned there is one subgroup of children who present with motor speech disorders that are due to some type of obvious neurological insult. Maybe they had a brain bleed at birth, children that are very premature. Often times that is the case. If a stroke has been suspected or early in life there was a traumatic brain injury. These situations, if the child is presenting with global neuromotor dysfunction, maybe with abnormal neurological exam, oftentimes a physician, neurologist or pediatrician will recommend brain imaging. For the average child presenting with a motor speech disorder but does not have global neurological dysfunction, often times MRIs don't reveal much. Certainly no specific findings you could put your finger on and that would change the child's prognosis or change the treatment approach. This would definitely be a decision you should make with your child's neurologist or pediatrician who has an area of expertise in your logical exams and knowing what to look for when it comes to recommending an MRI. I think most kids who present with the proxy of -- apraxia would not recommend an MRI for most children. >> Great. You mentioned AAC for some kids. This question is the child speaks at home by the parent is able to understand the child but at school other kids and the teachers have a hard time understanding them. There is concern if they use the AAC device at school they will stop trying to talk at school. Do you have any recommendations in that case? >> There isn't a lot of research evidence that dedicates introducing AAC will prevent a child from being motivated to talk in any circumstance. I think kids are generally pretty good at figuring out the best way for them to communicate the most efficient, the most effective way of communicating across environments. What I usually tell parents is communication is multimodal for everybody, especially in the time of zoom. Sometimes we have face-to-face conversations, sometimes a telephone call or email. It depends on the situation. Kids that are AAC users might have some situations were speech alone is getting the job done. There might be situations where there is a lot of background noise, in a group setting, try to give me a unfamiliar partners where there speech alone is not sufficient to get their point across. It's important in those situations the child does have access to some type of AAC to prevent frustration and increase their functional communication. What we don't want is for them to shut down in a school setting because they know other people just are not understanding them. >> Great, thank you. What should I be doing at home as a parent to help my child with a motor speech disorder? >> I think the best thing you can do is have really ongoing and open communication with your child's speech therapist. A good speech therapist will always get motivated parents specific activities and things to work on and a home environment. What you want to do is see what the child is doing in speech therapy and work on the same exact targets in the home environment. Doing this will increase generalization of skills. What a child is learning in the clinic can be applied and practiced in a home environment. That depends on what they are working on in therapy. The number one recommendation is make sure you talk to your child's speech therapist and ask what you should be doing in the home environment. >> This next person talks about how their child lost speech at a point in the development and are asking about potentially trying an intensive short speech therapy program more than a long-term. Is there evidence about that? >> I don't know if there is a lot of evidence for specific approaches for children who present with some type of regression, and the cause of the regression will probably play a large role on the child's ultimate prognosis. Some children, if they've had some type of neurological event, the onset of seizures is one thing we sometimes see where a child's speech will be significantly impaired afterwards. I think if you are seeing changes in your child's speech the first thing to do is make sure you do take them to a neurologist or a developmental pediatrician, someone who has a specific area of expertise in neurological conditions to make sure there is nothing significant going on that needs to be treated. Often times by treating the underlying problem you might see an agreement of speech as well. In this particular situation I say speech therapy sounds warranted. I would maximize speech therapy until a point where you are seeing some progress with your child. Even if it is a new onset problem, I don't think there isn't a reason you shouldn't get your child into intensive speech therapy. The amount of its will depend in your child's individual progress. >> You mentioned children who are nonverbal or minimally verbal cannot be diagnosed with a butter speech disorder. Can you clarify how much speech is necessary? >> What I tend to do in clinic is of a child is not really using a lot of spontaneous speech but are willing to attempt to produce words on repeat -- if I model something for the child and they at least try to attempt to say what I'm saying, often times I get a good enough idea of whether or not this could be a motor speech impairment. The kids that are challenging are the ones that are minimally verbal and really not willing to attempt to produce words on request, whether that is spontaneously labeling pictures or repeating what I say. I would say at the bare minimum it should be a child who has some spontaneous single words and also is willing to attempt to reduce many other words when given a model first. Ideally I feel the most optimal making a diagnosis in children who attempt phrase level speech, work, nations. -- in other words word, nations. -- word combinations. >> Should I have my child see an ear, nose and throat specialist? >> Typically craniofacial differences or hearing issues are not thing a role in it comes to motor speech impairment, but those things could play a role in having poor speech intelligibility and some type of articulation disorder. Is best practice anytime a child presents with a speech delay or some type of speech impairment that they should see an audiologist simply to relet hearing loss as one underlying cause for the language impairment. That is always best practice. I would recommend at least doing that to relet hearing loss as a contributive factor to their speech impairment. Certainly if you suspect they have some type of craniofacial difference, if you're suspicious of possible cleft palate or possible issues with dentition or residence, yes, seeing ENT for a good evaluation might make sense. Certainly those things wouldn't be an underlying cause of a proxy of -- apraxia but the could cause poor speech. >> Thank you so much and thank you for your time today. Thank you to everyone who joined the Q&A session. We hope you learned valuable information. Next again Marissa for sharing the presentation and participating in the question and answer today. We will see everyone at the next session. >> Thank you.