hi I'm Edie strand and today I'll be talking about diagnosis and management of childhood apraxia of speech or as we call it CAS I have been asked to speak about this today by the once-upon-a-time foundation who is committed to providing additional education for speech-language pathologists in the area of management of CAS I do have a couple of disclosures my I am on the advisory board for the childhood apraxia of speech Association of North America or Kasana which is a non paid position my financial disclosures include being paid royalties from both Pro II D and tema publishers for my books and I am being paid a stipend for this course I want to make a couple of introductory comments that I think are very important before we start talking about management of CAS the most important is that we're really embarking on a paradigm shift here in terms of our thinking about apraxia as speech-language pathologists we're very used to thinking in terms of sounds or phonemes today I want to encourage you to think more about movement we'll be talking a lot about movement today with respect to how it happens how movement is learned how we help children sustained that learned movement accuracy but we're going to do it in a very different way than we typically think about treating speech sound disorders I'm going to go over just a few important points that I want you to take away by the end of today's course first I want you to keep in mind that childhood apraxia of speech is not a medical diagnosis it's a label for a certain type of speech sound disorder this is important not only for you to understand but to help parents understand as well we'll talk a lot more about that the next really important thing to remember is that in childhood apraxia of speech the focus of treatment is the movement and making that movement more accurate not necessarily thinking about the phoneme or acquiring the distinctive features and use of a particular phoneme for the language in treating childhood apraxia of speech our focus that is what we observe during assessment tasks as well as what we treat has to be the movement accuracy and how that happens to be honest when we think about movement we're thinking about the fact that that changes almost everything about the words we use the type of feedback we give the stimuli we choose and we'll be talking a lot about that today there are many different types of treatment approaches in CAS that we'll talk about but in general the differences in treatment that we're talking about include the following things first of all kids with CAS are going to need more frequent therapy typically shorter sessions and more frequent therapy I'm going to suggest that you use an approach that's focused on improving motor skill versus linguistically based phonemes and most importantly probably is the fact that we need to think about and incorporate principles of motor learning in both our treatment planning and when we implement treatment and I'll be talking at some length about how we make that happen some specific examples of those differences with respect to motor learning though include first creating specific stimuli based on vowel content and syllable shape during early treatment and with more severe practice deficits using fewer stimuli with more dynamic shaping of the movement accuracy as you're working with the child I'm going to suggest that we maximize response trials per session and to do that we have to get away from some of the pictures and games that were used to working so that we can get enough Octus trials per session to do that we need to use quick but novel reinforcers and i'll talk about how that we can do that one of the most important and salient and effective methods of providing feedback to a child and in queueing is to have the child watch your face we've kind of known that from our own clinical experience for years but now we know that there's more evidence for how effective this can really be so it's important and I'll talk about how this might happen that we encourage the child and even help the child attain the ability to watch our face with attention and intention one of the other things that we'll do a little bit differently is to think about our we're going to how we're going to organize practice are we going to organize it in a way that's very random or are we going to do it in a way that's very blocked and I'm going to be suggesting for the more severe children that we work with that we use a modified block approach moving to a more random production as we move through therapy and we'll be talking about why that should be feedback we know how important feedback is when we're working with children that have any kind of speech sound disorder when we learn about the principles of motor learning we'll be talking about the fact that at first and when the child is more severe we have to give very specific feedback and we have to do it very frequently and we have to do it very quickly but over time to help improve their generalization we're going to provide less frequent feedback we're going to do it less immediately and probably get to the point where we're providing only very random feedback and only knowledge of results either it was right or wrong finally I'm going to suggest that we just can't take treatment data while we're working so hard to shape the accuracy of movement as a result I'm going to that we use a technique called probe testing where at specified intervals you sample a number of trials of your stimuli with no queuing in order to determine how well your treatment is working and most importantly this is something I really hope you take away from this video I'm hoping that you'll gain more confidence so that you can be sure that you have a rationale for every clinical decision you make and that you're going to be confident in your ability to explain that decision to parents as well as to others so although this course is focused on treatment we know that differential diagnosis is the first step in treatment planning so that means we need to distinguish in any child with a speech sound disorder how much of their problem is linguistically based phonological versus a motor planning impairment such as CAS or a dysarthria which is related more to weakness or difficulty with the execution of movement let's start though with just a brief introduction an introduction to childhood apraxia of speech especially excuse me especially for those people who maybe haven't worked with many children that have a CAS CIS is believed to be due to deficits in both the planning and programming of movement gestures for speech production we'll talk a lot about what that means and how to explain it to parents it often occurs along with language and phonological parent but the deficit when we use the word apraxia relates more to that child's ability to specify parameters of movement that is motor programming so that the movements occur at the right time in the right direction to get to the right place at the right time some of the means beach characteristics are vowel and consonant distortions inconsistent voicing errors pros otic errors especially equal stress and segmentation awkward and imprecise movement transitions and finally groping and or trial and error behavior that you typically see on elicited responses but not so much in their spontaneous behavior here are some clips of children with CAS so that you get a sense of what these children may sound like and look like have a potato potato potato put a yell and try to make your tongue tap at the end like mine let me let me show you first potato but any doodle good and then make sure you spin it at the beginning potato again let's say go perfect three get a dough my turn potato potato she spit it like a joke nice job how about this one Vidia failure though video swing angle good shine watch me students gather I'll show you with a ghost see do they deal beautiful big deal come on let's do it one more time a little faster together already deep so you bite your lip yeah nice job my turn video baby girl good try one more time video fancy girl good try boo boo to do watch my legs this time boo boo boo boo [Music] can you try to go boom-boom boom-boom good for the training [Music] mom might do that again Wow Wow cheap sound a little chick said little chick goes peeping my turn clean my cheese now my turn first P B good job let's try to do it all in one movement watching PE better let's do it together again we need my turn now you wait P P and we're just probing here tell me movie now I hear a lot of woo let's try to do it go slow at the same time with Edie [Music] let's go just stay there a minute see what it feels like can you feel that [Music] there you go now I've been using the term childhood apraxia of speech so what does that really mean what does this word praxis mean anyway well we're gonna talk more about this later but I want to begin talking about it now because it's very important that you understand what this word means why we use this word to as a label for some children with speech sound disorders how it differs from execution problems and later of course we'll be talking a lot about why it matters in terms of how we plan and implement treatment first of all let's talk about some practice deficits versus execution deficits in the practice deficits we're talking about deficits in the ability to conceptualize plan and program skilled volitional movement what does that mean well it means that in order to make an accurate movement we have to be able to start contracting certain muscles at just the right time so that movement happens in the right direction with the right speed with the right force with the right amount of muscle contraction and this all has to be timed perfectly so that all the structures move in a coordinated fashion now when there's problems with practice it could be due to some determined that is acquired cause such as for children maybe neonatal stroke more often though we don't know what causes the inefficiency this ability to specify movement parameters or do this motor programming we know that there must be some either weakness in terms of the synaptic connections or perhaps the synaptogenesis that happens during early development a lot didn't allow the efficient production of motor planning regardless of what may have caused the problem the important thing to remember and to tell parents is that we know how to treat it and I'll be talking about that over and over again execution deficits on the other hand are usually caused by some known impairment either in the central or the peripheral nervous system it often presents as weakness either due to perhaps spasticity or flaccidity and results in decreased range of motion decreased speed decreased force and movement and less ability to really vary the tightness of the muscles themselves during the movement and that brings us to a really important point that we need to talk about and the reason I want to bring it up here is that this is something that's often misunderstood by speech-language pathologists we have less training and movement and neurology than many professions do and so it's no surprise that this can be a confounding element when we are doing both assessment and treatment and that's the difference between weakness and muscle tone so let's spend just a moment talking about that muscle tone is the state of partial contraction of muscle fibers when the structure is at rest and this is happening all the time as you're sitting there or standing there your muscles are always in a partial state of contraction and this is maintained by a number of processes that we don't have time to go over today they're especially influenced by the cerebellum they include processes such as the gamma loop and the stretch reflex now for some reason the term muscle tone is often equated with strength so if you read a report that says the child has generalized low tone you might be tempted to think oh that means the child's weak and I better work on strengthening but they really aren't the same thing in fact if you read many reports written by a pediatric neurologist a very common statement might be generalized low tone normal strength how can that be well strength is associated with muscle contraction causing movement of a structure like if I go to scratch my nose in order for me to move this arm to scratch my nose and I have the intent to move this arm I'm going to do something called recruiting motor units now a motor unit is just neurons in our brain and we have upper motor neurons and lower motor neurons that talk to each other so we recruit these upper motor neurons usually up in motor strip and we say okay I'm going to recruit this many of these upper motor neurons because I need this much strength to move this arm to get to my nose while those motor neurons the upper motor neurons send the message down to the lower motor neurons now for the limbs it will be somewhere in the spinal cord but for the face for the muscles we use for speech it's going to be in the brainstem it's those lower motor neurons then that send out fibers that actually wrap around muscle fiber and cause muscle fibers to contract which cause ruptures to move so those are that's a very different process than what we talked about for muscle tone which is just a partial state of muscle contraction at rest so the point is a child can command with generalized low tone and still have enough strength normal strength for speech now we know that strength increases if we overload the muscle in some way either we increase the size and/or number of muscle fibers themselves or we recruit a greater number of motor units and/or we increase the firing rate of those motor units now even a child with generalized low tone might be able to recruit enough motor units at a firing rate that makes the movement adequate in strength for speech so tone and strength we really want to think about us being two different things we want to remember that if a child has generalized low tone they may not actually be weak for speech production so I want to ask you to think for just a minute about what kind of evidence you could look for that would help you feel confident that a child is not weak for speech and therefore confident that you don't need to do strengthening activities as part of your therapy let me give you some hints first of all if the child comes in and yes they may have this generalized low tone sometimes you even see a slightly open mouth posture and then they go I'd uh i bah a doctor good respiratory support good so good subtitle air pressure good phonation good closing you don't have any evidence for weakness in that scenario no nasality that means that the velum is moving fast enough and strong enough to actually block the nasal pharynx good volume good respiratory support is other evidence that the child is not too weak for normal speech production I think it's okay to think about the fact that if the child is observed to have normal closing good respiratory support good volume no nasality that you're pretty safe say in making the decision I don't need to work on strengthening even though this child may have generalized low tone now does that mean they don't need OT or PT probably not they probably will be in OT MPT what I'm saying is we don't need to work on strengths for speech if we're observing these behaviors now if the child actually is weak which is often due more to some problem with the lower motor neuron or due to spasticity I want you to ask yourself is childhood apraxia of speech the appropriate diagnosis in that case or would dysarthria be a more appropriate diagnosis similarly if the child has good respiratory support and no nasality and can make plosive sounds without any error ask yourself the same questions this childhood apraxia of speech the appropriate diagnosis or would dysarthria be a more appropriate diagnosis we're going to answer those questions as we go along in the course today I'd like you to be thinking about these questions though as we go along you may even want to jot them down if you don't feel sure about it right now but now we're gonna move on to maybe an even more foreign concept to us and that is what do we really mean by motor planning and programming you know we use these terms all the time we use it in adult apraxia of speech we learn about different models and theories of motor programming in our undergrad and graduate classes and we certainly talk a lot about it when we're talking about childhood apraxia of speech but I wonder how many of us are really confident in explaining it to our colleagues to a parent to a referring physician I'm going to argue today that we should be confident about that if we're dealing with a child that has a proxy of speech it's so important for us to understand what we mean by that how we're planning treatment to address that particular inefficiency in processing and be able to explain it well to the parent so today we're here to discuss childhood apraxia of speech and as I said we've attributed this label of a speech sound disorder to a problem in aspects of the motor planning programming processes involved in speech so in order to really talk about that let's just remind ourselves what we're talking about in terms of speech production in general because sometimes we have to talk to parents about this parents have never thought about what really happens when we go to talk many of them I mean did we add before we started grad school probably not so let's think about it well first you have to have respiratory support right because you need a source of sound because after all speech is just the acoustic representation of language right so we need good respiratory support to build sub glottal air pressure so the vocal folds can vibrate so there's sound or our source that sound source then resonates off the vocal tract walls the pharynx the nasal pharynx the oral pharynx the throat and then constriction of that voiced airstream to make individual noises so that the acoustic signal is very enough that we can have a meaningful message so how does planning and programming fit into all this well we know that speech sounds are produced because of a specific sequence of movement that are not discrete but that blend from one gesture to another so speech production involves this continuous movement of parts of the vocal tract especially at the level of the syllable there's no stopping of the movement or the sound during said the syllable production now I'm going to say this a lot during this video today but I think it's important you know they tell us when you learned it to teach they say well you got to say something at least nine times be for people hear it and understand it so you're gonna hear this more than nine times today probably but I'm really hoping you see why I'm belaboring this point the point being that speech production involves discontinuous movement we're really used to thinking about phonemes or sounds and because we're involved with literacy we're also really cognizant of this grapheme and both phonemes and graphemes are segmental phonemes are this conceptual unit that's in our mind but not yet in any reality it's a linguistic element made up of these distinctive features right and a grapheme is that pictorial representation of that phoneme perhaps and we can we can write that grapheme and that's what makes it realized well think about the acoustic production of phonemes in running speech we don't say these phonemes segmental ii like we might write them we don't say act we say cat and it's one sequential movement for that syllable think for a minute if a child is having problems specifying movement parameters it's probably pretty important that we practice that we help them learn to be more accurate and movement that we've worked to make the processing that isn't so efficient more efficient by working on what's not happening correctly which is the movement gesture at the level of the syllable you're going to hear that many times during the course of this lecture so we have to think about planning and programming in the context of this continuous movement gesture well the motor planning areas of the brain are what really specify these movement parameters well how do they do that well first they need to know what's going on to begin with so they need to know is the mouth open or closed is the tongue tight or loose is it forward or back is the V limb up or down and it takes that constant stream of incoming information typically we're talking about proprioceptive information about where the speech structures are in space whether or not they're moving and what direction they're moving with how much force with how much muscle tension and it takes all that information and uses it to program or specify the upcoming movement parameters for volitional speech production so as the speaker gets ready to talk particular muscle groups are selected to begin to contract at very specific times to cause structures to begin to move at very particular times in a particular direction at a certain speed with a certain amount of force and using a specified amount of muscle contraction now when I speak in front of our to them off and out so what do you mean by a specified amount of muscle tension and what I often have people do and you can do this at home is make an S sound and now make a T basically you've moved the tongue in the same direction to get to basically the same place but the thing you change the most is that you recruited more motor units so that the tongue fibers were tighter you recruited more motor units so that more lingual muscle fibers contracted so that you had more muscle tension which caused the airstream to stop completely all of that has to be specified it all has to be programmed so the direction of movement the speed of the movement how much muscle contraction there is how much force there is all of that has to be specified and think about this it has to be specified for all the respiratory muscles all the laryngeal muscles the jaw muscles the tongue the veal in the pharynx all in specific milliseconds so that everything comes together at the right place at the right time I'm often surprised when I hear very young children learning to speak so easily and I'm not surprised at all when children have a difficulty because this is difficult stuff now we call these things that have to be specified parameters of movement so the range of motion the direction of movement the speed the force and the amount of muscle tension all of that has to be specified so we call those parameters of movement and that movement specification is really what we're talking about when we say or use the term motor programming now we talk about the fact that these parameters of movement are specified again that just means that particular muscle groups are selected to begin to contract at just the right time to allow the structures or the articulator x' to move in just the right time at the right speed to get to the right place at the right time we call that reaching a spatial temporal target now it might be easier to think about if they were segmental and you just had one movement to one target do the next one but that isn't how it works this at the level of syllable anyway it's continuous gestural action and I like to use the term movement gesture or movement transition to represent the fact that this is not a segmented movement but that it's continuous now for children that have significant difficulty with practice for speech it may be that the primary difficulty is with the specification of movement parameters so that there's difficulty with the right articulator is getting to the right place at the right time but we don't know there also could be difficulty with processing that a ferret or incoming proprioceptive information that the motor planning areas of the brain need so we're not sure exactly at what point is a problem with the proprioceptive receptors the pathways to the motor planning areas of the brain the motor planning area of the brain itself because we can't be sure though I'm going to be talking to you about ways in therapy that we can work to improve or at least make more salient proprioceptive processing as well as working to improve the efficiency of the processing involved in this specification of movement or motor programming to sum it up though i think what i want to encourage you to do is to think in terms of assessing and treating these movement gestures or transitions rather than phonemes when we're actually interpreting assessment data coming to a differential diagnosis and certainly when we're planning treatment now a child might have difficulty with this practice for speech production that we've been talking about and then we use the label childhood apraxia of speech but they can also have difficulty with this practice problem for volitional that means on purpose or intended movement that is non speech but still oral aural non speech movement so these would be things like show me how you kiss your dolly can you cough show me how you cough can you lip smack your lips like this let me see you blow some children will have great deal of difficulty organizing the movement so we know now that's more specifying movement parameters to actually blow or kiss for example if you have given their dollar you say can you kiss it your Dolly's head they might go and just do an open mouth kind of touch you ask them to blow maybe they'll go they know what they want to do but they can't make their muscles move in the right direction with the right speed force etc all the things we've been talking about so that's called a nonverbal oral a axiom now I will make the point later but let me say it quickly now if a child has a practice of speech they may or may not have an aural non verbal apraxia some of the most severe apraxia of speech that I've seen in children were not accompanied by any nonverbal oral apraxia those kids were fine in that sense other children with apraxia of speech do indeed have a nonverbal oral apraxia on the other hand if a child does have oral non verbal apraxia the chances of you finding a proxy of speech go way up so the child with apraxia doesn't necessarily have nonverbal oral apraxia but if they have a nonverbal oral apraxia you really want to be careful as you look for evidence for childhood apraxia of speech now if a child has nonverbal oral problems because of actual weakness or paralysis then their problems in speech production fall under a different label which is dysarthria we won't be talking about dysarthria very much today other than to distinguish it from childhood apraxia however this is a little another caveat we have to I have to say something about another one kind of dysarthria that's not associated with weakness and this is a tactic dysarthria and the reason why this is so important to our discussion today is that there's a lot of overlap in the characteristics between ataxic dysarthria and childhood apraxia of speech just to muddy the waters you know what we do is hard it's really hard we have to know a lot of stuff we have to know a lot about cognition a lot about language a lot about child development child behavior we have to know about motor learning there's just so much that we have to know in our jobs and this overlap of characteristics between ataxic dysarthria and childhood apraxia speech is one of those things that makes what we do harder ataxic dysarthria is a speech problem that's characterized by impaired coordination in movement of the articulate errs usually it's due to problems of the cerebellum either acquired or developmental but it's hard to differentiate especially from childhood apraxia because of the idea of disk coordination if a child has coordination problems like over shooting and under shooting mistiming due to cerebellar issues you can imagine that some of those characteristics will be similar to those problems due to specification of movement parameters now there are some ways to distinguish them that I will talk about today let's think about this you know in a bigger sense here with this chart that I put up on the next slide at the top I have oral motor problem so we use that term a lot oral motor which I don't like to use but it's so pervasive in our field that I want to say if you use that term at least be very specific about what you're talking about because of oral mouth motor movement it could relate to anything like having your jaw wired shut because you've broken so you want to be really careful to differentiate or a motor problems that are due to execution say weakness or paralysis and that due to problems with practice that we've been talking about so in this chart you see execution on one side practice on the other under the execution side we see that that results in actual weakness or decrease and or decreased range of motion decreased strength decreased speed for example and if you look further down under execution you see that in the nonverbal context we would end up with things like drooling and dysphagia on the verbal side you see that on an execution problem we have the label dysarthria for the speech disorder on the other side we have praxis which is more of this planning and programming movement problem in the non verbal context we said they have a we have a label for the problem which is nonverbal oral apraxia and then on the verbal side we have the label childhood apraxia of speech I have noted this big arrow here though that shows a toxic dysarthria does have overlap in terms of the characteristics with childhood apraxia of speech so now we're talking about the differential diagnosis of speech sound disorders and you see on the chart that I put up here that we have phonological verses motor speech impairment and this will be a lot of what I'm talking about today with respect to differential diagnosis how do we tell whether this problem is more due to a motor planning programming problem versus just maybe a more severe deficit in phonology under motor speech impairment we have to differentiate childhood apraxia from dysarthria so one more little caveat here we've put a lot of emphasis on labels on taxonomy maybe even too much I mean these categories these labels aren't discrete they overlap they co-occur children with childhood apraxia always have phonological problems right and doesn't that makes sense if you have at least you know significant difficulty with planning and programming movement you're gonna have trouble practicing what you need to practice to develop the phonological system for your language problems in one area going to influence the development in another now lejos so are necessary we need terms to talk to each other so we know what we're referring to so we have to be careful not to put too much emphasis on a label and to recognize that these labels overlap interact with each other influence each other and keep that in mind as we're working with the child because labels change labels have to be considered in terms of the child's development and their developmental trajectory remember that as as development proceeds neurologic development and maturation continues long after birth right so we have to be cognizant of that as we're working with the child as development proceeds the characteristic of their speech problem may change as therapy proceeds hopefully the characteristics of their speech problem will change they will improve they may get to the point where they no longer have a set of characteristics that we associate with a certain label we're here to talk about CAS so when we're working with the child they may have many characteristics of CAS we feel confident in using that label for their speech disorder we continue to work with the child neural development continues and we realize that at some point they might just have some residual articulation errors but really don't have enough characteristics of childhood apraxia to warrant the use of that label we may always put in a report that the child has a history of childhood apraxia because that may influence some of our decisions even as we're working with residual articulation deficits but our therapy will be different at that point and it's appropriate to discontinue using the former label of CAS and talk about it as just being in the past that may influence what we do now so now we're going to move on to differential diagnosis