Effective Apraxia Therapy
Today's post is a continuation of my most recent interview with Sharon Gretz, MEd, the founder and current executive director of the Childhood Apraxia of Speech Association of North America
(CASANA). Please take a look back at this week's earlier post
, published on Tuesday January 26th
to read the beginning of our interview. The interview with Sharon will run in its entirety over a two week span and will end next Friday, February 5th
Here is the second part of our interview where Sharon outlines in detail what apraxia therapy really needs to look like to be effective and successful!
Stephanie: Back in the summer, we had a debate on the blog regarding oral motor techniques used to address apraxia. Many therapists weighed in on the topic and things became a bit heated. During the debate, you stated, "Speech therapy that incorporates principles of motor learning is what appears to be most effective for children with apraxia of speech". Can you expand on what "principles of motor planning" means? I believe both parents and therapists need a clear, well-defined plan for what apraxia therapy and "motor planning" techniques should look like.
Sharon: First of all, doesn't it make sense to you that if the child's major issue with speech production is the motor planning and programming for speech that the "remedy" should address speech motor planning and programming? We should be "attacking" the problem at the right level of the system. There is a lot of published literature on motor planning and programming and the role of these processes on how humans learn "skilled movement". Speech is perhaps the most highly skilled movement of all!
Appropriate speech therapy for children with CAS is based on the SLP's understanding of Childhood Apraxia of Speech as a motor speech disorder. Additionally, they need to provide treatment with the understanding that the child's main issue in regards to their speech production is the inability to plan and program SPEECH movements. The clinician would understand the need to use principles of motor learning in their therapy approach. There is a whole body of scientific data that exists and describes how humans learn skilled movement (motor learning). These principles involve conditions of practice that lead to permanent change in the motor system. Some of these principles are the careful consideration of the following:
- Amount of Practice—Practice matters. Developing skilled motor actions does not happen as a result of maturity or time; it is about practice of the actual skill, lots and lots of practice. Children with apraxia need a large number of speech practice opportunities for accurate speech movements to be learned. The amount of practice makes a very large difference in learning skilled movement.
- Practice Distribution—Carefully weighing how to practice the target utterances in either a "massed" approach or a "distributed" approach. The SLP should be seeking a way to see the child more frequently over several days, for example 2 - 30 minute sessions on different days of the week vs. one 60-minute session. For this reason, parents are also key to the process as they can help "distribute" practice if (and this is a very important IF) they are explicitly and carefully guided on how to elicit speech production at home and in the community from their child.
- Practice Schedule—Many experienced SLPs think that when a child is very severe or learning a new target that some period of "blocked" practice (the child is asked to say "mom" 10 times, then say "up" 10 times, then says "no" 10 times) is appropriate, versus what is called "random practice" where, during a therapy session, the speech targets are still elicited many, many, many times, but in random order such as: mom, mom, up, no, up, mom, no, up and so on. There is some thinking that blocked practice helps improve performance during the speech session but that overtime, random practice facilities motor learning.
- Variability of Practice—The SLP should be considering how to vary practice for the kids. They would not want to train the child to only be able to produce certain targets under certain conditions. Also, It doesn't help much if the child can only perform certain speech tasks in the speech therapy room and not in the waiting room, or in the car or at home. Kids with apraxia need opportunities for variable practice.
- Type of Feedback—In motor learning theory this is called "knowledge of performance" vs. "knowledge of results". It is the difference between providing feedback to the child based on the quality of the speech movements (i.e.: "you need to puff out your cheeks more," or "... not so wide") which is known as "knowledge of performance" vs. providing feedback based on whether or not the child achieved the target goal (i.e.: "yes, that was it"... "No, try again.") This later type of feedback is called "knowledge of results." Again, many knowledgeable SLPs feel that early in therapy or on complex speech movements, knowledge of performance helps the child through added input in order to shape their speech movements. As the child is more competent with their speech motor system, knowledge of results may be the more appropriate feedback for motor learning to occur.
- Amount of Feedback—Early in treatment, there is more feedback to the child on their performance or results, perhaps even after each trial. For example, when the child attempts a word, they get feedback. The child attempts again, they get feedback, and so on. When the child's system is more competent for the target, perhaps the feedback is given after every 3 attempts or every 5 attempts. Why? Again, this is so that at some point in time the child's own system takes over the processing load.
- Timing of feedback—Early in treatment, the SLP's feedback may be immediate. As the child is improving, the SLP may delay their feedback for a few seconds so that the child can process and judge for themselves, which may improve their self-monitoring skills.
Other important factors that we educate about are:
THERAPY IS FREQUENT—Per the American Speech Language Hearing Association (ASHA) Report on Childhood Apraxia of Speech for children with severe to moderate CAS the suggested range is 3 - 5 x a week of individual speech therapy, taking into account each child's individual circumstances and ability to tolerate it, etc. Do you see how this ties into principles of motor learning related to amount of practice?
THERAPY IS INTENSIVE—By intensive, I mean that the child has the opportunity and experience of producing speech targets and having assistance from the SLP to shape those utterances to be more accurate, dozens and dozens of times EACH speech therapy session. So, that would mean, for example, that providing GROUP therapy would reduce intensity for the child with severe CAS because they would not have as many practice opportunities nor the complete attention of the SLP who can individually assist them with their productions. This is why 1:1 therapy is recommended and why group therapy, while helpful for other reasons, is not likely going to lead to substantial progress in speech production skills and motor speech improvement for kids with significant apraxia of speech. This is also why we don't want to see these kids sitting silently in therapy with just occasional utterances or worse, with the SLP doing most of the talking! The child needs to be engaged and producing speech attempts and a lot of them, while receiving the appropriate feedback! Once more, this directly correlates back to principles of motor learning as it relates to practice conditions.
THERAPY ENHANCES SENSORY FEEDBACK DURING SPEECH—Most effective therapy methods for apraxia appear to include multi-sensory feedback in the form of visual, verbal, or even tactile/touch cues to help guide the child's speech movements. There is some research, and more emerging, that children with CAS may not be processing internal sensory feedback or are not able to adjust their movements based on their "online" internal sensory feedback systems. As SLPs will remember from their speech anatomy and physiology courses, the motor and sensory system are intimately connected. So, interestingly, perhaps that is why these multi-sensory methods appear to be more effective than other methods.
It is unfortunate, that there is no single "recipe" on speech therapy for children with CAS. The fact is, Stephanie that clinicians need to use their understanding of the nature of the disorder, the needs of the individual child and then apply thoughtful consideration to these issues that relate to motor learning principles. The clinician is always thinking, altering, and evaluating these conditions in a dynamic process for each child and within each therapy session. There is still much research needed on effective speech therapy for CAS. That is why we (CASANA) established the Apraxia Treatment Research Fund and award grants so that investigators can conduct the studies that will lead to better knowledge and thus, and most importantly, better outcomes for the kids. Until more is known, we need to rely on practices that theoretically make sense given the understanding that childhood apraxia of speech is a speech motor planning disorder.