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Early Intervention Speech Therapy

Effective Apraxia Therapy

Published January 29, 2010 10:47 AM by Stephanie Bruno-Dowling
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.

11 comments

Our granddaughter (4 years old) has apraxia, do you know of locations in Maryland that could be helpful to her? My daughters insurance will only cover so many sessions of therapy. I understand that she needs 4-5 1/2 hour individual seaaions each week. We are looking for different ways of getting the help she needs. Can you help us?

Thanks

jerry , engr asst. - verizon April 26, 2010 6:40 AM
hampstead MD

Thank u for very nice information regarding apraxia. and i have a client named gayatri and she got stroke when she is 13 years old and she is 20 years old and she came to therapy 6 years after the stroke and was diagnosed as severe apraxia ...... would u plz give guide lines for me regarding this client..............

March 6, 2010 6:42 AM

Thank you for all the good information. I know that I can use some of this info. when i go fight for my little girl. I have a 3 year old daughter who has neuromotor Apraxia, mild Cerebral Palsy . Right now the SLP only sees her two times a week at 15 min. a time. Her ENT said he would like her to have five times a week 30 min. each time. So I have called for another IEP meeting on march 8th to get her more time. I've already heard some feed back from some of the IEP team and they are not very happy that I'm asking for more time. I don't think the SLP knows much if anything about apraxia if she did she should have come to me and explained what treatment Lilly should be getting. I just want to tell others to fight for their kids and if someone turns them away then look some where else and keep fighting.

February 27, 2010 5:37 PM

I am a parent with a 32 yr old child who has TBI from an assult at collage 13 yrs ago and he has been diagnosed with apraxia, but his slp never told me about therapy for apraxia to teach him skills that would help teach him fine motor skills we work with him constently and he sings for me he remembers the words of the songs he knew befor his accident any info or training info you could send me to would be greatly appreciated

February 14, 2010 12:36 AM

Nice suggestions. I am new to E.I. and I am also wondering how to apply these practices with children in the 2-3 year old range with suspected apraxia. I have worked successfully with older children with Apraxia, but children under age 3 often will not/cannot repeat a word or sound over and over for motor practice. I usually work on just getting these children to make vocalizations in general and target /b,p,m,d/ initial sounds for high-interest items. I am finding that children in this category are very timid to vocalize at all. It is labor intensive to work with them!  I would appreciate any ideas for the younger crowd. Thanks.

February 12, 2010 2:26 PM

Great article.  I have a child who is approaching 2 years old with suspected apraxia.  Imitation skills are extremely poor and she remains quiet for the majority of sessions.   My goal is for the child to simply become more vocal!  I have referenced the "Becoming Verbal with Childhood Apraxia" book for some ideas, but I am constantly looking for more!  I would love to hear how other therapists are treating suspected apraxia in early intervention.  Any ideas are appreciated!!!

February 2, 2010 7:35 PM

I recently got a 15 month old cleft/lip and palate on my case load.  Using very little speech if any,  mom doesn't really have any feeding concerns right now, lip and palate have both been fixed. Would you integrate oral motor therapy into treatment for upper lip mobility ect?

February 1, 2010 8:08 AM

Thanks for the wonderful summary.  I finished my graduate program last and your post here has summarized everything we learned in our neuromotor class about therapy for apraxia.  However, it is still a challenge to apply these principles to early intervention, and I'm not even sure they all apply.  Kids in early intervention are too young to be diagnosed with apraxia (per ASHA, under 3 is too early).  Even so, when a child is showing signs of apraxia (suspected), I make a referral for outpatient speech, but it is difficult to get insurance to approve sessions as many times as they truly need without the diagnosis!!!

Also the children we work with may be too young for many of the researched principles - will they really understand why we are delaying feedback?  Or will they really understand knowledge of performance feedback?  I still use these but I wonder how effective they ae.

Finally, my goal for children in EI with SUSPECTED apraxia (again it is far too early to be diagnosed)  is simply that they attempt more sounds!! EI is all about teaching the parents what to do so I educate them on what sounds are appropriate to work on, what cues they can give, and what to expect in terms of sound development.   I'd like to hear how other people approach apraxia treatment in early intervention??  And how you apply the above principles, if at all.

January 29, 2010 7:15 PM

Thanks Sharon, for a nice succinct article. Will be excellent to share with students, new clinicians, and parents!

January 29, 2010 4:30 PM

GREAT summary of important aspects of motor-based therapy as opposed to working on sound patterns.

January 29, 2010 3:57 PM

Good article for exposure to Apraxia.  Would love to see more SLP researching apraxia

January 29, 2010 2:38 PM

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About this Blog


    Stephanie Bruno Dowling, M.S. CCC-SLP
    Occupation: Speech-Language Pathologist
    Setting: Early Intervention in Delaware County, PA
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