Skriftserie i logopedi 2013:1
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Table of Contents
Introduction Anita McAllister & Edythe Strand ... 1 1. A Danish Checklist for Children with Childhood Apraxia of Speech ‐ from Idea to first Edition Louise Skov ... 5 2. A case study of a six year old boy with normal language abilities and childhood apraxia of speech Zafira Karakezlidis ... 17 3. Evaluation of intensive Dynamic Temporal and Tactile Cueing therapy for a 17‐year‐old male with verbal dyspraxia, intellectual disability and ADHD. A case study Catarina Ragnar ... 31 4. Childhood Apraxia of Speech and concomitant functional problems: A case study Susanne Rex ... 45 5. Speech‐facilitating oral motor treatment of a suspected childhood apraxia of speech and oral apraxia in a 3 – year‐old girl. A case study Birgitta Fog‐Poulsen ... 63 6. Oral and Verbal Motor Function in a child with childhood Apraxia of Speech Helena Björelius ... 71 7. Verbal Dyspraxi och Alternativ och Kompletterande Kommunikation (AKK) – en forskningsstudie Marlene Andersson ... 79 8. Diagnostisering av barn med misstänkt verbal dyspraxi. Bedömning med VMPAC Laura Olsson ... 89 9. Behandling av två barn med verbal dyspraxi enligt Dynamic Temporal and Tactile Cueing (DTTC). En multipel fallstudie Åsa Engström ... 99 10. Sensorisk stimulans med eldtandborste och DTTC. En kombinerad behandlingIntroduction
Two advanced courses on oral and verbal apraxia in children have been held at Linköping University in the spring of 2009 and 2011. Several international researchers participated as lecturers and contributed to the success of the courses and the high course evaluations. As an examination assignment several students chose to do case studies investigating the treatment outcome of different methods for children or teenagers with oral and verbal apraxia. Many were inspired by the method Dynamic Temporal and Tactile Cueing, DTTC that was thoroughly described by Professor Edythe Strand during the course. The case studies are presented as chapters in the present publication. Most chapters are written in English but some also in Swedish depending on the requirements of the specific course. At present there is a significant lack of treatment efficacy research in the area of childhood verbal apraxia, and many publications have indicated the need for this type of clinical research. Since these reports represent an important contribution to the limited number of outcome studies in children with diagnosed or suspected CAS we decided to make them available to a larger audience.
Childhood Apraxia of Speech – An eluding diagnosis in
developmental speech disorders
The terminology to describe the disorders has varied historically and is still not agreed upon worldwide. Childhood Apraxia of Speech, CAS, has been proposed by the American Speech‐ Language‐Hearing Association and is now the most common term. However, the National Institute of Health, NIH, still uses the term Developmental apraxia of speech (DAS) on their web‐page (www.nidcd.nih.gov/health/voice/pages/apraxia.aspx). CAS, or DAS, is defined as a neurological childhood speech sound disorder where the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (www.asha.org/docs). In 2007 the ASHA Ad Hoc Committee on Childhood Apraxia of Speech reviewed the available research and published two reports (ASHA2007a and b). Consensus on three features consistent with a deficit in the planning and programming of speech movements was reached, these features are: 1) inconsistent errors on consonants and vowels in repeated productions of syllables or words, 2) lengthened and disrupted coarticulatory transitions between sounds and syllables and 3) inappropriate prosody (ASHA, 2007a). Regardless of terminology the disorders is present from birth and appears to affect more boys than girls. CAS is not just a developmental delay of speech where the child follows the “typical” path of speech development but does so more slowly. Children with CAS commonly have disrupted and limited speech production that may be difficult to understand even for the immediate family. Generally their understanding of language is much better than their speech production may lead the listener to believe. The severity of the disorder varies. Many children with CAS also have other co‐occurring problems such as dysarthria; language problems, problems with reading, writing or spelling, coordination or gross and fine motor problems, and/or chewing and swallowing difficulties. CAS sometimes occurs in the context of specific syndromes such as velocardiofacial syndrome or Galactosemia. Many times there is no specific etiology and CAS is considered idiopathic. CAS may also occur with severe cognitive impairment, autism or neuropsychiatric disorders. In these children the diagnostic procedure may be particularly challenging.
The papers in this report provide important observations regarding children with CAS. Four studies address assessment issues in children with CAS, a few of whom might have normal language abilities and others different types of concomitant problems. One study examines the effects of augmentative and alternative communication – AAC in a child with severe speech difficulties. Five papers provide observations of treatment effects based on intensive programs and motor learning principles using different combinations of dynamic, temporal and tactile cueing, DTTC, or sensory stimulation with vibration. Results are quite promising and noteworthy for most participants and rather remarkable for one patient in his late teens with CAS, an intellectual disability and ADHD (see chapter 2). The treatment research in CAS is still in its infancy. Case studies provide an important first step in developing important research questions for examining treatment efficacy in experimentally controlled single subject design research, and ultimately in larger randomized control trials. In this collaborative effort these studies on the characteristics of CAS and treatment outcome based on well described case studies provide an important contribution to the field. Anita McAllister & Edythe Strand Stockholm and Rochester, October 2013
References
American Speech‐Language‐Hearing Association (2007a). Childhood apraxia of speech [Position Statement]. Available from www.asha.org/policy. In 2013‐07‐05
American Speech‐Language‐Hearing Association (2007b). Childhood Apraxia of Speech:
[Technical Report] Ad Hoc Committee on Apraxia of Speech in Children, Rockville Pike,
MD:ASHA. In 2011‐01‐15
Apraxia of Speech. http://www.nidcd.nih.gov/health/voice/pages/apraxia.aspx. In 2013‐07‐ 05
1. A Danish Checklist for Children with
Childhood Apraxia of Speech ‐ from
Idea to first Edition
Louise Skov, Department of Language and Communication, University of
Southern Denmark, Denmark
Abstract
The aim of this paper is to describe the first step in creating a Danish checklist for children with Childhood Apraxia of Speech to be used in the everyday life of the Danish Speech and Language Pathologists in cases where they are in doubt of whether it is severe phonological problems or suspected CAS. The first edition was evaluated by a questionnaire with six questions about the checklist sent by e‐mail to twenty Speech and Language Pathologists. The results of the questionnaire showed unanimous positive impressions of the checklist and an agreed‐upon need for a Danish checklist for children with Childhood Apraxia of Speech in clinical practice. Next step is to access the validity and reliability of the checklist in future studies.Introduction
The first steps in the creation of a Danish checklist for children with Childhood Apraxia of Speech (CAS) are described in this paper, from the first idea to the evaluation of the first edition. The creation of the checklist is based on inspiration from the study of Joy Stackhouse (1992) and her four perspectives on the symptoms identified in children diagnosed with CAS. Symptoms from other studies are also brought in as supplement to the author’s view of CAS as a motor‐speech disorder (Caruso & Strand, 1999; Love, 2000, Kent, 2000; McAllister, 2007; ASHA, 2007; Morgan & Vogel, 2008) and studies of tests, to get an idea of what is important to be aware of in the creation of a checklist useful in the SLP clinic (McCauley & Strand, 2008). The idea behind making a Danish checklist is the general lack of detailed knowledge of the differential symptoms between more severe phonological problems in children and symptoms of CAS. It can sometimes be a challenge to differentiate between these two diagnoses. There are several reasons for this statement. First of all: Danish speech and language pathologists (SLP) do not know that much in detail about the diagnosis CAS often suspecting the child of having severe phonological problems without thinking of the possibility that it could be CAS (Skov, 2007). One of the doctors in Denmark who are responsible for diagnosing children with CAS, Svend Prytz, once said: ”if you don´t know what to look for – you will not find it” (quote from a one day visit at his clinic, January 2007). Second: In correlation with statement one, the
SLP’s has less experience with children showing symptoms of CAS. This in combination with the low rate of children with CAS makes it even tougher to get clinical experience with the symptoms of CAS and later on experience with the specific intervention used for children with CAS (Portwood, 1996; Shriberg et al., 1997; Caruso & Strand, 1999). Third: The symptoms of CAS vary over time in relation to the child’s developmental stage and degree of severeness (Davis, Jakielski & Marquardt, 1998; Davis & Velleman, 2000; Williams & Stephens, 2004; Morgan & Vogel, 2008). This change of symptoms makes differentiating between CAS, dysphonology, and dysarthria a complicated task. In Denmark many children are first diagnosed when they are five to six years old after long periods of intervention at the SLP by methods directed to children with dysphonology. Some may also have attended examinations at the hospitals pediatrics department without any conclusions of the childs problem (Stackhouse, 1992, www.dyspraksi.dk). Therefore, a checklist seems to be a missing tool in the Danish Speech and Language Pathologist’s toolbox.
The differentiation to dysarthria is less common in the clinic because children with suspected dysarthria most commonly are sent to further examination at the neurologist early in life, often before they start in kindergarten and school. Nevertheless of cause the SLP has to be aware of symptoms of dysarthria, because dysarthria still is a diagnosis often mentioned in the discussion on the differential diagnosis for children with CAS (Milroy and Morgan‐Barry; 1992, Caruso and Strand; 1999; Williams & Stephen, 2004). This first edition is supported by the Danish parental foundation ”Dyspraksiforeningen”. They have an interest in spreading the word of the existence of CAS among children with severe speech problems. The first sketch of the Danish checklist for children suspected of having CAS were created of three SLP’s deeply interested in the diagnosis (www.lydbyggeren.dk, Lahti & Skov, 2009). After the first sketches – the responsibility was giving to one of the three SLP members of the group, Louise Skov as a project for a course at Linköping University, ”Oral and Verbal Apraxia in Children: Assessment, Diagnostics, Therapy”. The aim of this paper is to describe the first step in creating a Danish checklist for children with Childhood Apraxia of Speech to be used in the everyday life of the Danish Speech and Language Pathologist´s in cases where they are in doubt of whether it’s severe phonological problems or suspected CAS.
Joy Stackhouse’s four perspectives and other studies
The study is a review on CAS where Stackhouse deals with four perspectives: The phonetic perspective, The clinical perspective, The linguistic perspective and The cognitive perspective. As a result of the review she is able to come up with a list of symptoms in relation to CAS under each perspective (Stackhouse, 1992; table 1). Because almost all symptoms are described and documented in the literature reviewed one should expect that the symptoms would be rather valid and therefore useful as a main inspiration for the creation of the Danish checklist. Another study important for the creation of the Danish checklist is the Master thesis of Louise Skov (2008). The study investigates the difficulties twelve Danish children diagnosed with CAS had with the Danish language. In the study eight hypotheses were posed based on results from studies of CAS. One of the interesting results in relation to the aim of this paper was aBergström, 1996; Shriberg, 1997; Davis, Jakielski & Marquardt, 1998; McCabe, Rosenthal & McLeod, 1998; Caruso & Strand, 1999; Love, 2000; Davis, Jakielski & Marquardt, 2005; Jacks, 2006). This makes it reasonable to get inspiration from research studies outside Denmark and in that way update the Danish SLP´s with the newest results in relation to CAS.
Method
First step in the creation of the checklist was the selection of symptoms that should be included and excluded from Stackhouse’s table 1 (1992). This selection was made in consideration of some practical issues in the daily work as a clinical Danish SLP. The following criteria were set up for the checklist:
Less time‐consuming as possible, but including all necessary questions to be able to check all kinds of symptoms seen in children with CAS. Not too long and not too short. The design had to be very structured and simple. The possible answers had to be straight forward – a bit ”black and white” to make it more simple, hoping that the SLP would find it an easy tool to use. With these three criteria in mind the selection and redefinition of the symptoms mentioned in Stackhouse’s table 1 (1992) started. The redefinition was necessary because we wanted the design of the checklist to be a ”Yes”, ”No”, ”Don’t know” list. In this way all the symptoms had to be included in a sentence defined as a question. After a lot of consideration it was decided that the checklist should only include questions considering the symptoms in relation to CAS and that the questions of more in depth anamnesis character had to be answered before the SLP uses the checklist. Additionally I skipped the four perspectives as headlines and instead used Stackhouse’s table 1(1992) as main inspiration combined with other studies both published recently and with a view more in the direction of CAS as a motor‐speech disorder as mentioned in the introduction.
The checklist ended up consisting of 44 questions under 10 headings: “General questions about the child’s speech and language” (five questions), “Questions about the child’s babbling” (four questions), “Questions about the child’s use of phonemes and articulation” (twelve questions), “Questions about the child’s prosody” (four questions), “Question about the child’s resonance” (one questions), “Questions about genetics” (two questions), “Questions about the child’s neurology” (two questions), “Question to pregnancy, birth and early development” (one question), “Questions about the child’s oral motor skills” (six questions) and “Questions about the child’s cognitive skills” (seven questions).
The purposes for using the checklist in the clinic were pinpointed in the introduction to the checklist. The purposes were as follows: 1) If the child had delayed speech and language
problems, 2) If former speech and language therapy had a minimum effect even though the child had attended many hours of teaching over a longer period of time, and 3) If the child had severe problems with pronunciation.
To find out more about the need of a Danish checklist it was decided to make an evaluation of the checklist consisting of a questionnaire with six questions in relation to the checklist. The checklist including the six questions was sent out via e‐mail to twenty SLP´s with clinical experience ranged from one to more than twenty years. Nine SLP´s answered the questions. The six questions were formulated with the main interest to find out what the SLP thought of
it as a new tool in their toolbox but there were also questions about the design. The six questions were as follows: 1) What is your general impression of the checklist? 2) What do you think of the design of the checklist? 3) What do you think of the content of the checklist? 4) What do you think of the length of the checklist? 5) What is the possibility that you will find it relevant to use the checklist if you in your clinical work meet a child with symptoms that may seems like suspected Childhood Apraxia of Speech? 6) Do you think there is a need for a Danish checklist for children with Childhood Apraxia of
Speech?
There were four possible answers to the first five questions, “Very good”, “Good”, “Less good” and “Not good”. Question number six could only be answered with “Yes” or “No”. Every answer from the nine SLP´s was registered in a Microsoft Excel table. After registration the distribution in percent was calculated. The overall distributions of every question were shown in table 1 and the distributions in percent were illustrated by figures 1 to 6.
Results
In this section the results of the questionnaire are shown. First the more overall results and later question by question. The nine SLP´s who answered the questionnaire ranged the overall impression of the checklist very positive, which means that they in almost all cases answered “Very good” or “Good” to the question asked. The only question with answers other than “Very good” and “Good” was question five. In table 1 is shown all answers to the six questions in each category and also in percent.Table 1: The distribution of all the answers from the nine Danish SLP´s who participated in the questionnaire. The results are shown both in numbers of answers to each of the four possible answers*: “very good”, “Good”, “Less good” and “Not good” and also in percent. *Question six had only two possible answers: “Yes” and “No”. N = 9.
Question Very good Good Less good Not good
1. "What is your generel impression 5 4 0 0
of the checklist?" Percent Percent Percent Percent
56% 44% 0% 0%
2. What do you think of the design of the checklist? Very good Good Less good Not good
1 8 0 0
Percent Percent Percent Percent
11% 89% 0% 0%
3. "What do you think of the content of the checklist?" Very good Good Less good Not good
5 4 0 0
Percent Percent Percent Percent
56% 44% 0% 0%
4. "What do you think of the length of the checklist?" Very good Good Less good Not good
1 8 0 0
Percent Percent Percent Percent
11% 89% 0% 0%
5. "What is the possibility that you will find it relevant
to Very good Good Less good Not good
use the checklist if you in your clinical work meet a
child 3 4 1 1
with symptoms that may seems like suspected Percent Percent Percent Percent
Childhood Apraxia of Speech?" 33% 45% 11% 11%
6. "Do you think there is a need for a Danish checklist Yes No
for children with Childhood Apraxia of Speech?" 9 0 Percent Percent 100% 0% Next follows a description of the results from every question in more detail.
Question one
The answers to question one “What is your general impression of the checklist?” were distributed with five out of nine answering ”Very good” the same as 56 % and four out of the nine answering ”Good” counting for 44 % of the answers received. The distribution of the answers to question one is shown in figure 1.
Figure 1: The distribution in percent of the nine answers to question one: “What is your general impression of the checklist?”
Question two
The answers to question two “What do you think of the design of the checklist?” were distributed with one out of nine answering ”Very good” the same as 11 % and eight out of the nine answering ”Good” counting for 89 % of the answers received. The distribution of the answers to question two is shown in figure 2.
Figure 2: The distribution in percent of the nine answers to question two: “What do you think of the design of the checklist?”
Question three
The answers to question three “What do you think of the content of the checklist?” were
Distribution in percent of the answers to question two
Very Good; 11% Less Good; 0% Not Good; 0%
Good; 89%
Distribution in percent of the answers to question one
Very good; 56% Good; 44%
Not good; 0% Less good; 0%
Figure 3: The distribution in percent of the nine answers to question three: “What do you think of the content of the checklist?”
Question four
The answers to question four “What do you think of the length of the checklist?” were distributed with one out of nine answering ”Very good” the same as 11 % and eight out of the nine answering ”Good” counting for 89 % of the answers received. The distribution of the answers to question four is shown in figure 4.
Figure 4: The distribution in percent of the nine answers to question four: “What do you think of the length of the checklist?”
Distribution in percent of the answers to question three
Very good; 56% Good; 44%
Not good; 0% Less good; 0%
Distribution in percent of the answers to question four
Very good; 11%
Good; 89%
Not good; 0% Less good; 0%
Question five
The answers to question five “What is the possibility that you will find it relevant to use the checklist if you in your clinical work meet a child with symptoms that may seems like suspected Childhood Apraxia of Speech?” were distributed with three out of nine answering ”Very good” the same as 33 % and four out of the nine answering ”Good” counting for 45 % of the answers received, one out of nine answering “Less good”, 11 % and one out of nine answering “Not good”, 11 %, to the question. The distribution of the answers to question five is shown in figure 5. Figure 5: The distribution in percent of the nine answers to question five: “What is the possibility that you will find it relevant to use the checklist if you in your clinical work meet a child with symptoms that may seems like suspected Childhood Apraxia of Speech?”Question six
The answers to question six “Do you think there is a need for a Danish checklist for children with Childhood Apraxia of Speech?” only had two possible answers, ”Yes” or ”No”. The distribution of the answers to this question was very convincing. All of the nine SLP´s answered ”Yes” to the question, which resulted in a distribution nine to cero in relation to ”Yes” versus ”No”. The distribution of the answers to question six is shown in figure 6.Distribution in percent of the answers to question five
Very good; 33% Good; 45% Not good; 11% Less good; 11%
Figure 6: The distribution in percent of the nine answers to question six: “Do you think there is a need for a Danish checklist for children with Childhood Apraxia of Speech?”
Discussion
The results of the questionnaire were very positive which means that the creation of the first edition of a checklist seems to have been a success. But it is very important not to forget the fact that we are only dealing with a first edition and not yet a complete checklist ready to use out in the clinic! Before it’s ready to be published, it needs to be further investigated whether the checklist is both valid and reliable. This should be tested with a much larger group of participants under very controlled conditions and criteria. One of the important parts for further developing of the checklist is a careful review of the scoring of all the questions in correlation to the three possible answers: “Yes”, “No” and “don’t know”. As seen under the results the only question where the spreading of the four possible answers was wider than “Very good” to “Good” was question five ‐ the question about the possibility that the SLP´s will use the checklist in their clinic. One good reason why the answers are more varied than for all the other answers could be explained by the fact that the checklist are not yet tested for its reliability and validity regarding the scoring system. This is needed for the future version of the checklist to make it a meaningful tool in the assessment of suspected CAS (McCauley & Strand, 2008).Conclusion
In general the results from the questionnaire about the first edition of a Danish checklist for children with CAS were positive regarding the content, design and need as a future tool in the SLP´s daily work at the clinic. The fact that all participants found it relevant as a future tool can only be taken as a promising sign and a motivating factor in the further steps in the development of the Danish checklist for children with CAS.
Distribution in percent of the two possible answers to question six
Yes; 100% No; 0%
References
American Speech‐Language‐Hearing Association. Childhood apraxia of speech. Position paper (short‐term in the paper: ASHA, 2007). http://asha.org/docs/html/PS2007‐00277.html (25th of June 2013).
Caruso, A.J., & Strand, E.A. (1999). Clinical management of Motor Speech Disorders in Children. New York: Thieme.
Davis, B.L., Jakielski, K.J., & Marquardt, T.P. (1998). Developmental apraxia of speech: determiners of differential diagnosis. Clinical Linguistics & Phonetics, 12, 25–45.
Davis, B.L., Jacks, A., & Marquardt, T.P. (2005). Vowel patterns in developmental apraxia of speech: three longitudinal case studies. Clinical Linguistics & Phonetics, 19(4), 249 ‐ 274. Davis, B.L. & Velleman, S.L. (2000). Differential diagnosis and treatment of developmental
apraxia of speech in infants and toddlers. The transdisciplinary journal; 10, No. 3, 177– 192.
Holmberg, E. & Bergström, A. (1996). ORIS Munmotoriskt funktionsstatus. Löddeköpinge, Sverige: Pedagogisk Design.
Jacks, A., Marquardt, T.P., & Davis, B.L. (2006). Consonant and syllable structure patterns in childhood apraxia of speech: Developmental change in three children. Journal of
Communication Disorders, 39, 424–441.
Kent, RD. (2000) Research on speech motor control and its disorders: a review and prospective. J Commun Disord.; 33, 391–428.
Lahti, U. & Skov, L. (2009) Lydalfabetet – et anderledes alfabet. Logos, 55, 5–8.
Love, R.J. (2000). Childhood motor speech disability. Needham Heights, U.K.: Allyn & Bacon. Pearson Education Company.
McAllister, A. (2007). Oralmotoriska störningar hos barn och ungdomar. In L. Hartelius, U. Nettelbladt, & B. Hammarberg (red), Logopedi. Lund, Sverige: Studentlitteratur.
McCabe, P., Rosenthal, J.B., & McLeod, S. (1998). Features of developmental dyspraxia in the general speech‐impaired population? Clinical Linguistics & Phonetics, 12, 105–126. McCauley, RJ. & Strand, E. (2008). A Review of Standardized Tests of Nonverbal Oral and
Speech Motor Performance in Children. American Journal of Speech‐Language
Pathology, 17, 81‐91.
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Morgan, AT. & Vogel, AP. (2008). Intervention for childhood apraxia of speech. Cochrane
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Portwood, M. (1996). Developmental dyspraxia. Identification and intervention. A manual for
Parents and professionals. London, UK: David Fulton Publishers.
Shriberg, L.D., Aram, D.M., & Kwiatowski, J. (1997). Developmental Apraxia of Speech: I–III.
Stackhouse, J. (1992). Developmental verbal dyspraxia I: A review and critique. European
Journal of Disorders of Communication, 27, 19–34.
Williams, P. & Stephens, H. (Eds) (2004). Therapy folder. Nuffield Centre Dyspraxia
Programme, London, UK: The Miracle factory. http://www.dyspraksi.dk/ (25th of June 2013).
www.lydbyggeren.dk (25th of June 2013).
2. A case study of a six year old boy
with normal language abilities and
childhood apraxia of speech
Zafira Karakezlidis, Department of speech and language pathology, Danderyd
University Hospital, Stockholm, Sweden
Abstract
This is a case study of a six year old boy (called T) that exhibits some of the clinical markers for Childhood Apraxia of Speech (CAS): a limited vowel repertoire, metathetic substitution errors, vowel distortions and articulatory struggle (groping). A analysis of the development of the speech sound repertoire show that syllable and word shapes are getting more complex but with great difficulty over a long period of time; approximately two years. There is no neurological or developmental disorder, no non‐speech oral motor problems or phonological speech problems which confirm that the origin of T’s speech problem is praxis; a deficit in the motor planning ability.Introduction
Childhood apraxia of speech (CAS) is, according to the definition stated by the American Speech‐Language‐Hearing Association (ASHA 2007), “...a neurological childhood (paediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.” That is to say that children with CAS present speech problems that originate in problems with praxis, praxis being “[..] ‘the generation of volitional movement patterns for the performance of a particular action, especially the ability to select, plan, organize, and initiate the motor pattern ‘(Shriberg et al. 2003)”. These difficulties are different from phonological speech problems and therefore need a different approach in therapy. The aim of this case study is to present such a case. A six year old boy with pervasive speech problems that do not match his overall age appropriate language abilities and that cannot be explained by any coexisting syndrome or other developmental delay ‐ a boy with problems of praxis. This six year old boy represents a group of children that is rare and stand out from the vast majority of children with speech problems that a speech and language pathologist
normally encounters in the clinic. As T has age appropriate language skills in every area except phonology and articulation this study will present the development and variation of the speech sound repertoire and motor speech skills over time. All examples of words and phonem substitutions are in T’s mother tongue Swedish and written with Swedish letters. The symbol ‐> that occur in the text and tables is indicating how a word is pronounced by T.
Case History
T was referred to the clinic at an age of 2 years and 11 months by the BVC Barnavårdscentralen (child health care clinic). The referral reported that he had problems with pronunciation and that he was almost completely unintelligible to everyone else but his mother. The history tells us that he babbled a lot as a baby and that his first words appeared early and two word sentences at 2:05 years of age. Language comprehension and vocabulary were adequate for his age. There was a history of speech delay in the family with three cuisines having problems with speech and literacy and the father still having mild pronunciation problems at the age of seven. No delay of motor development or oral motor problems, however there was a history of snoring. Direct treatment at the clinic was started after a three month period of homework with the Oral stimulation program with an electric toothbrush (Lundeborg&McAllister, 2006) to improve the sensory ability and the precision of the lingual movements. Treatment at the clinic was planed at a rate of once a week (45 minute session) with additional exercises at the preschool for 10 minutes twice a day and exercises at home on a daily bases. At the start of treatment the focus was to target and establish articulatory placement and gestures for a range of sounds.T had no problem understanding the underlying phonological principles but there were evident problems finding the place of articulation and when found it was difficult to sustain and equally difficult to shift. Much time was spent on practicing at a single sound and syllable level only. After four months the fricatives /s/ and /f/ started appearing in spontaneous speech. At this point, after about two years the fricatives /s//f/ have been established in speech but still the articulatory movement for these phonemes is exaggerated. Alveolar/palatal fricatives are starting to appear (sje/tje). Velar plosives appear in new positions but there is still a confusion of velar‐dental place of articulation and often there are metathetic substitutions. There has been a need for visual cues for every new sound that has been introduced. Being a fast talker T himself realised the need to slow down the rate of speech during the exercises in order to find the right movement. T has always paid much attention to the clinician’s mouth and face and has been very accurate in describing his observations of the form of the mouth.
Method
The study consists of two different types of data. First there is a retrospect from earlier conducted testing of language abilities and earlier follow‐up testing of the speech sound repertoire. Secondly there are recent assessments of the speech sound repertoire,
speech abilities. The motor speech examination was recorded on an audio recorder, part of the motor speech examination and some sessions with free speech and conversation were videotaped. All other assessments are available from transcripts only.
Instruments for assessment
Language comprehension, vocabulary and grammar
The Reynell Developmental Language Scales III (Aug 2006) was used to assess the language comprehension (age of patient 2:11 years). The vocabulary and grammar has not been formally assessed but the speech and conversation of T has never revealed any difficulties in need of further examination.Phonological awareness
The assessment of phonological awareness was performed 2009. Three parts of the Swedish test ‘Bedömning av Språklig Medvetenhet hos förskolebarn och skolbarn’ by Nauclér & Magnusson (1993) was used: Rimigenkänning (identification of words that rhyme), Fonemidentifiering (identification of phonemes in words), Stavelsegmentering (syllable segmentation).
Speech sound repertoire
For the assessment of the speech sound repertoire the Swedish test ‘Fonemtestet’ by Hellqvist (1991) was used in august 2006 (age of patient 2:11), September 2007 (age of patient 4:00) and September 2008 (age of patient 5:00), May 2009 (age of patient 5:07)Motor speech ability
For the assessment of the motor speech ability parts of the worksheet for Motor Speech Examination by Edith Strand (Strand, E. 2009) was used. Part A. Observations during connected speech and part B. Elicited utterances; monosyllabic words with the same and different first‐last phoneme, multisyllabic words, sentences of various length.
Lexical and sentential stress
Lexical stress was assessed with the repetition of three sets of words. Three words with acute accent (stegen, tomten, armen) and three words with grave accent (stegen, tomten, armen). Sentential stress was assessed in repetition of two short sentences with the stress shifting between words. Utterances used: kom hit, kom hit, kom hit nu, kom hit nu. There has also been an analysis of the sentences in connected speech.Oral motor skills
For the assessment of oral motor skills parts of the test Nellie ‐ Neurolingvistisk undersökningsmodell för barn med språkstörning (Sahlén&Holmberg, 1986) was used in 2006 and later in 2009.
Results
Language comprehension, vocabulary and grammar
Assessment of other areas of language such as language comprehension (Reynell 2006) shows age appropriate results. No grammatical errors were noted and therefore there has been no need for a formal assessment. The vocabulary had always met the age expectations.Phonological awareness
Rimigenkänning (Rhyme identification): 18 compared to the average score for the age at 21,2. Fonemidentifiering (Phoneme identification): 20 compared to the average score for the age at 18,8. Stavelsesegmentering (Syllable segmentation): 5 compared to the average score for the age at 6,6. April 2009, patient 5:07 years). The overall phonological awareness is at an age appropriate level which tells us that the origin of the pronunciation problems is not phonological.Speech sound repertoire
Fonemtestet, Aug 2006: The initial phonological assessment showed almost total absence of fricatives except /j/ and /v/ in medial/final position, fricatives were omitted at the beginning of words and replaced by velar plosives in other positions. Bilabial plosives were in place, no voicing problem. Dental plosives were replaced by velar plosives. Bilabial and velar nasals were in place; however the dental nasal was sometimes replaced by a velar nasal. All vowels were present but sometimes distorted (ex. Duscha‐>åcka, fot‐>åt). There were no consonant clusters and no deletions of unstressed syllables (see Appendix 1‐5). Fonemtestet, Sep 2007: At the second speech sound repertoire assessment dental plosives and dental nasals appeared in final position but still no voiceless fricatives. Assimilations of place of articulation and manner of articulation occured (banan‐>maman). Some confusion with distinction. There were no syllable deletions. In general no significant difference from the last assessment a year earlier (see Appendix 1‐5). Fonemtestet, Sep 2008: The third assessment showed that fricatives that had been addressed in therapy (/s//f/) were established but not in combination with consonants. The alveolar fricative (tje) was now present and replaced the palatal fricative (sje) (see Appendix 1‐5). Fonemtestet, May 2009: All fricatives exist in almost every position. There is still some difficulty with the voiceless palatal fricative (tje) and the voiceless palato‐alveolar fricative (sje) in medial/final position that is substituted with /s/. /l/ is established in initial position, substituted with /j/ in other positions. /r/‐ > /j/ in all positions. Velar plosives are substituted with dental plosives most of the times but backing also occurs in free speech. No cluster reduction but substitutions occur. Most clusters with s+consonant as well as cluster tv‐ are in place. No supradentals. Some vowel errors (see Appendix 1‐5).errors and substitutions of fricatives for stops have also been part of T’s speech development. In longer words T sometimes makes use of a rounded half‐closed back vowel (w) and the precision of articulation differs from time to time for the same word. Vowels in isolation are correct, in words however they are distorted and sometimes prolonged. In addition there is some glottal phonation and a hypo nasal resonance that have become more prominent over the last six months
Motor speech ability
The motor speech examination reveals that motor planning is a major problem regardless of context. In short words with the same first and last phoneme there is inconsistency in articulation, the same word will be differently produced after immediate repetition and after a pause. However, the immediate repetition does not always guarantee a successful articulation (ex sås‐>såk, båt‐>båk immediate repetition, sås‐>sås, båt‐>båt after a pause). Problems finding the correct articulatory position for a speech sound in context with other sounds is obvious, even though the phoneme in isolation is correct. This is true even for phonemes that have been in focus of therapy for a while. Most consonants are difficult to produce even in mono syllable words with a CVC structure. Both consonants in a word cannot be successfully produced; if the initial phoneme is achieved the final will be omitted or substituted or vice versa. There are also signs of groping to find the right position for speech sounds and sounds that have been established in spontaneous speech still have an over emphasized movement of articulation. The need for visual cues is obvious for multi syllable words and for new sounds introduced in therapy. In multi syllable words the vowel errors, omissions and metathetic substitutions increase. However some phonemes that are substituted in a CVC‐word (mål‐>måj) may appear correctly in a CVCV (måla‐>måla) and CVCVCV (målare‐>målaje) structure. The syllable shapes have for a long time been the same since the first assessment at 3:00 years of age. T has exhibited different syllable shapes (CV, VC, CVC, VCV) and have gradually added more syllables to a word. Still it is difficult to handle syllables with more than one consonant before vowel but this is slowly improving, there is also a change in word shapes in mulisyllable words. One example is the word ‘telefonbok’ which consists of four syllables CV‐CV‐CVC‐CVC that changed to V‐V‐V‐CV (/eeåbo/), another example is the word ‘dammsugare’ with the four syllables CVC‐CV‐CV‐CV that changed to CVC‐V‐V‐V (/pamuae/). The latest assessment shows increased rates of CCV and VCC syllables (see Appendix 6).
Lexical and sentential stress
Lexical and sentential stress is kept intact over shorter segments and in sentence repetitions. The imitation of the therapist’s intonation is exact during exercise with immediate repetition. In free speech the overall prosodic contour is effected and often deviant.Oral motor skills
The first assessment (2006) of oral motor skills with ‘Nellie’ (Sahlén&Holmberg, 1986) showed normal range of movement for the lips but difficulties to elevate the tongue tip. A second assessment was performed in 2009 with the same assessment material that shows no indication of oral motor problems. Neither does the medical history reveal any oral motor problems. Since the ability to perform voluntary non‐speech movements is intact and there are no signs of weakness the oral motor skills are not causing the speech problems.Informal observations of gross and fine motor skills and
temperament
Teverovsky et al. (2009) states in their research paper that “ Children with motor speech disorders, including CAS, may show generalized motor incoordination, problems with manual
dexterity and/or oral motor dysfunction.” This is true for the boy of this case study as well. T himself has often mentioned that his balance and coordination is not as good as it is for other children in his age and this has often been observed at sessions in an activity such as getting on and off a chair repeatedly. According to the parents this is confirmed by a pedagogue at T’s preschool and he has been assigned some special exercises for this purpose. The fine motor skills are also affected; T has difficulties handling scissors. He has no clear preference of hand and often grips the scissors upside‐down and his cutting is not smooth and the edges of the paper uneven. T has also noted that his hands are shaking after a physically demanding activity (leaning on a toy car while driving and steering it) and that he has to wait a few minutes before taking on a more fine motor activity such as using scissors or hold a pen. Teverovsky et al. (2009) also mention in the same paper that a survey amongst parent whose children exhibit speech and language problems to some degree have “ineffective behaviour management strategies”. Some sensitivity and low “threshold” for emotional stress has been observed in some situations, however these manifestations are difficult to classify.
A more general observation is the fatigue after a therapy session with focus on articulatory exercises which indicates just how demanding the articulation is.
Discussion
Looking at the development of the speech sound repertoire the unusual shift of one phonological process to another, from backing of dental plosives to fronting, is a red flag marking that the speech problems in this patient do not fall into the category of phonological difficulties. The persistence of metathetic substitution errors that have been noted in this case is another clinical marker for CAS. Although metathetic substitution errors is a sign of increasing awareness of the consonant clusters and a strategy to address the difficulty of producing the consonants (Håkansson G, 1998) for children with phonological problems, it is for children with CAS yet another indication of motor planning problems. Another characteristic of the speech, and sign of motor planning difficulties, is the groping behaviour and the altered syllable shapes. The prolonged vowels, perceived as exaggerated stress, could be a way to compensate for co articulation problems.
Another indication of praxis problems is the slow pace of progress. Even though the phonemic repertoire has expanded and is more complete (see Appendix 1‐5) it is a very slow process that is only half way and the difficulty of establishing the new articulatory movements is evident. The amount and frequency that is needed for these children is not easily met in the setting of the average speech and language clinic so the importance of having the parents and preschool involved in therapy is crucial and unquestionable. A valuable lesson from this case about the responsibilities of the SLP is the importance of explaining the severity and pervasiveness of CAS but also the need to give a clear picture of the plan for treatment of CAS to parents and other care‐givers. Here the use of “carry over phrases” and “core vocabulary” is useful. The boy in this study has adapted some communicative manners that could be considered strategies to improve his chances of being understood. Some of them are repeating utterances or parts of an utterance and giving clarifications during conversation even when this has not
evolved as a response to that. It would be interesting and beneficial for the children with CAS and other severe speech disorders to further examine the impact of the speech impairment on the children’s social interaction with peers and adults. Shriberg & Kwiatkowski (1994) address the issue of “psychosocial behaviour” of children with developmental phonological disorders and conclude that “..descriptive data indicate that a significant number of children with developmental phonological disorders experience psychosocial difficulties. As with most of the other descriptors, it is not known whether sampling biases inflate the magnitudes of these findings or whether they would differ significantly from data in a non‐speech‐delayed group. For intervention questions, however, such information clearly confirms the need to account for psychosocial variables in the overall plan of treatment.“
Conclusions
According to the definition of CAS some of the diagnostic markers are among others articulatory struggle (groping), metathetic substitution errors and vowel errors which all have been observed in the speech of this six year old boy in both habitual performance as well in controlled contexts. Pervasive articulatory problems exist in the absence of any neurological condition, however, there are some general gross and fine motor difficulties. The sound repertoire and the syllable and word shapes have gradually expanded but only after a considerable time and treatment. Great effort and struggle is still needed in order to achieve the articulatory movements and all the phonemic features, such as the distinction voiced‐ voicless and aspiration are not mastered. However, in other areas of language, such as comprehension, vocabulary, grammatics and phonological awareness, T’s performance is at an age appropriate level.
References
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Appendices
3. Evaluation of intensive Dynamic
Temporal and Tactile Cueing therapy
for a 17‐year‐old male with verbal
dyspraxia, intellectual disability and
ADHD. A case study
Catarina Ragnar, Habilitation services, Region Kronoberg, Sweden
Abstract
This paper describes the procedure for and evaluates the result of an intensive speech therapy period using Dynamic Temporal and Tactile Cueing (for Speech Motor Learning). The subject is a 17‐year‐old male with intellectual disability and ADHD, whose dyspraxic motor speech problems have been identified since childhood and who is clearly communicatively disabled by his speech impairment. Speech sound inventory and oral motor assessment was carried out prior to the therapy period. A baseline for the production of the chosen practice words was established. DTTC treatment was given during three weeks. The pre‐ and post‐therapy word productions were compared, using percentage measures regarding correctly produced units. These indicated improvement for the majority of the practiced stimuli, as well as some generalisation of performance to non‐practiced stimuli. The overall oral motor control was unchanged after the therapy but a minor improvement was noticed for lingual control. The cueing techniques applied and the subject’s response to them are described.Introduction
A consensus definition of verbal dyspraxia has only recently been reached and described by the American Speech‐Language‐Hearing Association in Childhood Apraxia of Speech: PositionStatement (2007). The definition includes three segmental and suprasegmental distinctive
criteria concerning difficulties in the planning and programming of speech movements: 1.Inconsistent errors for both consonants and vowels in repeated syllable and word production, 2. Prolonged and distorted transitions between speech sounds and syllables (coarticulation “mistakes”), 3. Prosodic deviations, especially concerning word and sentence stress.
Descriptions of comorbidity in cases of ‘verbal dyspraxia’ are frequently reported. Björelius Hort (2009) found that three out of four in a group of children with ‘verbal dyspraxia’
performed below expected level on gross and fine motor tasks. In a parental survey by Teverovsky, Bickel & Feldman (2009), balance problems and manual motor difficulties were reported for about 50 % of the children with ‘verbal dyspraxia’. Problems concerning focusing, writing and temperament were other common coexisting symptoms. As to ‘verbal dyspraxia’ in combination with intellectual disability (mental retardation, MR), Kumin (2006) finds that Childhood Apraxia of Speech, CAS, in the past has not been identified or treated in children with Down Syndrome, DS. The study investigates whether and to what extent this is done today and the results indicate that considerably more children than those having been diagnosed with CAS had clinical symptoms of CAS. Battini et al (2007) report on a boy with mental retardation and CAS resulting from a genetical deviation.
There is some documentation concerning ‘verbal dyspraxia’ treatment in individuals with intellectual disability, although not very extensive. According to Van Bystervelt, Gillon & Foster‐Cohen (2010), a combined intervention including speech training, phonological awareness activities and letter knowledge activities, is efficient for speech improvement in DS children but ‘verbal dyspraxia’ is not mentioned as being part of the children’s speech problem. In a study by Hejdedal & Westerlind (2010), an electric toothbrush stimulation programme resulted in improved orofacial motor function and oral sensory function in a group of DS children. Karin Bengtsson & Irene Johansson (2002) present a model for speech therapy in children with DS. The use of a palatal plate is central in the model, as well as creating awareness and knowledge of speech in both the child and its environment. One of the children in a study by Strand, Stoeckel & Baas (2006) has a mild mental impairment complementary to the ‘verbal dyspraxia’. The authors show that “frequent treatment, incorporating the principles of motor learning, may facilitate the treatment of severe developmental speech disorders accompanied by motor impairment”, reporting a positive therapy outcome for children with severe CAS, using the Dynamic Temporal and Tactile Cueing for Speech Motor Learning (DTTC). Baas, Strand, Elmer & Barbaresi (2008) describe DTTC treatment for a child exhibiting moderate mental retardation and severe CAS. It is evident from their results that functional verbal communication can improve even in older children with severe apraxia of speech. Several reports on ‘verbal dyspraxia’ treatment in children without intellectual disability have been found, among others Lundeborg & Mc Allister (2006) studying the effect of electropalatography therapy in a dyspraxic child.
DTTC is an integral stimulation (“watch‐listen‐imitate”) approach for children with motor
speech planning disorders, based on a treatment program designed for adults with acquired apraxia of speech. The method was described in Strand & Skinder (1999). DTTC emphasizes shaping the movement gestures for speech production and the continued practice of those in the context of speech. Imitation is facilitated by the therapist using tactile and temporal cueing techniques together with auditory and visual ones, e.g. guiding the articulators to the correct place and position, simultaneous production, reduced speech rate and delayed imitation. Tactile guiding and use of movement have been helpful in earlier speech therapy with the subject of this study, who is 17:8 years old. His diagnoses are moderate mental impairment, ADHD, oral and verbal apraxia (dyspraxia) and expressive language disorder.
