Handout Cover 1-17-12 - Northern Speech Services

Transcription

Children Who
Struggle To Speak:
The Kaufman Speech To
Language Protocol
SPEAKER
Nancy R. Kaufman
MA, CCC-SLP • CE Seminars
King of Prussia, PA
• On-line CEUs
• Products
Friday, September 27, 2013
Radisson Hotel Valley Forge
www.northernspeech.com
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SEMINAR OUTLINE
7:30 – 7:50
Check In and Onsite Registration (Coffee & Tea)
7:55 – 8:00
General Seminar Information
8:00 – 8:30
Overview of the K-SLP
8:30 – 9:00
Shaping Successive Approximations, Word Simplifications
and Implementation of Phonological Processes
9:00 – 9:30
Evidence-Based Practice: Research on the K-SLP Method
9:30 – 9:45
Break
9:45 – 11:15
The 6 Steps of the K-SLP: Detailed Descriptions and Videos
of Evaluation and Treatment Techniques
11:15 – 12:15
Lunch (on your own)
12:15 – 1:45
More on Evaluations and Establishing IEP Goals
1:45 – 2:00
Break
2:00 – 2:30
Cueing and Scripting Techniques To Move Into Functional
Expressive Language
2:30 – 3:00
More Treatment Techniques and Refinement & Integration
Skills
3:00 – 3:30
Special Populations To Include Autism Spectrum Disorders;
Pre/Post Video Evidence of K-SLP Effectiveness
3:30
Adjourn, Sign Out and Certificates
SPECIAL NOTE: AUDIO TAPING NOT ALLOWED
. Copyright 2013
No part of this material may be
reproduced or utilized in any form or
by any means electronic or
mechanical including photocopying,
recording, or by any information
storage or retrieval systems without
the prior permission of the copyright
owner.
©
2013 Northern Speech Services Inc.
. About The Speaker:
Nancy R. Kaufman, M.A., CCC/SLP is the owner and director of the Kaufman Children’s Center for Speech, Language, Sensory-‐Motor, and Social Connections, Inc., located in West Bloomfield, MIM. Since 1979, Nancy has dedicated herself to establishing the Kaufman Speech to Language Protocol, the K-‐SLP, a treatment approach to help children become effective vocal communicators. She serves on the Professional Advisory Board of the Childhood Apraxia of Speech Association of North America (CASANA), on the Board of Visitors of Wayne State University’s Merrill Palmer Skillman Institute for Child and Family Development, and is the speech and language pathologist consultant for the Parish School and Carruth Center in Houston, Texas and Suburban Speech Center in Short Hills, NJ. Nancy is the recipient of the 2011 Michigan Speech-‐Language-‐Hearing Association Distinguished Service Award, as well as the 2010 Michigan State University College of Communication Arts & Sciences Outstanding Alumni Award. Nancy is the author of several highly effective treatment materials to help children with childhood apraxia of speech or other speech sound disorders. Many specialists in the field of applied verbal behavior have adopted the K-‐SLP for children with autism spectrum disorders. Families from around the globe travel to the KCC to participate in intensive and specialized therapy programs. Nancy received her Bachelor’s degree at Michigan State University and Master’s degree at Wayne State University, having been awarded a graduate assistantship. She has three grown children and resides with her husband in West Bloomfield, MI. . The Kaufman Speech to
Language Protocol
Nancy R. Kaufman, M.A., CCC/SLP
Owner & Director
Kaufman Children’s Center for Speech, Language,
Sensory-Motor, And Social Connections, Inc.
West Bloomfield, Michigan 48322
Phone (248) 737-3430
www.kidspeech.com
[email protected]
The Kaufman Children’s Center for Speech, Language, Sensory-Motor, & Social Connections, Inc. is and owned and operated by Nancy Kaufman, M.A., CCC-SLP.
Nancy has developed the speech praxis treatment program known as the Kaufman Speech to Language Protocol. Nancy Kaufman is also the developer and author of
the Kaufman Speech Praxis Treatment Kits for Children, The Kaufman Speech Praxis Workout Book, The Kaufman Speech to Language Mutt Family Practice Puzzle,
The Kaufman Speech to Language Protocol Instructional DVD, and the Kaufman Speech Praxis Test. She is the co-author, with Tamara S. Kasper, M.S., CCC-SLP,
BCBA, of the K & K Sign to Talk Nouns & Verbs. Nancy benefits from the sales of these products published by Northern Speech Services.
The Kaufman Speech to Language Protocol
A method of practicing syllable shape gestures and word
approximations toward target vocabulary to be moved
directly into functional expressive language.
Typical developing toddlers who are just learning
to speak rarely begin to speak using whole words.
For example, the word “bottle” might be produced
in this sequence:
ba
baba
bado
bottle
1
© 2013 Northern Speech Services Inc
Children who struggle to speak do not go through
this process or may be stuck on approximations
much lower than their capability.
Continuously asking them to repeat whole words is
setting them up for failure!
The Kaufman Speech to Language Protocol (
)
helps the child produce words through practicing
simple to complex combinations of vowels and
consonants to form syllable shape gestures.
(CVCV, CV, VC, VCV, CV1CV2, C1V1C2V2, etc.)
Rather than practicing these with nonsense syllables,
the K-SLP practice is with real words for the purpose
of motor-speech coordination (K-SLPkits 1 and 2).
The Kaufman Speech to Language
Protocol (
) helps the child produce
words with their best approximations by
implementing phonological processes and
through the behavioral process of shaping:
using cues, fading cues, and implementing
reinforcement strategically, original principles
of B.F. Skinner from the 50’s and 60’s.
2
candidates….
1. Must have some vowels and consonants in
their repertoire.
2. Must be able to understand the task and execute vocal
imitation.
To gain a repertoire of vowels and consonants,
consider the implementation of Oral Placement
Therapy (OPT, Sara Rosenfeld Johnson): internal
cues (TalkTools) combined with external cues
(PROMPT, Deborah Hayden). Gaining the quality of
feeding skills may be necessary (Rosenfeld Johnson,
Beckman, Bahr, Overland and others).
To gain vocal imitation, consider: Sign to Talk
(Kasper, Kaufman), via an applied verbal behavior
(AVB) program, bridging sign language to vocal
communication.
The
approach is successful for those with apraxia of speech,
severe speech sound disorders, phonological processing challenges
and expressive language challenges.
The
approach takes the words out of the context (blahblah)
giving them acoustic and auditory perceptual parameters.
The
approach focuses upon the production of syllable shape
gestures toward improved motor-speech coordination.
The
approach focuses upon functional vocabulary and
expressive language.
The
approach is based upon B.F. Skinner’s researched
techniques of “shaping,” focusing on cueing, fading cues and using
powerful motivators.
The
approach considers the interests of the child, and keeps
the “drill” work fun and exciting, to stimulate mirror neurons.
3
Evidence-Based Practice
The K-SLP follows the most current research in:
• Motor learning theory
• Early language development
• Current neuroscience
• Sensory-motor development
• ABA verbal behavior
• Acquired apraxia of speech
• Childhood apraxia of speech
The
approach follows current research on
neurological development
The
begins with the gestalt or general shells
of the words (right hemisphere) and then helps the
child to fill in the perceptual/motor details of words
(left hemisphere). Dehaene-Lambertz, et al., 2006; Kuhl, 2004.
The
stimulates mirror neurons by helping
the child to be attentive, excited, vocally imitating
and socially connecting. Rizzolatti, Fogassi and Gallese, 2006
and Burns, 2009
Evidence-Based Practice (EBP)
Single Subject Design Observational Data
• 3-week period of intervention (summers of 2008-2012)
• 56 children total with characteristics of CAS
• 30 half-hours of individual K-SLP speech and language
intervention
• 15 hours of group speech and language intervention
(3 of which were sensory-motor groups) to also include
6 half-hours of music therapy specific to the K-SLP methods
4
Observational Research Study
Baseline testing included:
• A checklist of CAS characteristics
(ASHA)
• Goldman-Fristoe 2 Test of Articulation®
• The Kaufman Speech Praxis Test©
• Spontaneous language sample
Observational Research Study – 2012
Post-intervention testing showed
significant improvements in:
• Articulatory accuracy
• Syllable shapes production
• Expressive language
production
• Gross oral motor movements
(not a targeted goal)
Initial and Post Test Scores
for Children (n=56)
Test
GFTA-2
(standard scores)
KSPT
(raw scores)
Mean
Pre
61.70
Post
70.04
Oral Pre (n=56)
8.33
Oral Post
9.25
Simple Pre (n=56)
44.55
Simple Post
53.39
Complex Pre (n=56)
9.68
Complex Post
14.06
t
p
-9.69
<.001
-4.47
<.001
-12.03
<.001
-3.73
<.001
The number of scores included in each analysis varied slightly
due to a small number of children who were unable to complete the initial tests.
5
Progress Indicators – GFTA®
2012
n=54
25
►Pre
►Post
20
15
10
5
0
normal range
(86-100)
1 SD below norm
(71-85)
2 SD below norm
(55-70)
3 SD below norm
(<40-55)
In the range of 2-3 SDs, 68% of the children were very impaired before the K-SLP.
After intervention, 24% improved. Note the 39% improvement in the normal range and in the 1 SD range.
Nancarrow, Ficker, Kaufman, et al, 2012 ©
Progress Indicators – KSPT®
2012
n=54
60
►Pre
►Post
50
40
30
20
10
0
Oral Motor
Simple
Complex
Definition of CAS per the American Speech
Language Hearing Association’s Ad Hoc
Committee on Childhood Apraxia of Speech
Childhood apraxia of speech (CAS) is a neurological
childhood (pediatric) 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.
6
Childhood apraxia of speech
can and often does co-exist with
other speech and language
challenges. We need to consider
the nature of the primary interfering
factor to successful vocal language
development.
Signs & Symptoms of Apraxia of Speech
Source: CASANA/Apraxia-Kids.org
• Limited repertoire of vowels; less differentiation between
vowel productions; and vowel errors, especially
distortions.
• Variability of errors.
• Unusual, idiosyncratic error patterns (sometimes defying
transcription)
• Errors increase with length or complexity of utterances,
such as in multi-syllabic or phonetically challenging
words.
• Depending on level of severity, a child may be able to
produce accurately the target utterance in one context
but is unable to produce the same target accurately in a
different context.
• More difficulty with volitional, self-initiated utterances as
compared to over-learned, automatic, or modeled
utterances.
• Impaired rate/accuracy on diodochokinetic tasks
(alternating movement accuracy or maximum repetition
rate of same sequences such as /pa/, /pa/, /pa/ and
multiple phoneme sequences such as /pa/ /ta/ /ka/)
7
• Disturbances of prosody including overall slow rate; timing
deficit in duration of sounds and pauses between and
within syllables contributing to the perception of excess
and/or equal stress, “choppy” and monotone speech.
• At some point in time, groping or observable physical
struggle for articulatory position may be observed (possibly
not present on evaluation, but observable at some point in
treatment).
• May also demonstrate impaired volitional nonspeech
movements (oral apraxia).
Nancy’s observation:
• Verbal perseveration:
getting “stuck” on a
previously uttered word,
or bringing oral motor
elements from a previous
word into the next word
uttered.
Other characteristics that may describe children with
CAS, but are less likely to contribute to a differential
diagnosis include:
• Poor speech intelligibility
• Delayed onset of speech
• Limited babbling as an infant
• Restricted sound inventory
• Loss of apparently previously spoken words
Early speech sound characteristics of CAS:
Refer to Caspari & Overby’s presentation from the 2012
ASHA National Convention (list of references in handout)
8
Oral Motor Weakness (hypotonia)
(in severe cases, developmental dysarthria)
A speech disorder caused by dysfunctional or damaged
innervation to the speech musculature (tongue, lips, soft
palate, facial muscles, larynx). Generally, oral musculature
is weak, or there is significant low muscle tone.
Significant oral motor weakness, or in developmental
dysarthria, there is usually difficulty in vegetative
functioning. The children usually have early sucking,
chewing and swallowing challenges. They may also
“drool” for a lengthy period of time. They stick with
very soft foods to digest. They also may gag or
choke often.
Apraxia/dyspraxia of speech can
coexist with oral motor hypotonia,
or developmental dysarthria.
Speech Characteristics of
Oral Motor Hypotonia
(or developmental dysarthria)
1. Marked difficulties with strength, speed and
accuracy of articulatory movement
2. Imprecise or weakly targeted consonants,
i.e. / r/.
3. Imprecise or weakly targeted vowels, especially
those which involve spreading intrinsic tongue
muscles, such as /i/ , / a/, /e/,/ /.
4. Weak vocal quality (lack of respiratory support).
5. Hypernasality
9
6. Weak articulatory contacts
7. Slow and/or labored speaking rate
8. Speech clarity disintegrates with lengthy
utterances:
• may be due to lack of breath support or
muscle fatigue
• may resemble apraxia of speech
9. Weak targets, especially for /r,s,l/ and vowels
10. Generally weak, mushy, garbled, imprecise speech
Attempt to define the root of the speech
problem and co-existing conditions
These are some of the roots of speech challenges that we often see:
• Hard of hearing or deafness
• Oral structural deviation or differences
• Oral motor weakness (developmental dysarthria, oral motor hypotonia,
oral sensory processing, feeding issues and speech challenges
associated with oral motor weakness)
• Auditory-linguistic processing disorders (language processing;
CAPD; phonological disorders)
• Childhood apraxia of speech
• Severe cognitive challenges
• Speech sound disorders of unknown origin
Decide what would be best practices for each
10
SIX STEPS
1. Determine which vowels, consonants and syllable
shape gestures the child has in his/her repertoire via the
Kaufman Speech Praxis Test for Children.
2. Establish first words (considering evaluation findings),
and begin working on syllable shape gestures, and simple
nouns.
3. Establish a list of functional mands (requests) such as, on,
off, open, out, up, down, and help, including a list of
favorite foods, drinks, toys, activities, and people/pet’s
names, establishing best approximations for requesting
and commenting.
continued…
SIX STEPS
4. Help the child to combine words through pivot words
and phrases, as well as telegraphic language
structures, to include scripting functional language.
Move ahead on expressive language (combining
words), and back up on motor-speech (clarity).
5. Refine and integrate complex consonants and syllable
shape gestures. Continue to build expressive language
by adding in syntax and morphology.
6. Establish a home program.
Common
Therapy Mistakes
• Continuously and tirelessly working on vocal imitation
when it is unsuccessful (try sign language as a bridge).
• Not pairing yourself with pleasurable toys and activities.
• Bringing out Kit pictures without pairing them with
pleasurable toys and activities.
• Using toys and materials that are not preferred by the
child (but the SLP sure enjoys them)!
11
Common
Therapy Mistakes
• Not providing pleasurable motivators for children who
are usually compliant without them (or for older children)
who could all use a motivator!
• Not providing timely reinforcement for those who may
need a motivator after each response.
• Having the child practice random words that are not
within the lists of syllable shapes, functional words, or list
of favorites.
• Accepting the child's approximation and moving on to
another word without attempting to gain a better
approximation.
Common
Therapy Mistakes
• Sticking only with Kit pictures and not moving ahead on
other pertinent vocabulary lists or functional expressive
language.
• Giving full imitation and cues and not moving them a
step further to gaining the last response to be as
spontaneous as possible.
• Forgetting to fade cues or scripting each and every
word without fading to initial consonant cues, whispers,
oral postures or gestures.
• Adding a schwa "uh" after a final consonant.
Common
Therapy Mistakes
• Forgetting to model correctly, but when helping the child to
respond, gaining the best approximation.
• Promoting over generalization due to lack of mixing or
varying tasks.
• Not gaining enough responses within a session for
carryover to take place.
• Waiting for the child to have perfect articulation of a
significant number of single words before assisting them to
combine two and three-word phrases.
12
Common
Therapy Mistakes
• Scripting too many words (or high levels of syntax and
morphology) before the child is ready.
• Pulling away initial consonants. Should keep them paired
(glued) to the vowel if possible.
Shaping Techniques
• Proper modeling
• Cueing
• Fading cues
• Using reinforcement
strategically
• Errorless learning
• Pace
• Repetition
SIX STEPS
1
Determine which vowels,
consonants and syllable shape
gestures the child has in his/her
repertoire via the Kaufman Speech
Praxis Test for Children.
13
Using the Kaufman Speech Praxis Test for
Children, we can determine at what level a
child’s motor-speech skills are
compromised, and we can target those
levels in treatment.
The
(Test) hierarchy
includes the following:
I. Gross oral motor
movements
II. Simple Level
1. Isolated vowels:
2. Vowel to vowel movement:
(diphthongs)
3. C Simple:
4. CVCV (reduplicated syllables):
5. VCV:
6. CV:
7. CV1CV2 (repetitive syllables
with vowel change):
8. CVC (assimilated initial and
final consonants):
9. CVC CVC (initial and final
consonant inclusion):
10. C1V1C2V2 (simple bisyllabics):
11. CVCVCV (simple polysyllabics):
/ a, , ,, ,u,i/
/a, o, e, a, /
/m, b, p, t, d, n, h/
mama, papa, dada
opa, ah-po, oh-bow
da, me, bay, do
mommy, daddy, puppy
pop, mom, bib
man, home
happy, tummy, bunny
banana, potato, tomato
III. Complex Level
Complex C:
/k,,f,s,z,l,r,w,v,j, , t , d!, ", #/
CVC CVC:
(complex initial and final consonant inclusion)
Complex bisyllabics:
candle, chicken, machine
Consonant blends:
/ r ,s ,l /
f b (t, d k, ) and b f (k, t, d) words
(tip alveolar to back velar and back velar to tip alveolar)
Length and complexity words: win, window, windowsill
IV. Spontaneous Length and Complexity
14
SIX STEPS
2
Establish First Words
(considering evaluation findings).
• Increase the vowel and consonant
repertoire if narrow.
• Practice syllable shapes (the building
blocks of the act of speech)
CVCV, VCV, CV, VC, CV1CV2, CVC, C1V1C2V2, etc.
• Practice a list of simple nouns selected on
the basis of the child’s vowel and
consonant repertoire.
Treatment Tips for Establishing
First Words Vocabulary
a. Get the consonant vowel patterns the child has
spontaneously, upon imitation.
b. Make the consonants or vowels more gross motor and
visible by exaggerating them, i.e. dentalizing
/t,d,n,l/, or guttural, open-mouthed /k/
c. Use the pictures in Kit 1 for establishing easy syllable
shape gestures and for best word approximations to
then become a visual referent for eventual spontaneous
naming.
d. Use consonants and/or vowels that are already in the
child’s repertoire to form early vocabulary.
e. Reduplication is an early process and also does not
include final consonants. If the child only produces a
single syllable, bombard with more than two, and they
might produce two:
mama
baabaa
wawa
dada
hoohoo
nono
papa
booboo
moomoo
byebye
15
f. Final consonants are difficult. Choose words that do not
have final consonants:
(CV patterns from Kit 1):
me
hi
bye
dough
two
bee
tea
pea
no
new
now
CVCV, VCV, CV1CV2 and C1V1C2V2 also do not have final
consonants. We can achieve a great deal of progress
before even moving toward final consonant inclusion.
g. Initial consonants may be difficult, so choose words
without them:
(VC of Kit 1):
up
on
in
out
oat
eat
ouch
arm
h. Assimilation is an easy simplification of many CVC or
two-syllable words with bilabial to bilabial or tip alveolar
to tip alveolar, so choose words like:
pop
pup
boom
mom
toot
mob
bib
mop
tin
dad
map
tan
knot
puppy
dot
peppy
den
dirty
teddy
nutty
whoa
wow
16
i. It is easier to voice in the initial position and to devoice in
the final position. So choose words that start with /b,d,/
and end with / p,t,k/ (when in Kit 1)
j. Tense vowels and diphthongs are difficult especially if
the child cannot produce /i/ as in eat or /u/ as in
boo. We can soften these vowels in a word or make
it lax to help the child produce a word approximation.
Tense vowels:
Can be replaced with:
/u/ as in boo
/i/ as in eat
// as in book
// as in bit
Diphthongs:
Can be replaced with:
/o/ as in oat
// as in nut
/a/ as in high
/$/ as in hot
/e/ as in day
// as in bet
// as in boy
// as in bought
/j/ as in yes and
/i/ plus next vowel in word
/w/ as in want
/u/ plus next vowel in word
k. Consider co-articulation
/t, d/ co-articulate best with /i/ as in tea or deep
/k, / co-articulate best with /,%/ as in cup,
come, gum, and gut or /$/ as in cob, cot, or gob
/m,p,b/ co-articulate best with /,%/ or /$/
l. Continuants are the easiest initial consonants to target
as they can be prolonged before the vowel.
/m/
/n/
/s/
/ /
/f/
17
Treatment Tips for Establishing
First Words Vocabulary (continued)
m. To help with initial consonant inclusion, keep the initial
consonant paired with the vowel, prolong the vowel
and pull away the final consonant by just a little bit.
n. If both the initial and final consonant are voiceless
consonants such as /p,t,k/, practice them without
the vowel in the middle.
SIX STEPS
3
Establish a list of functional
mands (requests) such as, on, off,
open, out, up, down, and help,
including a list of favorite foods,
drinks, toys, activities, and
people/pet’s names, establishing
best approximations for
requesting and commenting.
Four Important Single-Word Lists
List 1: Syllable Shapes Practice Words
Syllable shapes for motor-speech coordination practice
(Kit 1) – CVCV, CV, VCV, CV1CV2, C1V1C2V2, etc.
For those with a limited vowel and consonant repertoire.
Make a list of the vowels and consonants at the top of
your page. Pull them down into simple words. Have visual
references of the words.
18
Example of a child’s limited repertoire:
If they only have ah, uh, eh, m, b, t, n,
we can establish words such as:
mama
knob
baba
ten
nana =banana
ton
mop
net
knot
on
List 2: Simple Nouns
Simple nouns of different categories that lend themselves
to the ability to then name their function.
bubbles (blow)
apple (eat)
water (drink)
ball (throw, kick, bounce)
shoes (put on, wear)
bike (ride)
List 3: Functional Manding Words
Functional words which serve to manipulate the
environment or are socially engaging. These can be
paired with a gesture.
open
up
here
come
on
down
there/deh
mama
off
yes
this/dis
dada
In
no
that/dat
out
don’t
go
* also, socially engaging words, such as hi, bye, please,
and thank you
19
Words to avoid
More
Want
Please
Help
All done
* Unless they are a pivot word in a two-word phrase
**Once these words are taught, there may be less
motivation to learn additional vocabulary
*** The child may only learn that when using these single
words, good things will probably happen
List 4: Favorites for Manding Words
List of favorite foods, drinks, toys, activities, people and
pets names.
* This is where simplification of words is most necessary
K-SLP Successive Approximations
Treatment Strategies
Listen: Listen to the child's production of a word.
Determine: Determine if the child can imitate a higher
approximation of the word just short of failure.
Teach: Teach an approximation of a word (or of a
phoneme) only if the child is not stimulable to produce the
word or phoneme with every technique the SLP knows to
try.
Extinguish: Once the child becomes stimulable for a better
approximation of the word (through treatment sessions) or
has achieved perfection, no longer accept any inferior
production.
continued…
20
K-SLP Successive Approximations
Treatment Strategies
Avoid
Avoid implementing an unnatural phonological process as
a simplification strategy such as backing (teaching /k,g/ for
/t,d/).
* Though dentalizing /t,d,n,l/ to make them more visible and
gross motor as an initial strategy is acceptable practice in
the K-SLP as long as accurate production of these
phonemes is also being practiced. Then dentalization
would be extinguished.
Two Ways to Simplify Words
Based Upon the Least Physiological Effort
1. Implement phonological
processes
2. Move backward on
the KSPT test hierarchy
Any word can be broken down
into a level that a child can imitate
Examples of children’s names (take from audience)
Nancy
=
complex two-syllable word
Nan-tee
=
stopping the /s/
Nan-dee
=
stopping the /s/ (and voicing)
Nae-nee
=
repetitive syllable with vowel change
Nae-nae
=
reduplication
Nah-nah
=
vowel neutralization
Nae
=
syllabic reduction
21
noodle
pasta
noo-do
pas-ta
doo-do
pah-ta
oo-do
pah-da
ah-da
spaghetti
ss-puh-geh-ti
puh-geh-tee
puh-deh-tee
buh-deh-dee
deh-dee
We can use our knowledge of phonological
processes to help children with apraxia of
speech simplify words into best approximations:
Final consonant deletion
ba for ball
Initial consonant deletion
ine for mine
Medial consonant deletion
buh-ee for bunny
Cluster reduction
top for stop
Reduplication
wawa for water
22
Deaffrication
ticken for chicken
Vowel neutralization
nem for name
Stopping
tum for thumb
Devoicing
bik for big
Fronting
tootie for cookie
Voicing
doo for too
Another way to simplify words into approximations
or shells is to move in reverse through the
Kaufman Speech Praxis Test hierarchy.
Example:
water
=
complex bisyllabic
wa-tuh
=
simple bisyllabic
wa-wa
=
reduplication
wa
=
oo-aw oo-aw =
single syllable (CV)
simplify the movement within a
dipthong
Apraxia Treatment Strategies
Compensatory placement for isolated phoneme errors
(simplification of the difficult aspect of the production of the
phoneme, while attempting to maintain its acoustic and motoric
properties.)
a. Dentalization for tip alveolars /t,d,n/ and phoneme /l/.
b. Deaffrication (or stopping) of fricatives/affricates:
/t,d/ instead of / s,z,t , d!/
/p,b/ instead of / f,v /
c. Exaggerated backing of velars
d. Voicing/devoicing
(easier to voice in initial and medial position and devoice in final)
23
e. Vocalization (vowels in place of consonants)
/w/ for /r/
/j/ for /l/
/o/ for final /l/
/%/ for final /r/
f. Vowel neutralization
g. Fronting:* /t,d/ for /k,/
h. Gliding* /j/ or /w/ for /l/
i. Labialization:* /f/ for “th”
*usually within context
Cueing Techniques
While establishing a “core” vocabulary, cues will be
necessary to remind the child of a new motor sequence for
each word (picture). Use as many cues as necessary for
the child to reach his/her best word approximation (or
whole word), then reduce each cue systematically until the
child can name the pictures spontaneously or mand for
their favorites, using their best word approximation or
whole target word.
a. Cognitive
(explanation) e.g. “bite your lip and blow” (for /f/)
“open your mouth” (for /k/ and //)
b. Visual/tactile hand signal cues for VOWELS
(on or around the clinician’s own mouth)
24
b. Visual/tactile hand signal cues for VOWELS
continued
(on or around the clinician’s own mouth)
b. Visual/tactile hand signal cues for SIMPLE
CONSONANTS (on or around the clinician’s own mouth)
b. Visual/tactile hand signal cues for SIMPLE
CONSONANTS (on or around the clinician’s own mouth)
25
For /k/:
Place your thumb underneath your chin and make the
motion of pushing up (as in pushing up under the tongue)
with an open mouth position.
For //:
Cup your hand just under your chin around the neck.
For / /:
Place your index finger across the lips vertically to make
the “be quiet” signal (shhhh) or pinch the lateral portion of
the lips together (forcing the lips to pucker).
For /t /:
Place the thumb and forefinger on the lateral portions of the
maxilla (upper jaw).
For /d!/:
Place the thumb and forefinger on the lateral portions of the
mandible (lower jaw).
For /s/:
Put teeth together and show them with opened lips while
making the letter /s/ in the air.
For voicing:
Place your hand on your throat i.e. as in “feeling” the
vibration of the vocal folds.
You can always create your own hand signals as long as
they are consistent for the child.
c. Oral postural cues
Placing your own articulators visibly for the initial,
medial, or final consonant without voicing.
d. First consonant or syllable cues
Say, whisper, or oral posture the first consonant or
syllable of a word or subsequent words in a phrase
sentence.
e. Contextual cues
“Fill ins” to songs, books, and rhymes.
Fill in the blank: “I drive the _______.”
“The wheels on the ________.”
“Twinkle twinkle, little ________.”
26
f. Touch cues
Physically touching your
body or the child’s body
for syllabic emphasis,
i.e. knee to knee, hand
to hand, etc.
g. Alternate naming for
verbal motor memory (breaking perseveration)
Using 2 new word approximations and having the child
name them, alternating between one and another.
Often, the words may be similar, and triggers
perseveration. Alternating naming between them with
cues may help, i.e. butter and bunny.
h. Pivot syllables
ny: bunny, money, honey, Barney, Winnie, Ernie, beanie
ter: water, batter, meter, matter, Peter, butter
dle=/do/: puddle, needle, noodle, poodle, beetle
ble: bubble, marble, table, hobble, pebble
dy: muddy, buddy, body, Daddy, handy, candy, Heidi, Paddy
ty: potty, party, beauty, nutty, putty, Betty
* ty can be pronounced dy
i. Gestural
Use signs or universal gestures.
j. Written
Highlighting errors so child can read cues.
k. Giving the answer first, then asking a question
“Look at her painting. What is she doing?”
l. Deletion of vowel in monosyllabic words
Moving from the initial consonant directly to the final
consonant without the vowel, then adding the vowel
back in.
27
m. Backward chaining on two and three syllable words
or “chunking” syllables
Imitating the last vowel or consonant-vowel of a word,
and moving backward or forward little by little.
cookie
ee
kee
uh-kee
cookie
banana
nana
ba-nana
n. Pictoral
Real pictures or pictures which represent consonants,
i.e. clock = t-t-t
o. Intensity
Presenting the target (errored) syllable louder in
intensity than the other syllable.
p. Melody
Using pitch variation or a “sing song” quality to the
stimulus target word.
q. Auditory contrast cues
Example: potty child says, teetee
Clinician should ask the child to produce their error
again on imitation: Say, “teetee.”
Now tell the child to say potty
while emphasizing the first syllable
louder and with a different pitch
to draw child’s attention to the
syllable in error.
r. Auditory bombardment cues
Say the syllable in error
three times
s. Simultaneous cues
Say the word together with
the child
t. Whisper cues
Whisper the word while the
child is attempting it
u. Using a context already in the child’s repertoire
If the child cannot say the word down, have him say,
dada (or a word that starts with /d/ that is easily in
their repertoire) then have him say, down.
28
v. Breaking up diphthongs into component parts
Examples: bike would be bah-eek
name would be neh-eem
home would be ho-oom
house would be ha-oose
boy would be baw-ee
(Don’t make a vocal break)
w. Pivot syllables
x. PROMPT system (Hayden)
Example of Fading Cues
1. Simultaneous: Say the whole word or phrase with the
child.
2. Whisper: Whisper the whole word or phrase with the
child.
3. Provide oral postural
cues with gestures.
4. Provide gestures only.
What about children who are not yet vocal
imitators?
Non-vocal/verbal children with autism spectrum disorders
or other developmental challenges
Sign language can be used as a bridge to vocal skills.
29
Some specific techniques for children
with apraxia of speech secondary to
autism spectrum disorder
Tamara Kasper, M.A., CCC/SLP, BCBA
1. While shaping functional signs, pair the word verbally
as well (for manding).
2. During echoic trials, work on CV combinations while
ensuring that the vowels are as accurate as possible.
3. Use the CV combinations for pivot syllables while
moving into any CVCV,CV1CV2 or C1V1C2V2 word types.
4. When the child produces an acceptable approximation
of the adult form of a word, show the card while
delivering a reinforcer.
5. Assist the child through cueing and fading to eventually
spontaneously name (tact) the picture.
6. Assist the child to always mand with best word
approximations (at least single word).
7. Refine and integrate best clarity through echoic trials.
8. Don’t use pictures that do not literally represent the
noun or verb of the picture, i.e. take away the dog
family because their names would be random. Take
out neigh-neigh etc. because you are not naming horse.
30
SIX STEPS
4
Help the child to combine words
through pivot words and phrases,
as well as telegraphic language
structures, to include scripting
functional language.
Move ahead on expressive language
(combining words), and back up on
motor-speech (clarity)
Pivot Words
Once the child has some consistent word approximations,
add words for a two-word phrase, such as pivot words:
my
open
help
want
no
on
tie
move
more
hi
bye
red
big
________
________
________
________
________
________
________
________
________
________
________
________
________
Script Functional Language with Pivot Phrases
I want __________.
I want to __________.
Can (may) I have _________?
Let me __________.
Put away __________.
Put on __________.
Take off __________.
Pick up __________.
Watch me __________.
31
Telegraphic Naming of Function & Action
Naming function of objects (N-V-O)
For each consistent word approximation or whole word, ask…“what
do you do with a ball?” Pattern the child to respond “I throw ball.”
This may even be “/$/ /to/ /b/,” each word being an
approximation. (For some children with autism spectrum disorders
we would not work on naming function because it would not
necessarily be a bridge to the use of this structure).
Naming action (N-V-O)
Present an action verb picture and ask the child “what is the boy
doing?” Pattern the response “boy eat apple.” This may have to be
“/b/ /i/ /$po/,” each word being an approximation. Ageappropriate syntax and morphology will be built-in later (i.e.
pronouns, function words).
Simple sequence stories for N-V-O structures
Present a simple 3-5 picture sequence story.
Assist the child with an N-V-O response for each, i.e.:
“Paddy wake up”
“Paddy go potty”
“Paddy wash hands”
“Paddy brush teeth”
“Paddy put on clothes”
“Paddy eat food”
Again, each word of the N-V-O pattern may still have to
be an approximation.
Kaufman Speech to Language Protocol Workout Book
32
Scripting Functional Language
Situation
The child approaches you and points, grunts or only utters a
single word or approximation.
If you can anticipate what a child is trying to convey, give
them a script.
You can already assume what the child wants because
you are familiar with their speech patterns and gestures.
Let’s assume the child wants to go outside.
You Say
“Oh, do you want to go outside? Tell me you want to go
outside.” Always model with correct speech patterns. (Cue) “I wa
do ou-t” or best whole words or approximations. Then let the
child go out.
Scripting Functional Language
Example: The child turns the doorknob and is unable to
open the door.
Say: “Do you want me to open the door?”
(use the answer words within your question)
Get best approximation for yes
Say: “Tell me you want to open the door.”
Help the child to say:
“opuh do” or “I wa o-puh” or “o-puh peez” or “o”
(open door) (I want open) (open please) (open)
* Eventually fade cues
33
Example of Fading Cues for a
Phrase in Scripting
1. Full answer first question.
(This provides an auditory perceptual cue).
2. Say: Tell me __________.
(This provides a second auditory perceptual cue)
3. Have the child fill in the blank with the last word in the
phrase.
4. Give the first word of the phrase and each subsequent
first phoneme of the rest of the words.
5. Give the first word and just an oral posture of the first
phoneme of the rest of the words.
6.
Give the first phoneme of the first word and the rest of
the words.
7.
Give oral postures and gestures for the first phoneme
of each word.
8.
Give gestures only.
9.
Now we can say, “What do you want?” or “What do
you want (me) to do?”
10. Now we can say, “Use your words.”
Tips for Scripting Functional Expressive Language
(Including Those with Immediate Echolalia)
1.
Avoid saying, say or tell me as the children might
imitate those words in their utterances.
2.
Think about what the child might wish to convey and
choose pivot words or
phrases if possible for them.
They would be more likely
to use these again as they
can now “plug in” a formula.
3.
Use vocal inflection in
a natural way that the child
would use.
34
4.
Use the pronoun “I” so the child
will begin their utterances with “I.”
5.
Use a familiar person’s name
if it is for a request or if the child
desires joint attention or shared
interest. “Mom, can I have
chips?” “Dad, look at the
bubbles.”
6.
Make the statement or question, then wait (be silent)
until the child imitates, then follow through by giving the
item or allowing the activity, or by making a comment
that lets the child know you understood them.
7.
Choose a pivot phrase to practice:
I want _____.
I want to _____.
Look at the _____.
I see a _____.
Can I have a _____?
Let me _____.
8.
Give a visual cue for small, linking words like is or to.
9.
Choose a grammatical skill or rule to focus upon and
cue or “correct” that skill only.
Ex: “I”, articles, auxillary verbs, “is, are”, “ing” verbs
10. Choose a consonant or vowel that has been of focus in
therapy and cue or “correct” that consonant or vowel
only.
11. Fade cues to visual oral postures or gestures only
Examples of fading cues:
a. Simultaneous: Say the whole
word or phrase with the child.
b. Whisper: Whisper the whole
word or phrase with the child.
c. Provide oral postural cues with
gestures.
d. Provide gestures only.
35
Scripting the Language of Games
•
•
•
•
•
•
•
•
•
Want to play?
You go first.
My turn.
Your turn.
I need that one.
I don’t need that one.
Do you need that one?
I got my wish.
I need blue
(other colors, etc).
• I need a _____.
• What do you need?
• How many more?
• I will win.
• Here’s the _____.
(spinner, dice, piece).
• I hope I get a ___.
SIX STEPS
5
Refine and integrate complex
consonants and syllable shape
gestures. Continue to build
expressive language by adding in
syntax and morphology.
Grammar
Begin to build in syntactic and morphologic structures:
• Begin with the present progressive: ing in describing
action pictures, i.e. instead of “boy eat apple,” assist:
“boy eating apple.” An approximation for ing might be
een /in/
•
•
•
•
•
Add is, i.e. assist “boy is eating apple.” Use a cue for
the word is
Continue to add in syntactic and morphologic
structures to negative and question formulation
Add pronouns
Add all function words last (articles, auxiliary verbs)
Continue to back-up on improving word
approximations toward target words
36
Refinement and integration
(back up on specific phoneme synthesis)
Begin to back up on specific phoneme synthesis, word
initial, medial, or final. Once a new phoneme is
produced successfully in synthesis at the word level,
you will extinguish a temporary phoneme or
approximation with this new correct pattern.
It is important to move forward on expressive language,
and back-up on motor speech skills. As soon as the child
has a consistent vocabulary of whole words or word
approximations, begin this hierarchy. Back-up on
increasing a consonant repertoire and initial and final
phoneme synthesis.
(For some children, especially those with autism
spectrum disorders or those with general developmental
delays, we would work on “Sign to Talk” for manding.)
Kasper & Kaufman, K&K Sign to Talk (2005, 2009).
Negatives and questions
Negatives are easy three word combinations to
establish:
do
goes with
don’t
are
goes with
not
does
goes with
doesn’t
can
goes with
can’t
will
goes with
won’t
37
Show pictures or simply ask without a referent (at this
point, we are not expecting the inclusion of function words)
“Do trees fly?”
Assist response: “No they don’t”
“Are you a girl?”
Assist response: “No I not”
“Does a cow say oink?”
Assist response: “No it doesn’t”
“Can a door talk?”
Assist response: “No it can’t”
Proper syntax is not necessary at this time and will
be built in later, as it increases the verbal motor load.
Remember, each
word in the response
may have to be
approximated.
Questions can also be patterned:
Say: “Ask me if I’m a boy”
Assist: “Are you (a) boy?”
Say: “Ask me if a tree can fly.”
Assist: “Can (a) tree fly?”
Remember, each word
may have to be approximated
Always move ahead on
expressive language while
backing-up on motor-speech
proficiency
38
Repetitive story books
Go through repetitive story books, assisting N-V-O or 2-3
word combinations so that the child can eventually
“read” them independently. They may continue to use
word approximations. They are still then, practicing the
basic structure of expressive language without waiting
until they achieve motor-speech perfection.
Kaufman Speech to Language Protocol Workout Book
Short Stories
“Vignettes” in response to specific WH questions.
• Who is this?
This is a _________.
• What does the ________
want to do?
The ______wants to _____.
• What is the _______ doing?
The ______ is _____ing.
Kaufman Speech to Language Protocol
Workout Book
• What was the _____ doing?
The ______ was _____ing?
Blank, M., McKirdy, L., Payne, P. (1996).
39
General Formulation
Assist with cues for function words in a short story
upon imitation. Gradually reduce cues. Move into
conversation, assisting with cues for obtaining the
highest word approximations or whole words within
simple discourse.
SIX STEPS
6
Establish a home program.
Home Program Suggestions
• Personalized notebooks/binders (Nancy to explain)
• The Kaufman Speech to Language Protocol
Workout Book (can be duplicated)
• The K-SLP Mutt Family Practice Puzzle
• Script functional single-word mands (requests) or
pivot phrases
40
Praxis
Requires
Practice
Four Levels of Charting
Syllable Shape Goals
1. Imitation plus cues (auditory and visual cues,
tactile if necessary)
2. Imitation only with minimal cues (visual only)
3. Spontaneous with
minimal cues
(visual only, such
as oral postural
or gestural)
4. Spontaneous
Setting Individual Educational
Planning (IEP) Goals
Example 1:
The child will be able to produce simple bisyllabics in such
words as happy, bunny, tuna, with 90% accuracy.
Subgoals:
a. Upon imitation with cues
b. Upon imitation with minimal cues
(visual only)
c. Spontaneously with minimal cues
(visual only)
d. Spontaneously
41
Setting Individual Educational
Planning (IEP) Goals:
Example 2:
The child will be able to synthesize /f/ in the initial
position of words with 90% accuracy.
Subgoals:
1a. Upon imitation with full auditory and visual cues
(tactile if necessary) - with /f/ prolonged
1b. Upon imitation with minimal cues (visual only)
1c. Spontaneously with minimal cues (visual only)
1d. Spontaneously (it is best to keep any initial
consonant paired with a vowel, if possible!)
General Treatment
Considerations for CAS
1. Model correctly. When you are speaking to the child,
use full words and appropriate grammar. When helping
the child to speak, help them with word simplifications
and approximation techniques.
2. “Functional clarity” is the short-term goal.
100% motoric speech proficiency is the long-term goal.
3. Work at least within the context of a syllable or word,
backing up to phonemic production when necessary.
4. Work from simple to complex at every level considering
the difficulty of articulatory movement involved as well
as the “length” factors. Use the “diagnostic hierarchy”
as a guide.
5. Use as many cueing techniques, compensatory
placements or word shells as necessary initially for
success, then shape toward the target production.
6. Repetition is the key element in treatment.
7. Always consider expressive language elements,
particularly when increasing length.
42
8.
At phrase and sentence levels, make sure that most of
the words surrounding the target are easy and
successful. Then build in the difficulty by adding other
words which are difficult.
9.
Push for self-monitoring and correcting and reinforce
these skills.
10. Developmental norms need not necessarily be
considered as many children are able to produce “laterdeveloping” sounds more accurately than “earlier” ones.
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Early Phonetic and Phonological Characteristics of
Childhood Apraxia of Speech, ASHA Convention, Atlanta GA, 2012
Megan Overby, PhD, CCC-SLP & Sue Caspari, MA, CCC-SLP
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Resources
Childhood Apraxia of Speech Association of North America (CASANA) www.apraxia-kids.org
The Late Talker: Marilyn Agin MD, Lisa Geng, Malcolm J. Nicholl
PROMPT: www.promptinstitute.com
LINKS to Language: Blank, M., McKirdy, L., Payne, P.
Websites for signs
commtechlab.msu.edu/sites/aslweb/browser.htm
aslpro.com/cgi-bin/aslpro/aslpro Click on “asl for babies”
Oral motor
Lori Overland www.alphabetsoupomtherapy.com
Diane Bahr www.agesandstages.net
Sara Rosenfeld Johnson: www.talktools.net
Debra Beckman www.beckmanoralmotor.com
Pam Marshalla: www.pammarshalla.com
47
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