Childhood Apraxia of Speech (CAS) - Ohio Speech

Childhood Apraxia of Speech (CAS)
Practical Treatment Strategies for More Intelligible Speech
What is Childhood Apraxia of Speech?
Clinical Contexts in Which Childhood Apraxia of Speech Occurs:
 Neurological etiologies: intrauterine stroke, infections, trauma
 Neurobehavioral disorders: genetic, metabolic
 Idiopathic Neurogenic Speech Sound Disorders
Cognitive
Linguistic
Motor Programming/Planning

Motor Execution
What It Is NOT
 Developmental articulation disorder
 Phonological process disorder
 Dysarthria
1
Definition (ASHA, 2007)
Childhood apraxia of speech (CAS) is a neurological childhood speech sound
disorder in which the precision and consistency of movements underlying speech
are impaired in the absence of neuromuscular deficits (abnormal reflexes,
abnormal tone). The core impairment is in planning and/or programming
spatiotemporal (space and time) parameters of movement sequences results in
errors in speech sound production and prosody.
CAS: Other Aliases
 Praxis
 Motor Planning Disorder
 Motor Incoordination
 Verbal (Dys) Apraxia – More widely accepted in other English speaking
countries outside of the United States
 Apraxia
 Apraxia of Speech – more widely accepted in the United States following
the Mayo Clinic (Duffy, 2005)
Prevalence
One to two children per one thousand (Shriberg, Aram, Kwiatkowski, 1997)
There is no validated list of diagnostic features of CAS.
Associated Diagnoses






Autism
Cerebral Palsy
Epilepsy
Fragile X
Rett Syndrome
Chromosome Translocations
2
Checklist: Distinguishing CAS from Other Diagnoses:
Vowels:
 Inconsistent use of VOWELS
 Limited repertoire of VOWELS
Consonants:
 May produce a sound correctly in one word position but not in another (i.e.:
ball, ba _ y)
 May use an initial sound correctly in one word and substitute a sound or
omit the sound in other initial position words (i.e.: ball, _aby)
 May say a word correctly one time, change the sounds in the word the next,
then change them again (bye, dye, mye)
 Substitution of voice and voiceless consonants
Coarticulation:
 Lengthened and disrupted coarticulatory transition between sounds and
syllables
Prosody:
 Atypical prosody
Language:
 Statistically significant discrepancy between receptive and expressive
language
3
Comparison of Speech Disorders
CAS
Inconsistent errors on
consonants (repeated
production)
Inconsistent errors on vowels
(repeated production)
Decreased vowel production
Disrupted coarticulation
transitions between sounds and
words
Increased errors in longer more
complex sequences
Decreased strength of oral
motor musculature
Motor control for chewing and
swallowing
Articulatory precision
Types of errors
Errors based on length of
utterance
Receptive and Expressive
Language
Prosody - lexical and phrasal
stress)
Dysarthria
Phonology
Disorder
Articulation
Consistent
errors but rule
based
Substitutions,
omissions,
additions,
repetitions.
Omissions
typically in
the final
position
consistent
Consistent
sound errors





If oral apraxia is


presented 
Inconsistent in the Imprecision
same word
but
consistent
Substitutions,
distortions
omissions,
additions,
repetitions.
Vowel
distortions,
voice/voiceless
consonant errors
Less precise
in connected
speech
Gap with
No
receptive higher
discrepancy

Disrupted

Disrupted
based on
type
(spastic,
flaccid, etc)
Sometimes a
difference
No disruption
Substitutions,
omissions,
additions,
repetitions.
consistent
No
difference
typically
No
disruption
4
Motor Planning Patterns
V
CV
VC
VCV
C1V1C1V1
C1V1C2V1
C1V1C2V2
C1V1C1
C1V1C2
CVCVCV
CVCV + CVC
5
Pivot Syllables
ny
dy
ty
ter
dle
tle
ble
ple
kle (cle)
gle
zle
sle
6
Childhood Apraxia of Speech
Evaluation
Hearing:
 Passed a complete audiological assessment
 Failed a complete audiological assessment
 Hearing screening: Date: __________________
Results
500 Hz
1000 Hz
2000 Hz
4000 HZ
Right Ear
Left Ear
Prelinguistic
 Limited cooing and babbling
 Delayed onset of first words
Emergence of first words: ___________________________________________________
 Limited vowel production
Vowels:
Short:
a
e
i
o
u
Long: a
e
i
o
u
 Limited consonant production
Consonants
p
b
m
h
s
z
w
t
d
n
f
v
k
sh
ch
j
y
l
r
th
g
Sound combinations elicited: Give examples
 V
 VC
 CV
 VCV
 C1V1C1V1
 C1V1C2V2
 C1VC1
 C1VC2
 Other
 Can make sounds in isolation but limited when sounds are combined
7
Example: __________________________________________________________
Page 2: Prelinguistic continued
 Receptive language better than expressive language
Test Given: ___________________________________________________
Results:
Age
Standard Score
Percentile
Receptive Language
Expressive Language
Comments: ________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Linguistic
 Inconsistent sound errors that are not a result of immature speech
 Learning Difficulties
 Spelling
 Reading
 Writing
 Receptive language better than expressive language
Test Given: ___________________________________________________
Results:
Age
Standard Score
Percentile
Receptive Language
Expressive Language
Comments: ________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
8
Page 3: Linguistic continued
Speech Assessment
Test Given: ___________________________________________________
Results:
Standard Score




Percentile
Errors on consonants
Voicing errors
Errors on vowel production
Single word production better than:
 Sentences
 Connected Speech
Comments: ________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Intelligibility
Known
Context
Familiar Listener
Unfamiliar Listener
Unknown
Context
%
%
Single
Words
%
%
Sentences
%
%
Connected
Speech
%
%
%
%
Prelinguistic and Linguistic
Oral Motor
 Symmetry at rest
 Asymmetry at rest
Describe: _____________________________________________________________
 Is able to imitate oral motor movements
 Is unable to imitate oral motor movements
 Groping noted
 Suspected oral apraxia
Describe: _____________________________________________________________
Strength:
9
Page 4: Oral motor continued
Lips
 Normal
 Abnormal
Describe: _______________________________________________________
Cheeks
 Normal
 Abnormal
Describe: _______________________________________________________
Tongue
 Normal
 Abnormal
Describe: _______________________________________________________
Jaw
 Normal
 Abnormal
Describe: _______________________________________________________
 Suspected Dysarthria
Diadochokinetic Rate:
Norms in seconds
Task
Repetitions
Seconds
6
7
8
9
10
11
12
13
p
20
4.8
4.8
4.2
4.0
3.7
3.6
3.4
3.3
t
20
4.9
4.9
4.4
4.1
3.8
3.6
3.5
3.3
k
20
5.5
5.3
4.8
4.6
4.3
4.0
3.9
3.7
Standard Deviation
1.0
1.0
.7
.7
.6
.6
.6
.6
p t k
10.3
10.0
8.3
7.7
7.1
6.5
6.4
5.7
2.8
2.8
2.0
2.0
1.5
1.5
1.5
1.5
10
Standard Deviation
Norms are from “Time-by-Count Measurement of Diadochokinetic Syllable Rate,” by S.G. Fletcher, 1972,
Journal of Speech and Hearing Disorders, 15, pp. 763–770). Copyright by the American Speech-LanguageHearing Association.
Comments: ________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
10
Page 5
Feeding Issues
 Forming bolus
 Storing food in
cheeks
 Swallowing
 Gagging
 Overstuffing mouth
 Choking
 Picky Eater
Textures
 Smooth
 Slightly lump
 Lumpy
 Mixed
 Crunchy
 Other: _______________________
Tastes
 Bland
 Salty
 Sour
 Bitter
 Other: _______________________
Temperatures
 Room temperature
 Warm
 Hot
 Cold
 Other: _______________________
Chewing pattern
 Munching
 Lateral jaw shift
 Diagonal movement
 Diagonal rotary
 Circular rotary
Checklist of Characteristics: General
 Inconsistent sound production
 Consonants
 Vowels
 Uses sounds inconsistently
 Changes sound production with repetition
 Lengthened or disrupted coarticulatory transition
 Between sounds
 Between syllables
11
Page 6
Prosody
Pitch
 Appropriate
 Too high for age
 Too low for age
Vocal Quality




Appropriate
Hoarse
Harsh
Nasal
 Hypernasal
 Hyponasal
Rate
 Appropriate
 Too fast
 Too slow
Stress
 Appropriate
 Stress is on the wrong syllable
Intonation
 Appropriate
 Inappropriate: Comment (appropriate rise and fall for types of sentences)
Loudness
 Appropriate
 Too loud
 Too soft
Fluency
 Appropriate for age
 Atypical
Describe: _______________________________________________________
________________________________________________________________
Other:
Sensory Issues
 Hypersensitive
 Hyposensitive
Comments: ____________________________________________________________
______________________________________________________________________
 Suspected
 Limb Kinetic Apraxia
 Ideomotor Apraxia
 Occupational Therapist consultation recommended
12
Hearing:
 Passed a complete audiological assessment
 Failed a complete audiological assessment
 Hearing screening: Date: __________________
Results
500 Hz
1000 Hz
2000 Hz
4000 HZ
Right Ear
Left Ear
Hearing acuity should be assessed to be sure that the delay in speech development
is not due to a hearing loss (conductive, sensorineural, or mixed). If there is a
hearing loss, this should be evaluated further in order to determine if this could be
the cause of the delay/disorder.
The frequency and characteristics of early vocalizations also can be affected by
perceptual factors such as early otitis media with effusion (Petinou, Schwartz,
Mody, & Gravel, 1999; Rvachew, Slawinski, Williams, & Green, 1999)
Prelinguistic
 Limited cooing and babbling:
Prelinguistic vocal experiences begin the process of speech and language
production.
Frequency of a child's vocalizations at 3-6 months correlates to his or hers
expressive vocabulary at 27 months. (Stoel-Gammon, 1992)
 Delayed onset of first words
13
Children who demonstrate consistent vocal motor schemes, or favorite babbles,
tend to develop words earlier (McCune & Vihman, 1987).
Children that are late talkers are at greater risk for academic difficulties especially
in literacy and reading skills (Lewis 2007).
Children with speech delay often also have language delays, especially in
expressive morphology (Paul & Shriberg, 1982; Rvachew, Gaines, Cloutier, &
Blanchet, 2005).
 Limited vowel production
Vowels:
Short:
a
e
i
o
u
Long: a
e
i
o
u
Accurate production of all vowels and most diphthongs (but not rhotic vowels)
should be achieved by age 3 (Bassi, 1983; Larkins, 1983; Pollock & Berni, 2003).
Pollock and Berni's study, the average percentage of vowels correct for children
18 and 23 months : 82%
24-29 months: 92%
30- 35 months: 94%
By 36 months: 97%
Maassen et al. (2003) reported that compared to children with typically developing
speech, children with CAS had poorer identification as well as poorer
discrimination of vowels.
14
 Limited consonant production
Consonants
p
b
m
h
s
z
w
t
d
n
f
v
k
sh
ch
j
y
l
r
th
g
Individual sounds may be produced variably, even within the same word,
although speech production patterns (i.e., frequent phonological processes) are
consistent (Demuth, 2001; Ferguson & Farwell, 1975; Taelman & Gillis, 2002;
Velleman & Vihman, 2002).
Children with nonapraxic speech sound disorders appear to be most
successful at producing the correct voicing features of a segment and least
successful at maintaining the correct place of articulation (Forrest & Morrisette,
1999).
Sound combinations elicited: Give examples
 V
 VC
 CV
 VCV
 C1V1C1V1
 C1V1C2V2
 C1VC1

C1VC2
 Other
 Can make sounds in isolation but limited when sounds are combined
 Receptive language better than expressive language
15
Test Given:
Results:
Age
Standard
Score
Percentile
Receptive Language
Expressive Language
There is general agreement in reviews of the literature that children suspected to
have CAS typically also have significant language deficits (Crary 1984, 1993;
Ozanne, 1995; Velleman & Strand, 1994).
Linguistic
 Inconsistent sound errors that are not a result of immature speech
 Learning Difficulties
 Spelling
 Reading
 Writing
Children with any sort of speech production deficit are at higher risk for difficulty
with phonological awareness, which itself is a “critical element of literacy
development” (Justice & Schuele, 2004)
Marion, Sussman, and Marquardt (1993) demonstrated that children with CAS
have more difficulty perceiving and producing rhymes than do children with
typically developing speech.
16
Marquardt et al. (2002) similarly showed that children with CAS score lower than
typically developing children on metaphonological (phonological awareness) tasks.
Lewis et al. (2004) found that children with CAS had deficits in word attack, word
identification, and spelling in comparison to children with speech disorders only.
 Receptive language better than expressive language
Test Given: ___________________________________________________
Results:
Age
Standard
Score
Percentile
Receptive Language
Expressive Language
(Morphology, Phonology, Syntax, Semantics, Pragmatics, Supralinguistics)
 Speech Assessment
Test Given: ___________________________________________________
Results:
Standard
Score
Percentile
Comment on vowel production even if measure does not specifically measure
vowels.
17
 Errors on consonants
 Voicing errors
 Errors on vowel production
 Limited vowel repertoire
 Single word production better than:
 Sentences
 Connected Speech
Available Tests:
 The Apraxia Profile (Pearson Assessments: Hickman, 1997) Cost: $88.00
ages: 3 years to 13 years. Assesses oral motor sequencing
 Kaufman Speech Praxis Test for Children (Wayne State University Press:
Kaufman, 1995) Cost: $180.00 ages: 2-0 to 5-11 Assesses simple to
complex motor speech movements using true words
 Screening Test for Developmental Apraxia of Speech 2(Pro-Ed: Blakely,
2000) Cost: $115.00 ages: 4-12, Expressive Language Discrepancy,
Prosody, Verbal Sequencing, and Articulation
 Verbal Motor Production Assessment for Children (Pearson) Cost: $144.00
ages 3-12 Global Motor Control, Focal Oromotor Control, and
Sequencing—and two supplemental areas—Connected Speech and
Language Control and Speech Characteristics
18
Coming soon:
 Dynamic Assessment of Motor Speech Skill (DEMSS). Dr. Edith Strand.
Mayo Clinic
Components of this new assessment:
Movement accuracy
Subtests
 Vowel Errors
 Consonant-Vowel (me; hi)
 Consistency
 Vowel-Consonant (up; eat)
 Prosody
 Reduplicated Syllables (mama; booboo)
 CVC1 (mom; peep; pop)
 CVC2 (mad; bed; hop)
 Bisyllabic 1 (baby; puppy)
 Bisyllabic 2 (bunny; happy; today; canoe)
 Multisyllabic (banana; video)
Intelligibility
Familiar Listener
Unfamiliar Listener
Known
Unknown Single
Sentences Connected
Context Context
Words
Speech
%
%
%
%
%
%
%
%
%
%
By 2 year: 26%–50% intelligible
By 3 years: 71%–80% intelligible
By 4 years: 100%
Coplan & Gleason, 1988; Weiss, 1982
19
Prelinguistic and Linguistic
Oral Motor
 Symmetry at rest
 Asymmetry at rest
Describe:
_____________________________________________________________
 Is able to imitate oral motor movements
 Is unable to imitate oral motor movements
 Groping noted
 Suspected oral apraxia
General awkwardness or clumsiness, impaired volitional oral movements, mild
delays in motor development, mildly low muscle tone, abnormal orosensory
perception (hyper- or hyposensitivity in the oral area), and oral apraxia (Davis et
al., 1998; McCabe et al., 1998; Shriberg et al., 1997)
The nonspeech motor features typically listed for oral apraxia are impaired
volitional oral movements (imitated or elicited postures or sequences such as
“smile-kiss”) and groping (Davis et al., 1998; McCabe et al., 1998; Shriberg et al.,
1997).
Strength:
Lips
 Normal
 Abnormal
Describe: _______________________________________________________
20
Cheeks
 Normal
 Abnormal
Describe: _______________________________________________________
Page 4: Oral motor continued
Tongue
 Normal
 Abnormal
Describe: _______________________________________________________
Jaw
 Normal
 Abnormal
Describe: _______________________________________________________
 Suspected Dysarthria
21
Diadochokinetic Rate:
Norms in seconds
Task Repetitions Seconds
6
7
8
9
10
11
12
13
p
20
4.8
4.8
4.2
4.0
3.7
3.6
3.4
3.3
t
20
4.9
4.9
4.4
4.1
3.8
3.6
3.5
3.3
k
20
5.5
5.3
4.8
4.6
4.3
4.0
3.9
3.7
Standard Deviation
1.0
1.0
.7
.7
.6
.6
.6
.6
p t k
10.3 10.0
8.3
7.7
7.1
6.5
6.4
5.7
2.8
2.0
2.0
1.5
1.5
1.5
1.5
10
Standard Deviation
2.8
Norms are from “Time-by-Count Measurement of Diadochokinetic Syllable Rate,”
by S.G. Fletcher, 1978, Journal of Speech and Hearing Disorders, 15, pp. 763–
770). Copyright by the American Speech-Language-Hearing Association.
Lewis et al. (2004) found significant differences between preschool and school-age
children with CAS and matched children with non-CAS speech delay in their
ability to repeat nonwords and multisyllabic words, with the CAS group
performing more poorly. Children with CAS also had significantly lower Total
Function scores on the Robbins and Klee (1987) oral-motor assessment, which
includes diadochokinetic rate.
22
Feeding Issues
 Forming bolus
 Storing food
in cheeks
 Swallowing
 Gagging
 Overstuffing mouth
 Choking
 Picky Eater
Textures
 Smooth
 Slightly lump
 Lumpy
 Mixed
 Crunchy
 Other:
_______________________
Tastes
 Bland
 Salty
 Sour
 Bitter
 Other:
_______________________
Temperatures
 Room temperature
 Warm
 Hot
 Cold
 Other:
_______________________
Chewing pattern
 Munching
 Lateral jaw shift
 Diagonal movement
 Diagonal rotary
 Circular rotary
23
Munching - This early chewing pattern combines phasic biting and some
nonstereotypic vertical movements of the jaw with tongue movement to the hard
palate. (emerges as early as 6 months of age)
Lateral jaw shift - This is a lateral (side to side) movement of the jaw with no
downward displacement of the jaw. (months)
Diagonal movement - This is a lateral, downward movement of the jaw to either
side with easy contact and release. It aids in the placement of food between molars
for chewing. There is no grinding movement, and no movement of the jaw across
midline. It occurs in conjunction with vertical jaw movement.
Diagonal rotary movement - There is a lateral, downward movement with upward,
horizontal sliding movements for grinding foods between molars. The jaw moves
to one side or the other, without crossing midline. It may accompany lateral
movement of food from the center of the tongue to the teeth. (24-30 months)
Circular rotary movement - This is the most mature chewing pattern, with jaw
movement laterally, downward, across the midline to the other side and upward to
close. It may occur either clockwise or counter -clockwise. It may accompany
transfer of food from one side of the mouth across the midline to the other side of
the mouth. (30-36 months)
http://www.beckmanoralmotor.com/patterns.htm
Early emerging chewing behaviors have often been viewed as providing the
infrastructure from which speech motor coordination emerges (Grillner 1982; Ling
1976; Mysak 1980; Thelen 1991).
24
Checklist of Characteristics: General
 Inconsistent sound production
 Consonants
 Vowels
 Uses sounds inconsistently
 Changes sound production with repetition
 Lengthened or disrupted coarticulatory transition
 Between sounds
 Between syllables
Prosody
Pitch



Vocal Quality




Appropriate
Too high for age
Too low for age
Appropriate
Hoarse
Harsh
Nasal
 Hypernasal
 Hyponasal
Rate
 Appropriate
 Too fast
 Too slow
Stress
 Appropriate
 Stress is on the wrong syllable
Intonation
 Appropriate
 Inappropriate: Comment
25
 Intonation/Prosody
 Listen for appropriate stress in syllables and words in sentences (video)
 Prelinguistic: Rise and fall pitch developed by 6-12 months
 Linguistic: Develops between 5 and 8 years
Listed in the order of development
 Falling intonation contours develop
 Sentence giving a statement
 Rising contours to mark phrase and utterance boundaries
 Answerable by yes/no
 Frequency, amplitude and duration to mark sentential emphasis
 is a single word or short phrase, usually interrupting normal syntax, used
to lend emphasis to the words immediately proximate to the adverb. (We
emphasize the words on each side of a pause or interruption in order to
maintain continuity of the thought.)
 Production of compound words
 Rise/fall or fall/rise to convey emotion
 High rising pitch to request clarification
 Accent on a nonfinal word to convey a message
 Comprehension of others emphasis to convey a message
 Pitch and pauses to mark different types of sentences
 Statement
 Exclamation
John likes Mary.
John likes Mary?
JOHN likes Mary.
John likes MARY.
No. Dogs are
allowed.
No dogs are allowed
 Questions
 Appropriate pauses for words and phrases
26
Loudness
 Appropriate
 Too loud
 Too soft
Fluency
 Appropriate for age
 Atypical
Other:
Sensory Issues
 Hypersensitive
 Hyposensitive
Resource: www.sensory-processing-disorders.com
 Limb Kinetic Apraxia
 The inability to make precise or exact movements with a finger, an
arm or a leg.
 These children may have difficulty with sign language due to the
difficulty coordinating fine motor movement
 Ideomotor Apraxia
 The inability to translate an idea into motion, resulting from some
interference with the transmission of the appropriate impulses from
the brain to the motor centers.
 There is no loss of the ability to perform an action automatically,
such as tying the shoelaces, but the action cannot be performed on
request.
 Occupational Therapist consultation recommended
 Anytime there are sensory issues
 Any suspected limb apraxia
27
TREATMENT
Overriding Goal: Improve overall communicative functioning to improve a
student’s ability to function within relevant social and educational contexts (World
Health Organization, 2001).
Motor Learning Theory:
Definition: A set of processes associated with practice or experience leading to
relatively permanent changes in the capability for movement. Therefore, the
change must be observed over time (generalized) not just during practice. This
should also be observable through generalization to untrained tasks.
Schema Theory (Schmidt, 1975, 2003; Schmidt & Lee, 2005)
 Definition of Schema: Memory representations that encode the relations among
these types of information, based on past experience with producing similar
actions. These schemas based on past experience with similar actions are
temporarily available in short term memory and used to update or create two
different schemas (recall and recognition schemas)
o Recall schema encodes the relations among the initial conditions, the
sensory consequences of the movement, and the outcome of the
movement.
o Recognition schema allows the system to evaluate movements by
comparing the actual sensory consequences with the expected sensory
schema.
 A series of generalized motor plans (GMP) that occur in a particular serial order
(i.e.: speech) may be integrated or chunked into a single larger motor plan with
large amounts of practice.
 Production of rapid discrete movements involves units of actions (motor
programs) that are retrieved from memory and then adapted to a particular
situation.
 A motor program is an organized set of motor commands that can be specified
before motor initiation (Keele, 1968).
28
 A generalized motor plan is an abstract movement pattern that specifies relative
timing and relative force of muscle contractions with absolute timing and force
scaled to meet certain tasks.
Generalization (transfer)
Maintenance (retention)
Acquisition through
practice
Example of Motor Learning: Golf swing
Duration and amplitude depend on the movement and muscles needed dependant
on the distance that ball must travel.
1. The motor system must know the relations among the initial condition
(position of the hands, distance between golf ball and hole).
2. The motor system must know the generated motor commands needed
(timing and amplitude of arm muscle contraction.
3. Next is the sensory consequences of the motor commands (propioception of
the arm movement, tactile sensation of the club hitting the ball).
4. Last, the outcome of the movement (where the ball ended up).
29
#2
1. The motor system must know the
relations among the initial condition
(position of the hands, distance between
golf ball and hole).
2. The motor system must know the
generated motor commands needed
(timing and amplitude of arm muscle
contraction.
#1
3.
3. Next is the sensory consequences of
the motor commands (propioception of
the arm movement, tactile sensation of
the club hitting the ball).
30
4. Last, the outcome of the
movement (where the ball ended up).
4.
 Motor speech disorders result from an impairment of the motor system
caused by disruption of:
o High level motor commands
o Neuromuscular processes
o Both
 Goal of therapy:
o Establish new motor routines
o Reestablish old ones
31
Schema Theory as Related to Speech Production
1. Initial Condition: Articulatory placement, voicing, prosody, intonation,
phrasing
2. Motor Commands Needed: Timing and amplitude of production
3. Sensory Consequences:
a. Tongue and lip movement for production
b. Tactile awareness of articulatory placement
4. Outcome: Were the speech sounds, voicing, intonation, and prosody
correct?
THERAPY
1. Prepractice
a. Target responses are explained (to parent or student)
b. Several correct productions are elicited using models, cuing, and
feedback
c. Attention to resulting sound instead of articulatory placement is more
effective
2. Practice
a. Maximize the number of trials of each target will enhance learning
b. Elicit targets in random order (shuffle cards for practice)
c. Variable practice will enhance transfer (orthographic, pictures, change in
loudness or pitch, change of carrier phrase, change of therapy location)
d. Reduce frequency of feedback to improve transfer
32
Overall Guidelines:
 Always do a thorough evaluation
 Therapy should be based on motor learning theory and practices of motor
learning.
 Target all areas identified through the assessment (speech, prosody,
receptive/expressive language skills, etc)
 Target speech and language simultaneously
 Shorter sessions several days a week better than a longer session
o Motor learning theory demonstrates that a high degree of direct
practice leads to the transfer and generalization of sequential motor
plans needed for correct speech production.
 If student cannot get the motor plan or if intelligibility diminishes with
practice of the same target, move to a different target, then come back to
previous target.
 Provide information to parents with ways to practice at home
o Home practice should be motor plans that have been mastered in
therapy.
33
PRISM: Underlying principles of treatment (Fish, Margaret. Here's How to Treat
Childhood Apraxia of Speech. San Diego, CA: Plural Pub., 2011.)
P
Phoneme Sequencing
R
Repetitive Practice
I
Intensity
S
Selection of Target Utterances
M
Multisensory Cues and Feedback
P
CAS involves the motor planning and programming of speech movements.
Therapy should concentrate on establishing increasingly complex articulatory
sequences.
R
Repetitive practice is required to establishing automaticity of speech motor
movements.
I
An intensive treatment schedule is recommended - intensity of practice
S
Only challenge the child on one level at a time. For example, if it is a word
shape (phonotactic complexity: VC, CV, CVC, CCVC) that is difficult for the
child, avoid introducing phonemes that the child does not yet possess. When
working on new phonemes, do not work on new word shapes.
M
Research shows that a multisensory cueing system is needed to increase
motor planning and motor sequencing. Cues should be faded systematically to
facilitate spontaneous production.
34
Treatment Approaches
Prelinguistic
Motor Precursor to First Oral Words
 Canonical babbling (7-10 months) - the rhythmic production of repetitive
consonant-vowel sequences
o Reduplicated babbling (C1V1C1V1)
 baba, mama
o Non-reduplicated babbling (C1VC1, V1C1V1)
 non, mam, peep
 aba, oomoo
 Variegated babbling (11-13 months) - more diverse patterns
o Ma-moo-mee
o booda
Children who demonstrate consistent vocal motor schemes or favorite babbles,
tend to develop words earlier (McCune & Vihman, 1987).
Sound Development:
12-18 months: The following patterns are typically represented in first word
production
Coronal - lifting tongue tip from its neutral position towards the teeth or the hard
palate (/t/, /d/, /n/, /s/, /z/ and /l/).
Labial stops - (/b/, /p/, /m/, /f/, /v/)
Nasals (/m/, /n/, /ng/)
Glides - sound which is articulated with very little constriction of the vocal tract (/y/
and /w)/.
Simple CV syllable shapes
Boysson-Bardies & Vihman, 1991; Eilers, Oller, & Benito-García, 1984;
Gildersleeve-Neumann, 2001; Goldstein & Cintrón, 2001; Oller, Wieman, Doyle,
& Ross, 1976; Teixeira & Davis, 2002; Vihman et al., 1986
35
Between 24-36 months - the sound system increases in complexity
Velars - (/k/ and /g/)
Fricatives- is articulated with almost a complete closure, but with just enough of an
opening to create turbulence in the airflow (/f/, /v/, /s/, /z/, and /sh/ )
Liquids - a liquid is a consonant that does not obstruct or constrict the flow of air
enough to create turbulence (/l/ and /r/)
By 36-40 months
Consonant clusters (by the first 3 months of the 4th year of age)
Final position develops first
Final consonants
Unstressed syllables
Establish expressive communication skills
 Linguistic Approach
o Morphology
o Phonology (rhyming, blending, segmenting, manipulating,
phonological short term memory, phonological retrieval)
o Syntax/grammar
o Semantics (semantic retrieval)
 Motor Planning Approach
o Tactile cues
 Hand prompts
 PROMPT
o Visual cues
 Pick a system that will link to sound-symbol program used in
your school.
 Signs
36
o Prosodic cues
o Augmentative/Alternative Communication Approach
 Picture symbols for objects and actions
 Picture board with choices for favorite foods/drinks,
activities, toys, family members, etc
 IPAD
o Album
o Proloquo 2
o Expression
o Tap to talk
o Combined Linguistic – Motor Planning- AAC Approach
Linguistic
General Guidelines:
Step I: Small group of stimulus
Step II: Stabilize existing vowel and consonant sounds
Sounds may be produced correctly in certain positions or contexts
Step III: Producing stabilized vowel and consonant sounds in motor planning
sequences




CVCV (mama)
VC (in)
CV (no)
VCV (oh no)
Step IV: Teaching new vowels and consonants
 Choose sounds for which the child is most stimulable
 Select sounds that occur more frequently in English
o Schwa /a/, /s/, /t/, /r/, /o/, /e/, /a/
 Select sounds that are visible (i.e.: /p/, /b/, /m/)
 Select sounds that are developmentally appropriate
37
Step V: Expand sound sequence skills
 Can follow Kaufman Speech Praxis Treatment Kit or develop own words
 Sound sequence
o CV (wuh)
o VC (on)
o VCV (oh no)
o C1V1C1V1 (mama, dada)
o C1V1C1V2 (baby, daddy, mommy)
o C1V1C2V2 (potty, hippo)
o C1V1C1 (dad)
o C1VC2 (cat, dog)
o CVCVCV (banana, domino)
o C1V1C2V2 plus CVC (muddy boot)
THERAPY STRATEGIES:
 Tactile prompts (touch cues and PROMPTS)
 Visual prompts (Signs, gestures, visual phonics)
 Prosodic prompts
38
Tactile:
PROMPTS (Prompts for Restructuring Oral Muscular Phonetic Targets)
“The technique is a tactile-kinesthetic approach that uses touch cues to a patient’s
articulators (jaw, tongue, lips) to manually guide them through a targeted word,
phrase or sentence. The technique develops motor control and the development of
proper oral muscular movements, while eliminating unnecessary muscle
movements, such as jaw sliding and inadequate lip rounding”
(Promptinstitute.com).
Levels of PROMPT Training:
1. PROMPT Technique Workshop
 Basics of the PROMPT technique
 trained how to make the “touch cues” to the articulators to help patient’s
produce a phoneme.
 They can also properly evaluate a patient
Clinicians who have completed the PROMPT Bridging Workshop have
had various levels of practice, but they have now gained a much-greater
understanding of how and when to use the technique. These clinicians
can develop much greater holistic intervention plans that address not only
speech-motor problems, but also cognitive-linguistic and socialemotional disorders that may affect speech.
2. PROMPT Certified clinicians: Completed all of the PROMPT training and
have demonstrated their effectiveness in using all of the different facets of
the PROMPT technique in practice.
3. PROMPT Instructors: are the best-trained PROMPT therapists.
39
TOUCH CUES:
Cues designed to touch the client (arm, leg, torso, face) to emulate the articulatory
input and duration of speech sounds.
©2013 Margo Kinzer Courter
Illustrated by: Serena Sherriff
40
Visual Cues
1.
2.
Use visual cues that will match up with whatever visual phonics your school uses.
This will make it easier for the student with childhood apraxia of speech to pair the cue for
the phoneme that you have taught with the symbol that goes with it for sound/symbol
awareness, phonological awareness, and literacy skills.
41
Long Vowels
Diphthongs
Digraphs
Visual Cues
1.
2.
Use visual cues that will match up with
whatever visual phonics your school uses.
This will make it easier for the student with
childhood apraxia of speech to pair the cue
for the phoneme that you have taught with
the symbol that goes with it for phonological
awareness and literacy.
42
Prosodic Prompts (suprasegmental features of speech: meter, stress,
volume, rate, pitch and intonation patterns)
 Prelinguistic: Rise and fall pitch developed by 6-12 months
 Linguistic: Develops between 5 and 8 years
Listed in the order of development
 Falling intonation contours develop
 Rising contours to mark phrase and utterance boundaries
 Frequency, amplitude and duration to mark sentential emphasis
 Production of compound words
 Rise/fall or fall/rise to convey emotion
 High rising pitch to request clarification
 Accent on a nonfinal word to convey a message
 Comprehension of others emphasis to convey a message
 Pitch and pauses to mark different types of sentences
(questions/statement)
 Appropriate pauses for words and phrases
Treatment Strategies:




Audacity.sourceforge.net
APP: Speech Prompts (Handhold Adaptive)
Melodic Intonation Therapy
Coarticulation Therapy (www.pediastaff.com Sarah
M. Gee, 9/20/2010)
o Vowel to Vowel (Iyam vs I am)
o Consonant to Vowel (picka vs pick a)
o Consonant to Consonant (horshoe vs horse
shoe)
 Use cards to represent each word and separate cards
for ending punctuation.
John likes Mary.
John likes Mary?
JOHN likes Mary.
John likes MARY.
No. Dogs are allowed.
No dogs are allowed
.
43
Input
Maximum input:
Multisensory cues,
sustained vowels, etc
Decreased input
Spontaneous
production
Spontaneous production
Increase cues
More cues
Maximum input:
Multisensory cues,
sustained vowels, etc
44
INTERVENTION TECHNIQUES
Integral Stimulation Therapy
Introduced in the 1950s by Milisen, who described a program for articulatory
treatment. The method involved mostly imitation, and emphasized both visual and
auditory models. This technique was developed for the treatment of acquired
apraxia of speech.
Dynamic Temporal & Tactile Cueing (DTTC)
This approach incorporates principles of motor learning and Integral Stimulation.
This approach is especially successful for students who are unsuccessful with
imitation or who are having difficulty achieving approximations for consonants
and vowels.
Strand, E. and Debertine, P. (2000). The Efficacy of Integral Stimulation
Intervention with Developmental Apraxia. Journal of Medical Speech Language
Pathology, 8, 295-300.
8 Step Continuum for Treatment
1. Imitation
2. Simultaneous production with prolonged vowels (using touch cues and
visual strategies)
3. Reduction of vowel length
4. Gradual increase of rate to normal
5. Reduction of therapist's vocal loudness to miming the word or utterance.
a. May still be using cues at this step.
6. Direct imitation
7. Introduce a 1-2 second delay (normal rate and prosody)
8. Spontaneous production
a. Through asking questions
b. Cloze tasks (Mary had a little ________)
c. Sentence completion (An elephant is big. A mouse is ___________.)
45
Dynamic Temporal & Tactile Cueing (DTTC)
• The student attempts to imitate SLP's production
Imitation
Simultaneous
productions
Reduction of
lenght of vowel
• If the child is unable to imitate, the SLP moves to this step. SLP uses normal
volume but slower rate supported with a touch andor visual cue. The vowel is
sustained. If the child is able to imitate, SLP monitors jaw and lip posture.
• The rate of the SLP's production increases reducing the prolonged
vowel. Provide increased time to motor plan.
• SLP's rate is normal. The child is able to match the rate and
Gradual increase
of rate
 SLP's loudness
level to a mimic
Direct Imitaion
1-2 second
delay
Spontaneous
production
production effortlessly.
• The SLP begins to reduce his/her loudness level until miming. The
student is expected to use normal loudness level to produce the
target. Multisensory cues may still be needed at this level.
• The SLP provides an auditory model. The student attempts to
repeat the model with repetition.
• May change prosody of words or senences
• The student uses normal rate, prosody, and articulatory placement.
The student's imitation is delayed by 1-2 seconds after the SLP
production.
• The SLP elicits a spontaneous production through questions, cloze
tasks, sentence completion, etc.
46
Progressive Approximation
 Uses the speech production that the child can make and the speech –
language pathologist uses feedback and practice to obtain closer
approximations of the target sound.
 Kaufman Praxis Kit for Children follows this approach
I.e.: CVCV
Target word: moo moo
Approximations: mmmm-oo mmmm-oo
mmm-uh mmmm-uh
mmm-oo
mmm-uh
Cycles Approach (adapted for motor planning)
 Auditory stimulation (formerly “bombardment”)
 Production practice opportunities for a given phonological pattern (e.g., final
consonants) for a small number of words
 Cueing allowed, but generalization is expected; in part because words are
chosen that are emerging in production
(Hodson & Paden, 1991; Prezas & Hodson, 2010)
Adaptations for Motor Learning
 Increase number of trials
 Use a smaller set of words
 Carefully arrange timing between model and the child’s attempt and modify
over time (lengthen if successful)
 Use other facilitators
 Slowed rate
 Tactile and gestural cues
(McCauley & Strand, 1999
47
TREATMENT GOALS
Prelinguistic
1. The student will increase the ability to produce
(VC, CV,
CVCV, CVC) with multisensory input with 80% accuracy.
2. The student will increase the ability to produce
(VC, CV,
CVCV, CVC) without multisensory input with 80% accuracy.
3. The student will increase imitation of model with multisensory input with 80%
accuracy. (This could be immediate or delayed imitation)
4. The student will increase imitation of model without multisensory input with
80% accuracy. (This could be immediate or delayed imitation)
5. The student will retain the targeted motor planning sequence (VC, CV, CVCV,
CVC) between therapy sessions with 100% accuracy.
6. The student will generalize the targeted motor planning to new motor sequences
with 80% accuracy.
7. The student will increase use of morphological endings to include plural and
possessive -s, -ing, -ed with 80% accuracy.
8. The student will increase his/her vocabulary to include nouns, verbs, and
adjectives for home and school use.
9. The student will increase his/her mean length of utterance to include
(noun/pronoun + verb, verb + noun/pronoun, noun/pronoun, noun/pronoun
+ verb + location, etc) with 80% accuracy.
10.The student will demonstrate prosody changes to indicate statements, questions,
exclamations with 80% accuracy.
48
Treatment Goals
Linguistic
1. The student will increase the ability to produce
(VC,
CV, CVCV, CVC) with multisensory input with 80% accuracy.
2. The student will increase the ability to produce
(VC,
CV, CVCV, CVC) without multisensory input with 80% accuracy.
3. The student will increase imitation of model with multisensory input with
80% accuracy. (This could be immediate or delayed imitation)
4. The student will increase imitation of model without multisensory input with
80% accuracy. (This could be immediate or delayed imitation)
5. The student will retain the targeted motor planning sequence (VC, CV,
CVCV, CVC) between therapy sessions with 100% accuracy.
6. The student will generalize the targeted motor planning to new motor
sequences with 80% accuracy.
7. The student will demonstrate the ability to correctly produce
(consonants or vowels that are in error) with 80% accuracy.
8. The student will demonstrate prosody changes to indicate statements,
questions, exclamations with 80% accuracy.
9. The student will increase phonological awareness skills to include
(rhyming, blending, segmenting, manipulating) of
speech phonemes with 80% accuracy.
10.The student will increase sentence structure and grammar to include
(regular past tense, irregular past tense, future
tense, subject pronouns, object pronouns, adjectives, adverbs, prepositional
phrases) 80% of the time.
11.The student will increase vocabulary skills to include
(basic vocabulary for home and school use, basic concepts, curriculum based
vocabulary).
49
Ways to Elicit Responses
peep
+
pup
+
tot
+
dad
+
peep
+++++
pup
pop
++--+
---++
visual/tactile visual/
tactile/
prosody
tot
--+++
prosody
visual
dad
--+++
visual
tactile
C1V1C1
1 change
peep
peep
peep
pup
pup
C1V1C1 peep
2 changes
peep
pup
pup
tot
C1V1C1 peep
3 changes
tot
pup
pup
dad
C1V1C1
alternate
pup
peep
pup
peep
tot
pup
dad
pipe
peep
C1V1C1 peep
4 changes
pop
+
50
Pivot Phrases/Sentences
My _________
Open ________
Help ________
No _______
Help ________
On _________
Hi ________
Bye _________
Color ________
Put on ______
Take off ______
I want _____
Can I have ____
Help me ______
I don’t want ______
The mommy had a _________
Cheap rhymes with ________
What do you call a baby dog?
Say puppy 3 times
Say, “My puppy.”
Say, “Big puppy.”
51
/R/
AR
Initial
art
army
arm
arc
Medial
tarp
bark
harp
tarp
bark
harp
cart
start
garlic
sparkle
heart
marble
guard
farm
yard
tart
dark
dart
card
yarn
garbage
market
Final
star
far
tar
ER
Initial
early
earn
herb
Earl
Medial
cursive
skirt
first
herd
turn
learn
fern
curds
hurt
concern
stir
dirt
germs
girl
Final
fur
mixture
whisper
never
spider
butter
purse
turkey
together
teacher
dinner
AIR
Initial
air
airport
airplane
airy
aired
Medial
parents
sheriff
barefoot
married
stereo
marathon
asparagus
parrot
cherry
dairy
parachute
arrow
hairy
bury
caring
staring
Final
where
square
lair
mare
dare
care
stare
share
fair
52
-IRE
Initial
Ireland
iron
Medial
pliers
tired
choirs
ironing
fireman
Final
choir
flier
umpire
dryer
fire
campfire
mire
dire
liar
buyer
hire
wire
empire
briar
admire
vampire
sapphire
sire
-EAR
Initial
ear
earring
ears
Medial
mirror
hearing
period
cheering
cereal
pyramid
weird
cafeteria
Final
fear
steer
year
hero
jeer
hear
near
pier
spear
beard
cheer
gear
disappear
pioneer
souvenir
cashier
chandelier
-OR
Initial
or
orbit
order
oral
orange
organ
Medial
board
shorts
sport
sword
short
fort
popcorn
storm
thorn
story
morning
horseshoe
tornado
north
port
orange
forest
Final
shore
pour
store
floor
more
score
chore
53
rl
girl
pearl
swirl
whirl
Carl
curl
hurl
squirrel
snarl
/r/ initial
read
road
red
row
rope
rip
ripe
rest
roast
rap
rack
raft
rag
ram
ran
wrap
rate
rat
raw
referee
wreck
real
ramp
rib
write
/r/ blends
braid
brain
breathe
bride
broken
branch
broom
crab
crane
crow
crayon
dress
drain
dream
dry
drove
drum
frog
fruit
frame
fries
grape
grill
greenhouse
grow
print
praise
prize
pretend
protect
tractor
train
triangle
tree
truck
http://www.speakingofspeech.com/Articulation_Materials.html#R
www.home-speech-home.com/
mommyspeechtherapy.com/wp-content/downloads/
54
Resources
Kaufman Materials
Kaufman Speech Praxis Kit Level I and II
Kaufman K-SLP Instructional DVD
Kaufman Speech Praxis Workout Book
K&K Sign to Talk NOUNS and VERBS
Becoming Verbal and Intelligible: A Functional Motor Programming Approach
for Children with Developmental Verbal Apraxia (Pro Ed: Kathleen E. Dauer,
Sandra S. Irwin, Sandra R. Schippits)
Moving Across Syllables (Pro Ed: Jill Kirkpatrick, Pamela Stohr, Deborah
Kimbrough)
Webber Big Apraxia Photo Cards (Super Duper: Sharon Webber)
Webber Word Flips (CV)
Clinical Management of Motor Speech Disorders in Children (Thieme, Anthony
Caruso and Strand, Edythe)
Here's How to Treat Childhood Apraxia of Speech. San Diego, Margaret Fish.
CA: Plural Pub., 2011.)
The Source for Childhood Apraxia of Speech. (Linguisystems. Robin Strode
Downing and Catherine Chamberlain, 2006)
The Sourcebook for Stuttering and Cluttering (Linguisystem: David Daly, 1996)
Easy Does it for Apraxia (Linguisystems: Robin Strode Downing, Catherine
Chamberlain)
Websites:
www.apraxia-kids.org
www.speech-express.com
www.cherabfoundation.org
http://health.groups.yahoo.com/group/YADAYoungAdultDyspraxiaApraxia/
55
APPS
Apraxia Rainbow Bee (29.99)
Linguisystems Apraxia Cards (24.99)
Smarty Ears Apraxia Ville (29.99)
nacd apraxia (CV only) 4.99 each
nacd words (CVC only)
nacd syllables
nacd final consonants
Super Duper Word Flips (CV, CVC, CVCV) 29.99
Smarty Ears Custom Boards (29.99)
SunnyTest Screening/Full Assess (49.99)
Artikpix Purchase individual phonemes or groups (29.99 full)
http:/www.speechgadget.com *** spreadsheet of apps *****
56
Associated Language Disorders
A Language Model
(Bloom and Lahey, 1978)
Form
Morphology,
Phonology (naming, &
working memory),
Grammar, Syntax
Content
Vocabulary,
Semantics
(semantic
retrieval)
Use
Pragmatics
Executive Function
Narrative Skills

Children that are late talkers are at greater risk for academic difficulties
especially in literacy and reading skills (Lewis 2007).

Children with a familial history of speech delay/disorder (including those with
CAS) are at higher risk for literacy difficulties, especially if they also
demonstrate language delay (Bird, Bishop, & Freeman, 1995)
57
 The specific underlying speech motor impairment has an impact on the
development of higher phonological and linguistic processing levels (Maassen,
2002).
 Syntactic competence in early preschool was highly predictive of later
reading levels at age 8 years ( Scarborough, 1990)
 Sentence complexity has a significant effect on struggling readers
(Distefano & Valencia, 1980).

Children with speech delays often also have language delays especially is
expressive morphology. Frequency of omission of morphemes was correlated
with MLU not articulatory skills. (Paul & Shribert, 1982, Rvachew, Gaines,
Cloutier & Blanchet, 2005).
 Morphological awareness has a significant impact on reading in the early
years (Nunes, Bryant, and Bindman, 2006)
 First-grade morphological awareness made a significant contribution to
later reading achievement (Carlisle, 1995).
 With regard to spelling in the early elementary years, Nunes, Bryant, and
Bindman (2006) found that six-year old children’s inflectional spellings
predicted their morphological awareness performance at the ages of
seven and eight.
 Children with speech sound disorders (SSD) are at significant risk of
concomitant delays in the development of phonological awareness (PA) and
literacy skills (Bird, Bishop, & Freeman, 1995; Larrivee & Catts, 1999; Raitano,
Pennington, Tunick, Boada, & Shriberg, 2004; Rvachew, Ohberg, Grawburg, &
Heyding, 2003).
58

Children’s phonological awareness ability at preschool is a powerful predictor
of later reading and writing success (Bradley and Bryant, 1980; Lundberg,
Olofsson, and Wall, 1983; Torgesen, Wagner, & Rashotte, 1994).

Children whose speech production problems persist until age 6; 9 perform
worse on tests of reading, spelling, and phonological awareness than controls
matched for age and performance IQ (Nathan et al., 2004).
 As with receptive and expressive language development, the same
components of language - phonology, morphology, syntax, semantics, and
pragmatics - play a vital role in reading and writing (Wolf Nelson, Catts,
Ehren, Roth, Scott, and Staskowski, 2009
59
References
Bassi, C. (1983). Development at 3 years. In J. V. Irwin & S. P. Wong (Eds.), Phonological
development in children: 18 to 72 months (pp. 87–105). Carbondale: Southern Illinois University
Press.
Bird, J., Bishop, D. V. M., & Freeman, N. H. (1995). Phonological awareness and literacy
development in children with expressive phonological impairments. Journal of Speech and
Hearing Research, 38, 446–462.
Bloom, L. and Lahey, M. (1978) Language Development and Language Disorders New York:
Wiley.
Boysson-Bardies, B. D., Sagart, L., & Bacri, N. (1981). Phonetic analysis of late babbling: A
case study of a French child. Journal of Child Language, 8, 511–524.
Carlisle, J. F. (1995). Morphological awareness and early reading achievement. In L. B. Feldman (Ed.), Morphological aspects of language processing (pp. 189-209).
Hillsdale, NJ: Erlbaum.
Coplan, J., & Gleason, J. R. (1988). Unclear speech: Recognition and significance of
unintelligible speech in preschool children. Pediatrics, 82, 447–452.
Crary, M. (1984). A neurolinguistic perspective on developmental verbal dyspraxia. Journal of
Communication Disorders, 9, 33–49.
Crary, M. A. (1993). Developmental motor speech disorders. San Diego, CA: Singular.
Crary, M. A. (1995). Clinical evaluation of developmental motor speech disorders. Seminars in
Speech and Language, 16, 110–125.
Crary, M. A., & Anderson, P. (1991, November). Speech and motor performance in
developmental apraxia of speech. Technical session presented at the annual convention of the
American-Speech-Language-Hearing Association, Atlanta, GA.
Davis, B., Jakielski, K., & Marquardt, T. (1998). Developmental apraxia of speech: Determiners
of differential diagnosis. Clinical Linguistics and Phonetics, 12, 25–45.
Davis, B. L., & MacNeilage, P. F. (1990). Acquisition of correct vowel production: A
quantitative case study. Journal of Speech and Hearing Research, 33, 16–27.
Davis, B., & MacNeilage, P. (1995). The articulatory basis of babbling. Journal of Speech and
Hearing Research, 38, 1199–1211.
60
Demuth, K. (2001, November). Prosodic constraints on morphological development. In J.
Weissenborn & B. Höhle (Eds.), Approaches to bootstrapping: Phonological, syntactic and
neurophysiological aspects of early language acquisition (pp. 3–21). Amsterdam: John
Benjamins.
Eilers, R. E. (1977). Context-sensitive perception of naturally-produced stop and fricative
consonants by infants. Journal of the Acoustical Society of America, 61, 1321–1336.
Eilers, R. E., & Minifie, F. D. (1975). Fricative discrimination in early infancy. Journal of
Speech and Hearing Research, 18, 158–167.
Ferguson, C. A., & Farwell, C. B. (1975). Words and sounds in early language acquisition.
Language, 51, 419–439.
Gildersleeve-Neumann, C. E. (2001). Constraints on infant speech acquisition: A cross-language
perspective (Doctoral dissertation, The University of Texas at Austin, 2001). In Dissertation
Abstracts International (Vol. 62, p. 11).
Goldstein, B., & Cintrón, P. (2001). An investigation of phonological skills in Puerto Rican
Spanish-speaking 2-year-olds. Clinical Linguistics & Phonetics, 15, 343–361.
Goldstein, B., & Washington, P. S. (2001). An initial investigation of phonological patterns in
typically developing 4-year-old Spanish-English bilingual children. Language, Speech, and
Hearing Services in Schools, 32, 153–164.
Justice, L. M., & Schuele, C. M. (2004). Phonological awareness: Description, assessment, and
intervention. In J. E. Bernthal & N. W. Bankson (Eds.), Articulation and phonological disorders
(5th ed., pp. 376–405). Boston: Allyn & Bacon.
Larrivee, L. S., & Catts, H. W. (1999). Early reading achievement in children with expressive
phonological disorders. American Journal of Speech-Language Pathology, 8, 118–128.
Lewis, B. A., Freebairn, L. A., Hansen, A. J., Iyengar, S. K., & Taylor, H. G. (2004). School-age
follow-up of children with childhood apraxia of speech. Language, Speech, and Hearing
Services in Schools, 35, 122–140.
Lewis, Barbara. "Literacy Problems Associated with Childhood Apraxia of Speech."Language,
Learning, and Education October (2007): 10-16.
Maassen, B., Groenen, P., & Crul, T. (2003). Auditory and phonetic perception of vowels in
children with apraxic speech disorders. Clinical Linguistics and Phonetics, 17, 447–467.
Maassen, B., Nijland, L., & van der Meulen, S. (2001). Coarticulation within and between
syllables by children with developmental apraxia of speech. Clinical Linguistics & Phonetics,
15, 145–150.
61
Macaluso-Haynes, S. (1978). Developmental apraxia of speech: Symptoms and treatment. In D.
F. Johns (Ed.), Clinical management of neurogenic communication disorders (pp. 243–250).
Boston: Little, Brown.
MacDermot, K. D., Bonora, E., Sykes, N., Coupe, A.-M., Lai, C. S. L., Vernes, S. C., et al.
(2005). Identification of FOXP2 truncation as a novel cause of developmental speech and
language deficits. American Journal of Human Genetics, 76, 1074–1080.
MacNeilage, P. F., & Davis, B. L. (1990). Acquisition of speech production: Frames, then
content. In M. Geannerod (Ed.), Motor representation and control (Vol. XIII, pp. 453–475).
Hillsdale, NJ: Erlbaum.
Marion, M. J., Sussman, H. M., & Marquardt, T. P. (1993). The perception and production of
rhyme in normal and developmentally apraxic children. Journal of Communication Disorders,
26, 129–160.
Marquardt, T., Sussman, H. M., Snow, T., & Jacks, A. (2002). The integrity of the syllable in
developmental apraxia of speech. Journal of Communication Disorders, 35, 31–49.
McCabe, P., Rosenthal, J. B., & McLeod, S. (1998). Features of developmental dyspraxia in the
general speech impaired population? Clinical Linguistics and Phonetics, 12, 105–126.
McCune, L., & Vihman, M. M. (1987). Vocal motor schemes. Papers and Reports on Child
Language Development, 26, 72–79.
Miccio, A., and Elbert. M. (1996). Enhancing Stimulability: A Treatment Program. Journal of
Communication Disorders. 29. 335-351.
Nathan, L., Stackhouse, J., Goulandris, N., & Snowling, M. (2004). The development of early
literacy skills among children with speech difficulties: A test of the “critical age hypothesis”.
Journal of Speech, Language, and Hearing Research, 47, 377–391.
Nunes, T., Bryant, P., & Bindman, M. (2006). The effects of learning to spell on
children’s awareness of morphology. Reading and Writing, 19, 767-787.
Oller, D. K., Wieman, L., Doyle, W., & Ross, C. (1976). Infant babbling and speech. Journal of
Child Language, 3, 1–11.
Ozanne, A. (2007). (1995). The speech of children with developmental apraxia of speech. In B.
Dodd (Ed.), Differential diagnosis and treatment of children with speech disorder (pp. 91–109).
London: Whurr.
Paul, R., & Shriberg, L. D. (1982). Associations between phonology and syntax in speech
delayed children. Journal of Speech and Hearing Research, 25, 536–547.
62
Petinou, K., Schwartz, R. G., Mody, M., & Gravel, J. S. (1999). The impact of otitis media with
effusion on early phonetic inventories: A longitudinal prospective investigation. Clinical
Linguistics & Phonetics, 13, 351–367.
Piggott, G. L., & Kessle Robb, M. (1999). Prosodic features of familial language impairment:
Pollock, K. E., & Berni, M. C. (2003). Incidence of non-rhotic vowel errors in chilren: Data from
the Memphis Vowel Project. Clinical Linguistics & Phonetics, 17, 393–401.
Robbins, J., & Klee, T. (1987). Clinical assessment of oropharyngeal motor development in
young children. Journal of Speech and Hearing Disorders, 52, 271–277.
Rvachew, S., Gaines, B., Cloutier, G., & Blanchet, N. (2005). Productive morphology skills of
children with speech delay. Journal of Speech-Language Pathology and Audiology, 29, 83–89.
Rvachew, S., Ohberg, A., Grawburg, M., & Heyding, J. (2003). Phonological awareness and
phonemic perception in 4-year-old children with delayed expressive phonology skills. American
Journal of Speech-Language Pathology, 12, 463–471.
Rvachew, S., Slawinski, E. B., Williams, M., & Green, C. (1999). The impact of early onset
otitis media on babbling and early language development. Journal of the Acoustical Society of
America, 105, 467–475.
Schmidt, R. A. (1975). A schema theory of discrete motor skill learning. Psychological Review,
82, 225–260.
Schmidt, R. A. (2003). Motor schema theory after 27 years: Reflections and implications for a
new theory. Research Quarterly for Exercise and Sport, 74, 366–375.
Schmidt, R. A., & Lee, T. D. (2005). Motor control and learning: A behavioral emphasis (4th
ed.). Champaign, IL: Human Kinetics. Schmidt, R. A., & Wulf, G. (1997). Continuous
concurrent feedback degrades skill learning: Implications for training and simulation. Human
Factors, 39, 509–525.
Shriberg, L. D., Aram, D. M., & Kwiatkowski, J. (1997a). Developmental apraxia of speech: I.
Descriptive and theoretical perspectives. Journal of Speech, Language, and Hearing Research,
40, 273–285.
Stoel-Gammon, C. (1992). Prelinguistic vocal development: Measurement and predictions. In C.
A. Ferguson, L. Menn, & C. Stoel-Gammon (Eds.), Phonological development: Models,
research, and implications (pp. 439–456). Monkton, MD: York Press.
Strand, E. (1995). Treatment of motor speech disorders in children. Seminars in Speech and
Language, 16, 126–139.
63
Strand, E. (2001). Darley's contributions to the understanding and diagnosis of developmental
apraxia of speech. Aphasiology, 15, 291–304.
Strand, E., & Debertine, P. (2000). The efficacy of integral stimulation intervention with
developmental apraxia of speech. Journal of Medical Speech-Language Pathology, 8, 295–300.
Strand, E., & Skinder, A. (1999). Treatment of developmental apraxia of speech: Integral
stimulation methods. In A. Caruso & E. Strand (Eds.), Clinical management of motor speech
disorders in children (pp. 109–148). New York: Thieme.
Taelman, H., & Gillis, S. (2002). Variation and consistency in children's truncation patterns. In J.
Costa & M. J. Freitas (Eds.), Proceedings of the GALA 2001 Conference on Language
Acquisition (pp. 263–270). Lisbon: Associacão Portuguesa de Linguistica.
Teixeira, E., & Davis, B. L. (2002). Early sound patterns in the speech of two Brazilian
Portuguese speakers. Language and Speech, 45, 179–204.
Velleman, S. L. (1994). The interaction of phonetics and phonology in developmental verbal
dyspraxia: Two case studies. Clinics in Communication Disorders, 4, 67–78.
Velleman, S. L. (2003). Childhood apraxia of speech resource guide. Clifton Park, NY:
Thomson Delmar Learning.
Velleman, S. L., & Shriberg, L. D. (1999). Metrical analysis of the speech of children with
suspected developmental apraxia of speech. Journal of Speech, Language, and Hearing
Research, 42, 1444–1460.
Velleman, S., & Strand, K. (1994). Developmental verbal dyspraxia. In J. E. Bernthal & N. W.
Bankson (Eds.), Child phonology: Characteristics, assessment, and intervention with special
populations (pp. 110–139). New York: Thieme Medical.
Velleman, S. L., & Vihman, M. M. (2002). Whole-word phonology and templates: Trap,
bootstrap, or some of each? Language, Speech, and Hearing Services in Schools, 33, 9–23.
Vihman, M. M., & Croft, W. (in press). Radical templatic phonology and phonological
Vihman, M., Ferguson, C., & Elbert, M. (1986). Phonological development from babbling to
speech: Common tendencies and individual differences. Applied Psycholinguistics, 7, 3–40.
Vihman, M. M., & Velleman, S. L. (1989). Phonological reorganization: A case study. Language
and Speech, 32, 149–170.
Vihman, M. M., & Velleman, S. L. (2000). Phonetics and the origins of phonology. In N.
Burton-Roberts, P. Carr, & G. Docherty (Eds.), Conceptual and empirical foundations of
phonology (pp. 305–339). Oxford, United Kingdom: Oxford University Press.
64
Weiss, C. E. (1982). Weiss Intelligibility Test. Tigard, OR: CC Publications.
Wolf Nelson, Catts, Ehren, Roth, Scott, and Staskowski. "Roles for SLPs in Reading and
Writing- 10 Years Later." National Convention. American Speech Language and Hearing
Association. National Convention, New Orleans. 18 Nov. 2009.
World Health Organization. (2001). ICF: International classification of functioning, disability
and health. Geneva: Author.
65