Encoding, Memory, and Transcoding Deficits in Childhood Apraxia of Speech (Annotated Summary)

Annotation of Article by Sharon Gretz, M.Ed.

Article: Encoding, Memory, and Transcoding Deficits in Childhood Apraxia of Speech

Clinical Linguistics & Phonetics, May 2012; 26(5):  445 – 482
Shriberg, L.D, Lohmeier, H.L., Strand, E.A., and Jakielski, K.J.

In this study, researchers were examining whether the deficits of children with CAS were limited to speech motor planning & programming (what the author calls “transcoding deficits”) or if the children also had difficulties in auditory perception (termed “encoding” in this paper) and/or memory (ability to store and access representations).  Various analyses and properties of a task called the “Syllable Repetition Task”, as well as other measures, were used to examine 369 children in four distinct groups.  The groupings of subjects were:

  • typical speech-language,
  • speech delayed – typical language,
  • speech delayed – language impairment,
  • and a group with childhood apraxia of speech

Overview

Origins of CAS

While there is extensive research about adult acquired apraxia of speech, research in CAS is still young, happening primarily in the last 20 years.  While adult AOS is due primarily to illness or injury, the origins of CAS are more complicated.  Various genes have been associated with CAS including FOXP2, FOXP1, FOXG1, CNTNAP2, ELP4, RAI1 and others.  Because the origins of CAS are by and large different than those for adult AOS, it can be expected that profiles or patterns of deficits would also show differences between adults and children.  First of all, adults who acquire apraxia of speech had a lifetime of a typical path of speech and language formation, development, acquisition and refinement.  We can contrast this to children who are identified with CAS.  Children with CAS are in the acquisition process and the system is already disrupted.  As the authors point out, the integrity and development of one system will influence and have ramifications to other related systems- each in and of themselves in the process of growth and development.  Some systems serve as building blocks for other systems.  Further, the influence of disrupted gene expression in the brain may include not only areas involved with speech processing but other related structures and neural circuits.  Classification systems used for adult motor speech may not relate well to child motor speech disorders.

Speech Processing System

Research often breaks down speech processing into four domains:

  • Auditory encoding – auditory information is taken in, interpreted, and transformed into representations of sounds/phonemes, syllables, and words.
  • Memory – allows one to store and access the representations
  • Transcoding – takes the representations and transforms them into plans and programs for speech movements
  • Execution – the neurological processes of actually performing – executing – the programmed speech movements

While speech motor planning is the “noticeable” deficit in CAS, research appears to suggest that encoding and/or memory impairments may also be present, represented by difficulties with reduced perception & production of vowels, syllables, rhymes, and phonemic sequences; problems in reading & spelling.

Transcoding deficits would reflect motor planning and programming difficulties but there is not total agreement in the research community as to what sort of speech behaviors represent planning or programming.  In current CAS research there are no firm markers that are sufficiently specific or sensitive to identify with certainty those children with apraxia of speech.  The authors of this study describe a speech behavior within a Syllable Repetition Task that they believe does tap into motor planning/programming processes.

The Syllable Repetition Task developed by Shriberg et al. includes 18 items and can be scored in 5 minutes. The procedure allows for assessment of the processes underlying nonword repetition in a simple context that can be used for speakers with mild to severe articulation errors.  Nonwords are used to remove linguistic load from the test items and can be a window through which to observe new word learning. The authors used various metrics developed and associated with SRT performance to index deficits in encoding, memory and transcoding.

Research Questions:

  1. Do children with apraxia only have speech motor planning/programming deficits (transcoding) or do children with CAS have deficits in multiple domains of the speech processing system?
  2. Can findings from a syllable repetition task (SRT) contribute significant diagnostic information on whether or not the individual has CAS?

In this study, researchers include 40 participants with CAS – 20 with genetic conditions and 20 subjects with idiopathic CAS (CAS of unknown origins).  The comparison groups were:

  • typical speech/language children,
  • children with speech delay and typical language, and
  • children with speech and language delay.

As the authors write, “the CAS participants … constitute one of the largest reported samples and the most diverse in age range and diversity of origins.”  In the CAS neurogenetic group, 55% of the sample was males as compared to 65% from the idiopathic CAS group, representing roughly equal gender prevalence in the genetic group.

Notes About Measurements & Scoring Within the Study:

Below is general information about some of the measurements reported in the study:

  • Competence scores denoted relative mastery.
  • Encoding scores (correct auditory-perceptual representations) were calculated using the mean percentage of within-class manner substitutions that occurred in the 3 and 4 syllable tokens. Higher scores reflect higher competence in encoding.
  • Memory scores reflect a ratio between percentages of sounds correct in longer three syllable-length items as compared to shorter two syllable-length items. Lower SRT memory scores point to greater difficulty in accurately repeating 3 syllable length items as compared to 2 syllable length items.
  • Transcoding scores were defined as percentage of responses to each of the 18 SRT items that included one or more sound additions, with the score subtracted from 100 (so that lower scores would denote less competence in speech motor planning/programming)

Results

  • Competence scores of participants with CAS were lower in both younger subjects (ages 3 – 6) and older subjects (7+ years) as compared to the comparison groups with speech delay, and especially for suprasegmentals and within the older subjects. Competence scores on segmental measures were generally lower in the CAS genetic group than the CAS idiopathic group.
  • Participants in the typical speech/language group had the highest competence and processing scores and subjects in the CAS group had the lowest competence and processing scores.
  • Subjects with CAS have lower SRT scores than the other three groups on 11 of 12 comparisons.
  • Particularly relevant to the study questions, the adjusted mean transcoding score (purported to represent motor planning & programming) for the CAS group was significantly different than adjusted mean scores for the other three comparison groups.
  • CAS subjects had significantly lower scores on all measures than the Group 1 (typical speech/language subjects); lower SRT competence and memory scores than Groups 2 & 3 (speech delay/normal language, speech delay/language delay); and significantly lower encoding scores than the Speech delay/normal language comparison group, but not the speech & language delay group 3.

Did the SRT indexes help with diagnostic accuracy of the CAS individual speakers?

Results

  • Out of all of the SRT measures, the transcoding scores had the highest diagnostic accuracy for discriminating subjects with CAS (74% accurate in discriminating those with CAS from those with speech delay, with and without language impairment).
  • Transcoding scores of 80% ruled out CAS with 93.9% accuracy.
  • Transcoding scores of less than 80% were 8.3 times more likely from subjects with CAS than from subjects with speech delay

Transcoding score Differences within the CAS group

  • Significantly more CAS subjects with idiopathic origins had low transcoding scores indicating the possible importance of etiology in CAS (neurogenic vs. idiopathic) in future explanatory accounts of the disorder.

Discussion

– Based on the comparisons in this study, CAS is more consistent with an explanation of deficits across multiple speech processing domains, with the most significant deficit in transcoding.

– Transcoding scores were moderately sensitive to CAS, yet some participants from the comparison groups also had low transcoding scores.

– SRT scores can provide significant diagnostic information for CAS, but are not diagnostically conclusive.

– No one diagnostic marker is likely to identify CAS in individuals of all ages, cognitive abilities, competencies, or etiologies.

Conclusions

  • Findings from this study indicate that deficits in auditory-perceptual encoding, memory, and transcoding are core features of CAS in idiopathic and genetic contexts, although transcoding (motor planning/programming) was most significant.
  • Those with CAS will have quantitative differences in speech, voice and prosody than those with other speech sound disorders rather than conclusive differences and to identify them will require a battery of standard assessment items in these areas.

 

 

We Are Not Defined By Our Struggles

What follows is a long, emotional post. Around a year ago, I graduated from a great school, Emory University, on the same week as Apraxia Awareness Day, and I just happened to have worn a blue dress. I was diagnosed with apraxia when I was around 4 years old, back in the nineties.

There was very little known about the disorder, so little that a local college actually used me as a case study for 13 years. I and my parents had to consistently battle with school, friendships, confidence, communication, and bullies.  I had never witnessed an Apraxia Awareness Day until this year.

To look at all this unity, not only makes me beyond emotional, but you all are giving voices to the voiceless and the struggled voices. Growing up, I often felt defined by my voice and speech – the “girl with the funny accent.”  But I eventually learned something very important.

alyson taylor

In these graduation pics, I’m not defined by my blue dress- I got a black graduation robe like everyone else. And I am not defined by my “funny” speech or accent, because at least I have a voice like everyone else whether it be orally, written, or even emotional facial expressions. I suppose the point I’m trying to bring across in this emotional post is celebrate and raise awareness for apraxia, those diagnosed, and their accomplishments; but also remember that we are not defined by our struggles and should find our strengths even within our weaknesses.

¿Qué Hace Que La Terapia Del Habla Sea Diferente En El Tratamiento De Los Niños Con Apraxia del Habla Infantil?

Como mencioné anteriormente, el apraxia del habla infantil es un desorden motor del habla que implica una dificultad o inhabilidad de planear y programar la secuencia y la sincronización rápida de movimientos necesarios para producir habla que pueda ser entendida por otros. Las estructuras faciales y orales como los labios, lenguaje, paladar blando, mandíbula y pliegues vocales- y los músculos que mueven dichas estructuras – necesitan ser activados y moverse en el momento justo, con un orden específico y con la fuerza exacta para que las palabras que su hijo/a quiere decir sean producidas con exactitud.

Debido a que el problema principal en el AHI es la planeación y programación motriz del habla, la terapia del habla debe estar enfocada en el movimiento en sí de las estructuras y músculos del habla durante los intentos de producción  de habla (Nota: las palabras importantes son “movientes durante los intentos de producción del habla). El enfoque usado por el terapeuta debe ayudar al niño/a producir en forma más clara y correcta palabras, frases y oraciones.

¡Porque el habla consistente en una serie de movimientos, nosotros podemos usar en terapia del habla ideas que, generalmente, son usadas para ayudar a las personas a adquirir habilidades en el aprendizaje de un movimiento! ¿Cómo aprenden las personas de mejor manera a lanzar la bola de basquetbol y encestar? ¿Cómo aprenden las personas de mejor manera a pegarle a una bola de golf y a hacer que la bola se vaya en el hoyo?  ¿Cómo aprenden las personas a montar bicicleta? ¿Cómo ocurre el “aprendizaje motriz”?

Hay un cuerpo extensiva y complete de evidencia acerca de cómo ocurre el aprendizaje motriz en las personas. Los principios y teorías que se tienen como resultado de dichas investigaciones ha sido aplicado al aprendizaje motriz del habla también y forman la base de las ideas que se han incorporado al tratamiento apropiado de terapia del habla para los niños/as con AHI. Se necesitan más investigación específicamente en el AHI,  pero los expertos han usado los “Principios de Desarrollo Motor” como una base de conocimiento común acerca de cómo tratar el Apraxia del Habla Infantil.  Por ende, hay un número de características de terapia del habla que parecen ser más exitosas para ayudar a los niños/as con apraxia del habla, sin importar el nombre que tenga el método de tratamiento. Dichas características incluyen:

Práctica y repetición – con habla.

La terapia del habla para los niños/as con apraxia incluye un alto nivel de práctica y repetición. Las investigaciones muestras que la terapia para los niños/as con apraxia del habla es más efectiva cuando los objetivos del habla (palabras, frases) son practicados con un mayor grado de frecuencia e intensidad. Los niños/as en terapia del habla apropiada trataran de producir sílabas, palabras y frases  muchas, muchas veces durante cada sesión mientras el terapeuta del habla trabaja en moldear y dar forma a los intentos de habla y los movimientos subyacentes, para que el habla sea más clara y los movimientos más exactos.

A los padres y a las personas que cuidan al niño/a se les pedirá ayuda para que el niño/a practique en la vida real, por fuera de terapia del habla. La intensidad (practicar mucho) y la frecuencia (practicar muy a menudo) son los conceptos claves en el aprendizaje motor del habla. Es por esta razón, especialmente en la fase inicial del tratamiento, que los niños/as con apraxia del habla deben recibir terapia individual. Aunque que la terapia en grupo puede ser apropiada cuando se da sumada a la terapia individual frecuente, los niños con AHI que tienen poca habla o cuya habla es muy ininteligible, tienden a no desarrollar todo su potencial y alcanzar los objetivos de los que serían capaces si se les da solo terapia en grupo.

[Nota especial: De acuerdo con las investigaciones actuales, dedica tiempo valioso de terapia a movimientos orales pero no del habla (por ejemplo, soplar burbujas, lamer mantequilla de maní, movimientos linguales, etc.) no es considerado como un enfoque efectivo para el tratamiento que mejore la producción del habla. Dichas prácticas han estado bajo escrutinio en el campo de la terapia del habla y el lenguaje durante algún tiempo. Aun cuando no existen investigaciones que apoyen dichos procedimientos, muchos profesionales creen que dichas actividades pueden llevar a mejorar el habla o que estas se deben usar antes de que el niño o la niña trate de practicar el habla y por esto usan las actividades orales sin que haya datos publicados de investigaciones que soporten su uso.]

Uso de Claves

La terapia apropiada para los niños/as con apraxia usualmente incluye el uso de mayor información sensorial para ayudar en el control de las secuencias de movimientos del habla. Por lo tanto,  las claves / ayudas visuales, verbales y táctiles son usadas en la terapia que es apropiada para la terapia del habla en niños/as con AHI. Las claves que el terapeuta bringa son diferentes tipos de “recordatorios” acerca de lo que su niño/a debe de hacer cuando esté tratando de decir una palabra o una frase. Por ejemplo, el terapista se toca la parte superior de su garganta cuando el primer sonido de la palabra que el niño/a va a tratar de decir es un sonido que se produce en la parte de atrás de la boca (como los sonidos /k/ y /g/). El niño/a ve donde el terapista esta señalando y esto dispara una memoria sobre la posición de su lengua en la parte posterior de la boca. El niño/a está recibiendo una “clave visual” acerca de donde se está produciendo este objetivo de habla. Ver al terapista señalándose la garganta le recordará al niño/a como empezar el movimiento para una palabra en articular. Otro ejemplo, es cuando el terapista delicadamente pone un poco de presión en los labios del niño/a para generar un contacto de los dos labios cuando el niño/a  intenta producir una palabra objetivo que contiene un sonido “labial” (los sonidos que se producen con los labios se llaman sonidos bilabiales e incluyen /m/, /b/, y /p/). El sentir el contacto de los labios juntos y la presión ayudan al niño/a a saber cómo empezar a producir un sonido labial. Este es un ejemplo de una clave “táctil”. Hay muchos ejemplos de claves que aprovechan y usan la vista, el tacto y de la comprensión para asistir al niño/a en lograr los movimientos necesarios para el habla.

Mientras que el fonoaudiólogo o terapeuta del habla experto utiliza claves en la terapia para los niños/as con AHI, ellos también tienen en cuanta que con el tiempo las claves deben de ir disminuyendo hasta que sean eliminadas pro completo lo antes posible. Un niño/a que es capaz de producir su potencial de habla solo cuando alguien le proporciona claves no está adquiriendo independencia. Su fonoaudiólogo / terapeuta del habla no querrá que su niño/a dependa excesivamente en las claves. El terapeuta querrá  ver que el sistema de procesamiento del habla de su niño/a está empezando a  trabajar en vez de depender de otros para ayudarle. El proceso de “minimización o desvanecimiento” es también individual y ocurre con el tiempo.

Feedback o Retroalimentación.

El terapeuta de su niño/a pensará cuidadosamente y hará énfasis en cómo decirle a su niño/a si sus intentos de habla son exactos o correctos o si por lo contrario no lo son.  El terapeuta del habla también  balanceara con cautela cuanta ayuda le dará al niño/ a para guiarle en la producción de sus intentos de habla y además cuando  le proporcionarán feedback o retroalimentación a su niño/a acerca con respecto a su intento de producción de habla. Por ejemplo, el terapeuta del habla puede decir alfo como “Necesitas apretar tus labios juntos antes de empezar. Muéstrame tus ‘labios apretados’.”  Este tipo de información, acerca de la forma específica en que su niño o niña está formando sonidos y silabas y como corregir en forma específica la producción se conoce como “conocimiento de desempeño”. Otro tipo de retroalimentación se conoce como “conocimiento del resultado”. En el conocimiento de resultados el terapeuta dice algo como “Bien” o “Casi” después de que su niño/a luego de que su niño/a  produce un objetivo de habla.  La retroalimentación de resultados se enfoca en la información general con referencia a su niño/a fue o no fue exitoso en la producción de su palabra o frase objetivo. Los terapeutas del habla con experiencia en el tratamiento de apraxia pensaran con mucho cuidado:

  • ¿Cuánta retroalimentación brindarán?
  • ¿Qué clase de retroalimentación?
  • ¿Cuándo se debe dar la retroalimentación?

Generalmente hablando, los niños/as  que inician terapia del habla y/o aquellos con casos severos de AHI necesitan más retroalimentación inmediata y especifica acerca de los movimientos para la producción del habla que los niños/as que han mejorado en su habilidad de producir habla inteligible. Algo de investigación se han empezado a dar para que podamos comprender mejor el rol de la retroalimentación en el tratamiento de los niños/as con AHI.

Uso de ritmo.

El uso de ritmo puede ayudar a controlar el flujo del habla y a ayudar con la naturalidad de la entonación, con los patrones de acentuación de las palabras y las silabas – las cuales son particularmente problemáticos para los niños/as con apraxia. El ritmo, la entonación y el acento en el habla se conocen como la prosodia. Ejemplos del uso del ritmo en la terapia del habla para los niños/as con apraxia pueden ser aplaudir o golpear para marcar cada silaba o aplaudir más fuerte cuando se produce una silaba que debe ser acentuada en una palabra.

Enfoque en la secuencias del movimiento de habla.

Mientras que algunos niños/as con apraxia del habla necesitan ayuda para expandir el numero individual de sonidos que son capaces de producir, el principal “trabajo” y la práctica de estos niños/as se enfoca en el movimiento del habla que ocurre de sonido a sonido, sílaba a sílaba y / palabra a palabra.  Recuerde que el habla es una serie de movimientos rápidos y altamente refinados y los niños/as con apraxia del habla tienen dificultades con la planeación y programación de los movimientos específicos subyacentes a la producción del habla. Los profesionales que tienen mucha experiencia con AHI defienden el que los objetivos del habla (palabras, frases) deben ser funcionales para el niño/a. ¡Esto significa que las palabras deben ser útiles, prácticas y algo que el niño/a realmente quiera decir! Por ejemplo, las palabras “hola” y “chao / adiós” son muy útiles (funcionales) para los niños/as muy comprometidos con AHI. En la vida diaria, a todos los niños/as se les insiste en que saluden “¡Di hi!” o “¡Despídete, di bye, bye!” En ingles, estas palabras son de una sola silaba y no contienen consonantes al final delas palabras por lo cual el pronunciarlas es más fácil que producir palabras con más de una sílaba o palabras que contienen consonantes al final.

La terapeuta del habla de su niño/a debe pensar muy buen cuales van a ser los objetivos de habla que son apropiados para su niño/a. Él o ella cuidadosamente pensará en cuidadosamente en todas las consonantes y vocales que su niño/a puede producir (aun aquellas que en ese momentos no sean perfectas pero que su niño/a produce algo bien). El terapeuta del habla también considerará cuales son los tipos de sílabas que su niño/a puede producir (Los tipos de silaba son diferentes formas y dependen de la combinación de las vocales y las consonantes para la formación de las sílabas; por ejemplo, Consonante-Vocal (CV), Vocal-Consonante (VC), Consonante Vocal Consonante (CVC), and así sucesivamente). El terapeuta del habla  pensara acerca de las palabras y también le pedirá a usted cuales palabras usted cree que su niño/a disfrutaría el tratar de decir o cuales él o ella necesita decir con bastante frecuencia. Luego, el terapeuta del habla creará una lista corta de palabras útiles (alias: funcionales) que su niño/a podría razonablemente practicar con ayuda, dado su nivel de apraxia y del “inventario” de sonidos y de los tipos de sílabas que pueda producir.

Mientras que algunos niños/as necesitan aprender sonidos aislados uno por uno, los terapeutas de habla expertos no se enfocan exclusivamente en la producción de sonidos individuales en el tratamiento de los niños/as con apraxia ni tampoco hacen que la mayor parte de la terapia consista en la práctica de sonidos individuales. En cambio, ellos incorporan los sonidos que se deben enseñar en palabras cortas y funcionales que se vuelven los objetivos de terapia y en la casa. ¡Los terapeutas con experiencia en apraxia, no “esperan” a que los sonidos que el niño producen sean perfectos antes de pasar a palabras o a sonidos nuevos!  La terapia del habla es como una forma de arte. El terapeuta cuidadosamente ayudará a su hijo/a a construir sílabas, palabras y frases más complejas y las practicará implacablemente, las guiará y moldeará para que se acerquen con mayor y mayor precisión las palabras y frases objetivo y “retrocederá / dará marcha atrás” para enseñar sonidos nuevos o perfeccionar los sonidos en proceso.

Enfoque en la secuencias del movimiento de habla

Muchos niños/as con apraxia del habla se han sentido derrotados por las dificultades que ellos experimentan cuando tratan de hablar. Un gran número mayor de niños/as han recibido terapia del habla que realmente no los ha ayudado a hablar o a comunicarse. Muchos padres y terapistas reportan en forma anecdótica que los niños/as con AHI están profundamente al tanto de lo difícil que el “hablar” es para ellos/as. Y, ciertamente, algunos niños comunican sin palabras que “boca rota” o que “la boca no les sirve o les funciona.”

Es muy importante que los terapeutas del habla que trabajen con hijo/a se enfoquen inmediatamente en como pueden ayudar a su niño/a tener éxito rápidamente en terapia. Un niño/a con apraxia puede dejar de tomar riesgos con su habla, anticipando la dificultad  y el fracaso que han tenido en intentos anteriores al hablar o en terapia del habla anterior. Mediante la planeación cuidadosa de los objetivos de terapia a practicar y la estructuración de terapia para lograr que el niño/a sea exitoso, los niños/as con apraxia pueden llegar a confiar en el terapeuta del habla y  en el proceso de terapia, aumentan la confianza y seguridad en sí mismos y comienzan el importante y duro trabajo por venir.

Igualmente, es importante para su niño/a que experimenten el éxito con sus intentos de habla en casa. ¡Los padres frecuentemente están ansiosos de hacer algo! Ellos frecuentemente preguntan, “¿Qué puedo hacer en casa?” ¡Los padres y otros guardianes son definitivamente una parte importante de la travesía para mejor el habla del niño/a! Especialmente para los niños/as con apraxia, la participación de los padres es crucial.  Dicho lo anterior, un terapeuta del lenguaje y el habla con experiencia y que haya tenido éxito con niños/as que tienen apraxia del habla servirá como guía y como instructor para darles herramientas para ayudarlos en casa de la mejor manera. Ellos quieren asegurarse, en la medida que les sea posible, que nada va a “amargar” a su niño/a en los que refiere a la práctica del habla. El éxito produce éxito. Entre mayor confianza el niño/a gane al tomar riesgos al hablar o hacer intentos de habla, mayor será el beneficio que tendrá de la terapia del habla.

¿Será que mi hijo/a con Apraxia del Habla Infantil (AHI) llegará a hablar normalmente?

Escrito por

KATHY J. JAKIELSKI, PH.D., CCC-SLP

La pregunta contenida en el título de este artículo, que se relaciona con el pronóstico y los logros a largo plazo, es una que casi todos los padres se hacen a sí mismos y a los profesionales en algún momento después de su hijo/a recibe el diagnóstico de Apraxia del Habla Infantil (AHI). Esta pregunta puede surgir durante la evaluación inicial del niño/a o más adelante durante el tratamiento. Es una pregunta importante que requiere consideración tanto por parte de los padres como para las fonoaudiólogas/ patólogas del lenguaje y el habla involucradas en el caso. Desafortunadamente, no hay investigaciones publicadas hasta la fecha que específicamente nos den repuesta a esta esta pregunta. Por ende, la repuesta, en el mayor de los casos, será una suposición educada basada en los síntomas particulares del niño/a y la experiencia clínica de la patóloga del lenguaje en el diagnóstico y tratamiento del AHI.

Muchos niños/as con AHI llegan a desarrollar un habla normal pero algunos no. Puede ser difícil predecir cuales niños/as probablemente desarrollarán habla normal antes o en la adultez y en cuales casos es poco probable que los niños/as  lo hagan. Hay indicadores que la patóloga de lenguaje puede utilizar para distinguir estos dos grupos. En mi experiencia, la mayoría de los indicadores importantes son específicos de cada caso y relacionados con factores internos y externos de cada niño/a. Estos factores incluyen la severidad del AHI, el progreso inicial del niño/a cuando empieza el tratamiento y la presencia y severidad de los síntomas co-ocurrentes. Los síntomas concomitantes que pueden afectar el pronóstico más significativamente, en mi experiencia, incluyen retrasos del lenguaje, impedimentos cognitivos, y el apraxia oral o de las extremidades. Aunque la interacción de estos desordenes con el AHÍ es desconocida, entre mayor sea la severidad de los síntomas concomitantes, mayor será el reto para que el niño/a pueda alcanzar a desarrollar habla como la de un adulto. Otros indicadores que son específicos a cada niño/a y requieren atención son la motivación del niño/a, el nivel de atención, la continuidad del progreso y el acceso a recibir servicios de terapia. Entre más favorables sean los factores anteriormente mencionados, más positivo será el pronóstico del niño/a.

Yo he trabajado con niños/as con AHI tanto en el área de investigación como en la práctica clínica por más de 20 años. Durante este tiempo, he visto niños/as con AHI cuya habla ha llegado a mejorar hasta llegar a un habla normal (o casi normal) con intervención. Aun niños/as con AHI moderada o severa pueden alcanzar  un nivel de habla normal con servicios de intervención apropiados y extensivos; sin embargo, he encontrado que el pronóstico más favorable para aquellos niños/as con menor cantidad y/o menor severidad de síntomas co-ocurrentes. Los niños/as  que presentan menos síntomas concomitantes y/o cuyos síntomas co-mórbidos son de menor severidad, tienden a progresar hasta desarrollar habla normal antes o en la adolescencia cuando se les brinda terapia del habla suficiente y apropiada, aun cuando el apraxia del habla (AHI) fuera más severa en el momento del diagnóstico. Después de darles de alta  de terapia, uno puede notar errores sutiles en la articulación cuando el adolescente está cansado o estresado; de otra manera, el habla permanece bien articulada e inteligible para el oyente.

También hay otros niños/as con AHI severa o moderada cuyo pronóstico para lograr habla normal en el transcurso de su desarrollo hasta llegar a la adultez es desfavorable. En mi experiencia, estos niños/as inicialmente presentan con múltiples y más severos síntomas co-ocurrentes. Estos niños/as frecuentemente continúan progresando en terapia del habla hasta la adolescencia y, aun cuando ellos/as no alcanzan a desarrollar habla completamente normal, ellos/as logran mejorar y el habla es a menudo su fuente primordial de comunicación. El discurso conexo (es decir la producción en frases largas y complejas de corrido) permanece con un reto constante, como también lo son la producción correcta de aspectos suprasegmentales del habla (la prosodia o melodía del habla, la acentuación, la velocidad del habla, etc.) Para la los niños/as que presentan mayor severidad en el diagnóstico, los sistemas de comunicación alternativa pueden ser usados en combinación con la producción del lenguaje oral para aumentar la capacidad de comunicación. El usar una combinación en las técnicas de comunicación puede ser de gran ayuda particularmente para los adolescentes / adultos jóvenes que se ven enfrentados a una gran diversidad de situaciones comunicativas.

En general, es importante recordar que los niños/as con AHI pueden mejorar y progresar con el tratamiento de terapia del habla. El pronóstico en lo que se refiere al desarrollo de habla normal depende de una variedad de factores; muchos de estos factores son específicos para cada niño/a y están sujetos a cambiar con el tiempo. ¡Continúe creyendo en la habilidad que tienen los niños/as de progresar y trate de celebrar cada logro ya que es un paso positivo en el camino!

Qué causa el Apraxia del Habla Infantil (AHI) y Se puede prevenir?

Primero, es importante para los padres que entiendan que es muy probable que ustedes no hayan hecho nada para “causarle” a su hijo/a  una discapacidad en el habla. No se trata de cuanto le hablaron a su hijo/a o de si los pusieron en una guardería infantil, por ejemplo. Su hijo/a no tiene apraxia porque usted se separó de su esposo/a o por haberse mudado a una ciudad nueva. Mientras conocemos el rol tan importante que cumplen los padres en el desarrollo de un niño saludable, al menos que hubiera algún tipo de abuso, negligencia o aislamiento, usted no es el directamente responsable de la causa de que su hijo/a tengo un problema del habla.

Actualmente sabemos que el apraxia del habla infantil (AHI)  ocurre en las siguiente condiciones:

  • Impedimentos neurológicos causados por infección, enfermedades o accidentes antes o después del nacimiento o por anomalías aleatorias o fallas en el desarrollo fetal. Esta categoría incluye a los niños/as con resultados son positivos a nivel cerebral en el IRM (Imagen por Resonancia Magnética).
  • Desórdenes complejos en el desarrollo neurológico. Sabemos que el apraxia del habla infantil (AHI) puede ocurrir como una característica secundaria de otras condiciones como son condiciones de origen genético, metabólico  y/o trastornos mitocondriales. En esta categoría estaría el apraxia del habla infantil (AHI) concomitante con Autismo, Frágil X, Galactosemia, algunas formas de Epilepsia y translocaciones cromosómicas que involucran duplicaciones y supresiones cromosómicas.
  • Desorden Idiopático del Habla (un desorden de “causa desconocida”) – con esta condición, actualmente no sabemos “porque” el niño/a tiene AHI. Los niños/as no tienen anomalías neurológicas observables u otras condiciones del neurodesarrollo fácilmente observables.

 

Los padres frecuentemente preguntan si sus hijos tienen Apraxia del Habla debido a complicaciones médicas durante el embarazo o el parto. En la actualidad no existen estudios que indiquen una relación directa entre las complicaciones durante el embarazo o el parto y un aumento específico en el riesgo de tener apraxia del habla. Por ejemplo, un cordón umbilical enredado en el cuello de un feto puede, en teoría, cortar el flujo de oxígeno y posiblemente llevar a un daño neurológico, resultando eventualmente en el diagnóstico de AHI. Sin embargo, dicha condición puede NO resultar en AHÍ o incluso en una lesión neurológica. Algunos niños nacen sanos aun cuando haya habido una complicación durante el embarazo o el parto. Mientras que es posible que una complicación pueda resultar en un daño neurológico que contribuya a un desorden motor del habla como AHI, las investigaciones no nos han dicho como o cuando esto sucede. Algunos especulan que algunas formas de AHI y otras condiciones que  se dan durante la infancia pueden darse, en parte, debido a condiciones ambientales como la exposición a toxinas y/ o contaminantes antes o después del nacimiento. Otros especulan que déficits en la nutrición o malabsorciones pueden causar AHI. Sabemos que, por lo general, las toxinas y los déficits nutricionales causan algunos problemas en el desarrollo pero, hasta el momento, estas teorías en lo que se relaciona específicamente con AHI son solo especulaciones.

Dicho esto, la buena salud de un niño puede contribuir con su habilidad de  beneficiarse de la exposición a oportunidades de aprendizaje y de terapia que este diseñada para ayudarles. Un que esté saludable es más capaz de tomar ventaja de las oportunidades de aprender. Los niños que se enferman frecuentemente con infecciones de oído o sinusitis, amigadlas o adenoides  inflamadas, asma, alergias o que tienen desórdenes del sueño, dietas pobres, dificultades se atención o problemas de comportamiento, van a tener mucha mayor dificultad de beneficiarse de la ayuda que les es brindada. Ayudar a su niño a estar saludable y por ende más “presente” durante las oportunidades de aprendizaje que le rodean, es una forma en que los padres pueden ayudar.

Muy probablemente en el futuro aprenderemos que el AHI es causado por múltiples factores y condiciones, no una sola. En la medida en que la evidencia de las investigaciones demuestre que el AHI es causada por algunos factores que puedan ser manipulados para reducirlos o eliminarlos se determinará si el AHI es o no es prevenible. Hasta que llegue ese momento, lo que si conocemos es que la terapia del habla proveída frecuentemente y teniendo en cuenta los principios del tratamiento motor de habla ofrece la oportunidad de mayor impacto e importancia para que los niños con AHI mejoren su habilidades a nivel de articulación y habla. Los niños que puedan mantener un nivel de salud óptima muy probablemente se beneficiaran directamente cuando se les brinda la ayuda adecuada.

A Mother’s Poem

I open my mouth… Caleb
I try my best….
But what is words to me…
Is babble to the rest…

They turn their heads and look away…
Many just don’t know what to say…

I’m that “special” kid that’s different from the rest….

But…

What they don’t know is that I’m trying my best…

I’ve tried and I’ve tried to be so clear…
I’ve even tried to whisper in their ears…
I’ve shouted and I’ve screamed…
I’ve begged and I’ve cried…
Each time my words have been denied…

I promise I am trying…
I try each and every day…
Please don’t avoid me because I’m “special” in this way…

Someday…
I will have something to say…
Someday…
I will say my name…
And Someday…
I will say yours…

And if I keep trying each and every day…
Someday I will tell you that I love you in each and every way.

Please don’t turn your head….
Please don’t walk away…
Please try to understand what I’m trying to say…
I know it’s not easy…
I know that it’s hard…

I know people stare….
Show them you don’t care..
Show them you love me…
Special and all….

I open my mouth….
I try my best….
What I think are words…
Are just babble to the rest…

But I have you with me…
Each and every day…
And although I can’t say it yet…
You know…
that I love you…
in each and every way.

Speech Motor Learning in Childhood Apraxia of Speech

Children with apraxia of speech (CAS) often display slow progress during speech treatment, which includes difficulty acquiring, retaining and generalizing new skills. In August 2012, CASANA awarded a competitive research grant to Dr. Maria Grigos and Ms. Julie Case of the Department of Communicative Sciences and Disorders at New York University. Funds from this grant were used towards their study of speech motor learning in children with CAS and children with typically developing speech and language skills (TD). The aims of this research were to explore how children learn novel speech targets and maintain newly acquired skills.

Facial tracking technology was used to investigate changes in speech production and articulatory control while children practiced novel words. Sixteen children between the ages of five and six years participated in the study: eight children with CAS and eight TD controls. Novel words were presented to the children at the beginning of the experiment. These words were produced at three different time periods: baseline, short-term, and long-term. Baseline represented the very first time children produced the novel words and was followed by an intense practice session designed according to principles of motor learning. Following this practice session, short-term change was measured. Children then returned three days later to assess long-term retention. These time periods were selected to capture speech production changes within a therapy session (i.e., short term change), as well as between sessions (i.e. long term retention). A three-day time period was selected to represent a typical lapse between therapy sessions.

grigos article

The children with CAS displayed short- and long-term improvements in consonant/vowel accuracy and consistency; however, their performance remained consistently poorer than the TD control group. Articulatory control was examined during accurate word productions. The children with CAS demonstrated longer duration of jaw movement than TD controls across each of the three time periods. Further, articulator movement variability remained high in the CAS group across all sessions, while children in the TD group produced more stable movements. In other words, children with CAS took more time to move their articulators and did so more variably than the TD controls as they produced novel words.

The main finding from this research is that children with CAS showed improved consonant/vowel accuracy and consistency with practice, while their underlying movement patterns did not change. This result is particularly interesting as children with CAS often make slow progress in treatment and have difficulty generalizing treatment gains.  During treatment, a child with CAS may improve sound production and appear to be making steady gains; however, increases in consonant/vowel accuracy alone may not reflect changes in the underlying movement patterns. Refined articulatory control may be required in order to maintain and generalize improved speech patterns. Additional work is needed to better understand the type and amount of practice required for long-term speech production changes to occur. Such research will contribute to our understanding of why certain treatment techniques are more effective for children with CAS than others.

2014 Summer Camps for Speech, Language, and Communication

camp

In anticipation of the need for some parents to find appropriate summer camps for their children with apraxia, we have compiled a list of programs which may be appropriate for children with apraxia and related issues. We have only included camps that are holding sessions this summer.  They are listed in alphabetical order.

If you are interested, please contact the camp to find out if it is suitable for your child’s particular needs.  If you are aware of other camps that may be appropriate for children with CAS, speech disorders, or learning needs please send the contact information to dawnk@apraxia-kids.org.

[Please note, inclusion of a camp in the listing below does not constitute endorsement by Apraxia-KIDS or CASANA.  The listing of camps is for information purposes solely.  Parents should carefully review camp materials, interview, and thoroughly investigate programs.]

CANADA

Ontario

Anderson Speech Consultants Speech Summer Camp in Ontario
Burlington, Ontario
Day Speak and Ride Camp combines horseback riding with speech therapy
Contact:  Sarah Aljas, M.Cl.Sc., SLP(C), Reg. CASLPO, Speech-Language Pathologist at ascsaljas@gmail.com or (905) 639-9219

Camp Inukshuk
Newmarket, Ontario
Day camp for children with speech/language/communication issues
Contact:  info@familyspeechclinic.com or (905) 954-1312
http://www.campinukshuk.com/

Camp Kodiak
McKellar, Ontario, Canada
A unique, integrated, non-competitive program for children & teens with & without ADHD, LD, NLD & high-functioning Asperger Syndrome
Contact:  info@campkodiak.com or (877) 569-7595
http://campkodiak.com/index.html

Talking About Fun Camp
London, Ontario, Canada
Summer day camp for children with speech and language issues
Contact: http://www.londonspeech.com/speech-language/group-programs/talk-about-fun/

UNITED KINGDOM

Christopher Place
London, United Kingdom
Summer camp for children with speech and language issues
Contact:  http://www.speech-language.co.uk/parents/what-we-offer/summer-programme/

UNITED STATES

National Cued Speech Association
Learn Cued Speech in the relaxed atmosphere of various camps located throughout the United States.
http://www.cuedspeech.org/cue-camps

National Easter Seal Society
Day and/or overnight camps for children with disabilities located throughout the United States
Contact:   (800) 221-6827
http://www.easterseals.com/our-programs/camping-recreation/

PrAACtical AAC Pinterest Camp Listings
Nationwide AAC Camps Online Pin Board
Contact:  http://pinterest.com/aacandat/aac-camps/

The Scottish Rite Mason’s RiteCare Childhood Language Program
Nationwide Speech and Language Summer Clinics
Contact: http://scottishrite.org/about/philanthropy-scholarships/ritecare-directory/

Arizona

Foundations Development House
Chandler, Arizona and Scottsdale, Arizona
Speech and Language Summer Camps
Contact: http://www.fdhkids.com/contact_us.html
http://www.fdhkids.com/programs/speech_and_language_summer_camps.html

Kamp Talkalot
Chandler, Arizona and Scottsdale, Arizona
Speech and Language Summer Camps
Contact: http://pediatricspeech.net/contactUs.php
http://pediatricspeech.net/summerPrograms.php 

California

Building Bridges Camp
Boulder Creek, California
Overnight camp for AAC users
Contact:   http://www.bridgeschool.org/about/contact/index.php or (650) 696-7295
http://www.bridgeschool.org/camp.html

Camp Chatterbox
San Jose, California
Social skills camp, for children of all disorders including Childhood Apraxia of Speech
Contact:  (408) 246-2566
http://progressivespeech.com/index.php?option=com_frontpage&Itemid=1

Say ‘n’ Play Speech Camp
Culver City, California
Summer camp for children with speech and language issues
Contact:  http://www.speakla.com/Home

Square Peg Horse Camp
San Francisco, California
Camp for children with special needs; includes instruction in several horsemanship disciplines, including vaulting (acrobatics on horseback), riding, trail riding, jumping, dressage, and even polo.
Contact: http://www.squarepegfoundation.org/programs/horsemanship/

Summer Reading Camp at PRIDE Learning Center
Los Angeles, California, Redondo Beach, California, Newport Beach, California, Mission Viejo, California
Summer program with intense therapy for students with speech delays, auditory processing or developmental delays struggling with speech, language, reading and comprehension.  Orton-Gillingham multisensory one-on-one reading and language sessions with credentialed and certified teachers.
Contact:  info@pridelearningcenter.com
http://www.pridelearningcenter.com

Total Education Solutions Camp
Los Angeles, California, San Diego, California, Sacramento, California, Fairlawn, Ohio, Troy, Michigan
Enrichment program for children ages 2-5 years with focus on speech, language, and early reading skills and specialized programs designed for children who between the ages of 6 and 12 years old.
Contact:  http://test.tesidea.com/AboutUs/ContactUs/tabid/156/language/en-US/Default.aspx
http://www.tesidea.com

Colorado

Sensational Kids Kamp
Greenwood Village, Colorado
Therapy Day Camp for children ages 4-10 with Sensory Processing Disorder, ADD & Asperger’s Disorder and their siblings.
Contact:  http://spdstar.org/sensational-kids-kamp/

Talking with Technology Camp
Empire, Colorado
Overnight camp for AAC users
Contact:  http://www.childrenscolorado.org/departments/audiology-speech-learning/camp

District of Columbia

CHAMP (Childhood Apraxia and Motor Planning) Summer Camp
Washington, DC
Summer Camp for children with apraxia at George Washington University
Contact: Jodi Kumar, M.S., CCC/SLP, Clinical Supervisor, George Washington University at jkumar@gwu.edu

Florida

The Foundation For Dreams
Sarasota, Florida
Overnight camp for children with various disabilities
Contact: http://www.foundationfordreams.org/

Georgia

Camp Rayim
Atlanta, Georgia
Summer camp for children ages 2-6; serving all children, including those with special needs.
Contact: http://www.rayimconnection.com

P.R.O.M.P.T. and Play
Suwanee, Georgia
Intensive speech therapy camp utilizing the PROMPT facilitation technique, (Ages 4-7), appropriate for a variety of diagnoses including: apraxia, dysarthria, and autism spectrum
Contact: http://www.kidscreektherapy.com 

Illinois

The Hyde Park Day School
Chicago, Illinois
Summer Programs for children with learning disabilities
Contact:  http://hpds.uchicago.edu/summer-school-programs/

Intensive Summer Language Program
Chicago, Illinois
Eight Week Summer Day Camp for Children with Speech and Language Issues Ages: 4-12
Contact:  (312) 944-6336

Indiana

Turnstone Summer Speech Camp
Fort Wayne, IN
Children, ages 3 to 8, may enroll in the program.  The children will be placed in groups according their age, speech and language needs.  This year’s summer speech program will be from June 18 to August 2.
Contact: Chanda Lichtsinn, Speech Language Pathologist and Pediatric Therapy Manager at Turnstone (260) 483-2100 or chanda@turnstone.org
http://turnstone.org/2012/04/summer-speech-camp/

Maryland

Camp Littlefoot
Rockville, Maryland
Day camp for children with speech, language, perceptual motor, and/or learning issues
Contact:  http://www.ttlc.org/camp_littlefoot.htm

Cue Camp Friendship
Buckeystown, Maryland
Summer weekend camp to anyone interested in learning about Cued Speech. Classes are for all skill levels, from beginner to proficient.
Contact: http://www.marylandcues.org/

Speech Pathways
Carroll County, Maryland
Special summer groups throughout Carroll county for social skills, early language/play groups, reading groups, writing groups and art groups
Contact:  Kimberly A Bell at kim.bell@speechpathyways.net or (410) 374-0555
http://www.speechpathways.net

Massachusetts

Aspire Summer Camps
Boston area
Children entering 1st grade through age 15 who have the cognitive capacity for solid peer connections but who lack the skill set to form these connections. We use an interdisciplinary approach based on the fields of psychology, special education, speech therapy, recreational therapy and occupational therapy.  At times we integrate adjunct therapies, this summer we offered music, art and drama therapies.
Contact: mghaspire@partners.org
http://www2.massgeneral.org/youthcare/camp.html

Michigan

Camp Shout Out
Muskegon, Michigan
Summer camp for young people who stutter
Contact:  http://www.campshoutout.org/

Central Michigan University Summer Speech-Language Specialty Clinics
Mount Pleasant, Michigan
Half-day sessions for children with communication disorders
Contact:   (989) 774-3904
https://www.cmich.edu/colleges/CHP/hp_academics/communications_disorders/clinical_programs/Pages/Speech-Language-and-Audiology-Clinics.aspx

Communicative Disorders Clinic University Of Michigan
Ann Arbor, Michigan
Summer day camp for language, learning and literacy
Contact:  (734) 764-8440
http://www.languageexperts.org/

Kaufman Children’s Center for Speech, Language, Sensory-Motor and Social Connections
West Bloomfield, Michigan
Three-week intensive CAS summer program with Nancy Kaufman and intensive sensory integration programs with our occupational therapists. Sessions personalized for child and include group time.
Contact:  (248) 737-3430
http://www.kidspeech.com

Total Education Solutions Camp
Los Angeles, California, San Diego, California, Sacramento, California, Fairlawn, Ohio, Troy, Michigan
Enrichment program for children ages 2-5 years with focus on speech, language, and early reading skills and specialized programs designed for children who between the ages of 6 and 12 years old.
Contact:  http://test.tesidea.com/AboutUs/ContactUs/tabid/156/language/en-US/Default.aspx
http://www.tesidea.com

Minnesota

Missouri

Saint Louis University Childhood Apraxia of Speech Summer Camps
St. Louis, Missouri
Intensive Camps for Early Diagnosis/Emerging Speech, Preschool (Verbal), Early Grades/School Aged and Later School Aged/Adolescent (Target residual issues: prosody, vowels, multisyllabic words, carryover)
Contact:  http://www.slu.edu/x12349.xml

SCAMP (Summer Classes for Articulation and Motor-Speech Progress)
Ballwin, Missouri
Camp for young children, ages 3-6, with CAS or significant phonological delays.
Contact:  http://www.gotospeech.com/

New Hampshire

Easter Seals New Hampshire
Various Camps are offered for Children with Disabilities
Contact: http://nh.easterseals.com/site/PageServer?pagename=NHDR_Dover or http://nh.easterseals.com/site/PageServer?pagename=NHDR_camping_recreation&s_esLocation=serv_cr

New Jersey

Camp Chatterbox
Hudwick, New Jersey
Overnight camp for AAC users
Contact:   Dr. Joan Bruno at JBruno@childrens-specialized.org or (908) 301-5451
http://www.campchatterbox.org

Open Hearts/Open Doors
Medford, New Jersey
Provides accommodations in order for children with disabilities to fully participate with age-appropriate peers in the JCC Camps at Medford
Contact:  http://www.jcccampsatmedford.org/special-needs

North Carolina

Camp Our Time
Hendersonville, North Carolina
Summer camp for young people ages 8-18 who stutter and their young friends and family
Contact:  http://www.campourtime.org/welcome-stuttering-camp-our-time/

The Speech Garden Summer Camp
Charlotte, North Carolina
Camp for children 24 months through second grade with mild to severely delayed expressive and/or receptive language, oral motor and/or articulation skills that benefit from speech-language therapy.
Contact:  https://speechgarden.org/summer-camp

Ohio

Total Education Solutions Camp
Los Angeles, California, San Diego, California, Sacramento, California, Fairlawn, Ohio, Troy, Michigan
Enrichment program for children ages 2-5 years with focus on speech, language, and early reading skills and specialized programs designed for children who between the ages of 6 and 12 years old.
Contact:  http://test.tesidea.com/AboutUs/ContactUs/tabid/156/language/en-US/Default.aspx
http://www.tesidea.com 

Oklahoma

Camp ClapHans
Norman, Oklahoma
Residential summer camp for ages 8 to 16 for children with developmental disabilities
Contact:  http://www.campclaphans.com/

Pennsylvania

CAS Summer Intensive Program
Philadelphia area
This intensive summer therapy program offers 2x a day x 5 days a week x 5 weeks of speech therapy for children with apraxia of speech that qualify.  See flyer for details regarding costs and contact information. Click here to view flyer.

Lee Mar Summer Camp And School
Dresher, Pennsylvania
Special needs camp for children and young adults with mild to moderate learning and developmental challenges
Contact:  http://www.leemar.com

Luma Center – Speech and Language Explorers
Malvern, PA
June 16 – 20, 2014
For children with childhood apraxia of speech and other speech sound disorders.  Daily individual and group speech sessions; Fun sensory motor group with an occupational therapist; Parent participation and workshops, Written summary with home activities and suggestions
Contact: Nancy Allard at 610.296.6725 x308 or naallard@vfes.net
http://www.vfes.net/summer-bursts-of-fun-week-at-the-luma-center

Tennessee

Camp Livitup
Memphis, Tennessee
Eight-week day camp for persons ages 5-18 with any disability
Contact: Jo Gibbons at jgibbons@ucpmemphis.org  (901) 761-4277 ext. 1107
http://www.ucpmemphis.org/index.php?option=com_content&view=article&id=11:camp-livitup&catid=8:main&Itemid=101

Parent Child Services Group Inc. Summer Programs
Knoxville, Tennessee
Summer program for children with speech/language; sensory, motor or learning issues
Contact:  (865) 584-5558
http://www.parent-childservices.com

Texas

Capitol School of Austin Summer Camps
Austin, Texas
Fun and enriching summer learning experience for children, pre-school through 3rd grade, identified as having speech, language and learning differences
Contact:  (512) 467-7006
http://www.capitolschool.com/Programs/Summer%20Camp.htm

Kaufman Apraxia Boot Camp (K-ABC) at the Carruth Center
Houston, Texas
Intensive 3 week summer program for children with apraxia and phonological disorders modeled after Nancy Kaufman’s (with permission) SPEAK summer program; intensive individual speech, music, occupational and group language therapy. Home practice materials and DVD included.
Contact:  Karen Dickerson, Ph.D. CCC-SLP, Clinic Director at kdickerson@carruthcenter.org or (713) 935-9088 ext. 138

Texas Tech University Health Sciences Center Department of Speech, Language and Hearing Sciences
Lubbock, Texas
Programs are designed for children ages 3 to 12 with various types of speech, language and learning disabilities
Contact:  (806) 743-5678
http://www.ttuhsc.edu/sah/patient

University of Houston’s Speech, Language, and Hearing Clinic
Houston, Texas
CCG, or Cougar Communication Groups, is a summer day camp geared toward children who have difficulty with speaking clearly, being understood, expressing thoughts, engaging in conversations, reading and engaging in positive social interactions.
Contact: http://www.uh.edu/class/comd/slhc/speech-svcs/index.php

Utah

Wasatch Speech and Language Center
Salt Lake City, Utah
Summer therapy program for social communication skills.
Contact: Maria or Tom Gurrister, CCC-SLPs, at mgurrister@gmail.com or (801) 308-0400

Virginia

Cue Camp Virginia
Williamsburg, Virginia
Camp focusing on cued speech
Contact: http://www.nvcsa.org/

 

A Comparison of the Use of Low-Tech and High-Tech Communication Systems for Children with CAS

MaestroBACKGROUND

Children diagnosed with childhood apraxia of speech (CAS) struggle to communicate basic needs to even those closest to them. In addition to severely unintelligible speech, CAS is often accompanied by language and literacy deficits, academic difficulties, deficits in phonological processing and literacy, and social disadvantages (ASHA, 2007; Lewis, Freebairn, Hansen, Stein, Shriberg, Iyengar, et al., 2006; Overby, Carrell & Bernthal, 2007). Since children with CAS have such restricted sound systems, they cannot build more complex words and sentences, which in turn restricts their expressive language development. Children with CAS who communicated with voice output devices enhanced their expressive language by increasing mean length of utterances (MLU), increased overall language skills, increased number of words, number of different words, and multi-word messages, and increased speech accuracy (Cumley & Swanson, 1999; Miller, Light, & Schlosser, 2006; Stading, Ball, Larson, & Dulany, 2005). Miller and colleagues (2006) also found that supporting communication with a voice output device did not decrease the number of speech attempts.  Research has also shown that children with CAS who use voice output devices were able to repair communication breakdowns, establish topics, have longer social interactions, participate more in academics, reduce non-communicative behaviors, and had people speaking for them less (Culp, 1989; Cumley & Swanson, 1999; Stading, et al., 2005).

Despite the availability and supportive evidence of voice output devices, children with CAS frequently do not use them due to high cost, lack of insurance reimbursement, and parental fear of the child giving up on speech.  Initial research has shown devices increase speech and language development and give the child a way to communicate more effectively with others.  They provide a speech model during each communicative use, which is suspected to increase natural speech, expressive language and communicative effectiveness.  However, no available research has determined the effectiveness of high-tech voice output devices compared to low-tech communication systems in their impact on components of speech and language development.

This study compared the impact of high-tech voice output devices to low-tech communication systems and no-tech communication on accuracy of speech, expressive language, and communication interaction (CI) for children with CAS.

METHODS

Participants.

Two children with severe CAS, between the ages of 5-6, participated in this study. Each child used mainly single words in speech productions, and had issues with intelligibility of spontaneous speech with all communication partners. Each child was able to navigate a dynamic display communication device.

Procedures.

We utilized a single subject alternating-treatment design to measure the effects of high-tech, low-tech and no-tech (speech only) communication supports on speech, expressive language, and Communication Interaction for children with CAS. The study occurred over the course of a year. Each child received their own voice output device (i.e., DynaVox V) for the entire year in addition to low-tech communication boards (i.e., screen shots from their DynaVox V). The participants received individual therapy 3 times per week. Two sessions focused on speech sound development, and one session focused on use of the voice output communication device and low-tech communication boards. Half of each session was spent using the DynaVox V and half was spent using the low-tech communication board. The order was alternated each session. Training on use of the communication systems occurred for an average of 21 sessions, until each child passed a performance test with at least 80% accuracy to ensure competency of navigation on the systems.

Data was collected on the percentage of consonants correct (PCC), percentage of vowels correct (PVC), variety of types of words used (e.g., nouns, verbs, article, etc.), Mean Length of Utterance (MLU), and on communication interaction (i.e., adequate, inadequate, and ambiguous responses, initiations, recodes, comments, obliges, no responses, and requests for clarifications) The Communication Interaction measures were based on research by Blank & Franklin (1980). This data was collected at baseline during three different treatment sessions. Treatment data was collected after each child passed their performance test. Data was collected monthly during treatment sessions for six months. Data was collected in each of the three conditions (speech only, high-tech voice output communication device, low-tech communication boards)

RESULTS

The use of a communication system, either low-tech or high-tech, did have a positive impact on many of the language and communication interaction measures. There was no change in the Percent of Consonants Correct or Percent of Vowels Correct across conditions, indicating that the use of a communication system did not impact the child’s articulation of words. However, it was not expected that a communication system would improve the actual accuracy of speech productions in a positive or negative way. There was an increase in the Mean Length of Utterance when both low-tech communication boards and high-tech voice output communication devices were use, which means that the children were combining more words to make longer phrases or sentences when they used a communication system as compared to their speech alone. There was an increase in the use of adjectives when both communication systems were used as well, but this impact was not seen for other grammatical components of language. There was a decrease in the use of yes/no responses when high-tech communication devices were used. This means they were not giving yes/no answers as often, but were providing more complex answers.

When Communication Interaction was measured, there were many benefits seen in the use of communication systems. There were a decrease in responses, and an increase in initiations for children using both low-tech and high-tech communication systems. This means they were not just responding to questions, but they were initiating communication more often and helping to direct the conversation. This resulted in an increase in comments, where the child initiates sharing information on a topic. There was also an increase in recodes, or clarification or expansion of a communication attempt, when either a low-tech or high-tech communication system was used. There was a slight benefit in the use of low-tech communication boards on the increase of obliges, which is asking a question or making a statement that requires a response from your communication partner. There were more adequate, or accurate, responses when high-tech voice output communication devices were used, as compared to speech only and low-tech communication boards. There was also a decrease in no responses, which is ignoring or not responding to a question asked, in all three conditions as compared to baseline data. This means that the children were attempting to communicate more overall. See the table below for a summary of the results.

No Change Speech Only Low-Tech High-Tech
PCC MLU MLU
PVC Decrease in Negatives and Affirmatives
All other grammatical parts of speech Increase in Adjective use
Request for Clarification Decrease in Responses Decrease in Responses
Increase in Initiations Increase in Initiations
Increase in Comments Increase in Comments
Increase in Recodes Increase in Recodes
Increase in Obliges
Increase in Adequate Responses
Decrease in No Responses Decrease in No Responses Decrease in No Responses

CONCLUSIONS

Both low-tech communication boards and high-tech voice output communication devices showed a significant benefit over the use of speech alone in communication. The biggest changes were seen in Communication Interaction measures. They were able to initiate, comment on topics, ask questions, and clarify their messages more. They also used longer phrases and sentences when communication systems were used and increased their use of adjectives. The use of these systems did not have a negative impact on their speech productions either.

There were benefits of both low-tech and high-tech communication systems, but high-tech voice output devices had a slight advantage, as they lead to a decrease in reliance on yes/no answers to questions and an increase in accurate responses in this study. This advantage was slight, and much less than was hypothesized. This may be because the low-tech communication boards used in the study consisted of screen shots from their DynaVox pages. This was done to make the two systems as comparable as possible, but it is not how low-tech communication boards are typically set up. These were full communication pages, not anything like a Picture Exchange Communication System (PECS) notebook. These low-tech systems contained vocabulary focused on building sentences, commenting, giving an opinion, and asking questions (core word pages, quickfires/chat, and my phrases). This type of vocabulary is important for growth in many of the measured areas, and it should be included in all forms of communication systems for children with CAS, low-tech or high-tech. Traditional PECS systems typically allow for some combining of words (I want ___, or colors + objects), but they focus on requesting items. They do not typically support commenting, asking questions, or stating an opinion. These types of communications are typical for children, and inclusion of this vocabulary is critical to see changes in communication interaction as described above. Page editing software is typically free to download for most dynamic display voice output communication devices. This can be used as a guide to identify vocabulary that is important to include when setting up communication systems for children with CAS.

References

American Speech-Language-Hearing Association (2007). Childhood apraxia of speech [Technical report]. from Available from www.asha.org/policy

Blank, M., & Franklin, E. (1980). Dialogue with preschoolers: A cognitively-based system of assessment. Applied Psycholinguistics, 1, 127-150.

Culp, D. M. (1989). Developmental apraxia and augmentative or alternative communication-a case example. Augmentative and Alternative Communication, 5(1), 27-34.

Cumley, G. D., & Swanson, S. (1999). Augmentative and alternative communication options for children with developmental apraxia of speech: Three case studies. Augmentative and Alternative Communication, 15(2), 110-125.

Lewis, B. A., Freebairn, L. A., Hansen, A. J., Stein, C. M., Shriberg, L. D., Iyengar, S. K., et al. (2006). Dimensions of early speech sound disorders: A factor analytic study. Journal of Communication Disorders, 39, 139-157.

Millar, D. C., Light, J. C., & Schlosser, R. W. (2006). The impact of augmentative and alternative communication intervention on the speech production of individuals with developmental disabilities: A research review. Journal of Speech, Language, and Hearing Research, 49, 248-264.

Overby, M., Carrell, T., & Bernthal, J. (2007). Teachers’ perceptions of students with speech sound disorders: A quantitative and qualitative analysis. Language, Speech, and Hearing Services in Schools, 38, 327-341.

Stading, K., Ball, L. J., Larson, D., & Dulany, S. (2005). AAC strategies to increase expressive communication: Childhood apraxia of speech. Paper presented at the Poster session at the Annual Convention of the American Speech-Language-Hearing Association.

SLP and Parent Reported Experiences Related to iPad Use for Childhood Apraxia of Speech

ipadDepartment of Speech-Language Pathology, Duquesne University, Pittsburgh, PA

Presented at the Annual American Speech-Language-Hearing Association Convention, November, 2013

Introduction and Purpose

The purpose of this study was to explore parent and clinician reported perspectives and experiences six months after the introduction of iPads and relevant applications. This study was part of a larger investigation associated with the iPads for Kids with Apraxia Pilot Program initiated by the Childhood Apraxia of Speech Association of North America (CASANA).  CASANA provided 40 children with CAS an iPad and appropriate applications free of charge to support their treatment.  This study sought to investigate the impact of the implementation of this technology in therapy and at home.

Despite widespread and rapidly growing use of iPad and related application technology, there is limited empirical data on the specific use of iPads in treatment for individuals with communication disorders (though see growing literature base in the area of autism spectrum disorders: Kagohara, et al., 2013).  Additionally, there are no current examinations of the use of technology, in this case iPad applications as a tool to increase speech sound accuracy (though see DeThorne, et al., 2009) rather than a facilitator of communication in children (e.g.,  Cumley & Swanson, 1999; Miller, Light, & Schlosser, 2006 for a review).

Likewise, the value of studying the qualitative experiences of those affected by communication disorders and their surrounding community is also growing in terms of scope and application (McCormack, et al., 2010a; 2010b).  Moreover, though our understanding of treatment related outcomes for children with CAS is improved from the publication time of the ASHA (2007) Technical Report on CAS, this study contributes to the still relatively sparse literature base on treatment of severe speech disorders associated with CAS.

Research Questions

This study sought to explore the following research questions:

  • What are parents’ perceptions of the effect of iPad use on their children’s speech production skills and overall communication?
  • What are SLPs’ perceptions of the effect of iPad use on their client’s speech production skills and overall communication?
  • What are the experiences associated with iPad implementation during the first six months of use as reported by parents of children with CAS?
  • What are the experiences associated with iPad implementation during the first six months of use as reported by clinicians of children with CAS?

Design

A combined quantitative and qualitative group pretest-posttest research design was employed.  Surveys were used for quantitative comparisons. Quantitative data were collected via seven-point Likert-type scale survey items.  Qualitative data were collected using open-ended questions regarding parental and clinician experiences.

Participants

Eighty total participants were enrolled, including 40 guardians and 40 SLPs of the children (32 boys; 8 girls) that were selected by CASANA as part of their iPads for Kids with Apraxia Pilot Program following extensive applications and review. The children averaged 6.9 years of age (SD=3;0 y.o; range 3;0 – 16;3 y.o.).  According to the parents and SLPs, all children had received a primary speech diagnosis of CAS.  According to the clinicians, 14 did not have any noted concomitant diagnoses.  All 40 parents and 32 of the SLPs completed the post-test survey.

Procedures

Each participant digitally completed a total of four surveys.   The guardians and SLPs also completed two additional surveys (see attached) via www.surveymonkey.com.   The first set of surveys was completed prior to receiving the iPad and the second set of similar surveys were completed six-month after the iPad applications are initiated.  The post-test survey responses are the focus of this study.

Though there was attrition of eight SLPs for the post-survey, all guardians completed the second survey.  Posttest surveys consisted  of 30 close-ended and 10 open-ended items for parents and 18 close-ended and 16 open-ended items for SLPs.  Though not analyzed for this study, the Focus on the Outcomes of Communication Under Six (FOCUS) Survey (Thomas-Stonell, Oddson, Robertson, & Rosenbaum, 2009) was also completed by the parent and SLP before and after iPad implementation.

Data Analysis

The quantitative data were descriptively analyzed and between group comparisons were analyzed using independent t-tests.  The qualitative data were analyzed by the first author using a phenomenological approach (e.g., van Manen, 1990). The content from each response was initially coded for thought units, and then reanalyzed to collapse the codes into emergent themes/subthemes. A second author completed reliability on the entire qualitative dataset by examining the transcripts given the list of themes/subthemes to check that the “themes appropriately encompassed the codes” (McCormack, et al., 2010a, p. 383). Agreement between the two coders was high for both parent codes/themes (r=0.75) and SLP codes/themes (r=0.76).

Quantitative Results

Overwhelmingly, parents (M=6.53; SD=1.06) and SLPs (M=5.66; SD=0.63) indicated that the children were willing to use the iPads.  Almost all of the parents (39/40) stated that they would continue to use the iPad , while 27 (84%) of the SLPs stated they would continue use of the iPad in therapy.  Though most parents (M=6.18; SD=1.11) stated that the iPad technology was beneficial in facilitating accurate speech production, SLPs were less in agreement (M=5.66; SD=1.07; t = -5.15, p<.0001) (Figure 1).  Likewise, a discrepancy of parental report and SLPs (M=6.18; SD=0.96) of iPads benefitting overall communication compared to SLPs accounts and SLPs (M=4.78; SD=1.34) was reflected in the data (t = -4.06, p<.0001).  Parents and SLPs both perceived the other (M=6.25; SD=0.83 and M=5.59; SD=0.71, respectively) as being competent with the iPad and its applications.

Figure 1

(Figure 1.  Percentage of responses to the question: “iPads/apps are beneficial in facilitating
accurate speech production.” Click image to enlarge)

Figure 2

(Figure 2.  Percentage of responses to the question: “iPads/apps are beneficial in facilitating
overall communication.” Click on image to enlarge.)

Qualitative Results

Four of the SLPs (12.5%) used the iPad very little in therapy due to behavioral issues or concerns of the school regarding the iPad being misplaced or broken. These participants were excluded.  Other responses of SLPs and parents were excluded for providing general information rather than answering the question provided or not responding.

Data are presented for the following qualitative items, description of the individual’s initial experiences with the device, perceived benefits of implementing the technology and perceived obstacles associated with iPad implementation.  For each item, a table presents the most frequent themes that emerged and example responses are provided.

SLP Experiences

Description of Initial Experience

22b: “Very positive! He was motivated by it and took real ownership of it.”

13b: “Somewhat overwhelming for me but he seemed very comfortable using it.”

29b: Initially, there was some excitement for the student, but there were also control issues with regard to compliance…”

Table 1

(Table 1.  Number of SLP meaning units that emerged into the five most prevalent themes regarding the initial experience with the iPad.)

Benefits of iPad in Therapy

10b: “Really motivated the child and it was easy for the parent and child to practice at home.”

38b: “It serves so many purposes…therapy mode, communication device, social skill development and reinforcer.”

37b: “The iPad definitely motivated the student to engage in therapy and produce the targeted syllables/words-much more so than using traditional articulation cards.”

Table 2

(Table 2. Number of SLP meaning units that emerged into the three most prevalent themes regarding the benefits of iPads.)

Obstacles of iPad Use in Therapy

37b: “Only the short attention span and impulsivity of the student.”

30b: “Child saw the iPad as a toy/game so it was difficult to engage him in the therapy apps in the context of therapy sessions.”

26b: “Just initially did not understand certain aspects of the specific program.”

Table 3

(Table 3. Number of SLP meaning units that emerged into the five most prevalent themes regarding the obstacles for iPad use.)

Parent Experiences

Initial Experience with iPad

23a: “He took immediate ownership of the iPad which is a huge deal as he would ignore other alternative devices.”

15a: “In the beginning he was overwhelmed with all of the apps out there and wanted every single one.”

3a: “I was shocked at the way my son took it from my arms, sat down and immediately started exploring all parts of it.”

Table 4

(Table 4. Number of parent meaning units that emerged into the seven most prevalent themes regarding the initial use of the iPad.)

Benefits of iPad at Home

17a: “He is much more willing to practice his speech with the iPad than with traditional therapy methods.”

36a: “The main one is it is portable, we can use it anywhere, so anyone can also help him practice. It isn’t all on me to help him.”

Table 5

(Table 5. Number of parent meaning units that emerged into the six most prevalent themes regarding benefits of iPad technology.)

Obstacles of iPad Use at Home

6a: “The only obstacle we saw was if we would let him take the iPad to school…”

31a: “The hardest thing was to get him to use the iPad for education and speech.  He right away wants to play a game.”

Table 6

(Table 6. Number of parent meaning units that emerged into the themes associated with obstacles to iPad use at home.)

Discussion

Overall, parents and therapists reported positive perceptions of and experiences with iPad technology at home and during intervention.  Shared themes of excitement, motivation, immediacy, and the ability to practice outside of the therapy environment emerged. Likewise, common challenges were noted in shared themes of impulsivity/behavior, confusion/frustration of adult, desire to play instead of practice, and school/transportation issues.  Clinical implications of this study include that iPad technology may be a particularly useful tool for extending speech sound intervention outside of therapy settings.  This study suggests that a phenomenological approach is a valuable methodology to employ concurrently with quantitative methods.  Thus, this study provided quantitative and qualitative information on the impact and experiences of iPad technology for children with a significant speech sound disorder and provided support for the integration of this technology in treatment as well as a focus of future experimental investigations.  Future studies may elucidate the utility of iPads for speech sound practice versus communication device for children with severe speech sound disorders (SSDs) such as CAS.  These data, combined with the continued growth of such tablet technology, strongly point to the need for a study of treatment efficacy using applications in the treatment of CAS and other SSDs.

Acknowledgments: We are grateful to CASANA and the families and therapists that participated in this investigation.

References 

American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech [Technical Report]. Available from http://www.asha.org/policy.

Cumley, G. & Swanson, S. (1999). Augmentative and alternative communication options for children with developmental apraxia of speech: three case studies. Augmentative and Alternative Communication, 15(2), 110-125.

DeThorne, L.S., Johnson, C.J., Walder, L., Mahurin-Smith, J. (2009). When “Simon Says” Doesn’t Work: Alternatives to Imitation for Facilitating Early Speech Development.  American Journal of Speech-Language Pathology, 18, 133-145.

Kagohara, D.M., van der Meer, L., Ramdoss, S., O’Reilly, M.F., Lancioni, G.E., Davis, T.N, Rispoli, M., Sigafoos, J. (2013). Using iPods and iPads in teaching programs for individuals with developmental disabilities: A systematic review. Research in Developmental Disabilities, 34, 147-156.

McCormack, J., McLeod, S., Harrison, L.J., McAllister, L. (2010). The impact of speech impairment in early childhood: Investigating parents’ and speech-language pathologists’ perspectives using the ICF-CY. Journal of Communication Disorders, 43 (378-396).

Miller, D., Light, J.C., & Schlosser, R.W. (2006). The impact of augmentative and alternative communication intervention on the speech production of individuals with developmental disabilities: A literature review. Journal of Speech, Language, and Hearing Research, 49, 248-264.

Thomas-Stonell, N., Oddson, B., Robertson, B., & Rosenbaum, P. (2009). Predicted and observed outcomes in preschool children following speech and language treatment: Parent and clinician perspectives. Journal of Communication Disorders, 42(1), 29-42.

Van Manen, M. (1990). Researching Lived Experience: Human science for an action sensitive pedagogy. London, Ontario: The Althouse Press.