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Children with Apraxia and the Use of Augmentative and Alternative Communication

By
Gary Cumley, Ph.D., CCC-SLP

Children with severe phonological disorders have a higher probability of failed communication interactions because of a reduced level of intelligibility. A severe phonological disorder results in children having difficulty initiating and participating successfully in communication interactions. As a coping mechanism, these children may avoid talking situations, may simplify their vocal responses, and may rely more on nonverbal gestures to support and convey the intent of their communicative message (Kent, 1992). In general, children with severe expressive communication disorder frequently develop behavior problems, poor self-esteem, and become generally frustrated over their expressive communication disorder (Rogers-Adkinson & Griffith, 1998; Prizant, Audet, Burke, Hummel, Maher & Theadore, 1990).

A sub-group of children with severe phonological disorders are children diagnosed as having or suspected of having developmental apraxia of speech (DAS). However, little agreement exists among experts regarding a descriptive label, definition, salient characteristics, assessment procedures, and intervention approaches for children having DAS (Marquardt & Sussman, 1991; Hall, Jordan & Robin, 1993; Guyette & Diedrich, 1981). In the field of communicative disorders, there is confusion and controversy surrounding DAS (Bernthal & Bankson, 1993). The controversy is due to the various terms or labels used to describe children who show unusual speech production patterns suspected to be motoric in origin (Crary, 1993). Such terms as developmental apraxia of speech (Strand & McCauley, 2000; Strand & Skinder, 2000; Rosenbek & Wertz, 1972), developmental verbal apraxia (Edwards, 1973), acquired articulatory apraxia (Morley, 1965), verbal dyspraxia (Velleman & Strand, 1994, 1995), developmental verbal dyspraxia (Davis, Strand, & Velleman, 1998), and congenital articulatory apraxia (Eisenson, 1972) have been and are being used to describe children with unusual developmental speech production problems. For purposes of this article, DAS will be defined as a neurologically-based disorder affecting the ability to program and produce volitional movements for speech without the presence of any impaired neuromuscular function (Smith, Marquardt, Cannito, & Davis, 1993). This basic difficulty in executing and coordinating the speech mechanism results in a high frequency of unintelligible responses (Marquardt & Sussman, 1991). Generally, these children are characterized as having congenital articulation problems, which are moderate to severe in nature and generally are resistant to traditional articulation and/or phonological intervention methods. In addition, there is limited progress or generalization over time and the prognosis for intelligible speech is guarded (Hustad & Beukelman, 1998; Bernthal & Bankson, 1993; Crary, 1993; Hall, Jordan & Robin, 1993; Marquardt & Sussman, 1991; Haynes, 1985; Yoss & Darley, 1974).

Children with severe phonological disorders, including children with DAS, frequently produce unintelligible responses, which result in frequent interactional breakdowns. Research has documented that the process of language learning begins from the moment of birth and extends through puberty and beyond (Locke, 1993; Vygotsky, 1992; Bruner, 1981; Snow, 1977, 1979;). Most children have the capacity for spoken language, but some will not be able to express their communication needs through spoken language (Locke, 1993). Children with severe phonological disorders have the capacity for spoken language, but their frequent unintelligible responses prevent them from successfully engaging in communication interactions and achieving a functional level of communicative effectiveness.

In young children, communication interaction is an important component affecting the ongoing development of language and communication skills. Social interaction facilitates the development of intentional and symbolic speech acts, which serve different communication functions and result in different consequences for the communication partners (Dore, 1986). The intentional and symbolic acts along with the linguistic and cognitive abilities become interwoven as children develop their language and communication skills. Language develops because human beings are motivated to interact socially with others, and through successful language usage humans develop a sense of self (Locke, 1993; Nelson, 1993; Jordan & Robin, 1993; Vygotsky, 1992 Bruner, 1981). Social interaction provides the scaffolding needed for further development of children’s lexical, syntactical, and social-pragmatic development (Cumley, 2000; Cumley & Swanson, 1999; Swank, 1994; Jenkins & Bowen, 1994; Hoffman, 1992; Kent, 1992; Hodson & Paden, 1991; Marquardt & Sussman, 1991; Lewis & Freebairn-Farr, 1991; McCormick & Schiefelbusch, 1990; Hoffman & Norris, 1989; ; Marquardt, Dunn, & Davis, 1985; Liberman & Shankweiler, 1985; Smit & Bernthal, 1983; Blakely, 1983, Ekelman & Aram, 1983; Panagos & Prelock, 1982; Paul & Shriberg, 1982; Guyette & Diedrich, 1981).

Communication interactions are important in the process of language and communication development, but what effect does a high frequency of unintelligible speech have on the quality and quantity communication interactions? For some children with severe phonological disorders and/or suspected DAS, intervention has primarily focused on improving the phonological proficiency of these children. Frequently these children remain severely communicatively limited due to the negative effect their phonological disorder has on their communication interactions and their overall communicative effectiveness, which results in a lower “communication pay”.

In the field of communicative disorders, there is confusion and controversy surrounding DAS (Bernthal & Bankson, 1993). There are many factors, which influence this confusion and controversy. One factor is the complexity of this speech production disorder, frequently interventionist may inaccurately diagnosis a child with DAS when in reality they are not or not make a proper diagnosis of a child who has DAS. Secondly, many SLPs may lack the knowledge, expertise, and/or experience diagnosing and working with children having DAS. There are no easy answers to this very complex phonological disorder.

DAS is considered a phonological disorder, neurologically based and results in difficulty executing and coordinating the speech mechanism. Crary (1993) suggests that there is not only difficulty in the production of speech for children with this disorder, but also a disruption in the central sensory-motor processes, which interferes with the motor learning for speech. Stand and McCauley (2000) define developmental verbal apraxia as a speech disorder, due to delays or deviance in those processes involved in planning and programming movement sequences for speech. These children have difficulty reaching and maintaining specific articulatory configurations, as well as difficulty moving from one articulatory configuration to the next. Generally, these children are characterized by congenital phonological problems that are moderate to severe in nature and resistant to traditional phonological intervention methods (Velleman & Strand, 1994; Marquardt & Sussman, 1991; Haynes, 1985; Yoss & Darley 1974;). As a result of this production difficulty, these children have a high frequency of unintelligible responses (Crary, 1993; Marquardt & Sussman, 1991). The effect of this generalized poor motor control results in difficulty in sequencing, planning, coordinating, and transitioning motor speech movements in the production of speech (Davis, Strand, & Velleman, 1998; Velleman & Strand, 1994, 1995; Velleman, Strand, Pollock, & Hall, 1992). Some common speech characteristics found in this population are as follows:

  • Receptive language superior to expressive language skills
  • Presence of an oral apraxia (may or may not exist with DAS)
  • Phonemic error- often in the form of sound omissions
  • Difficulty with achieving the initial articulatory configuration
  • Increase in errors with increase in word length and phonetic complexity
  • Connected speech poorer than word production
  • Errors more frequently occurring on the complex sound, for example fricatives (i.e.,s, z, sh, etc.) ,affricates (i.e., ch, j), and consonant clusters, (i.e., st, sp, sl, etc.)
  • Inconsistent error patterns
  • Groping and/or trial error behavior
  • Presence of vowel errors (Strand & McCauley, 2000)

Children with DAS often exhibit other nonspeech characteristics, which may include oral and/or limb apraxia (Velleman, Strand, Pollock, & Hall, 1992; Love, 1992; Hall, Hardy, & LaVelle, 1990; Ferry, Hall, & Hicks, 1975;; Marquardt, Dunn, & Davis, 1985; Horwitz, 1984; Yoss & Darley, 1974; Rosenbek & Wertz, 1972; Walton, Ellis, & Court, 1962). In addition to these “soft” neurological signs, delays or disorders involving language, mental retardation, and neuromuscular disorders may be present in differing degrees for children presenting a diagnosis of DAS (Marquardt, Dunn, & Davis, 1985; Cermak, 1985; Crary, 1984; Aram & Nation, 1982; Rosenbek & Wertz, 1972).

The objective for many traditional intervention approaches for DAS has been to focus on increasing or improving the articulatory proficiency of these children. Intervention programs such as Prompts for Restructing Oral Muscular Phonetic Targets (PROMPT) (Chumpelik, 1984); Touch-Cue methods (Bashir, Grahamjones, & Bostwick, 1984); and Melodic Intonation Therapy (MIT) (Helfrich-Miller, 1984) have been developed or adapted from the adult motor speech literature as a means of improving the intelligibility of children with DAS. Today, intervention approaches for children focus on incorporating a motor speech perspective in intervention planning. For example, programs or intervention methods and procedures by Stand and McCauley (2000); Strand & Skinder (1999), and Kaufman (2001) are just a few examples of these motor speech programs.

Frequently, children with DAS develop idiosyncratic gestural systems or use many gestures, which allows them greater opportunity to communicate, despite functional limitations of their articulatory system (Hall, Jordan, & Robin, 1993). Because of their ability to develop these sometimes elaborate gestural systems, it seems logical that a more formal gestural system, such as sign language would be beneficial for these children for conveying their communication intents. Because of this notion, intervention approaches combining sign language and speech (total communication) have been frequently introduced to children with DAS (Hanrahan & Odykirk, 1992; Air, Wood, & Neils, 1989; Jaffe, 1984) have been introduced to enhance and support the articulatory performance of children with DAS.). The introduction of manual communication is considered by some as an unaided augmentative communication system, because the manual sign system can augment, enhance, or support the individual’s verbal communication attempts (Beukelman & Mirenda, 1998). Total communication approach can be a positive option for some children with DAS, but it requires that the children’s communication partners, their family members, and teachers become proficient in learning and communicating with sign language. Many children with DAS have generalized motor planning difficulties or limb apraxia (Hall, Jordan, & Robin, 1993; Crary & Anderson, 1991; Dewery, Roy, Square-Storer, & Hayden, 1988; Rappaport, Urion, Strand, & Fulton, 1987; Cermak, 1985; Aram & Horwitz, 1983). For communication purposes to be successful in using sign language these children need to be proficient in motor planning and executing sequential motor patterns in the formulation of accurate signs. If sign language is considered as part of the intervention plan, then one needs to consider the motor demand of successfully using sign language for communicative purpose. If SLPs don’t consider the motor demands and requirements for the introduction of sign language these children may be learning a communication system that is no more efficient or effective than their natural speech.

Previously mentioned intervention approaches and/or programs for children diagnosed with DAS has primary focused on improving the articulatory proficiency and/or supporting these childrens’ speech attempts through the sign language. However, despite the variety of approaches, children with DAS continue to demonstrate limited progress. Crary (1993) and others suggest a more integrated intervention approach incorporating linguistic components is essential for these children (Strand & Skinder, 2000; Velleman & Strand, 1994). Crary suggests that focusing only on the articulatory proficiency does not address the negative effect a severe phonological disorder has on the children’s communication interactions. Due to the severity of the phonological disorder, children with DAS have a higher frequency of unintelligible responses. This lack of intelligibility can negatively affect the listener’s level of comprehensibility within communication interactions and negatively affect the childrens’ overall communication effectiveness (Hall, Jordan & Robin, 1993; Marquardt & Sussman, 1991; Marquardt, Dunn, & Davis, 1985; Blakely, 1983; Guyette & Diedrich, 1981; Chappell, 1973). The question needing to be answered by researchers and interventionists is, What effect does the introduction of augmentative and alternative communication (AAC) with children having DAS on the quality and quantity of their communication interactions and their overall communicative effectiveness? The American Speech-Language-hearing Association (ASHA) has defined AAC as: An areas of clinical practice that attempts to compensate (either temporarily or permanently) for the impairment and disability patterns of individuals with severe expressive communication disorders (i.e., the severely speech-language and writing impaired) (1989, p. 107).

In ASHA’s position paper published in 1991, it states: “It is important to emphasize that AAC interventions should always be multimodal in nature and should utilize the individual’s full communication capabilities, including any residual speech or vocalizations, gestures, signs and aided communication. An AAC system is an integrated group of components, including the symbols, aids, strategies, and techniques used by individuals to enhance communication. The use of aids refers to a physical object or device used to transmit or receive messages (e.g., communication book, board, chart, mechanical or electronic device, computer) ASHA, 1991, p.10).

Research has shown that, the introduction of AAC positively supports the communication interactions and language development of individuals with cognitive and/or motor impairments. AAC has provided these two groups of individuals with greater opportunity and access to participate in communication interactions (Romski & Sevcik, 1993; Iacono, 1992; Blackstone, 1989; Mirenda & Schuler, 1988; Light 1988; Romski, Sevcik, & Pate, 1988; Romski, Lloyd, & Sevcik, 1988; Goossens’ & Kraat, 1985; Light, Collins, & Parnes, 1985; Romski & Ruder, 1984; Harris, 1982).

The possibility of circumventing the phonological system as the primary mode for message transmission through the introduction of AAC may increase the level of communicative effectiveness for children with severe phonological disorders and/or suspected DAS. Traditionally, the introduction of augmentative and alternative (AAC) intervention techniques has not been incorporated into the communication intervention of children with severe phonological and/or suspected developmental apraxia of speech (DAS). Blockberger and Kamp (1990), Kravit (1991), and Cumley and Swanson (1993, 1999) have written about introducing various AAC techniques (voice output communication aids and communication boards) with children with DAS. However, little empirical research has been reported regarding the implementation of incorporating an AAC intervention approach with children having DAS.

Traditionally, SLPs have not introduced AAC into their intervention plan with this population. Some of the possible reasons why professionals have not introduced AAC are as follows: their fear that if AAC is implemented the children will stop talking; being overwhelmed with implementing AAC for children who move easily and quickly in and out of different environments; lack of AAC knowledge associated with implementation; fear of “the technology”; difficulty approaching parents who are not accepting of incorporating AAC into their child’s intervention approach.

Blackstone (1989), provided rationale for the use of AAC with children with DAS. In her newsletter she states the following rationale: overlays or displays help support the communication partner’s understanding of the unintelligible utterances; overlays provide a strategy for assisting in repairing communication breakdowns; overlays provide access to language and enables the child the opportunity to exchange information, make comments, tell jokes, etc.; overlays stimulate speech production; overlays facilitate language understanding and expression; overlays help compensate for memory deficits.

Culp (1989), conducted a single case study with an eight-year-old girl with DAS and her different communication partners, her mother and school staff. Her partners received instruction on using different AAC modes (i.e., sign language, gestures, and a communication book) as a means of facilitating communication interaction between the girl and her different communication partner.

  • Culp’s study highlights the positive results obtained by training the communication partners in AAC techniques, which enhanced the girl’s communication interactions. Cumley and Swanson (1999), conducted a descriptive case study of a preschooler, elementary school-aged, and a junior high school student diagnosed with DAS or suspected DAS. They investigated what effect the introduction of a multimodal AAC intervention approach using speech, gestures, manual signs, and various AAC had on these children’s communication.
  • The AAC system provided the preschool-aged student the scaffold needed to provide her the opportunity to engage in early language and conversational discourse development (Bruner, 1983; Letto, Bedrosian, & Skarakis-Doyle, 1992). After the Wolf, a voice output device, was introduced there was an increase in her mean length of utterance, which provided her greater opportunity for facilitating her expressive language development.
  • Her remnant book supported her early discourse skills by allowing her the opportunity to initiate and reference past experiences with familiar and unfamiliar communication partners.
  • The multimodal AAC intervention approach for the school-aged student supported her natural speech attempts and gave her the opportunity to successfully establish communication topics through the use of her remnant book.
  • It provided her a means of repairing her frequent communication breakdowns through the use of her symbol dictionary.
  • Kelly’s intervention focused both on her natural speech productions along with providing effective strategies and AAC aids that supported her natural speech and increased her opportunities for successfully engaging in different communicative interactions.
  • The multimodal communication systems provided the junior high-age student a means of supporting his natural speech by providing him the opportunity to initiate, maintain, and repair communicational breakdowns.
  • In the past, he frequently did not initiate or attempt to repair his communication breakdowns; instead he relied on his communication partners to take an active role in the repair process. With AAC aids available to him, Carl took more responsibility for attempting to repair his frequent communication breakdowns.

In summary, results indicated that all children had greater opportunities to initiate and maintain interactions as well as to repair communication breakdowns across various communication situations with both familiar and unfamiliar communication partners.

Cumley, (1997) conducted a research study with a total of sixteen school-age children between the ages of 3-7years of age who had received ongoing speech and language intervention services through a public school intervention model. All of these children had ongoing services and had made minimal progress even though they had received intensive speech language services. The research question for this descriptive study was to determine what effect AAC would have on the quality and quantity of these childrens’ communication interaction.

The study was based on the following phases; pre-treatment (no AAC boards available); treatment (AAC boards available); and post-treatment (no AAC boards available).

  • Children were involved in the study for only 1 hour and 40 minutes, which is a short time period.
  • AAC communication boards were designed around contextual based activities.
  • The interactions between the children and the investigator were video taped and later analyzed.
  • AAC frequency-use groups were established by calculating the total number of times each child accessed his/her AAC board. There was a low frequency AAC user group and a high frequency AAC user group. It should be mentioned that the high frequency AAC users tended to have a more severe phonological disorder as compared to the low frequency AAC users. However, all children were verified through assessment data to all have a severe phonological disorder.
  • Proportional data was calculated and group comparisons were made across no AAC communication boards available, AAC communication boards available and across comprehensibility, communication modality, contingent communication, and communication breakdown repairs.

Comprehensibility and Communication Modalities

  • The children’s communication attempts were classified into comprehensible (understood) and non-comprehensible (not understood) attempts. These comprehensible and non-comprehensible attempts were next classified into specific communication modality (ies) or forms used by the children during their communication interactions: gestures, non-conventional signs, manual signs, vocalizations, verbalizations, AAC, drawing, and writing.
  • Low frequency AAC users consistently used either spoken words and/or gestures as their primary mode of communication. Even when the communication boards were available, little change was noted in the proportion of spoken words and/or gestures used.
  • High frequency AAC users were more comprehensible when the AAC option was available.
  • High frequency users when the boards were available the proportion of gestural use decreased resulting in an increased use of AAC. The proportion of spoken words used remained constant across treatment conditions.
  • For the high frequency users replacing the gestures with a more symbolic communication option like AAC raised the children’s likelihood of being more comprehensible or understood.

Contingent Communication

Frequency of yes/no and Wh question forms were classified according to the children’s response(s) to question forms; responses to yes/no questions, and Wh questions.

  • Low frequency AAC users showed no apparent pattern in their answering of yes/no and Wh questions.
  • Higher frequency AAC users were more successful in answering yes/no and Wh questions during the board condition than on the no board conditions. There were fewer “no responses” to question forms during the treatment condition than the pre and post treatment conditions.
  • These findings support the notion that the availability of AAC provided the children greater opportunity to be successful during contingent communication situations.

Communication Breakdowns

The severity of the children’s phonological disorders affected their level of intelligibility and resulted in a high frequency of communication breakdowns.

  • Low frequency AAC user only used spoken words for repairing their communication breakdowns.
  • Low frequency AAC user when AAC communication boards were available the boards did not have an adverse effect on their speech, but indicated a marked increase in their speech use when the boards were available.
  • High frequency AAC users with no AAC communication boards available, primarily used spoken words and gestures to repair their communication breakdowns. When having AAC communication boards available 50% of their successful communication repairs were accomplished through the use of the AAC boards.
  • There seemed to be a possible suppression of speech, in these situations when the boards were available. The boards may have provided a more efficient means of repairing rather than attempting to use their natural speech. With the increased use of AAC for repairing communication breakdowns came a decrease, or a replacement of gestures, as their primary communication repair strategy.
  • High frequency users tended to replace a less symbolic form of communication, gestures, with a more symbolic form of communication, AAC symbols and may of realized that the AAC option afforded them more chance of successfully repairing their communication breakdowns then using their speech.

Relationship Between Phonological Severity and AAC Use

From the results of this study the speculation could be made that the level of severity of the children’s phonological disorder directly influenced the level of AAC used by the children. The children who had a more sever phonological disorder tended to use AAC more often when the communication boards were available.

Impact of AAC Use On Gestures

Children with severe phonological disorders frequently use gestures in an attempt to successfully communicate and support their natural speech attempts. When children use gestures to support their natural speech attempts these gestures are symbolically could be considered more difficult for the communication partner to understand. AAC communication boards could be considered a more symbolic communication form, therefore increase the level of understanding across different communication partners. Results of this study indicated that when AAC communication boards were made available the high frequency AAC users tended to decrease or replace their gestural communication modality with the newly introduced AAC communication modality. Because AAC is considered a more symbolic communication modality the use of AAC provided the children the opportunity of achieving greater communication effectiveness. By providing these children another communication modality, AAC modality allowed the children access to different communication strategies, which better supported and enhanced their natural speech attempts. Having these multi-modal communication options available provided the children greater opportunity for communication effectiveness and increased their “communication pay off”.

Use of AAC To Repair Communication Breakdowns

The severity of the children’s phonological disorders affected their level of intelligibility and resulted in a high frequency of communication breakdowns. Results indicated that during the no board conditions the children used spoken word and gestures for repairing their communication breakdowns. When the high frequency AAC users were provided communication boards the children tended to use their AAC communication boards as the primary repair strategy. The issue of the symbolic nature of AAC seemed to be a contributing factor in it use. The other speculation could be that the children realized that the probability of successfully repairing communication breakdowns would be enhanced through the use of their AAC communication boards. Having a successfully means of repairing their communication breakdowns provided the children greater opportunities for communicative effectiveness all allowed them to maintain the communication interaction.

Traditionally, AAC has not been introduced into the intervention plans of children with severe phonological disorders and/or suspected DAS. Frequently, SLPs and parent worry that the introduction of AAC will inhibit the use of speech. This study clearly showed that the introduction of AAC boards did not adversely effect the frequency of speech use by either the low or the high frequency AAC users. It could be speculated that the communication boards may have visually supported their language and speech output.

Frequently, the primary focus of intervention for this population is to improve their phonological proficiency. All children who participated in this study, indeed had a severe phonological disorder and a suspected language disorder as indicated by their low language production and vocabulary levels. If AAC was introduced into the intervention plan of these children the AAC option would not only support their natural speech attempts but also support their language disorder and enhance their communication effectiveness.

Even with minimal exposure to the AAC communication boards, a total of 1 hour and 40 minutes, positive changes were noted in the different quality and quantity factors of the children’s communication interactions. This heterogeneous group of children showed that the children with the most severe phonological disorder, the high frequency AAC users tended to use their AAC communication modality more than the children whose speech was less severe, the low frequency AAC users. The children early in the intervention phase established the need and the benefit of using the provided AAC communication boards during the various interaction activities. The children who did not see a need for the AAC communication boards did not use them during the activities. It is the hope of the investigator that the empirical data from this study will provide speech-language pathologists the rationale for introducing AAC into the intervention plans of children with severe phonological disorders and/or DAS . The seemingly short time period after introducing the AAC boards seemed to determine which of the children were benefiting from the AAC boards. Knowing this, SLPs could introduce AAC into the intervention plan and determine if this approach was benefiting the children. The introduction of AAC into the intervention plan may help to support the communication interaction and language needs of children with severe phonological disorders and/or suspected DAS, rather than having intervention only focused on improving the children’s phonological proficiency. The “communication pay off” for introducing AAC into this populations intervention plan would be that the AAC options would provide this population greater opportunity of being a more effective communicator.

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