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Apraxia Therapy – Evidence for Frequent and Intensive Speech Therapy Services

frequency and intensity

Children with childhood apraxia of speech (CAS) are often described as needing frequent and intensive speech therapy services in order to address the speech motor planning and programming issues that are at the heart of their speech difficulty. Typically, the need for speech therapy will extend over a number of years. Families and caregivers may need to advocate for the appropriate speech therapy services for a child with apraxia.

Children with CAS who receive appropriate speech therapy are capable of making meaningful and substantial gains in speech intelligibility and communication. As their speech becomes more and more intelligible, the frequency of services can be adjusted according. Each child’s individualized needs and circumstances must be considered. In addition to their speech motor planning and programming needs, children with CAS often have other speech and/or language needs that need factored into therapy goals. For example, some children may also require training with augmentative communication devices in addition to speech therapy specifically targeting their speech production.

Included below are the most relevant citations available in the professional published literature for communication sciences and disorders and in prevailing expert opinion that describe the need for frequency and intensity for children with CAS. Additionally, there are quotes and excerpts from the American Speech Language Hearing Association (ASHA). ASHA is the professional organization and licensing body for speech-language pathologists.


The American Speech-Language-Hearing Association (ASHA)

In 2007, ASHA issued its “Position Statement on Childhood Apraxia of Speech” and the “Technical Report on Childhood Apraxia of Speech” in order to update speech-language clinicians regarding the science of CAS and its consensus expert guidance for speech-language pathologists. ASHA is the national professional, scientific, and credentialing association for 186,000 members and affiliates who are audiologists; speech-language pathologists; speech, language, and hearing scientists; audiology and speech-language pathology support personnel; and students. This position statement is an official policy of the American Speech-Language-Hearing Association (ASHA). Here are relevant citations regarding speech therapy frequency and intensity:

“It is the policy of ASHA that the diagnosis and treatment of CAS are the proper purview of certified speech-language pathologists with specialized knowledge in motor learning theory, skills in differential diagnosis of childhood motor speech disorders, and experience with a variety of intervention techniques that may include augmentative and alternative communication and assistive technology. It is the certified speech-language pathologist who is responsible for making the primary diagnosis of CAS, for designing and implementing the individualized and intensive speech-language treatment programs needed to make optimum improvement, and for closely monitoring progress.”
[Position Statement: Childhood Apraxia of Speech, American Speech-Language-Hearing Association (ASHA); http://www.asha.org/policy/PS2007-00277.htm; Accessed 08/01/2017]

Given the need for repetitive planning, programming, and production practice in motor speech disorders, clinical sources stress the need for intensive and individualized treatment of apraxia, especially for children with very little functional communication. There is emerging research support for the need to provide three to five individual sessions per week for children with apraxia as compared to the traditional, less intensive, one to two sessions per week (Hall et al., 1993Skinder-Meredith, 2001Strand & Skinder, 1999). Ideally, this should be done in as naturalistic an environment as possible to facilitate carry-over and generalization of skills. Although home practice is critical for optimal progress, it cannot take the place of individual treatment provided by a speech-language pathologist who has expertise in motor speech skill facilitation. For the diverse backgrounds of children seen for early intervention, including their stages of psychological/emotional development, the Committee sees value in endorsing a treatment plan for optimum progress based on provision of intensive therapy.

Individual differences among children will also underlie rationale for changing the form, content, and intensity of treatment throughout the course of intervention. If toddler and preschool-age children are seen for early intervention that targets their speechmotor deficits, the frequency of treatment may be able to be reduced over time. As long as the primary goal is to improve the motoric aspects of the child’s speech production (i.e., more time for motor practice), individual therapy should be the preferred approach regardless of age. For children whose severity of involvement has decreased and whose treatment goals have begun to move toward language and pragmatic skills enhancement, a combination of both individual and small group therapy may also be optimal for some children, providing that a treatment focus is maintained on speech production.”
[Technical Report: Childhood Apraxia of Speech; American Speech-Language-Hearing Association, 2007; http://www.asha.org/policy/TR2007-00278.htm; Accessed 08/01/2017]

From the ASHA Practice Portal:  Childhood Apraxia of Speech

Dosage refers to the frequency, intensity, and duration of service and the culmination of those three variables (Warren, Fey, & Yoder, 2007). Treatment dosage for CAS is consistent with principles of motor learning (McNeil, Robin, & Schmidt, 1997). Given the need for repetitive production practice in motor speech disorders like CAS, intensive and individualized treatment is often stressed. A number of research studies support the need for three to five individual sessions per week versus the traditional and less intensive one to two sessions per week (Hall et al., 1993; Skinder-Meredith, 2001; Strand & Skinder, 1999). For younger children, the frequency and length of sessions may need to be adjusted; shorter, more frequent sessions are often recommended (e.g., Skinder-Meredith, 2001).

Format refers to the structure of the treatment session (e.g., group and/or individual). The appropriateness of treatment format (individual vs. group vs. both) depends on the primary goal for the child at a particular point in the treatment process. For example, if the primary goal is to improve the motor aspects of speech, individual sessions that emphasize motor practice might be the preferred approach. However, once the child has made progress on goals targeting motor speech production, goals might then include language and the enhancement of pragmatic skills. At that point, a combination of individual and group treatment may be appropriate.
[Practice Portal: Childhood Apraxia of Speech; American Speech Language Hearing Association; http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935338&section=Treatment; accessed 08/01/2017]

 


Other citations on frequency and intensity from published journals and books:

Individual therapy is recommended because it offers more opportunities for intensive practice and child and parent feedback. Group therapy is a complex learning environment with more potential distractions and fewer opportunities for practice of speech targets with individualized cueing and feedback. Young children with suspected CAS may have difficulty focusing on the clinician and may not have sufficient practice opportunities to develop and establish new speech motor patterns within a group setting.”
[Pukonen, M., Grover, L., Earle, C.,  Gaines, R., and Theoret-Douglas, C. (2017). A proposed model for identification of childhood apraxia of speech in young children. Canadian Journal of Speech-Language Pathology & Audiology; 41(1), 10 – 32.]


“It is commonly agreed that children with CAS need intensive speech therapy (McCauley & Strand, 2008). Edeal and Gildersleeve-Neumann (2011) found that frequent and intense practice of speech resulted in more rapid response to treatment in two children with CAS. Treatment approaches for children with CAS typically involved therapy at least twice a week, often more. Strand et al. (2006) provided sessions two times a day, five days a week. Iuzzini and Forrest (2010) provided 20 therapy sessions over 10 weeks. Martikainen and Korpilahti (2011) provided therapy three times a week for six weeks.”
[Kiesewalter, J., Vincent, V., and Lefebvre, P. (2017). Wee words: a parent-focused group program for young children with suspected motor speech difficulties. Canadian Journal of Speech-language Pathology & Audiology; 41(1), 58 – 70.]


The principle of motor learning that has the greatest evidence supporting its use in children with CAS is that of treatment intensity—where a higher number of sessions and practice trials per session results in the greatest gains within one block of treatment. The minimum intensity that has been shown to work is two sessions a week (Namasivayam, Pukonen, Goshulak, et al., 2015; Thomas, McCabe, & Ballard, 2014) with most articles employing sessions 3–5 times a week and 100 production trials per session (Edeal & Gildersleeve-Neumann, 2011; Murray et al., 2015).
[Murray, E., and Iuzzini-Seigel, J. (2017).  Efficacious treatment of children with childhood apraxia of speech according to the international classification of functioning, disability and heath. Perspectives of the ASHA Special Interest Groups SIG 2; 2(2); 61 – 76.]


“Evidence level of reviewed studies ranged from moderate to strong (ASHA, 2004). With regard to research phase, only one study was considered to be phase III research, which corresponds to the controlled trial phase. The remaining studies were considered to be phase II research, which corresponds to the phase where magnitude of therapeutic effect is assessed. Results suggested that higher treatment intensity was favourable than lower treatment intensity of specific treatment technique(s) for treating childhood apraxia of speech and speech sound (phonological) disorders”
[Kaipa, R & Peterson A.M. (2016) A systematic review of treatment intensity in speech disorders. International Journal of Speech-language Pathology; 18(6)      ]


“There is evidence that speech therapy provided in frequent sessions multiple times per week can yield superior outcomes over traditional, less frequent service delivery (Allen, 2013; Namasivayam et al., 2015; Kaipa and Peterson, 2016), and some motor-based speech treatments are specifically designed with intensive schedules in mind (Ramig et al., 2001; Strand et al., 2006; Murray et al., 2014).”…..“Intensive therapy programs with visual feedback may be one option for increasing speech accuracy for some school-age children with CAS. All participants showed an increased ability to perform the desired speech movements for perceptually accurate productions during treatment, but this approach did not immediately result in generalized improvements to untrained items or to connected speech for all children.”
[Preston, J., Leece, M. & Maas, E. (2016). Intensive treatment with ultrasound visual-feedback for speech sound errors in childhood apraxia of speech. Fronteirs in Human Neuroscience   ]


“The primary purpose of the present study was to explore the effects of treatment intensity on outcome measures for children with CAS undergoing motor speech intervention. A secondary purpose was to assess the magnitude of change as a function of treatment intensity across outcome measures in this population.

Results indicate that both higher intensity groups (RND lists 1 and 2; tables 2 and 3) yielded significant results for changes in articulation (GFTA-2 standard score) and functional communication (FOCUS scores). However, lower intensity treatment (table 1) did not yield any statistically significant results. Importantly, there were no significant changes in speech intelligibility scores (for word or sentence level) across either treatment intensity. In general, higher intensity treatment produced large effect sizes for the articulation (GFTA-2 standard score) and functional communication variables (FOCUS scores) and moderate effect sizes for sentence-level speech intelligibility (BIT for higher intensity RND list 1; figure 3). On the other hand, lower intensity treatment yielded relatively smaller effect sizes than higher intensity treatment for articulation and functional communication, but for word-level speech intelligibility (CSIM) both lower and higher intensity (RND 1) treatments resulted in similar magnitude of effect sizes. For sentence-level speech intelligibility (BIT scores) only one higher intensity treatment group (RND 1) showed moderate effect sizes.

Children with CAS who received 2×/week (higher intensity) individual MSTP intervention for 10 weeks demonstrated significantly better outcomes for articulation and functional communication compared with those who received 1×/week (lower intensity) intervention.”
[Namasivayam, A., Pukonen, M., Goshulak, D., Hard, J., Rudzicz, F., Rietveld, T., Maassen, B., Kroll, R., & van Lieshout, P. (2015), 50(4);     ]


Intensive treatment delivery in impairment-based intervention appears crucial for obtaining positive treatment outcomes. These treatments provided therapy at least 2-3 times a week, with sessions of up to 60 min. The dose of treatment, defined as the “number of properly administrated teaching episodes during a single intervention session” (Warren et al., 2007, p. 71), should probably also be high (Edeal & Gildersleeve- Neumann, 2011). This review suggests that at least 60 trials per session represents a “high” dose. Williams (2012) suggested that, with phonological therapy for speech sound disorder, ≥50 trials per session over ≥30 sessions is effective, although dose and intensity need to increase as impairment severity increases.”
[Murray, E., McCabe, P., & Ballard, K. (2014). A systematic review of treatment outcomes with childhood apraxia of speech. American journal of speech-language pathology, 23(3), ]


While both children appeared to benefit from other aspects of their treatment, the data indicate that learning and maintenance of skills for both children was greater for speech targets treated with more intensity—that is, a higher frequency of production. The effect size for treatment condition was large for motor performance tasks in both children..Data show that the speech targets treated with the HiF condition led to higher in-session accuracy and greater generalization effects for both children than for speech targets treated with the lesser number of repetitions in the ModF condition. The treatment differences observed may be due to the greater intensity and pace of the HiF condition in which the subjects had more opportunity for practice of speech sounds and received more cues when needed. Not only did speech targets treated with a higher number of productions and a greater level of intensity show higher levels of accuracy overall during the course of the treatment, but high levels of accuracy were achieved in fewer sessions than targets treated with fewer productions. Speech targets treated with a high number of productions showed less variability, meaning accuracy did not vary from session to session as much as it did for targets treated with fewer productions. Speech targets treated with more productions generalized better to untrained words and showed more stability overall. Both children also demonstrated better retention of the targets treated with more productions during the posttreatment probes.”
[Edeal, D. & Gildersleeve-Neumann, C. (2011).  The importance of production frequency in therapy for childhood apraxia of speech. American Journal of Speech-Language Pathology; 20; 95 – 110.]


“How Many Treatment Sessions Are Required to Improve My Childs Speech?”
For the phonologically disordered children, an average of 29 individual, 45-minute treatment sessions (range of 21 to 42 sessions) were required for parents to increase their ratings from having less than half of their child’s speech understood by an unfamiliar listener to having about three-fourths of their child’s speech understood. In stark contrast, the eight children with apraxia speech whose parents stated that three-fourths of their child’s speech could be understood following treatment, required 151 individual treatment sessions (ranging from 144 to 168 sessions) to achieve a similar level of parental estimated speech intelligibility. In other words, the children with apraxia of speech required 81% more individual treatment sessions than the children with severe phonologic disorders in order to achieve a similar functional outcome.”
[Campbell, T. (1999). Functional treatment outcomes in young children with motor speech disorders. In Caruso, A. & Strand, E. (Eds.). Clinical management of motor speech disorders in children (p 394).  New York, NY: Thieme Medical Publishers Inc.]


Regardless of the primary deficit, children with severe speech impairment need intensive speech therapy early on. Young children benefit from frequent shorter sessions (e.g., up to four times/week for 30 minutes each session). These are preferable over longer, less frequent sessions. In general, children with phonologic delay progress more quickly than children with DAS. This means that the child with DAS will need these intensive services longer.”
[Skinder-Meredith, A. (2001). Differential diagnosis: developmental apraxia of speech and phonologic delay. Augmentative Communication News; 14 (2 & 3).]


Several decisions need to be made regarding the frequency, length, and the type of treatment sessions. Given that most researchers in motor learning agree that motor skill is acquired only through practice (Rose, 1997; Schmidt, 1988, 1991), sessions should be frequent and long enough to allow the practice that is needed. How those sessions are scheduled, however, is important. Magill (1998) suggested that for continuous skill a distributed practice schedule is preferable, whereas for discrete skill, mass practice is better. Fletcher (1992) discussed this concept with respect to speech and suggested that distributed practice will likely yield better speech motor performance and speech motor learning for this serial motor learning task. This brief review of the concept of mass versus distributed practice leads to the suggestion that for children with significant motor planning or programming problems, distributed practice will likely result in better motor learning. For example, if 2 hours of therapy per week are recommended, sessions should be scheduled four times per week for half hour, versus two times a week for an hour. Given that we know frequent repetitive practice is necessary to learn skilled movement, however, it seems logical to assume that individual treatment sessions go much further in offering the child the opportunity to practice the movement gestures with enough frequency for the motor learning to be retained.”
[Strand, A. & Skinder, A. (1999) Treatment of developmental apraxia of speech: integral stimulation methods (120-121). In Caruso, A. & Strand, E. (Eds.) Clinical management of motor speech disorders in children.  New York, NY: Thieme Medical Publishers Inc.]


To summarize, although there are differences in definitions of intensive remediation for children with CAS, there appears to be emerging consensus within the literature that therapy should be conducted at least three to five times weekly, in sessions lasting between 30 and 60 minutes each, and that the intervention should be conducted on an individual basis.”
[Hall, P. , Jordan, L. & Robin, D. (2007) Developmental apraxia of speech: theory and clinical practice, 2nd Edition. p. 200, Texas: Pro-ed Publishers.]


Intensive Services are Needed for the Child with DAS. Children with DAS are reported to make slow progress in the remediation of their speech problem. They seem to require a great deal of professional service, typically done on an individual basis. Therefore, clinicians working with DAS must accommodate this need and schedule as much intervention time with the child as the child and/or his/her circumstances can allow. Thus, the clinician may be thrust into the position of becoming an advocate on behalf of the child to assure that services are provided as frequently as possible. In some cases, the clinician may need to help the family find the financial resources or assistance thy may need to cover the costs of professional service; a child with DAS can quickly become an expensive child to his/her family or school system because of the amount of therapy they typically require.”

“The definition of intensive varies from clinician to clinician and from work setting to work setting. Rosenbek (1985), when discussing therapy with adult apraxics, defines the work as meaning that the patient and the clinician should have daily sessions; Macaluso-Haynes (1978), Haynes (1985), and Blakeley (1983) also advocate daily remediation sessions. Blakeley (a983, p.27) stated that I do not expect to provide speech education for children with developmental apraxia of speech on a cursory basis for it may be the most important part of their entire education.”
[Hall, P. , Jordan, L. & Robin, D. (1993) Developmental apraxia of speech: theory and clinical practice, p. 125, Texas: Pro-ed Publishers.]