Programming for Motor Disorders of Speech (A Neurogenic Base)
Motor disorders of speech can vary widely in type or quality. Type and severity of the disorder are related primarily to the location and extent of the nervous system damage. Children with motor speech disorders may have problems with the production of specific sounds, sounds in sound sequences, and at a higher level, simple sentences. In a speech disorder voluntary speech production is affected; consequently, the planning, coordination and timed execution of the movement patterns of speech are impaired. In order to produce normal speech, various levels of the motor system must be controlled. Nerve impulses coming from the brain are transmitted along the pathways of the nervous system to the muscles and structures of the speech system. The muscles of the lungs, vocal folds, velum, tongue, lip, and jaw create flows and air pressure which we perceive as speech. Disruptions in these areas affect muscle strength, muscle tone, and timing. Motor impairment is the underlying speech disturbance for both Developmental Dysarthria and Childhood Apraxia of Speech.
Childhood Apraxia of Speech (CAS)
Apraxia is a term that is frequently used too broadly to describe children with severe speech production difficulties. It is an area that still requires further research and is not fully understood. “In its purest form, DAS is an exclusionary disorder”. “Diagnosis by exclusion implies that a conclusion about the disorder is reached by excluding other known conditions.” To clearly identify CAS one must exclude sensory disorders, cognitive disorders, receptive language disorders, emotional and/or pragmatic language disorders, deviations of muscle tone and imbalance, and global neurological involvement. “Developmental Apraxia of Speech is a disorder of the ability to translate phonemic and linguistic codes to differing planes of movement over time.” The problem is primarily with the organization of movements in time and space. The child has difficulty with the organization of muscle movements specifically for the production of speech. However, muscle tone which affects strength and range of the articulators (i.e. speech muscles) is normal. Sounds may be produced correctly in isolation but as the sequence of sounds grows, the organization of muscle movements becomes more difficult and intelligibility decreases. The problem seems to exist between the transition of movements. The more complex the transitions, the more difficulty the child is likely to have. Frequently, children who are diagnosed with CAS may have both a mild motor control and a sequencing problem.
Developmental Dysarthria is a disorder of muscle tone, strength or imbalance. Specific muscles or muscle groups may be too weak or too tight. It is caused by a neurological impairment which directly affects oral movement and speech production skills. “Control of these muscles or muscle groups is also disordered. Muscles used for speech which have a hypo (too little) or hyper (too much) tonicity will result in decreased strength and/or range of movement of the articulators. When one or more of these affected muscle groups are required to interact for speech production, the cumulative result may produce disorders of articulation, phonation, rate, and rhythm. If muscle groups lack control, movement of the speech support systems and articulators, such as the tongue, lips, or jaw may not move towards or finish at the correct target position for a specific sound or sound sequence. The final result is distorted, substituted or omitted sounds.” This disorder may coexist with other developmental delays or disorders (i.e. cognitive or phonological) and if severe, may drastically limit speech potential.
PROMPT© Overview, Prompts for Restructuring Oral Muscular Phonetic Targets
PROMPT© (a dynamic, tactile-kinesthetic system) is probably best known as a technique used in restructuring the speech production output of children and adults with a variety of speech disorders e.g. phonological, dysarthria, dyspraxia, and hearing impaired. However, it would be most accurate to describe PROMPT© as a philosophy of treatment that strives to (re)connect and integrate the motor, cognitive-linguistic and social-emotional aspects of communication. PROMPT© may be described as a system of treatment that helps clients gain voluntary control of motor-speech systems and links the necessary motor movements to linguistic (word, phrase) equivalents for use in functional communication.
PROMPT© is a system of assessment, an approach to treatment planning and goal setting and a set of specific techniques for guiding the speech musculature in the production of sounds, words and phrases. At all levels programming is functional and interaction based. The major objective is to provide input, for each client, in such a way as to maximize the potential of the neuro-motor system. For each client this will differ. However, functional communication is always the primary indicator of treatment success.
What is the PROMPT© System?
The PROMPT© System stands for “Prompts for Restructuring Oral Muscular Phonetic Targets”. It is a dynamic tactile method of treatment for motor speech disorders which is based on touch pressure, kinesthetic and proprioceptive cues. It helps to reshape individual and connected articulatory phonemes and sequences (coarticulation). The clinician helps to manually guide articulators to produce specific sounds or words that seem to be problematic. This is a hands-on approach and thus the clinician uses his/her hands to cue and stimulate articulatory movement, at the same time helping the child to limit unnecessary movements. “The PROMPT© System imposes control on the articulators by providing tactile and kinesthetic (closed-loop) feedback, while guiding the structures toward sequential feed-forward (open-loop) programming.” Generally, this reduces inappropriate feedback and shows the correct sequence of movements to achieve “normal” articulation.
Where are prompts applied?
Prompts are designed to help a child get a feel for the movement, the muscles required, the manner of production, and the combining of movements to form words and phrases. Each English phoneme has a different “end product” prompt. Prompts are applied externally by manipulating the muscles of the face, the mylohyoid muscle under the chin, and structures that are associated with voicing (the lungs and the larynx), nasality (the nose), and jaw opening (the mandible of the jaw). Prompts provide input for a number of parameters such as spatial targeting for place and manner, degree of mandible excursion, protrusion or retraction of facial muscles, number of speech muscles needed to contract, and relative durations of the segment and syllable. Because of the number of parameter combinations for each English phoneme, it would be too difficult and lengthy to analyze each one here. The PROMPT© System helps to change client awareness at the self-monitoring and self-correction levels. The prompts used are only cues and programming aspects of motor control whose ultimate goal involves carry-over, or generalization which must be realized and carried out by the child. The system has been used to treat a number of disorders including phonological, developmentally delayed, dysarthric, apraxic, fluency, and hearing impaired. Children and adults have been treated both individually and in group sessions. A total therapeutic program should not solely use the PROMPT© System alone, but should also incorporate different elements like sub-step learning, positive reinforcement, appropriate pragmatic and language goals, and so on. The system is used as a tool for augmentation while collaborating with these approaches.
Questions and Answers about PROMPT
The following questions were those asked in an interview with Deborah Hayden, Founder and Executive Director of the PROMPT Institute, with offices in Santa Fe, New Mexico and Toronto, Canada.
Q. Could you briefly explain what the PROMPT© System is, its basis, and its development?
A. The PROMPT© is a philosophy, a system, an approach and a technique. What most clinicians, teachers and parents see is the technique of prompting, the application of the tactile-kinesthetic cues. However, the entire philosophy and approach that PROMPT© embodies is what guides the selection of those cues and gives the therapist a way to both evaluate and decide on what goals are appropriate. The clinician must always choose goals that will help the client achieve functional language and intelligible speech so that social, emotional and academic interactions with the world are possible. PROMPT© has evolved over time. It began as a way to help children and adults use tactile-kinesthetic information to help guide their articulators and produce more appropriate and intelligible speech; now it is much more and involves not only speech but a bridge to language and interaction.
Q. In what ways does the PROMPT© System help to treat children who are apraxic and/or dysarthric?
A. You have just asked two questions. First, how the system is used with developmental dysarthria and second, how it is used with developmental apraxia. These disorders, although they may overlap in many children must be analyzed separately and then a decision made as to what parameters of movement will be targeted first. For example, a child with developmental apraxia will most likely need more integration and sequencing of motor movements than will a child with a pure dysarthria. Using the PROMPT© the clinician will assess all areas of speech support, evaluate the child’s use of individual articulators and the ability of the child to integrate the movement of these articulators for smooth control and transition. The clinician will also take into consideration the age of the child, the cognitive level of the child, the communication style of the child and the general behavior of the child. Once all of these areas have been assessed the clinician will decide where to place the primary focus of the intervention. Although the clinician may use various parts and complexities of the PROMPT© technique with both groups, it will vary from child to child. A child with developmental dysarthria will need more help at each level of the system (parameters of breath support, jaw, facial musculature and lingual control) to guide the various articulators through smooth movement while keeping the relationship of all the articulators together. The clinician using prompts with this type of child will need to focus much more on the development of all movements necessary for each sound and then begin to put the movement (sounds) together to help the child form short words . The child with developmental apraxia, however, will need more help in organizing and sequencing the movements but should not need help to control the various muscle groups through the movements. With this type of problem, the clinician using prompts will need to do much less controlling and should be able to focus on whole words or phrases.
Q. A trained Speech-Language Pathologist can use the PROMPT© System to administer therapy, but what might you suggest a parent or parents do in order to continue therapy at home?
A. Parents are as critical to the success of PROMPT© treatment as is the clinician-child relationship or the technique of PROMPTing itself. Parents are not encouraged to prompt their child and most do not feel comfortable doing so. They realize that the clinician has had years of experience and also realize that PROMPTing incorrectly may cause their child more frustration. However, they do want to help and be part of the therapy process. This is encouraged and reinforced by supporting the nature of communication between a parent and child. Parenting and loving a child, sharing experiences and talking about daily events, is what good communication is about. Clinicians trained in PROMPT© encourage parents to ask about what the child did in the session, show them the crafts they made, the words they worked on, read the stories that were used to elicit sounds or words, play games that include well rehearsed words or phrases and finally, use the words or phrases the child has learned in other fun and natural environments. Good communication between the parent/caregiver and the clinician is also essential and should be part of every session. Parents are encouraged to observe sessions (behind a one-way mirror) as often as possible. When parents/caregivers observe in this way it provides a basis for discussion of the child’s successes, difficulties and activities that promote the best speech and language opportunities.
Q. How effective is the PROMPT© System and what are the prognosis and outlook into the future using this approach?
A. There are many ways to answer this question. The first may be to address how subjectively clients feel about the changes in their speech and language. The second way might be to address specific treatment studies that have objectively assessed changes in clients behavior and the third might be how easily the approach can be learned by clinicians who will carry out the treatment. I will try to answer all three of these questions.
First, when clients are treated by a skilled PROMPT© therapist, the changes will reflect the maximum potential possible for that client. With each person, depending on their motor system’s potential, environment, etc., they will gain more functional use of their speech. Some clients have gone from almost no speech to almost normal communication ability; others have only been able to achieve simple words or phrases. Each client has felt proud of their accomplishments and has been enabled in their broader communication environments. Their sense of self has always increased as has their awareness of “what is possible” versus ” what may not be possible”. The PROMPT© is no panacea; it is simply a deep understanding of how human motor, cognitive, social and language systems work within a human being and the ability of the clinician to translate that understanding to the client.
Second, research studies of PROMPT© efficacy in adults have shown excellent results with the addition of tactile-kinesthetic information. Formal studies are currently being conducted that will help us assess the benefit to children, using a group approach, with the addition of this input and framework.
Third, clinician skill and knowledge is the most critical part of treatment success. It is a systematic and lengthy process to train a PROMPT© clinician. Like any skill it takes practice and time to acquire, as well as a love for the continual integration of information into good therapy practices. To become a highly skilled PROMPT© clinician takes a minimum of one year and can take as much as four years. My hope is that PROMPT© will endure through good clinicians who will continue the clinical research, training and treatment necessary to help clients with speech production disorders.