Assessment & Treatment of CAS in School-Aged Children

Assessment & Treatment of CAS in School‐Aged Children,” Presented by: Shelley Velleman, PhD, CCC‐SLP, October 7, 2015, Sponsored by CASANA

Assessment & Treatment of CAS in School-Aged Children

Shelley L. VellemanUniversity of Vermont

CASANA Webinar October 2015

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Disclosures & Acknowledgements

• CASANA Professional Advisory Board

• Author Cengage Publishers and Lippincott Williams & Wilkins (royalty payments)

• Research supported by NIH and Simons Foundation (as well as UMass and UVM)

• Very grateful to the above institutions, as well as to the many families, colleagues, and students who have contributed to this research and to my growth in this fascinating and rewarding profession.

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Overview of Presentation

• CAS most easily identified in young and severe children:

– motor speech symptoms obvious

– major impact on child's output

• With time and intensive, specialized speech-language intervention:

– motor speech symptoms more subtle

– linguistic and literacy symptoms of more concern

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Overview of Presentation

• Research into treatment inadequate, especially among older/milder children

• Certain principles either demonstrated empirically (in studies) and/or have clinical consensus among CAS specialists

• Purpose of presentation: review what we know/have reason to believe about status and treatment of CAS in school-aged population

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Overview of Presentation• Specific challenges in school-aged children

and how to address them

– Residual speech production errors

– Prosodic differences

– Grammatical errors

– Literacy difficulties

– Effective Communication & Advocacy

• Discussion/Q & A

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Overarching Purpose of Intervention

• Ultimate goal: communicative flexibility in all modalities

– New content

– New structure

– New context

– New combinations of above

• Includes listener awareness and strategies to help listener

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Residual Speech Production Errors

• Often sounds usually mastered later: /s/, /z/, /tʃ/, /dʒ/, /θ/, /ð/, /ʒ/, /ɹ/

• May also include /k/, /g/, /l/, /ʃ/

• Inconsistent nasality due to poor timing/ coordination of velum

• Vowel deviations

• Voicing errors

• Often inconsistent

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Residual Errors: Intervention

• Motoric strategies: explicit practice of challenging speech sequences, contexts

– Distributed, varied, random practice

– Knowledge of performance (communicative success)

– Decreased feedback to encourage self-monitoring

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Principle Acquisition Phase Retention Phase

Practice Distribution

Mass Distributed

Practice Variability Consistent context, prosody, pitch, rate

Varied context, prosody, pitch, rate

Practice Schedule Blocked, predictable

Random, unpredictable

Feedback Type Knowledge of performance

Knowledge of results

Feedback Timing & Frequency

Often, immediate Inconsistent,delayed

Rate Slowed but natural Normal, varied

Principles of Motor Learning *** Adapted from Stoeckel, 2013 9

Residual Errors: Intervention

• Practice articulatory gesture patterns (e.g., alveolar-velar; fricative-stop) if needed*

• Phonological knowledge: don’t assume child knows phonemic role of sounds

• Distinctness vs. precise accuracy

• Listener cues if needed

*Moving Across Syllables or Blue Whale 10


Videos: Set 1

• Age 11 HAPP Liquids

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Videos: Set 1

• Velars-Seq-Vowels

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Videos: Set 1

• 15-year-old VMPAC nasality

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Videos: Set 1

• 15 YO girl fronting

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Prosody Challenges

• Excess equal stress

– Sometimes (partially) therapy-induced (iatrogenic)

• Slow, choppy speech

• Pauses in inappropriate places make appropriate pauses less usefullinguistically

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Prosody Intervention

• Stress Patterns

– Word stress: differentiate stress on different syllables

– Compound word versus phrase stress

– Sentence stress: emphasize key words

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Word Stress

dino saur

kan garoo

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Prosody Intervention• Use backward build-ups to practice challenging

words, phrases, sentencesor

AtorgerAtor

FRIgerAtorreFRIgerAtor

• Natural coarticulation & prosody • Rehearse each part until smooth before

going on to next part18


Prosody Intervention– Phrase Stress: match phrase vs.

compound word with meaning

Which one is a:

[ˌhɑʔ|ˈdɔg]?

[ˈhɑʔˌdɔg]?

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Prosody Intervention– Sentence stress: contrastive stress

No, spaghetti and MEATballs.http://noahpinionblog.blogspot.com/2012/08/flinging-spaghetti-at-inequality.htmlhttp://en.wikipedia.org/wiki/File:Baseball_%28crop%29.jpg 20



• Backward build-ups for sentences

HOMEwork

my HOMEwork

ate my HOMEwork

DOG ate my HOMEwork

That DOG ate my HOMEwork.

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Prosody Intervention– Sentence Stress: wh-questions

Who eats cheese? Mary eats cheese.What does Mary eat? Mary eats cheese.What does Mary do to cheese? Mary eats cheese.Where does Mary eat cheese? Mary eats cheese in the kitchen.

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23Fokes, J. (1976). Fokes Sentence Builder. Boston, MA: Teaching Resources Corporation.

Fokes-Like Apps• Sentence Builder • Rainbow Sentences(both by Mobile Education Store LLC)• Clicker Sentences (Crick Software)• Sentence Key: WHO is DOing WHAT

(Computerade Products)All available at: https://itunes.apple.com/us/appSee also:http://www.thespeechknob.com/2013/10/fokes-sentence-builder-like-ipad-apps.html

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• Pauses at phrase and clause boundaries

The clown (breathe) with the red nose (breathe)juggled 6 balls (breathe) with his feet.

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Prosody Intervention• Carry over these skills to:

– Reading aloud (mark words/pauses/etc.)

– Controlled conversation (e.g., in therapy)

– Repairs

– Real conversation

• Explicitly train generalization in different contexts (social, linguistic, etc.)

• Review to maintain progress

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Videos Set 2

• 7yrold_VMPACstory_EES

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Videos Set 2

• 15 Yr Old Multisyll EES to Music

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Videos Set 2

• BBU_MSW

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Videos Set 2

• 15 Yr Old Girl Sentence Stress

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Semantic & Grammatical Challenges

• Morphology:

– English suffixes - final consonant clusters

– Multisyllabic words - challenging stress patterns

• Sentence formulation

– Word order

– Marking morphology in the right place

– Subject verb agreement31

Grammatical Intervention

• Ease of production order for morphemes:– extra syllable e.g., "ing"; "children"

– added syllable e.g., "horses", "patted", "Joyce’s"

– significant vowel changes e.g., "mice"; "sang"

– vowel-final e.g., "shoes", "chewed", "Moe’s”

– clusters, in order of difficulty

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• Irregular nouns and verbs fall into groups; teach together

Ex: diphthong/tense vowel in present tense lax vowel in past tense

Hide/hid, slide/slid, feed/fed, lead/led

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Semantic & Grammatical Intervention

• Morphology predicts: stress patterns, vowels, consonants. Examples: “-ity”, “ial”, “Ation”

[ˈsinɑɪl] [səˈnɪləɾi] SEnile seNIlity

[əˈlɛktɹɪk] [ˌilɛkˈtɹɪsəɾi]

eLECtric ElecTRIcity

[ˈkɑlɪdʒ] [kəˈlidʒəl] COllege colLEgial

[kənˈdɛm] [ˌkɑndəˈmeɪʃən]

conDEMN CONdemNAtion34



• Stress differentiates verbs (iambic) from nouns & adjectives (trochaic):

• preSENT vs. PREsent

• perMIT vs. PERmit

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• Use Fokes Sentence Builder (or the like) and backward build-ups to systematically practice sentence formulationwith appropriate:– Lexical and phrasal stress– Sentence stress– Pausing– (Intonation)

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Videos Set 3

• 8yrold_Morph

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Videos Set 3

• 11 Yr Old Formulating Difficulty

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Literacy Challenges

• Phoneme-grapheme correspondence: w/o good grasp of what phonemes are and how to pronounce them

• Phonological memory & awareness

– Elision

– Blending

– Other mental manipulation of sounds

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Literacy Challenges

• Encoding (spelling)

• Decoding (reading)

– Spelling/decoding of familiar words: automaticity (may be fine)

– Spelling/decoding of unfamiliar or nonsense words: flexibility; challenging

• Reading comprehension and narrative

– Part-whole

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Literacy Therapy

Be aware of task requirements:• Phonetic (auditory) processing (listening,

discriminating)

• Letter-sound correspondence (reading, spelling)

• Motor speech planning (speaking)

• Visual recognition of letters (usually okay)

• Phonological awareness

• Phonological memory/mental manipulation

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Literacy Therapy

Be aware of task requirements:

Example: Rhyming• Point to word that rhymes with “cat”.

• Do “cat” and “tack” rhyme?

• Do these two written words rhyme?

• Say a word that rhymes with “cat”.

• Say “cat” in Pig Latin

• Say “cat” backwardsStackhouse & Wells (2000)

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Literacy Intervention

• Post et al. (1999):

– Vowel errors in reading reflect poor

vowel underlying representations

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Literacy Intervention• Articulation & phonological awareness together

more efficient intervention (Moriarity & Gillon,

2006)

Hypothesized reasons:

– More grounded phonological representations

upon which to build phonological awareness

– Multi-modal representations better

phonological memory

• Speech-print connections (e.g., LiPS)44


Lindamood LiPS Program45

Literacy Intervention

• Reading and spelling

Key symptom of CAS is difficulty merging units into larger wholes

• Sound-by-sound decoding – as in phonics, Association Method – exacerbates this problem

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Literacy Intervention• Word families

– English spelling is not phonetic BUT there are patterns (e.g., “-tion”, “aught”)

– Teach patterns: “rhymes”/“word families”

“an” spells [æn]

“p” + “an” = [pæn] “t” + “an” = [tæn]

“m” + “an” = [mæn] “c” + “an” = [kæn] Example: Wilson Method, Benchmark

– Actually better for English spelling patterns

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Word Families Apps

• ABC Phonics Word Family (Free)

http://appcrawlr.com/ios/abc-phonics-word-family-free

• Ace Writer - Word Family HD (Free Lite)

http://appcrawlr.com/ipad/ace-writer-word-family-hd-free-

• WordFamilies ($1.99)

http://appcrawlr.com/ios/wordfamilies

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Decoding Multisyllabic Words

• Combine with learning higher-level morphemes (Latin, Greek):

– Stress patterns (see above)

– Meanings

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Literacy Therapy

• Story grammar: Integration of story components in reading and writing – Visual/tactile cues (e.g., Story Grammar

Marker; Moreau & Fidrych-Puzzo, 1994)

• Organization of other written texts– Comprehension and production

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StoryGrammarMarker

character

setting

initiating event

internal response

attempt

attempt

attempt

attempt

attempt

resolution

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Videos Set 4

• 15 year old blending words

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Videos Set 4

• Lindamood

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Communication!• Age-appropriate• Listener awareness

– Attend to listener reactions– Repair (including rate)– Highlight meaning

• Cue topic• Stress/articulate unusual, new, key words

(prosody)

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Communication!• Listener awareness

– Cue grammar • Pauses (prosody)• Redundancy (e.g., “two days ago” as well

as past tense)– Cue sounds if needed

• Motivation– Tie performance to grades– Content academics- and/or peer-related– Set own goals

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Communication!• Self-advocacy

– Ability & willingness to educate others– Awareness of own challenges and needs– Ability & willingness to self-identify and ask

for needs

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Videos Set 5

• Younger girl slow rate

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Videos Set 5

• 15 year old girl repair

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Videos Set 5

• Kate

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Questions?🙋

Thank you!!�

[email protected]

References• Blue Whale (ND). Speech therapy for apraxia: NACD Home

Speech Therapist. Retrieved from https://itunes.apple.com/us/app/speech-therapy-for-apraxia/id512647583?mt=8

• Fokes, J. (1976). Fokes sentence builder. Boston, MA: Teaching Resources Corporation.

• Kirkpatrick, J., Stohr, P., & Kimbrough, D. (1990). Moving Across Syllables and Test of Syllable Sequencing Skills. Tucson, AZ: Communication Skill Builders. (packaged together)

• Lewis, B. A., Freebairn, L. A., Hansen, A. J., Iyengar, S. K., & Taylor, H. G. (2004). School-age follow-up of children with Childhood Apraxia of Speech. Language, Speech, and Hearing Services in the Schools, 35(2), 122-140.

• Lewis, B. A., Avrich, A. A., Freebairn, L. A., Hansen, A. J., Sucheston, L. E., Kuo, I., . . . Stein, C. M. (2011). Literacy outcomes of children with early childhood speech sound disorders: Impact of endophenotypes. Journal of Speech, Language, and Hearing Research, 54, 1628-1643.

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References• Lindamood, P., & Lindamood, P. (1998). Lindamood®

Phoneme Sequencing Program for Reading, Spelling, and Speech (3rd ed.). San Luis Obispo, CA: Gander Educational Publishing.

• Moreau, M. R., & Fidrych-Puzzo, H. (1994). How to use the Story Grammar Marker. Easthampton, MA: Discourse Skills Productions.

• Moriarty, B. C., & Gillon, G. T. (2006). Phonological awareness intervention for children with childhood apraxia of speech. International Journal of Language and Communication Disorders, 41(6), 713-734.

• Post, Y. V., Swank, P. R., Hiscock, M., & Fowler, A. E. (1999). Identification of vowel sounds by skilled and less skilled readers and the relation with vowel spelling. Annals of Dyslexia, 49, 161-194.

• Stackhouse, J., & Wells, B. (Eds.). (2000). Children's speech and literacy difficulties: Identification and intervention: Book II. London: Whurr.

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Assessment & Treatment of CAS in School-Aged Children