Motor Speech Disorders in Pediatric Practice

Megan M. Hodge, PhD, R.SLP, CCC-SLPUniversity of AlbertaEdmonton, Canada

ASHA Conference, Chicago, ILNovember 22, 2008

Definitions/Assumptions/CharacteristicsDecision-making for diagnosis Implications for treatment

Childhood Motor Speech DisordersChild is learning to understand and use sound system of language but…

is constrained in ability to plan, sequence, and/or control movements of muscle groups used to generate speech due to neurological and/or neuromuscular impairment

Brain: Left Lateral View

Primary Motor Strip

Perisylvian Region

Supplementary Motor Area

Areas of nervous system important for speech production…

• Neurons in various regions of the brain cortex (includes upper motor neurons) and connections– e.g., perisylvian areas in frontal, temporal and parietal

lobes; insula; supplementary motor cortex • White Matter Connections:

– to each other– to and from the brainstem and spinal cord

• Neurons in subcortical structures and connections– Basal ganglia and functionally related structures– Thalamus– Cerebellum

Areas of nervous system important for speech production cont.

• Neurons in the brainstem and connections with body

– Send axons out to body (muscles in head and neck) Lower Motor Neurons

– Receive sensory information from the body

• Neurons in the spinal cord and connections with body– Send axons out to body (muscles of trunk and limbs)

Lower Motor Neurons

– Receive sensory information from the body

Childhood Motor Speech Disorders– Typically do not “grow out of” or are “cured” of physical

basis of speech disorder (underlying impairment)“chronic” condition

– Children with MSDs demonstrate neuroplasticity• Experiential learning (including well designed, principled

treatment) can improve communicative function!! • Need more opportunities for this (not fewer) than other

children!!!

Treatment can capitalize on neuroplasticity of child and child’s communication partners to improve communicative function

(speech plus)!

M. Hodge ASHA 2008

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Neuroplasticity!

Capacity of nervous system for change:

- applies across all levels of cognitive-neural system from neurochemistry to behavior

What causes the brain to change ?

This is a result of both:– internal (genetic) factors– external (experiential) factors

that lead to new learning.

Learning has been defined as:

“the ability to acquire new knowledge or skills through instruction or experience”

Factors

within child

Factors

outside of child

(activities, experiences, environment)

We know that children with MSDs do demonstrate neuroplasticity for speech

learning but….

• It takes them much longer and the level of speech skill they achieve is typically less than for other children.

It might be expected that children with deficits in neural resources for speech learning require considerably more repetition of trial and error experiences to establish neural circuitry for skilled motor behavior than children without these deficits.

Implications for children with severe speech delay and suspected MSD…

• Brain is not wired (yet?) to move child through these developmental stages – being in ambient language is not sufficient to stimulate speech development processes

• Extra, focused stimulation and consequent opportunities for task specific practice are needed to develop child’s neural connections to change speech sound input into actions of the speech mechanism to produce Cs, Vs, syllable shapes and syllable shape combinations of ambient language

Speech change involves both “upregulating”speech areas of brain and learning effective compensatory strategies

Recent studies of persons with brain injury provide behavioral evidence of:

• Experience-dependent, • Training-induced improvement

that corresponded with changes in synaptic connectivity in relevant areas of the brain cortex (Mateer & Kerns, 2000; Ogden, 2000 - see Hodge, 2006).

Implications from these studies about how to best capitalize on mechanisms of brain plasticity include:1) The importance of active attention to sensory input

from the environment. Active engagement matters

2) The importance of many opportunities for active learning that provide specific input back to areas of the brain where change is desired. Repetition and intensity matter; plasticity is experience specific

3) The importance of mediated opportunities for learning to occur in “lifelike” contexts and enriched environments. Salience matters

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If we are going to exploit the power of neuroplasticity…

• From an early age we need to alter these children’s environments

• Multiply their opportunities to engage in experiences that promote speech learning.

To make effective changes in these children’s speech behaviors need:

• Explicit, systematic, focused, frequent practice opportunities that encourage “talking” in general and that provide context and feedback on specific speech goals:

At an appropriate level for the child’s phonetic abilities and speech motor developmental level

In “enabling” (aka fun, enjoyable, motivating) learning contexts

Where child practices “speaking” to code meaning while engaging in communicative acts (social routines, behavior regulation, joint attention).

As the key component of these children’s environments…

• Parents need to provide abundant social interactions within the child’s daily routines, and,

• Within each, create multiple “mediated”opportunities (“multiple doses”) to: – obtain the child’s attention and,–“tempt” the child to produce “speech like” vocalizations,

- in fun and playful learning activities (build on those child already enjoys)

- within child’s phonetic capabilities

While the idea appears simple, it is not easy…

• It requires commitment, persistence and patience to incorporate these enriched learning opportunities into each day’s routine but…

• Parents can be very successful in learning how to adjust and adapt their behaviour (reflecting reorganization of their underlying neural circuitry!) to accomplish this with their child.

This is a particular challenge for young children with very limited vocalizations and

few spoken words.

• Following from the preceding information, a very important early goal for these children is to increase the number of times that they attempt speech or “speech like” behaviors in a day (frequency increases cortical representation),

before trying to focus on increasing the accuracy of these or adding new ones.

Speech-language pathologists have a key role in helping parents to understand

and maximize a child’s “brain plasticity” for learning speech

Factors

within child

Factors in environment

Factors related to task

Parents

SLP

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Key role for SLPs(Hodge, 2006 Apraxia-Kids Website)

• To guide and support parents in developing the necessary techniques, skills and confidence to:– foster the child’s communication development and,– maximize the child “speech learning” ecology through

education, active modeling and coaching of others

• This includes helping parents to:– select appropriate “speech” behaviors to focus on– set up and carry out specific opportunities to stimulate

the child to attempt these.

Neurological damage affecting speech motor control typically delays speech development,

as well causing a motor speech disorder (specific disturbances in learning speech motor skills and producing skilled speech motor behaviors)

Selected Speech “Behavioral” Accomplishments in First Year of Life (Kent, 1992)

Vocables, protowords, phonetically consistent forms; first word

10-12

Babbling takes on sentence-like intonation, takes on some phonetic characteristics of native language

8-10

“conversational turn-taking behavior”Multisyllable babble stage – rhythmic strings

6-8

Shared positive affect; triadic eye gaze

Expansion:Increase in “consonants’; increase in surpraglottal articulation

4-6

Cooing1-4

Phonation: crying, vegetative sounds <1

General Development

Production(*Perception Leads Production)

Age (mo)

Typical Early Phonological Acquisition 1- 3 Years

(Hodson, 2008)

• Canonical babbling and vocables (12 months)• Recognizable Words (by 18 months)

– CV words structures– Stops nasals, glides

• Communication with Words (by 2 years)– “syllableness”– VC and CVC (word final consonants)

• Velars and clusters (by age 3 years)– /s/ may be distorted but not omitted

Typical Early Phonological Acquisition 3 - 7 Years

(Hodson, 2008)3 – 5 Yr

• Syllable structures– Omissions rare by age 4

• Final consonants• Clusters

• Few simplifications– E.g., fronting, stopping

• Intelligibility > 90%

5 – 7 yr• Phonemic inventory

completed– Liquids (4-6 years)– “th” (by age 7)

• Phonetic distortions disappear– E.g., lisps

• Multisyllabicity• Adult-standard

Importance of models of speech to observe and imitate and child’s attention to these.

(Kent, 2004)

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Mirror Neurons

• A mirror neuron is a neuron that fires both when an animal acts and when the animal observes the same action performed by another (especially conspecific) animal.

• Thus, the neuron "mirrors" the behavior of another animal, as though the observer were itself acting.

• These neurons have been directly observed in primates, and are believed to exist in humans and in some birds.

• In humans, brain activity consistent with mirror neurons has been found in the premotor cortex and the inferior parietal cortex.

Guenther et al. (2004)

Speech Production Processes

Sensory(Auditory &

Visual)Perception

Cognitive-LinguisticLinguistic knowledge

Mental lexiconNon-linguistic

“World Knowledge”

Application of Phonological Rules

Phonological Planning/Memory of Stored Plans

Assembly of Speech Motor

Plans & Programs

Execution of Speech Motor

Programs

Speech Signal(Auditory & Visual)

Implementation of Speech

Motor Programs

Sensory Feedback

Speech Processes•Respiration•Phonation (voice)•Resonance•Articulation

- Actions of lips, jaw, tongue & soft palateto make consonants and vowels

- Spatial-temporal precision important•Prosody

Rate-RhythmStress patternsIntonationFluency

Sound Generation and Shaping“Creating sound and filtering it to produce consonant and

vowel sequences of the language”

Pressurized Air Stream

RADIATEDSPEECH SOUND WAVE

CONSTRICTION 'AND OCCLUSION NOISE SOURCEINPUT TO VOCAL TRACT

VOCAL TRACT RESONANCE OF

. VOICE AND NOISE SOURCE

~

GLOTTAL VOICE SOURCETO VOCAL TRACT

Source-Filter Model Of Speech Production Speaking“Movements made audible that carry

meaning coded in language”

Sound “Source”

Sound Filter

Speech

Language,coded in sound patterns, produced by sequencesof rapid, coordinated actions, of sets of muscle groups

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Reasons for impairment to speech neural control centers and pathways – some examples

Genetic AbnormalitiesHeritabilitySporadic

Cerebral Dysgenesise.g.,

Underdevelopment of perisylvian area of brainCompromised/delayed myelination of white matter tracts between cortical and subcortical regions

Fetal InfectionHypoxia/IschemiaNeonatal ComplicationsPost-natal Trauma/InfectionSeizures Tumours

Developmental Motor Speech Disorders

• Occur prior to or during primary period of speech development*Major implications for social and language development

• Child has limitations on neural resources for learning speech motor skills –– Positioning and timing of

muscle groups for sounds; sequencing sounds; rate-rhythm patterns can be affected

• Occur after primary period of speech development

• Child has to “relearn”how to talk with fewer neural processing resources and decreased control over actions used to produce the sound patterns of speech

Later Onset Motor Speech Disorders

Major Motor (Sensorimotor) Speech Disorder Diagnoses

Dysarthria

(subtypes)

Childhood Apraxia of Speech

(subtypes)

Mixed

Suspected Motor Speech Disorder?

?Motor Impairment?Topography of motor control impairment:

Speech mechanism aloneSpeech mechanism plus

Dysarthria

• Breakdown in execution of motor commands – “sending neural signals from brain out to

muscle groups to execute motor plans & programs”

“neuromuscular”

Dysarthria cont.• Abnormal neuromuscular function that disrupts

execution of movements

• Characterized by weakness, slowness, muscle tone abnormalities, reduced movement coordination and accuracy of muscle groups of the speech mechanism– Reduced accuracy and precision of

actions/valving of structures for consonant and vowels, and linking these together over time

• Adversely affects one or more of the speech processes of articulation, resonance, phonation, respiration and prosody

Dysarthria Subtypes– Spastic Dysarthria

• CNS (upper motor neurons and tracts to brainstem and/or spinal cord damaged)

– voluntary movements affected– Dyskinetic or Hyperkinetic Dysarthria

• CNS (basal ganglia and related structures damaged)- both voluntary & involuntary (e.g. athetosis) effects

– Ataxic Dysarthria• Cerebellar system damaged

– slowness, movement incoordination– Flaccid Dysarthria

• Lower motor neurons in brain stem and/or spinal cord and cranial and spinal nerves to muscle fibers affected

– Mixed Dysarthria• Combination of signs of more than one subtype

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Speech Characteristics that Children with Dysarthria May Exhibit

• Short breath groups (few words per breath)• Abnormal voice quality (strained; breathy) and

volume • Difficulty using contrastive stress (equal stress on all

words)• Slow rate of speech movements and speaking rate• Nasal resonance and nasal air emission• Imprecise vowels/consonants overall• Particular difficulty with sounds that require more

precise timing (speed) and accuracy – diphthongs, liquids, fricatives, affricates, consonant clusters

• Overall sense that it requires effort to talk

Dysarthria:Implications for Treatment

• Need to develop child’s physiologic reserve for source (respiratory-phonatory) and filter (soft palate, lips, tongue, jaw) aspects of speech production,

- in tandem with developing child’s phonological system and use of speech (utterances – words – sentences-discourse)

- as part of communication system

*** Changing strength and endurance of muscle groups alone will not develop the child’s speech skills

Need to learn what to do with muscle groups for speaking tasks – skill specific

Speech specific skills:

– Increase physiological drive and effort (increase performance envelop for speech subsystems)

• Breath support; vocal pitch and quality - can alter and sustain changes?

– e.g., LSVT approach

– Increase phonetic inventory and articulatory precision• Tongue!

– Constraint-induced movement therapy (bite block) – Feedback (EPG, Ultrasound)

– Eliminate sound omissions

– Design and implement effective management for velopharyngeal impairments

– Develop effective compensatory strategies • e.g., rate control

Strengthening Exercises• Strength can only be increased by overloading

muscle

• Strengthening exercises can be isometric of isotonic

• Strengthening exercises require repetition to be effective– Guidelines: 5-10 reps per set; 3 sets per session,

several times a day – should see effects in 2-3 weeks

• Specificity of muscle fiber recruitment for specific task and need for overload training decide that conditioning program is most effective when training tasks closely mimic but exaggerate task for which muscles are being conditioned.

Dysarthria:Implications for Treatment cont.

. Need to develop child’s physiologic reserve and other skills that use the affected muscle groups:

- chewing, swallowing- control of saliva- resting posture of lips, jaw, tongue

Alter rest position of lips, jaw and tongue and improve control of saliva – increase “attractiveness as a communication partner”

• Oromyofunctional therapy

Case Study: Dysarthria

• CA: 8 Years

• Neurological Diagnosis: Mixed athetoid quadriplegic cerebral palsy

• Speech Diagnosis: Severe congenital mixed dysarthria

• Highly motivated to speak at age 6 years

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Speech Mechanism

– All speech subsystems affected – Poor respiratory control for speech

• Short breath groups ( 2-3 words per breath)– Reduced inspiratory volumes– Variable air pressure – loudness variations

– Phonation initiated but variable loudness– Hypernasality – Articulators

• Open lips resting posture• Slow, tongue movements, not dissociated from jaw

Speech Characteristics

• Suprasegmental

– Short breath groups– Inconsistent syllable omission in multisyllabic

words and utterances, more frequently at end of words and end of breath groups

– Cluster reduction – only singletons produced

Speech Characteristics• Segmental

– Consonants:• Sounds in his repertoire

– p, b, f, v, m, w,”th”, “y”, k, g – Omitted inconsistently, especially in medial

and final word positions and as phonetic complexity and utterance length increased

– Decreased consonant precision as effort and motivation decreased

• Sounds not in repertoire– t, d, n, “ch”, “j”, all produced as velar stops – r, l, (produced as glides) w/r; “y”/l– s, z, “sh” all produced as interdental

fricatives

Speech Characteristics

• Segmental

– Vowels:• Stimulable for all vowels and diphthongs but

reduced vowel space in connected speech

Treatment Goals

• Overall– Increase Intelligibility/Communicative

Effectiveness

– Increase Desirability as a Communication Partner

Treatment Goals• Steps

• Consistent pre-utterance inspiration• Consistent use of consonants in phonetic

repertoire(all word positions in multi-syllabic utterances)

• Monitor change in trained and untrained phonemes

• Monitor effect of hypernasality on phoneme identity• Determine phonics, reading and spelling abilities;

incorporate print into treatment activities• Effective use of repairs strategies (letter board and

turn-talking)• Closed lips – rest posture decrease drooling

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Phonologic-Phonetic TrainingEstablish lingua-alveolar place (bite-block –and

tongue tip to alveolar ridge – nonspeech)Shape/develop emergent /l/ in word (CV) initial

position (low vowel context) Shape/develop /d/ - contrastive manner with /l/ (low

vowel context first)Shape/develop emergent /n/ in word initial position

(CV) contrastive with /l/ and /d/ (low vowel contexts first)

Shape /develop emergent /t/ in word initial position (contrastive with /l/d/n/) (low vowel context first)

“Fish game”(alveolar consonant targets)

“Titanic” theme to play with “Daddy”

• bow blow• dough toe no go so low

Key word practice:• Do you have___?• No• Go fish

Principles

• Build on existing capabilities

• Task- oriented model of treatment- Focus on accomplishing functional goals (acquisition of

speech specific skills) versus “normalizing movement patterns”

- Present with problem to solve (has to make minimal pair words distinct)

- has to use new behavior (alveolar placement) to accomplish task successfully “self-organization”

- Avoid negative practice• No error sounds in training words other than target

Results

• Lingua-alveolar place established across manner categories

• Overgeneralized – fronting of velars (temporary)

• With introduction of each new phoneme, training time decreased

• Spontaneous generalization to /l/ blends and alveolar stops for syllable initial affricates

Results

• Increased frequency of letter board use in sessions

• New sight reading vocabulary for training targets

• Speech breathing and inconsistent consonant deletion issues remain

• Resting lip posture – needs reminders– Showed had physiologic capability – issue of self-

regulation?

Lee Silverman Voice Treatment-Children with Cerebral Palsy

(Fox et al., 2006; 2008)• Issues

• Changes observed on tasks– Maximum phonation time above threshold loudness

– Pre-treatment 3 s Post-treatment 5.5 s

– Pitch range– Did not increase but ability to make octave

change consistently on tasks improved (reach low and hold; reach high and hold)

• Change in speech intelligibility

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LSVT Daily VariablesFirst 30 minutes:

• Maximum duration of sustained vowel production– “Sustain “ah” as loud and as long as possible”– 10 – 12 repetitions

• Maximum fundamental frequency range– “Start from “ah” at typical pitch and sing up scale as high as can

and hold for 2 -3 seconds”– “Start from “ah” at typical pitch and sing down scale as low as

can and hold for 2 -3 seconds”– 10 repetitions

• Maximum functional speech loudness– Client makes up 10 – 15 “everyday” phrases; says each 3 – 5

times at maximal phonatory effort (loudness)

LSVT Daily VariablesSecond 30 minutes:

• Hierarchical Speech Loudness Drills– All using increased phonatory effort

• words, phrases• sentences• paragraph reading• conversational speech

• Home Practice Assignment “Maintenance”

Childhood Apraxia

• Developmental disorder of mental functions of sequencing and coordinating complex, purposeful movements (International Classification of Function and Health, 2002)

• A disorder of “movement learning” (Crary, 1995)– Deviant movements that result can not be explained

by weakness, or cognitive or attention deficits“Motor learning disability”

• Affects various motor skills: (learned movements that are goal directed)

e.g., fine motor, gross motor, eye tracking, speech movements, nonspeech oral movements

Childhood Apraxia cont.• Difficulties abstracting information from sensory

input and transforming this to action patterns

• Difficulties in learning, storing (memory) and organizing movement patterns to achieve goals

• Support that a common mechanism underlies disruptions to limb, verbal and orofacial praxis in children with dyspraxia as evidenced by consistency in types of praxis errors across modalities (Dewey, 1995)

• Dyspraxia = Impairment or immaturity of the organization of movement: – associated with this there may be problems of

language, perception and thought (Portwood, 2000)

Childhood Apraxia of SpeechASHA Position Statement (2007)

www.apraxia-kids.org

• CAS exists as a distinct diagnostic type of neurogenic childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in absence of neuromuscular (weakness, abnormal reflexes) deficits

Childhood Apraxia of SpeechASHA Position Statement (2007)

www.apraxia-kids.org

• Core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody

“Speech motor learning - planning disability”

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Childhood Apraxia of SpeechASHA Position Statement (2007)

www.apraxia-kids.org

• Occurs in three distinct clinical contexts:– Associated with known neurological causes

• E.g., stroke, trauma, seizures, tumours

– Primary or secondary sign in complex neurobehavioral disorders (genetic, metabolic)

• E.g., Klinefelter’s syndrome (XXY), autism

– Unknown (idiopathic) cause

CAS Position Statement cont. - No “validated” list of diagnostic features- Some consensus that these features are

consistent with a deficit in planning and programming movements for speech:

• **Inconsistent errors on consonants and vowels on repeated productions of same syllables or words

• Lengthened and disrupted coarticulatory transitions between sounds and syllables

• Inappropriate prosody, especially for lexical or phrasal stress

CAS Position Statement cont. • Complex of behavioral features associated

with CAS places child at increased risk for

– Early and persistent problems in speech, expressive language and phonological foundations for literacy

– Possible need for augmentative and alternative communication approaches

CAS = symptom complex

CAS

Limited to impairments in:

- Planning programming space and time properties of movements for speech sound productions

or, includes impairments in:

- Representational level segmental and/or suprasegmental units in both input processing and production?

Childhood Apraxia of Speech (Idiopathic)

- Congenital origins not well understood; evidence that in some cases, there is a positive family history (Hurst et al, 1990); more males than females affected

- Often is no neurological diagnosis (idiopathic)

- Language comprehension better than expression with severe phonological delay as well as delays in grammar and syntax

Childhood Apraxia of Speech cont.

- Show early limited speech output, little reduplicated babbling, little variety in babbling, (limited inventory of vowel, consonant and word/syllables shapes) slow to chain syllables and words together (reduced ability to sequence sounds and syllables)– *Increased errors on longer sequences– *Groping postures or lack of willingness/ability

to imitate a model

- May show an oral apraxia

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Childhood Apraxia of Speech cont.

- *Altered suprasegmental characteristics including rate, pitch, loudness and nasality

• May appear in milder forms

- Periods of severe dysfluency have been reported

- Appear to have specific speech motor learning problem; slow progress with intensive treatment

“Childhood Apraxia of Speech”; “Developmental Apraxia of Speech”; "Developmental Verbal Dyspraxia cont.

- May show other "soft" neurological signs, with awkwardness and poor motor planning in other motor systems

• Lewis (2002) – “Profile of CAS” changes with development

Articulation problems may resolve somewhat while language and learning problems persist affecting literacy development as well - Other learning disabilities may emerge in school years

Neurological Impairment in CAS

• To date we do not have a unified picture of the underlying impairment in CAS.

• However, have consensus that CAS results from brain differences due to genetic or other factors that limit the child’s neural resources for speech sensorimotor learning (cerebral dysgenesis).

• These brain differences:

– Delay the onset of, and impair the learning processes by which children:

• Decode speech sounds and movements that they hear and see, and

• Encode these into movements of their articulators to make:

–sound patterns of their language (sounds and how sounds combine into syllables, words and phrases)

–rate and rhythm aspects of speech

Implications: CAS Speech Specific Treatment Focus

• Teach child to “program” (brain is source of programming activity and is where programs are stored, once they are learned), movements of their articulators to achieve accurate production of speech sounds

• Teach child to program articulators to sequence movements for speech sounds in words and maintain accuracy of these sounds in various word shapes in multisyllable utterances

• Need for careful planning and over learning (practice/repetition of target sounds (movements)– Cueing hierarchies– Careful selection of speech targets based on

knowledge of child’s inventory of sounds, syllable shapes, words

Treatment Approaches Specific to CAS

Cueing (Square, 1999)– Place– Manner– Sequencing (rebus, finger cues)

Visual (pictures, gestures)Handshape cuesMouthshape cuesLetter cues

Tactile - Kinesthetic

Touch Cue, PROMPT, Cued Speech, Lindamood cues etc.

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Strand, E., Stoeckel, R. & Baas, B (2006). Treatment of severe childhood apraxia of speech: A treatment efficacy study. Journal of Medical Speech-Language Pathology, 14(4), 297-307.

Dynamic temporal and tactile cuing (DTTC) (adaptation of Integral Stimulation

Direct Imitation (child watches and listens)

Simultaneous Production Delayed Imitation (1-3 s)- slow as needed;

emphasize placement and movement

Additional Cues Spontaneous Production- tactile-kinesthetic- e.g., PROMPT Variable Practice

Move beyond imitation to spontaneous production

Child must practice retrieving target (sound, word, word combo), planning the sounds and making them

Variable practice needed for retention!

Treatment Approaches Specific to CAS cont.

• Amount of repetition to learn

– Extensive practice opportunities that gradually increase load on child for retrieving and producing correct motor pattern for target utterance

– Practice opportunities must be engaging for child (challenge!)

Treatment Approaches Specific to CAS cont.• Need for small steps, start with easy words (early sounds,

simple syllable shapes)

– Child needs to experience success – start where child is and build on this

– Only 1 new motor speech challenge at a time• Old sounds in new syllable shapes• New sounds in old syllable shapes• Old syllables in new multisyllabic targets• Old words in new word combinations

Treatment Approaches Specific to CAS cont.

• Need for specific training on multisyllabic utterances from beginning of treatment

• Print – text support helps in developing phonological awareness, sequencing

• High probability that will require explicit intervention to develop phonological awareness abilities for reading and spelling skills

P: Summary of Speech Behaviors based on Pre-treatment Assessments and Parent Report

GrammaAuntieUncleKelly

Thank you

WantHurt (ow ok)PleaseLove

Me, I

Desired, but not in

spontaneous or imitative repertoire

muh muhbuh buh

woo woo woo

mpbh

ahowee

Bubbamama

Ba – ball (1x)Bye (1x)MaWow

Imitative

ai – ai (bye bye)oh oh

tnwdsm

(inconsistent)

aiuo

uh

bubjubs (bubbles)Nana

MommaDadaPoppa

Wawa (Laura)Numnum (food)

ai (eye), (hi)no

uht (hat, hot, bus)ontwoup

es (yes)whoa

owts (house)Mom

tshoes (shoes)juice

Spontaneous

VariedReduplicatedConsonantsVowels2+ syllables1 syllable

MULTI-SYLLABLE SEQUENCESSOUNDSWORDS

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Initial Ideas for Speech Goals Sounds vowels; consonants

“ah”, O, “E”, “ow” buh, yuh, luh, huh

Sound Sequences (same sound; different sounds)ah ah ah; O O O; E E E; O-E; E-O; yuhyuh

Words (V, CV, VC, CVCV, CVC)ba(ll) Bubba, Pea, Ma, “M”, Pa, doh, bow, Bobo, boat, Luhluh (Gramma)

Word Sequences (Combinations)

No ___; ____up;

Behaviors- Watch and listen- Turn-taking- Self-cueing

On average, children with SLI/SSD have poorer motor performance (gross and fine motor; speech diadochokinetic tasks) than unaffected children, so it is probable that a child with SSD has poorer motor performance than the “norm”(Hodge, 2004)

Important questions are:

- Does impairment in the child’s speech motor control system appear to be a significant contributor to child’s speech delay, reduced speech intelligibility and/or speech acceptability?

-If so, what is the nature of the impairment?

Motor execution pathways (CNS and/or PNS) (L&R)

Motor planning/programming centres & pathways –cortical/subcortical speech specific (Lang. dominant hemisphere)

Site of Lesion

DysarthriaCASParameter

CAS and Dysarthria

have been differentiated along several parameters

Motor control problem is present regardless of task or context

Seen in voluntary actions for speech tasks but not in automatic actions for same muscle groups

Impairment

DysarthriaCASParameter

-See weakness, slowness, poor coordination of speech muscles in speech movement

- Muscle tone abnormalities

- May see extraneous, involuntary movements

See problems in positioning speech articulators and sequencing movements for speech; deficit in temporal organization of muscle activity, but normal sensori-motor profilePre-articulatory oral gestures (groping)Post-articulatory repetitions and revisionsMetathetic/sequencing errors

ImpairmentDysarthriaCASParameter

Abnormalities

Difficulties due to weakness, slowness, abnormal reflexes, abnormal muscle tone

No abnormalities

No difficulties

Resting posture of lips, tongue, jaw; dental malocclusion

Automatic control over oral structures for familiar, often used movements

DysarthriaCASParameter

More specifically…

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Same difficulties as observed with automatic movements

Difficulties if have oral apraxia –inconsistent, pauses, put articulator in wrong position then may try and correct this

Volitional nonspeech novel movements/ sequences of movements of articulators (imitation)

DysarthriaCASParameter

Same difficulties as observed with automatic nonspeech movements

**Slow; similar performance on repetition of same syllable (e.g. puhpuhpuh) and repetition of alternating syllables (puhtuhkuh)

Inconsistent, pauses, put articulators in wrong position then may try and correct this (“articulatory groping”)

Slow; alternating syllable repetition task (puhtuhkuh) much more difficult that repetition of same syllable (e.g. puhpuhpuh)

Volitional verbal movements

Diadochokinetic Rate Tasks

DysarthriaCASParameter

Respiration, phonation, resonance, articulation, and prosody may be affected

Articulation and prosody(Excessive, equal stress (?+effort)Inappropriate timing (syllable segregation), altered resonance patterns may co-occur

Speech Process Affected

DysarthriaCASParameter

Difficulty if have reduced respiratory support and poor laryngeal valving

No difficulty, once understand task

Maximum sustained phonation tasks

DysarthriaCASParameter

Differential diagnosis is difficult at younger ages because...

• Have very limited sound repertoire and speech output

• Tasks that aid in differential diagnosis require cooperation, attention span, speech and cognitive behaviors beyond child’s present capabilities– e.g., DDK tasks, imitating oral movements,

syllables and syllable sequences

• Davis & Velleman (2000)• Gretz (2005)

Protocols to help determine if child has a motor component to speech delay/disorder…

Look at child’s ability to produce speech or speech-like movements:

in isolation (accuracy)in sequences (accuracy & speed)- same “slot” or “frame” repeated- changing “slots” across frames

Plus other signs of motor impairment in speech muscle groups and inferred from speech characteristics

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Verbal Motor ProductionAssessment for Children

(Hayden & Square, 1999)

Purpose

- Determine presence or absence of a motor disruption affecting speech production

- Identify nature of impairment- Identify best teaching modality- CA: 3 – 12 yr.- Compare performance to %ile ranks on 5 scales

VMPAC1. Global Motor Control

– vegetative function and oromotor integrity for tone, respiration, phonation, reflexes

2. Focal Oromotor Control– volitional oromotor control for non-speech and speech

tasks using mandible, labial-facial and lingual control for isolated and combined movements

3. Sequencing– sequences for non-speech and speech movement

VMPAC

4. Connected Speech and Language Control– assess motor precision in context of language

5. Speech Characteristics– evaluate pitch, resonance, vocal quality, loudness,

prosody, automatic versus self-formulated speech

Verbal Motor Production Assessment for Children (VMPAC)

(Hayden & Square, 1999)

• Imitative, delayed imitation, picture prompts/stimuli• Use of visual and tactile cues as well as auditory• Score based on level of prompt/cue and level of motor

proficiency• Obtain percentage for each area and plot on a graph

corresponding to age• Also get severity level based on percentage score• Need training to use• Must be videotaped

Mixed MSD:Characteristics of both motor planning and motor

execution (dysarthria) difficulties

Example:Worster-Drought Syndrome

“CEREBRAL PALSY OF THE SPEECH MECHANISM”(congenital suprabulbar paresis; “Perisylvian Tetraplegia”)

www.wdssg.ork.uk

Diagnostic ChallengeOften misdiagnosed as CASHas a major dysarthric componentMay also see speech motor planning difficulties

Core Features• Sub-type of cerebral palsy primarily affecting

muscles of the vocal tract (Clark et al., 2000)

• Spastic (plus athetoid sometimes) cerebral palsy affecting upper motor neuron pathways to brainstem

• Affects muscles receiving innervation from brainstem (lips, tongue, soft palate, pharynx, larynx)

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Core Features cont.• Difficulty with sucking, chewing/swallowing

• Drooling

• Other signs of oral-motor incoordination; exaggerated jaw stretch reflex

• Dysarthria

• Dental problems and middle ear infections associated with palsy of lip, tongue, velo-pharyngeal muscles

Core Features cont.

• Mild-moderate quadriplegia

• History of motor delay in walking and running

• Some degree of upper limb organizational problems or clumsiness

• Not progressive

Childhood Suprabulbar Paresis Subsidiary Features

• Cognitive impairment present an early language delay with global mild-moderate impairment later, sometimes with specific difficulties

• Behavioral Disorders (high rate of ADHD)

• Seizure Disorder

Childhood Suprabulbar Paresis cont.

Range of severity, but usually not so severe that child does not talk

Most common presentation is deviant pattern of motor dysfunction of “bulbar” muscles, out of proportion to other developmental problems

Complete vs. Incomplete Types (Crary, 1993)

• Complete: Involves lips, tongue, velopharynx and larynx so see lingual and labial speech errors, hypernasality, history of dysphagia, excessive drooling

• Incomplete: Speech error patterns depend on selective involvement of lips, tongue or velum. In incomplete form, frequency of speech muscle group involvement:

Incomplete "Types"Childhood Suprabulbar Palsy

Soft Palate Only

Soft Palate &TongueTongue & Lip

Soft Palate & Lip

Incomplete "Types"Childhood Suprabulbar Palsy

Soft Palate Only

Soft Palate &TongueTongue & Lip

Soft Palate & Lip

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David Hammer (see www.apraxia-kids.org)

Errors are generally consistent as length of words/phrases increases

Number of errors increases as length or word/phrase increases

Substitution, omission (final), distortion errors; vowel distortions not as common

Substitutions, omission (initial), additions, distortion, repetition errors; centralize vowels to “schwa”

Consistent errors that usually can be grouped into categories

Inconsistencies in articulation –same word may be pronounced several different ways

Severe Phonological Disorder

CAS vs.

Typically no disruption of rate, rhythm or stress

Rather, rhythm and stress of speech are disrupted; some “groping” for placement of articulators may be noted

Sometimes differences Receptive skills better than expressive skills

No difference in how easily speech is produced based on situation

Well-rehearsed “automatic”speech is easiest to produce; “on demand”speech most difficult

Severe Phonological Disorder

CAS

Effects of Childhood MSDsReduce:• Rate & quality of speech development• Frequency of speech use and of communicative

interactions• Intelligibility of speech• Rate at which speak (slow, less efficient)

• Overall “acceptability” of speech

*Child with severe speech delay is significant stressor on family, especially mothers

Goals of Treatment include:• Caregivers –

– Have the necessary techniques, skills and confidence to foster child’s communication development

– Can teach others to do the same via modeling and coaching

“Parents or other caregiversare key factors in treatment for these children; however, do not know how to help “naturally” and may not be suited for working 1-1 with their child”

• Child –

– Can produce self-generated, controlled, intelligible utterances (adapted from Hayden & Square, 1994)

– To participate in successful communicative interactions and achieve communicative goals

– With as few restrictions on conversational partners and contexts as possible

Secondary Effects of Childhood Motor Speech Disorders cont.

At risk for:Psychosocial development

Limitations imposed by MSD on social interactions

Literacy developmentFewer opportunities for language experiences

Oral-Pharyngeal Structural abnormalitiesDental malocclusion, resting posture of lip, jaw and tongue

Need to consider issues of communication and language development in treatment program…

Importance of AAC!!

Higher risk for co-occurring conditions resulting from brain damage or dysgenesis

• Limitations in higher cortical functions

– Cognition

– Language (comprehension and expression)

– Executive function

– Social communication

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Higher risk for:

Nonspeech motor dysfunction Feeding• Control of oral secretions• Other motor systems

– posture and ambulation (gross motor)– eye – hand (fine motor)– eye – reading

Sensory and perceptual impairments• Visual and auditory

Reduced Stamina

• Early differential diagnosis is complicated by limited speech output

• If no multiword utterances are produced, voice, resonance, fluency, prosody are difficult to assess

• As more speech is produced, additional impairments may be identified

• See considerable variability in childhood motor speech disorders: – Different subgroups exist with larger categories of

“dysarthria” and “childhood apraxia of speech”

• Children are evolving through neurological maturation while acquiring developmental skills“MSDs in childhood are dynamic – profile within a child changes over time”– Expression of impairment may not be obvious until

time that skill is typically acquired

• Need team approach to assessment and intervention– Parents as key collaborators

• ** First goal – ensure child has functional means of communication

• When planning intervention, think BIG picture: – speech + communication + pre-literacy skills

• When planning speech treatment, consider implications of child’s motor speech diagnosis for:– Goals, service delivery, treatment approaches– Outcomes

• When planning and implementing treatment, remember importance of role as “agent of neuroplasticity”

Communicative Effectiveness

• Teach effective use of interaction enhancement strategies.

• Model and promote use of effective conversational repair strategies and speech production self-monitoring skills

• Teach effective cognitive strategies so child can use word choice and syntactic structure to maximize listeners' comprehension.

• Promote maintenance of speech production skills that have been established and self-monitoring of communication skills; implement strategies to increase child’s self-confidence and self-esteem in initiating and participating in communication interactions.

General Considerations

• Educate family members, other caregivers and peers about child’s speech disorder and ways to communicate effectively with the child.

• Augment speech with developmentally appropriate alternative communication modes if child’s speech is not functional for communication needs

• Provide receptive and expressive language treatment (both spoken and written) as appropriate and integrate this with speech training activities when possible.

• Address related issues, including management of any interfering behaviors (e.g., attention, lack of motivation); andsensory (auditory-visual) status.

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References

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Crary, M. (1993). Developmental motor speech disorders. San Diego, CA: Singular Publishing Group. Davis, B. & Velleman, S. (2000). Differential diagnosis and treatment of developmental apraxia of

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