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What is the definition of childhood apraxia of speech?
CAS is a neurological childhood speech sound disorder in with the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g. abnormal reflexes, abnormal tone)
What is the core impairment with CAS
The core impairment is in planning and/or programming spatio-temporal parameters of movement sequences, resulting in errors in speech sound production and prosody (sing-song intonations that go with speech)
We have ___ prosody when we talk to our peers then to kids
Describe CAS and the comorbidity with other disorders?
The complex of behavioral features reportedly associated with cas places a child at increased risk for early and persistent problems in speech, expressive language, and the phonological foundations for literacy, and the possible need for augmentative and alternative communication.
Children with CAS have a hard time _____ and they are at higher risk for not learning to ____.
CAS is a label for ______ which can _____
- Speech disorder
- change over time
CAS is ____ and it _____ as a result of _____
- changes over time
- neural maturation or as a result of treatment
CAS many times evolves into _______these disorders ________
- a speech sound disorder
- occur and overlap
Basically as a child's characteristics change ...
The most appropriate label to describe that child changes too.
Children with CAS are a subset of
Children with speech sound disorder
What is Apraxia
Problem with movement sequences related to sounds. Focus is on the movement
WHile many children also have linguistic deficts, (________) the term apraxia relates to _____
- phonological, semantic, syntactic
- their movement difficulties ONLY
Describe the model of disorders within the mild motor issues
CAS, Dysarthria and phonological all overlap and exist in speech sound disorders
Does CAS = Dysarthria?
NO they can overlap but they are not the same thing.
It is a motor speech disorder. The muscles of the mouth, face, and respiratory system may become weak, move slowly, or not move easily.
What is dysarthria often characterized by?
What is the cause of dysarthria?
nervous system (neurological) disorders such as stroke, brain injury, brain tumors, and other conditions that cause facial paralysis or tongue or throat muscle weakness. Can be caused by medications
What are the 12 speech characteristics of CAS?
- 1. Difficulty with achieing initial articulatory configuration
- 2. Difficulty moving from one articulatory configuration to another
- 3. Groping and or trial and error behavior (trying to move in the way you want)
- 4. Presence of vowel distortions (neutral)
- 5. Limited consonant and vowel repertoire
- 6. Use of simple syllable shapes
- 7.Frequent omissions of sounds
- 8. Increased errors with increased word length and phonetic complexity
- 9. Difficulty completing a movement gesture for a phoneme easily produced in a simple context, but not in a longer one.
- 10. Connected speech poorer than isolated word production
- 11. Altered suprasegmentals (lexical and sentential stress as well as overall prosodic contours) what conveys question, exlamation or period.
- 12. Altered timing between sounds and syllables
- 13. inconsistent error patterns.
What are the red flags characteristics for toddlers?
- 1. Quiet baby: did not play with sounds or babble much.
- 2. When babbling occured, it was undifferentiated (included few or no consonate sound)
- 3. little attempt to imitate sounds or words
- 4. resists attempts of adults/others to get him to imitate sounds/words
- 5. Limited vocabulary for age level
- 6. Poor intelligibility
- 7. Attempts to communicate through gestures, vowel sounds or other means
- 8. Demonstrates frustration at not being understood but seems to understand at an age-expected level
What are red flags characteristics preschool and older
- Voicing errors
- Difficulties with sound sequencing (Metathetic errors, transposition of sounds/syllables and difficulty with a particular sequence of sounds even when the individual sounds are correct in isolation or CV combinations)
- Resources may be allocated to planning articulatory movement and thus not available for planning appropriate prosody.
- Children have been taught to speak 'syllable by syllable' to say multisyllabic utterances correctly
- Errors increase with increasing length of work or utterance -Easier in one word than conversation
- Supported repetition (drill work) elicits better articulatory performance than the spontaneous production
- Errors are inconsistent across trials
- Articulatory accuracy improves when rate is decreased.
What markers are essential to (although not exclusive to) the phenotype of CAS?
- Difficulty achieving and maintaining articulatory configurations
- Presence of vowel distortions
- Altered suprasegmentals
- Inconsistent error patterns
What are often present but not desciminative between CAS and phonological impairment
- Limited consonant and vowel repertoire
- Use of simple syllable shapes
- Frequent omission of sounds
- prosodic errors
What may be discriminative?
- Difficulty moving from one articulatory configuration to another
- Groping and/or trial and error behavior
- Presence of vowel distortions
- Prosodic errors
Are vowel distortions different than a limited vowel repertoire?
Describe the oral motore evaluation
- Structural Functional Evaluation
- Check for strength (jaw, lips, tongue) to rule out or identify possible dysarthria
- Velar elevation (timing related issues may be CAS, strength related issues may be dysarthria)
Note- none speech tongue movements may be helpful in evaluting__________ but not _____
feeding and swallowing but not CAS
What five activities do you use for oral non-verbal apraxia
- Smack Lips
- Sequential imitative movement
Describe motor speech elicitation
- Vowels (collect in phonetic inventory, also elicit variety of vowels)
- Elicit CVVCCVC productions (same C and V and then alternating differeent C1V1C2V2) etc. ahrd time with configuration and movement
- Monosyllabic, bisyllabic, polysyllabic
- Vary temporal aspects of presentations for more specific information (slow it down and pull it down)
Describe Strand's perspective
- Focus on treatment of movements (not the sound)
- Facilitate movement so that it can be completed with less effort
- Gradual prompting (fading) (work on movements: big-little, tight-loose- fast-slow)
- Initial configuration transition to second configuration (b and oy --> b-oy)
What is motor learning
A set of strategies associated with practice and experiences leading to relatively permanent changes in the capacity for movement
What is prepractice?
Instructions and modeling state why we are practicing
Specific, repetitive, speech motor practice:
Repetitions help support the neural and behavioral changes necessary for improvement
Should you use speech or non speech stimuli
Which is better, mass practice or distributed practice
MASS ( 50 trials in one sitting is better than 10 trials spread out 5 times a day)
with severe children you should use?
a reduced stimulus set (5-6 configurations at a time)
WHat feedback should be provided?
Specific but back off over time.
What are teh four cues and strategies you should use for motor learning
- Augmentative models
From the movie Hope Speaks, what advice would you give the parent of a three year old with CAS?
- Parent knowledge of strategies and cues used is important and the more you do at home the better the outcome
- When enrolled in treatment evaluate if this treatment is necessary with your SLP and consider multimodal communication
- We expect, based on expert opinion that children with CAS will be effective communicators and even up to 75% intelligible (they may have subtle speech differences)
The effortless flow of speech
a disruption or breakdown in the flow of speech
what are the two types of fluency disorders?
stuttering and cluttering
a type of disfluency disorder that is characterized by a very rapid rate of speech and uneven rate. Many sounds are omitted. Cluttering often emerges in school age children. A person who clutter's is Unaware of his/ her speech patterns.
What is episodic stuttering?
short burst of stuttering in children followed by periods of relative fluency.
Some people ___ stuttering and some _____
WHat is chronic stuttering?
Stuttering that will continue to occur throughout an individuals life.
What is stuttering?
Stuttering/stammering is a communication disorder in which the flow of speech is broken by repetitions (li-li-like this), Prolongations (lllllllike this) and or abnormal blocks of airflow and sound (no airflow- can be audible or visual)
With stuttering there may also be.....
unusual facial and body movements associated with the effort to speak
Stuttering can look-
lots of different ways- lots of variability.
what is SLD?
Stutter like disfluency = stuttering
stutterer vs person who stutters PWS
two of the SFA books we are reading use the term stutterer in the tittle. These books are written by a person who stutters. Non-stuttering individuals should use person first language
What are the two types of fluency disorders?
- Non-developmental stuttering (less common)
- Developmental stuttering
Describe non-developmental stuttering (less common)
Neurogenic stuttering: results from neurogenic conditions (e.g., brian injury, drug interaction)
Psychogenic stuttering: an extremely rare condition referring to people who have a diagnosed psychopathology (personality disorder etc.) and then later begin to stutter.
what is most stuttering ?
developmental or chronic
Developmental stuttering is found to occur in what languageS?
All languages of the world
Developmental stuttering occurs in 1 out of every _____ individuals (___%)
The onset of developmental stuttering usually occurs from
2-5 years of age
Stuttering affects ____ as many ___ as ____
What are the three primary/core stuttering behaviors?
- 1. Repetitions: at phoneme, syllable, word, or phrase level
- 2. Prolongations: a sound is prolonged longer than 1 second
- 3. Blocks: airflow is blocked by articulators
All speakers will demonstrate _______, but less than ____ of our speech is non-fluent
What are the secondary / learned stuttering behaviors?
- Any behaviors that are not primary or core stuttering.
- Secondary behaviors are learning in an attempt to escape the stuttering movement and may include:
- bodily movements (facial grimace, head movements, eye twitch, other bodily movements) or word avoidance, sentence abandonment, circumlocution, and other behaviors.
Stuttering is highly ________ meaning.....
idiosyncratic, uniques in each individual, so these secondary behaviors can vary tremendously.
Why are secondary behaviors usually learned?
to escape the primary behaviors.
What is Wendell Johnson's historical definition of stuttering? What was his theory?
- Stuttering occurs when speaker expects to stutter, dreads it, becomes tense in anticipation and tried to avoid it.
- Diagnosogenic theory.
What is the diagnosogenic theory and is it true?
- Stuttering beings NOT in the child's mouth but in the listener's (mothers) ear.
- Not true, has been disproven and you can not induce stuttering.
What was charles van riper's historical definition of stuttering?
- Stuttering occurs when the flow of speech is interrupted abnormally by repetitions or prolongations of a sound, syllable or articulatory posture or by avoidance and struggle reactions
- these produce interruptions and breaks in the forward flow of speepch.
What is Oliver bloodstein's historical definition of stuttering?
- Stuttering is an anticipatory-struggle reaction. It represents an exacerbation of the tensions and fragmentations that are common occurrences in the speech of normally developing children.
- Stuttering develops readily in circumstances in which speech pressures are unussually heavy, the child's vulnerability to them is unusually high or communicative difficulties are unusually frequent, severe or chronic
Describe the Diagnosogenic theory- who founded it?
- Johnson emphasized the overlap between children beginning to stutter and children who were normally nonfluent
- Based on the idea that stuttering results from its (mis-) diagnosis
- Stuttering begins not in the child's mouth, but in the listenter's/mother's ear.
- Johnson was wrong this theory has been proven to be inaccurate.
- Monster study
According to Bloodstein, children with communication difficulties (artic, language, word-finding, are ...
more at risk for stuttering to develop
When kids have a hard time being understod, especially in a demanding environment then...(according to Bloodstein)
they are even more vulnerable.
Early communicative failures lead to what? (according to bloodstein)
tension and fragmentation which can lead to anticipatory struggle and stuttering
Bloodstein had what model of stuttering?
Communicative failure and anticipatory struggle.
Starkweather had what model of stuttering?
Capacities and Demands
What are the 3 capacities and Demands that Starkweather presented for stuttering?
- 1. The child's capacity for fluency does not equal environmental demands for it.
- 2. Reduced capacity may be caused by "organic predisposition" for stuttering
- 3. Decreasing the linguistic demands placed upon the child becomes a focus of therapy.
Who presented the first model that takes into account other things?
According to the national stuttering foundation in 2012, what are the 4 causes of stuttering? Explain each.
- Genetics (60% of those who stutter have a family history of stuttering)
- Differences in child development (Children with speech-language or developmental delays are more likely to stutter)
- Neurophysiology (there is evidence of "hard wiring differences" in how people who stutter process speech and language)
- Family dynamics (high expectations and fast-paced lifestyles can contribute to or aggravate stuttering)
What causes stuttering (summary)
Although the etiology of stuttering is not fully understood, there is strong evidence to suggest that it emerges from a combination of constitutional and environmental factors
Doesn't everyone stutter a little bit?
Yes, most non stuttering individuals demonstrate a little bit (<10% of the time) of other dysfluencies or normal non fluencies.
What are normal nonfluencies and what are characteristics of normal nonfluencies?
Normal nonfluencies are regular bumps heard in typical speakers' speech.
- Characteristics are:
- easy, effortless, rhythmic, infrequent
- word an phrase repetitions
- revisions, interjections
- usually only one or maybe two reiterations (difference is in frequency)
- Frequently related to revision or formulation of message.
What are 5 SLD and 3 OD?
- 1. Part word repetition
- 2. single-syllable word repetition
- 3. multisyllabic word repetition
- 4. Dis-rhythmic phonation (prolongaion)
- 5. Tense pause
- 1. Phrase repetition
- 2. interjection
- 3. revision-incomplete phrase
What are feelings?
- Relative to developmental stage
- ex: frustrated, nervous, scared, upset, embarrassed, guilt, shame, denial.
What are Attitudes
- Related more to your beliefs about stuttering and stutters.
- ex: that stuttering is bad, wrong, nasty, etc. that stutterers are stupid, unworthy
Who described stuttering as an iceberg and what does it mean
- the core features are what you see (repetitions, prolongations, blockages.)
- The secondary features are also what you see above the surface ( escape and avoidance)
- But the attitudes and feelings are below the water (fear, guilt, denial, shame)
these feelings and emotional responses ___________ stuttering. but are a _______ to stuttering and may _______.
- DO NOT CAUSE
- aggravate stuttering
Stuttering is NOT an ______
- what you can see (above the water)
- What you cannot see (below the water)
Practice the overt and covert stuttering chart
Describe the Pre-disruption
Emotional and behavioral (avoidance)
Describe Fluency disruptions
- ONLY BEHVIORAL
- disfluency, fluency failure, stuttering.
Describe post disruption?
What is the prevalence of spontaneous recovery in children and what is the problem
- 32-80% recovery, but problems with methodology in these studies
- Girls recover faster and more frequently then boys
_____ of stuttering is not a predictor of recovery
_____ are indicators of chronic stuttering?
_____% of children (ages 3-4) showing stuttering danger signs spontaneously recover while ____% persist and will have a chronic stutter
What is a factor for spontaneous recovery?
- Time post onset (TPO) is a factor: how long since it started
- 6 months or < TPO = high chance of spontaneous ecovery
- 18 months or > TPO = high risk of chronic stuttering. Not all children recover if we ignore it.
chronic stutterin is highly probable when?
in children who are dysfluent past age 6
What is the assessment question for young children? For school age, adolescent and adult?
- Is the child stuttering? If so , what levelof severity do we see?
- Have client's disfluencies and response to disfluencies changed?
To answer these questions we need to...
Describe surface features of stuttering and describe the internal response and resulting behaviors of stuttering.
Describe mapping surface features of stuttering
- We map surface features of stuttering using a variety of behavioral measures that involve detailed observation and analysis.
- Detailed speech sample
- Dsifluency count (% of stuttered syllables)- number of repetitions, prolongations and blocks. Also number an type of secondary behavior, not a check list, need as much detail as possible.
- We are interested in: Frequency, tension, duration (longest stuttered moment) secondary behaviors.
The goal of the assessment should be....
the investigation and exploration of speech behaviors that someone has identified as problematic.
A good report includes...
a rich clinical description of stuttering
- Molecular Analysis
- of 3 speech samples (250-300) words each
- Conversation, reading, monologue
- You can apply stuttering severity instrument or other scoring framework to this once transcribed.
- Transcribe language
- transcribe speech (because of higher occurrence of phonological disorder)
- Code stuttering in sample
- *words per second (words/sec)
- Syllables per minute
- MOST IMPORTANT IS PERCENTAGE OF STUTTERED SYLLABLES
% of stuttered syllables is important for?
During the assessment, to describe the internal response to stuttering we ask what questions? What do you do with kids?
- Not yes or no
- Describe how your son reacts to moments of difficulty with speech/stuttering
- does the child stop talking because it is too hard?
- Other evidence of negative awareness.
- School age children we may also complete an interview and possibley a self rating scale
- For young childen, we gather this information through parent interview that is not infront of child
at what age are children discovering they are stuttering and what age do they know
What do self rating scales allow and who is it great for?
- The client to assess him-/herself.
- great for adults, teens and school age.
In a self rating scale, the client should indicate?
- what their overall speech/stuttering is like. Relate to quality of life
- What their speech/stuttering is like right now/time of assessment
We use self rate scales because why? What else is useful and for who?
it is nice to bring this information into a report using the clients own words.
For school age, teens, and adults, interviews about stuttering are also recommended to tap into internal response to stuttering.
What are the two widely used traditional approaches for treatment of fluency disorders?
- Fluency Shaping
- Stuttering Modification
What is fluency shaping
Based on the idea that a PWS can become near fluent if they constantly apply their fluency shaping strategies. (goal is fluent speech and they can become fluent if they use the strategies)
What is stuttering modefication
Based on the idea that a PWS can mange his/her stutter by facing the stuttering and learning to change and take control over his/her stuttering. (goal is to face stuttering and you will get through life by facing fears. )
Describe Fluency Shaping in detail. (3 strategies)
- Fluency is established through explicit practice of fluency shaping strategies, including-
- easy onset of voice: adults or children. putting in air to reduce hard adduction, typically h in front of a vowel.
- Breathy speech: more pauses, more air, whispering, spread it out.
- Light articulatory contacts: like a breathy contact. Less contact force.
Describe stuttering modification in detail and what are the strategies?
- SM teaches the PWS to modify his/her moments of stuttering, using stategies inclduing-
- Pseudo stuttering: stutter on purpose to demonstrate control
- Cancelations: by replacing it with a fluent statement
- Pull-outs: Pull out of stuttered moment and finish the statement
- Preparatory sets: Practicing phrases that you may us
Stuttering modification does what?
SM reduces the fear and negative emotions that the PWS experiences and eliminating the avoidance behaviors associated with this fear.
What are the Nontraditional treatment approaches? Describe each
- Hypnotherapy: a psychologically based approach to the treatment of stuttering. NO EFFICACY for this type of treatment
- Drug Therapy: Use of anti-anxiety medications to reduce moments of stuttering. Does not cure or treat stuttering- rather treats anxiety associated with stuttering.
- Electronic Devices (Easy speak and delayed auditory feedback devices): closely resemble hearing aids that provide an auditory distraction to help alter the individual's overall speaking behavior. A treatment approach not a cure ($4000)
Are low efficacy and alternate approaches to stuttering recommended?
I read about a new cure for stuttering- Is there such a thing?
- There are no instant miracle cures for stuttering
- However, a specialist in stuttering can help not only children but also teens, young adults, and even older adults make significant progress toward fluency and STUTTERING LIGHTLY.
What should you NOT do or say to a stutter
- Finish what they want to say
- Say: take a breath, slow down.
- Look away.
What are the 12 rules in the self stuttering therapy book?
- 1: Make a habit of always talking slowly and deliberately whether you stutter or not
- 2:When you start to talk, do it easily, gently and smoothly without forcing and prolong the first sounds of words you fear
- 3: Stutter openly and do not try to hide the fact that you are a stutterer
- 4: Identify and eliminate any unusual gestures, facial contortions, or body movements which possibly you may exhibit when stuttering or try to avoid difficulty.
- 5: Do your best to stop all avoidance, postponement or substitution habits.
- 6: Maintain eye contact with the person to whom you talk
- 7: Analyze and identify what your speech muscles are doing improperly when you stutter
- 8: Take advantage of block correction procedures designed to modify or eliminate your abnormal speech muscle stuttering behavior
- 9: Always keep moving forward as you speak
- 10: Try to talk with inflection and melody in a firm voice
- 11: Pay attention to the fluent speech you have
- 12: Try to talk as much as you can