Intervention for childhood apraxia of speech

The Influence of Quantitative Intervention Dosage on Oral Language Outcomes for Children With Developmental Language Disorder: A Systematic Review and Narrative Synthesis

Purpose The aim of this study was to examine the degree to which quantitative aspects of dosage (dose, dose frequency, and total intervention duration) have been examined in intervention studies for children with developmental language disorder (DLD). Additionally, to establish the optimal quantitative dosage characteristics for phonology, vocabulary, and morphosyntax outcomes. Method This registered review (PROSPERO ID CRD42017076663) adhered to PRISMA guidelines. Search terms were included in seven electronic databases. We included peer-reviewed quasi-experimental, randomized controlled trial or cohort analytical studies, published in any language between January 2006 and May 2020. Included articles reported on participants with DLD (M = 3-18 years); oral language interventions with phonology, vocabulary, or morphosyntax outcomes; and experimental manipulation or statistical analysis of any quantitative aspect of dosage. Studies were appraised using the Cochrane risk-of-bias tool. Results Two hundred forty-four articles reported on oral language interventions with children with DLD in the domains of interest; 13 focused on experimentally/statistically manipulating quantitative aspects of dosage. No article reported phonological outcomes, three reported vocabulary, and eight reported morphosyntax. Dose frequency was the most common characteristic manipulated. Conclusions Research is in its infancy, and significant further research is required to inform speech-language pathologists in practice. Dosage characteristics are rarely adequately controlled for their individual effects to be identified. Findings to date suggest that there is a point in vocabulary and morphosyntax interventions after which there are diminishing returns from additional dosage. If dose is high (number of learning opportunities within a session), then the literature suggests that session frequency can be reduced. Frequent, short sessions (2/3 × per week, approximately 2 min) and less frequent, long sessions (1 × per week, approximately 20 min) have yielded the best outcomes when composite language measures have been used; however, replication and further research are required before clinicians can confidently integrate these findings into clinical practice. Supplemental Material https://doi.org/10.23641/asha.13570934.

Feasibility of an app-based parent-mediated speech production intervention for minimally verbal autistic children: development and pilot testing of a new intervention

BACKGROUND

Training speech production skills may be a valid intervention target for minimally verbal autistic children. Intervention studies have explored various approaches albeit on a small scale and with limited experimental control or power. We therefore designed a novel app-based parent-mediated intervention based on insights from the video modelling and cued articulation literature and tested its acceptability and usage.

METHODS

Consultation with the autism community refined the initial design and culminated in a pilot trial (n = 19) lasting 16 weeks. Participants were randomly allocated an intervention duration in an AB phase design and undertook weekly probes during baseline and intervention via the app. We evaluated the acceptability of the intervention via feedback questionnaires and examined the usability variables such as adherence to the testing and intervention schedule, time spent on the app and trials completed during the intervention phase.

RESULTS

High acceptability scores indicated that families liked the overall goals and features of the app. Ten participants engaged meaningfully with the app, completing 82% of the test trials and uploading data in 61% of intervention weeks; however, of these, only three met the targeted 12.5 min of intervention per week.

CONCLUSION

We discuss the possible reasons for variability in usage data and how barriers to participation could be surmounted in the future development of this intervention.

Interventions for childhood apraxia of speech

BACKGROUND

Childhood apraxia of speech (CAS) affects a child's ability to produce sounds and syllables precisely and consistently, and to produce words and sentences with accuracy and correct speech rhythm. It is a rare condition, affecting only 0.1% of the general population. Consensus has been reached that three core features have diagnostic validity: (1) inconsistent error production on both consonants and vowels across repeated productions of syllables or words; (2) lengthened and impaired coarticulatory transitions between sounds and syllables; and (3) inappropriate prosody (ASHA 2007). A deficit in motor programming or planning is thought to underlie the condition. This means that children know what they would like to say but there is a breakdown in the ability to programme or plan the fine and rapid movements required to accurately produce speech. Children with CAS may also have impairments in one or more of the following areas: non-speech oral motor function, dysarthria, language, phonological production impairment, phonemic awareness or metalinguistic skills and literacy, or combinations of these. High-quality evidence from randomised controlled trials (RCTs) is lacking on interventions for CAS.

OBJECTIVES

To assess the efficacy of interventions targeting speech and language in children and adolescents with CAS as delivered by speech and language pathologists/therapists.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, eight other databases and seven trial registers up to April 2017. We searched the reference lists of included reports and requested information on unpublished trials from authors of published studies and other experts as well as information groups in the areas of speech and language therapy/pathology and linguistics.

SELECTION CRITERIA

RCTs and quasi-RCTs of children aged 3 to 16 years with CAS diagnosed by a speech and language pathologist/therapist, grouped by treatment types.

DATA COLLECTION AND ANALYSIS

Two review authors (FL, AM) independently assessed titles and abstracts identified from the searches and obtained full-text reports of all potentially relevant articles and assessed these for eligibility. The same two authors extracted data and conducted the 'Risk of bias' and GRADE assessments. One review author (EM) tabulated findings from excluded observational studies (Table 1).

MAIN RESULTS

This review includes only one RCT, funded by the Australian Research Council; the University of Sydney International Development Fund; Douglas and Lola Douglas Scholarship on Child and Adolescent Health; Nadia Verrall Memorial Scholarship; and a James Kentley Memorial Fellowship. This study recruited 26 children aged 4 to 12 years, with mild to moderate CAS of unknown cause, and compared two interventions: the Nuffield Dyspraxia Programme-3 (NDP-3); and the Rapid Syllable Transitions Treatment (ReST). Children were allocated randomly to one of the two treatments. Treatments were delivered intensively in one-hour sessions, four days a week for three weeks, in a university clinic in Australia. Speech pathology students delivered the treatments in the English language. Outcomes were assessed before therapy, immediately after therapy, at one month and four months post-therapy. Our review looked at one-month post-therapy outcomes only.We judged all core outcome domains to be low risk of bias. We downgraded the quality of the evidence by one level to moderate due to imprecision, given that only one RCT was identified. Both the NDP-3 and ReST therapies demonstrated improvement at one month post-treatment. A number of cases in each cohort had recommenced usual treatment by their speech and language pathologist between one month and four months post-treatment (NDP-3: 9/13 participants; ReST: 9/13 participants). Hence, maintenance of treatment effects to four months post-treatment could not be analysed without significant potential bias, and thus this time point was not included for further analysis in this review.There is limited evidence that, when delivered intensively, both the NDP-3 and ReST may effect improvement in word accuracy in 4- to 12-year-old children with CAS, measured by the accuracy of production on treated and non-treated words, speech production consistency and the accuracy of connected speech. The study did not measure functional communication.

AUTHORS' CONCLUSIONS

There is limited evidence that, when delivered intensively, both the NDP-3 and ReST may effect improvement in word accuracy in 4- to 12-year-old children with CAS, measured by the accuracy of production on treated and non-treated words, speech production consistency and the accuracy of connected speech. The study did not measure functional communication. No formal analyses were conducted to compare NDP-3 and ReST by the original study authors, hence one treatment cannot be reliably advocated over the other. We are also unable to say whether either treatment is better than no treatment or treatment as usual. No evidence currently exists to support the effectiveness of other treatments for children aged 4 to 12 years with idiopathic CAS without other comorbid neurodevelopmental disorders. Further RCTs replicating this study would strengthen the evidence base. Similarly, further RCTs are needed of other interventions, in other age ranges and populations with CAS and with co-occurring disorders.

A systematic review and classification of interventions for speech-sound disorder in preschool children

BACKGROUND

Multiple interventions have been developed to address speech sound disorder (SSD) in children. Many of these have been evaluated but the evidence for these has not been considered within a model which categorizes types of intervention. The opportunity to carry out a systematic review of interventions for SSD arose as part of a larger scale study of interventions for primary speech and language impairment in preschool children.

AIMS

To review systematically the evidence for interventions for SSD in preschool children and to categorize them within a classification of interventions for SSD.

METHODS & PROCEDURES

Relevant search terms were used to identify intervention studies published up to 2012, with the following inclusion criteria: participants were aged between 2 years and 5 years, 11 months; they exhibited speech, language and communication needs; and a primary outcome measure of speech was used. Studies that met inclusion criteria were quality appraised using the single case experimental design (SCED) or PEDro-P, depending on their methodology. Those judged to be high quality were classified according to the primary focus of intervention.

OUTCOMES & RESULTS

The final review included 26 studies. Case series was the most common research design. Categorization to the classification system for interventions showed that cognitive-linguistic and production approaches to intervention were the most frequently reported. The highest graded evidence was for three studies within the auditory-perceptual and integrated categories.

CONCLUSIONS & IMPLICATIONS

The evidence for intervention for preschool children with SSD is focused on seven out of 11 subcategories of interventions. Although all the studies included in the review were good quality as defined by quality appraisal checklists, they mostly represented lower-graded evidence. Higher-graded studies are needed to understand clearly the strength of evidence for different interventions.

Deep phenotyping of speech and language skills in individuals with 16p11.2 deletion

Recurrent deletions of a ~600-kb region of 16p11.2 have been associated with a highly penetrant form of childhood apraxia of speech (CAS). Yet prior findings have been based on a small, potentially biased sample using retrospectively collected data. We examine the prevalence of CAS in a larger cohort of individuals with 16p11.2 deletion using a prospectively designed assessment battery. The broader speech and language phenotype associated with carrying this deletion was also examined. 55 participants with 16p11.2 deletion (47 children, 8 adults) underwent deep phenotyping to test for the presence of CAS and other speech and language diagnoses. Standardized tests of oral motor functioning, speech production, language, and non-verbal IQ were conducted. The majority of children (77%) and half of adults (50%) met criteria for CAS. Other speech outcomes were observed including articulation or phonological errors (i.e., phonetic and cognitive-linguistic errors, respectively), dysarthria (i.e., neuromuscular speech disorder), minimal verbal output, and even typical speech in some. Receptive and expressive language impairment was present in 73% and 70% of children, respectively. Co-occurring neurodevelopmental conditions (e.g., autism) and non-verbal IQ did not correlate with the presence of CAS. Findings indicate that CAS is highly prevalent in children with 16p11.2 deletion with symptoms persisting into adulthood for many. Yet CAS occurs in the context of a broader speech and language profile and other neurobehavioral deficits. Further research will elucidate specific genetic and neural pathways leading to speech and language deficits in individuals with 16p11.2 deletions, resulting in more targeted speech therapies addressing etiological pathways.

Non-speech oral motor treatment for children with developmental speech sound disorders

BACKGROUND

Children with developmental speech sound disorders have difficulties in producing the speech sounds of their native language. These speech difficulties could be due to structural, sensory or neurophysiological causes (e.g. hearing impairment), but more often the cause of the problem is unknown. One treatment approach used by speech-language therapists/pathologists is non-speech oral motor treatment (NSOMT). NSOMTs are non-speech activities that aim to stimulate or improve speech production and treat specific speech errors. For example, using exercises such as smiling, pursing, blowing into horns, blowing bubbles, and lip massage to target lip mobility for the production of speech sounds involving the lips, such as /p/, /b/, and /m/. The efficacy of this treatment approach is controversial, and evidence regarding the efficacy of NSOMTs needs to be examined.

OBJECTIVES

To assess the efficacy of non-speech oral motor treatment (NSOMT) in treating children with developmental speech sound disorders who have speech errors.

SEARCH METHODS

In April 2014 we searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (R) and Ovid MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Education Resources Information Center (ERIC), PsycINFO and 11 other databases. We also searched five trial and research registers, checked the reference lists of relevant titles identified by the search and contacted researchers to identify other possible published and unpublished studies.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared (1) NSOMT versus placebo or control; and (2) NSOMT as adjunctive treatment or speech intervention versus speech intervention alone, for children aged three to 16 years with developmental speech sound disorders, as judged by a speech and language therapist. Individuals with an intellectual disability (e.g. Down syndrome) or a physical disability were not excluded.

DATA COLLECTION AND ANALYSIS

The Trials Search Co-ordinator of the Cochrane Developmental, Psychosocial and Learning Problems Group and one review author ran the searches. Two review authors independently screened titles and abstracts to eliminate irrelevant studies, extracted data from the included studies and assessed risk of bias in each of these studies. In cases of ambiguity or information missing from the paper, we contacted trial authors.

MAIN RESULTS

This review identified three studies (from four reports) involving a total of 22 children that investigated the efficacy of NSOMT as adjunctive treatment to conventional speech intervention versus conventional speech intervention for children with speech sound disorders. One study, a randomised controlled trial (RCT), included four boys aged seven years one month to nine years six months - all had speech sound disorders, and two had additional conditions (one was diagnosed as "communication impaired" and the other as "multiply disabled"). Of the two quasi-randomised controlled trials, one included 10 children (six boys and four girls), aged five years eight months to six years nine months, with speech sound disorders as a result of tongue thrust, and the other study included eight children (four boys and four girls), aged three to six years, with moderate to severe articulation disorder only. Two studies did not find NSOMT as adjunctive treatment to be more effective than conventional speech intervention alone, as both intervention and control groups made similar improvements in articulation after receiving treatments. One study reported a change in postintervention articulation test results but used an inappropriate statistical test and did not report the results clearly. None of the included studies examined the effects of NSOMTs on any other primary outcomes, such as speech intelligibility, speech physiology and adverse effects, or on any of the secondary outcomes such as listener acceptability.The RCT was judged at low risk for selection bias. The two quasi-randomised trials used randomisation but did not report the method for generating the random sequence and were judged as having unclear risk of selection bias. The three included studies were deemed to have high risk of performance bias as, given the nature of the intervention, blinding of participants was not possible. Only one study implemented blinding of outcome assessment and was at low risk for detection bias. One study showed high risk of other bias as the baseline characteristics of participants seemed to be unequal. The sample size of each of the included studies was very small, which means it is highly likely that participants in these studies were not representative of its target population. In the light of these serious limitations in methodology, the overall quality of the evidence provided by the included trials is judged to be low. Therefore, further research is very likely to have an important impact on our confidence in the estimate of treatment effect and is likely to change the estimate.

AUTHORS' CONCLUSIONS

The three included studies were small in scale and had a number of serious methodological limitations. In addition, they covered limited types of NSOMTs for treating children with speech sound disorders of unknown origin with the sounds /s/ and /z/. Hence, we judged the overall applicability of the evidence as limited and incomplete. Results of this review are consistent with those of previous reviews: Currently no strong evidence suggests that NSOMTs are an effective treatment or an effective adjunctive treatment for children with developmental speech sound disorders. Lack of strong evidence regarding the treatment efficacy of NSOMTs has implications for clinicians when they make decisions in relation to treatment plans. Well-designed research is needed to carefully investigate NSOMT as a type of treatment for children with speech sound disorders.

Auditory-verbal therapy for promoting spoken language development in children with permanent hearing impairments

BACKGROUND

Congenital or early-acquired hearing impairment poses a major barrier to the development of spoken language and communication. Early detection and effective (re)habilitative interventions are essential for parents and families who wish their children to achieve age-appropriate spoken language. Auditory-verbal therapy (AVT) is a (re)habilitative approach aimed at children with hearing impairments. AVT comprises intensive early intervention therapy sessions with a focus on audition, technological management and involvement of the child's caregivers in therapy sessions; it is typically the only therapy approach used to specifically promote avoidance or exclusion of non-auditory facial communication. The primary goal of AVT is to achieve age-appropriate spoken language and for this to be used as the primary or sole method of communication. AVT programmes are expanding throughout the world; however, little evidence can be found on the effectiveness of the intervention.

OBJECTIVES

To assess the effectiveness of auditory-verbal therapy (AVT) in developing receptive and expressive spoken language in children who are hearing impaired.

SEARCH METHODS

CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, speechBITE and eight other databases were searched in March 2013. We also searched two trials registers and three theses repositories, checked reference lists and contacted study authors to identify additional studies.

SELECTION CRITERIA

The review considered prospective randomised controlled trials (RCTs) and quasi-randomised studies of children (birth to 18 years) with a significant (≥ 40 dBHL) permanent (congenital or early-acquired) hearing impairment, undergoing a programme of auditory-verbal therapy, administered by a certified auditory-verbal therapist for a period of at least six months. Comparison groups considered for inclusion were waiting list and treatment as usual controls.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles and abstracts identified from the searches and obtained full-text versions of all potentially relevant articles. Articles were independently assessed by two review authors for design and risk of bias. In addition to outcome data, a range of variables related to participant groups and outcomes were documented.

MAIN RESULTS

Of 2233 titles and abstracts searched, only 13 abstracts appeared to meet inclusion criteria. All 13 full-text articles were excluded following independent evaluation by two review authors (CGBJ and JW), as they did not meet the inclusion criteria related to the research design. Thus, no studies are included in this review.

AUTHORS' CONCLUSIONS

This review confirms the lack of well-controlled studies addressing the use of AVT as an intervention for promoting spoken language development in children with permanent hearing impairments. Whilst lack of evidence does not necessarily imply lack of effect, it is at present not possible for conclusions to be drawn as to the effectiveness of this intervention in treating children with permanent hearing impairments.

A comparison of two treatments for childhood apraxia of speech: methods and treatment protocol for a parallel group randomised control trial

Background

Childhood Apraxia of Speech is an impairment of speech motor planning that manifests as difficulty producing the sounds (articulation) and melody (prosody) of speech. These difficulties may persist through life and are detrimental to academic, social, and vocational development. A number of published single subject and case series studies of speech treatments are available. There are currently no randomised control trials or other well designed group trials available to guide clinical practice.

Methods/Design

A parallel group, fixed size randomised control trial will be conducted in Sydney, Australia to determine the efficacy of two treatments for Childhood Apraxia of Speech: 1) Rapid Syllable Transition Treatment and the 2) Nuffield Dyspraxia Programme – Third edition. Eligible children will be English speaking, aged 4–12 years with a diagnosis of suspected CAS, normal or adjusted hearing and vision, and no comprehension difficulties or other developmental diagnoses. At least 20 children will be randomised to receive one of the two treatments in parallel. Treatments will be delivered by trained and supervised speech pathology clinicians using operationalised manuals. Treatment will be administered in 1-hour sessions, 4 times per week for 3 weeks. The primary outcomes are speech sound and prosodic accuracy on a customised 292 item probe and the Diagnostic Evaluation of Articulation and Phonology inconsistency subtest administered prior to treatment and 1 week, 1 month and 4 months post-treatment. All post assessments will be completed by blinded assessors. Our hypotheses are: 1) treatment effects at 1 week post will be similar for both treatments, 2) maintenance of treatment effects at 1 and 4 months post will be greater for Rapid Syllable Transition Treatment than Nuffield Dyspraxia Programme treatment, and 3) generalisation of treatment effects to untrained related speech behaviours will be greater for Rapid Syllable Transition Treatment than Nuffield Dyspraxia Programme treatment. This protocol was approved by the Human Research Ethics Committee, University of Sydney (#12924).

Discussion

This will be the first randomised control trial to test treatment for CAS. It will be valuable for clinical decision-making and providing evidence-based services for children with CAS.

Trial Registration

Australian New Zealand Clinical Trials Registry: ACTRN12612000744853

Evidence-Based Practice for Children With Speech Sound Disorders: Part 1 Narrative Review

Purpose

This article provides a comprehensive narrative review of intervention studies for children with speech sound disorders (SSD). Its companion paper (Baker & McLeod, 2011) provides a tutorial and clinical example of how speech-language pathologists (SLPs) can engage in evidence-based practice (EBP) for this clinical population.

Method

Studies reporting speech sound intervention for children with SSDs published from 1979 to 2009 were identified and coded.

Results

One hundred thirty-four intervention studies were identified. Intervention typically was conducted by an SLP in a one-to-one individual format for 30- to 60-min sessions 2 to 3 times per week. Total duration of intervention (from assessment to discharge) was reported for 10 studies and ranged from 3 to 46 months. Most studies were either Level IIb (quasi-experimental studies, 41.5%) or Level III (nonexperimental case studies, 32.6%). Single-case experimental design (29.6%) was the most frequently used experimental research design. There were 7 distinct approaches to target selection and 46 distinct intervention approaches, with 23 described in more than 1 publication. Each approach was associated with varying quantities and levels of evidence, according to research design.

Conclusion

Collaborative research reflecting higher levels of evidence using rigorous experimental designs is needed to compare the relative benefits of different intervention approaches.

A treatment for dysprosody in childhood apraxia of speech

PURPOSE

Dysprosody is considered a core feature of childhood apraxia of speech (CAS), especially impaired production of lexical stress. Few studies have tested the effects of intervention for dysprosody. This Phase II study with 3 children investigated the efficacy of a treatment targeting improved control of relative syllable durations in 3-syllable nonwords representing strong-weak (SW) and weak-strong (WS) stress patterns (e.g., BAtigu or baTIgu). Treatment sessions were structured along the principles of motor learning (PML) approach.

METHOD

Three children, age 7 to 10 years, with mild to moderate CAS and normal language development participated in an intensive 3-week treatment. Within-participant designs with multiple baselines across participants and behaviors were used to examine acquisition, generalization, and maintenance of skill.

RESULTS

All children improved in their ability to control relative duration of syllables in SW and WS nonwords. Improvement was also noted in control of loudness and pitch contrasts. Treatment effects generalized to untreated nonword stimuli, but minimal change was seen in production of real words.

CONCLUSION

Findings support the efficacy of this approach for improving production of lexical stress contrasts. Structuring the intervention according to the PML approach likely stimulated strong maintenance and generalization effects.