A survey of the clinical management of childhood apraxia of speech in the United States and Canada

PURPOSE

Limited information is available about the current practices of generalist speech-language pathologists (SLPs) in relation to their management of childhood apraxia of speech (CAS). This study was designed to investigate four primary questions separately for the US and Canada; 1. What treatment approaches are used by SLP clinicians to treat CAS? 2. What treatment format and intensity are used to deliver CAS treatment? 3. What are the attitudes and perspectives of SLPs to evidence-based practice (EBP) as it pertains to CAS treatment? and 4. What are the perceived barriers to the implementation of EBP in CAS treatment?

METHOD

An online questionnaire was used to investigate the four primary research questions. The questionnaire was distributed online through social media, some state-based associations and through forums affiliated with national speech-language-hearing associations.

RESULTS

Most survey respondents reported frequently using an eclectic approach to treat CAS (US 85%; Canada 89%). Although no intervention emerged as the most preferred primary treatment for CAS, US-based clinicians more commonly reported using the Kaufman Speech to Language Protocol (K-SLP) (33%) and Dynamic, Temporal and Tactile Cueing (DTTC) (28%); while clinicians in Canada used PROMPT ® (31%). SLPs demonstrated a positive attitude towards EBP however, they identified a range of perceived barriers that impacted their implementation of EBP.

CONCLUSION

SLPs in the US and Canada frequently used an eclectic approach to treat CAS which is consistent with previous findings both in the CAS literature and the wider speech disorders literature. The more commonly used primary interventions were the K-SLP and DTTC (US); and PROMPT ® (Canada), with one of the strongest factors that influenced clinicians' choice of intervention being familiarity with the treatment approach. Face to face therapy was preferred by clinicians across both countries, with clinicians in the US providing therapy between 2-5 times per week, while those in Canada delivered therapy up to once per week. Clinicians identified a number of barriers to implementing evidence-based practice, among which, being time poor was most commonly selected across clinicians in both the US and Canada.

Predicting progress in word learning for children with autism and minimal verbal skills

Background

Approximately 30% of children diagnosed with autism remain minimally verbal past age 5. Interventions are often effective in increasing spoken communication for some of these children. Clinical and research decisions would be facilitated by identifying early indicators of progress in interventions. The purpose of this study was to investigate the relationship between speech sound measures obtained from the early phases of treatment and later treatment outcomes in children with autism and minimal verbal skills.

Methods

Twenty-three children (18 boys) between 5 and 9 years of age participated. We compared scores reflecting the phonemic features of word attempts produced during probes, and the number of correct words after 4 weeks of intervention to later word learning outcomes.

Results

Correlational and hierarchical regression analyses showed that both predictors were positively correlated with outcomes, but the phonemic scores were more strongly related than number of correct words.

Conclusion

We conclude that phonemic scoring may be a useful measure to determine proximal gains in a spoken word learning intervention. Proximal measures are particularly helpful when trying to decide if the current course of intervention should be maintained or altered.

Trial registration

https://register.clinicaltrials.gov/prs/app/action/LoginUser?ts=2&cx=-jg9qo3.

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.

Illustrating a Supports-Based Approach Toward Friendship With Autistic Students

PURPOSE

The present clinical focus article describes and illustrates 3 key elements of a supports-based approach to enhancing friendship with autistic students.

METHOD

In comparison to the predominant skills-based approach, we highlight 3 key elements of a supports-based approach to social interaction for autistic children and youth. We then offer descriptive details of the activity-based music program as an illustrative example of a program that integrated all 3 elements of a supports-based approach. Specifically, we designed an activity-based music program to enhance social interaction among a 7-year-old autistic student and 4 of his nonautistic peers.

RESULTS

We focused on 3 key elements of a supports-based approach for enhancing peer interaction: (a) focusing on participation in a shared activity, (b) encouraging flexible use of multiple communicative resources, and (c) supporting egalitarian interaction.

CONCLUSION

A supports-based approach presents a theoretically distinct and viable alternative to a skills-based approach in the design of social supports for autistic students and their peers.

Effects of a Conversation-Based Intervention on the Linguistic Skills of Children With Motor Speech Disorders Who Use Augmentative and Alternative Communication

Purpose

This study was conducted to evaluate the effects of a conversation-based intervention on the expressive vocabulary and grammatical skills of children with severe motor speech disorders and expressive language delay who use augmentative and alternative communication.

Method

Eight children aged from 8 to 13 years participated in the study. After a baseline period, a conversation-based intervention was provided for each participant, in which they were supported to learn and use linguistic structures essential for the formation of clauses and the grammaticalization of their utterances, such as pronouns, verbs, and bound morphemes, in the context of personally meaningful and scaffolded conversations with trained clinicians. The conversations were videotaped, transcribed, and analyzed using the Systematic Analysis of Language Transcripts (SALT; Miller & Chapman, 1991).

Results

Results indicate that participants showed improvements in their use of spontaneous clauses, and a greater use of pronouns, verbs, and bound morphemes. These improvements were sustained and generalized to conversations with familiar partners.

Conclusion

The results demonstrate the positive effects of the conversation-based intervention for improving the expressive vocabulary and grammatical skills of children with severe motor speech disorders and expressive language delay who use augmentative and alternative communication. Clinical and theoretical implications of conversation-based interventions are discussed and future research needs are identified.

Supplemental Materials

https://doi.org/10.23641/asha.5150113.

Bridging the Gap Between Speech and Language: Using Multimodal Treatment in a Child With Apraxia

Childhood apraxia of speech is a neurologic speech sound disorder in which children have difficulty constructing words and sounds due to poor motor planning and coordination of the articulators required for speech sound production. We report the case of a 3-year-old boy strongly suspected to have childhood apraxia of speech at 18 months of age who used multimodal communication to facilitate language development throughout his work with a speech language pathologist. In 18 months of an intensive structured program, he exhibited atypical rapid improvement, progressing from having no intelligible speech to achieving age-appropriate articulation. We suspect that early introduction of sign language by family proved to be a highly effective form of language development, that when coupled with intensive oro-motor and speech sound therapy, resulted in rapid resolution of symptoms.

Speech therapy for children with dysarthria acquired before three years of age

BACKGROUND

Children with motor impairments often have the motor speech disorder dysarthria, a condition which effects the tone, strength and co-ordination of any or all of the muscles used for speech. Resulting speech difficulties can range from mild, with slightly slurred articulation and breathy voice, to profound, with an inability to produce any recognisable words. Children with dysarthria are often prescribed communication aids to supplement their natural forms of communication. However, there is variation in practice regarding the provision of therapy focusing on voice and speech production. Descriptive studies have suggested that therapy may improve speech, but its effectiveness has not been evaluated.

OBJECTIVES

To assess whether any speech and language therapy intervention aimed at improving the speech of children with dysarthria is more effective in increasing children's speech intelligibility or communicative participation than no intervention at all , and to compare the efficacy of individual types of speech language therapy in improving the speech intelligibility or communicative participation of children with dysarthria.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015 , Issue 7 ), MEDLINE, EMBASE, CINAHL , LLBA, ERIC, PsychInfo, Web of Science, Scopus, UK National Research Register and Dissertation Abstracts up to July 2015, handsearched relevant journals published between 1980 and July 2015, and searched proceedings of relevant conferences between 1996 to 2015. We placed no restrictions on the language or setting of the studies. A previous version of this review considered studies published up to April 2009. In this update we searched for studies published from April 2009 to July 2015.

SELECTION CRITERIA

We considered randomised controlled trials and studies using quasi-experimental designs in which children were allocated to groups using non-random methods.

DATA COLLECTION AND ANALYSIS

One author (LP) conducted searches of all databases, journals and conference reports. All searches included a reliability check in which a second review author independently checked a random sample comprising 15% of all identified reports. We planned that two review authors would independently assess the quality and extract data from eligible studies.

MAIN RESULTS

No randomised controlled trials or group studies were identified.

AUTHORS' CONCLUSIONS

This review found no evidence from randomised trials of the effectiveness of speech and language therapy interventions to improve the speech of children with early acquired dysarthria. Rigorous, fully powered randomised controlled trials are needed to investigate if the positive changes in children's speech observed in phase I and phase II studies are generalisable to the population of children with early acquired dysarthria served by speech and language therapy services. Research should examine change in children's speech production and intelligibility. It must also investigate children's participation in social and educational activities, and their quality of life, as well as the cost and acceptability of interventions.

Causal effects on child language development: A review of studies in communication sciences and disorders

We reviewed recent studies published across key journals within the field of communication sciences and disorders (CSD) to survey what causal influences on child language development were being considered. Specifically, we reviewed a total of 2921 abstracts published within the following journals between 2003 and 2013: Language, Speech, and Hearing Services in Schools (LSHSS); American Journal of Speech-Language Pathology (AJSLP); Journal of Speech, Language, and Hearing Research (JSLHR); Journal of Communication Disorders (JCD); and the International Journal of Language and Communication Disorders (IJLCD). Of the 346 eligible articles that addressed causal factors on child language development across the five journals, 11% were categorized as Genetic (37/346), 83% (287/346) were categorized as Environmental, and 6% (22/346) were categorized as Mixed. The bulk of studies addressing environmental influences focused on therapist intervention (154/296=52%), family/caregiver linguistic input (65/296=22%), or family/caregiver qualities (39/296=13%). A more in-depth review of all eligible studies published in 2013 (n=34) revealed that family/caregiver qualities served as the most commonly controlled environmental factor (e.g., SES) and only 3 studies explicitly noted the possibility of gene-environment interplay. This review highlighted the need to expand the research base for the field of CSD to include a broader range of environmental influences on child language development (e.g., diet, toxin exposure, stress) and to consider more directly the complex and dynamic interplay between genetic and environmental effects.

LEARNING OUTCOMES

Readers will be able to highlight causal factors on child language development that have been studied over the past decade in CSD and recognize additional influences worthy of consideration. In addition, readers will become familiar with basic tenets of developmental systems theory, including the complex interplay between genetic and environmental factors that shapes child development.

Investigating a Multimodal Intervention for Children With Limited Expressive Vocabularies Associated With Autism

PURPOSE

This study investigated a new intervention package aimed at increasing expressive word learning by school-age children with autism who have limited expressive vocabularies. This pilot investigation was intended to show proof of concept.

METHOD

Ten children between the ages of 6 and 10 years participated, with educational diagnoses of autism and limited expressive vocabularies at the outset of the study. A multimodal intervention composed of speech sound practice and augmentative and alternative communication was used to teach individualized vocabulary words that were selected on the basis of initial speech sound repertoires and principles of phonotactic probability and neighborhood density. A multiple-probe design was used to evaluate learning outcomes.

RESULTS

Five children showed gains in spoken-word learning across successive word sets (high responders). Five children did not meet learning criteria (low responders). Comparisons of behaviors measured prior to intervention indicated that high responders had relatively higher skills in receptive language, prelinguistic communication, vocal/verbal imitation, adaptive behavior, and consonant productions.

CONCLUSIONS

The intervention package holds promise for improving spoken word productions for some children with autism who have limited expressive vocabularies. Further research is needed to better describe who may most benefit from this approach as well as investigate generalized benefits to untaught contexts and targets.

Natural Speech and AAC Intervention in Childhood Motor Speech Disorders: Not an Either/Or Situation

The future of natural speech development is uncertain for children with motor speech disorders (MSD). There is a strong desire to put plans in place as early as possible to anticipate long-term needs. Simultaneously, the knowledge that natural speech development may take time and effort and the idea that augmentative and alternative communication (AAC) can help to fill in the gap while such progress is being made makes sense on a foundational level. However, practical questions remain about the balance of natural speech intervention along with AAC use, particularly when both skills may require intervention and practice before functional benefits are realized. Although AAC stands for augmentative and alternative communication, what the acronym does not provide is an indication of how balance between augmenting natural speech and seeking more of an alternative is to be obtained. In this article, we review impairments in natural speech in children with MSDs. Through this lens, we navigate a path to understanding how, on a practical level, AAC and natural speech strategies can be implemented simultaneously and in a complementary fashion. Following an overview of literature, we move to a discussion of the dual paradigm approach. Finally, we conclude with practical applications of principles through a case study.