Apraxia Treatment

Posted by | January 11, 2011 | Apraxia Treatment, Treatment

Apraxia of Speech Therapy

There is therapy for both childhood apraxia of speech and acquired apraxia of speech.  Some of the treatments can be used for either, but may need modification.

Integral Stimulation

Integral stimulation is a treatment strategy that uses a hierarchy of steps that gets more difficult as clinician modeling and cueing is reduced.  It was originally applied to acquired apraxia of speech by Rosenbek et al. (1973).  Integral stimulation is also used with children with CAS.  The technique is more widely used now partly due to research of Strand and colleagues (Strand & Skinder, 1999; Strand & Debertine, 2000; Strand, Stoeckel, & Baas, 2006). The priniciples of cognitive motor learning are used in this approach in building a hierarcy.  Multimodal cues are used in therapy to teach the client new information.

The following are the six steps to treatment of children with CAS:

1. The child watches and listens and simultaneously produces the stimulus with the clinician.
2. The clinician models, then the child repeats the stimulus while the clinician simultaneously mouths it.
3. The clinician models and provides cues and the child repeats.
4. The clinician models and the child repeats with no cues provided.
5. The clinician elicits the stimulus without modeling, such as by asking a question, with the child responding spontaneously.
6. The child produces stimuli in less-directed situations with clinician encouragement, such as in role-play or games.

Speech tasks should also be in a hierarchy from easy to difficult.
Therapy begins with what the child is able to do. Initially have the child practice the isolated sounds he is able to produce. These speech targets are determined from the evaluation results, including the phonetic inventory, measure of speech production, and informal observation. There are several reasons for starting with sounds the child can produce.
• By practicing sounds the child can already produce, he begins with a task where he can be immediately successful.
• Correct articulator placements are habituated so the child can consistently and voluntarily produce the sounds before he begins sequencing them. Repetitive practice and drill are used to stabilize his existing sounds.
• At this level, begin to introduce multisensory cueing techniques to facilitate habituation of the sounds before sound sequences are introduced. (tactile cues; pairing the sound with a picture)
• Practicing existing sounds validates the child’s communication attempts and increases his confidence, creates a successful experience, and makes it more likely that he will attempt new speech tasks.

Practice targeted consonant and vowel sounds in isolation so that productions are consistently under the child’s voluntary control before they are practiced in sequencing tasks. Drill and repeated practice, multisensory cueing, and consistent feedback are important. You should also utilize strategies such as describing the target sound (e.g., the /p/ sound is a “lip sound”), using a specific touch cue (e.g., touch the finger to the lips), or using a hand signal (e.g., fist opening as the /p/ is produced). For vowel sounds, these strategies may be used in the same manner. You can then incorporate the isolated sound productions into daily activities and interactive play, practicing them in a functional way over and over in a variety of settings at school and at home. For example, whenthe child can produce the /m/ sound, he can use it to express pleasure when eating a favorite food.

Prosody can be introduced at this level by having the child produce the sounds loudly, softly, using a high or low pitch, or with different rates or rhythms. For example, the child could pretend to drive a race car as he produces the /m/ sound. Using a track drawn on a sheet of paper, he would drive his car down the straight away, producing the /m/ sound loudly as he accelerates his car. When he comes to a turn, he would produce the /m/ softly because he would have to slow his car down to go through the turn.

Producing stabilized vowel and consonant sounds, sound sequences, and simple consonant-vowel (CV) and vowel-consonant (VC) syllables
Ask the child to sequence established vowel and consonant sounds to form simple sequences and syllable shapes. then increasing to words, phrases, sentences with many repetitions to establish a successful motor plan for speech production.
Velleman and Strand suggest beginning with CV(consonant-vowel: BA) word structures for one class of sounds (e.g. bilabials- /b, p, m/) then slowly changing the movement pattern into another class of sounds (e.g. alveolars- /t, d, n, l/). It can be at the discretion of the speech pathologist to proceed from the CV word structure to a CVC word structure for one class of sounds. The main goal of beginning with small word structures and slowly increasing to larger ones is the idea of developing and refining a motor pattern for speech production.

To encourage children to follow your directions, positive reinforcement will usually work well.  For example, after the child produces the stimulus, give the child a reward.

Examples of rewards/games:
-Desired food
-Stacking rings
-Placing a block/ball in a bin
-Shooting a ball through a hoop
-Placing a sticker on a game board (the child can get a reward after a certain amount of stickers)

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