Tales From Apraxia Boot Camp

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In August of this year, I was selected to be a part of The Childhood Apraxia of Speech Association of North America’s 2014 Intensive Training Institute, otherwise known as “Apraxia Boot Camp.” Twenty-four speech-language pathologists, including myself, trained with three mentors–Ruth Stoeckel, Kathy Jakielski, and Dave Hammer–at Duquesne University over four days. In its third year, the goal of the boot camp is to spread a high level of knowledge about Childhood Apraxia of Speech (CAS) assessment and treatment throughout the United States and Canada. This conference accomplished that and so much more.

This experience was different than any other continuing education seminars that I have attended. We did not listen to speakers discuss CAS. Instead, Ruth, Kathy and Dave became our mentors. This was powerful. They moderated discussions on evaluation and treatment approaches. We reviewed research papers and had long debates on the principles of motor learning. We highlighted and critiqued therapy methods for those brave enough to show videos of themselves. We problem solved and brought up more questions than we knew were possible.

In smaller groups, our mentors provided insights and personal perspectives on how they work. In this intimate setting, we felt comfortable asking questions and sharing our experiences. The mentors shared constructive criticism along with thoughtful suggestions. In all, they made me think, reflect and question everything I do. Why do I give that test? Why do I treat that way? What is the research behind it? They encouraged us to become critical thinkers.

As therapists, we often get used to using the same materials and therapy techniques we learned in graduate school or during our early experiences. Those methods are not always effective with every child we treat nor are they all proven effective with evidence based-research. Specifically, children with CAS require different therapy techniques than other children with articulation or phonological delays.

Ruth, Kathy and Dave provided valuable information in a small, engaging setting. Their mentoring and passion for CAS has inspired me and I hope to pass along this valuable information to others through mentoring, improving my competency in treatment and diagnosis of CAS, and, in the end, helping children to communicate.

Based on my experience, I’d recommend asking yourself a few questions when selecting your next continuing education event:

  • What am I passionate about? Is there a child or an area of speech pathology that truly inspires me?
  • How will it improve my skill set?
  • How will it help me better serve my clients?
  • Who is doing the most current, researched-based evaluation or therapy techniques?
  • How will it further our profession?

 

Amanda Zimmerman, MA, CCC-SLP, is a pediatric speech-language pathologist in Columbus, OH. She can be reached at azimmerman@columbusspeech.org.

Why Suspected Childhood Apraxia of Speech Requires Careful Assessment

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Recently I got one of those phone calls that speech-language pathologists often dread. It went something like this:

Parent: Hi. I am looking for a speech therapist who uses PROMPT [Prompts for Restructuring Oral Muscular Phonetic Targets] to treat my son’s childhood apraxia of speech. Are you PROMPT-certified?

Me: I am PROMPT-trained and I do treat motor speech disorders but perhaps you can first tell me a little bit about your child? What is his age? What type of speech difficulties does he have? Who diagnosed him and recommended the treatment?

Parent: He is turning 3. He was diagnosed by a neurodevelopmental pediatrician a few weeks ago. She recommended speech therapy four times a week for 30 minutes, using PROMPT.

Me: And what did the speech therapy evaluation reveal?

Parent: We did not do a speech therapy evaluation yet.

Sadly, I get these types of phone calls at least once a month. Frantic parents of toddlers ages 18 months to 3+ years call to inquire about PROMPT therapy based on a neurodevelopmental pediatrician’s diagnosis. The speech-language diagnosis, method of treatment and treatment were typically specified by the physician in the absence of a comprehensive speech language evaluation and/or past speech-language therapy treatments.

The conversation that follows is often uncomfortable. I listen to the parent’s description of the symptoms and explain that the child needs a comprehensive speech language assessment by a certified SLP before being treated. I explain to the parent that, depending on the child’s age and the findings, the assessment may or may not substantiate CAS because symptoms are similar in a number of other speech and communication disorders.

Parents react in a number of ways. Some hurriedly thank me for my time and resoundingly hang up. Some stay on the line and ask me detailed questions. Some request an evaluation and become clients. A number of them find that their child never had CAS! Past misdiagnoses have ranged from autism spectrum disorder (CAS was suspected because of imprecise speech and excessive jargon) to severe phonological disorder to dysarthria secondary to cerebral palsy.

CAS is a disorder that disrupts speech motor control and creates difficulty with volitional, intelligible speech production. Research indicates that while children with CAS have difficulty forming words and sentences at the speech level, they also struggle with areas of receptive and expressive language. In other words, “pure” apraxia of speech is rare.

This condition needs to be diagnosed by an SLP. In fact, due to the disorder’s complexity, it is strongly recommended that parents seek an assessment by an SLP specializing in assessment and treatment of motor speech disorders. Here’s why.

  • CAS has a number of overlapping symptoms with other speech sound disorders, such as severe phonological disorder and dysarthria.
  • Symptoms that may initially appear as CAS may change during the course of intervention, which is why diagnosing toddlers under 3 years of age is problematic. Instead, a “suspected” or “working” diagnosis is recommended in order to avoid misdiagnosis.
  • Diagnosis of CAS is nuanced, complex and challenging, though a new instrument—Dynamic Evaluation of Motor Speech Skill (DEMSS)—shows promise with respect to differential diagnosis of severe speech impairments in children.

When children with less severe impairments, SLPs need to determine where the breakdown is taking place by designing tasks assessing:

  • Automatic versus volitional control.
  • Simple versus complex speech productions.
  • Consistency of productions on repetitions of same word.
  • Vowel productions.
  • Imitation abilities.
  • Prosody.
  • Phonetic inventory before and after intervention.
  • Types and levels of cuing required for response.

Given the complexity of CAS assessment and treatment described here, you can see that the PROMPT approach may not even be applicable to some children. Thus, I strongly urge developmental clinicians to first refer a child for a speech language assessment—and refrain from making recommendations for specific types and frequencies of treatment—when difficulty with speech production is observed.

For more information on childhood apraxia of speech, please visit the Childhood Apraxia of Speech Association of North America website or visit the ASHA website to find a professional specializing in the diagnosis and treatment of CAS near you.

 

Tatyana Elleseff, MA, CCC-SLP, is a bilingual speech-language pathologist with Rutgers University Behavioral Healthcare and runs a private practice, Smart Speech Therapy LLC, in Central New Jersey. This post is adapted from a post that originally appeared on her blog, Smart Speech Therapy LLC. She specializes in working with multicultural, internationally and domestically adopted children and at-risk children with complex communication disorders. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education, 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, and 16, School-Based Issues.