Maximizing the Speech Ability of Children with Motor Speech Disorders Handout #1. Multiple Factors to Consider

Transcription

1 Maximizing the Speech Ability of Children with Motor Speech Disorders Handout #1 Speech-Language & Audiology Canada Conference Ottawa, ON May 8, 2014 Megan Hodge, Ph.D., R.SLP, SLP(C) University of Alberta Multiple Factors to Consider Teacher Child Parents SLP/SLP-A System - Employer Funding Source (Health, Education, Other) Severity of Condition (Speech Disorder) = Increased Demand for Clinical Resources Time Assessment Treatment Case Management Expertise of SLPs Number of Professionals Involved Support for Families 1

2 Acknowledgments Children and Parents Colleagues Students LST Team CHEO at Children s Hospital of Eastern Ontario University of Alberta Canadian Language and Literacy Research Network Alberta Health Services Edmonton Zone Early Childhood Programs Edmonton Area Outline: Morning Session 1. Target Population a. Recast as Children with Neurodevelopmental Disabilities b. Characteristics 2. Speech Ability a. Fit within the ICF-CY Framework b. Outcome Measures 3. Current Ideas about Best Practice 4. Getting Speech Started: 2 & 3 year-olds Outline Afternoon Session 5. Increasing Speech Clarity & Acceptability (4+ year-olds) a. Articulation b. Voice c. Prosody d. Self-Confidence 6. Edmonton Pilot Project: Building a Care Path for Children with Severe Speech Delay/Disorders with Motor Speech Involvement 7. Summary and Questions 2

3 Motor speech disorders Dysarthrias spastic dyskinetic ataxic mixed flaccid Stuttering Mixed CAS Planning Executive Childhood Motor Speech Disorders *Child is learning to understand and use sound system of language but is constrained in ability to - plan - sequence - control and coordinate positions and movements of muscle groups used to generate speech due to impairment in the brain (damage/dysgenesis affecting neurons & connections) Hypothesized Regions of Brain Affected Dysarthrias Supplementary Motor Area Primary motor cortex/sensorimotor cortex lateral Stuttering Supplementary Motor Area Broca s Area Basal Ganglia Cerebellum (above Sylvian fissure) Basal Ganglia Perisylvian Cerebellum Areas Upper Motor Neuron Pathways (temporal, parietal, frontal Lower Motor Neurons & Cranial/Spinal nerves lobes) CAS Supplementary Motor Area Broca s Area Prefrontal cortex Basal Ganglia Cerebellum Left Perisylvian Areas (temporal, parietal, frontal lobes) 3

4 Hickok & Poeppel (2007) Hypothesized Neural Functions Affected CAS Creating/ retrieving motor plan and program for actions (positions and movements) of vocal tract muscle groups and sequencing these for intended utterance Stuttering Can use feed back this requires slower rate of speech production; problems arise when use open loop feedforward systems Dysarthrias Executing motor program for intended utterance Disruptions in signals from brain (direct and indirect upper motor neuron pathways, modulated by basal ganglia & cerebellar control circuits) sent to brainstem and spinal cord to muscles results in slow, imprecise movements of speech muscle groups Childhood Apraxia of Speech (Speech Learning Problem) Dysarthria* (Speech Learning Delay and Neuromuscular Problem) Difficulty positioning muscles for volitional production of sounds, or sequencing movements for speech/ speech-like tasks, that can not be explained by: - weakness - muscle tone abnormalities Actions of oral muscles not affected for chewing, feeding, swallowing, controlling saliva, resting posture of lips and tongue Articulation & Prosody affected Weakness, muscle tone abnormalities interfere with muscle actions for speech regardless of type of task (consistent) Actions for oral muscles also affected for nonspeech tasks (chewing, feeding, swallowing, controlling saliva, resting posture of lips, tongue, jaw) Respiration, Phonation, Resonance, Articulation & Prosody all may be affected 4

5 Sound Generation and Shaping Creating sound and filtering it to produce consonant and vowel sequences of the language Speech Processes Prosody (rate-rhythm over breath groups) Articulation (Actions of jaw, lips, tongue & soft palate to make consonants and vowels and link these into syllables: spatial-temporal precision important for sound identity) Resonance (soft palate pharynx) Phonation/Voice (vocal folds) Respiration (diaphragm, rib cage, abdomen) Speaking Movements made audible that carry meaning coded in language Sound Source Sound Filter Speech Language, coded in sound patterns, produced by sequences of rapid, coordinated actions, of sets of muscle groups Impairment: Childhood Apraxia (not specific to speech) Developmental disorder of mental functions of sequencing and coordinating complex, purposeful movements (International Classification of Function, Disability and Health, 2002) Difficulties abstracting information from sensory input and transforming this to action patterns (gross motor, fine motor, oral motor, occulomotor skills may be affected) Difficulties in learning, storing (memory) and organizing movement patterns to achieve goals In Childhood Apraxia of Speech speech processing networks are affected 5

6 Childhood Apraxia of Speech ASHA Position Statement (2007) CAS exists as a distinct diagnostic type of neurogenic childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in absence of neuromuscular deficits (weakness, abnormal reflexes) Core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody Hypothesized Impairment in CAS Debate. Limited to impairments in: - Planning and programming space and time properties of movements for speech sound productions or, includes impairments in: - Representational level segmental and/or suprasegmental units in both input processing and production? e.g., transforming the sound patterns heard into constituent phonemes (speech sounds), maintaining the ordered and phonologically coded string in working memory, and organizing the articulatory output. Impairment: Childhood Apraxia - May show other "soft" neurological signs, with awkwardness and poor motor planning in other motor systems (Developmental Coordination Disorder) Lewis (2002) Profile of CAS changes with development Articulation problems may resolve somewhat while language and learning problems persist (literacy) - Other learning disabilities may emerge in school years 6

7 Childhood Apraxia of Speech ASHA Position Statement (2007) cont. Complex of behavioral features associated with CAS places child at: Increased risk for early and persistent problems in speech, expressive language and phonological foundations for literacy Possible need for augmentative and alternative communication approaches Cochrane Review (Morgan & Vogel, 2009) Some agreement that children with CAS may have impairments in one or more of the following domains: Non-speech oral motor function, motor speech function, speech sounds and structures (i.e., syllable and word shapes), prosody, language, phonemic awareness/ metalinguistic skills, and literacy Ongoing deliberation over etiology and diagnosis Impairment: Dysarthria Breakdown in sending neural signals from brain out to muscle groups to execute motor plans & programs Speech Muscles Show: Weakness Slowness Reduced range of movment Muscle tone abnormalities (hypertonia; hypotonia) Reduced coordination and accuracy of muscle groups of the speech mechanism (distorted sounds) All speech processes can be affected: Articulation Resonance Phonation Respiration Prosody 7

8 Impairment: Dysarthria Motor control problem is present regardless of task or context (speech and nonspeech movements, volitional and automatic ) See problems in chewing, swallowing, controlling saliva, resting lip, jaw and tongue posture neuromuscular problem Developmental dysarthria is the most common speech disorder in children with cerebral palsy (CP) In CP, motor control of trunk and limbs are typically affected as well Focal Developmental Childhood Motor Speech Disorders without co-occurring deficits in at least one other developmental domain are rare Gross Motor Fine Motor Expressive Language Cognition Bigger Picture Perspective Childhood motor speech disorders are a type of neurodevelopmental disability (Accardo, 2008) Neurodevelopmental disabilities result from CNS impairment (static and chronic) While underlying CNS pathology remains constant, as the child grows and develops,: Manner in which the disability presents clinically changes Priorities on child s problem list change 8

9 What Causes Childhood Neurodevelopmental Disabilities? CNS impairment due to: (Accardo, 2008) Genetic Abnormalities (inherited/sporadic) Peri-Post Natal Events Neonatal Complications Trauma/Infection Seizures Organic Brain Syndromes Fetal Infection Hypoxia/Ischemia Toxins Nutritional Deficiencies Metabolic Problems Rarely arise de novo: *Profile of characteristics evolves from infancy to adulthood Lifelong brain differences/not necessarily handicaps Childhood Apraxia of Speech ASHA Position Statement (2007) cont. Occurs in three distinct clinical contexts: Associated with known neurological causes e.g., stroke, febrile seizures May be a primary or secondary sign in complex neuro developmental disorders (genetic; metabolic) *Unknown (idiopathic) cause Same as Causes of Neurodevelopmental Disabilities children with CAS have a neurodevelopmental disability. Big Picture Perspective Neurodevelopmental Disability ( from Accardo, 2008) 9

10 Accardo (2008) Most children presenting for developmental assessment have one specific stream of development highlighted (e.g., delays in gross/fine motor speech, social/adaptive milestones) But primary neurodevelopmental diagnosis is often a marker for much larger underlying continuum of CNS dysfunction (heterogeneity of expression) Accardo (2008) Rare for brain involvement severe enough to produce a significant delay in one area to affect only that stream of development Underlying continuum of cerebral dysfunction results in wide range and severity of associated dysfunctions that tend to occur in addition to the primary disorder Associated deficits often reveal more about severity of disability and likelihood of various outcomes than primary diagnosis Accardo (2008) Importance of sequential appearance of prelinguistic vocalizations to early diagnosis of neurodevelopmental disability Associations between these and: later IQ score, language age, communication disorders and learning disabilities support interpretation of pre-linguistic milestones as neuromaturational markers for entire neurodevelopmental disabilities spectrum 10

11 Selected Speech Behavioral Accomplishments in First Year of Life (Kent, 1992) Age (mo) <1 1-4 Production (*Perception Leads Production) Phonation: crying, vegetative sounds Cooing General Development Expansion: Increase in consonants ; increase in surpraglottal articulation Conversational turn-taking behavior Multisyllable babble stage rhythmic strings Babbling takes on sentence-like intonation, takes on some phonetic characteristics of native language Vocables, protowords, phonetically consistent forms; first word Shared positive affect; triadic eye gaze fmri Study (Peeva et al., 2010) Results suggest that different brain regions are involved in: Movements for sounds left SMA, pallidum, posterior superior temporal gyrus, and superior lateral cerebellum Production of syllables left ventral premotor cortex - Broca s area Production of multisyllabic utterances - right superior lateral cerebellum In typical development, children are doing this by 8-10 months (Kent, 1992) - implications for children with severe speech delay? WHO Childhood Motor Speech Disorders Recast Children with (or suspected) neurodevelopmental disabilities where the underlying (suspected) CNS impairment: Delaysonset of prespeech linguistic vocalizations and speech behaviors (delays learning to talk) and Impairs (deviancy): Development of specific mental functions used to plan/program volitional gestures and gesture sequences for speech due to impairment to brain networks involved in these processes (speech praxis disturbance - CAS), and/or Development of neuromuscular control over the muscle groups used to speak due to damage to the neural pathways from the brain to these muscle groups and associated sensory pathways back to the brain (dysarthria) 11

12 Childhood Motor Speech Disorders Recast While the presenting speech disorder may be the primary area of concern, reasonable likelihood of associated deficits; some that may not appear until later Deficits in associated domains that affect learning may compound the severity the speech disorder and limit child s speech ability outcome e.g., attention, memory, cognition, social-affective, executive function Assumptions about Learning Disabilities People with learning disabilities and disorders can learn strategies for coping with their disabilities. Getting help earlier increases the likelihood for success in school and later in life. If learning disabilities remain untreated, a child may begin to feel frustrated, which can lead to low selfesteem, depression, and other problems. Usually, experts work to help a child learn skills by building on the child s strengths and developing ways to compensate for the child s weaknesses. Interventions vary depending on the nature and extent of the disability. Severity of Condition (Speech Disorder) = Increased Demand for Clinical Resources Time Assessment Treatment Case Management Expertise of Professionals (SLPs) Number of Professionals Involved Support for Families 12

13 Therapy Handout 1 Megan Hodge Team of Choice for Children with Motor Speech Disabilities Family Child OT/PT School SLP Psychologist Pediatrician Feeding Fluency Voice Resonance Oromyofunctional Implications for Management Early Identification Early Intervention Expect that children will require extended period of time to develop their speech abilities Expect that during this time, blocks of intensive, developmentally appropriate speech therapy will be needed to help these children learn to become intelligible talkers Expect that interventions will change as child s speech abilities change Need to provide a service delivery plan to address the needs of children and their parents over the period that these children are developing their speech abilities, that anticipates and supports transitions between service types Developmental Childhood Dysarthrias: Cerebral Palsy (CP) CP affects children per 1,000 live births (Bax et al. 2006; Msall & Park 2009) Group of disorders of development of movement and posture, causing activity limitation attributed to nonprogressive disturbances in developing fetal or infant brain. Motor disorders are often accompanied by disturbances of sensation, cognition, communication, perception, and/or behaviour, and/or by seizure disorder (Bax et al., 2005) 13

14 Cerebral Palsy Possible Associated Disturbances When areas of the brain that control speech production are affected, a child has to learn to control and coordinate the muscles to speak with a faulty neuromotor substrate, plus potential impairments in other domains that are also developing... Motor Sensory Perception Cognitive Communication Behavior Seizures Cerebral Palsy **In addition to speech production, other aspects of communication that may be affected include (Bax et al.,2005): Understanding and use of words (vocabulary) Comprehending and formulating linguistic messages using appropriate grammar and syntax Using language for different purposes and follow conversational norms (pragmatics) Hustad et al. (2010) identified 4 groups of children based on presence or absence of motor speech disorder in a convenience sample of 4 year-olds with CP: - Normal language & no observable speech impairment (23.5%) - Normal language & motor speech impairment (26.5%) - Delayed language & motor speech impairment (18.0%) - No functional speech (32.0%) Speech plus Motor control problem is neuromuscular in nature and is present regardless of task or context, involving speech and nonspeech movements of the affected muscle groups. Other oral-pharyngeal and laryngeal-respiratory functions (e.g. chewing, swallowing, controlling saliva, resting lip, jaw and tongue posture, airway maintenance and clearance) can be affected. Early feeding difficulties and persisting primitive oropharyngeal reflexes are pre-speech risk factors for developmental dysarthria (Otapowicz et al. 2007). 14

15 Speech Disorders in Children with Cerebral Palsy Up to 80% of those with CP have dysarthria (Odding et al, 2006) No standardized system specific to classifying developmental dysarthria. Problem as site of lesionspeech characteristic correspondences observed in adult-onset dysarthria (e.g., Mayo system) not as robust in children (Morgan et. al., 2010; Schölderle et al., 2013) Range of severity of speech disorders mild to profound Estimated that at least 16% of children with CP do not have functional speech (anarthric) (Sigurdardottir &Vik, 2011) Characteristics of childhood apraxia of speech may co-occur Fluency disorders may co-occur Impact of Cerebral Palsy on Motor Control for Speech Production Delays early speech learning Impairs strength, speed, accuracy, coordination and endurance of the muscle groups used to speak. These factors constrain development of differentiated, precise, dynamic actions of the oral articulators and their coordination with the respiratory-phonatory system to produce clear, efficient speech patterns Speech Characteristics Children with Cerebral Palsy May Exhibit Difficulty producing voice Short breath groups (few words per breath) Abnormal voice quality (strained; breathy) and volume Hypernasal resonance and nasal air emission Imprecise, distorted vowels and consonants Particular difficulty with sounds that require more precise timing and accuracy diphthongs, liquids, fricatives, affricates, voicing contrasts, consonant clusters Difficulty using contrastive stress (equal stress on all words) Slow rate of speech movements and slow speaking rate (words per minute) Imprecision increases towards end of utterances in longer utterances Increased effort to speak 15

16 Tongue Issues Children with spastic and dyskinetic CP and developmental dysarthria often show a persisting pattern of dependency of lip and tongue movements on jaw movement, and lack differentiated anterior and posterior tongue movements when producing speech sounds (Workinger 2005). Without specific intervention, many children with developmental dysarthria: Do not elevate the tongue tip for lingual-alveolar place of articulation (use dental or interdental placement) Show a persisting pattern of undifferentiated tongue movements that are linked to jaw and lip movements (Love 1999). Associated with this are a persisting low resting posture of the tongue and immature swallowing pattern. Speech Characteristics Children with Cerebral Palsy May Exhibit Speech can be affected adversely by fatigue to a greater extent than for children without neuromotor impairment. Augmentative and alternative communication (AAC) systems are often provided to supplement natural communication modes However, children with dysarthria prefer to communicate using speech (Pennington et al. 2009). Viking Speech Scale 4 Levels (children with CP) Pennington et al. (2013) I Speech not affected by motor disorder II Imprecise speech but usually understandable to unfamiliar listeners out of context - adequate loudness for 1-1 conversing - harsh or breathy voice but does not affect intelligibility - most consonants produced but deterioration is noticeable in longer utterances 16

17 III IV Viking Speech Scale 4 Levels (children with CP) Pennington et al. (2013) Unclear speech not usually understandable to unfamiliar listeners out of context - difficulties with breath control - one word per utterance and/or - speech sometimes too loud or soft to be understood - voice may be harsh - pitch may change suddenly - may hear marked hypernasality - small range of consonants produced No understandable speech Speech Sound Error Patterns of Children with Cerebral Palsy Bauman-Waengler (2008) and Hodge et al. (2013) Errors related to impaired motor control and phonetic placement Developmental Fronting Stopping Gliding Vowelization of [l], [r] Developmental Monophthongization CONSONANTS Unusual Nasalization Lateralization of lingual fricatives Backing Dentalization of /s, z, l, n, t, d/ Labiodental placement for bilabials VOWELS Unusual Nasalization (May also result from impairment in temporal coordination) Centralization 17

18 Errors related to impaired temporal coordination CONSONANTS Developmental Consonant cluster reduction Final consonant deletion Stopping of fricatives Weak syllable deletion On and off glides Unusual Frication of stops Prevocalic voicing Variable realizations of voiced-voiceless cognates (e.g. voicing of unvoiced sounds; devoicing of initial consonants) Inappropriate aspiration Ingressive fricatives Additions (sounds, syllables) Worster-Drought Syndrome Non-progressive spastic (plus athetoid sometimes) cerebral palsy affecting upper motor neuron pathways to brainstem i.e., corticobulbar tract Affects muscles receiving innervation from brainstem (lips, tongue, soft palate, pharynx, larynx) Complete and Incomplete forms Difficulty with sucking, chewing/swallowing Drooling Other signs of oral-motor incoordination Dysarthria Some children with WDS show signs of CAS & dysarthria Signs may change as child develops Apraxia impairment may not be obvious after child develops speech Signs of dysarthria become more evident and persist Complete vs. Incomplete Types (Crary, 1993) Complete: - Involves lips, tongue, velopharynx and larynx - Lingual and labial errors - Hypernasality - Dysphonia, low pitch - History of dysphagia, excessive drooling Incomplete: - Error patterns depend on selective involvement of lips, tongue or velum. - Tongue and velopharyngeal muscle groups affected most frequently - Soft Palate Only : 45% - Soft Palate & Tongue: 22% - Tongue & Lip: 18% - Soft Palate & Lip: 15% 18

19 Case Example When not obvious signs to identify dysarthria at young age default to suspected CAS when see evidence of red flags for motor speech disturbance Worster-Drought Syndrome Congenital Suprabulbar Palsy plus Congenital Bilateral Perisylvian Syndromes Worster-Drought Syndrome is one of these (Clarke, 2010) Identification Children diagnosed with cerebral palsy, cranial nerve damage or genetic syndromes involving speech are typically identified earlier than children without other obvious motor deficits Children with severe feeding difficulties are at high risk for motor speech disorders e.g., Worster-Drought Syndrome (congenital bilateral perisylvian syndromes) Developmental Dysarthria Prevalence Estimate in Population of Children with CP (including congenital bilateral perisylvian syndromes) 1.9 per 1000 children 19

20 One of the most perplexing and controversial speech disorders in the profession is apraxia of speech in children (Ruscello, 2007) Since first reference to it in 1954 (Morley, Court & Miller) researchers and clinicians have struggled to: Label and define the disorder Formulate an explanatory theoretical model Identify a key list of diagnostic features that reliably identify children with the suspected disorder Develop appropriate interventions Childhood Apraxia of Speech ASHA Position Statement (2007) cont. No validated list of diagnostic features Some consensus that these features are consistent with a deficit in planning and programming movements for speech: Inconsistent errors on consonants and vowels on repeated productions of syllables or words Lengthened and disrupted coarticulatory transitions between sounds and syllables Inappropriate prosody, especially for lexical or phrasal stress Suspected CAS? Identification is a challenge Overlap of signs/behaviours between CAS and other developmental speech/language difficulties; associated difficulties in expressive language, gross and fine motor development and higher level reasoning not yet obvious When CAS is suspected in young children, 6-12 months of diagnostic therapy is recommended before applying a label (Davis & Velleman, 2000) 20

21 Particularly associated with CAS: Difficulty moving smoothly from one sound, syllable or word to another Groping movements with the jaw, lips or tongue to make the correct movement for speech sounds Vowel distortions, Using the wrong stress in a word, or Using equal emphasis on all syllables, such as saying "BUH- NAN-UH" Separation of syllables-putting a pause or gap between syllables Inconsistency - making different errors when trying to say the same word a second time Difficulty imitating simple words Inconsistent voicing errors, such as saying "down" instead of "town" Characteristics seen in both children with CAS and in children with other types of speech or language disorders: Reduced amount of babbling or vocal sounds from ages 7 to 12 months old Speaking first words late (after ages 12 to 18 months old) Using a limited number of consonants and vowels Frequently leaving out (omitting) sounds Difficult to understand speech Challenges to Diagnosis Early differential diagnosis is complicated by limited speech output If no multiword utterances are produced, voice, resonance, fluency, prosody are difficult to assess No validated list of diagnostic features for CAS (ASHA, 2007) As more speech is produced, additional impairments may be identified Children are evolving through neurological maturation while acquiring developmental skills Expression of impairment may not be obvious until time that skill is typically acquired Diagnosis for Young Children with Severe Speech Delay and Suspected Motor Speech Disorder Based on: Detailed history Speech motor examination Analysis of speech sound repertoire (vowels and consonants), syllables shapes, multisyllabic utterances Response to treatment (intervention RTI) at younger ages Need systematic observation over time e.g., Pukonen et al. (2011) Neurodevelopmental SLPs 21

22 Madison Speech Assessment Protocol (MSAP) (Potter et al., 2012) Four age-based protocols: Preschool, school-aged, adolescent, adult Each protocol includes 15 speech tasks Articulation Task DDK Task Challenging Word Tasks (2) Phonation Task Challenging Phrase Task Nonword Repetition Tasks (2) Consonants Task Conversational Sample Stress Tasks (2) Vowel Tasks (3) Pediatric Adaptation of Mayo Clinic System (Lohmeier & Shriberg 2011) Classification of a speaker as positive for CAS (CAS+) required at least 4 of the following 10 signs in at least 3 of the MSAP speech tasks: Vowel distortions Difficulty achieving initial articulatory configurations or transitionary movement gestures Equal stress; lexical or phrasal stress errors Distorted substitutions Syllable or word segregation Groping Intrusive schwa Voicing errors Slow speech rate and/or slow DDK rates Increased difficulty with multisyllabic words Some Recent Findings A Four-Sign Diagnostic Marker to Discriminate CAS from Speech Delay Shriberg (2013) Classification Criterion for CAS: Positive finding on at least three of the four signs of CAS Sign Finding Inappropriate Pauses + Slow Articulatory Rate + Inappropriate Stress + Inaccurate Transcoding + Any 3 or all 4 = CAS PAUSE+STRESS+ has been shown to be the main diagnostic feature that separates children with CAS from age/gender matched peers with Speech Delay (Bayliss et al., 2013) 22

23 Some Recent Findings The Fourth Diagnostic Sign is Obtained from the Syllable Repetition Task (SRT) Sign: Inaccurate Transcoding Lohmeier & Shriberg (2011); Shriberg & Lohmeier (2008); Shriberg et al. (2009; 2012) SRT Results: Children Classified with CAS Have Difficulties with Speech Auditory Processing Competence Accuracy of consonant matches Processing Encoding (within manner substitutions) Memory (more errors on longer items) Transcoding (sound addition errors) Prevalence of CAS In a study of 12,000 to 15,000 estimated diagnostic outcomes for children referred with speech delay of unknown origin from 1998 to 2004, a staff of 15 speech-language pathologists in a large metropolitan hospital diagnosed 516 (3.4% 4.3%) of these children as having suspected CAS (Delaney & Kent, 2004) Prevalence of speech sound disorders in young children is estimated to be 8-9%. 4% of 8/100 young children with SSD-unknown = Estimated 0.34 children per 100 or 3.4 per 1000 with CAS 23

24 Diagnosis for Young Children with Severe Speech Delay and Suspected Motor Speech Disorder Based on: Detailed history Speech motor examination Analysis of speech sound repertoire (vowels and consonants), syllables shapes, multisyllabic utterances Response to treatment (intervention RTI) at younger ages Need systematic observation over time e.g., Pukonen et al. (2011) sample checklist Neurodevelopmental SLPs English Assessment Tools Kaufman Speech Praxis Test for Children (Kaufman, 1995) Verbal Motor Production Assessment for Children (Hayden & Square, 1999) Purpose - Assist in diagnosis of developmental apraxia of speech - Assist in treatment of developmental apraxia of speech - Determine severity Purpose - Determine presence or absence of a motor disruption affecting speech production - Differential diagnosis of apraxia of speech vs. dysarthria - Identify best teaching modality - Determine severity Red Flags for MSDs Presence of a medical condition that is known to affect brain development Positive family history for speech problems History of gross motor/fine motor difficulties Delay Difficulty imitating and learning new motor movements (motor planning) Motor coordination problems Difficulty matching rhythm patterns 24

25 Red Flags cont. History/Presenting Speech Difficulties Delayed speech onset Comprehension of language superior to speech (dissociation); intent to communicate (gestures) Low frequency of early vocalizations Limited repertoire of early vocalization Slow progress increasing phonetic repertoire and syllable/word shapes Inconsistent errors Errors increase as utterance length increases Abnormal voice quality and/or resonance Abnormal prosodic patterns (e.g., stress, pause, fluency) Limited, slow movements of speech muscle groups during speech (slow speaking rate) Effortful speech production Red Flags cont. Difficulty with Non Speech Oral-Motor Function History of feeding difficulties Sucking, chewing Messy or slow eater Oral sensory issues Gagging, strong texture/taste preferences Low tolerance for oral stimulation (e.g. toothbrushing) Mouth breather; abnormal lip, jaw, tongue resting postures and/or muscle tone Lack of or reduced facial expression Reduced range of motion, coordination or speed of movement of speech muscle groups Lack of independent movement of lips, tongue and jaw after age 5 years Developmental Motor (Sensori-motor Perceptuo-motor) Speech Disorders Continuum Childhood Apraxia of Speech (subtypes) Mixed Not Otherwise Specified Dysarthria (subtypes) Suspected Motor Speech Disorder? Topography of motor control impairment: Speech mechanism alone Speech mechanism plus 25

26 Criteria for Motor Speech Involvement Namasivayem et al. (2013) Child (3;11 6; 7) must have at least 4 of following: 1. Limited variety of speech motor movements 2. Variable productions 3. Limited vowels/has vowel distortions 4. Limited consonants/consonant distortions 5. Limited syllable and word shapes 6. Number of age inappropriate phonological processes 7. Atypical intonation 8. Inappropriate pitch, rate, loudness and nasality Difficulty maintaining sound and syllable integrity with increased length and complexity of utterance 9. Increased error variability 10. Groping 11. Fatigue 12. Decreased intelligibility Effects of Neurologic Impairment in Childhood Motor Speech Disorders Impaired Movement for Speech Lack of movement, difficulty imitating movements, difficulty sequencing movements, slow and limited range of movement, weakness, inaccurate movements, lack of differentiated movements (tongue especially) Reduces: Rate & quality of speech development Intelligibility of speech - how well it can be understood Speaking rate (slow, less efficient) Acceptability of speech Opportunities for child to engage in social communication routines in daily life Success of communicative interactions Limits social, language (oral & written), cognitive development Body Structure and Functions (Impairment) Neural [brain] speech processing networks and pathways to control speech muscles Respiratory Laryngeal Velopharyngeal Articulators lips, tongue, jaw ICF-CY Framework Childhood Motor Speech Disorders Activity Speaking Speech Sounds Intelligibility Efficiency Quality/Acceptability Participation Communicative Effectiveness Speech Plus Independence Contexts Partners International Classification of Functioning, Disability and Health Children-Youth Version Integrates medical & social models of disability 26

27 Contextual Factors Environmental Factors Caregivers, Services Knowledge and skills to facilitate child s communication development Type and frequency of: Social interactions Opportunities to practice speech skills Speech language services Personal Factors Child Personality (attention, motivation, cooperation) Severity of speech disorder Other domains affected Language, cognition, motor skills, perception How underlying impairment is expressed as child grows and develops Goals of Speech-Focused Treatment Increase Speech Abilities (ICF-CY Activity Level) to Improve Communicative Effectiveness (ICF-CY Participation Level) Measuring Communication Participation Outcomes Focus on Outcomes Under Six FOCUS New outcome tool for use by both parents and clinicians that measures changes in the communicative participation skills of preschool children Five-level Communication Function Classification System (CFCS) (Cooley Hidecker et al. 2011) for persons with cerebral palsy Can be used by parents, caregivers or professionals familiar with the individual; has no age specifications. All methods of communication are considered (speech, gestures, eye gaze, facial expressions, augmentative and alternative communication. Three factors used to distinguish among levels: Performance in roles of communication sender & receiver Pace of communication Type of conversational partner (familiar/unfamiliar). 27

28 Activity Measures - Speech Ability Goals of treatment to increase speech ability: Consonant and Vowel inventory and accuracy Word shape accuracy 1 syllable: V, CV, VC, CVC, CCV, CCVC etc. > 1 syllable CVCV, VCV, CVCVC, etc. Word shape accuracy maintained in connected speech Match prosodic patterns (rate and rhythm) of language Maximize speech intelligibility Maximize overall speech quality/acceptability Gain confidence using speech Measuring Vowel Production Number of Vowel Types Percent vowels correct Percent monophthongs correct Percent diphthongs correct Error types Tensing, laxing, height, place, centralized, etc. Speech Samples: Imitated/spontaneous words/connected speech Measuring Consonant Production Number of Consonant Types Percent consonants correct Percent singletons consonants Percent clusters correct Error Types Manner, place, voicing Patterns fronting, stopping, gliding, etc. Speech Samples: Imitated/spontaneous words/connected speech 28

29 TOCS-30 Group Comparisons: 3 year-olds Woolridge & Hodge, (2012) Number * Unique Syllables Unique Consonants Unique Vowels Phonetic Measures * scas SSD TS *Significant group difference TOCS-30 Group Comparisons:3 year-olds Woolridge & Hodge, (2012) Percent scas SSD TS 0 * * * PCC PCC-R PVC Phonetic Measures *Significant group difference Measuring Syllable Production - Number of Syllable Shape Types - Percent syllable shapes correct Measuring Whole Word Production (Schmitt et al., 1985; also see Ingram et al., 2001) - Number of Word Shape Types - Percent exact word matches (all sounds in word are accurate; stress pattern appropriate for multisyllable words) Speech Samples: Imitated/spontaneous words/connected speech 29

30 TOCS-30 Group Comparisons: 3 year-olds Woolridge & Hodge, (2012) Percent scas SSD TS 0 PWP Phonetic Measures PWWA * * *Significant group difference Measuring Intelligibility (Hodge & Whitehill, 2010) How many words can a listener understand? Audio record the child saying a list of 50 words or phrases Later, play these back one at a time to a listener listener does not know the words in advance Listener writes word(s) heard Count how many words the listener identified correctly convert to percentage = % intelligible words Sample Intelligibility Measures TOCS+ Word and Sentence Tests (Hodge, 2013) Intelligibility Score (%) Word TOCS+ Measure Sentence Typically Developing 4-6 yr SSD-UNK 4-6 yr Dysarthria 4 12 yr 30

31 Intelligibility in Context Scale (ICS) (McLeod, Harrison & McCormack, 2012) Quick parent report measure of children's intelligibility. 7-item questionnaire rates the degree to which children's speech is understood by different communication partners (parents, immediate family, extended family, friends, acquaintances, teachers, and strangers) on a 5- point scale. Developed to provide speech-language pathologists with information about children's intelligibility (e.g., children with speech sound disorders, childhood apraxia of speech). Free and downloadable from: Measures of Prosody and Voice Example: Prosody-Voice Screening Profile (Shriberg et al., 1990; 1992) Percentage of utterances with appropriate phrasing Percentage of utterances with appropriate rate Percentage of utterances with appropriate stress patterns Percentage of utterances with appropriate pitch Percentage of utterances with appropriate loudness Percentage of utterances with appropriate voice quality Laryngeal Features Resonance Features Speech Sample: Based on 24 codable utterances from audio recording of a conversation sample Other speaking rate measures: Words per minute, syllables per minute, intelligible words per minute Sample Rate Measures Words/Minute & Intelligible Word/Minute (Hodge, 2013) Typically Developing 4-6 yr SSD-UNK 4-6 yr Dysarthria 4 12 yr 120 Speaking Rate WPM IWPM TOCS+ Sentence Rate Score Type 31

32 Measuring Speech Acceptability Refers to the perceived pleasingness of the speech sample and how well it conforms to the listeners expectations for talkers of the same age and sex as the talker being rated. Many factors contribute to ratings of speech acceptability: intelligibility, voice quality, pitch and loudness, resonance and prosody. Purpose of an Acceptability Rating is two-fold: A tool for evaluating the child s quality of speech, which may assist in identifying areas to target in treatment An integrated functional outcome measure for speech production (level of speech ability on the ICF framework). Acceptability Measure: Sample Procedure A. Record the Sample: Audio record the child reading aloud a passage that is appropriate for his or her reading ability. Have the child read from the hardcopy of the passage. If the child is not able to read, have him/her repeat each sentence of the passage after you. Later, you will need to remove your models from the recording using audio editing software before listeners judge the recording Acceptability Measure: Sample Procedure B. Judge the Sample Have at least three listeners who are not familiar with the child s speech, with normal hearing, listen to the child s recording and judge the acceptability of the child s speech. Use the Speech Acceptability Rating form with the visual analog scale (VAS)*. Play the recording through headphones or external speakers. If you have all listeners rating at the same time, make sure that each makes an independent rating, without knowledge of the others ratings. Use the mean for the listeners ratings as the acceptability score 32

33 Acceptability Measure: Sample Procedure Instructions: Listen to the recording of this child s speech. Before you listen, you will be told the child s age, and if you are judging the speech of a boy or a girl. Rate the acceptability of the child s speech on the scale below by drawing a vertical line on the horizontal scale below to indicate your rating. Acceptability has been described as the perceived pleasingness of the speech sample and how well it conforms to listeners expectations for talkers of the same age and sex as the talker being rated. Very Acceptable 10 cm Very Unacceptable Measuring Confidence Using Speech Self-report Scale: Not confident at all Very Confident How confident are you using your speech to: 1. Talk with your family - In person - By phone 2. Talk with your friends - In person - By phone 3. Talk with strangers - In person - By phone 4. Talk in front of a small group of people 5. Talk in front of a large group of people Treatment for Neurodevelopmental Disabilities (Accardo, 2008) No medically effective therapies that can restore damaged brain tissue to normal function (no cures) but are medical and nonmedical interventions to: Facilitate learning response to normal experiences (as early as possible) Lessen impact of damage on child s function and participation in society Compensate/adapt when does not have physiological capacity (compensatory articulation*, slowed rate; AAC) Change aspects of child s environment Treat associated deficits 33

34 What causes the brain to change? Result of both: internal (genetic) factors external (experiential) factors that lead to new learning. Learning has been defined as: the ability to acquire new knowledge or skills through instruction or experiences gained from our actions influenced by the characteristics of our environments Factors outside of child (activities, experiences, environment) Factors within child How does speech learning occur? For many children, speech learning progresses through: - an interaction of internal factors and experiences, - gained in social interactions, - as part of their daily activities in their everyday environments, - without specific instruction Developmental Motor Speech Disorders Typically do not grow out of or are cured of physical basis of speech disorder (underlying impairment) chronic condition But, these children demonstrate neuroplasticity Experiential learning (including well designed, principled, task-focused treatment) can improve speech skills and communicative function! 34

35 Recent Speech Treatment Research in Children with Cerebral Palsy see Conclusions Children with cerebral palsy as young as age 3 years demonstrated improvement on measures of speech function following intensive speech treatment that focused on voice and respiration Variability in response to treatment reported in all studies Need for more studies with well-defined treatment procedures for replication with more children Cochrane Review CAS Treatment Studies (Morgan & Vogel, 2009) Found no high-level evidence (quasi-experimental) CAS intervention studies in systematic review. Highest level evidence - a few time series/single subject studies (e.g., Strand et al. (2006) limited generalizability Concluded that: There are a wide range of treatment approaches reported in the literature, however their effectiveness has not been examined with scientific rigour Given critical lack of evidence in the field, it is premature to definitively advocate a particular approach for clinical practice 35

36 More Recent Speech Treatment Research in CAS (see We know that children with MSDs do demonstrate neuroplasticity for speech learning but. It takes them much longer and the level of speech skill they achieve is typically less than for other children. It might be expected that children with deficits in neural resources for speech learning require considerably more repetition of trial and error experiences to establish neural circuitry for skilled motor behavior than children without these deficits. Implications for children with severe speech delay and suspected MSD Brain is not wired (yet?) to move child through these developmental stages being in ambient language is not sufficient to stimulate speech development processes Extra, focused stimulation and consequent opportunities for task specific practice are needed to develop child s neural connections to change speech sound input into actions of the speech mechanism to produce Cs, Vs, syllable and word shapes of ambient language Speech change involves both upregulating speech areas of brain and learning effective compensatory strategies 36

37 Implications for Management Early Identification Early Intervention Expect that children will require extended period of time to develop their speech abilities Expect that during this time, blocks of intensive, developmentally appropriate speech therapy will be needed to help these children learn to become intelligible talkers Expect that interventions will change as child s speech abilities change Need to provide a service delivery plan to address the needs of children and their parents over the period that these children are developing their speech abilities, that anticipates and supports transitions between service types Translating Ideas About Best Practice to Practice in Action Theory/Principles Practice Practice Evidence Use real-world practices as laboratories for developing effective treatments Conceptual Framework for Speech-Focused Treatment: Children with Motor Speech Disorders Parent and child-centered focus Neuroplasticity Development of early communication & speech behaviors Development of speech motor control Motor learning principles Treatment techniques/approaches identified from literature for children with motor speech disorders 37

38 Implications about how to best capitalize on mechanisms of brain plasticity: from recent studies that show: Experience-dependent, Training-induced improvement that correspond with changes in synaptic connectivity in relevant areas of brain cortex 1) Importance of active attention to sensory input from the environment. Active engagement matters 2) Importance of many opportunities for active learning that provide specific input back to areas of the brain where change is desired. Repetition and intensity matter; plasticity is experience specific 3) Importance of mediated opportunities for learning to occur in lifelike contexts and enriched environments. Salience matters To make effective changes in these children s speech behaviors need: Explicit, systematic, focused, frequent practice opportunities that encourage talking in general and that provide context and feedback on specific speech goals: At an appropriate level for the child s phonetic abilities and speech motor developmental level In enabling (aka fun, enjoyable, motivating) learning contexts Where child practices speaking to code meaning while engaging in communicative acts (social routines, behavior regulation, joint attention). Gain multiple repetitions of utterances for speech movement practice in meaningful utterances 38

39 If we are going to exploit the power of neuroplasticity From an early age we need to alter these children s environments Multiply their opportunities to engage in experiences that promote speech learning. As the key component of these children s environments Parents need to provide abundant social interactions within the child s daily routines, and, Within each, create multiple mediated opportunities ( multiple doses ) to: Obtain the child s attention and then, Tempt the child to produce speech like vocalizations, as part of communicative acts, in fun and playful learning activities (build on those child already enjoys) This is a particular challenge for young children with very limited vocalizations and few spoken words. Following from the preceding information, a very important early goal for these children is to increase the number of times that they attempt goal-directed speech or speech like behaviors in a day (frequency increases cortical representation), 39

40 While the idea appears simple, it is not easy It requires commitment, persistence and patience to incorporate these enriched learning opportunities into each day s routine but Parents can be very successful in learning how to adjust and adapt their behaviour (reflecting reorganization of their underlying neural circuitry!) to accomplish this with their child. Key role for speech-language pathologists* To guide and support parents in developing the necessary techniques, skills and confidence to: foster the child s communication development and, maximize the child speech learning ecology through education, active modeling and coaching of others This includes helping parents to: select appropriate speech behaviors to focus on set up and carry out specific opportunities to stimulate the child to attempt these. You are Teaching Caregivers by Modeling, Coaching, and Scaffolding During Sessions Modeling strategies to facilitate their child s speech production Reflecting with them on what strategies seem to be working Building their confidence by giving supportive, positive feedback Modeling structured home practice activities on selected targets Seeking their input in goal selection; revision Developing their insights into what sounds, syllable shapes, and word shapes, prosody, voice targets are easier for their child and which are more challenging REPEAT! Adults need multiple active learning opportunities to practice & master new skills too! 40

41 DIVA Model (Guenther, 2006) DIVA (Directions Into Velocities of Articulators) Neural network model of: Speech motor skill acquisition Speech production DIVA Model (Guenther, 2006) In computer simulations, model learns to control movements of a computer-simulated vocal tract (larynx, soft palate, lips, jaw, tongue) to produce speech sounds Model's neural mappings are tuned during a babbling phase in which auditory feedback from self-generated speech sounds is used to learn relationship between motor actions and their acoustic and somatosensory consequences. Model needs practice with multisyllabic utterances to learn to produce and combine words After learning, model can produce arbitrary combinations of speech sounds, even in the presence of constraints on the articulators. Guenther et al. (2006) A three stage model is hypothesized: 1. Semi-random articulatory movements (like babbling) are used to learn a systemic mapping between motor commands and their auditory and somatosensory consequences. - System knows what movements to make to produce an auditory target, and can predict the auditory outcome of a certain motor configuration 41