An annotation of the published research article, “The Importance of Production Frequency in Therapy for Children with Apraxia of Speech (CAS).”

Published May 2011 | By Sharon Gretz, M.Ed.

The Research

The American Journal of Speech-Language Pathology recently published an article titled, “The Importance of Production Frequency in Therapy for Children with Apraxia of Speech (CAS).” The research was conducted by Denice Edeal and Christina Gildersleeve-Neumann from Portland State University. Their research question was to determine whether or not more practice of speech targets would lead to better performance by children with CAS within a speech therapy session and if more practice would lead to better “generalization” (increased performance on words that were not involved in the child’s training).

Because the hallmark feature of CAS is faulty speech motor planning and programming, it is theorized that using variables or principles from the professional literature on other types of motor learning may be advantageous in the treatment for CAS. Clinical practice as well as a growing body of research seems to bear out those ideas. Speech-language pathologists (SLPs) who are successful in treatment for children with apraxia often state that these children, in particular, need more INTENSIVE speech therapy. In this instance, intensive refers to the degree of practice the child receives within the individual speech therapy session. In citing leading researchers on motor learning, the author’s write, “Schmidt and Lee propose amount of practice is a key variable in motor learning. They suggest that the more practice opportunities an individual has, the better the individual’s performance of a motor task will be, which in turn lead to greater learning of these motor tasks.” Overall, more productions of speech targets by the child equals a greater degree of intensity.

In addition to considering the question of intensity of speech practice opportunities, the researchers decided to use an “integral stimulation” therapy method that is consistent with the Schmidt and Lee theories and the principles of motor learning. Dynamic Temporal and Tactile Cueing (DTTC) is a modification of the integral stimulation method used in the treatment of adult apraxia of speech. DTTC has been adapted for use with children, specifically children with a diagnosis of apraxia of speech. Multisensory cueing (visual, verbal, tactile, auditory, etc.) and other strategies such as a slowed rate of production are used within a hierarchical framework in order to target syllables, words or phrases, depending on the child’s current level of functioning. An SLP can move up or down the hierarchy depending on the child’s “real time” level of performance. In Edeal & Gildersleeve-Neuman’s research, they created an experiment in which two children with apraxia each received two conditions of practice in each session. One condition was called “moderate frequency” in which, through the DTTC therapy approach, 30 to 40 speech productions were elicited from the child. The other condition, using the same DTTC method of therapy, was called “high frequency” in which 100 to 150 speech targets were elicited during that segment. In the course of a session, each child received 15 minutes of moderate frequency and 15 minutes of high frequency practice. Different types of speech targets were used in each condition so that the effect of each condition could be evaluated.

Results

Regarding the overall therapy approach, the researchers found that an integral stimulation approach to speech therapy (DTTC), which incorporates principles of motor learning, benefitted both children. One child’s consonant accuracy rose nearly 50 percent in 11 weeks. The other child’s intelligibility rose 11 percent in five weeks.

Regarding the moderate versus high frequency condition of practice, the researchers found that both children benefitted more from the high frequency practice than they did the moderate frequency practice. The speech targets treated in the high frequency condition led to increased in-session accuracy as well as greater generalization to untrained targets. In addition to the improved in-session accuracy and generalization with higher frequency practice, the authors point out that this same practice demonstrated the accuracy could be achieved in fewer sessions. Furthermore, targets that received treatment in the high frequency condition were more stable and accurate from session to session compared to speech targets trained with the moderate frequency condition.

The Bottom Line

The results reported in the Edeal and Gildersleeve-Neumann study are very encouraging yet have limitations. First of all, the number of reported subjects was very small. Secondly, subjects had some variability in the length of their treatment. Issues such as the motivation of the child may also enter into the mix. However, on the positive end, this report confirms other studies in which multi-sensory therapies such as DTTC, which incorporate the principles of motor learning, are effective methods to treat a difficult disorder like CAS. Keep in mind to aim for the following in speech therapy sessions:

• A high degree of direct practice of speech targets. A child should have dozens and dozens of speech productions during each therapy session. A child that is saying or attempting little in a speech therapy session will not likely make progress like a child who is able to have a high degree of practice opportunities.
• Therapy approaches that incorporate principles of motor learning may be key to progress for children with a primary diagnosis of apraxia of speech.
• It is worth mentioning that children with apraxia of speech should work on actual speech during speech therapy. This is consistent with motor learning theory which suggests that to improve performance for a particular task, one should practice that specific task.

Source: Edeal, DM and Gildersleeve-Neumann, CE. The Importance of Production Frequency in Speech Therapy for Childhood Apraxia of Speech. American Journal of Speech-Language Pathology. May 2011, Vol. 20, 95 – 110.

Reviewed 11-5-19

By Edythe Strand, Ph.D., CCC-SLP, BC-NCD

Clinicians and parents commonly observe that practice and repetition facilitate progress in therapy for childhood apraxia of speech. Why is this aspect of treatment more important in children who have apraxia, than for children who’s primary deficit is in language or phonology? The answer lies in the fact that children with apraxia of speech primarily exhibit deficits in planning and executing movement. The researchers in the area of cognitive motor learning have taught us a great deal about how skilled movement is acquired and how we can facilitate new motor learning. Motor learning involves acquiring the ability for producing skilled actions, and occurs through practice. The researchers who study cognitive motor learning have done numerous experiments that show that limb movement practice is influenced by a variety of factors, and have demonstrated a number of principles of motor learning that can be used as guides for planning treatment for speech production.

One of the most robust variables that affect motor learning is the necessity for repetitive practice. That is why it is recommended that children with apraxia receive therapy frequently for shorter sessions versus less frequently for longer sessions. It is much better to schedule a child for two half-hour sessions rather than one session lasting an hour, or even four 20 minute sessions versus two one hour sessions. Clinicians also work to maximize the number of practice trials per session, by keeping reinforcements quick, using novel fun activities that involve continued practice with the target utterances. Other factors that influence practice include how practice is organized. This falls under the principle of mass vs. distributed practice. It is recommended that for children with severe motor planning impairment, the number of target utterances remain small (5 to 6). That allows enough mass practice for success (motor performance), yet brings in some distributed practice that facilitates motor learning (generalization). As the child improves motor planning ability, the stimulus list is gradually increased. Types and schedules of feedback have also been shown to facilitate both motor performance and motor learning. Early in therapy, more immediate feedback facilitates motor performance, but may not facilitate motor learning or generalization. Therefore, providing less frequent and less immediate feedback as the child improves accuracy is recommended. Finally, it is important to vary rate. Slowing rate improves movement accuracy, but can lead to deficits in prosody, or the natural rhythm of speech. Frequently clinicians will start with slower movement practice, gradually increasing rate to normal, and gradually varying prosody with continued repetitions.

While the literature in cognitive motor learning has been very helpful to speech pathologists who work with apraxic children, clinical research needs to be directed at how the principles of motor learning influence the acquisition of speech motor planning and execution, especially in children with motor planning deficits.

(Dr. Strand is a consultant in the Department of Neurology, Division of Speech Pathology, at the Mayo Clinic in Rochester, Minnesota, and Associate Professor in the Mayo Medical School. Her primary research and clinical interests have been in Neurologic Communication Disorders, especially developmental and acquired apraxia of speech, dysarthria, and neurologic voice disorders. She has published articles and chapters regarding the clinical management of motor speech disorders in children, including treatment efficacy. Dr. Strand is co-editor of the recent book (1999), Clinical Management of Motor Speech Disorders of Children. She lectures frequently throughout the country on childhood apraxia and motor speech disorders in both children and adults. Dr. Strand is a member of the Childhood Apraxia of Speech Association’s Professional Advisory Board.)

Always a challenge to try and get those multiple speech practice repetitions from children with apraxia, Becky Edge has put together her tips of how to do just that in that challenging preschool population.

By Becky Edge, M.H.S., CCC-SLP

I compiled a list of activities and toys that the children (0-5) I’ve work with have enjoyed and have allowed me to elicit multiple repetitions. A couple of thoughts first, though. Please don’t go out and buy all of these toys without thinking about the child’s interests. Not every toy is engaging to all children. Remember that novelty is also key. Play with it, then put it away in a place that the child cannot access it. If the child only sees it once a week, it’s much more interesting, motivating, and engaging, which is key to eliciting repetitions. Toys can be expensive. Garage sales, Ebay, and clearance shelves are the first place I look. Finally, while age guides are great, don’t let that stop you from utilizing the toy as long as you’re going to be playing with the child. Many of the toys I’ve listed are meant for kids age 3-7 for safety reasons. As long as you are using the toy as a tool, you’ll be with the child. Just make sure to count all of the little pieces beforehand and do not leave the child alone with it until the child is old enough.

Think of any games/activities with lots of pieces or highly engaging activities that require assistance. Some of my (and the kids’) favorites include:

• Old Fisher Price cash register from the ’70’s – It makes no sound, but the kids love to put the money in, find it, push the buttons, etc.
• Farm Families by Milton Bradley – I don’t typically use this as a “game”. I use the animals and the sound “machine,” not the game board itself. Many of the kids can’t figure out how to make the animals make their sounds without assistance, so they have to ask me to do it.)
• An inexpensive wooden train with lots of pieces for the track and train cars
• Discovery Toys has some wonderful toys, if you don’t mind making an investment.
• Marble Works is the best (just make sure you keep track of the marbles with the little guys!)
• Gears (The safari one is my favorite.)
• Builders, Benders, and more
• In the Works Submarine and Race Car Set
• Give it a Whirl (outside fun)
• Stack and Pop (another favorite!)

Some other great activities are:

• Stickers – Make a book or just let them put the stickers on a piece of paper.
• Any Play-doh activity – Play-doh, Rose Art, cookie cutters, etc. The trick is to withhold as much dough as you can at a time so they have to ask for more
• Bubbles – keep the lid closed, have them ask for more, open, bubbles, pop, up, body parts, etc.
• Tops and wind up toys
• Candy, cereal, fruit snacks, popcorn, grapes, etc.
• Barnyard Bingo by Fisher Price
• Tape recorder with two microphones and music (Time to Sing! CD, Barney, and Singing Sounds seem to be the best)
• Two echo microphones
• Colorforms and/or window clings
• Foam bath toys that are designed to stick to the bath tub wall and a squirt bottle (All you need is a window!)

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