Effectiveness of Treatment Approaches for Children Diagnosed with Childhood Apraxia of Speech

The process of communication is one most of us typically take for granted. However, it is one of the most complex motor processes executed by the human body. Many systems within the body are required to work simultaneously to produce intelligible and articulate speech, and to appropriately use language. When one's ability to communicate is impaired due to a speech or language deficit, it's likely to disrupt and impact many other aspects of their life. Consider how limiting and frustrating it would be for a child to be unable to communicate their feelings, wants, needs, and desires.

This is the day-to-day struggle that children diagnosed with Childhood Apraxia of Speech (CAS) experience. Their inability to execute articulate speech impedes the ability to communicate and interact with peers, family, teachers, and everyone they encounter. The diagnosis of CAS remains controversial. Continuous research regarding the diagnosis and effective treatment approaches is warranted. Since this diagnosis and its effective treatment approaches remain controversial, this study delves deeper into two different, potentially effective, treatment approaches, namely, a phonological approach and a tactile approach. It provides an in-depth description of the disorder and how it manifests in children, the necessary services, and the comparison of treatment approaches. It also discusses the importance of familial support, and how the disorder may interfere with social, academic, and cognitive aspects (Lewis et al., 2004; Newmeyer, 2009; Teverovsky et al., 2009).

Literature review

There are many intricate systems in our body that work together to produce intelligible, articulate speech. When any of these systems are interrupted due to various causes, it can result in a speech and/or language deficit. In the case of motor speech disorders, common etiologies suggest disruptions of the primary motor areas in the brain. However, childhood apraxia of speech (CAS) is different and is often misunderstood. Therefore, it may be misdiagnosed or underdiagnosed. Unlike other motor speech disorders, CAS does not inhibit the necessary muscle movement of the articulators. Childhood apraxia of speech is a developmental disorder (ASHA, 2007). It disrupts and impairs the planning and programming aspects of the motor movements that are necessary to carry out speech motor movements, such as speech production and prosody (ASHA, 2007; Hall, 2007; Maassen, 2002; Nijland et al., 2002; Skinder, Strand, & Mignerey, 1999). However, CAS does not present with neuromotor weakness (Ozanne, 2005; Velleman & Strand, 1994; Velleman, 2003).

It is a complex disorder, leaving many professionals and researchers with unanswered questions about the etiology of the disorder, the assessment of the disorder, and effective treatment approaches. Differential approaches and therapeutic strategies continue to be scrutinized. Researchers are considering clinical judgement, evidence-based practice, and patient preferences, in hopes of answering the growing list of clinical questions regarding CAS.

Unlike other motor speech disorders, which can be identified by structural abnormalities or an oral mechanism examination, CAS is most commonly diagnosed based on perceptual features (Darley, Aronson, & Brown, 1969, 1975; Duffy, 2005). The identification of these perceptual deficits was outlined by ASHA in 2007. The definition remains consistent and has undergone few modifications in many research articles. Due to the controversy, many cases may go unreported, resulting in a lack of evidence-based research. The evidence supporting the overall diagnosis and most effective treatment approaches for childhood apraxia of speech is inadequate.

For a professional to know where to begin with treatment, a standardized assessment can often be administered to assist in collecting baseline data, or the current level at which the child performs. In the case of CAS, the Goldman-Fristoe Test of Articulation can be administered to determine areas of deficit. The International Journal of Speech-Language Pathology contains an article discussing the use of an illustration as an assessment tool to facilitate conversational reading. According to another source within the International Journal of Speech-Language Pathology, authors discuss the use of a connected speech sample to assess the client’s functional use of speech sounds (Duffy, 2005). Based on perceptual features, use of assessment tools, and baseline data, it can be determined which approach would be most effective for treating the disorder. For a treatment to be considered effective, the child must display the ability to generalize and maintain the treatment target for a designated time period after therapy has ceased (Olswang & Bain, 1994).

The frequency and intensity of treatment are dependent upon the severity of the disorder. Research articles for this study consider the frequency and intensity of treatment for each approach. Most studies involving CAS treatment administer high-frequency, intensive therapy (ASHA, 2007). However, the article "Rapid Syllable Transitions" (ReST) Treatment looks further into depth at a specific phonological approach, and how lower-frequency therapy may be more effective than high frequency therapy. The article highlights the impractical demands of an intensive, high-frequency treatment in a clinical setting, as well as the intensive demands required of the caregiver (Thomas, McCabe, Ballard, 2014). The more practical, lower-frequency administration of ReST therapy was delivered two times a week for a total of six weeks. The outcomes were compared to ReST therapy outcomes when therapy was delivered during four sessions a week for three weeks. While the lower-frequency therapy resulted in stronger retention of skills long-term, the results regarding acquisition and generalization were very similar for both frequencies (Thomas, McCabe, and Ballard, 2014).

The previously mentioned ReST therapy approach is considered a phonological-based approach. Strategies such as visual and verbal cueing, modeling, syllable segmentation, and reduced speed of production are techniques utilized while administering this therapy approach (D.C. Thomas, 2014). The Goldman Fristoe Test of Articulation was utilized within the study to collect baseline data and was also administered in the form of a post-test one month after the cessation of therapy. The test was administered by certified speech-language pathologists, and the sessions were video-recorded. This ensures reliability within the study, as it assists the clinician in thoroughly assessing the client. The data was represented visually through the use of a line graph, including baseline, treatment, and maintenance information. The client’s generalization and maintenance abilities were assessed four months post-therapy to gauge the effectiveness of the treatment approach. The participants showed significant improvements since baseline, and the sustained ability to produce target speech sounds (D.C., Thomas et al., 2014).

A phonological approach may also be beneficial for children diagnosed with CAS since they are at risk of having underlying language deficits. An article in the Journal of American Speech-Language Pathology highlights these literacy deficits, stating that children with this diagnosis are specifically at risk for reading failure (Bishop & Adams, 1990; Hesketh, 2004; Snowling, Bishop, and Stothard, 2004). The results revealed the extensive therapeutic methods within the study were effective and confirm the hypothesis that a decreased working memory impairs a child’s phonemic awareness abilities (Zaretsky, 2012). An article scrutinizing phonological awareness intervention highlights its importance in reading and spelling acquisitions. They also struggle with word recognition and decoding abilities (Gillon, 2004). Data regarding the study was visually represented by a line graph, and the post-treatment results revealed significant improvement across all treatment phases. The effectiveness of this treatment is supported by evidence suggesting a therapy approach targeting speech production, phonological awareness, and literacy difficulties in children diagnosed with CAS. They benefit from this treatment because even once articulation abilities stabilize, children still suffer language and literacy deficits (Lewis et al., 2004). Overall, the phonological approaches within the research articles highly favored the effectiveness of phonological approaches for children diagnosed with childhood apraxia of speech.

A tactile therapy approach differs from a phonological approach and utilizes more sensory cues than verbal and phonological cues. Since CAS impairs the motor planning aspects of speech production, there is evidence supporting the idea that implementing motor learning principles in therapy is effective for treating those with apraxia of speech (e.g., Freed, Marshall, & Frazier, 1997; Rosenbek, 1985; Rosenbek et al., 1973; Square, Chumpelik, Morningstar, & Adams, 1986; Wambaugh, Kalinyak-Fliszar, West, & Doyle, 1998). A study within the Journal of Speech, Language, and Hearing Research examines the frequency and intensity of motor learning, and how the motor movements are learned in therapy (Maas et al., 2008; Schmidt & Lee, 2005). It compares random versus blocked therapy approaches. One approach learns motor movements randomly, while the other strategy requires a more structured learning of the tasks. The frequency for each approach was analyzed and compared. The results of the study revealed that while both children benefited from the treatment, it was most beneficial when delivered at a high intensity and frequency. The subjects who received high-intensity therapy showed greater retention and maintenance of target motor skills. While there is minimal evidence regarding the effectiveness of a tactile approach, the two articles mentioned above reveal the effective strategies utilized to target the motor aspects of speech production. The evidence-based practices discussed within the research articles mention the warranted need for further research of effective treatment approaches for childhood apraxia of speech.

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