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. There are many systems within the body that are required to work simultaneously in order to produce intelligible and articulate speech, and appropriately use language.

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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 experience. Their inability to execute articulate speech impedes their ability to communicate and interact with peers, family, teachers, and everyone they encounter. The diagnosis of CAS remains controversial. Continuous research regarding the diagnosis as well as effective treatment approaches is warranted. Since the diagnosis and effective treatment approaches remains controversial, this study looks further in depth at two different, potentially effective, treatment approaches. It will compare the different treatment approaches for Childhood Apraxia of Speech. More specifically, a phonological approach and a tactile approach. It will provide an in-depth description of the disorder and how it manifests in children, the necessary services, and the comparison of treatment approaches. It will discuss the importance of familial support, and how the disorder may interfere with social, academic, and cognitive aspects as well (Lewis et al., 2004, Newmeyer, 2009, Teverovsky et al., 2009).

Literature review

There are many intricate systems in our body that are recruited to work together for the production of intelligible, articulate speech. When any of these systems are interrupted due to various causes, it is likely to result in a speech and /or language deficit. In the case of motor speech disorders, common etiologies suggest disruption of the primary motor areas in the brain. However, childhood apraxia of speech (CAS) is different, and is often misunderstood definitively. Therefore, the diagnosis may be mis or under diagnosed. Unlike other motor speech disorders, CAS does not inhibit the necessary muscles 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, 1994Velleman, 2003).

It is a complex disorder, leaving many professionals and researchers with unanswered questions about the etiology of the disorder, assessment of the disorder, and effective treatment approaches. Differential approaches and therapeutic strategies continue being scrutinized. Researchers are taking into consideration 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 may be identifiable 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 few modifications throughout many research articles. Due to the controversy, there may be many cases that go unreported, which results 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.

In order for a professional to know where to begin with treatment, a standardized assessment can often be administered to assist in the collection of baseline data, or the current level at which the child performs. In the case of CAS, the Goldman-Fristoe Test of Articulation could be administered to determine areas of deficit. The International Journal of Speech-Language Pathology contains an article that discusses 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, assistance of assessment tools, and baseline data, it can be determined which approach would be most effective in treating the disorder. In order 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 once therapy has ceased (Olswang & Bain, 1994).

The frequency and intensity of treatment is 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 in dept at a specific phonological approach, and how lower-frequency therapy may be more effective than a 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 2 times a week for a total of 6 weeks. The outcomes were compared to ReST therapy outcomes when therapy was delivered during 4 sessions a week for 3 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 1 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, and included baseline, treatment, and maintenance information. The client’s generalization and maintenance abilities were assessed 4 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 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, which 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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