Children with Childhood Apraxia of Speech (CAS) present with a speech sound disorder in which precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (ASHA, 2007). CAS may impact both non-speech and speech movements. As infants and toddlers, children with CAS may have limited babbling, limited-expression, but seemingly typical receptive skills. Older children with CAS may have poor oral imitation skills, erratic speech sound errors, and lack of a verse phonemic repertoire (Kaufman 2013). Often conversed in the concept on Non-Speech Oral Motor Exercises (NSOME) and that the use of NSOME is not evidenced-based according to presentations and meta-analyses by Dr. Gregory Lof. His philosophy has been that in order to improve speech we must work on speech (Lof, 2007), but some children are non-verbal secondary to severe deficits in motor execution and other diagnoses (ASHA, 2007). These children do not imitate sounds and words. Since CAS may coexist with autism, sensory processing deficits, Down syndrome, and dysarthria, a multi-sensory, tactile-kinesthetic approach is often necessary (Roy-Hill & Merkel-Walsh, 2014).
It is well understood that all therapeutic assessment and intervention must be evidenced-based, so why the pillars of EBP are often ignored (Merkel-Walsh, 2017)? For example, Gomez, McCabe, Jakielski, & Purcell(2018) stated in their pilot study on the Kaufman (K-SLP) program, that there is “no evidence” for commercially available CAS treatment programs; however, this is not inclusive of all levels of the ASHA evidence-based map which includes: best available clinical evidence, patient values, patient expectations and clinical evidence (ASHA, 2005;2019). Several therapy protocols have been used to assist children who are non-verbal with suspected oral apraxia. This includes but is not limited to Oral Placement Therapy (OPT) and Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT). Both of these methods have been under fire in social media, state conventions, national conventions and professional debates. For example at the 2019 New Jersey Speech-Language and Hearing Association, Caruso & Elesseff presented a course titled “Research-Based Treatment Approaches for Childhood Apraxia of Speech”. In this course they stated that the TalkTools® Apraxia Kit “has no studies to test the efficacy of the program or tools”; however this program is based on OPT which is a modern extension of Phonetic Placement Therapy (Van Riper, 1954) and The Feedback Model (Mysak, 1971). It is based on a very common sequence (Young and Hawk 1955): 1. Facilitate speech movement with the assistance of a therapy tool (ex. horn, tongue depressor) or a tactile-kinesthetic facilitation technique (ex. PROMPT facial cue); 2. Facilitate speech movement without the therapy tool and/or tactile-kinesthetic technique (cue fading); 3. Immediately transition movement into speech with and without therapy tools and/or tactile-kinesthetic techniques. The specific tool does not require specific “research” just like a mirror for visual feedback has not been formally assessed, which most SLPs use in therapy for speech sound placement. Merkel-Walsh (2016) described the modern application of phonetic placements to assist patients with varying degrees of motor execution disorders. The difference today is that therapists invent orally safe tools rather than rely on unsafe materials such as feather and matchbook covers (Merkel-Walsh, 2016). Tactile / placement cue methodologies are documented in numerous publications such as: Bahr & Rosenfeld-Johnson (2010), Grigos, Hayden & Eigen (2010), Dale & Hayden (2013), Merkel-Walsh (2016), and Roy-Hill & Merkel-Walsh (2014) all of which were based on motor-learning principles, orofacial myology and task-analysis of motor function commonly used by physical and occupational therapists. These tactile cueing methods are widely accepted on an international level but are somehow a constant debate in our own association because of the poorly defined concept of Non-Speech Oral Motor Exercises (NSOME), a term created by Dr. Lof, but not used in any other form of medicine and dentistry (Bathel, 2007). The lack of definition and clarity clouds the evidence (Kent, 2015), and could subsequently discouraging clinicians from using these approaches. Conclusion: By using sequential oral placement targets (lip closure, tongue retraction, jaw stability, etc.) via tactile cues for children with CAS, we can achieve the necessary placement of the articulators to produce sounds. Repetition and reinforcement is helpful based on motor learning theory (Hammer, 2007; Mysak 1971) and this is only NSOME if the therapist is not immediately trying to transition the cued movement into (Roy-Hill, 2013). Treatment for non-verbal children does not give us the option of drilling sounds and words and we need alternative methodologies that consider all levels of the evidence-based map.
Presentation explores 1) current debates within the field of speech pathology focusing on therapy methods for CAS; 2) differentiation of NSOME and phonetic placement; 3) rationale for therapeutic interventions using tactile tools to facilitate sounds for non-verbal children with CAS.
As a result of this presentation, participants will be able to:
- List two tiers of the evidence-based practice map
- Explain at least two goals of a tactile treatment approach
- Implement two phonetic placement methods
Content Disclosure: This presentation will focus on treatment methods related to the use of TalkTools® OPT resources. Other similar treatment approaches will receive limited or no coverage during this lecture.
Schedule (12:00PM - 1:30PM Eastern)
- 15 min- What ASHA says about Apraxia
- 30 min- Review of current methods used with CAS
- 15 min- Review of assessment and OPT as it relates to CAS
- 20 min- Discussion of when a Tactile approach may be helpful and how it relates to current practice
- 10 min- Takeaways and Q&A
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