Apraxia Dallas, PLLC

🧠Thoughtful Thursday 🧠

The thoughts that have been circulating 🔁 our clinic this week include remembering everything we need to listen for to ensure the target movement is accurate for children with . This is enough to make our head spin and our brain tired 🤯 by the end of the day! However, it is incredibly important when working to make a motor system more efficient.

Here is our friendly reminder to you to listen for:
👂vowel accuracy
👂sound accuracy
👂intrusive schwa (or other intrusive sounds)
👂voicing accuracy
👂natural prosody
👂accurate and varied stress
👂smoothness from sound to sound
👂consistency from trial to trial for each production

Remember to avoid:
❌exaggerating the missed sound or syllable so that the stress is inaccurate or segmented
❌targeting sounds in isolation
❌ targeting voiced final consonants by added a schwa
❌ using the same prosody for each repetition

Instead, try to remember to:
✅vary prosody often
✅use prolongation to smoothly sequence the sounds
✅ add a vowel that helps shape the target sound (e.g. low back vowel for velars)
✅ always use accurate stress

Remember, when treating childhood of speech, focus on the movement for improvement! 🙌

🧠Thoughtful Thursday 🧠

As we discussed in a previous post, if we see weakness, that is not due to childhood of speech. Either the child does not have , or they also have another disorder in addition to CAS that is causing weakness.

An orofacial myofunctional disorder (OMD) is one cause of weakness (see our previous post on OMDs). Another cause is dysarthria.

Dysarthria is the abnormal neuromuscular activation of the speech muscles, affecting the speed, strength, timing, range, or accuracy of movements involving speech (Duffy, 1995). Dysarthria is caused by a neurological insult (e.g. stroke, head injury), nervous system disorders, or conditions that cause facial paralysis or muscle weakness. It can range in severity from mild to severe. Dysarthria can affect articulation as well as phonation, breathing, and/or prosody (emotional tone) of speech. Characteristics of dysarthria include talking too fast, slow, soft, robotic or choppy, uncoordinated movement of articulators, and changes in the voice including hoarseness, breathiness, or nasalization.

When differentiating between CAS and dysarthria, listen 👂for respiration (volume, speech breathing, atypical voice quality) and resonance (consistent or intermittent hypernasality). These are distinguishing factors that can help decide if it is CAS, dysarthria, or both.

A fantastic (and FREE) tool called the ProCAD (Profile of Childhood Apraxia of Speech and Dysarthria) was published last year by Iuzzini-Seigel, Allison & Stoeckel in Language, Speech & Hearing Services in Schools. If you are treating children with motor speech disorders, be sure to check it out at https://pubs.asha.org/doi/pdf/10.1044/2022_LSHSS-21-00164
We 🫶 using it to analyze our assessment data. The color-coded chart and flow-chart are 🤌

CAS and dysarthria do co-occur and it is possible to treat both simultaneously. Evidence-based practice for dysarthria is speech therapy based on the principles of motor learning, with some additional compensatory strategies to address the specific characteristics of dysarthria. 🙌

💡Tip Tuesday 💡

Continuing our series on the Principles of Motor Learning (PML)! Let's talk about pre-practice.

Pre-practice is setting the stage for the session of motor-based therapy and for motor learning 🧠to occur! It is basically the first couple of minutes of a therapy session.

Pre-practice has 3 main parts:
1. Motivation 🏆
2. Understanding of the Task & Reference of Correctness 👍
3. Stimulability 🙌

Motivation 🏆- the child wants to practice and has some understanding of why its important. This might sound like "Let's practice moving your mouth so you can tell us your great ideas!" Of course we can have external motivators and incentives for practicing, but don't forget the power 💪of motivating targets 🎯 (e.g. words and phrases the CHILD wants to say)!

Understanding of the Task & Reference of Correctness 👍- The child needs to have an understanding (at their language and cognitive level) of what they are trying to accomplish. We can provide the reference of correctness - the accurately produced target word or phrase 🎯- and the child needs to understand that they are trying to move just like us to produce that target. 🎯 The goal is "Move your mouth 👄just like me to say (their target word)!"

Stimulability 🙌- The child is able to produce the target🎯 accurately, either without cueing or with as much multisensory cueing as needed! When the child produces the target 🎯(regardless of the cueing level), this gives them an internal reference of correctness - they've actually felt what needed to happen and moved accurately to produce the target. 🎯

In summary, at the beginning of a therapy session where we want motor learning to occur, take a couple of minutes to make sure the child is:

➡motivated to practice
➡knows why they're practicing
➡knows what the goal is
➡can accomplish it!

Stay tuned as we continue to break down PML into manageable and clinically-relevant chunks!

Our team is thrilled that the Kids National Conference will be right in our backyard this summer, July 6th-8th in Plano! 🥳Apraxia Dallas is a proud sponsor of the Conference and all of our will be attending. Did you know that the conference is also open to parents and caregivers?! 🙌

Breanna will be presenting 3 sessions:
➡Perspectives: Your Child's Journey with with Katherine Le
➡Let's Taco 'bout Coarticulation
➡Reading Instruction for Children with Childhood of Speech

A little more about Breanna:
🔹Speech-language pathologist for 15 years
🔹Primarily treated children with CAS for 11+ years
🔹Owner of Apraxia Dallas for 7+ years
🔹Recognized for Advanced Training and Expertise in CAS by Apraxia Kids
🔹Attended dozens of hours of continuing education on motor speech disorders, including CAS
🔹Presented >20 sessions at state and national conferences since 2016
🔹Provides full-day trainings to school districts
🔹Mentored >12 SLPs on CAS treatment
🔹Program Director for Child Apraxia Treatment (2020-2022) - created website and social media content and coordinated research grants

Registration is open! https://www.apraxia-kids.org/apraxia-kids-national-conference/
Who will be there? Let us know!👇

🧠Thoughtful Thursday 🧠

Children with childhood of speech (CAS) experience difficulty accurately & efficiently moving the muscles of their face, lips, tongue, and throat (articulators) to produce speech. However, this is NOT due to weakness. We know the does not cause weakness (ASHA, 2007).

When a child with CAS is also experiencing weakness, what could be the cause?
➡️Dysarthria - stay tuned to future posts to learn more!
➡️Orofacial myofunctional disorder (OMD)

OMDs are caused by learned behaviors, anatomical physical/structural differences, and/or genetic and environmental factors that misplaces the tongue at rest, decreases lingual movement within the oral cavity, makes it difficult to achieve lip closure, and impacts the ability to maintain the correct oral resting position.

Signs of OMD include:
Resting open mouth posture
Limited tongue movement
Resting tongue position that is not up against the roof of the mouth
Difficulty closing the lips to swallow
Drooling, especially beyond age 2
Eating may be messy or difficult
An overbite, underbite, and/or other dental problems
Distorted sounds
Sleep difficulty

We can address both CAS and OMD at the same time. OMD therapy includes exercises to strengthen and increase the range of motion of the specific muscles required for appropriate function of the mouth, face, and neck while breathing, sleeping, eating, and talking. Sometimes a myofunctional deficit may need to be resolved before any progress can be made on sounds that are impacted. You can incorporate these exercises while working on motor speech goals.

If you are unsure of OMD, be sure to refer to an expert in this area! Resources to learn more:

https://www.asha.org/public/speech/disorders/orofacial-myofunctional-disorders/
https://www.iaom.com/
https://www.oralmotorinstitute.org/
https://orofacialmyology.com/orofacial-myology-home/myo-info/blog/

, be sure to check out the ASHA Practice Portal and Evidence Map on OMD!

💡Tip Tuesday 💡

This is a big one - Principles of Motor Learning (PML)! It can be a daunting 🫣 topic but it's incredibly important for treating children with motor speech disorders. In this first part of a series, let's start breaking it down. 🕵️

What are Principles of Motor Learning❓ PML were established in research on how people learn (non-speech) motor skills. 🫳 Remember, speech is a (very complicated) motor skill! Researchers then looked at how PML applies to speech 🗣 For all the details, read Maas, E., Robin, D., Austermann Hula, S., Freedman, S., Wulf, G., Ballard, K., Schmidt, R. (2008). Principles of Motor Learning in Treatment of Motor Speech Disorders. American Journal of Speech-Language Pathology, Volume 17, p. 277-298.

We also know from the research 📚that the most effective treatment for motor speech disorders is speech therapy based on PML. Understanding PML starts with knowing the difference between motor performance 📞and motor learning. 🧠

Motor performance 📞 is establishing the movement with cueing. This is what we often do in therapy - we help the child perform the movement gesture for the target word or phrase accurately, using multisensory cueing.

Motor learning 🧠 is using the movement in another context and time - basically, generalization.

Our ultimate goal is motor learning, 🧠 but we often start with motor performance. 📞However, it is possible to have motor performance 📞 (phone it in!) without motor learning occurring, if we aren't careful about implementing PML.

Stay tuned for future posts in this series to learn more about how to go from motor performance 📞 --> motor learning! 🧠

Breanna is excited 😁to return to the Sunshine State ☀️ and help spread knowledge about childhood of speech at the FLASHA Convention July 13th-16th!

Breanna will be presenting two sessions:

1. Treating Childhood Apraxia of Speech with Evidence-Based Practice
and
2. What to Do When You Suspect Childhood Apraxia of Speech

Registration is open with the early bird 🐦 discount! https://www.flasha.org/page/2023convention

💡Tip Tuesday 💡

🚫Avoid Negative Practice!

Negative practice is when a child is practicing an incorrect motor plan for speech. This may happen because the selected target word or phrase for practice is too difficult or is being taught incorrectly.

Children, especially children with childhood of speech (), learn what they practice. Motor ex*****on (practice) ➡ Motor Learning

If they rehearse an incorrect motor plan for speech (negative practice), they will learn an incorrect motor plan for speech. 😳

The incorrect motor plan will then have to be changed or re-learned, which can be even more difficult for children with CAS than learning a new motor plan. 🤦‍♀️

When selecting speech targets for children with CAS, we want to be particularly careful that the target word or phrase is stimulable with multisensory cueing, so that the new motor plan can be practiced accurately. ✅

Accurate practice means that we are taking into account coarticulation and how the entire target is actually said, not how we write it , spell it or say it if we break it into parts. 👍

💡Tip Tuesday 💡

Diagnosis --> Treatment

Speech sound disorders can be classified as being cognitive-linguistic 🧠or motor-💪based. Phonological disorder and inconsistent phonological disorder are considered to be resulting from cognitive-linguistic causes, whereas childhood of speech, pediatric dysarthria, speech motor delay and articulation are considered motor-based.
❓Not familiar with speech motor delay as a diagnosis? 🤷‍♀️Check out ✅ the article "Initial studies of the phenotype and persistence of speech motor delay (SMD)" by Schriberg, Campbell, Mabie and McGlothlin (2019) in the journal Clinical Linguistics & Phonetics. https://www.tandfonline.com/doi/full/10.1080/02699206.2019.1595733

Not all speech sound disorders are mutually exclusive. ❌ Some children have a mixed motor speech disorder (CAS + dysarthria). And many children have CAS + phonological disorder. ➡️Although not according to ICD-10 codes – use of the code for CAS excludes the code for phonological. 😒But clinically, children can and often do have both disorders.

We know from the research () that effective therapy for motor-based speech sound disorders must be based on the principles of motor learning. But if there is a phonological disorder, it also needs to be addressed at the appropriate time. ⏰

Stay tuned 👀 for more information in upcoming posts about therapy based on the principles of motor learning ()!

Great turnout and participation for my presentation on evidence-based practice (EBP) for childhood of speech! Love 💙 sharing information from the research and my 10+ years of primarily treating children with . And the questions at the post-presentation discussion were 🤌

Immediately after that presentation I presented another session on incorporating literacy 📖instruction in speech and language therapy, based on EBP. Awesome opportunity to help other know how to support literacy for the children on their caseload, including those using !

And that's a wrap for ! Thanks to the amazing TSHA volunteers who made this conference happen! 👏

Day 2 - prepped for my two presentations tomorrow - even when you think you're prepared, there are always last minute tweaks! 😬

Attended 2 fantastic presentations on the assessment and treatment of speech sound disorders, particularly phonological disorders, by . 👏 Can't wait to share what I learned with the rest of the Apraxia Dallas team!

Helped answer a couple of questions from at the Apraxia Kids booth! 👍

Time for bed - early morning tomorrow! 😴

TSHA Conference 2023 - Day 1! Excited to be in Austin for my 11th (?) TSHA conference and my 7th year to present here! 😁

Today I showed up ready to learn! Went to a great course about team work, which reinforced a lot of how and why we collaborate so much at Apraxia Dallas, both within our practice and with other . Hint: Better outcomes for the children we treat. 👍

TSHA Convention is NEXT week! 🤗

Breanna will be presenting two sessions:

➡How to Treat CAS - An Updated Look at Evidence-Based Practice
➡Incorporating Reading Instruction into Speech and Language Therapy

Registration is open! https://www.txsha.org/annualconvention

Who will be there? 🙋‍♀️🙋🙋‍♂️

🧠Thoughtful Thursday 🧠

The thoughts and conversations that have been circling 🔁our clinic this week included knowing when and how to fade cueing and feedback, which is especially important for children with childhood of speech (). This reality check ✅ is so important and we like to gently remind each other on a regular basis! ⏰

So here is your gentle reminder! 😊

We know from research 🕵️‍♀️on the principles of motor learning that feedback is required for motor learning to occur. Two types of feedback include: knowledge of performance 👩‍🎤 and knowledge of results. ✅❌

Knowledge of performance 👩‍🎤 is specific information about how the movement is performed. 👄For example, "move your tongue up behind your teeth", "close your lips all the way", "round your lips and push out air". This feedback is more appropriate at the initial phase of learning a new motor movement.

Knowledge of results is a simple yes ✅ the production was accurate or no ❌ the production was not accurate. This feedback is more appropriate when the child gains control and awareness of the motor plan.

If the speech-language pathologist () provides too little 🤏 feedback, the child may fail to make progress because their system does not have sufficient information for accurate internal feedback. 🧠🗣👂🧠

If the SLP provides too much feedback, the child's system will not be taxed to develop their own accurate internal feedback loop. 👎

The gentle push ➡️and pull ⬅️of providing sufficient feedback and then reducing ⬇️feedback to observe the child's ability to rate their own correctness 👍👎 is the most important! Generalization is key 🔑and generalization occurs when there is an accurate internal feedback loop!

💡Tip Tuesday 💡- ❤️ Valentine's Day Edition ❤️

Ways to be kind & inclusive on ❤️Valentine's Day ❤️ or ANY day! 💙💚💜🖤🧡💛

💞Encourage all modes/forms of communication! This includes 👍gesturing, body language, 🤟sign language, 🗣speaking, writing,📱using a device or pictures and more. All forms are 🟰 equal and valid! Acknowledging the communication is vital.

💞 Remember to listen with your 👀 eyes and your👂ears. This helps you to understand what the individual is communicating, regardless of the forms.

💞 Be open minded. Everyone is different! We communicate differently, play differently, live differently. Think outside the box 📦and try to take someone else's perspective. 👣

💞 Be friendly. 😁A smile goes a long way to start and continue communication! 👥

💞 Ask, don't assume. If you're not sure how to interact with someone, ask! Engage instead of ignore - most people want to feel seen and heard. 💓

💞Always keep growing! 🌱No one is perfect. Know better, do better! 🫶

Only 3 weeks until TSHA Convention! 🤗

Breanna will be presenting two sessions:
➡How to Treat CAS - An Updated Look at Evidence-Based Practice
➡Incorporating Reading Instruction into Speech and Language Therapy

Registration is open! https://www.txsha.org/annualconvention

🧠Thoughtful Thursday 🧠

The thoughts and conversations that have been circling 🔁our clinic this week have been around dysfluencies.

According to ASHA, "fluency refers to continuity, smoothness, rate, and effort in speech production."

For children with childhood of speech (), motor planning and/or programming for speech is inefficient. As a result of this inefficiency, their speech is often not fluent - it may not be continuous or smooth or have typical rate and may be effortful. They may go through particular periods of dysfluency that include repetitions, pauses or revisions in their speech. This seems to happen especially during periods of big language development or life changes. The amount of brain power for motor planning/programming is lessened or the motor system can't keep up. Much of the time, the dysfluencies decrease over time. 📉

However, that doesn't mean that we should ignore these dysfluencies when they occur. 🧏‍♀️When dysfluencies arise, it is usually important to lessen speech (motor) demands until the imbalance evens out. The can work on indirect stuttering techniques such as easy onset, language goals, breathing and mindfulness techniques🧘‍♀️ or other goals while they lessen speech demands and monitor dysfluencies.

During periods of dysfluency, parents/caregivers can also help at 🏠 home by:
➡️ waiting patiently for their children to finish talking
➡️ maintaining neutral body language during their child's dysfluencies
➡️ modeling easy, relaxed speech
➡️ reducing speech demands by asking fewer questions

When deciding whether or not a child may be going through a dysfluency period or developing a stutter, it is important to keep in mind the emotional ❤️connection the child has to their speech. 🗣The secondary behaviors or reactions to their own speech will provide insight 👁 to their awareness.

If awareness arises and secondary behaviors are noted, a referral to an SLP who is a BCS-F (Board Certified Specialist in Fluency) is warranted. ✅

Due to road conditions and inclement weather, we are providing telehealth only today. Stay warm and safe!

We are providing telehealth only today due to the weather. 🌨 Stay warm and safe!

We are not conducting in-person therapy today due to inclement weather! ❄️You should have received an email or text message from your clinician about cancelling or moving to telehealth! Stay warm🔥and safe!

Can childhood of speech () be accurately diagnosed in children under age 3? 👧🧒

Answer below! 👇

Yes, children can be diagnosed with CAS under the age of 3 BUT this should be done with caution ⚠️ (ASHA, 2007).

WHY? A couple of reasons.

1. An accurate evaluation for CAS includes assessing for the presence of CAS characteristics across multiple speech tasks using a dynamic motor speech exam.
BUT many children under the age of 3 are not yet producing enough speech to engage in multiple speech tasks to assess for the characteristics across tasks.

2. Some features that are considered characteristics of CAS in older children:
➡️Vowel errors
➡️Voicing errors
➡️Inconsistency in repeated trials
Can be developmentally appropriate in young children under the age of 3!

To sum up:
CAS CAN be accurately diagnosed in some children under the age of 3 IF the child can engage in a dynamic motor speech exam AND is displaying enough OTHER characteristics of CAS across speech tasks. ✅

Please help us welcome our newest team member, Jordyn Brechler, MS, CF-SLP! 👏

Jordyn is a graduate of the University of Texas at Dallas where she received her Master’s of Science in Speech-Language Pathology. She received her Bachelor of Science degree in Interdisciplinary Studies with an emphasis in Special Education at Texas A&M University (Gig’em! 👍) and is a member of the American Speech and Hearing Association (ASHA). She has experience in the assessment and treatment of children with various speech sound disorders, language delays, pragmatic language issues, and fluency. She has worked with children from various backgrounds, needs and disorders through her time in the public school setting, outpatient clinics and various private practices across the Dallas area. Jordyn has always had a passion for helping children find their voice and make their mark on the world and is thrilled to be doing so at Apraxia Dallas! 🤗

Fun Fact: Jordyn studied abroad in Australia 🇦🇺 where she went to see an opera 🎼at the Sydney Opera House and swam at the Great Barrier Reef! 🐙🐠🐡🐟🦀