The Relationship Between Treatment Intensity & Treatment Outcomes for Children with Apraxia of Speech

by Aravind Namasivayam Ph.D. S-LP(C)

Childhood Apraxia of Speech (CAS) is in terms of diagnosis and treatment a very challenging and complicated speech disorder in children. Children with CAS find it difficult or impossible to accurately produce speech sounds and/or words despite having a good understanding of language. Although there are several treatment approaches for CAS, there are very few published studies examining their efficiency and effectiveness. For example, at present, we do not know the amount of change in speech intelligibility (the degree by which their speech can be understood by a listener) or their ability to communicate effectively in real world situations (i.e., functional communication) following treatment. We also do not know if more intense treatment (although promoted by most clinicians) is actually better for this population.  Thus, there is a strong need for well-designed research studies in this area to advance clinical practice.

In July 2011, the Childhood Apraxia of Speech Association of North America (CASANA) awarded a competitive clinical treatment research grant to Dr. Aravind Namasivayam of the Speech and Stuttering Institute in Toronto, Ontario, Canada. His team consisted of experts in the areas of CAS research (Dr. Ben Maassen, University of Groningen in the Netherlands), speech science (Dr. Pascal van Lieshout, University of Toronto in Canada) and speech disorders treatment (Ms. Margit Pukonen from the Speech and Stuttering Institute, Toronto, Canada). The CASANA funding was used in support of the research project titled “Exploring the Relationship Between Treatment Intensity and Treatment Outcomes for Children with Apraxia of Speech”. 

Using the funds from the CASANA grant a specialized screening tool was developed to identify a subpopulation of two to five-year-old children, who demonstrated characteristics of CAS, from a larger database of 102 preschool age children with motor speech issues. All children received a specialized motor speech treatment program delivered by qualified speech-language pathologists in one of two possible treatment formats: high-intensity (2 times a week for 10 weeks) or low-intensity (1 time a week for 10 weeks).  Each speech therapy session lasted for 45 minutes. The speech-language pathologists providing the treatment were randomly assigned to either of these treatment formats. A child’s ability to correctly produce speech sounds in words, speech intelligibility and functional communication were evaluated both before and after treatment. Speech intelligibility was assessed at the word-level (percentage of words correctly identified by a listener) and at the sentence-level (percentage of words correctly understood in imitated sentences by a listener).

Overall, the results of the study demonstrated that the outcomes of the high-intensity treatment were superior to those of the low-intensity treatment. Specifically, high-intensity treatment resulted in a significant change in a child’s speech production abilities, word-level intelligibility and functional communication when compared to low-intensity treatment.  Furthermore, high-intensity treatment produced almost twice the amount of positive changes and had fewer children failing in treatment (i.e. not showing any real progress- especially for speech production) relative to the low-intensity treatment.  However, neither high- nor low-intensity treatment improved sentence-level speech intelligibility in children with CAS.

This CASANA funded study represents the largest data set available to-date relating the amount of therapy induced change and treatment dose and its effects on speech intelligibility and functional communication outcomes in children with CAS. The results from the study could be used to set appropriate levels of clinician and parental expectations prior to treatment and could potentially guide clinical practice (e.g. amount and possibly type of treatment required for this population).

Importantly, even though positive changes were found for speech production and functional communication in CAS children with 20 sessions (2 times a week / 10 weeks) there was only minimal improvement in sentence-level speech intelligibility following treatment. Thus, the CAS children may benefit from more than 20 sessions of therapy and from a treatment program that systematically builds in practice of speech production targets in longer utterances (i.e. phrases, sentences, connected speech). At present additional analyses are being carried out to identify factors contributing to positive outcomes in children with CAS. For example, we ask which of the following factors affect a child’s treatment outcomes: child’s participation in the therapy process, amount of home practice and/or quality of parent-child interaction? With further analysis, we will be able to identify key factors that contribute to positive treatment outcomes in children with CAS and thus make a significant contribution to future clinical practice in this area.

[CASANA funded research dollars are raised through the Walk for Children with Apraxia]

Confusion with English Spelling of Vowels

Question:  My son has apraxia and memory issues. Is there a way of learning the differences between spelling for a sound like or, ore, oar, au, oar, and aw?   My son gets so confused and frustrated.  The other day he spelt 'caught' as 'cawght.'

No single approach works for all children, especially for spelling.  There are programs that address teacher training for high quality instruction and programs for student intervention from research-based models of
achievement.  Teachers must understand individual learners and differentiate instruction to target their identified needs.  Quality programs to teach beginning reading should also teach beginning writing with related spelling patterns (like those described in the question), and build upon the foundational belief about the connection to early literacy development.  In other words, achievement in reading, writing, and spelling is dependent upon high quality explicit instruction not only in reading and writing but also with attention to the underlying early literacy components of listening and speaking, including possible deficits during that stage of development.   Students who have experienced delay in or difficulty with sound play and oral language often require additional intervention with explicit instruction to learn the language arts in their written form.

LETRS (Language Essentials for Teachers of Reading and Spelling) is based upon the textbook and related workbook, Speech to Print by Louisa Cook Moats from Sopris West Educational Services.  This professional
development program for teachers of reading, writing, speaking and listening is designed to teach teachers the elements of delivering successful instruction of English "language arts."  English is a "deep language" that spells both for meaning and phonics, so spelling can be a challenge for students.  Moats describes, "The teacher who understands language and how children are using it can give clear, accurate, and organized information about sounds, words, and sentences.  The teacher who knows language will understand why students say and write the puzzling things that they do and will be able to judge what a particular student knows and needs to know about the printed word.  Literacy is an achievement that rests on all levels of linguistic processing, from the elemental sounds to the most overarching structures of text."

SpellRead Phonological Auditory Training, acquired by Kaplan in 2006, and generally used with students in grades 2-12 who are still having difficulty with text is "an innovative method for helping struggling students master the critical skills of reading," (which includes spelling).  Instruction is delivered by a trained teacher to small groups during a one-hour pull-out across a set progression of lessons to an end point.  The largest emphasis for instruction in the program used with grade 3-5 students is on the word level for reading.  Smaller instructional sections are dedicated to comprehending text and writing. This "writing" piece focuses more on student writing production (including spelling) than on content.  A June 2006 press release describes the program like this:
       "The SpellRead program helps students to recognize and manipulate sounds in the English language, then to transfer those skills to reading text and eventually to writing. It is generally administered in schools in grades two through high school during a daily one-hour pull-out program led by a specially trained teacher."

According to a review from the Florida Center for Reading Research,
       "The SpellRead P.A.T. program, when implemented properly, can produce significant and substantial effects on reading skill for children ranging in age from grade one through grade six. Results from several clinical samples support the finding that the SpellRead program can provide instruction that is sufficiently powerful to normalize most of the reading skills of struggling readers older than 12 years of age." (FCRR report on SpellRead P.A.T., November 2003)

"The all new Fountas and Pinnell Leveled Literacy Intervention (by Irene Fountas and Gay Su Pinnell) has been developed in response to the demands of teachers and administrators for a powerful, scientifically-based early intervention program that can prevent literacy difficulties before they turn into long-term challenges."  ([http://www.fountasandpinnellleveledliteracyintervention.com/aboutLLI.asp] http://www.fountasandpinnellleveledliteracyintervention.com/aboutLLI.asp)
It is a systematic supplementary program designed for small group instruction of young children from Pre-K to Grade 3 that includes close monitoring to work toward benchmark acceleration across prescribed beginning to end points.  Learning goals are achieved through high quality teaching with a solid foundation in alphabet knowledge, phonemic awareness, phonics, conventions of print, high frequency words, syntax, fluency, and comprehension, especially for children who are achieving below grade-level competency.  Logically found within such a program design, is a spelling-related goal described as follows from the LLI kindergarten level synopsis:   "Using letters and sounds to solve words.  As children learn letter-sound relationships, they begin to apply them to solve simple words.  LLI provides a great deal of systematic instruction to help children understand how words are constructed using letters and letter patterns. They read and write words that are in continuous text."

In the end, the Report of the National Reading Panel, p 2-99, may describe it best:
       "Learning to read is a complex task for beginners.  They must coordinate many cognitive processes to read accurately and fluently.  Readers must be able to apply their alphabetic knowledge to decode unfamiliar words and to remember how to read words they have read before.  When reading connected text, they must construct sentence meanings and retain them in memory as they move on to new sentences.  At the same time, they must monitor their word recognition to make sure that the words activated in their minds fit with the meaning of the context.  In addition, they must link new information to what they have already read, as well as to their background knowledge, and use this to anticipate forthcoming information.  When one stops to take stock of all the processes that readers perform when they read and comprehend text, one is reminded how amazing the act of reading is and how much there is for beginners to learn." — Including WRITING and SPELLING!!

Submitted by Kenda L. Hammer, M.Ed., 

Early Literacy Specialist
 Fox Chapel Area School District Family Literacy Center
July 24, 2009–Spelling Interventions Response for CASANA

The Roller Coaster Ride That Is Childhood Apraxia of Speech

[by Jill, as part of CASANA'S Parent Scholarship application for the 2009 National Conference on Childhood Apraxia of Speech Conference]

Before my son was born, I was an enthusiastic middle school teacher in a tough part of Chicago. I was dedicated to struggling readers, writers, and mathematicians. But I drew the line at "special education." That wasn't my territory, not because I didn't care, but because I didn't know how to really participate. Back then, special education and general education were two very separate worlds.

Then I had my son and slowly over time, my world view changed both professionally and most dramatically, personally. Evan was perfect and beautiful and filled my heart with indescribable joy. I never dreamt that he would encounter challenges beyond the normal life experiences. I was a first-time mom, living in a rural area, with no extended family to "hang out" with. As I took my little baby in for his well-child visits, I would look at the poster on the wall of the exam room. It outlined language development for the typical child, with all the important milestones. I noticed that Evan was not doing most of the things he was supposed to be doing. During his nine-month checkup, I expressed my concerns to his pediatrician. He said, "Let's wait and see. Boys tend to lag behind girls in development." Everyone else echoed that same feeling, some people even mentioned how Einstein didn't talk until he was four. Looking back, his minimal vocalizations, lack of tongue movement, etc. were so obviously different than the norm. I regret that no one ever seemed alarmed, not that I feel that intervention at this point would have made any difference.

At each doctor visit thereafter, I expressed my concern about his language development and how it was not at all comparable with what was listed on the chart. Finally, at 18 months, the pediatrician recommended that I contact the local Birth - 3 program for an evaluation. The results of the evaluation were quite a shock. I thought he had delays in language development, but in fact, their results indicated that he was delayed in 4 out of 5 categories! Hearing these results was the beginning of a long roller coaster ride of emotions and advocacy that continues today as my son progresses through elementary school.

Progress in speech development has been painstakingly slow. This slow progress has me on a mission to find out how I can help my son. At first I thought he was just slow in learning to talk. A gap began to grow between his expressive and receptive language. Eventually, he was diagnosed with Childhood Apraxia of Speech. As we progressed through therapy and Early Childhood programs, I learned that I had to be the "case manager" for my child. This affects my life in many ways: I invest a lot of time in searching for appropriate services, making phone calls, driving to therapy appointments, meeting with school personnel, and educating myself and others on this mysterious condition known as apraxia.

Professionally I have, of course, become more interested in special education. I'm trying to figure out this inclusion thing - how to make it work for everyone (not an easy task). I also got involved in an interdisciplinary leadership training program that focuses on children with developmental disabilities and their families. This has, among other things, allowed me to attend national advocacy conferences.

Personally, I have become a parent advocate. I am proactive in educating the community about apraxia. I spent man hours in my son's classroom, helping his classmates understand why it is that my son has difficulty talking. At first they would say to me, "Evan can't talk." I would respond, "No, Evan can talk, it's just harder for him." I was glad I was able to be there to discourage that perception of him. I never wanted Evan to hear someone say that he can't talk.

As a teacher, I am now a big believer in the potential of inclusive education. While in kindergarten, my son's language grew more than ever before. Being around same-age peers that not only model language, but also engage Evan in academics and social activities is invaluable. Our school is somewhat unique in that it is very multicultural. When talking about diversity, most people talk about race, culture, language, and religion. We often neglect to include the abundant diversity in ability. I know that Evan's classmates have benefited from his presence as I've been fortunate to spend a lot of time with his classmates and their parents. Educators need to take on the responsibility of providing children with the opportunity to accept and celebrate the many differences in our society. We adults need to nurture and value the compassion that exists in young children. Wouldn't our world be an amazing place if we valued compassion as much as we do competition?

How does Childhood Apraxia of Speech affect my son? I'm not really sure. At this point, he can not express to me what is in his heart. I don't really, really know how he sees himself and I can't infer what his self-concept is. I don't know his own unique perspective on the world. He does know that he is "different" and that few people understand what he says. Right now, his social nature is an asset as he is persistent in forming friendships with other children. He's also a relatively happy child and doesn't get explosive in his frustration. He finds many ways to communicate, using gestures and words. I do think that his challenges with apraxia have allowed him to develop an incredibly empathetic spirit. When he sees a child cry, he puts his arm around that child. In silent gestures, he communicates that he cares and understands.

How does Childhood Apraxia of Speech affect me? Personally, I'm still riding an emotional roller coaster. I thought by now I would be more "together", that I wouldn't get sad at unexpected times. As I write this essay, I get tearful reflecting on the fact that I don't know anything about the inner life of my child. I get angry that he has such a huge challenge that affects just about every aspect of his life. I get frustrated that I can't ever do enough to help him or that I can't make it "go away." I get stressed over the behavioral challenges that arise. But I also get energized when Evan makes gains in the words he says. I celebrate even the littlest things that other parents take for granted. But mostly, when I tuck my son into bed every night, my heart fills with a feeling of love that I never knew before he came into my world.