Preventative Intervention: Narrative and Social skills in Childhood Apraxia

ASHA CONVENTION

Chicago, November 14, 2003

Seminar 1032

Preventative Intervention: Narrative and Social skills in Childhood Apraxia

Claire M. Waldron, Ph.D., CCC-SLP, Professor

Jennifer Bradley, M.S.

Danielle Blackburn, B.S.

Radford University

Today’s topic: Treating the Social and Linguistic

aspects of

Childhood Apraxia of Speech (CAS)

CAS

¶ A developmental motor speech disorder marked by difficulty with or inability in carrying out purposeful, voluntary speech in the absence of paralysis or weakness in the speech musculature (Caruso & Strand, 1999; Skinder & Strand, 1999; Yorkston, Beukelman, Strand, & Bell, 1999).

A definition written in parent friendly language:

“A disorder in which children have difficulties voluntarily making the movements needed to produce the speech sounds… or series of speech sounds or series of syllables they want to make when they want to make them.” (Hall, 2000, p. 173)

Case Study #1: the ramifications of failing to treat the social and linguistic aspects of CAS

Client: Jane Jones, age 11 years, 11 months; an attentive and motivated 5^th grade student, referred by school-based SLP who was concerned about Jane’s slow progress in speech therapy; he suspected that Jane had childhood apraxia

History

SLP reported

é good non-verbal oral-motor control

é ability to produce all speech sounds in isolation and words of up to three syllables in length

é numerous consonant and vowel errors in longer words, sentences, and conversational speech

é groping motions such as head nods, unusual prosody, and reliance on facial expression for communication, even with her twin sister

é Jane speaks English as if it were a foreign language

é Jane’s difficulty putting basic English sentences together affects her communication with her teachers and peers

é concern that Jane will experience social isolation when she moves to middle school next year

Parents reported

é Jane runs words together when speaking fast, slurs words, knows the words but just cannot say them

é Reading skills are one grade below level

é Speech problems since 5 years of age

é consulted every teacher (K thru 5^th grade), every year about their concerns about overall academics; teachers have assured them that she is “doing great” and that progress will take time.

é understood fairly well by her immediate family members; however, her speech is not as understandable to others

é requires 4-5 attempts to successfully communicate a question to a teacher. Often, does not talk at all because she does not want the attention

é Jane is a loner who does not participate in group activities outside of the family setting

é Even at home, doesn’t talk much, but prefers using the computer

é doesn’t speak on the phone with friends; has limited telephone skills (if she talks on the phone, she only speaks using single words)

é Currently getting A’s and B’s in her classes, and her teachers continually report that she is doing well

Assessment Results

Spoken language

é conversational utterances initially telegraphic, limited to a single word at a time

é eventually talked at length about favorite television shows and activities

é as length of utterances increased, intelligibility decreased

é discussed interests in science, science-fiction, oceanography, and recent trip to Virginia Beach

é conversational discourse was accurate and relevant, but 2-3 word turns often failed to convey enough information to adequately develop a topic

é Errors in speech sound production and differences in prosody and speech rate made speech difficult to understand; speech often faded to the point of being inaudible.

Reading

é Reading 1^st grade passage, able to produce only 3-4 words before pause

é Reading 3^rd grade passage, only produced 2-3 words before pause

é Frequently read only 1 word at a time

é Miscue analysis revealed use of phonetic cues to decode words, but not use of meaning (semantic) or language structure (syntactic) cues

lookàlike and severalàseven

é Decoding strategy: look at initial letter; then leap

crawlàclimb madàmean sameàsome.

warm fireàfire place anywhereàeverywhere

everàeven

Written Language

é printed name and name of school with no cues

é when asked to write a short description of the television show, Babylon 5, asked for help spelling the name of the show, then took 6-8 minutes to write

Babylon 5 is about to cip the peses.

é does well on spelling tests, but does not retain spelling words 1-2 weeks after a test.

Summary:

Jane exhibited classic symptoms of CAS

· overall speech intelligibility was reduced as length or complexity of words and utterances increased

Jane had unrecognized difficulty with expressive spoken language

· difficulty speaking affected participation in academic, social and even family interactions

· difficulty producing phonological aspects of English affected spoken syntax, morphology, semantics, and pragmatics

Jane’s had unrecognized written language difficulty

· difficulty sounding out unfamiliar words in 1st and 3^rd grade passages

· devoted so much attention to decoding unfamiliar words that sound blending and silent comprehension suffered

· serious writing problems, with both linguistic generating and encoding a written sentence and motoric aspects of executing a written sentence

Jane’s speech problems were recognized, but not her language problems!

Traditional treatment of CAS

Speech-language pathologists (SLP’s) are called upon to plan and act preventatively (American Speech-Language-Hearing Association, 1991) and to address the reading, writing, and discourse demands faced by their students in the classroom (American Speech-Language-Hearing Association, 2001)

SLP’s can address narrative proficiency, which is closely linked with both successful peer interactions and academic achievement (Bernstein & Tieferman-Farber, 1997), early in treatment, even before child can produce spoken narrative

SLP’s can plan and act preventatively to address the increasingly complex, decontextualized conversational and narrative discourse demands faced by children with CAS

Treatment Planning

Treatment must be planned and delivered to address past, current, and future communication skills

Treatment planning should address the level of expressive communication (Dowden, 1999)

§ Emerging: child does not yet have any reliable means of symbolic communication

§ Basic: child has at least one reliable strategy of symbolic communication, but can’t yet convey novel messages

§ Advanced: uses or can learn a wide variety of communicative strategies; has functional grammar & spelling, can compose messages independently

Treatment planning should consider incorporating functional outcomes determined by parent-professional team (Campbell, 1999)

Case Study #2 Preventative treatment strategies, goals, and outcomes for a child with limited speech production.

Treatment strategies

Target multi-modal communication, including use of print
Emphasize social communication
Pre-emptive focus on development of symbolic communication and use of decontextualized language
Promote conversational and narrative discourse even before routine production of multi-word spoken utterances

Client: Hannah Martin, a 3 year, 9 month old female; severe speech and expressive language impairment characterized by limited spontaneous vowel and consonant repertoires and difficulty imitating vowel and consonant combinations

History

é born prematurely, complex medical history including oral motor/ feeding problems; hypotonia; and reoccurring episodes of pneumonia, croup, respiratory problems, and apnea.

é followed for treatment of speech, language, and feeding difficulties since birth

é When first followed by us, communicated using gestures such as finger pointing and head nodding/shaking, some single sign utterances and a speech repertoire consisting of 3 single word approximations: bye, moo, and ma, some vowel approximations.

é frequently frustrated when not understood

é played alone most of the time in her preschool class

é did not initiate communication with her classmates

é began to sign in combinations of two to four words: TOY-MINE, ME-WANT-BABY, EAT-DRINK-ME, BYE-BYE-MOMMY-DADDY-BROTHER, ME-FEED-MY BABY.

Treatment Strategies:

Integrate motor speech needs with socially relevant language needs (Waldron et al., 2000)

a. Make symbolic communication a high priority. Symbols can be in form of pictures, signs, mutually intelligible gestures, spoken language, written language, line drawings

b. Target transition from communicating about the here and now to communicating about people, events, places, and feelings that are decontextualized

c. USE PRINT EARLY, CONSISTENTLY, and INDIRECTLY at first

a. Signed alphabet can be used when child has some phonological awareness

b. Use magnetic letters, Scrabble tiles, Magnetic Poetry as stimulus materials

c. Make sure that all picture stimuli include printed word

d. Make sure that print is always related to the alphabet (which should be visible somewhere in room)

e. Use children’s story books in treatment

f. Don’t get stuck at level of word or sentence. Children have to process and create narrative text in order to succeed in school.

Include families and other team members in routines and activities

Professionals’ interactions with children are important, but family members and caregivers have to know how to interact as well
All team members can do quick regular checks of treatment outcomes (see Campbell, 1999)
In preschool, INTERACTION IS THE CURRICULUM!
Interaction with peers is critical
Flexibility is important, especially when AAC is an issue.

3. Consider AAC early, as needed by child, always related to communicative effectiveness. Both comprehensibility and intelligibility are always goals.

Routines & Activities

Use a back-and-forth journal containing topical photos & print (digital camera or Polaroid’s I’zone cameras and sticky film) to orient family, teachers, SLP’s, & others about weekly themes, preschool events, new topics, events, people, to increase comprehensibility of speech

Example 1: Vending Machine Adventure (no product endorsement intended)

Example 2: Bluebirds in the park

Use talking photo album (inexpensive ($30-50, available on-line-search for “talking photo album” or through gadget companies) to add speech output component for non-speaking child…this allows for personal narrative production and conversation before child has speech capability to produce text)
If child is not able to say a word intelligibly, she can point to a more static symbol as a referent for conversation. Always use print with pictures.

Massed practice and repetition can be facilitated in socially-authentic ways:

Participation in Social Routines can be facilitated by adults (see Bahr et al., 1999)

Modify environment to maximize opportunities for children to interact
Use share time to provide a script to child for asking questions, fading support

Make use of snack time for natural verbal interaction (hand washing & drying, requests for plates or napkins, more juice, etc.)
Identify social phrases for children to use with peers
Encourage dramatic play, transitioning from action-oriented play to more interpersonal play

Use real props
Rehearse scripts ahead of time
Help children with verbal negotiation scripts

Goals and objectives for a multi-modal communicator

Long Term Goal:

Communicate effectively using expressive spoken and/or signed words with a variety of people in a variety of settings

Short Term Objectives: Language Form/Content (Waldron et al., 2000)

1. Imitate sounds and words.

2. Spontaneously produce a variety of single words.

3. Combine words into two word utterances.

4. Increase the number and variety of word and syllable shapes.

5. Increase phonetic inventory to include a variety of phoneme classes (stops, nasals, glides, fricatives)

6. Readily imitate words that child already knows and uses.

7. Establish a larger lexicon of spoken and signed words.

8. Communicate about events that are displaced in time and space, using a variety of symbolic communication

9. Produce short personal narratives using comprehensible modalities and a variety of symbolic communication

Short Term Objectives: Language Use (Hadley & Schuele, 1998)

1. Make positive verbal initiations to peers 3 times during a 5- minute observation of routine classroom activities without any adult assistance on three different days within a one-week period

2. Spontaneously produce prosocial functional phrases 3 times per day to request object from peer partner

3. In 10 minute dramatic play activity, produce 5 positive verbal initiations to peers and 10 verbal responses to peers on 3 days in week

4. When participating in conversationally oriented dramatic play activities, stay engaged in activity for 5 consecutive minutes

5. Generate three different verbal strategies to achieve a specific social goal

6. Make a second verbal bid to achieve a social goal when a first bid is unsuccessful

Case Study #3 Illustration of goal selection and treatment planning based on developmental expectations for narrative production and kindergarten/first grade curricular Standards of Learning for oral language, reading, and writing. Presentation of strategies for promoting improved narrative production.

Client JJ , now 6 years, 3 months

History Age 3 Emerging expressive communication skills (Dowden, 1999), barely able to imitate simple word shapes, no reliable means of symbolic communication, most speech production was imitated, not spontaneous

Age 3;6 Began to convey novel messages, utterances only 1 to 2 words in length, inventory of speech sound still deficient

Age 4 Producing novel 2-, 3-, and 4-word utterances, communicated about people and events that were displaced in time and space. Prosodic difficulties become apparent. Struggling with conversational discourse. Limited or no ability to produce narrative discourse.

Example of conversation about JJ’s visit to King’s Dominion

Clinician: How are you?

JJ: Fine.

Clinician: What did you do this weekend?

JJ: Nothing.

Clinician: Did you go on any rides?

JJ: No.

Clinician: What kind of food did you eat?

JJ: I didn’t eat.

Clinician: Who did you go with?

JJ: No one.

Treatment Strategies:

Provide picture cues and conversational examples as scaffolding for more detailed conversational discourse
Joint storybook reading/imitation of story text for motor speech practice, including emphasis on improving prosodic features of speech
Interaction, questions centered around storybook

Routines & Activities

Picture books including Play Ball, Toad on the Road, One Fish, Two Fish, Red Fish, Blue Fish, Freight Train, Who’s Making That Noise?, Ted in a Red Bed, I am a Leaf, No, David!, Boo Who?, I’m a Fire Fighter, Hiccups for Elephant, Hop on Pop, Just Me and My Puppy, Little Critter is Helping, Little Critter is Hiding, and Me Too!. Each book had relatively short, but high interest utterances and pictures that closely paralleled the text.

Goals and objectives

Long Term Goal: Communicate effectively using intelligible expressive spoken language.

Short Term Goals:

1. Spontaneously produce multi-word utterances illustrating a variety of semantic-grammatical combinations in both conversational and narrative discourse

2. Produce accurate word and syllable shapes in utterances up to 5 to 6 syllables in length without breaks and pauses, with emphasis on the production of

unstressed syllables.

3. Name the letters of the alphabet, both individually and in sequence.

4. Identify word initial letter names.

5. Decrease rate of speech during conversational speech.

6. Maintain a natural speech melody in an utterance with 5 to 6 syllables.

7. Produce continuous sequences of words pausing at appropriate breathing points.

8. Increase phonetic inventory to include accurate production the glides /w/ and /j/ and the lateral /l/.

Age 5. JJ started kindergarten, passed speech-language screening. Language problems became primary concern:

é continuous struggles with narrative discourse, including personal narratives, story retells, scripts, and story generations

é had fluent speech and was intelligible, but social communication was challenging

é unable to respond to simple questions such as, “what did you do today” or “tell me about your trip to ...”

é became frustrated and consistently responded with “I don’t know.”

Example of Story Retell of When Sophie gets Angry, Really Really Angry

He sister taked away from her and said no. She fell over the dump truck. She got angry. She got angry and she…….

JJ (making a conversational aside) : “I don’t know, If I turn the other page it will help me”.

She got angry and run and run and she couldn’t run no more. And she was all alone. She was sad. And she and she heard the bird tweet tweet go tweet tweet. And she climbed the tree the tree and she felt the wide open and she

JJ (making a conversational aside): “Let’s turn the page again”

And she wanted to go home, and she wanted to go home, and she drawed a picture.

JJ’s story retell was characterized by listing or chaining of events, with no cause and effect relationships being presented.

Example of story generation supported with contextual cues, produced while looking at wordless picture book A Boy, a Dog, and a Frog by Mercer Mayer.

JJ said, “I can’t do this! I can’t read.”

Clinician provided model of story generation, then JJ produced the following story.

A boy wanted to catch a frog and, and, he tripped over the log and fell into the water and he runned down the hill and he tripped over the log and fell into the water and he fell into the water and the frog think-ted of “you’re a silly boy.”

JJ (making a conversational aside): “I can’t read. I don’t want to. Let’s just quit.”

And the frog jumped off the lillypad to the log, and the boy, and…

JJ (making a conversational aside): and I (sigh), I’m gonna turn the page again cause I can’t read this part.

He said to go that way and I’m gonna go the other way. And he almost catched the frog and he almost got the froggy and he catched the dog. He was mad. And he was really, really, super duper mad. And he could see the frog, he was on the…….rock and he said to catch

that frog because he will catch him and he started to his home and he was lonely and he was mad and he hadded to start back to home. And he followed and he wanted to follow the footprints. And he was, and his doggy and he was takin a bath with his doggy, he, the frog want to jumped into the bathtub to enjoyed it, and he want and they comed friends. The end.

JJ’s story retell was characterized by listing or chaining of events with no causal relationships being expressed. Fluency decreased dramatically during story retell.

Treatment Strategies

Target narrative discourse because of its complexity
Target narrative discourse to facilitate the development of conversational discourse
Target well-formed narratives to enhance JJ’s communicative competence and his daily interactions with other people, and promote social acceptance by peers
Refer to Standards of Learning for oral communication, reading and writing for planning treatment goals

Goals and Objectives

Goal 1: Improve conversational discourse

é Begin to follow implicit rules for conversation with peers and adults, including being polite, taking turns and staying on topic

Goal 2: Develop and expand narrative skills

é Recount a personal narrative from a recent or past event

é Use pictures to make predictions about content of written text

é Tell and retell stories and events in logical order

é Discuss characters, setting, and events

é Use story language in discussions and retellings

é Write and draw to communicate ideas and retell past experiences.

Treatment strategies

Use Stickwriting (Ukrainetz, 1998) to support narrative production, including representations of characters, setting, and sequences of actions with simple, chronologically or episodically organized stick-figure drawings in conjunction with arrows that describe chronological sequences of movement from one event to the next
Incorporate children’s literature into every session. Use a variety of verbal prompts to elicit predictions about the text
Use graphic organizers such as story flow charts as a scaffold to elicit both setting details and temporally sequenced story recalls
Encourage child to illustrate personally experienced events, then use that visual scaffold to support narratives
Use digital photography to capture events experienced, then arrange the photos to scaffold production of detailed personal narratives.

Outcomes

· JJ is able to spontaneously provide personal narratives. He is able to describe events in a coherent and temporally ordered sequence. JJ’s personal narratives frequently include elements of story grammar, including the setting, characters and events.

JJ is able to make predictions about the content of stories independently.
JJ attempts to relate events in stories to personal events.
JJ enjoys reading.
JJ can tell and retell stories in a temporal sequence.
JJ uses story language to mark the beginning and end of his story retells and personal narratives when using “stick writing”.
JJ uses pictography successfully to give him the structure to discuss personal experiences, stories, people, objects and events. When asked to record information about events he and the clinician experience together he has spontaneously suggested using “his stick writing” to record the events

Examples of Post-Treatment Narrative

JJ was instructed to write a story about his day at the clinic using pictography (i.e. stick writing). As JJ was drawing the pictures he narrated the story. When he retold his own story looking at the pictures he had drawn, he included specific events that he normally would have omitted or had difficulty finding the words to express. He also included events in his story retell that he did not include in the “stick writing” activity. JJ’s story retell was fluent, told in a temporal sequence, and coherent.

JJ: We put on our coats. Then we went to my daddy and asked permission if we could go outside and then

Clinician: Wait, wait, wait. What’s this little thing here? You got your coats and you went to get permission from your dad …

JJ: This is the candy for me and my dad.

Clinician: Okay, so start over and don’t forget that little detail.

JJ: Here is Danielle and Me and we put on our Jackets. Then we went to my dad to ask permission and he gave me some snacks to snack on. And I shared with Danielle. Then we were carrying some books and here’s the place.

Clinician: You were just carrying books? Did you do something with the books?

JJ: We put them back on the shelf.

Clinician: Oh, you returned the books!

JJ: I sawed a scary skeleton and I was afraid of it.

Clinician: So, you got permission and snacks from your dad and then you returned …

JJ: the books. Then we went outside and blew bubbles.

Clinician: Where were you when you blew bubbles?

JJ: We went outside at that big ‘ol construction sight and here’s the construction sight and here’s the truck

Clinician: How did you know you were blowing bubbles? Did you draw bubbles?

JJ: We went inside and washed our hands, we have to wash our hands now

Clinician: Where does the skeleton come into the story? Did you do the skeleton before or after the books?

JJ: I don’t know …

Clinician: Tell me where in the story it would be.

JJ: It should have been right here, after the place.

Clinician: After the books?

JJ: Yeah, after the books

The following is another example of JJ’s story retell using pictography as a scaffold for generation of a personal narrative:

JJ: Today me and you, we were going to ask my Lanny “Can we go outside? And she said yes. And then we went outside. And then we are going to play basketball and then

Clinician: Wait. You are supposed to go from here to here. You are doing good, but just remember come from here to here. You left out that part. So we played basketball and you got…?

JJ: Got five shots

JJ: And then we blew bubbles.

And then we went inside and drawed a story and “The end.”

After the session was over JJ voluntarily told his grandmother about the session:

JJ: “Me and Danielle wrote another one of those stories today. We played basketball outside, and blew bubbles, and wrote on the sidewalk. I was a good boy today, so I got two USA stickers, see!

Conclusions: JJ continues to have some phonological and prosodic difficulties, but he has the language foundation needed for succeeding in first grade.

References

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Biographical Sketches:

Claire M. Waldron, Ph.D., CCC/SLP, is a Professor, Department of Communication Sciences & Disorders, Radford University (RU). Her teaching and research interests are in child language and phonological disorders. She teaches a graduate course titled Childhood Apraxia of Speech.

Email address: cwaldron@radford.edu

Jennifer Bradley earned a Bachelor of Arts in Psychology from Marshall University in 1994 and completed a Master of Science degree in Speech-Language Pathology at RU in May, 2003. She was selected as a Scottish Rite Child Language Disorders Fellow for 2002-2003. She is currently employed as a speech-language pathologist by Montgomery County Public Schools.

Danielle Blackburn earned a Bachelor of Science degree in Communication Sciences and Disorders from RU in May, 2002. She is a second year graduate student in speech-language pathology at RU. She was selected as a Scottish Rite Child Language Disorders Fellow for 2003-2004.

Recommendations for Jane Jones

1. Because Jane is going to be transitioning to middle school, this is a logical time for Jane’s family, her teachers, and Mr. Warren to collaborate about re-evaluating and revising her Individualized Educational Plan (IEP) as necessary to address her communication and written language needs. We provided Mr. & Mrs. Jones with copies of the attached articles, and these can be used to make sure that Jane’s educational team is aware of the nature of DAS, its educational significance, and Jane’s treatment needs. Because Jane has so much difficulty with motor speech output, the WISC-III Verbal scores, and therefore the Full scale IQ score obtained in November of 1999 should not be considered valid. Any further cognitive assessment must take Jane’s unique speech output problems into account; i.e., non-verbal assessment is strongly recommended.

2. Jane should have ongoing speech-language therapy that is as intensive as possible. A combination of motor programming and linguistic approaches is recommended; with a “total communication” philosophy that accepts, encourages, and allows any form of communication that helps Jane get her message across.

3. If Jane has not had recent educational assessment, we would recommend specific assessment of Jane’s use of phonetic, meaning, and sentence structure cues as she reads aloud and silently. Her overall reading comprehension is the most important issue now and in the future. Similarly, her writing ability is of concern. Because children with DAS often have gross and fine motor skill deficits that affect handwriting, we strongly recommend that Jane be seen for occupational or physical therapy evaluation which addresses both Jane’s need for treatment to improve her handwriting ability and her needs for technology support, for example, a laptop computer and printer for academic writing in the classroom and at home. A class to increase Jane’s keyboarding skills would help her become a more fluent, productive writer. Meanwhile, Jane should use print for all spelling assignments and tests to increase visual cues.

4. Jane social development should be encouraged and planned. It will be important to increase her participation in social activities both in and outside of school. She needs the opportunity to interact with peers in groups such as Girl Scouts, clubs related to her academic interests in science, and/or church groups). She may need to practice specific speech scripts for these activities, including routines for talking on the phone. Her use of written language for social purposes can be encouraged through the use of e-mail and other computer based communication opportunities such as Instant Messenger.