A Goal-Writing Framework for Motor-Based Intervention for Childhood Apraxia of Speech.

PURPOSE: There are multiple frameworks for goal writing that are applicable to the practice of speech-language pathology. Motor-based speech disorders are a subset of speech sound disorders that are thought to require specific elements of intervention that are typically not addressed in the traditional frameworks used in the clinical setting. The purpose of this tutorial is to review general approaches of goal writing and suggest additional elements that may be used to improve the efficiency and effectiveness of treatment for childhood motor speech disorders, specifically childhood apraxia of speech (CAS). METHOD: Existing models of goal writing were reviewed to ascertain elements common to most of these models. A basic framework was chosen and modified to include behaviors, conditions, and approaches to goal measurement tailored to the clinical needs of children with CAS. A resource for clinical decision making for children with CAS was developed to inform goal writing at the onset of treatment and adaptations that occur over the course of treatment. Case studies are presented to demonstrate how the presented framework can be applied to writing goals for motor-based treatment for two different children with CAS. DISCUSSION: Children with CAS require a specialized approach to intervention, which requires goals to reflect the unique clinical needs of this population. This tutorial offers resources that use the best available research evidence and current understanding of effective treatment practices for CAS to guide clinical decision making for motor-based intervention and goal writing. This tutorial is intended to guide treatment planning across varied settings to facilitate progress and optimize treatment outcomes for children with CAS.

Dynamic Temporal and Tactile Cueing in Young Children With Childhood Apraxia of Speech: A Multiple Single-Case Design.

PURPOSE: Childhood apraxia of speech (CAS) is a multivariate motor speech disorder that requires a motor-based intervention approach. There is limited treatment research on young children with CAS, reflecting a critical gap in the literature given that features of CAS are often in full expression early in development. Dynamic Temporal and Tactile Cueing (DTTC) is a treatment approach designed for children with severe CAS, yet the use of DTTC with children younger than 3 years of age has not been examined. METHOD: A multiple single-case design was employed to examine the use of DTTC in seven children with CAS (aged 2.5-5 years) over the course of 6 weeks of intervention. Changes in word accuracy were measured in treated words from baseline to posttreatment and from baseline to maintenance (6 weeks posttreatment). Generalization of word accuracy changes to matched untreated words was also examined. A linear mixed-effects model was used to estimate the change in word accuracy for treated and untreated words across all children from baseline to posttreatment and to maintenance. A quasi-Poisson regression model was used to estimate mean change and calculate effect sizes for treated and untreated words. RESULTS: Group-level analyses revealed significant changes in word accuracy for treated and untreated words at posttreatment and maintenance. At the child level, six of seven children displayed medium-to-large effect sizes where word accuracy increased in an average of 3.4/5 words across all children. Each child displayed some degree of generalization to untreated targets, specifically for words with the same syllable shape as the treated words. CONCLUSIONS: These results demonstrate that DTTC can yield positive change in some young children with CAS. Key differences in each child's performance are highlighted.

The Relationship Between Speech Accuracy and Linguistic Measures in Narrative Retells of Children With Speech Sound Disorders.

BACKGROUND: Speech and language are interconnected systems, and language disorder often co-occurs with childhood apraxia of speech (CAS) and non-CAS speech sound disorders (SSDs). Potential trade-off effects between speech and language in connected speech in children without overt language disorder have been less explored. METHOD: Story retell narratives from 24 children (aged 5;0-6;11 [years;months]) with CAS, non-CAS SSD, and typical development were analyzed in Systematic Analysis of Language Transcripts (SALT) regarding morphosyntactic complexity (mean length of C-unit in words [MLCU]), lexical diversity (moving-average type-token ratio [MATTR]), and linguistic accuracy (any linguistic error/bound morpheme omissions) and compared to 128 age-matched children from the SALT database. Linear and mixed-effects logistic regressions were performed with speech accuracy (percent phonemes correct [PPC]) and diagnostic group as predictors of the narrative variables. RESULTS: PPC predicted all narrative variables. Poorer PPC was associated with lower MLCU and MATTR as well as a higher likelihood of linguistic errors. Group differences were only observed for the error variables. Comparison to the SALT database indicated that 13 of 16 children with CAS and SSD showed a higher-than-expected proportion of linguistic errors, with a small proportion explained by individual speech errors only. CONCLUSIONS: The high occurrence of linguistic errors, combined with the relationship between PPC and linguistic errors in children with CAS/SSD, suggests a trade-off between speech accuracy and language output. Longitudinal studies are needed to investigate whether children with SSDs without language disorder show more language difficulties over time as linguistic demands increase.

Dynamic Temporal and Tactile Cueing: Quantifying Speech Motor Changes and Individual Factors That Contribute to Treatment Gains in Childhood Apraxia of Speech.

PURPOSE: Speech motor skill is refined over the course of practice, which is commonly reflected by increased accuracy and consistency. This research examined the relationship between auditory-perceptual ratings of word accuracy and measures of speech motor timing and variability at pre- and posttreatment in children with childhood apraxia of speech (CAS). Furthermore, the degree to which individual patterns of baseline probe word accuracy, receptive language, and cognition predicted response to treatment was explored. METHOD: Probe data were collected from seven children with CAS (aged 2;5-5;0 [years;months]) who received 6 weeks of Dynamic Temporal and Tactile Cueing (DTTC) treatment. Using a multidimensional approach to measuring speech performance, auditory-perceptual (whole-word accuracy), acoustic (whole-word duration), and kinematic (jaw movement variability) analyses were conducted on probe words produced pre- and posttreatment. Standardized tests of receptive language and cognition were administered pretreatment. RESULTS: There was a negative relationship between auditory-perceptual measures of word accuracy and movement variability. Higher word accuracy was associated with lower jaw movement variability following intervention. There was a strong relationship between word accuracy and word duration at baseline, which became less robust posttreatment. Furthermore, baseline word accuracy was the only child-specific factor to predict response to DTTC treatment. CONCLUSIONS: Following a period of motor-based intervention, children with CAS appeared to refine speech motor control in conjunction with improvements in word accuracy. Those who demonstrated the poorest performance at treatment onset displayed the greatest degree of gains. Taken together, these results reflect a system-wide change following motor-based intervention.

Dose frequency randomized controlled trial for Dynamic Temporal and Tactile Cueing (DTTC) treatment for childhood apraxia of speech: protocol paper.

BACKGROUND: Childhood apraxia of speech (CAS) is a pediatric motor-based speech sound disorder that requires a specialized approach to intervention. The extant literature on the treatment of CAS commonly recommends intensive treatment using a motor-based approach, with some of the best evidence supporting the use of Dynamic Temporal and Tactile Cueing (DTTC). To date, a rigorous and systematic comparison of high and low dose frequency (i.e., frequency of therapy sessions) has not been undertaken for DTTC, resulting in a lack of evidence to guide decisions about the optimal treatment schedule for this intervention. The current study aims to fill this gap in knowledge by comparing treatment outcomes when dose frequency is varied. METHODS: A randomized controlled trial will be conducted to examine the efficacy of low versus high dose frequency on DTTC treatment outcomes in children with CAS. A target of 60 children, 2;6-7;11 years of age, will be recruited to participate in this study. Treatment will be provided in the community setting by speech-language pathologists who have completed specialized training administering DTTC in a research reliable manner. True randomization with concealed allocation will be used to assign children to either the low or high dose frequency group. Treatment will be administered in 1-h sessions either 4 times per week over a 6-week period (high dose) or 2 times per week over a 12-week period (low dose). To measure treatment gains, probe data will be collected before treatment, during treatment, and 1 day, 1 week, 4 weeks, and 12 weeks post-treatment. Probe data will consist of customized treated words and a standard set of untreated words to assess generalization of treatment gains. The primary outcome variable will be whole word accuracy, encompassing segmental, phonotactic, and suprasegmental accuracy. DISCUSSION: This will be the first randomized controlled trial to evaluate dose frequency for DTTC treatment in children with CAS. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT05675306, January 6, 2023.

The Multilevel Word Accuracy Composite Scale: A Novel Measure of Speech Production in Childhood Apraxia of Speech.

PURPOSE: The Multilevel word Accuracy Composite Scale (MACS) is a novel whole-word measure of speech production accuracy designed to evaluate behaviors commonly targeted in motor-based intervention for childhood apraxia of speech (CAS). The MACS yields a composite score generated through ratings of segmental accuracy, word structure maintenance, prosody, and movement transition. This study examined the validity of the MACS through comparison to established measures of speech accuracy. Reliability was also examined within and between practicing speech-language pathologists (SLPs). METHOD: The MACS was used to rate 117 tokens produced by children with severe CAS. Ratings were performed in the laboratory setting by two expert raters and by practicing SLPs (N = 19). Concurrent validity was estimated through comparison of expert MACS ratings (i.e., MACS score and each component rating) to measures of speech accuracy (percent phoneme correct and the 3-point scale) using correlational analyses. Reliability was examined between expert raters and across SLP raters using the intraclass correlation coefficient to examine interrater reliability of expert ratings, in addition to inter- and intrarater reliability of SLP ratings. RESULTS: Correlation analyses between MACS ratings (i.e., MACS score and component ratings) and existing measures of speech accuracy revealed small to large positive correlations between measures. Reliability analyses revealed moderate to excellent reliability for MACS ratings performed by expert raters and between (interrater) and within (intrarater) SLP raters. CONCLUSIONS: Analyses of concurrent validity indicate that the MACS aligns with established measures, yet contributes novel elements for rating speech accuracy. Results further support the MACS as a reliable measure for rating speech accuracy in children with severe speech impairment for ratings performed by expert raters and practicing clinicians.

The Effect of Practice on Variability in Childhood Apraxia of Speech: A Multidimensional Analysis.

Purpose Variability has been interpreted in differing ways according to context (e.g., development, speech impairment, and learning). A challenge arises when interpreting variability in the context of learning for children with speech impairment characterized by high movement variability, as in childhood apraxia of speech (CAS). The objective of this study is to investigate changes in variability in CAS with practice in comparison to patterns seen in children with non-CAS speech sound disorders (SSD) and typical development. Method Speech production variability was examined in 24 children (5-6 years of age) with CAS, non-CAS SSD, and typical development in production of nonwords of varied motoric complexity. Multidimensional analyses were performed using measures of token-to-token speech consistency (percent word consistency), acoustic variability (acoustic spatiotemporal index), and movement variability (lip aperture spatiotemporal index). Changes in variability were examined in each group of children by comparing the first half to the last half of nonword tokens in the same data collection session. The impact of token complexity on practice effects was also explored across groups of children. Results All children displayed increased speech consistency within this practice period (p = .01). Only children with CAS displayed increased movement variability following practice (p = .01). Differences in acoustic and kinematic variability were observed across complexity levels in all groups, though these did not interact with practice effects. Discussion These findings suggest that increased movement variability in children with CAS might be facilitating perceptual consistency. It is believed that this finding reflects an inefficient strategy adapted by children with CAS in the absence of motor-based cueing and feedback to guide speech performance with practice.

A Framework of Motoric Complexity: An Investigation in Children With Typical and Impaired Speech Development.

Introduction The current work presents a framework of motoric complexity where stimuli differ according to movement elements across a sound sequence (i.e., consonant transitions and vowel direction). This framework was then examined in children with childhood apraxia of speech (CAS), other speech sound disorders (SSDs), and typical development (TD). Method Twenty-four children (CAS, n = 8; SSD, n = 8; TD, n = 8), 5-6 years of age, participated in this study. The children produced words that varied in motoric complexity while transcription, acoustic, and kinematic data were collected. Multidimensional analyses were conducted to examine speech production accuracy, speech motor variability, and temporal control. Results Analyses revealed poorer accuracy, longer movement duration, and greater speech motor variability in children with CAS than TD (across all measures) and other SSDs (accuracy and variability). All children demonstrated greater speech motor variability and longer duration as movement demands increased within the framework of motoric complexity. Diagnostic grouping did not mediate performance on this task. Conclusions Results of this study are believed to reveal gradations of complexity with increasing movement demands, thereby supporting the proposed framework of motoric complexity. This work also supports the importance of considering motoric properties of sound sequences when evaluating speech production skills and designing experimental and treatment stimuli.

Does Implicit Voice Learning Improve Spoken Language Processing? Implications for Clinical Practice.

Purpose: In typical interactions with other speakers, including a clinical environment, listeners become familiar with voices through implicit learning. Previous studies have found evidence for a Familiar Talker Advantage (better speech perception and spoken language processing for familiar voices) following explicit voice learning. The current study examined whether a Familiar Talker Advantage would result from implicit voice learning. Method: Thirty-three adults and 16 second graders were familiarized with 1 of 2 talkers' voices over 2 days through live interactions as 1 of 2 experimenters administered standardized tests and interacted with the listeners. To assess whether this implicit voice learning would generate a Familiar Talker Advantage, listeners completed a baseline sentence recognition task and a post-learning sentence recognition task with both the familiar talker and the unfamiliar talker. Results: No significant effect of voice familiarity was found for either the children or the adults following implicit voice learning. Effect size estimates suggest that familiarity with the voice may benefit some listeners, despite the lack of an overall effect of familiarity. Discussion: We discuss possible clinical implications of this finding and directions for future research.

Short-term implicit voice-learning leads to a Familiar Talker Advantage: The role of encoding specificity.

Whereas previous research has found that a Familiar Talker Advantage-better spoken language perception for familiar voices-occurs following explicit voice-learning, Case, Seyfarth, and Levi [(2018). J. Speech, Lang., Hear. Res. 61(5), 1251-1260] failed to find this effect after implicit voice-learning. To test whether the advantage is limited to explicit voice-learning, a follow-up experiment evaluated implicit voice-learning under more similar encoding (training) and retrieval (test) conditions. Sentence recognition in noise improved significantly more for familiar than unfamiliar talkers, suggesting that short-term implicit voice-learning can lead to a Familiar Talker Advantage. This paper explores how similarity in encoding and retrieval conditions might affect the acquired processing advantage.

Changes in movement transitions across a practice period in childhood apraxia of speech.

This study examined changes in speech motor control across a movement transition between sounds within a motor learning task in children with apraxia of speech (CAS) and typical development (TD). It was investigated whether oral articulator movement was refined with practice and whether practice gains generalized to words not included in the practice session. A total of 16 children (ages 5-6) with CAS (n = 8) and TD (n = 8) participated in this study. Novel and real word tokens were produced at three time points. Kinematic data was collected using facial motion tracking at each time point. Children completed a practice session following baseline data collection session that integrated motor learning principles. Three tokens were included in the practice session and the remaining stimuli assessed carryover of practice gains. Kinematic data was then collected immediately following practice and 3 days later. Kinematic analyses were conducted on the movement gesture for the first syllable of each word. Narrow transcription analyses examined speech production accuracy. Children in the CAS group displayed increased consonant and vowel accuracy only for the practised tokens. Adjustments to spatial control and movement variability were observed in the CAS group, though only for practised words. Children in the TD group altered spatial and temporal domains of movement and variability across both practised and non-practised tokens. Interestingly, the CAS group displayed a pattern of increased displacement along with decreased variability, which was not observed in the TD group. The degree to which these findings reflect facilitative or maladaptive changes are discussed. Results are also interpreted in relation to vowel properties, novel/real word status and variable practice of novel and real words.

Articulatory Control in Childhood Apraxia of Speech in a Novel Word-Learning Task.

Purpose: Articulatory control and speech production accuracy were examined in children with childhood apraxia of speech (CAS) and typically developing (TD) controls within a novel word-learning task to better understand the influence of planning and programming deficits in the production of unfamiliar words. Method: Participants included 16 children between the ages of 5 and 6 years (8 CAS, 8 TD). Short- and long-term changes in lip and jaw movement, consonant and vowel accuracy, and token-to-token consistency were measured for 2 novel words that differed in articulatory complexity. Results: Children with CAS displayed short- and long-term changes in consonant accuracy and consistency. Lip and jaw movements did not change over time. Jaw movement duration was longer in children with CAS than in TD controls. Movement stability differed between low- and high-complexity words in both groups. Conclusions: Children with CAS displayed a learning effect for consonant accuracy and consistency. Lack of change in movement stability may indicate that children with CAS require additional practice to demonstrate changes in speech motor control, even within production of novel word targets with greater consonant and vowel accuracy and consistency. The longer movement duration observed in children with CAS is believed to give children additional time to plan and program movements within a novel skill.