Integral Stimulation

Developed by Strand & Skinner (1999)

•  This treatment is known by most as the “watch me-listen” approach to therapy (Strand & Skinder, 1999, p.109). This treatment approach requires that the child imitates the utterances modelled by the clinician. The child's attention should be kept on both the auditory model (i.e. listening) and visual attention to the clinician's face (i.e. looking) (Yorkston, Beukelman, Strand, & Bell, 1999).

•  Integral stimulation is an articulatory method and follows a ‘bottom-up' sequence of treatment (Yorkston et al., 1999). As with tactile-kinesthetic methods, this means treatment starts with short, phonetically simple utterances, and progresses to longer, more phonetically complex utterances (Yorkston et al., 1999).

CAS AND INTEGRAL STIMULATION

It is suggested that the integral stimulation method is appropriate for those children for whom motor impairment may contribute to the speech disorder (Strand & Skinder, 1999). It has also been suggested by Yorkston et al. (1999) that this method is commonly used for those children with moderate to severe CAS. Strand and Skinder (1999) emphasise mass practice for more severe cases; and distributed practice for moderate cases. Integral stimulation is consistent with traditional treatment approaches to CAS that use a “bottom-up” perspective (Blakely, 1983; Chappell, 1973; Haynes, 1985; Marquardt & Sussman, 1991; Rosenbek, Hansen, Baughman & Lemme, 1974; Yoss & Darley, 1974). The “bottom-up” approach to CAS treatment means the clinician:

• Starts with giving the child maximum cueing for the hierarchy of syllable shapes (i.e. CV to CVC to CCVC syllable shapes; then onto longer words, carrier phrases, sentences, and so forth).
• Slowly fades the use of cues until the child is able to produce target words spontaneously.

THEORY AND EXPLANATION

The rationale for using integral stimulation is that many of the principles of motor learning are represented in these approaches (Strand & Skinder, 1999). Strand and Skinder (1999) suggest that it is difficult to determine which levels of motor skill are impaired in children with CAS. Therefore, they believe that it is necessary to target a number of factors that are known to be important to the development of a motor skill. These factors may include improving sensory monitoring of articulatory configurations and/or practicing with specific and various movements. (Strand & Skinder, 1999). As all responses by the child are movements, this allows for the repetitive practice that is very important for motor learning (Yorkston et al., 1999)

IMPLEMENTATION OF INTEGRAL STIMULATION (TIME FRAME)

One of the most recent treatment approaches illustrating how integral stimulation techniques can be adapted for children with CAS has been described by Velleman and Strand (1994). Velleman and Strand (1994) propose the following recommendations for treatment:

- The main focus of treatment should be on syllable structure control within a variety of linguistic contexts.

- Treatment should not emphasise working on phoneme production in isolation prior to moving to words phrases.

- Sessions should be frequent and short in order to avoid fatigue.

More specifically Velleman and Strand (1994) suggest that sessions should be divided into four parts:

1. Imitation of body and/or oral motor sequences (this is a warm up activity).

2. Syllable sequence drill activities. Work towards consistent connected syllable productions that the child can already produce. Include sequences that vary articulatory positions (e.g. front to back, as in “buttercup” or “go to bed”).

3. Meaningful single word activities. These need to include a core vocabulary that will help to increase the intelligibility of the child's speech.

4. Short sentence activities. Start with a key carrier phrase and change one word, gradually increasing the length and complexity of the target.

Strand and Skinder (1999) suggest:

1. Begin with direct imitation of the word at a slowed rate.

2. If the child is successful, continue with direct imitation until the child is able to imitate at a normal speech rate with varying prosody.

3. Gradually increase the delay after the model.

OR

2. If the child is unsuccessful at a slowed rate, then provide the child with simultaneous productions.

3. If the child is still unsuccessful with simultaneous productions alone, then add tactile cues ad slow the production even further.

4. Once the child can do simultaneous productions at a normal rate, go back up to direct imitation (1).

Other integral stimulation techniques described by Chappell (1973), Yoss & Darley (1974), Haynes (1985), Crary (1993), all share commonalities with Velleman and Strand's (1994) approach. Most use a “bottom-up” method of introducing stimuli, starting with the simplest phonetic context and progressively moving to more difficult contexts. Many of these approaches incorporate at least some of the principles of motor learning, including:

•  Repetitive production of targeted stimuli.

•  The manipulation of rate.

•  The gradual lengthening of the retention span for programming the articulatory movements.

All integral stimulation techniques advocate the use of systematic drill (Strand & Skinder, 1999).

Decisions regarding the frequency, length and type of treatment sessions are the responsibility of the treating clinician (Strand & Skinder, 1999).

 PROFESSIONAL TRAINING

Not required

 ADVANTAGES OF INTEGRAL STIMULATION

• Integral Stimulation allows the clinician to focus on the areas of motor skill development.
• It is easy to make the principles of motor learning more salient for children who have more severe motor planning impairment (Strand & Skinder, 1999).

DISADVANTAGES OF INTEGRAL STIMULATION

• Children need to be able to maintain attention and eye contact to watch the clinician's lip, jaw, and tongue movements in order to benefit from this approach. Children that have not yet developed these skills, or for whom these skills are difficult (i.e. those with autism or severe cognitive deficits due to acquired brain injury) may not benefit from this approach (Strand & Skinder, 1999).
• There is disagreement as to whether to use non-speech stimuli or nonsense syllables as part of the treatment program (Strand & Skinder, 1999).

LEVEL OF EVIDENCE

Pannbacker's (1988) reviewed 10 approaches to treating children with CAS. The review revealed that one of the methods that had preliminary results of being efficacious was a method that included working on movement sequences through systematic drill (using particular hierarchies of stimuli). This method is in line with integral stimulation approaches (i.e. going form CV to CVC to bisyllabic words to carrier phrases to sentences, etc.).

Refer to evidence table

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Tactile-Kinesthetic Methods

• Introduction
• Moto-kinesthetic Speech Training
• Speech Facilitation
• PROMPTS: Prompts for Restructuring Oral Muscular Phonetic Targets

Introduction

CAS AND TACTILE-KINESTHETIC METHODS

This technique is beneficial for children identified with jaw, lip, and tongue speech motor problems (Square, 1999). These methods clarify movement parameters, amplitudes, trajectories , and durations which is useful for the child (Square, 1999). Ozanne and Square, Hayden, and Ozanne (as cited in Square, 1999) have reported that oral movement control has been the most frequent problem identified in children with CAS.

THEORY AND EXPLANATION

A theoretical understanding of developmental motor speech control and motor learning that relates to each of the three treatment types (Moto-kinesthetic Speech Training, Speech Facilitation, and PROMPTs) will enable clinicians to select an appropriate treatment approach based on the characteristics of a child's oral and speech motor performances (Square, 1999).

These approaches have been developed with the aim of modifying disordered speech production through the enhancement of orofacial tactile and kinesthetic feedback (Square, 1999). This involves manipulating the oral structures through movements in order to enhance the child's oral-sensory-perception of speech (Square, 1999).

There is limited evidence base behind treatment for CAS. Hence, the following literature from Square (1999) on the process of ‘ normal speech acquisition ' in early childhood and the ‘ principles of motor learning ' are included here to aid clinician's in gaining a theoretical understanding for the use of tactile-kinesthetic approaches in the treatment of motor speech disorders. This theory may continue to aid clinician's as they search through the numerous treatments for CAS, with the hope of finding an appropriate treatment that suits the underlying characteristics of this diverse paediatric population.

Normal Speech Acquisition

Square (1999) explains that speech motor skills appear to develop in the following ‘bottom-up' hierarchical manner:

•  Postural Stability

•  Vocal Play (non-speech as well as speech like vocalizations)

•  Squeals and syllabic like vocalizations approximating consonant-vowel utterances

•  Noise-making activities (providing the infant with practice in the process of linking sensations to oral movements )

•  Babbling (providing opportunities for motor practice and sensory integration)

•  Syllable reduplication (providing further motor practice that underlies the development of linkages between vocal sounds and their corresponding tactile and kinesthetic vocal tract sensations; may also play a role in developing speech rhythm templates)

Lashley (as cited in Square, 1999) and many others since hypothesize that rhythm plays an important regulatory role in the control of skilled movements and that the rhythmic structure for speech may initially develop through syllable reduplication.

•  Child attempts first words (using a trial and error strategy)

•  The knowledge of speech sounds develops along with sensory templates that correspond with different speech units.

From the process of normal speech acquisition it has been suggested that the treatment of developmental speech disorders in early childhood should focus on (1) single words or word-combination utterances that occur in early development and (2) utilisation of the feel, sound, and visual appearance of sound sequences (Square, 1999).

Principles of Motor Learning

 The Schema Theory, as described by Square (1999), explains the process of acquiring skilled movement. The establishment of schemas is reliant on one's ability to integrate sensory information for error feedback so that subsequent movements may be refined (Square, 1999).

Based on the schema theory it is suggested by Schmidt (as cited in Square, 1999) that the goals of early speech treatment should include:

•  Establishment of the most facilitory posturing for the production of efficient speech

•  Establishment of the physical parameters of speech utterances (as these children have not developed central templates of these parameters)

•  Heightening sensory awareness of the feel of speech and establishing the integration of sensory feedback from the tactile, kinaesthetic, auditory, and visual modalities

•  Providing explicit information about the child's productions and further feedback, especially kinaesthetic, regarding the parameters of a more refined response.

The Theory of Motor Programming provides a framework for the control of skilled movements (Square, 1999). Square (1999) describes motor programs “as centrally stored road maps that specify the directions and destinations and sequences of movements” (p.155). The construction of motor programs requires that the child have the ability to update both recall and recognition schemas during motor learning (Square, 1999). The 4 types of information discussed by Schmidt require integration for the establishment of motor planning (Square, 1999).

The 2 theories above highlight the importance of a speaker's ability to detect and process orosensory feedback (Square, 1999). Therefore, the feel of speech must be salient and treatment methods that enhance this saliency should be theoretically sound ( Strand , 1999). Further, the feel of sound must be integrated with how it sounds and appears visually (Square, 1999). Thus, clinical approaches that “map in” spatial and temporal parameters of movement and highlight sensory results will assist development of recognition and recall schemas that have not naturally developed (Square, 1999). Providing therapy based on these theories is what tactile-kinesthetic methods appear to have achieved.

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IMPLEMENTATION OF TACTILE-KINESTHETIC METHODS

MOTO-KINESTHETIC SPEECH TRAINING

Young and Stitchfield-Hawk (1955)

• Originally developed for adults, however this approach has been adapted to the paediatric population by Sara Stitchfield-Hawk.
• Stitchfield-Hawk advocates that speech practice should utilize words and that the words should be elicited during play.
• The clinician simultaneously stimulates the location of the musculature that's involved in the target movement, and the “feeling” of the direction of movement by using varying degrees of pressure and timing.
• The clinician says the word simultaneously with the application of the tactile-kinesthetic cues.
• This method reportedly helps muscles achieve a standard goal.

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SPEECH FACILITATION

Square (1999)

• This method is an outgrowth of Moto-Kinesthetic Speech Training.
• Uses intra-oral appliances to signal spatial targeting.
• Uses the phoneme as the unit of movement training.

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PROMPTS: PROMPTS FOR RESTRUCTURING ORAL MUCULAR PHONETIC TARGETS

• This system, originally developed for adults, has been adapted for speech disordered children by Hayden (Hayden & Square, 1994).
• The original system prescribed a PROMPT that related to each of the English phonemes. For each phoneme details were specified regarding: jaw height and facial-labial contraction; tongue height and advancement; muscular tension; duration of contractions; and air stream management at the laryngeal and oral-nasal valves (Chumpelik, 1984).
• Hayden still advocates that clinicians learn the system for each phoneme by practicing PROMPTs (personal communication, as cited in Square, 1999), as becoming a proficient PROMPT clinician requires a new manual motor behaviour to be learnt. Learning the PROMPT system aids the clinician's development of motor recall and recognition schemas for hand shapes and movements.
• Using the PROMPT system of treatment for children with motor speech disorders has always emphasised the PROMPTing of meaningful linguistic movements . Therefore, clinician's need to target age-appropriate meaningful words and phrases that are at the linguistic formulation level of the child.
• PROMPTs are applied in connected speech to alter the spatial and temporal aspects of speech motor control.
• PROMPTs will vary based on the child's individual problems. The areas of control that require assistance, i.e., jaw, labial-facial and lingual movement parameters and speech sequencing, are individually assessed and individualised treatment hierarchies are developed for each child based on his or her areas of difficulty.
• Hayden and Square (1994) propose a speech motor treatment hierarchy for use in PROMPT therapy. By applying PROMPT treatment systematically to speech subsystems in the following hierarchical fashion, spatial configurations and target sound sequences are established.

Level I: Focuses on the establishment of postural support for speech and emphasises the attainment of

trunk, neck, and head control, and the suppression of abnormal oral-motor reflexes.

Level II: Focuses on phonatory control (ability to voice) for at least 2 to 3 seconds.

Level III: Focuses on the control of jaw movements in speech. That is, different degrees of opening for different vowels. There is establishment of control over vertical jaw movements, while inhibiting horizontal and anterior-posterior movements. Maximal jaw opening for normalised speech is established, i.e., the degree of opening of the jaw should not exceed that of the position required for / a / in connected speech. Control over the degree of jaw opening is then established using age appropriate words that contain vowels of varying heights.

Level IV: This is practiced once jaw control becomes adequate. Lip rounding and retraction are practiced at this level. Symmetry and coordinated movements of upper and lower lips are PROMPTed. The lip refinements are then integrated with jaw control.

Level V: This is introduced once jaw and lip parameters of action are set, refined, and integrated. Anterior and posterior tongue action as well as raising-lowering movements, and contraction along the tongue body are established and integrated with jaw and labial movements.

Level VI: Retain control of the above for longer lengths of speech production.

Level VII: Retain control of the above while normalizing rate and intonation.

(Hayden 1994)

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PROFESSIONAL TRAINING

• Hayden and Square (1994) recommend that clinicians receive specific training in the use of PROMPTS. To run PROMPT treatment programs effectively all clinicians should receive official training. Through training, clinician's will receive the resources and skills necessary to run the PROMPT program. PROMPT training workshops are conducted world-wide throughout the year. There are PROMPT training workshops held in most states of Australia every year. For details regarding the next ‘Introduction to PROMPT: Technique' workshop in your area log onto ‘The PROMPT Institute' website (Hayden, 2006). The cost of this workshop is $550.00 (as at Oct 2006).

ADVANTAGES OF TACTILE –KINESTHETIC METHODS

• Both Moto-Kinesthetic Speech Training and PROMPT emphasize the facilitation of normalised developmentally appropriate movement sequences and focus primarily on the production of sequenced movements that correlate with meaningful words and phrases (Square, 1999).
• The PROMPT System Treatment Hierarchy is based on the principle of establishing a level of movement control, whereby each newly acquired level of skill is integrated with the previous level (Square, 1999). Treatment deemphasises phoneme end products and is in keeping with contemporary motor literature (Square, 1999). The Prompt System is consistent with the theory of the establishment of motor movements in all motor subsystems in the developing child (Thelen & Smith, as cited in Square, 1999).
• The PROMPT System training provides clinician's with a clear program to guide their intervention. The training may also equip clinician's with improved problem solving skills to assist in altering this program for each individual child.
• Moto-Kinesthetic Speech Training and PROMPT methods advocate that an age-appropriate vocabulary of interest and functionality be chosen for training at each level of the hierarchy (Square, 1999).

DISADVANTAGES OF TACTILE-KINESTHETIC METHODS

• The speech appliances used in Speech Facilitation may detract from the facilitation of normalized developmentally appropriate sequences (Square, 1999).
• Speech Facilitation appears to focus on the production of accurate phonemes. This approach is far removed from the principles of motor learning and speech-language acquisition.
• To administer PROMPT for therapy the clinician needs to attend a training workshop. The cost of attending this workshop may be more than some organisations are willing and/or able to pay for the professional development of their therapists.

LEVEL OF EVIDENCE

Refer to evidence table

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Rhythmic and Melodic Approaches

• Introduction
• Slow Speech
• Rhythmic Methods(Touch-Cue Method of Therapy, Nuffield Centre Dyspraxia Programme, Music and Movement Program)
• Melodic Methods (Melodic Intonation Therapy (MIT) & Melodic Apraxia Training (MAT))

Introduction

CAS AND RHYTHMIC AND MELODIC APPROACHES

Velleman (2003) suggests that speech production is aided by rhythms or tunes.

THEORY AND EXPLANATION

Rhythmic and melodic approaches have been used effectively for children with speech movement sequencing disorders (Square, 1999). These methods may be successful due to the timing and rhythmic frame within which speech movements are achieved (Square, 1999).

Pre-speech rhythmic behaviour is normally observed during the first year of development, thus, rhythm seems to be a mechanism for organizing motor behaviour (Square, 1999). Early vocal play behaviour of children with CAS has been reported by both Eisenson and Chappel (as cited in Square, 1999) to be greatly reduced. However, more recent reports by Shriberg , Aram , and Kwiatkowski (1997) indicate that a subset of children with CAS use inappropriate stress in speech production.

Elbers and Thelan (as cited in Square, 1999) have found rhythmic therapies to be somewhat consistent with normally developing pre-speech vocal behaviour. Thelan (as cited in Square, 1999) suggests that syllable reduplication and alternating contrasts are early speech behaviours. Furthermore, Thelan (as cited in Square, 1999) suggests that synchronization of hand and head movements with speech is an early emerging skill. If Thelan's hypothesis (as cited in Square, 1999) is correct, such behaviours must be firmly established before more complex rhythmic patterns, such as the movements required for connected speech, can emerge. It may be appropriate to speculate that some aspect of rhythmic regulation of speech is disrupted in CAS, due to the numerous reports of the efficacy of rhythmic approaches in the treatment of CAS (Square, 1999).

IMPLEMENTATION OF RHYTHMIC AND MELODIC APPROACHES

SLOW SPEECH

• Square and her colleagues (Square, 1994; Square & Martin, 1994; Square, Roy, & Martin, 1997) have suggested that lengthened syllabic nuclei, as achieved through slowing of speech production, results in the mandible and tongue maintaining positions in space for longer periods of time. Hence, this provides the system with more time to establish articulatory positions (Square, 1994). Square (1994) suggests that this extension of sensory feedback may assist the child:

(1) To establish the feedback necessary for the initiation of a motor sequence.

(2) To update central programs that are already unfolding.

(3) To provide extended time periods in which the motor program for the next small chunk of speech (i.e.

the next syllable) may be recalled from motor memory.

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RHYTHMIC METHODS

• In addition to slowing down speech production, rhythmic methods may increase the saliency of the normal points of stress in a speech utterance.
• The developing literature by Thelan (as cited in Square, 1999) points to the emergence of simple patterned rhythmic subroutines as precursors to coordinated behaviour. Touch-Cue Method of Therapy (Bashir, Grahamjones, & Bostwick, 1984) that includes the rhythmic repetition of single syllables and sounds; the Nuffield Centre Dyspraxia Programme (1992); and Smith and Engel's (1984) Melodic Apraxia Training using metronomic pacing, are all examples of therapies in which simple rhythmic repetitions are set in the therapy techniques.
• Therapies that utilise the production of simple rhythmic repetitions of sounds or syllables recommend that the next level of treatment incorporate the rhythmic repetition of alternating syllables and words such as /b^-d^/;/b^-d^/ or “beet-beep, beet-beep” (Bashir et al., 1984; Chappel, 1973; Nuffield Centre Dyspraxia Program, 1992; Smith & Engel, 1984). Rosenbek (1978) and Rosenbek, McNeil, & Aronson (1984) advocate matching of body movements with speech production. The use of foot tapping/stomping, or swinging of an arm to mark each syllable for multisyllabic words (e.g. elephant) or the syllables of short phrases (e.g. ba ba black sheep) has been suggested in various literature (Jaffe, 1984; Rosenbek, 1978; Yoss & Darley, 1974). A varied approach has been to pair speech production with the use of natural gestures to signify word meaning, such as waving when saying “bye-bye” (Haynes, 1985; Jaffe, 1984; Rosenbek, 1978).

Nuffield Centre Dyspraxia Programme (1992)

This programme was developed by speech pathologists working at the Nuffield Hearing and Speech Centre to cater for children showing severe speech difficulties who were not responding to more traditional therapy. This program has been modified over many years by the Nuffield Centre. This program enables clinician's to systematically assess and treat children with severe speech disorders. This program advocates that parents should be involved in therapy so that practice sessions can take place frequently, and enable carry-over to home. The Nuffield Centre Dyspraxia Programme:

- Provides the child with a visual cue for each sound (for example, “s” is represented by a snake).

- Works in stages, beginning with production of single vowel and consonant sounds and moves through to various consonant and vowel combinations.

A flyer and order form can be downloaded from the ‘Nuffield Centre Dyspraxia Programme' website. Guidance on implementing this program at each level is provided in the manual. The materials provided in the program are most suitable for children between the ages of 3 to 7 years, however have been adapted for use with younger children and have also been used successfully with children up to 10 years of age.

The developers of this program suggest that daily practice is essential in order for children with CAS to develop automatic speech patterns. The developers suggest that children with CAS will require regular speech therapy for at least two years, but often much longer.

Music and Movement Program (2000)

Excess and equal stress is a common characteristic of children with CAS (Velleman, 2003). Thus, the use of rhythm is important in therapy to reduce this commonality occurring. The use of rhythm and movement, such as in the Music and Movement Program, currently being offered at the La Trobe University Communication Clinic, enables the child to beat out the number of syllables per word to keep time with the songs and rhymes (Joffe, 2000). The use of drums, clapping, and marching provide rhythm for word and syllable production (Velleman, 2003).

The Music and Movement Program also utilizes aspects of the ‘typical session' suggested by Velleman and Strand (1994); beginning the session with a “warm-up” activity and ending with “closure”. Between these periods, Joffe (2000) suggests targeting approximately three linguistic goals with traditional approaches, through the structured use of music and movement. Shelley Velleman has contributed extensively to the production of materials and resources for treatment of CAS based on expert opinion.

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MELODIC METHODS

Melodic Intonation Therapy (MIT)

MIT is a singing technique that has been created by Helfrich-Miller (1984, 1994). It is a method for CAS intervention that focuses on the prosody of speech for the facilitation of motor planning and programming (Yorkston et al., 1999). There are three levels of therapy. The stimuli advance as through the following stages:

- Grammatically simple two- and three-word phrases.

- Phrases of four or five words (with grammatical morphemes and more complex articulations).

- Phrases that contain age-appropriate syntactic, morphologic, and phonologic complexity.

In using MIT programs for children, Helfrich-Miller (1994) recommends the use of symbols of signed English. Signed English is used to highlight language structure as well as to act as a pacer (Helfrich-Miller, 1994).

Helfrich-Miller (1994) suggests that:

•  In the beginning, signed English is used to keep the time/rhythm.

•  Gradually, the clinician's signing and intoned cues are faded, while the client continues to produce the utterance with normal speech prosody.

Helfrich-Miller (1994) recommends:

•  A gradual increase in output length.

•  A gradual increase in phonemic complexity.

•  A gradual decrease in reliance on clinician's cues.

•  A gradual decrease in reliance on intonation patterns.

An average MIT program takes 10 to 12 months to complete when sessions are scheduled 3 to 4 times per week (Helfrich-Miller, 1984).

Melodic Apraxia Training (MAT)

The MAT program developed by Smith and Engel (1984) is quite different from MIT. The speech stimuli utilised by Smith and Engel (1984) consists of stop consonants in sentences with 3 to 15 syllables. Entry level into the program is based on the results of pretesting (Smith & Engel, 1984). The levels of stimulus difficulty developed by Smith and Engel (1984) are modelled for the child using three levels of support: (1) intonation paired with tapping; (2) tapping paired with verbal stress; and (3) verbal stress alone. Each successive level offers less support for the child. Thus, the final level of the MAT program offers the child the least amount of organisational support and encourages speech production independent from tapping (Smith & Engel, 1984).

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PROFESSIONAL TRAINING

Not required.

The Nuffield Dyspraxia Programme available for purchase on the internet from the ‘Nuffield Centre Dyspraxia Programme' website (Nuffield Centre Dyspraxia Programme Limited, 2006). The program materials provide all the resources necessary to implement the techniques.

ADVANTAGES OF RHYTHMIC AND MELODIC APPROACHES

• The prosodic aspects of rhythmic and melodic methods seem to facilitate motor planning and programming to improve speech production (Square, 1999).
• The Nuffield Dyspraxia Programme (1992) is a flexible tool and the material provided enables the speech pathologist to design a program to cater for each individual child's problems (e.g. for the cleft palate child there is a considerable amount of oral-nasal contrastive work). The program has been used successfully with children with hearing impairment, cleft palate, and phonological disorders , and the early parts of the program are suitable for children with dysarthria (Nuffield Centre Dyspraxia Programme, 1992).
• The Nuffield Dyspraxia Programme (1992) has been developed so that each child can experience success at some level of the program. With encouragement, success will aid the child to attempt the next step in the program (Nuffield Centre Dyspraxia Programme, 1992).

DISADVANTAGES OF RHYTHMIC AND MELODIC APPROACHES

• As not all rhythmic and melodic approaches provide a clear hierarchy of therapy intervention, clinicians need to take extra care to begin at a level of therapy in which the child will experience success (Square, 1999). If the child is not succeeding at any particular level of therapy, then it is most likely that the child has not established skills at an earlier level (Square, 1999). Therefore, the clinician needs a clear understanding of motor development in order to take the child back through the levels of development needed for that skill (refer to ‘theory and explanation' for Tactile-kinesthetic methods).

LEVEL OF EVIDENCE

• Reports of efficacy of rhythmic and melodic methods of speech treatments for CAS have appeared in the literature (Square, 1999).
• Rate Control Therapy has also shown to be effective. This therapy may be facilitative solely due to slowing speech production (Square & Martin, 1994).

Helfrich-Miller (1994) has reported successful outcomes for MIT for five children ranging in age from preschool to school aged with the implementation of MIT therapy.

Refer to evidence table

Strand and Skinder (1999) recommend clinician's to determine whether rate control, rhythmic, or melodic methods are facilitative of the speech of their clients and to determine the appropriate stage of rhythmic development in which to intervene. Strand and Skinder (1999) suggest that with the aid of these methods, many children diagnosed with CAS are able to produce speech within an imposed rhythmic structure. Schaeffer (as cited in Square, 1999) has proposed that melody provides a greater framework for motor organisation than does rhythm. However, further research is required to determine why these approaches are effective, and whether one method is more effective than another (Square, 1999).

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Gestural Approaches

• Introduction
• Adapted Cueing Technique (ACT)
• Signed Target Phoneme Therapy (STP)
• Jordan 's Gestures
• Cued Speech
• Touch Cue Method
• Sign Language

Introduction

CAS AND GESTURAL CUEING METHODS

Various methods have used hand symbols as pacers for speech (Blakely, 1983; Helfrich-Miller, 1984, 1994; Jaffe, 1984; Rosenbek, 1974). Methods that use manual symbols include Adapted Cueing Therapy (ACT) (Klick, 1984, 1994), Jordan's Gestures (Hall, Jordan, & Robin, 1993), Signed Target Phoneme (STP) Therapy (Shelton & Garves, 1985); and Cued Speech (Cornett, 1972). These methods are often a supplement to other primary approaches.

THEORY AND EXPLANATION

Gesture has been used to pace speech production and to provide supplementary visual/tactile information about articulatory movements and postures (Velleman, 2003).

IMPLEMENTATION OF GESTURAL CUEING METHODS

ADAPTED CUEING TECHNIQUE (ACT)

Klick (1984, 1994)

• Klick (1994) has described ACT as the “gestural presentation of speech in motion (p.175).” Furthermore, she has stressed that ACT cues are used to bring attention to speech segments and their co articulators; the purpose is not to teach the gestural cues per se.
• Developed to gesturally demonstrate the “ patterns of articulatory movement and manner of production ” (Klick, 1984, p.258).
• This is achieved by the clinician moving her hand next to her own face in full view of the client.
• Speech segments are represented by hand configurations that are loosely based on the American Manual Alphabet.
• The hand is moved continuously throughout the demonstration of an utterance in order to reflect trajectories, movement dynamics of the vocal tract, and air flow release.
• Paired with the gestural demonstration, the clinician provides an auditory model.

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SIGNED TARGET PHONEME THERAPY (STP)

Shelton and Garves (1985)

• Like ACT, STP therapy also uses the American Manual Alphabet as its form of gestural input, however, only the sign for a targeted phoneme is presented.
• The sign for the phoneme is produced by the clinician as she simultaneously models the word or utterance in which it occurs.
• Thus, a demonstration is given to the child to where the phoneme occurs in the utterance, but the entire movement sequence of the word is not indicated.
• STP therapy has been incorporated with traditional articulation approaches for making greater gains in therapy than with traditional approaches alone.

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JORDAN 'S GESTURES

Hall , Jordan & Robin (1993)

• Jordan 's Gestures are a set of visual symbolic gestures that demonstrate the actions involved in the production of individual phonemes.
• Jordan 's Gestures are used as a supplementary technique to other types of therapies for CAS.
• Manual gestures that are thought to be representative of the following features are used: contact points of phoneme, manner of production of the phoneme (including voicing) and the required articulatory movements.
• Movement symbols for each of the phonemes are not taught. Instead, gestures are used only for the specific phonemes that each individual finds difficult.

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CUED SPEECH

Cornett (1972)

• Cued Speech consists of 4 different hand positions and eight different hand shapes, combined to represent 32 possible cues that signal voicing, orality-nasality, and other articulatory features.
• Cued Speech has been used to treat children with CAS as a means of signalling articulatory features of phonemes (including voicing and nasality).
• Clinicians who are proficient in the use of Cued Speech are also able to provide cues for the sequence of phonemes in words.
• Thus, the method may be used to cue individual speech sound targets or to signal speech sound order in utterances.
• Cued Speech places additional cognitive demands on clients. The child must learn the entire symbolic system of cues. Children with CAS often have coexisting language processing difficulties (Crary, 1993). Cued Speech is a symbolic system and the processing demands are great. Crystal, Kamhi, and Panagos (as cited in Square, 1999) believe that these demands may exceed the cognitive level of the child with CAS.

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TOUCH-CUE METHOD

Bashir, Grahamjones, and Bostwick (1984)

• Described as being a systematic approach to improving motor skill for production of phonemes.
• Tactile cues to the face and neck along with simultaneous auditory and visual cues are used through three stages of treatment.

- Stage 1 involves a series of nonsense syllable drills to teach the cues, improve movement sequencing, and facilitate self-monitoring.

- Stage 2 moves those learned movement sequences into monosyllabic and polysyllabic words. These include both real and nonsense words and emphasise distinctive feature contrasts.

- In Stage 3 the child is asked to produce multiword utterances, and then move to spontaneous speech.

Incorrect productions are ignored, but are always followed by the opportunity for correct production.

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SIGN LANGUAGE

Yorkston et al. (1999).

• Children with CAS often learn and use signs with little difficulty. One problem with this approach is that sometimes it is introduced in place of treatment for speech production. Furthermore, using sign language is not indicated if there are few people in the child's environment who will use sign with the child. If the treatment goals are to establish some form of communication so that language development will be facilitated, and so that the child will be less frustrated in attempts to convey communication intent, the child's environment needs to be rich in opportunities for communication. If few people in the family or at school use sign, the child will be limited in communication attempts.

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PROFESSIONAL TRAINING

To implement these techniques it is necessary to gain access to the pictures and descriptions for the techniques, and information on how to implement these within the session. Pictures of the gestures can be found in the original articles for each method (most of which are in the reference list). Clinician's must complete a university course in ‘sign language' prior to implementing it as the method of choice.

ADVANTAGES OF GESTURAL CUEING METHODS

• These methods may be used as supplementary approaches to other therapy techniques described above.
• In using gesture along with other methods of intervention (whole approaches), clinicians are better equipped to address both the ‘linguistic' and ‘motor' aspects of developing speech, thereby increasing the child's potential to improve (Skeat & Joffe, 2003).

DISADVANTAGES OF GESTURAL CUEING METHODS

• Although these methods (like integral stimulation) target the salient parameters of speech production, they require interpretation from one symbolic system to another and hence also require good cognitive skills on the part of the child. Many children with CAS also have coexisting language delays or disorders ( Strand , 1995). Therefore, gestural cueing methods may be appropriate only for a select subgroup of children with CAS (i.e. those that have good receptive language and cognitive abilities) ( Strand , 1995).
• Clinicians should be cautious when selecting methods of therapy. Processing load should be an area of consideration when selecting an appropriate speech treatment ( Strand , 1995). The transcoding load for Cued Speech and STP are considered to be quite high because the symbols used in these systems are less representational of what is supposed to happen in the vocal tract ( Strand , 1995). The transcoding load for ACT and Jordan 's Gestures is thought to be less ( Strand , 1995).

LEVEL OF EVIDENCE

Refer to evidence table

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TIME FRAME

• Frequent practice is mandatory for successful treatment of CAS (Yorkston et al., 1999). Sessions should be short in duration to reduce fatigue. Therefore, Yorkston et al. (1999) recommends that if funding allows for 2 hours therapy to the child per week, this time should be split into 4 x 30 minute sessions per week.

• The Nuffield Centre expects that intervention may be required for up to two years, if not longer. Parents should be informed about the speech pathologists expectations so that their own expectations are also realistic (Nuffield Centre Dyspraxia Program, 1992).

• Children with CAS require a great deal of professional service. Therefore, the clinician may need to advocate on behalf of the child to assure that services are provided as frequently as possible (Hall, Jordan, & Robin, 1993).

• Although there have been reports that it is easier for children with apraxia to learn sounds in isolation, this does not appear to carry over to the use of the same sounds in syllables and words, thus, it is not the best use of therapy time (Velleman & Strand, 2003).

• Since CAS is a dynamic disorder, system fatigue is a problem (Velleman, 2003). Therefore:

-Frequent, short sessions with breaks are most successful.

-Focus on only one new aspect of production at a time, as simultaneous multiple changes (e.g. a new sound in a new position in a new context) can be overwhelming for the child.

SPECIAL CONSIDERATIONS

Traditional treatment for CAS often consisted of repeated drilling of a small set of words (Velleman, 2005). Both automaticity and flexibility should be addressed. Therefore, drill alone is insufficient as it addresses only automaticity (Velleman, 1994). A sound-by-sound treatment plan does not address the difficulty children with CAS have with putting sounds together into a smooth, fluent utterance (Velleman, 1994). Therefore, Velleman (1994) suggests it is more efficient to begin at syllable level. If the child has difficulty producing full syllables (a consonant combined with a vowel), simple syllables composed of a vowel and a glottal consonant (e.g. “uh-oh”, “ha-ha”, “hey”, “hi”, etc.) or a vowel and a glide (e.g. “wow”, “yay”, “whee”, “whoa”) may be accessible due to the emotional content conveyed by these simple words (Velleman, 1994). Velleman (1994) suggests that if you are using isolated phonemes in therapy, then those that carry meaning (e.g. [o:] to express surprise, [m:] to mean “yummy”, or [?] to mean “be quiet”) should be targeted as these will increase communication efficacy.

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Evidence Table

Table 1: Taken and adapted from Joffe, B., & Reilly, S. (2004). The evidence base for the evaluation and management of motor speech disorders in children. In S. Reilly , J. Oates & J. Douglas (eds.), Evidence Based Practice in Speech Pathology, (pp.219-257). London: Whurr Publishers.