DEVELOPMENTAL APRAXIA IMPROVING INTELLIGIBILITY: A CASE STUDY

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DEVELOPMENTAL APRAXIA IMPROVING
INTELLIGIBILITY A CASE STUDY

• LILA J. CARSON, M.S., CCC-SLP
• BROOKE LIGHTSEY, GRADUATE STUDENT
• SUMMER JACKMAN, GRADUATE STUDENT
• AMANDA LITTLE, GRADUATE STUDENT
• VALDOSTA STATE UNIVERSITY
• ASHA CONVENTION 2007

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ABSTRACT

• SOME RESEARCH HAS SHOWN THAT CHILDREN WITH
  MODERATE AND SEVERE EXPRESSIVE PHONOLOGICAL/ARTICU
  LATION DISORDER/DELAY, ARE AT RISK FOR DEFICITS
  IN PHONOLOGICAL AWARENESS (BIRD, BISHOP, AND
  FREEMAN, 1995) AND (Rvachew, Ohberg,Grawburg, and
  Heyding, 2003).

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• GILLON, G. (2000) (2005) FOUND THAT THE
  INCLUSION OF PHONOLOGICAL AWARENESS ACTIVITIES
  INTO THERAPY SESSIONS DIDNT DETRACT FROM A CHILD
  MAKING GAINS IN SPEECH ARTICULATION. SHE
  SUGGESTED THAT PHONOLOGICAL AWARENESS AND
  KNOWLEDGE OF HOW SPEECH AND PRINT ARE RELATED MAY
  HELP ESTABLISH MORE FULLY SPECIFIED UNDERLYING
  PHONOLOGICAL REPRESENTATIONS AND THUS MAY
  FACILITATE ACCURATE SPEECH PRODUCTION.

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• THIS CASE PRESENTATION IS THE SECOND ONE WITH
  WHICH PHONOLOGICAL AWARENESS ACTIVITIES WERE
  INCORPORATED INTO ARTICULATION THERAPY. AS IN
  THE PREVIOUS CASE, THE CLIENT MADE GREAT GAINS IN
  ARTICULATION AS WELL AS PHONOLOGICAL AWARENESS.
  THE FIRST CAN BE FOUND IN ADVANCE for SPEECH
  LANGUAGE PATHOLOGISTS AND AUDIOLOGISTS, Vol. 16
  No. 12, March 20, 2006, PP. 13, 20, AND 50.

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• IDEAS FOR INCORPORATING PHONEMIC AWARENESS
  ACTIVITIES INTO THERAPY FOR CHILDREN WITH
  DEVELOPMENTAL APRAXIA (OR OTHER MODERATE TO
  SEVERE ARTICULATION DISORDERS/DELAYS) WHO MAY BE
  AT PARTICULAR RISK FOR READING DIFFICULTY CAN BE
  FOUND IN THAT ARTICLE TITLED APRAXIA CASE STUDY
  INCREASING PHONEMIC AWARENESS SKILLS.

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CASE BACKGROUND

• CLIENTS TEACHER REFERRED HIM FOR SPEECH
  EVALUATION DUE TO CONCERN ABOUT POOR SPEECH
  INTELLIGIBILITY
• CLIENT WAS EVALUATED AT AGE 4 YEARS, 3 MONTHS
• THE CLIENT EXHIBITED THE FOLLOWING TYPES OF
  ARTICULATION ERRORS DISTORTIONS, SINGLE WORD
  APPROXIMATIONS WITH DELETIONS, DIFFICULTY
  MAINTAINING THE SAME MOTOR SPEECH PATTERN TWICE,
  FAVORED SOUNDS , AND DISINTEGRATION WITH
  INCREASED LENGTH AND COMPLEXITY

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• THE TYPES AND ERRORS THE CLIENT EXHIBITED (THE
  INABILITY TO COORDINATE THE ORAL MOVEMENTS
  NECESSARY TO PRODUCE AND COMBINE SPEECH SOUNDS TO
  FORM SYLLABLES AND WORDS IN THE ABSENCE OF ORAL
  PARESIS OR PARALYSIS) INDICATE CHILDHOOD APRAXIA
  OF SPEECH

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• BEFORE CLIENT STARTED TX ON THE KAUFMAN SPEECH
  PRAXIS TEST FOR CHILDREN, HE MADE MANY
  SUBSTITUTION ERRORS BUT NOT MANY WERE CONSISTENT
  IE. HE SUBSTITUTED s/f BUT HE ALSO SUBSTITUTED
  th/f AND ch/f ETC. WHEN ASKED TO IMITATE THE
  SIMPLE PHONEMES /m/,/t/,/p/,/b/,/h/,/d/,AND /n/
  HE COULD IMITATE THOSE CORRECTY IN ISOLATION
  EXCEPT /n/., BUT MADE ERRORS ON THESE PHONEMES IN
  WORDS.

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• HE COULD NOT PRODUCE SOME OF THE MORE COMPLEX
  CONSONANTS /f/, /v/ /r/ /s/ /z/ /sh/ /ch/
  /d / AND VOICED AND UNVOICED /th/. THE OTHER
  COMPLEX PHONEMES WERE NOT PRODUCED CONSISTENTLY.
• SINCE HE COULD NOT PRODUCE THESE PHONEMES
  CONSISTENTLY, THE SOUND BOOK FROM THE PROGRAM OF
  AUDITORY ARTICULATION THERAPY FOR CHILDREN BY
  DIANE PAGNOTTO HILL WAS PRACTICED IN EVERY
  SESSION.

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THERAPY

• THERAPY CONSISTED OF A COMBINATION OF APPROACHES
• SEQUENCE OF TX AS OUTLINED IN EASY DOES IT FOR
  APRAXIA AND MOTOR PLANNING- PRESCHOOL (Strode,
  Robin and Chamberlain, Catherine)
• TRADITIONAL APPROACH FOR SOME VOWELS AND THE
  CONSONANTS IN ISOLATION, SYLLABLES, WORDS, ETC.
  (NOTE REAL WORDS USED WHENEVER POSSIBLE)

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THERAPY(continued)

• PHONOLOGICAL APPROACH HODSONS AND PADENS
  CYCLES APPROACH WAS USED FOR THE TWO AND THREE
  SYLLABLE WORDS
• AUDITORY BOMBARDMENT WAS USED IN THERAPY
• THE SOUND BOOK FROM THE PROGRAM OF AUDITORY
  ARTICULATION THERAPY FOR CHILDREN BY DIANE
  PAGNOTTO HILL WAS PRACTICED IN EVERY SESSION
  (SPRING/SUMMER)

• PHONEMIC AWARENESS INCLUDED
• LABELING OF GRAPHEMES
• WRITTEN WORDS DISPLAYED WHEN PRACTICING
  ARTICULATION
• PRODUCTION OF PHONEMES WHEN PROVIDED WITH
  GRAPHEMES

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COMPARISON OF TEST RESULTS OVER TIME

• NOVEMBER 2005
• GFTA-2
• RAW SCORE 51
• PERCENTILE RANK 3
• JULY 2006
• GFTA-2
• RAW SCORE 18
• PERCENTILE RANK 32

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KAUFMAN SPEECH PRAXIS TEST FOR CHILDREN

• NOVEMBER 2005
• PART 1 (ORAL MOVEMENT LEVEL)
• STANDARD SCORE (NORMALS) 91
• PERCENTILE RANKING 11
• STANDARD SCORE (DISORDERED)101
• PERCENTILE RANKING 35

• JULY 2006
• PART 1 (ORAL MOVEMENT LEVEL)
• STANDARD SCORE (NORMALS) 106
• PERCENTILE RANKING 24
• STANDARD SCORE (DISORDERED) 109
• PERCENTILE RANKING 40

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KAUFMAN RESULTS (cont.)

• NOVEMBER 2005
• PART 2 (SIMPLE PHONEMIC/SYLLABIC LEVEL)
• STANDARD SCORE (NORMALS) N/A
• PERCENTILE RANKING N/A
• STANDARD SCORE (DISORDERED) 64
• PERCENTILE RANKING 7

• JULY 2006
• PART 2 (SIMPLE PHONEMIC/SYLLABIC LEVEL)
• STANDARD SCORE (NORMALS) 49
• PERCENTILE RANKING 2
• STANDARD SCORE (DISORDERED) 104
• PERCENTILE RANKING 27

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KAUFMAN RESULTS (cont.)

• NOVEMBER 2005
• PART 3 (COMPLEX PHONEMIC/SYLLABIC LEVEL)
• STANDARD SCORE (NORMALS) N/A
• PERCENTILE RANKING N/A
• STANDARD SCORE (DISORDERED) 82
• PERCENTILE RANKING 13

• JULY 2006
• PART 3 (COMPLEX PHONEMIC/SYLLABIC LEVEL)
• STANDARD SCORE (NORMALS) 74
• PERCENTILE RANKING 9
• STANDARD SCORE (DISORDERED) 111
• PERCENTILE RANKING 74

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KAUFMAN RESULTS (cont.)

• NOVEMBER 2005
• PART 4 (SPONTANEOUS LENGTH AND COMPLEXITY)
• STANDARD SCORE (NORMALS) N/A
• PERCENTILE RANKING N/A
• STANDARD SCORE (DISORDERED) 80
• PERCENTILE RANKING 13

• JULY 2006
• PART 4 (SPONTANEOUS LENGTH AND COMPLEXITY)
• STANDARD SCORE (NORMALS) 67
• PERCENTILE RANKING 5
• STANDARD SCORE (DISORDERED) 104
• PERCENTILE RANKING 42

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THERAPY GOALS AND PROGRESS SPRING/SUMMER 2006

• THE CLIENT WILL IMITATIVELY PRODUCE CV, VCV,
  AND CVC WORDS WITH 90 ACCURACY
• PROGRESS 100 (WITH WORDS CAREFULLY SELECTED
  USING CONSONANT PHONEMES AND VOWELS THE CLIENT
  HAD IN HIS REPERTOIRE)

• THE CLIENT WILL IMITATIVELY AND SPONTANEOUSLY
  PRODUCE /l/ IN INITIAL, MEDIAL, AND FINAL
  POSITION IN SYLLABLES, AND WORDS WITH 90
  ACCURACY
• PROGRESS 100 - WORD LEVEL IMITATIVELY

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THERAPY GOALS AND PROGRESS SPRING/SUMMER 2006
(cont.)

• THE CLIENT WILL IMITATIVELY AND SPONTANEOUSLY
  PRODUCE THE FOLLOWING PHONEMES IN ISOLATION WITH
  90 ACCURACY /UR/ /j/ /f// //sh/
• PROGRESS /UR/ - 100 SPON. /j/ - 100
  SPON./sh/- 100 SPON. / / - 100- SPON. /f/ -
  100- IMIT

• THE CLIENT WILL IMITATIVELY PRODUCE THE CORRECT
  NUMBER OF SYLLABLES IN SELECTED TWO-SYLLABLE AND
  THREE SYLLABLE WORDS WITH 100 ACCURACY
• PROGRESS 100
• BASELINES WERE CONDUCTED TO DETERMINE WHICH
  GRAPHEMES THE CLIENT COULD LABEL AND PROVIDE THE
  PHONEME ASSOCIATED WITH EACH GRAPHEME. GOALS
  WERE ESTABLISHED FOR ONES HE DID NOT KNOW.

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THERAPY GOALS AND PROGRESS FALL SEMESTER 2006

• BASELINES WERE CONDUCTED TO DETERMINE WHICH
  GRAPHEMES THE CLIENT COULD LABEL AND PROVIDE THE
  PHONEME ASSOCIATED WITH EACH GRAPHEME. GOALS
  WERE ESTABLISHED FOR ONES HE DID NOT KNOW.

• AT THE BEGINNING OF FALL SEMESTER 2006, THE
  PHONOLOGICAL AWARENESS LITERACY SCREENING (PALS)
  WAS USED TO EVALUATE LITERACY FUNDAMENTALS. THIS
  TEST WAS ADMINISTERED TO ESTABLISH A BASELINE.

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BEGINNING OF FALL SEMESTER 2006

• RESULTS OF THE PALS WERE
• RHYME AWARENESS ABOVE AVERAGE
• BEGINNING SOUND AWARENESS BELOW AVERAGE
• LETTER-SOUND KNOWLEDGE SEVERELY BELOW AVERAGE

• THE CLIENT CORRECTLY LABELED THE FOLLOWING
  GRAPHEMES
• A, B, C, D, E, G, H, I, J, K, M, N, Q, R, S, T,
  U, V, W, X, Y, AND Z

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THERAPY GOALS AND PROGRESS FALL SEMESTER 2006
(cont.)

• BY THE END OF FALL SEMESTER, THE CLIENT COULD
  PRODUCE ALL OF THE FOLLOWING SOUNDS FROM THE
  SOUND BOOK SPONTANEOUSLY /w//r//t / /d/
  /sh/ /n/, /m//f/ /v/ /t/,/d//p/,/b/,/k/,/g/
  ,/s/,/z/,/h/, AND /l/
• HE COULD ALSO LABEL ALL OF THE GRAPHEMES (UPPER
  CASE) AND PROVIDE MOST OF THE ASSOCIATED
  PHONEMES.

• BY THE END OF FALL SEMESTER, HE COULD ALSO
  PRODUCE /s/ SPONTANEOUSLY IN INITIAL POSITION OF
  CVC WORDS WITH 85 ACCURACY /s/ SPONTANEOUSLY IN
  INITIAL POSITION OF MULTISYLLABIC WORDS WITH 85
  ACCURACY/s/ IMITATIVELY IN FINAL POSITION OF CVC
  WORDS WITH 90 ACCURACY /l/ SPONTANEOUSLY IN
  INTIAL POSITION OF CVC WORDS WITH 97 ACCURACY,
  AND IN MULTISYLLABIC WORDS WITH 87 ACCURACY /f/
  IN INITIAL POSITION OF CVC WORDS WITH 98
  ACCURACY

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• The client returned to VSU for therapy during
  summer 2007. He continues to misarticulate
  voiced and voiceless th. In addition, he still
  has difficulty with some multisyllabic words that
  contain complex phonemes. He is currently
  receiving services through the public school.

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CONCLUSIONS

• THE CLIENTS ARTICULATION AND PHONEMIC AWARENESS
  SKILLS DRAMATICALLY IMPROVED USING THIS
  COMBINATION OF APPROACHES
• CLIENTS MOTHER REPORTED THAT THE CLIENT IS AT
  THE TOP OF HIS CLASS IN READING ABILITY (APRIL
  2006)
• ARTICULATION CONTINUES TO IMPROVE

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RECOMMENDATIONS

• ADDITIONAL CLIENTS MAY BENEFIT FROM A COMBINATION
  OF THERAPY APPROACHES WITH THE INCORPORATION OF
  PHONEMIC AWARENESS ACTIVITIES TO PREVENT LATER
  READING DIFFICULTY AS WELL AS IMPROVE
  ARTICULATION
• MORE RESEARCH NEEDED

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REFERENCES

• Bird, J., Bishop, D.V.M., Freeman, N.H. (1995).
  Phonological awareness and literacy development
  in children with expressive phonological
  impairments. Journal of Speech and Hearing
  Research, 38 446-62.
• Gillon, G., (2000). The efficacy of phonological
  awareness intervention for children with spoken
  language impairment. Language, Speech, and
  Hearing Services in Schools, 31 126-41.

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REFERENCES (cont.)

• Gillon, G., (2005). Facilitating phoneme
  awareness development in 3- and 4-year-old
  children with speech impairment. Language,
  Speech, and Hearing Services in Schools, 36
  308-22.
• Rvachew, S., Ohberg, A., Grawburg, M., Heyding,
  J. (2003). Phonological awareness and phonemic
  perception in 4-year-old children with delayed
  expressive phonology skills. Language, Speech,
  and Hearing Services in Schools, 12463-471.

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REFERENCES (cont.)

• Carson, L., Enloe, T., Cook, M., Cannon, L.,
  Guobaitis, L., and Boutwell, A., (2006). Apraxia
  Case Study Increasing speech intelligibility
  and phonemic awareness skills. Advance for
  Speech-Language Pathologists Audiologists, 16,
  No. 12 13,20, and 50.