9/17/2020

CHILDHOOD APRAXIA OF
SPEECH WITH
CO-OCCURRING LANGUAGE
AND COGNITIVE CHALLENGES

National Conference abrapraxia

October 3, 2020
Ruth Stoeckel , PhD, SLP

PLAN FOR TODAY

Brief review of co-occurring conditions and

CAS, which may include
Medical problems (comorbidities)
Developmental problems

Consider how to adapt treatment with a focus

on co-occurring language and cognitive
challenges

EXAMINING CO-OCCURRING PROBLEMS IN

CHILDHOOD APRAXIA OF SPEECH
BAAS , KOS E Y,S TOE CK E L & S TRAN D AS HA 2016 S E MIN AR
Retrospective Study
A cohort of 391 children was
identified
Detailed information
abstracted from the records 37.34
included: % Male
62.66 Female
Demographic data %
Birth and development
history
Neurologic findings
Other health issues Demographics
Age of diagnosis
Treatment information
(when available)

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INITIAL ANALYSIS:
CO-OCCURRING PROBLEMS

 Cardiac issues  Neurologic problems

 Craniofacial issues (including abnormal
 Developmental/Cogniti MRI)
ve Delay  Psychiatric/Behavior
 Dysarthria al Disorders
 Genetic anomalies  Visual problems
 GI/Feeding problems  Other
speech/language
 Hearing problems issues
 Other health issues

LIMITATIONS

Specific information on learning disorders and

academic outcomes was not collected
 Some children were only seen at preschool age
Because these children were seen at a tertiary
medical center, it is likely that complex cases
are over-represented
However, developmental delay and language
co-occurred at a rate that suggests a need for
awareness for any child with CAS

CO-OCCURRING PROBLEMS
400

350

300

250

200

150

100

50

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CONNECTIONS FOR CHILDREN WITH CAS

Cognitive Language
Impairment Impairment

Other
Motor Issues Co-occurring
Problems
Reduced vision or hearing,
sensory, physical differences, etc.

COGNITIVE IMPAIRMENT/CI
Impairments of general mental abilities that
impact adaptive functioning in 3 areas:
1. Conceptual  language, reading, writing,
math, reasoning, knowledge, memory
2. Social  empathy, social judgment,
interpersonal communication skills, ability to
make and retain friendships
3. Practical self-management such as self care,
job or school responsibilities, money mgmt,
recreation

DSM-5

LANGUAGE IMPAIRMENT

Preferred term = DLD: Developmental Language

Disorder
 Impairment in
 understanding others (receptive)
 sharing thoughts, ideas, and feelings coherently
(expressive)
 both understanding and sharing information (mixed
receptive-expressive)

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Children with CAS and DLD/CI may be less

able to use cognitive resources effectively
due to
 Need to focus on how they talk instead of what
they are saying
 Slower or less efficient word retrieval
 Less efficient verbal formulation
 Emotional response to the struggle

Cognitive Resources

With instruction, we help them develop

 Automaticity in motor skills that reduces
cognitive demand
 Language strategies that facilitate recall
 More consistent use of strategies
 Increased confidence,improved emotional
regulation

Cognitive Resources

PLANNING INTERVENTION

 Because communication involves an

interaction of
cognitive (thinking/social) skills,
linguistic skills (vocabulary, language) and
motor skills (speech production)
Intervention needs to prioritize the problem that
has the greatest impact at a given time
 which will likely change over time and with
intervention

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ADAPTING FOR COGNITIVE SKILLS

Children with cognitive and language/learning

challenges will learn more slowly
 Learning can still happen!
 More practice and repetition will be needed to
acquire and retain new skills
Consider multiple modes of communication
 Behaviors count as communication
 Visual referents, gestures, voice output, etc. may
attract the child’s interest and support vocabulary
development

ADAPTING FOR COGNITIVE SKILLS

Children with cognitive/language challenges

typically have reduced vocabulary
 Increasing vocabulary and language skills may
need to be a priority at first
 Which may include AAC (gestures, pictures, voice-
output device)

ADAPTING FOR COGNITIVE SKILLS

Speech clarity has the greatest value if it

improves the child’s ability to convey a
meaningful message
 Use functional targets from the beginning of intervention
to facilitate carryover (e.g., Baas et al., 2008; Strand, Stoeckel &
Baas, 2006 )
 As a child progresses in therapy, we may use “social
scripting” (not just for children with autism)

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CAS AND LANGUAGE

Studies have primarily investigated English-

speaking children.
Children with CAS…
 Tend to perform more poorly than comparison groups
(Speech, Speech/Language) on language measures
 Show relative strength in receptive language skills
across studies
 Make errors in grammar and syntax (e.g., pronouns,
verb forms)

CAS AND LANGUAGE

Rvachew, Gaines, Cloutier & Blanchet, 2005

 Children with CAS often omitted /s/ and /z/ as
grammatical morphemes while using the sounds
correctly in uninflected words of similar phonetic
complexity
 related to MLU rather than speech skill

The take-home message: Grammatical errors made

by children with CAS may not be related only to
phonetic complexity.

ADAPTING FOR LANGUAGE

Be conscious of language level for teaching

new skills
Provide instruction slightly above language
level (choice of stimuli, practice conditions)
Be especially conscious of the need for
multimodal instruction

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ADAPTING FOR LANGUAGE

Provide good examples of language

Do not oversimplify
 need to hear correct forms to internalize them
Call attention to how sentences are structured
(grammar and syntax)
Scaffold skills in fun/functional activities that
incorporate work on speech and language
goals (songs, joint book-reading, crafts, etc.)

ADAPTING FOR
COGNITIVE & LANGUAGE:
SOCIAL/PRAGMATIC SKILLS
Children with CAS alone or CAS and DLD/CI
May lack confidence in their ability to
communicate
May be frustrated by lack of success in
communicating, resulting in
Acting out
Withdrawal

“quiet”
child

Reduced Social Reduced

partner
vocabulary competence attention

Reduced
input to
child

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More
“quiet”
verbal
child
child

Increase
Reduced
Reduced
Increased Social
vocabulary competence partner
partner
vocabulary attention
attention

Increased
Reduced
inputto
input to
child
child

INTEGRATED INTERVENTION FOR

CAS + DLD/CI

Use the child’s phonetic repertoire to build a

functional core vocabulary
Include sequences that are stimulable in
addition to already-acquired sequences
Consider a variety of syllable shapes and
syllable sequences
Include a range of vocabulary and
communicative functions

•Accurate lexical stress

Prosody •Accurate phrasal stress

•Nouns
Vocabulary •Verbs
•Conceptual vocabulary

Grammar/ •Length of utterances

•Complexity of utterances
Syntax

•Greeting
Social •Requesting/Refusing
Interaction •Commenting
•Attention/Interaction

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INTEGRATED INTERVENTION FOR

CAS + DLD/CI

Use the child’s phonetic repertoire to build a

functional core vocabulary
Functional targets can improve motivation
 They facilitate the child’s ability to interact with, and
control their environment
 They contribute to social interaction by being
pragmatically relevant
 They allow scaffolding of skills in “fun” activities
(songs, book reading, crafts, etc.) that can address
speech and language goals

EXAMPLE OF INTEGRATED INTERVENTION

Activity: using a nursery school song

 Child can say the vowel “ ee” with a few consonants
(me, tea, see) and “oo” (too).
 Speech targets: “me” and “two”
 Embedded goals: improved prosody, sentence
structure/grammar
Two little monkeys sitting in a tree, teasing Mr.
Crocodile, can’t catch me! Can’t catch me! Aloooong
comes Mr. Crocodile, (quiet) as can be, aaaaand SNAP!
One little monkey, sitting in a tree…….

EXAMPLE OF INTEGRATED INTERVENTION

Activity: Repetitive Book Reading

Brown Bear, Brown Bear
 Speech targets: phrases “I see a…” & “What do you
see?”
 Embedded goals: Prosody, sentence structure,
socially relevant phrases

Brown Bear, Brown Bear what do you SEE?

I see a red bird looking at me.
Red Bird, Red Bird, what do you see?
I see a purple cat looking at me.

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EXAMPLE OF INTEGRATED INTERVENTION

Maximizing communication in multiple modes

 12-year-old child with CHARGE syndrome (Baas, Elmer, Strand,
& Barbaresi, 2008).
 Child was essentially nonverbal aside from sound effects and use of
“baba” (bathroom) and “wawa” (water). Occasional use of device.
 Initial verbal targets: no, home, on, mom, off, dad
 Atypical vocal behaviors addressed
 Modified device vocabulary to reflect current
activities and interests
 Practiced responding to cues to use device
 To extinguish atypical vocal behaviors
 To communicate messages more effectively

Outcomes
 Became primarily verbal in known contexts with
familiar listeners
 Reduced atypical/nonrelevant vocalizations
 Improved appropriate use of device
 Generally improved social communication

 Generalization of learned skills was documented

ADAPTING CAS THERAPY FOR CHILDREN

WITH DLD/CI: SUMMARY

Prioritize goals based on the issue of greatest

threat to communication ability at this time
Cognitive – Language – Motor Speech
Gather information from caregivers, when
possible, to inform choice of targets
Involves them in the process; honors family
culture
Assures vocabulary is relevant for this child

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ADAPTING CAS THERAPY FOR CHILDREN

WITH DLD/CI: SUMMARY

Develop goals based on positive expectations

and adjust them based on child’s response to
intervention
 Progress (or lack of progress) in learning to
express information independently will
 Influence modifications in treatment
 Inform expectations

ADAPTING CAS THERAPY FOR DLD/CI

SUMMARY

The child’s skills and needs will change over

time, therefore…
Intervention should change over time
Be ready to stop working on skills that are
mastered or not progressing after
reasonable efforts and start on new skills
that are needed

New diagnoses may be identified over time

REFERENCES

 B a a s, St ra n d , E lm er, & B a rb a resi. (2 0 0 8 ).Trea t m ent of sev ere CAS in a

1 2 -yea r-old m a le wit h CHARGE Assoc ia t ion. Jour n a l of Medica l Speech -
L a n gua ge Pa th ology . 16 : 1 81 -1 9 0 .
 B red in -Oja & Fey (2 01 4 ). Child ren’s resp onses to telegra p hic a nd
g ra m m a t ica lly c om p lete p rom p t s to im it a te. Amer ica n Jour n a l of
Speech -L a n gua ge Pa th ology, 2 3 , 1 5 -2 6 .
 Fey, M .E ., Lon g , S.J . & Fin est a c k , L.H. (2 0 0 3 ). Ten p rinc ip les of
g ra m m a r fa c ilit a t ion for c hild ren wit h sp ec ific la ngu a ge im p a irm ent s.
Amer ica n J our n a l of Speech -L a n gua ge Pa th ology, 1 2 , 3 -1 5 .
 Rv achew, G ai nes, Cl out i er & Bl anchet . (2005) Product i v e m orphol ogy
ski l l s of chi l dren wi t h speech del ay. Journal of Speech -Language
Pat hology and Audiology . 29: 83-89.
 St ra n d , Stoec kel & B a a s (2 0 0 6 )Trea t m ent of Sev ere CAS: A t rea t m ent
ef fic a c y st u d y. J our n a l of Medica l Speech L a n gua ge Pa th ology , 1 4 : 2 97 -
3 07

 Ta r sh is, Ga rc ia Win n er & Crooke (2 0 2 0 ). Wha t d oes it m ea n to b e

soc ia l? D efin in g t h e soc ia l la nd sc a p e for c hild ren wit h CAS.
Per sp ec t ives of ASHA SIG 2 : 1 -1 0 .

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