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2010 TSHA Convention


Thursday 4:00 to 6:00 PM

3-D Apraxic Therapy for Kids Kay J. Giesecke, MS, CCC-SLP Heather C. MacFadyen, MA, CCC-SLP

Key Points of Defining Childhood Apraxia of Speech ((CCAASS))

Previously known as Developmental/Verbal Dyspraxia/Apraxia

Both CASANA and ASHA today recommend usage of CAS - common among all titles is the word “praxis”

Praxis planned movement; “neurological process by which cognition directs motor action…ability to formulate or plan different actions…before the actual motor execution” (Ayres, 1985)

Apraxia lack of praxis; inability to plan movement

The execution of a motor plan is the result of praxis; the visible result of a successful invisible process

Not simply a series of postures, must include information about the sequencing of these postures

“Symptom complex”/syndrome: no one feature is adequate for diagnosis. Top three features from ASHA Ad Hoc Committee on CAS, 2007:

Inconsistent errors on consonants and vowels in repeated productions of syllables or words

Lengthened and disrupted coarticulatory transitions between sounds and syllables

Inappropriate prosody

18 other additional speech features that might be present for CAS

Features of Traditional Apraxic Therapy:

Intensive frequent practice

Multiple repetitions of speech movements

Memorization of speech movement sequences

Systematic progress through the use of hierarchies

Slower Rate


Compensatory speech and language strategies

Multi-modality input

Prosody remediation

Integration of receptive and expressive language

What about using non-speech oral motor therapy (NS-OMT)?

Not advocated by the authors of graduate level text books.

Recent research proves that NS-OMT is only validated by opinion, but not evidence (Pannbacker & Lass, 2003).

Research also suggests that the physiological mechanisms that control speech and speech movements are quite different (Campbell, 2004)

Gregory Lof in 2006 ASHA presentation concluded that parents need to be informed that NS-OME have not been shown to be effective and their use must be considered experimental.


2010 TSHA Convention


Thursday 4:00 to 6:00 PM

What about including other forms of communication?

Augmentative? Yes, if appropriate to the child’s age, cognitive abilities, and is used with verbal communication, not in place of, if working towards verbalization.

Signing? Gestures? Yes, same as above.

Grunts, squeals, and other nonverbal sounds for words? Instead, encourage using some sounds in the English language even if only vowels.

Own idiosyncratic words? Instead, encourage approximations of real words. Definitive Design Differences of 3-D Apraxic Therapy

1. Where to Start: 3-Dilemas

2. Keeping Track: 3-way documentation

3. Talking gets results: Deliberate Declarations that Delight

4. Everybody on Board: 3-Dependent Co-workers

5. How to organize the therapy session: 3-Divisions

6. 3 Ways to Memorize Movements: 3 Drill Techniques

7. Drill can be fun: 3-D materials

8. 3 Different Goals Concurrently

9. 3 Direct Teaching Strategies

10. 3-Way Dependence Between Words

11. 3 Distinctive Hierarchies: Diagrams, Details, and Decisions to Adjust Them


Where to Start: 3-Dilemas.

What positive behaviors to target: Deliver what Deficits Demand


Analyze test data


Interview parents


Observe the child

What negative behaviors to eliminate

How to share goals and direction with child and family


Keeping Track: 3-Way Documentation

Keeping Track of Targeted Responses

Keeping Track of Self Monitoring Attempts

Keeping Track of Negative Behaviors


Talking Gets Results: Deliberate Declarations that Delight

Review Sound Repertoire and Incorporate Compensation Strategies

Decide on target words which are functional for that child

Create situations which foster use of the targeted words and result in dramatic reinforcement


Everybody on Board: 3-Dependent Co-Workers Intrinsic Parental Involvement: A Gratifying Approach to Rapid Progress in Therapy

Intrinsic parental involvement (IPI) is not the following:

1. Sitting in the waiting room during therapy

2010 TSHA Convention


Thursday 4:00 to 6:00 PM

2. Reading or talking on the phone during therapy

3. Receiving a verbal summary

4. Attending ARD committee meetings

5. Chatting on the phone with the SLP

Agreement between the SLP and parents must include:

1. How often parent attends therapy

2. How to handle discipline

3. The parent will be trained by the SLP

4. The parent will execute home practice

5. The parent will take notes during therapy of targeted goals and activities.

Teaching Parents to Take Notes:

1. Provide them with a Steno Pad. For each session their notes should include:


Targeted goals

Stimuli (what parent should say) and response (what child should say)

Materials used

2. What parents took home for practice

3. After completion of home practice parents place a checkmark on the page.

Rules for home practice materials:

1. Must see them demonstrated in therapy

2. Use materials at least once before next session

3. Use them solely for speech practice

4. Replace or pay for them if damaged

5. Return the previous activity borrowed before taking home another activity

5. How to organize the therapy session: 3-Divisions

Review progress on homework

Drill target behaviors using 2-D materials

Elicit multiple repetitions through engaging 3-D materials

6. 3 Ways to Memorize Movements: 3 Drill Techniques

Within the response

Within the activity

Across activities and sessions

7. Drill can be fun: 3-D materials

Survey results indicated that 64% of families given worksheets for home practice practiced less than when given 3-D materials.

Can be inexpensive, readily available

Can be books, commercial games, happy meal prizes/garage sale treasures grouped creatively, reusable crafts, and simple homemade games

2010 TSHA Convention


Thursday 4:00 to 6:00 PM

8. 3 Different Goals Concurrently

Select multiple goals

Choose an activity compatible with at least 1 goal

Ask questions that stimulate responses which address other goals

9. Don’t Keep Them Guessing: 3-Direct Teaching Strategies

Clearly state the goal(s) to student and family

Indicate the desired response from them and cueing provided by you

Provide clear feedback on the accuracy of their response and changes needed

10. I want to talk faster: 3-D Dependence Between Words

Definition of Coarticulation: The influence that sounds exert on one another is called coarticulation, which means that the articulation of any one sound is influenced by a preceding or following sound. (Bernthal &Bankson)

Pervasive Coarticulation Contexts

1. Vowel to Vowel: “Do it”

2. Vowel to Consonant: “I need”

3. Consonant to Vowel: “take a”

4. Consonant to Consonant: “bathroom”

Find other instances of coarticulation: “I need to take a friend to the bathroom.”?

11. Hierarchies: Diagrams, Details, and Decisions to Adjust Them Definition of Hierarchy: An arrangement into a graded series. For diagrams and details of hierarchies, please see last page of handout.

3-D Diphthongs

of the two vowels

of the diphthong

Use of the target diphthong in a

Use of the diphthong in an unblended



Teaching Multi-syllabic Words: 3-D Difficult Words

Clapping, tapping or counting cueing added as needed.

of the syllables of part of the syllables of all of the syllables of the syllables

Regular rate with accent in place

2010 TSHA Convention


Thursday 4:00 to 6:00 PM

Contributing Features of successful therapy in all types of disorders; including CAS

1. Normal to mildly impaired cognitive performance

2. Parental involvement

3. Attention to task

4. Desire to communicate or improve communication

5. Rapport with clinician

6. Regular attendance at therapy

7. Disorder properly diagnosed and treated with appropriate therapy

8. Few concomitant disorders

Features of 3-Apraxic Therapy contributing to successful CAS therapy

1. Identifying and eliminating interfering negative behaviors

2. Starting where each child can succeed, making small incremental steps thru


3. Teaching and shaping behavior directly

4. Building in self monitoring

5. Training the child to use co-articulation

6. Incorporating Intrinsic Parental Involvement

7. Using frequent and varied drill

8. Making the drill fun with 3-D materials

Features of therapy not found to contribute to success of CAS therapy

1. Non-speech oral motor exercises (Lof, 2006)

2. Group therapy

3. Early childhood language rich classes like PPCD (can contribute in other ways)

4. Regular articulation or language therapy

5. Starting with long words when the child can not even say a CV or VC

6. Indirect therapy - playing games with the student without directing or shaping behavior

7. Using same criteria for goal completion and dismissal as articulation/language

8. Failure to use both mass and distributed practice


American Speech-Language-Hearing Association. (2007). Childhood Apraxia of Speech (Position Statement). Available from Campbell, Thomas (Mar. 5, 2004), Does training non-speech oral movement facilitate speech sound production in children with motor speech disorders?, A response to a question on www.apraxia- Velleman, Shelley (2003), Childhood Apraxia of Speech Resource Guide. Clifton Park, NY, Delmar Learning. Lof, Gregory (2006). Logic, Theory, and Evidence Against the Use of Non-Speech Oral Motor Exercises to Change Speech Sound Productions. Paper presented at the annual Convention of ASHA, 2006. Pannbacker, M. & Lass, N. (Nov., 2003). Ethical issues in oral motor treatment. Poster presented to the annual convention of the ASHA, Chicago, IL.

2010 TSHA Convention


Thursday 4:00 to 6:00 PM

2010 TSHA Convention 6 Thursday 4:00 to 6:00 PM