First Steps in Evaluating and Treating Childhood Apraxia of Speech
HOW IT WORKS
Listen, take a quiz, and earn a certificate of completion! Listen to this episode course at the bottom of this page or on your favorite podcast listing platform (Spotify, Apple Music, etc.). ASHA requires that CE courses take attendance (your unique login) and learner earns a certificate of completion (by passing the quick quiz). This program has been approved for 1 clock hour of continuing education credit by the Texas Speech-Language-Hearing Association (TSHA). TSHA approval does not imply endorsement of course content, specific products, or clinical procedures.
TSHA continuing education (CE) hours can be used toward renewal of your Texas license (and most other states too) and as professional development activities for the maintenance of your ASHA Certificate of Clinical Competence (CCC).
The Pep Talk Podcast for SLPs podcast episode courses have been planned and implemented in accordance with the policies of the Continuing Education Board of the American Speech-Language-Hearing Association (ASHA). TSHA is accredited by the ASHA CEB to provide continuing education for speech-language pathologists and audiologists.
DESCRIPTION AND LEARNING OUTCOMES
This course reviews childhood Apraxia of speech. It explains who can diagnose and how to diagnose Apraxia in children. It also informs the listeners on writing goals and planning treatment.1 clock hour of continuing education credit (Introductory Level, Professional Area).
As a result of this presentation the participant will be able to:
1. Learner will be able to define who can diagnose Childhood Apraxia of Speech.
2. Learner will be able identify what is required from the child in order to be diagnosed with Childhood Apraxia of Speech.
3. Learner will be able to summarize characteristics of appropriate goals for a client diagnosed with Childhood Apraxia of Speech.
ABOUT THIS EPISODE’S SPEAKERS
Michelle Andrews M.S. CCC-SLP
Founder and Managing Director
Michelle has been a speech-language pathologist since 2014. She has worked in the schools, private clinics, and home health. She started creating speech therapy materials for SLPs years ago and founded Pep Talk LLC. She discovered her passion for education and developed this continuing education podcast for SLPs everywhere. She desires to help SLPs feel confident and to produce the best treatment by increasing knowledge and skills.
Erin Gaul M.S. CCC-SLP
Erin is the owner and primary speech-language pathologist of your Speech Path, LLC in Lower Gwynedd Township, PA. While Erin is a multi-faceted SLP, treating an array of populations, her primary areas of focus have evolved and now provides expert, passionate treatment for Childhood Apraxia of Speech (CAS) and other Speech Sound Disorders (SSD). Erin has sought out extensive, professional, ongoing trainings in Childhood Apraxia of Speech (CAS) with renowned speech-language pathologists and experts. Erin is also listed in the Apraxia-Kids SLP directory for experienced, expert treatment of CAS. Learn more about Erin here.
Michelle Andrews’ financial disclosers include: She has a Teachers pay Teachers, Boom Learning, and Teach with Medley store under Pep Talk LLC. She is also the founder and manager of Pep Talk and the Pep Talk Podcast. Teach with Medley Educational Games is a sponsor of this podcast.
Michelle Andrews’ non-financial disclosures include: She has a stock participation plan with Teach with Medley Educational Games.
Erin Gaul’s financial disclosers include: No relevant financial disclosers
Erin Gaul’s non-financial disclosers include: No relevant non financial disclosers
10 min: Introduction, bio, disclosures, learner objectives
5 min: Review of CAS
15 min: Diagnosing CAS
10 min: Evaluation
15 min: Developing a treatment plan
5 min: Summary, ”take away” points, closing
Click to expand this episode's transcript.
Michelle Andrews: Hey there, I’m Michelle Andrews. And I’m your host for the pep talk podcast. This episode is all about first steps in evaluating and treating childhood apraxia of speech. This topic is featuring Erin gall, a fellow’s SLP in childhood apraxia of speech specialist. Erin has her own private clinic, where she primarily focuses on clients with childhood apraxia of speech. has clients driving from all over for her expertise. In this area. Erin is going to explain the process of evaluating and getting started planning your treatment when presented with a child of a apraxia of speech who can diagnose a apraxia when, what do you need all of this and more will be talked about in this episode, when we’re done, you will feel more confident and have ready to use skills in this area. If you’re listening along while you are driving a car, doing the dishes on a run, this episode is transcribed for you to refer back to easily. So you don’t have to worry about taking notes, learners prefer or need to read along. So a transcription of the entire episode is provided in a link in the show [00:01:00] notes.
Okay. First, we need to go over some formalities for the course, by going over our financial disclosures. My financial disclosures include, I have a teachers pay teachers, boom, learning, and teach with medley store under pep talk, LLC. I am also the founder and manager of pep talk and the pep talk podcast teach with medley is also a sponsor for this podcast. My nonfinancial disclosures include, I have a stock participation plan with teach with medley. Now, here are the learner objectives for this course. Number one learner will be able to define who can diagnose childhood apraxia of speech. two, the learner will be able to identify what is required from the child in order to be diagnosed with childhood apraxia. And number three learner will be able to summarize characteristics of appropriate goals a client diagnosed with childhood apraxia of speech.
Okay. Let’s get started. This episode of the pep talk podcast is all about a [00:02:00] Apraxia who feels extremely confident in diagnosing and treating a Apraxia crickets, crickets. I can’t hear you, but I assume if you’re here, if you’re here, you are looking to strengthen your skills in this area. am so excited to learn all of what Erin is going to teach us today. She is going to help us all feel more confident when a child walks into your therapy room what suspected childhood apraxia of speech. I am so happy to have Erin here today. Hi there, Erin.
Erin Gaul: hi, Michelle.
Michelle Andrews: Hi, Erin is going to teach us what to do first when evaluating and treating a apraxia of speech. So let me tell you a little bit about Erin. Erin is the owner and primary speech language pathologist of your speech path, LLC, and lower Gwynedd township, Pennsylvania. Erin earned her bachelor’s in sociology, deaf studies at Rosemont college and her master’s in speech language pathology from Gallaudet. Well, Erin is, is a multi-faceted SLP treating an [00:03:00] array of populations. Her primary areas of focus have evolved and now provides expert passionate treatment for childhood apraxia of speech other speech sound disorders. Erin has sought out extensive professional, ongoing trainings and childhood apraxia of speech renowned speech, language pathologist, and experts. Erin utilizes dynamic temporal and tactile queuing. DTTC, If you’ve heard of it Erin is prompt technique bridging and practicum trained and is proficient in American sign language. She has a member of the American speech and language hearing association and is licensed in the state of Pennsylvania. Erin is also listed in Apraxia kids, SLP directory for experienced expert treatment of CAS. Erin Gaul’s, financial disclosures include Erin is the owner of your speech path, LLC. nonfinancial disclosures include relevant nonfinancial disclosures. All right, Erin, let’s go ahead and tell me a little bit more about yourself. I know. Introduced you [00:04:00] for a bit, but tell me a little bit more about what you’re doing.
Erin Gaul: So right now I am in private practice, but I definitely did not start out that way. Um, I started out as a oral habilitation specialist and basically what that means is speech therapy for a deaf and hard of hearing kids. Um, like you mentioned, I went to Gallaudet university in Washington, DC, and that’s a university primarily for deaf and hard of hearing students. Um, so it was a really unique program to go through. Um, what I quickly learned when I graduated and discovered my love for private practice was that. Not a lot of kids with deaf and hard of hearing services are looking for private because school-based is actually pretty, pretty good, at least in my area. So, my path went elsewhere. I still have a soft spot for deaf and hard of hearing and sign language. I incorporated into my sessions and all, I’ve taught ASL [00:05:00] online as an intro class for adults. And then. My first job as a clinical fellow was in an age three to five special needs preschool, gradually.
They sent me into homes and I quickly discovered that was not for me. Um, so once my clinical fellowship was done, I left and I found a job in a private practice and continue doing some early intervention on the side, , accepting only deaf and hard of hearing kids. but overall, I just found that I loved the freedom that private practice brings versus school districts.
Michelle Andrews: right, right. I understand that completely. Um, so tell me about how you became to specialize in Apraxia?
Erin Gaul: Um, it’s so interesting because I can like, almost pinpoint the moment where I became fascinated because I had this little guy in the private practice post my clinical fellowship and he came to me. Barely said [00:06:00] anything in the evaluation and he was silent for the first month, month and a half of sessions. And I was thinking, oh my gosh, this, this might be undiagnosed hearing loss. So I sent him for a hearing test. It came back completely typical, no issues. So I was like, all right, we’re going to keep going. And then all of a sudden, one day he pointed to the top of a shelf with a bunch of toys and he just grunts, uh, uh, but I was like elated because he used his voice. And then it started clicking to me like, boy, this kid has very little sounds. , it sounds more like a grunt in my very limited exposure to a proxy of speech in grad school. It made me think, huh, maybe this is motor speech. Um, so that ended up leading me to. Taking courses. And that, that was in person online.
And I tried to look up like the gurus, I say the gurus of [00:07:00] CAS. And so I took classes with eat a strand, Carrie Ebert, Sue Caspari, Dave hammer, um, and gradually through practicing, I was like, huh, what is, what’s the modality I want to use? Uh, what has the most research? And so I ended up taking, this course was specific to Edith Strand, dynamic temporal and tactile queuing. DTTC and I also really, really was fascinated by prompt the tactal queuing, kinesthetic, training. And so I dove into that and ever since DTTC and prompt are my go tos for apraxia of speech.
Michelle Andrews: awesome. Yeah, I would love to be trained in those, those are really awesome.
Erin Gaul: Yeah.
Michelle Andrews: That’s awesome. Okay. So Erin, I think most of us know what apraxia is, but let’s just for the sake of understanding everything. um, let’s just go over those signs and symptoms of apraxia and then [00:08:00] after that, we’ll go into who can diagnose it.
Erin Gaul: Okay. Um, you know, it’s kind of crazy that today’s the day that we’re doing this podcast, because I just had a client this morning and mom was like, I can not get people to understand what a apraxia is. And I was like, well, since you mentioned it, you know, so we discussed it a bit. And so, um, so by definition, CAS is a motor speech disorder that makes it difficult to plan for the complex sequenced movement. That are necessary for intelligible speech. It’s a movement disorder. And if we’re going to break down the word, even that prefix a without we’re lacking and then apraxia is movement. So you put it together. We have without or lacking movement. That’s apraxia. Now, do I go into all of that with parents? Not necessarily some want to hear that clinical definition, but what I, what I say to parents is that as we speak, messages are constantly being fired from [00:09:00] the brain to the mouth. That’s what sequences are sounds, or syllables are words allows us to converse for kids with CAS. Those messages or pathways are not reaching the mouth and we have to help establish those pathways with motor speech therapy.
Michelle Andrews: That’s awesome. So how about you go into the markers of CAS
Erin Gaul: Okay. Um, so when I am listening to and watching. A child with suspected CAS, I’m listening for some, um, pretty distinct atypical errors. these include vowel distortions, inconsistent productions, which means if a kid says ball one time and it sounds like bah, it might change the next time he says it, it might turn into goo. Then the next time it’s gone and then it’s Bubba. So you can’t predict how the word is going to sound. It’s very inconsistent. Um, kids generally have difficulty with imitation. They have a limited sound repertoire. [00:10:00] You can see groping voicing errors, difficulty with longer strings of speech, or as the syllable shapes get more complex. children have difficulty getting those words, those sentences out, and these markers become even more apparent. So those are, those are some big ones that I look for during my evaluations.
Michelle Andrews: That’s great. Thank you for giving us that great definition and talking about all those markers. So now that we know that tell us who can diagnose apraxia?
Erin Gaul: That’s the hottest question when it comes to apraxia and it’s, I really want to stress this particular part of what I’m talking about, because I think parents are very much misinformed. It just, just by the, um, apraxia groups I’m part of on Facebook. , it is just not clear to parents and they’re not going to the right people. Um, and they’re not getting correct diagnoses. So, um, the diagnosis [00:11:00] should be made by a speech language pathologist, specializing in CAS. Now, what does that mean? An SLP. With this experience has sought out extensive training and has experienced an expertise evaluating and treating CAS. I say that they have sought it out because you get such limited education in grad school so this is something you have to choose to do. , SLPs treating CAS are constantly analyzing movement and you have to have experience for that. And also SLPs are going to be the ones that have that knowledge of the principles of motor learning. I’m not going to get into the details of that. That is an entire podcast based on treatment and goals and what therapy looks like but in a nutshell, it should be an SLP specializing. Now, oftentimes I hear, well, my school-based SLP or my early intervention, SLP suspects. But either they can’t diagnose [00:12:00] because of school regulations and policies. Um, they don’t feel skilled enough to make the diagnosis, or they’re just playing that shore. They think, well, it’s not fitting into any other box, so maybe it’s apraxia so to piggyback on all that, what I would say is that you’re not going to get an accurate diagnosis of a proxy of speech by a pediatrician or a neurologist. They come into play. When we’re thinking about possible comorbidities, like, does this child have a genetic disorder?
What else is happening? You need an expert in speech first for diagnosing this very rare disorder. And a little bit more on that families come to me and they say, well, My school, my doctor said any SLP should be able to treat apraxia. And I was like, well, that would be great. That would be nice. Um, it’s in our scope, [00:13:00] but not all SLPs are trained. There are SLP specializing in swallowing disorders, AAC, and that’s because the umbrella of speech pathology is so big. , we can’t do it all. , for me in particular, I never feel confident evaluating a child for an AAC device. It is not my jam. I would have no idea. Um, but it’s in my scope, but that’s not enough. That’s not enough to say yes, I’m qualified. I am the best choice for your child. Um, CAS is the same.
Michelle Andrews: Right. Yeah. The umbrella of speech pathology is so broad that. Specializing and, and seeking out a specialist, um, for that you’re child or your client needs is, is crucial. It really
Erin Gaul: I mean, yeah. As an SLP, it’s almost unfair how wide the scope is for speech. Cause then parents come to you thinking you can do it all. And it’s like, you have to explain why that’s not the case legally I can, but am I competent? [00:14:00] No, to be honest, like, no. So it, gets sticky.
Michelle Andrews: it does, it gets sticky also when maybe somewhere that you’re working just expects you to take on every client when maybe you aren’t confident in that specific area. And I think being confident enough to refer out.
Erin Gaul: That is a great point. Yes.
Michelle Andrews: and that’s totally okay to do. Cause what I hear about a lot are SLPs that maybe don’t have enough training and they’re either over-diagnosing apraxia.
Erin Gaul: Yes. All the time.
Michelle Andrews: or under diagnosing apraxia um, but yeah, so we really need to bridge that gap either more SLPs need to gain more experience and knowledge or maybe they need to speak up and refer out and that’s totally okay.
Erin Gaul: Yeah, it is.
Michelle Andrews: yeah. And, and with that in mind, Erin, you were telling me about, um, earlier about how there’s some resources to find SLPs who are specialized. Can you tell me a bit more about those reasons?
Erin Gaul: Sure. Yeah, there is one that is always a go-to for me that I recommend anyone. Um, sometimes clients call me and I’m [00:15:00] just too far, or I don’t have availability. And I say, I’m go to apraxiakids.org. They have a directory of speech therapists that have essentially gone through a bit of testing, an application to show their knowledge for CAS, and then it’s approved. I thought it was just the most amazing thing. Cause Dave Hammer. Approved my application. And I just thought that was the coolest thing. Cause I love Dave Hammer. Like you have experts looking at these applications and saying yay or nay. and you can filter by your zip code, whether they accept insurance and all that. So that’s, that’s the first one I go to, I tend to shy away from Facebook groups because it can be so subjective. Um, some, some families could have a wonderful experience at one clinic, but the speech therapy isn’t motor speech therapy, but yet they’re recommending this particular therapist and it’s like, well, that’s not the most accurate modality for your child, but I’m glad you’re happy. You know, it’s [00:16:00] just, it depends. It’s too much is up in the air. So I say go to apraxiakids.org. Um, that’s the big one.
Michelle Andrews: Yeah. That’s such a helpful resource. Thank you for sharing that.
Erin Gaul: Sure.
Michelle Andrews: I will link that in the show notes. If you’re driving or can’t write it down, I’ll, I’ll just link it in the show notes for you guys, for if anyone wants to check that out. All right now let’s dive into what an evaluation looks like? Let’s say a child walks into your clinic. What do you do first? Like let’s through that initial evaluation,
Erin Gaul: Oh boy, it’s, that’s a loaded question. Just cause there’s so much to it. Um, so one thing I want to address age, that’s another hot topic. Even amongst SLPs. When can you diagnose apraxia of speech?
Michelle Andrews: magical number 3.
Erin Gaul: magical number three, once they’re three. It’s like, well, not necessarily, but in a good way, you have [00:17:00] to know what you’re doing.
But I want to say that it’s a myth that a client has to be three years old. What you need, what Is that the child has enough speech to analyze for the markers of a apraxia the ability to attempt imitation. Cause there’s going to be a lot of repetition in a motor speech evaluation, and they need to be able to participate in the evaluation.
If they have these three in, in my idea, prerequisites, I go for it. Um, the magic word is speech, not age. Now some SLPs and some that I know and really respect do wait until three because they find the kids just aren’t talking enough until then. And don’t feel confident about a diagnosis. That’s not me.
I tend to say, if you have those three prerequisites, I’m going for it, I’m jumping in, and even if I’m still not quite sure, I reflect that in my evaluation that this is suspected. I’m not confirming.[00:18:00] I’m not denying a diagnosis. There are markers, but we need to wait until there’s more speech. Cause I also want to warn SLPs against, um, jumping to CAS just because a kid isn’t talking, so trained eyes and ears are super, super important. Now, when we look at the actual testing, standardized informal, what am I looking for? I tell the parents right away, we need an updated hearing test, but they pass the newborn hearing screening. Sure. But there can be undiagnosed, gradual hearing loss.
I have seen it. That was my first specialty. So we have to rule it out a child can’t imitate what they’re not hearing. So that’s the first step. And usually, um, I try to get that done before they even show up to me because it’s so important then as far as the actual testing, I am a go-to um, for Edith Strand, I just love her, [00:19:00] the dynamic evaluation of motor speech skills, the DEMs, that is typically for kids three and up, um, and for suspected like moderate, severe, apraxia , I do use it as a guide if needed for slightly younger kids.
I think the youngest I’ve personally diagnosed was two years and three months about then. He had had enough language for me to analyze and guess what it was so clear, cut. This was apraxia of speech and I’m still seeing him and he’s making remarkable progress. Um, but I use the DEMs for him as a guide, based on the syllable shapes included, they are simple syllable shapes. Then they graduate to more complex while considering all the markers of CAS. some prompts are allowed during testing. I find you might lose younger kids with all of the prompts allowed, you know, their attention is just not great. They don’t want me up in their face. So I get at least three repetitions of each word so that’s motor speech, [00:20:00] articulation and phonology. Now this gets tricky for the little ones but if they’re old enough, let’s say they’re three and above. I’m going to give one of those articulate articulation tests, Goldman Fristoe. The clinical assessment of articulation of phonology, the cap. Um, I have that one at my clinic cause we need to know, are there predictable age appropriate errors, whether it’s articulation or phonological, those patterns of language? Um, cause that’s not apraxia, that’s predictable, that’s expected. , and then I look at expressive and receptive testing. I try to make this quick for the younger ones. The receptive and expressive one word, picture vocabulary tests are my go tos because they’re just so quick. Um, because if there are no other comorbidities, no other diagnoses going on, there is typically a pretty significant discrepancy between expressive and receptive language. I would say [00:21:00] 90% or more of the clients I have seen. Have significantly high, if not above average receptive skills and their expressive skills are just so low. So below average, so that’s super important. a language sample I’m going to just sit there and record, ideally at least 50, hopefully a hundred of their utterances. Now I will say a lot of times, if you looked at my language samples, it’s a lot of the same utterance because of their limited repertoire.
And that’s, that’s a sign for me. I’m like, wow, he’s only using B and K and this random, you know, huh. That’s kind of strange, so that’s super important. How are they using their language? Um, and then of course, I’m going to look in their mouths. The oral mechanism evaluation is important. Structure and function got to make sure all of that’s working. Okay. Um, so that is the bulk of the assessment. [00:22:00] And I try to get as much done in one session as I can. Doesn’t always go super well and we have to bleed into another session. Um, I know that some like really big clinics will have kids there for hours and I’m just not willing to put a kid through that for, for three to four hours. Um, I tell them, I’m like, come back another day. We got as much as we can let them rest. They’re crying, they’re hungry, they’re tired. Like let’s, let’s not torture them anymore. Um, so it can definitely take time, but I always tell other SLPs don’t, don’t scrimp on the eval, you know, cross your T’s dot your Is, get it all so that you’re confident in your diagnosis.
Michelle Andrews: I was going to ask, so how much speech do you need to analyze? You said like 50 to a hundred utterances, but as they have around that, or are you looking for a certain number?
Erin Gaul: not necessarily. Yeah. That’s, that’s a good question. So if I’m looking at a language sample and you see 50 to 100 [00:23:00] utterances, but they’re all the same thing, Buh Buh Eh, that’s not really enough, you know, that might be a kid. I’m like, okay, we might take a motor approach, but I can’t say, yay or nah right now. What’s going on. Um, if I hear enough of a varied phonetic repertoire, um, and they’re trying words, that’s a big thing. If they are watching me and I’m going through a test and you can just see it on their face. I can’t say that it’s not that they’re distracted by toys. It’s not that they’re, you know, upset or anything. I get a gut feeling and I’m like, you just, you can’t do this. I get it. Like you can’t do this.
Michelle Andrews: context
Erin Gaul: yes, yes. Uh huh. Yeah. Um, so I have to see a bit of some varied sounds, ideally some different syllable shapes so that we can at least attempt other syllable shapes other [00:24:00] sounds and see what I can get out of them,
Michelle Andrews: Okay.
Erin Gaul: that makes sense.
Michelle Andrews: does make sense. So tell me, so what are the questions that you asked the parents?
Erin Gaul: I have four go-tos. Um, I will ask them just because research shows that kids with apraxia not all of them, but often they don’t babble as babies, or it’s very limited or it’s one sound. It’s not that very a gated. Um, Babel that we tend to hear in kids at babies as they get older. Um, so I asked about the babble I asked, does your child tend to use the same sounds or words for everything? Like, does dah mean everything? Oh, because I’ve had families come in and the kid literally says, duh, the whole time. And I’m like, huh. Okay. Is this typical? And they’re like, oh, well that meant mom. I said, okay. But then he said, duh, while we were [00:25:00] playing with ice cream. Yeah. That means vanilla. Okay. Well he just said duh pointing to the door. Yeah. That means he wants to go home. Okay. That’s in my head. I’m like, okay. That’s, that’s something to look at.
Um, then I asked, do productions for the same word change, like I said earlier. And I explain this to parents. Like if he just loves Hulk, does he say Hulk the same way every time? Or does it change? And then you kind of. The light bulb goes on. They’re like, oh, actually it changes. It’s never quite the same word. I’m like, okay, there we go. There’s something to help me out. And the last one is, does your child try to imitate you? Is he at least making an attempt accuracy out the window? Is he or she trying? If they’re not, if they prefer to just stick with their own repertoire or that [00:26:00] one syllable, that CV duh for everything then to me, I’m like, all right. All right. We got a lot to look at here. Those are my four questions.
Michelle Andrews: That’s great. That’s great to make sure you ask the parents. .Do you send the diagnosis to the child’s pediatrician or insurance? Tell me more about that process? Say you diagnose a child, what, besides just telling the parents and having the treatment change to be catered towards that. What other things do you need to do?
Erin Gaul: That’s a great question. Um, so it really depends on what the family is asking me to do, there are some families that come in and, apraxia is completely unexpected. They didn’t even know it existed. Um, it’s going to be in my evaluation and I recommend them, um, show the evaluation to pediatricians, teachers, anything like that. Um, some families come to me specifically because school is asking for a diagnosis in order to justify certain treatments, um, or mostly frequently [00:27:00] of treatment. They’re trying to get three times a week and he’s once or twice a month, let’s say they’re like, well, we need proof of diagnosis. and in that case, sometimes the evaluation will suffice, but often I’m signing consents to release just so I can speak directly with other SLPs pediatricians, um, developmental pediatricians, anyone who needs to hear specifically what this is, um, and how it impacts this particular child. So I give the documentation, but I do whatever else it takes. If it takes a phone call, I’m going to, I’m going to make the phone call. If I need to fax the eval over, I’m going to do that too.
Michelle Andrews: okay. So it kind of depends on what the specific child may need what, um, yeah. What, the case is. Okay. Okay, once you have that diagnosis, next is the treatment plan. So, how will you develop your treatment plan based on this new diagnosis?
Erin Gaul: so, I [00:28:00] mean, you hear this all the time. Every child is different, but I have a general kind of outline of what I’m looking at when I have a cat. And I’m like, all right, this is apraxia or this is at least we are suspecting it in a very significant way.
Um, first I have to look at what is co-occurring. I have had kids come to me with genetic disorders, autism, low tone. I mean, down syndrome. I’ve had some kids, have more than one of these co-occurring. So that’s gonna come into play. Um, family participation is this kid just coming to me and the family expects me to do the work and then send them on the. Or are they sitting in on sessions? Are they eager to hear about the homework? I need to know how much they’re going to be doing at home, because that is a huge part of motor speech therapy. It’s based on high repetitions. We’re building those pathways between the brain and the mouth, and that can’t just happen [00:29:00] in my therapy room.
Um, so I stress that immediately. Um, then looking at the child, their attention and engagement, they have to be able to watch my mouth. Oftentimes I am training them in the beginning. Look it up, miss Erin’s mouth helps you, you know, oh, watch my mouth. That’s so silly. Um, stickers on my nose, on my forehead, anything like that to get them watching me. cause apraxia is not like a language delay where, oh, you hear it enough times and you just start saying it. No, you have to watch that movement and you have to hear it. Some kids have to feel it on their face. Um, so that’s a big one. I talked to the families about frequency of therapy. I think most SLPs know, even if they’re in the specialty or not, the more, the better. ASHA research recommends three to five times a week.
Um, it, it’s pretty simple. I mean, at the end of the day, my kids who come to me once a week versus the ones who come to me three times a week, let’s say there’s no co-occurring diagnoses, [00:30:00] anything like that. Um, pretty similar kids. I’m going to see quicker progress with the one coming three times a week. I get that it’s a financial commitment. It’s a time commitment, parents work, you know, I don’t fault parents at all. Um, it’s just the simple fact of the matter. I’m going to establish trust with that child. That first session I am not jumping in. I am playing. I’m being goofy. I’m showing this kid, miss Erin’s fun. Miss Erin is here to help you. Um, I’m the bridge to their communication. They have to love me. They have to want to run into the room to see me and play. so I will work for usually, usually it happens pretty quickly, but I have sometimes worked two, three sessions just establishing that rapport and then once that’s established, I’m looking at targets.
So what targets, AKA goals, words, phrases. What are we working towards? Notice I used the word targets. Not sounds we’re not [00:31:00] working on individual sounds with apraxia. It’s about the movement between sounds, so I’m going to start thinking about that. I get into targets a little bit later but most of all the child needs to be actively engaged. The brain has to be activated and that is happening because they are engaging with me looking at my mouth. If a child is not motivated to talk, we will likely be unsuccessful at least for a period. If not like, Hey, maybe this is not going to work right now. Um, this mostly happens when I have kids come to me with co-occurring autism.
And it’s more on the severe side of the spectrum where they’ve been, um, minimally verbal. I have found I’ve had a handful where I’ve had to have conversations with the family. Like, look. I don’t think he’s motivated to talk. He’s not watching me. He’s kinda goofing [00:32:00] off. It was just, it was just not in the cards at that time. So the child has to buy into it. , you need to want it. It’s not me wanting it. I want every kid that walks in to talk if that’s what they want and if that’s what the family wants, but me wanting it is not enough.
Michelle Andrews: That’s so true. I’ve seen such a difference once a real connection between myself in a in a child. Sometimes that takes time, but it, really does make all the difference.
Erin Gaul: oh, it does. It does. I mean, when a family says he wanted to invite you to his birthday party, you know, like things like that, I’m like, that is why I do what I do because they don’t look at me as the teacher drilling them. You know, they don’t even realize they’re working. They’re just having fun.
Michelle Andrews: Yeah.
Erin Gaul: that’s, I think that’s the magic of speech therapy when you’re doing. The right way, you know, for, for the younger kids, the older ones. Yeah. We gotta sit down, we gotta do some work, you know? Um, but when you get that connection, it’s priceless.
Michelle Andrews: Yeah, [00:33:00] absolutely. Awesome. All right. SoLet’s move on into goals. So what are the characteristics needed for appropriate goals?
Erin Gaul: So my goals look very different than let’s say, you know, you, you look at an IEP and you’re going to see frequency and percentages and across three consecutive sessions. And it’s like not, not so much with apraxia, um, their movement based goals. They are going to include the phonetic repertoire, um, of the child maybe listed like specific sounds that they have. , my goals might say. The syllable shape the syllable shape within the child’s phonetic repertoire. It’s pretty open-ended. I am not typically reflecting specific sounds when you see specific sounds in my goals. It’s because we’re kind of at the end of the road, like, oh boy, he is still having a hard time with, [00:34:00] oh, so I’m going to put that in there. ,loaded CVCs with the stimulus will O sound, things like that. They’re going to be specific to the syllable shape the phonetic repertoire.
And we also want to include those prostatic skills, the stress, the rhythm, the pitch. Um, you’ll see some of my goals saying, um, eliminating segmentation X will produce CVCV with appropriate stress. so you’re not really going to see those percentages. Um, you might see overall cumulative accuracy at 80% but it’s pretty rare that I write them that way. Um, so at the end of the day, you’re going to see probably three to five syllable shapes and my goals, and then containing accuracy, with skills and targets within their phonetic repertoire. And it just leaves it open. If, if a kid masters, you know, boo [00:35:00] in three sessions, I don’t have to go back and edit the goals, you know, because oo is mastered. Now, now my goals are broader. We’re working on a, on a bigger scale here. What can we get? Sometimes the goals aren’t going to work. I realize I’m in two to three sessions. If target is not stimuli. I move on. There’s other things to work on. Um, there’s other things I’m sure the child is stimulus for so I had a question when I, when I posted on, um, Instagram that I was going to be doing the podcast. I had a question similar to what I’m talking about now and saying, when do you take a phone, a logical approach to kids with CAS? And I’m going to say eventually, and often I do, but that’s because motor speech is almost on the back burner. A lot of times kids with motor speech will turn into phonological kids. And that’s when I look at phonological targets, but still within the DTTC hierarchy. And my goals are still gonna look the same.
Michelle Andrews: So [00:36:00] just further down the road a little bit, once there’s more progress.
Erin Gaul: Yeah. I mean, there’s a whole, yeah. There’s so much to say about what a treatment session looks like for a young kid versus let’s say a middle school. You know, um, those therapies look very different.
this was so quick because I
Michelle Andrews: This is so great because I had really never seen goals written that way. It’s always a percentage it’s always, you know, just kind of, written like for sounds. This is completely different information than how I’ve seen things done. This is, but it makes total sense. This is catered to apraxia this isn’t just for anyone.
Erin Gaul: it makes sense. Yeah. Because motor speech therapy is different than phonological or articulation therapy. So the goal should look different.
Michelle Andrews: very true.
Erin Gaul: Yeah.
Michelle Andrews: Could you pick a few more examples of some goals? I know every kid is different, You know, it can look very different, but so I can hear them in my head.
Erin Gaul: so I’ll give you an example. Okay. So I’ll use a fake name. Here’s a [00:37:00] goal. I have written for a three-year-old I’m pretty new to a CAS diagnosis. I’m going to call him Billy. Billy will produce CV, VC CVC. CVCV and VCVC targets heavily loaded with stimulus sounds with adequate placement and manner, including elimination of segmentation. Now that sounds like a lot, but to me it’s okay, what, where are we right now? We’re working on simple syllable shapes and no segmentation. That’s a big one for this kid. I didn’t specify sounds. So if we’re working on go, there’s a CV. I just want him to say, go without, oh, I don’t want him to say, oh, I want him to say up.
Um, so hopefully the goals, if they’re being passed onto another SLP while it’s [00:38:00] pretty detailed and I have seen even more detailed CAS goals, literally like three lines long to me, that’s a lot, And for someone trying to interpret like a parent, I try to keep them simple. And I try to explain them, um, verbally to the parents. Um, I might say something really simple, like Billy will produce and mark all syllables in multi-syllabic functional utterances containing sounds in his phonetic inventory. That’s a little simpler we’re working on multi-syllabics. and in, I didn’t put in there to include all the prosodic features and all, because that’s a strength of this child. Um, so I have a caseload of CAS kids and some of their goals look similar. Some of them look very different because one is very robotic and one sounds really great. His voice goes up and down, up and down and all, but his vows are all over the place. So, um, apraxia is unique and the [00:39:00] goals are just as unique.
Michelle Andrews: right. What about a goal for those vowel shapes? Can you tell me an example of a goal?
Erin Gaul: Yeah. In that case, I would say, I would simplify the syllable shapes. I might, I might list three. Billy will produce CV, VC and CVC, syllable shapes heavily loaded with stimulus sounds containing correct vowels, correct sequencing of the sounds. Um, now I’m just, I’m thinking out loud here. I’m not actually reading goals right now. Like they’re, they’re, they’re written much more eloquently, but basically syllable shape, and prosodic features we’re working on. If there are any specific vowels or sounds, but that’s usually down the road that’s included.
Michelle Andrews: So you’re still not going to list the specific vowel sounds in your goals?
Erin Gaul: I typically don’t, unless, unless [00:40:00] I can identify, Billy cannot do rounded vowels. He cannot do. Ooh. Oh, oh. You know, then I will put them in. But unless it’s really specific like that, no, I’ll put a general ensuring accurate vowels in the goal somewhere.
Michelle Andrews: That makes sense. And that sounds like an SLP that if they needed to, they moved to another state, or far away from you that another slp could take that plan..
Erin Gaul: there should be no question, there should be no question. And usually, the goals get more specific like that as the child progresses but in the beginning it’s kinda like, alright, um, anything is game, whatever we can get, especially if there’s such a limited sound inventory.
Michelle Andrews: Right. Cause it sounds like you may need to try one thing, one sound this week and maybe they master it or maybe they don’t
Erin Gaul: therapy changes so quickly [00:41:00] in motor speech treatment. In my experience now, sometimes there are really tricky syllable shapes that some kids just really struggle with. And then we’re going to do more of that blocked mass practice. That’s going back to the principles of motor learning, but as the motor skills start to develop, we are moving. We are moving. This train is going, and I want, I want the, uh, the goals to follow us to be justice quick. So, you know, I’m fine tuning them probably every three months. Depending on how quickly the child is moving alone. Yeah.
Michelle Andrews: Awesome. All right. Yeah, that makes sense. All right. Well, so were kinda going through the process here, so now, we went though the goals. So now you have that kiddo and you’re trying to select target words for therapy, what do we need to know about this?
Erin Gaul: So I will never show a child, like, first of all, especially if they’re toddlers, but I, they will never get a list of words to take [00:42:00] home, like a list of 20 words, never. Um, these targets are going to be highly motivating to this child. Um, so what I do is before the first session, I send an inventory to the parents or the caregivers and there’s going to be important category. On that inventory, people, places, activities, foods, friends’ names, words that are functional and will facilitate high trials in speech and at home, um, examples of this, I had a little guy come to me and he could not say his Italian grandmother’s name, Nana, Nana. He was saying Bubba, Bubba. I mean adorable, but we want it. We want it to be accurate. You know, so Nana was listed as soon as he was stimulated for N for that N um, we moved into the syllable shape, Nana. Um, so I’m working on na-na, I’m not [00:43:00] working on let’s say, you know, I’m just thinking of like traditional articulation books or workbooks, like where you see these random vocabulary words.
And I’m like, who needs to know this? So I am going to take words from this list that the parents have made, um, all while keeping in mind. What sounds does this child have? Um, what vowels, what consonants? , for example, I have a ten-year-old right now with a new diagnosis. I diagnosed him for 10 years he went on undiagnosed. He never got motor speech. Um, so the inventory came back and one of the words in important places was I had to laugh couch cause he loves playing Minecraft. And so he’ll play it on the couch, but he has, oh, the poor kid. He has such a hard time with that vow ow. So when we did couch in simultaneous productions, it was awkward. That was groping. The vowel was distorted [00:44:00] so I thought, okay, let me simplify this, that to the. It’s too much. Let’s just isolate to ow. Cause that’s still a functional word. Oh, I got hurt ow. Well, he could do that a lot easier than I said, oh, well, let’s make it a little more complex out. He was able to do that. When I put it back into the context of the CVC couch, he could not get it. So it’s an important word, but we’re not there yet. He has all the sounds, but the movements are just not smooth and stimulus will yet it’s worth working on. Um, but this is just to say, I don’t just jump and say, oh, that’s on the list.
So we’re going to practice it. No, they have to show stimulus ability. And if he doesn’t get it two to three sessions in, throw it away for a little bit. And I come back to it down the road. When I think, um, the movements might be a little bit easier for him. so every session is. So personal, and that’s what I love about [00:45:00] CAS. Um, I go from one session talking about Minecraft and Legos. The next we are working on Henry and Thomas and Percy, because guess what? That is, what is important to that child. And that’s what keeps them engaged in the sessions. I’m not doing these random words that they don’t care about. You know, these are highly motivating and I embed them into play. I get at least three repetitions of these targets at a time because usually that’s what my little toddlers can handle three at a time. and we, we have fun. Like our sessions are fun because those targets are so based on that child.
Michelle Andrews: that’s so awesome. Yeah. That, that motivation has to be there. That’s so important.
Erin Gaul: Oh yeah, yeah.
Michelle Andrews: great.
Erin Gaul: I can’t sell this kid, you know, working on snow and I’m trying to smell and, you know, smile like for like, I’m just thinking of like S blends, worksheets, you know, like that’s just not how it works. Right? [00:46:00]
Erin Gaul: Yeah. Um, I think it’s an important part of how to get that repetition for kids in particular that are so young. It’s that personable piece. Hey, I get you. I understand you. I know that this is important to you. We’re gonna work on it together.
Michelle Andrews: Oh, that’s That’s amazing. This has been so informative.
Erin Gaul: I could speak all day. I’m such a CAS nerd. I love it. I love it.
Michelle Andrews: I love it too, because like you said, you know, you take a class in grad school, but I think unless you seek out training, just, you’re just not going to specialize in it enough to treat.
Erin Gaul: I’m sure we all have these like cringe moments, like, especially from our clinical fellowships where you think back to like a child that you had absolutely no clue what to do. And I keep thinking of this one particular kid with Apraxia and I had no clue. I had no clue. And I cringe thinking about the therapy I was giving him it had, I had such good intentions, but it wasn’t motor speech, you know? [00:47:00] So grad school just doesn’t prepare you. Um, so yeah, to your point. Yeah. You, you need those trainings.
Michelle Andrews: Yeah, absolutely.
Erin Gaul: Yeah, so I think at the end of the day, like in summary, I want to stress that a diagnosis for apraxia should be from an SLP. We are the experts in speech, um, a specialized SLP, there is no magic age. There is a magic amount of speech to be analyzed and therapy should be very personalized. It should be based on the principles of motor learning. The child should be having fun. He should not realize that he is working and. I think every parent and SLP hopefully will walk away from this podcast with more information to share, um, SLPs in particular, to be able to give this information to parents. Um, so they know who to look for. So they know what to ask SLPs that they’re, you know, maybe, maybe calling to, [00:48:00] to, you know, find a diagnosis. I encourage parents to kind of interview SLPs. You know, what is your experience with CAS? You know, tell me about the principles of motor learning. Achieving that balance of, Hey, I’m not, you know, sometimes I felt quizzed, you know, by parents and I want, you know, um, you have to be careful, but I think parents should feel free to ask those questions. What is your experience with CAS? Because you need someone that knows what they’re doing.
Michelle Andrews: absolutely. That’s so true.
Erin Gaul: And another thing is that an evaluation and diagnosis, um, age is there’s no magic number for age. The child has to have enough speech to analyze the ability to attempt imitation and the ability to participate in the evaluation. Um, and then for goals, goals should reflect syllable shapes, simple to [00:49:00] complex, prosodic features. Goals for childhood apraxia speech. Aren’t going to reflect the typical specific sounds, um, consecutive sessions for mastery or percentages. It’s going to reflect syllable shapes, vowel accuracy, prosody, and as they gradually make more progress, maybe we start to specific to specify rounded vowels within CVC and VC contexts. Um, they’re going to look very different than typical articulation and phonology goals.
Michelle Andrews: right. Awesome. This has been amazing. I’ve loved, loved listening to all the things you’ve had to say. And honestly, that’s so helpful. I have seen kids that have a diagnosis of apraxia, uh, and I wrote a goal definitely about sounds or, oh, well, syllable shapes, but I probably stuck sounds in there. And I’m like, now [00:50:00] you know.
Erin Gaul: If you’re seeing an older kid that, oh my gosh, they’re still stuck on S blends. Like I will probably, it would not be the typical photo goal, but it would be a list because it might not be all as blends that they have trouble with, you know, because that’s the inconsistency with apraxia. So I can’t make a blanket statement and say, we’ll produce S blends in single words. No, like maybe they can get, you know, S T but they can’t get SP in the word spoon, but then, Like spy, spy. They get perfectly, but they can’t say spoon, you know, it’s so inconsistent. Um, so it’s like hardly ever,
Michelle Andrews: Yeah.
Erin Gaul: those vowels, those vows. Um, yeah. And getting parents on board with. Like there’s so much to say about a treatment session. Cause some parents will be like, why are we only working on two words? Like, is that all they’re going to walk out saying, it’s like, well, no, we’re working on me because then that’s going to [00:51:00] help with bee and, happy, you know, like it, we’re building a foundation for more, more extensive work.
Michelle Andrews: Yeah. I really think that explaining to parents, you know, they’ll they, maybe they ask, or maybe you need to explain ahead of time. I know, even just with, any kind of early language where I’m with real young kids. And I, I, I mean, I look like I’m just playing with them. I mean, parents are probably like, I’m paying you how much
Erin Gaul: I try to explain what I’m doing because I feel like such a fool, like they’re thinking, what do you know? You went to school for this you’re playing. It’s like, so I’m like, so I’m targeting this and targeting that, you know,
Michelle Andrews: Yeah. Especially if they’re in the room or through a window or something, just staring
Erin Gaul: Uh, huh.
Erin Gaul: They think we’re just playing, yeah, you got it. You got to justify everything. Yup.
Michelle Andrews: Do you have a, story, I guess I’m putting you on the spot, but [00:52:00] have another story that would be beneficial or Just an example of going through, planning the treatment.
Erin Gaul: One case stands out. I had a young kid, I mean really a young man come to me. Mom gave me his whole story. He was never diagnosed with a apraxia. He got in here. She used the language, you know, typical speech therapy, which parents don’t know that there’s a difference. So he had gotten typical articulation and phonological therapy growing up. Now, when you think of those types of therapies, you’re thinking of sound emphasis. You’re like, oh, we’re working on final consonant. Ha huh. Well guess what this kid showed up and sounded like a phonological therapy kid. And I’ll give an example of that. Um, let me think of a sentence. , so [00:53:00] if we were talking about what he ate for lunch at school, he would say I ate macaroni and cheese because he was taught to emphasize sounds.
He was also very robotic sounding. The super segmentals were never incorporated. Um, the stressing of the syllables, the changing of the pitch, this kid in particular, we were, we were working on changing the tone of your voice. Okay. I’m going to give you a sentence. You’re going to ask it like a question. You’re going to raise your voice at the end. Boy, he really, really struggled with this. Um, I tried to have him say something sarcastic. He could not do it and he would laugh. And I would say, I hear you trying so hard and we would literally analyze where to raise the voice, where to lower it, even how to use your face to help your voice like change because you know, when you’re sarcastic, your eyebrow [00:54:00] might go up, you know, things like that, just to help him feel and experience. I’m changing my face, my gestures. I need to do the same thing with my voice. Um, and that he was, he was a very tough case because so many of his speech skills were so ingrained. So ingrained. It was still difficult for him to raise his voice at the end of a question, by the time we were done.
And eventually he had to take a break. He was coming from a from a far distance and all. Um, so we still had things to work on. Um, but this is just to emphasize the importance of motor speech therapy from the beginning. It is different. It is not articulation or language or phonological therapy. And when a child who has motor speech, doesn’t get that. You will typically hear it as they get older, so[00:55:00] this kid will always have a spot in my heart just because he was trying so, so hard when he came to me and at a certain point, it’s like, you know, how much do you push when something is so ingrained?
Michelle Andrews: he’s, he’s spent so many years
Erin Gaul: oh yeah. And now he’s like,
Michelle Andrews: Yeah.
Erin Gaul: Now he’s like 13, 14, you know? Um, and there’s a social component to that, you know, how does he sound with his friends, with other kids that don’t know him? Um, so it’s important as SLPs to say and acknowledge, I don’t have expertise in this. I’m going to find someone or pass you on to someone who does, you know, just as I would for someone with aphasia or a swallowing disorder or AAC, you know? Um, so I hope it empowers SLPs after listening to this, you know.
Michelle Andrews: I hope so too. I hope we can hear that, take that to heart because it doesn’t mean anything [00:56:00] less. if you’re not an expert in this topic or that specific topic.
Erin Gaul: And it’s, I feel so badly for like school-based SLPs because they are expected to do everything and I could never, I could never, um, that’s why I love my private practice. I have a niche. I stick with what I know I’m good at and like the districts that just say, well, you’re an SLP, you will treat this. And that’s what they tell the parents too, because that’s another thing parents come to me and say, they won’t give us a prompt. They won’t give us, uh, they’re not calling it motor speech therapy. And I’m like, well, yeah, they’re looking at educational impact. Um, They can’t necessarily give you what I can give you at a private practice. Oftentimes it’s more generalized therapy versus that really specialized it’s. It’s really [00:57:00] tricky.
Michelle Andrews: it is yet SLPs in private practice and uh, areas and they’re all different worlds.
Erin Gaul: oh my gosh. Like so different. God bless the school-based SLPs. Truly like I have nothing but respect for them. They have an impossible job.
Michelle Andrews: Very true. That is very hard. Awesome. Erin, this has been so amazing. Thank you much for coming on this podcast
Erin Gaul: Oh, I loved it. I hope I can come back and talk more like treatment the littles.
Michelle Andrews: I would love that. I’ll have to plan for that for sure.
Erin Gaul: Awesome.
Michelle Andrews: All right. Well, thank you for speaking with me today.
Erin Gaul: Thank you.
Michelle Andrews: We hope you have learned something today. All of the references and resources throughout this episode in the show notes and also listed on the pep top podcast for SLPs website. If you’ve been listening while you’re driving on a run during the dishes, this entire episode is transcribed for you to refer back to easily. Erin. Thank you again for joining me today.
Erin Gaul: you’re so welcome. I had a great time.
Michelle Andrews: [00:58:00] Thanks.
The SLP’s Guide to Treating Childhood Apraxia of Speech. Authors: Cari Ebert MS, CCC-SLP & Dave Hammer MA, CCC-SLP
Strand EA. Dynamic Temporal and Tactile Cueing: A Treatment. Strategy for Childhood Apraxia of Speech. Am J Speech Lang Pathol. 2020 Feb 7;29(1):30-48. doi: 10.1044/2019_AJSLP-19-0005. Epub. 2019 Dec 17. PMID: 31846588.
Fiori S, Pannek K, Podda I, et al. Neural Changes Induced by a Speech Motor Treatment in Childhood Apraxia of Speech: A Case Series. Journal of Child Neurology. 2021;36(11):958-967. doi:10.1177/08830738211015800
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