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Treatment of severe childhood apraxia of speech in a 12-year-old male with CHARGE association.

Article Excerpt
This study employed a single subject, multiple baseline across behaviors design to examine the effects of dynamic temporal and tactile cueing (DTTC). The participant is a 12-year-old male with CHARGE association, a complex genetic disorder. He exhibited moderate mental retardation and severe childhood apraxia of speech (CAS). He was nonverbal and exhibited communicative vocalizations that drew negative attention. Treatment was implemented to extinguish aberrant ocalizations, improve his ability to produce accurate movement gestures for a core set of functional words and phrases, reduce rate, and improve comprehensibility. Treatment was provided over three phases. Results are reported for the effects of treatment focused on establishing a core functional vocabulary as well as for pre-and post changes in the number of aberrant volcalizations and speech rate. Changes in his ability to be understood in context are also reported. Our data provide evidence that improvement in functional verbal communication can occur even in children with severe apraxia who are over 12 years of age. Discussion focuses on the need for children with severe apraxia to continue in treatment, sometimes for long periods of time, before the full effects of therapy are seen. Issues related to measures of disability and societal limitation and the need for more treatment efficacy research in children with severe speech disorders are addressed.

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Determining prognosis for verbal communication for children with severe speech disorders is clinically challenging and made more difficult due to a lack of evidence for efficacy of intervention. This is especially true for nonverbal children whose parents frequently ask speech pathologists to state a prognosis for functional verbal communication. Although evidence-based practice would dictate that we refer to the literature to answer that question (Dollaghan, 2004, 2007; Robey, 2004; Ylvisakier et al., 2002), there is little research addressing treatment efficacy provided to children with severe motor speech disorders. Limited data have shown that intensive treatment can facilitate early speech acquisition for young children with childhood apraxia of speech (CAS) who have not benefited from other treatments (Strand & Debertine, 2000; Strand, Stoeckel, & Baas, 2006). However, there is no evidence for treatment of severe apraxia in older children with CAS who also exhibit cognitive impairment.

This study reports treatment effects for a nonverbal child, D, seen between the ages of 12:8 to 14:11 who carried the diagnoses of moderate mental retardation and severe CAS. Diagnosis of CAS has been somewhat difficult in the past due to controversy regarding the specific behavioral markers that should be used to identify this level of impairment (Davis, Jakielski, & Marquardt, 1998; Forrest, 2003; McCabe, Rosenthal, & McLeod, 1998). In the last several years, however, there has been increasing consensus regarding the characteristics of this disorder. The position statement concerning CAS (American Speech-Language-Hearing Association, 2007) now provides a definition of the disorder, with a list of behavioral characteristics that are associated with the label. In that document, CAS is noted to be a speech sound disorder "in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits" (p. 1). It goes on to note that "the core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech" (p. 1) that include consonant and vowel distortions, dysprosody, and inconsistency over repeated trials. D exhibited all of these characteristics when attempting particular CV, VC, and CVC targets during the motor speech examination.

In addition to being nonverbal, D exhibited communicative vocalizations that drew attention and negatively affected his social interactions. He had been receiving school and private therapy for 10 years with little improvement in verbal communication. His parents had requested a trial of thera py targeted at reducing aberrant vocalizations and to determine...

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