Persistent Speech, Language, & Learning Needs

of Older Children & Teens with CAS

Kathy J. Jakielski, Ph.D., CCC-SLP

Augustana College, Rock Island, IL

2009 National Conference on CAS

Chicago, IL
July 10, 2009
 Topics

1. Prognostic Indicators
2. Research Evidence
3. Speech: Persistent Difficulties & Interventions
4. Language: Persistent Difficulties & Interventions
5. Video Examples
6. Your Own Questions!
1. Prognostic Indicators
You might have an older child with CAS who receives
continued speech & language services
and
you might be wondering how long services will be needed.
Or, you might be wondering…

Will my younger child with CAS

continue to need speech & language therapy
when he/she reaches middle-school age & beyond?
 Answering those questions
is what we refer to as
providing a prognosis…
it’s our educated guess as to what your child’s
speech & language needs will be in the future.
 Prognosis
 Many children with CAS develop normal speech by adolescence,
however, some do not.
 Prognostic indicators are child-specific and include:
• severity of CAS
• history of progress in intervention
• presence and severity of co-occurring symptoms, such as:
– language ability
– cognitive ability
– oral/limb apraxia
 Although the interaction of these indicators is unknown, the
higher they are in number & severity, the more challenging it can be
for a child to achieve completely adult-like speech.
 Other child-specific prognostic indicators include:
• motivation
• history of progress
• cooperation
• attention
• access to services

 The more favorable these indicators are, the more positive a

child’s prognosis for normal speech will be.
However, just how common is it for children with CAS
to need both speech & language intervention
when they reach pre-adolescence & beyond?
 Research evidence
indicative of
dual & persistent problems…
2. Research Evidence
 Co-morbidity: Deficits Often Extend Beyond Speech

 Motor planning deficits are central in CAS, however:

 Ball et al., 2002

• Evidence of subtypes of children with CAS:
– language, vocabulary, behavior cluster
– speech, speech accuracy, speech intelligibility cluster
• Stated that effects of CAS go beyond speech-sound
deficits.

 Lewis et al., 2004

• Found that children with CAS very often have persistent
speech & language problems in school-age years.
• Also found that children with CAS performed more like
children with speech & language impairments than like
children with speech impairment only.
 Gillon & Moriarty, 2007
• Evidence of co-occurring problems:
– children with CAS had persistent reading disorder
– children with CAS had persistent spelling disorder
• Again, evidence that effects of CAS can go beyond
speech-sound deficits.

Therefore,
you want to be certain that your SLP considers the
speech & language needs that your child might have,
even & especially at the younger ages.
3. Speech: Difficulties & Interventions
 The Speech System

 Components
 Common Difficulties
 Interventions for Older Children
 The Speech System:
Components

 We can think of the speech system as having 3 components:

• “segmentals” consonants, vowels, & word shapes
• “segmental errors” correct/incorrect speech sound
production
• “suprasegmentals” melody of speech, rate of speech, stress
on syllables, etc.
 Segmentals:
Common Persistent Difficulties & Interventions
Difficulties
 Some of the more difficult consonants to produce include:
k/g, th, s/z, sh, ch/j, r, l
 Some of the more difficult vowels to produce include:
any vowel followed by an r, such as er, or, ar, ear, etc.

Interventions
 Some older children with CAS still will need to work in therapy
to develop these sounds on a sound-by-sound basis. Using
principles of cognitive motor learning should guide this work.
 And realize that you might need to revisit “stubborn sounds”
periodically!
 Integral Stimulation Therapy
(Rosenbek et al., 1973, 1974)

 Integral stimulation therapy:

• a cognitive speech-motor drill intervention approach

• initially used to achieve skill acquisition

• ultimately used to achieve motor learning

• contains pre-practice, practice, feedback, and hierarchical

cueing components
 Integral Stimulation Therapy: The Cueing Hierarchy
 The cueing hierarchy consists of 8-10 steps.
1. maximal cueing (auditory, tactile, visual)
2. simultaneous production (watch & listen; unison)
3. mimed production (watch & listen; faded auditory cue)
4. immediate repetition (with only an auditory model)
5. successive repetition
6. delayed repetition (1-5 second delay)
7. reading
8. reading with a delay (silent reading, then verbalization)
9. question response
10. role-playing
 See the Appendix for a summary of the cognitive motor therapy
principles underlying integral stimulation.
 Integral Stimulation Therapy: The Rating Scale

Rate using 0-2 scale:

2 = produced without error
1 = intelligible, but 1-2 errors
0 = did not meet criteria for 1 or 2

Also, manipulate cues:

from simultaneous production
to delayed repetition.
Additional Difficulties
 Some of the more difficult word shapes to produce include:
• words containing strings of consonants (exs., play, must)
• words ending in a consonant (exs., cap, house)
• words with multiple syllables (exs., Mississippi, McDonald’s)

Interventions
 Work on saying the consonants in the middle of words (exs.,
baseball, soccer). Learning to pronounce these sounds will
improve your child’s overall speech in conversation.
 Work on words with multiple syllables that are functional — go
to your child’s textbooks for words to practice. Think social
studies & you’ll find words like Mesopotamia! Think science and
you’ll find words like photosynthesis! Count the # of syllables,
then say each one. Great academic-related practice!
 Segmental Errors:
Common Persistent Difficulties & Interventions

Difficulties
 By the time children with CAS reach (pre-) adolescence, they
often have developed specific speech error patterns.
 These error patterns can affect consonants, vowels, & word
shapes.
 These error patterns can be different for each child.

Interventions
 A traditional approach is to work on eliminating these error
patterns one at a time. With older children with CAS, however,
think about working on functional sentence-length stimuli,
addressing numerous error patterns in every sentence.
 Suprasegmentals:
Common Persistent Difficulties & Interventions

 Even older children with CAS tend to have difficulty producing

suprasegmental aspects of speech.
 These aspects of speech require excellent motor planning skills.
 Suprasegmentals include:
• saying stress on the correct syllable
• speaking with an appropriate rate (not too fast or too slow)
• speaking with an underlying rhythmic quality
• speaking with appropriate nasality
• varying pitch up and down appropriately
Difficulties

Children with CAS tend to:

 over-stress all of the syllables in a word
 speak with poor overall rhythm
 intermix fast & slow speech
 intermix hypernasal and hyponasal speech
 speak without varying pitch, so that speech sounds monotone
Interventions

 Many older children with CAS have never had therapy to

address suprasegmental production difficulties.
 Yet theses aspects of speech are what makes for natural-
sounding speech.
 Good news is that working on suprasegmentals is a lot of fun!
 Even better is that it’s not too late to begin this work!
 Overall, set up functional & real-life situations for practice.
Stress:

• Begin by teaching the general concept of stress marking

using blocks to represent the syllables in words.
• Next, color-code the stressed syllable in each target word and
clap the number of syllables, clapping loudest on the
stressed syllable.
• Then say the stressed vowel sound for each syllable, saying
the stressed syllable the loudest.
• Last, practice pronouncing each word, marking stress
correctly. Try to focus more on correct stress marking than
on correct articulation.
Rate:

• Teach your child the general concept of speech rate. Have

fun varying the rate of speech in simple phrases, saying
some phrases quickly, while saying others very s-l-o-w-l-y.

• Children with CAS improve their speech accuracy

dramatically simply by slowing their rate. Teaching a slower
rate of speech is the single best strategy I can suggest for older
children with CAS to improve their speech intelligibility.
Pitch:

• Overall, play around with pitch and have some fun!

• You might begin work by having your child produce a
variety of pitches, going from high to low and low to high.
• You might have your child try to reach a particular pitch
that you model, using vowels, syllables, or words.
• You can ask your child to produce a particular type of
speaking voice, for example.
 The Language System:
Components

 We’re going to focus on 4 components of language:

• “semantics” words and their meanings
• “morphology” smallest units of meaning
• “syntax” grammar—how we combine words into
sentences
• “pragmatics” the verbal & nonverbal behaviors that
accompany speech

 But I’ll share a single intervention approach that can be used to

address all of these components and help you work toward
better functional communication for your child.
 Semantics

 Some children with CAS exhibit difficulty learning and using

new vocabulary words.
 This likely is not related to their difficulty with speech.
 Vocabulary-building activities continue to be important,
especially for academic success.
 Morphology

 Some older children with CAS exhibit difficulty understanding

the meaning of these small units.
 Many older children with CAS exhibit difficulty producing these
small units in their language.
 Some of these errors may related to their difficulty producing
speech. For example, if your child cannot say the “s” sound and/or
cannot say consonant blends, then your child likely will leave off
“s” in plural words, saying “cat” instead of “cats.”
 Making certain that your child understands the meaning and use
of these small units is important, even if your child is unable to
produce those markers.
 Syntax

 Many older children with CAS exhibit difficulty understanding

and correctly using grammar.
These errors might occasionally be related to your child’s speech
difficulties; however, problems with syntax often are not
directly related to speech production problems.
 Work on the grammatical components of language is critical to
the understanding and usage of normal communication.
 Pragmatics

 Many older children with CAS exhibit difficulty reading the

verbal and nonverbal cues expressed by others.
 Many older children with CAS also exhibit difficulty correctly
using verbal and nonverbal cues.
 These difficulties can negatively affect your child’s relationships
with peers, teachers, other adults, and you.
 Work on helping your child comprehend suprasegmental aspects
of speech (for example, joking, sarcasm, etc.) can go a long way
to improving your child’s relationships with others.
 Likewise, so can work on understanding and correctly using
nonverbal communication.
 An Overall Approach to Addressing Multiple Language Needs

 Even though work on all of the various components of language

is beneficial to your child, I have found that working on
question comprehension and response an effective way to address
multiple language areas at one time.
 The language approach that I most like to employ with older
children with CAS uses a 4-level question hierarchy.
 Level 1 questions/commands/requests are the easiest to
comprehend and respond to, while level 4 questions are the most
difficult.
 I have found that teaching older children how to attack the
higher-level questions leads to better and more functional overall
communication ability.
 The Question Hierarchy
(Blank, Rose, & Berlin, 1976)

 There are 4 basic question/command/request levels.

 Each question level consists of a variety of question types.
 The higher the question level, the more abstract the correct
response will be.
 Therefore, the higher the question level, the more complex the
language demands.
 Older children with CAS tend to have difficulty with some of the
level 3 & 4 questions, with levels 1 & 2 largely mastered.
 The Question Levels

 Level 1: Matching Sensory Information

• Find one like this.
• Show me what you heard.
• What did you hear?
• What is this?
• Say this, …….
• What did you see?
 Level 2: Thinking about Specific Sensory Information
• Find one that can ……
• What is happening?
• What things did I talk about?
• Answering story questions of Who?, What?, Where?
• Finish this ……
• Tell me about this: color, size, shape.
• How are these different?
• Find one that is … and …
 Level 3: Rethinking the Sensory Information
• Find one to use with this.
• What will happen next?
• What could … say?
• Tell me how to ……
• What happened?
• Tell this story.
• How are these the same?
• Find the things that are not ……
• What is a ……?
 Level 4: Reasoning about the Sensory Information
• Where will …… be if …… happens?
• What will happen if ……?
• Why will ……?
• Why wouldn’t it?
• What made it happen?
• What could you do
• Why is …… made of that?
• How can we tell?
• Why is this called ……?
• Why can’t we ……?
 Older children & teens with CAS often have speech & language
needs, and they need both types of interventions.
 Develop comprehensive speech & language goals, keeping in
mind that ultimately you want to build functional
communication.
 So the SLP will need to develop functional & fun intervention
activities.
 And always remember that progress can be made, even by older
teens!
 APPENDIX
Principles of Cognitive Motor Learning
(Rosenbek et al., 1974; Schmidt, 1991)

 Motor Performance vs. Motor Learning

• performance – reflects production accuracy within a session
• learning – reflects retention & generalization across sessions

 Factors Related to Practice Conditions

• blocked – to practice the same target repeatedly within one block of time

vs. random – to practice multiple targets throughout a block of time

• mass – to practice for longer periods of time

vs. distributed – to practice more frequently, for shorter time periods

(Cognitive motor learning principles continued.)

 Feedback related to Results vs. Performance

• results – to provide comments about production accuracy

• performance – providing specific information about productions

 Influence of speech rate on progress

• a slow model will facilitate accuracy of child’s speech in imitation

• having child slow own productions will increase accuracy