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Kate Grandbois: Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy
Amy Wonkka: Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each
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Kate Grandbois: Hello and welcome to SLP Nerdcast. We are here today with a totally brand new, different kind of episode. For those of you who have been following along with us for a while, about six months ago, we announced the launch of [00:02:00] something that we call SLPD On Demand, which is an opportunity for our members to write in.
with their clinical questions and our resident doctor of speech language pathology, Dr. Annapala Moomy, is going to walk us through the case study. She's done a little bit of research to, um, basically answer your clinical questions. So welcome, Annapala. Why don't you start by telling our audience a little bit about yourself?
Ana Paula Mumy: Follow me and a program director and associate professor at a small private university in East Texas. And I've also been in SLP for nearly 25 years. It seems crazy to say that, um, and I just love clinical work.
Kate Grandbois: Well, we can tell because you always, I mean, I'm just looking at all of the research that you've done for this clinical problem.
Uh, I'm really excited to get into it. Today's question comes to us from [00:03:00] one of our members. Lauren P. Um, and B, the question in and of itself was related to childhood apraxia of speech and how that intersects with eligibility criteria in the schools. Um, so we're going to read the question, unpack everything, but before we get into that, I am going to read our learning objectives and disclosures.
I will try and get through that quickly so we can launch right into the good stuff. Learning objective number one, list at least two potential adverse impacts on educational performance for children with apraxia of speech. And learning objective number two, Describe the role of specially designed instruction on dismissal criteria.
Financial disclosures. Kate, that's me. My financial disclosures. I am the owner and founder of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures. I am a member of ASHA SIG 12 and I serve on the AAC advisory [00:04:00] group for Massachusetts Advocates for Children.
I'm also a member of the Berkshire Association for Behavior Analysis and Therapy. Thank you. Ana Paula, how about your disclosures?
Ana Paula Mumy: Yes, I received compensation from SLP Nerdcast for my work as ASHA CE Administrator and as the SLPD on demand. I'm also employed at East Texas Baptist University. In my non financial disclosures, I'm the co founder and president of Sparrow Stuttering.
I'm a member of ASHA and TISHA, and I serve on TISHA's University Issues Committee. And I'm also a member of several special interest groups. with ASHA fluency and fluency disorders, issues in higher education, administration and supervision, and cultural and linguistic diversity.
Kate Grandbois: Excellent. All right, well, why don't we start by Reading this clinical problem.
So what did Lauren P have to say about one of her students and how can we help her?
[00:05:00] Yes, so I'll first share the a little bit of information about the student She has a first grade student in an elementary setting who was diagnosed with Childhood apraxia of speech, and she does really well with, um, their target lists in blocked and distributed practice, and is demonstrating carryover of those words into conversation.
Ana Paula Mumy: And Lauren also says that Um, let's see, their difficulty is that they'll randomly come across curricular or random words that she'd like to be able to say, so they go back to working on sequencing them. Is there a better way to approach this, and how do I know when we're ready for discharge? Um, she's obviously always going to have apraxia, so at what point do we know that we can exit from therapy?
And so here's her, um, more formal question that came from this little blurb here. Just when do I [00:06:00] end treatment for students with childhood apraxia of speech that are intelligible but still have occasional difficulty with novel multi syllabic words? If they respond well to traditional CAS interventions and quickly are able to sequence the novel words with carryover, when do we say that our skills services are no longer needed?
Kate Grandbois: That's a great question, and I wouldn't even know where to begin finding that answer. So I know that you went to the literature to kind of figure out what the research says about that. Maybe we should start unpacking this clinical problem by leveling the playing field a little bit and talking about like what characteristics of childhood apraxia of speech are present that we then kind of need to work with.
Go for it.
Ana Paula Mumy: Sure. So I'm just going to start with a working definition of CAS, uh, which is essentially a motor speech disorder where children have difficulty learning and [00:07:00] carrying out the complex sequenced movements that are necessary for intelligible speech. And when we think about speech, I was actually just, fun fact, I was looking at just some of the, um, information about speech movements, and I'm also teaching phonetics, and so this is really interesting to me, um, that speech movements meet some of the most exacting coordination demands of any human muscular system.
So I think we know that intuitively, but just, you know, Good reminder, right? There's just a ton of coordination that's happening, not just the placement, right? But just that, um, coordination of movement. And so, that's really where children with apraxia of speech, um, break down, is being able to sequence those complex, uh, movements.
And we'll see things like, um, inconsistent errors, so not saying words the same way every time. Uh, we may hear issues with stress on wrong syllables or words. Um, You might hear distortions of sounds. [00:08:00] A lot of times vowels are impacted, which is different or, um, unusual in the sense when compared to phonological disorders.
They also tend to struggle with longer words. So that fits Lauren's case where the multisyllabic words are a problem for this child. Um, and then it also may co occur with other language issues, reading issues, and so on. But. There is a really good, um, leader article that talks about, um, discriminative characteristics.
So I'm just going to do a quick overview here. Um, this article talks about the often present, but not necessarily discriminatory characteristics of childhood apraxia of speech. So those would be things like, A limited consonant and vowel repertoire, which you could also see, of course, with phonological disorders.
Um, the use of simple, uh, syllable shapes and frequent omission of sounds. So again, it [00:09:00] could also mimic phonological disorders. Uh, numerous errors, um, so they'll score poorly on articulation tests and then poor intelligibility. So those are kind of the Um, you know, maybe more umbrella or kind of like the overarching things that you would hear, but then if you really want to discriminate, um, between childhood apraxia of speech and a phonological disorder, you would be looking for things like, um, difficulty moving from one articulatory configuration to another.
So. maybe they're, you know, clumsy in how they articulate things. And that's why you hear some of that variability in how they might say something one time versus another time, right? Um, you might also see, uh, groping, um, or trial and error type of behavior where they're almost like searching for the position for that sound or, or how to, um, you know, place their tongue or whatever it may be.
So you see some maybe facial, um, Uh, groping behaviors. [00:10:00] Um, I mentioned the vowel distortions. So these are not necessarily substitution errors, but just distortions of the vowel sounds. Um, because maybe. how they're shaping their tongue or their mouth, um, you know, is just different. And so you're, you're hearing those differences in their vowels.
And then the prosodic errors, hearing either, um, lexical stress differences, um, maybe even phrasal stress. So you hear some like intonation patterns that maybe sound different. And then the, um, last one is inconsistent voicing errors. So the child might use, um, Corrective voicing inconsistently, and that's one I think characteristic with CAS is that inconsistency that you, you know, because with, phonological disorders, you know, there's a very distinct pattern of error.
And you can pretty much count on like, okay, they're going to be, you know, fronting their K's and G's, or they're going to be [00:11:00] omitting final consonants, you know, and it's a pretty consistent pattern of error. Whereas with CAS, there's just a lot more variability and inconsistency, which makes it difficult.
Kate Grandbois: Okay. So all of this, all of this kind of tracks with, you know, what I think most of our audience is speech language pathologists who. You know, remember this at the bare minimum from graduate school. I think what's really interesting about this clinical question is the intersection of eligibility criteria, because in a lot of districts, at least in my experience, you know, I have heard the argument, well, speech sound disorders don't prevent access to the curriculum, right?
They might not impact reading or writing, um, which we know doesn't feel good, but I'm curious to learn what The actual literature says about CAS and how that intersects with like IDEA and, and our general requirements for eligibility in the schools. What did you learn when you went [00:12:00] a digging in the literature?
Ana Paula Mumy: So because eligibility for this particular child was already determined, what I'm going to zone in on really is the question at hand, which is essentially, is there continued adverse impact, right? Which is. The other thing that we looked at because, well, let me back up. So, of course, when we're thinking about eligibility, thinking about, you know, does the child have a disability, right?
Is there something, um, that is impaired? And then is there impact? So does disability adverse, adversely affect, um, the child's educational performance? And then we have also, um, instruction where we look at the, does that student require specially designed instruction in order to access the curriculum and, um, thrive educationally?
So, so for this child, we know She's eligible. She's been receiving therapy. So now we want to know, is there a [00:13:00] continued impact? And then is there a continued need for specially designed instruction? So when we think about impact, we have to look at, is there a relationship between the child's speech difficulties and their academic achievement when it comes to, of course, reading, writing.
We could also think about Phonological awareness is that speech difficulty translating into difficulty with phonological awareness, um, or even spelling difficulties. So those were, would be questions to potentially ask it or things to look into, um, through, You know, teacher interview through, um, looking at maybe samples of the child's work and those kinds of things and really just asking the right kinds of questions to determine, um, is there something happening, you know, beyond, um, just the intelligibility piece, which we know based on Lauren's little blurb that she's [00:14:00] saying she is intelligible, but there's still times when communication is breaking down, right?
So, the, the second question might be, you know, are there persistent errors, or if there are persistent errors, are these errors limiting that child's participation in the classroom? So, for this child, if she is largely intelligible. Maybe it's not impacting her or limiting her participation, but maybe, um, there is still significant awareness of those challenges, or maybe the child's afraid to speak up, right?
She's afraid to maybe, um, contribute to a classroom discussion, or read out loud, or maybe Or those like
Kate Grandbois: awful oral presentations that they made us give, or like the terrible book reports that they made us do in the front of the classroom.
Ana Paula Mumy: Right. And of course, for this child, she's a first grader, so I'm not, uh, she's probably not doing any kind of like formal presentations, [00:15:00] but they're still having to maybe, um, I think even love situations like if they do, you know, show and tell, or maybe it's a more social like, uh, type of participation in class where they're just talking through things and, and, or showing something and, and having to, um, explain or describe or, you know, whatever the case may be, but is.
Is the child or the continued difficulty that she's having with particular words, is that impacting her to, in a sense that she's becoming withdrawn or maybe not, uh, willingly participating. So that would be something to look into. And then is this, um, or is the difficulty still noticeable across settings?
So, um, and if it is, is it drawing undue attention to that child? So thinking about, you know, maybe she's. relatively comfortable in the classroom with her classroom teacher, but in other, [00:16:00] uh, types of class room settings, like maybe art or P. E. or, you know, there's maybe other areas where the student is Um, participating throughout the day where there are more significant communication breakdowns potentially, right?
So just looking further beyond just that regular classroom. And then, um, is the student consistently intelligible to all the adults, significant adults in their lives, right? So parents, teachers, other professionals, um, and peers, of course, right? Um, without knowing. All the detail about this child, she's reporting intelligibility, um, and just difficulty with more complex utterances or in multisyllabic words, um, but if the child is still feeling an impact from that, it could potentially justify additional [00:17:00] work, right?
So I wouldn't just say, well, just because there is intelligibility, most of the time that it would just completely erase. any potential impact that could be present. So we would just have to dig further. And again, I would just talk to the teachers and talk to the parents and talk to the child and just try to gauge, um, how is she feeling?
Is she, you know, talking openly and not feeling, you know, some kind of, um, barriers there?
Kate Grandbois: Would you also maybe think that in that instance, it could be, um, Good practice to check in with the school counselor or, you know, if you don't have a lot of counseling skills to maybe have a conversation with them about questions you could ask to kind of, you know, I'm just thinking of a small child, if they're having a negative social impact or not speaking up in the classroom or feeling, you know, that they're hiding their communication in any way, that might be a really difficult thing for a small child to handle.
communicate about maybe they might not [00:18:00] even be aware of it. Just, just given the nature of their age. So I would also imagine that there has to be some counseling that's happening and not all of us have had counseling training. So I'm, I'm wondering if like, you know, there's a room, there's room here to kind of have a conversation with the school counselor and get some tips.
Like what are some things, what are some strategies to kind of best measure and best gauge this level of social, emotional impact?
Ana Paula Mumy: Sure. I think absolutely. If you. feel less ready to do that or to have those kinds of conversations. I think the counselor definitely could, um, help you figure out how to elicit more from the child.
Um, I would say because of my background with working with stuttering and having those vulnerable conversations sometimes with children or teens, um, I, I feel fairly comfortable whether it be through Um, maybe utilizing a storybook that would kind of open up the opportunity to talk about it, right, or maybe it's through [00:19:00] drawing or, um, you know, just whatever the case might be, but, but definitely I think if you feel less capable to approach that, um, I think the counselor could be a great, um, source of help, so for sure.
So moving into specially designed instruction, I would say. The two questions that came to mind were, does the student know what to do most of the time? So do they know how or what strategies are needed in that moment? Or can they? relatively independently, um, figure it out, right? So like if I'm struggling through a word, um, do I know what to do with my tongue?
Do I know what movement or do I know if I slow down enough or if I articulate with more precision or what does that look like, right? So if the child is able to cue themselves relatively, um, Like, or was just minimal, [00:20:00] uh, excuse me, minimal support, um, then I think maybe that specially designed instruction is no longer necessary because they're showing that they're capable, right, of doing it on their own and maybe just need some periodic reminders, right?
Um, Um, then if that, those periodic reminders are needed, if they need maybe some cues or modeling or explanations or whatever it might be, could it be provided by the teacher or a paraprofessional or somebody else, rather than it still needing to come, you know, from me as the SLP. So if you feel like the child.
knows what to do and has the skills that are there and just needs maybe an extra boost here and there, then maybe there could be someone else, you know, that is providing that reminder or providing some kind of minimal instruction. But if they're still needing, I would say, you know, moderate to significant [00:21:00] levels of prompting or instruction, then that's going to be more our role and reserved for our Specialized instruction that we can provide, you know, for that child, and it's also making
Kate Grandbois: me think of, um, service delivery, because, you know, if you're thinking about possibly transitioning out of direct service and making sure that other communication partners are trained, maybe shifting to that 3 1 model where you three sessions of direct instruction and one session of consultation to kind of talk to the classroom teacher, make sure they know what prompts to give or what the history is there.
Just kind of like leveraging some of that indirect service that we don't tend to see very often in our field, but we know from lots of different research studies across the entire span of our field is very, very important and effective.
Ana Paula Mumy: Right. In thinking about, for example, if you use any kind of tactile cuing or, or even if it's just [00:22:00] verbal cues, does the teacher know what those are, right?
So the video can be that continuity across what you're doing with what they're doing. And of course, if you're doing it from the get go, the teacher is going to feel very comfortable being able to provide those occasionally if they're needed, right? Whether it's a tactile cue or verbal cue, um, or, or a sign, or whatever it is, right?
And so I think, um, definitely if we're doing, I would say if we're doing our job well in terms of collaboration with teachers and really preparing them to essentially support what we're doing. outside of the classroom, then when it is time to move maybe towards more of a consultation model and them maybe, um, helping you along to maintain that carryover, then I think they'll be, you know, ready and there won't be a huge need for a lot more.
So it's almost like they're already doing it anyway, right? They're just [00:23:00] continuing essentially what they've been that we've already been doing in a sense.
Kate Grandbois: Mm hmm. So I know this, you know, concept of service delivery and indirect service provision is also making me think about our service delivery. And I know you found a really interesting research article on dosage.
And I'm really excited for you to share that because I'm very curious.
Ana Paula Mumy: Yes. Um, I think we've always known, uh, well, I shouldn't say we've always known, but I think it's relatively known at this point that we need high frequency. Um, of repetitions to affect change, right? When there's any kind of motor, speech motor concern, um, whether it's phonological or CAS, I, I think the, the research shows intensity being really important, um, and high number per session, um, and ways to, uh, so that.
you're essentially doing a lot of drill play or [00:24:00] drill type of activities to get as many repetitions as you can. So I think that's a relatively known concept, right? I don't think we struggle with that. And I think too, we've seen more research pointing toward, um, having maybe shorter, um, more frequent sessions, right?
So I can get a hundred repetitions in 15 minutes. That would be much more useful to do over two to three days than just trying to do one session that's 30 minutes long. Are you really accomplishing more by doing that, right? Not really, because I can get 200 reps pretty quickly and have a relatively productive spin that way.
Um, so what, what I found when I was looking is that for the, um, phonologically, uh, disordered. Child or the child with a philological disorder that the, the research is pointing to an average of 29 individual treatment sessions for at least parents to come, uh, [00:25:00] begin to rate a change where they're perceiving a difference.
Okay.
Kate Grandbois: 29.
Ana Paula Mumy: 29.
Kate Grandbois: That's a very specific number.
Ana Paula Mumy: It ranged from 21 to 42.
Kate Grandbois: Oh, okay. Average. Yep. I can do math. Some. Yeah.
Ana Paula Mumy: So average 30 ish. Right. Interesting. This was, and this was 45 minute sessions. And again, I don't tend to function that way. I tend to say I would much rather work with that child twice in the week for 20 minutes and get 40 minutes that way versus one long session because I can achieve a high number of trials fairly quickly.
So that's my own personal. Uh, bias or, or preference, and I think that the research does support it, but when it came to the, um, the children with childhood apraxia of speech, it actually required a hundred and fifty sessions, an, an average. So it ranged from 144 to [00:26:00] 168 for there to be a noticeable change.
Um, in intelligibility. And again, this is based on parental, 150, 150 sessions. I
Kate Grandbois: just grabbed my calculator. I'm doing 150 divided by 20. That's five times as many sessions.
Ana Paula Mumy: So 81 percent more individual treatment sessions are needed. Um, for childhood apraxia of speech than for a child with a severe phonological disorder.
So and we're just talking about, you know, achieving games across, um, and again, this is based on, you know, parental perception of speech change and intelligibility.
Kate Grandbois: But that's functional change in their, in their everyday environment. That's very important. It's an accurate measurement.
Ana Paula Mumy: Yes, so I, I was like, wow, this is really impressive, um, or, or just really impactful information because I think if you think [00:27:00] back, so I'm looking at Lauren's question again, right?
And she says, she's been working with this child for what, a year or so, um, she's in first grade. Have they achieved what they want? a significant number of sessions for there to truly be this change that's going to last over time, right? And of course, we're seeing that she's responding well. Um, she reports she's responding well to CAS interventions.
She's quickly able to, um, sequence, novel words with carryover and so on. So this child, of course, is responding to treatment, right? And there's been marked improvement based on what we know. Um, but at the same time, we also know that kids with childhood apraxia or speech are going to need a way more, um, contact, right, with us, um, than a child that just has a severe phonological delay.
So I just think that's really important to consider when we're thinking about dismissal, that we don't [00:28:00] do it too early, um, and that, that child really has achieved some solid gains and has a clear, um, Understanding of what are the strategies that they're utilizing to be able to be more intelligible, to achieve the consistency, right, to, um, work through those prosody, um, differences, you know, so I think it's just really important to, um, not to quickly arrive at, oh, they're good, right?
Kate Grandbois: Right. Right. I mean, that's a tremendously high number of sessions.
Ana Paula Mumy: It is.
Kate Grandbois: I mean, in comparison, that's, I mean, it doesn't, I guess, doesn't surprise me. We know that I was always told that, you know, the number of trials that you need for motor speech is way higher than what you would need for, or for apraxia specifically is way higher than what you would need for, let's say articulation.
Um, so it doesn't surprise me, but I think I'm, I'm still taken aback by how that. [00:29:00] Level of intensity would fit into a school model and would intersect with all of these other variables as well,
Ana Paula Mumy: right? And so if you think about it, you know, I did the math too and thinking about 36 weeks of school right in one academic year Um, if sessions are occurring twice weekly, we would say we need about 75 weeks, which would be at least two academic years, right, for that child to really, um, for you to see those measurable gains.
Um, if sessions were occurring three times weekly, we would still need about 50, you know, so it is still a big chunk, right, of time where we are very intentionally working with this child. And, um, of course, um, Aiming for a lot of repetitions, and so just a high number of trials, you know, per session.
Kate Grandbois: And that doesn't even touch all of those other social emotional components that you mentioned earlier.
I mean, that's another, that's another big factor.
Ana Paula Mumy: Yeah. [00:30:00] One thing that was interesting too, there was another study that showed that the continuation of novel word challenges is to be expected. So that does. seem to align with what Lauren is seeing, right? So that difficulty with those multisyllabic words, it could persist over time.
So this one particular study, uh, Lewis et al in 2023 showed that it may persist into adulthood, um, for individuals with CAS. So that is not, um, Maybe a shocking thing that she is still struggling with those. Um, so just something to consider there. The only other thing I would add is then looking at, you know, is there any potential impact on literacy?
Right. There is some research that shows that. Sometimes kids with CAS are at risk of being placed back on an IEP by fourth or fifth grade because of learning issues or because of some literacy related, um, [00:31:00] aspects, you know, uh, whether it be because of phonological processing or language or reading difficulties.
So just something to be, again, just aware of, um, in considering that an impact on literacy and not being too quick to dismiss without looking into those components.
Kate Grandbois: That's so interesting. This was so, so helpful. I didn't know I could learn so much in such a short period of time. What I love so much about unpacking Clinical problems like this and case studies is looking at the intersection.
So this is not just necessarily about childhood apraxia of speech, right? But we've talked about everything from eligibility criteria to literacy to communication partner training. Uh, social emotional impact, um, and I think when you are in, you know, Lauren's position of trying to decide whether or not to discharge, I think it's so, it's so important to kind of take a step back for a minute and really think about how the dominoes fall or think about [00:32:00] the, the incidental impact of, of some of, you know, these lived experiences across these different domains.
So thank you so much for, Doing all of this digging for us. This was really really interesting
Well anyone who is listening who would like to write in with their clinical questions There is a link in your SLP nerdcast dashboard for members to write in clinical questions for our SLPD On Demand, our resident doctor of speech language pathology, Ana Paula, to dive into the literature, and we will unpack it on the show.
So we hope to hear from more of you moving forward. You can look forward to more of these SLPD On Demand clinical cases to be published in the future. Ana Paula, thank you so much for your brilliance and expertise, and we will be back again soon.
Ana Paula Mumy: Thank you.
Kate Grandbois: Thank you so much for joining us [00:33:00] in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study.
Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com
thank you so much for joining us and we hope to welcome you back here again soon.
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