In this episode, I got to sit down and chat with Amy Graham (again!) to talk about childhood apraxia of speech. The last time she was here, Amy talked about oral-facial exams and improving confidence while administering them.
Today, Amy is sharing tips and strategies that SLPs can use when treating students with CAS. She discusses the importance of incorporating the principles of motor learning and shares practical tips for implementation.
As per always, I learned so much. And it’s no wonder why — Amy has been a speech-language pathologist for 20+ years, and she is the owner of Graham Speech Therapy, a private practice in Colorado Springs that specializes in speech sound disorders.
She’s also listed on the Apraxia Kids Directory of SLPs with expertise in Apraxia and is PROMPT trained. In addition to her private practice, she has worked in a variety of settings: numerous public/charter schools, acute care/rehabilitation hospitals, and an audiology clinic.
If you don’t follow her on Instagram, you definitely should. She does an amazing job supporting and equipping SLPs to provide evidence-based therapy through her practical videos and posts. 💪
So, grab your beverage of choice (I’ll have a chai latte!), put your feet up, and listen in.
– What drew Amy to childhood apraxia of speech
– Resources for SLPs who want to learn more about CAS
– The difference between treating motor deficits vs traditional disorders
– Setting kids up for success
– Dynamic temporal and tactile cueing technique
– The principles of practice for motor learning and what they can mean for speech therapy
– Choosing meaningful targets
– Amy’s favorite outside-the-box but practical therapy tips for each principle
Links Mentioned in the Podcast
– Child Apraxia Treatment site (Free CEUs!)
– Apraxia Kids
– Apraxia Kids Webinars
– The Informed SLP’s review of Mass et al., 2019
– Dr. Maas’s article on principles of motor learning
– Melissa & Doug wood veggies
– Dot marker
– Smelly markers
– Amy’s Instagram
– Amy’s Website
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Thanks so much!
Marisha: Hi there and welcome to the SLP Now Podcast. I am incredibly excited to be introducing Amy Graham again. She is the first person to be on the podcast two times, which is super exciting. She was on episode 17, if you want to check back and look at her previous episode. Just in case you're not familiar with Amy Graham, she has been an SLP for 20 years and is the owner of Graham Speech Therapy, a private practice in Colorado Springs that specializes in speech sound disorders. She's listed on the apraxia kids directory of SLPs with expertise in apraxia, and she's also PROMPT trained.
Marisha: That apraxia kids directory comment is especially important today because we are focusing on practical strategies for apraxia treatment. This is all things practical, It's not your full-on crash course in apraxia. We'll share some different resources for you if that's what you're looking for. But Amy, as you can tell, has a wealth of practical experience and she is going to share some strategies for us that we can use in our therapy when working with students with childhood apraxia of speech. Without further ado, hello Amy.
Amy: Hi Marisha. Thanks for having me back.
Marisha: Yeah, I am incredibly excited. Your last podcast episode was incredibly popular, people loved hearing from you. I can't wait to dive into all things apraxia, or at least practical therapy things related to apraxia of speech. We've gotten a lot of questions about how to navigate that. It's one of the areas that I think a lot of us are... we just don't have a high incidence of it on our caseload typically, so it's one of those things that's a little bit scary. You've spent quite a bit of time learning about apraxia of speech and I'm curious... Last time we talked about why you were drawn to speech sound disorders in particular, but what led you to learn more about CAS?
Amy: Well, given that CAS is indeed a speech sound disorder, I was finding that there were a few kids that I really thought, this was several years ago as I was back in the schools. I thought, "Man, there's something else going on here." Then as I would do more continued education I just thought, "This is something I really need to bone up on." I started doing a ton of online continued ed. I started taking courses whenever I would go to ASHA, and then I started seeking out... whenever they would come to town, I would seek out those courses as well.
Amy: If you specialize in speech sound disorders, which I do, you are just going to see kids with apraxia because those kids are typically very highly unintelligible. When I have parents bringing their kids to me and they're like, "We're not understanding what our child is saying," that always has to at least be on your radar. Even though it is a very low incidence speech sound disorder, it's under that umbrella. That's how I got interested in it, and over the last several years, like I said, I've just been seeking out, more continued education.
Amy: By no means do I consider myself an apraxia expert, I am a work in progress. There are still so many more courses and trainings that I would love to go to. But because I do specialize in SSDs, I always... It seems like, I would say, the incidence of my caseload is probably about... maybe 25% of my caseload right now is apraxia. It's definitely a good portion of who I work with. Therefore, I have had to come up with some really practical strategies for myself on how to incorporate what we know from the research works, and will help our kids who have apraxia become more intelligible.
Amy: I've had, in the last, gosh, almost three and a half, four years of my private practice, a lot of practice doing that. I've figured out some helpful strategies and how to incorporate things that we know that are beneficial to kids with apraxia because we know that it is a motor speech disorder, and so it makes sense that we need to use techniques that incorporate motor, and motor planning, and motor learning. What I try to do always is incorporate principles of motor learning, and I think we'll probably talk about that a little bit more today.
Marisha: That sounds amazing. As you were talking about that, a bunch of questions popped up for me, but you already answered them, which is amazing. Like we said, we are going to be focusing on practical therapy strategies like what we would actually do in the treatment room. But we definitely need a little bit more of a foundation when it comes to knowing whether a child has apraxia speech, that differential diagnosis, and more of the theoretical framework in deciding between different treatment approaches and all of that. Can we chat a little bit about some of your favorite courses, books, or resources that you would recommend for someone who doesn't have that foundation yet and is looking to learn more?
Amy: Yeah. I usually have two recommendations right off the bat when I get questions from SLPs because I get actually quite a few questions about this on my Instagram account, which is where I post most of my therapy videos, about, "How do I learn more about CAS? How do I diagnose it? How do I treat it?" My first recommendation is always, "Go take a [inaudible 00:05:56] free," which is huge. This free online course by Edythe Strand, and I think it's presented by UT Dallas. Marisha, you might have more information on how to find that, but it is a fabulous introductory, but even more than introductory. It's just super in-depth about how to, first of all, assess apraxia, and then how to treat it effectively. That's my first recommendation is go watch that... it's pretty long. I can't even remember how many hours it is. But you can break it up into chunks. It's a few hours long. But I feel like if you have any questions, if you're uncomfortable with what apraxia is, that is your first stop. Go take the Edythe Strand course. Then-
Marisha: I could not agree more with that.
Amy: [crosstalk 00:06:44]-
Marisha: I will share... What was that?
Amy: You've taken that too I believe, right?
Marisha: Yeah, and I loved it. Dr. Strand is amazing, and I'll share the link to the course in the show notes. You can find those at slpnow.com/31, because it might be worth pausing this episode and taking that to get the foundation and then you can come back for all of the practical tips. But that is such an amazing resource, I could not recommend it more. The cool thing is, too, that she has additional in-person trainings. They are only a couple of times a year typically, at least from what I've seen, but they have options to go even more in-depth. If you take that online course, you have the option to learn even more, if you're like Amy and you're wanting to specialize in speech sound disorders, or it's just something that really fires you up. There's even more options down the road if you're really, really excited about it. It's just a cool opportunity, and it's all free, and you can get CEUs for it. Even if you're just looking for CEUs, that online course is amazing and can't be beat.
Amy: Yeah, I couldn't agree more. In fact, that more in-depth course that she does in person is on my SLP bucket list. I haven't been able to attend that yet, but I'm really looking forward to the time when I can.
Marisha: Yeah, and then-
Amy: Tell you really quickly about my second one. I always recommend going to apraxiakids.org, they have webinars, and I think this year they started a new program, I think, where it's an annual membership and then you can get unlimited webinars on there. I think I have that right, but go check out apraxiakids.org. That is basically... Every year also they have a conference and this last year I was able to go to that. That was in Pittsburgh. I think next year it's going to be in Dallas. It's always in July. If you really want to look into apraxia research and practical tips, because parents attend the conference every summer, that is a really great place to go. Because, I mean, you get to go and sit and listen to Ruth Stoeckel and Trisha McCabe and just Edward Moss and all these experts in the field, and it's just a really great place to get more information.
Marisha: I love that. Such a great recommendation. Is there anything else that you would recommend or do you feel like those cover it?
Amy: Well, it's tricky because I feel like those are the places to start. Then from there you see these names pop up and you think, "Okay, well Edythe Strand, she's an expert in the field. Ruth Stoeckel, all these different names." Then if you see their names... I look at names when I get these, the ASHA Conference handouts. "Okay, I know who the experts are, that's why I want to go here." I think if you just are familiar with who the experts are in the field, and you seek out those trainings, that's where I am at this point in my training. I'm looking to go hear all the experts.
Marisha: Yeah. That's a really great strategy. That's perfect because that ASHA Conference is coming up.
Amy: I know.
Marisha: It will be fun.
Amy: Yeah, [crosstalk 00:10:08]-
Marisha: Go find [inaudible 00:10:09]. Yeah. Find all of our SLP heroes.
Amy: Yeah, for sure.
Marisha: Okay. Yeah. Then those are great resources. Definitely an awesome place to start. Now, let's dive into all things therapy. I'll let you decide where we want to start. Do you want to start talking just about the principles of motor learning or...
Amy: Yeah, I think I'll back up just a tad for those that aren't super familiar with apraxia, and just touch on the point that it is a motor speech disorder. It's a motor-based deficit. These are not the kids, we're not going to be working on individual phonemes. This isn't like your traditional artic therapy. It's not your traditional phonological therapy, because we're not working at particular sounds. We're looking at... the emphasis is on movement from one sound to another, because the emphasis is going to be on the motor aspect of speech. These are the kids who have inconsistent errors because it's not that they've learned this one way to say this sound, it's that these transitions between speech are always just a little bit different.
Amy: They'll have those lengthened coarticulatory transitions between sounds, so you'll hear some odd or inappropriate prosody, these are some of the key features, and vowel distortions because if you can't quite figure out what the jaw grading is supposed to be for a particular vowel, it's always going to be a little bit different. If you understand that it is a motor-based speech disorder, that's, I think, our jumping off point.
Amy: Then secondly, I think, before we jump into the principles of motor learning, I think we have to think about how can we set our kids up for success? Because many times I will get children who are just... speaking is so hard for them. It's not like, "Okay, well let's just do a few rounds of the cycles approach," like we do with some of our phono kids, and then they pick up on it really quick. It's so difficult for these kids. We have to recognize that, and to first focus on building trust and rapport is huge. I frequently don't jump right into therapy as far as working on our targets right away.
Amy: I'm building trust with these kids and letting them understand that I am here to help them, and if something is too hard, I can make it easier. I think setting the expectations for these kiddos to know what to do with that frustration, like letting me know like if they are verbal, if they can communicate. I'll tell them, "Listen, if this is too hard, you tell me, I'll make it easier for you. I have ways I can do that." Once they feel that, then we can jump into those harder things and they trust me more to help them with those difficult things and they're not shrinking away, and not wanting to come to speech. That's not as much of an issue. I think that is the first hugely important aspect of therapy for kids with CAS that we need to make sure that we touch on before we jump right into those principles of motor learning.
Marisha: I'm so glad that you brought that up. I've only had a handful of students on my caseload who have CAS, but they were definitely different than the other students in that we really... I mean you obviously want to establish rapport with all of your students, but they were... because they're typically... I feel like the few kids that I worked with they were, not that the other kids aren't smart, but they're really smart. They're really savvy, and they have an acute awareness of how difficult it is for them to produce sounds. Not to produce sounds but to produce speech.
Amy: Right. Yeah, it is. It's true. To produce sound sometimes, to produce any kind of speech on a consistent basis, it can be really tricky for these kids.
Marisha: Yeah, and it's just really... I personally really love that challenge and, "Okay, so you don't want to do this. How can we get to [inaudible 00:14:17] speech?" It does take a little bit of time and there's some trial and error, but once you win them over they trust you like no other. It's amazing. Then it's like some of the best moments in therapy. I just wanted to put that out there because it can be a little bit challenging. But once you overcome that hurdle and you start seeing the success, it's the best thing ever.
Amy: Yeah. If you can figure out how to make something a little easier for that kind of child who's really apprehensive, if you need to simplify the task, or if you need to add or increase the type of prompting, or change the type of prompting that you're giving, then they'll immediately see that, "Oh, she's telling the truth. She can make this easier for me." If you can figure that out. Those are my two tips too when I have SLPs ask me, "Oh this child just can't do this. This is just so hard for them." Then my next question is, okay, well can you simplify it? Can you make it easier as far as changing the task itself, and/or can you make the prompting different to make it easier for the child? Do you need to add a tactile cue? Do you need to get a mirror out to make make sure they're looking at your face?
Amy: Those kinds of cues are super, super important. Actually that's why I also recommend that Edythe Strand course, that Dr. Strand course, because she goes in detail about the dynamic temporal and tactile cueing technique, which is just that hierarchy of cueing that sometimes doesn't come naturally to clinicians. I think many times we're not focused on providing the maximum support right away, we're just like, "Okay, here's this artic card, say this sound. Oh, that didn't work, huh? We'll try it again." As opposed to backing up and thinking, "Okay, we need to slow down the rate. You need to look at my mouth, how it's moving. Look and let's say it together." Then to slowly back off. That heavy support is at the root of DTTC, that dynamic temporal and tactile cueing. At this point with the ages of my kids and the severity, that is my go-to technique. I highly recommend that as well.
Marisha: Yeah. I couldn't agree more. Dr. Strand's course breaks it down incredibly well, and I feel like it's also been... We don't have magic wands in speech therapy, but I feel like DTTC is as close to a magic wand as we can get in terms of really being strategic with how we're supporting students and helping them make it easier like you said.
Amy: It's so true and it really doesn't... I'm surprised it doesn't necessarily come naturally to us as SLPs, but once you start using it and it can seem daunting like, "Oh my gosh, there's all these different hierarchies, and it's dynamic, and I have to change it depending on how the child is doing." You're going up and down on that hierarchy scale just in the moment. It can seem really technical, but it's not. Once you understand what you're providing that child, and then how to help them be more independent in their productions, it really does become almost second nature. I find myself doing it with all my kids. Even my kids who are working on artic and sometimes even phonology, I'm actually using some of those techniques just naturally, they just ooze out of my pores sometimes. Once you start using it, it's not as daunting as it might seem initially.
Marisha: Yeah, I agree. It definitely becomes second nature, and then once you start using it, it's really hard to stop, which is good, because it can be really helpful in breaking things down. Okay. I love that. Any other tips for setting ourselves up for success?
Amy: I think that about covers it unless I'm forgetting something. But if you want, we can jump into these principles of motor learning and what they can mean for speech therapy. Does that sound good?
Marisha: Let's do it.
Amy: Okay. There's two main areas to these principles, and Edwin Moss right now, I've tried to read everything I could get my hands on from him because he's doing so much amazing research when it comes to using them with children with speech sound disorder, specifically CAS. The different areas are basically the conditions of practice. Excuse me. These are variables that we can actually manipulate during our sessions to optimize learning of new motor speech plans for these kids. Then there's the feedback and how we provide input to those kids in response to their performance. I think those are two different areas that we can look at, and the first one, which I think is incredibly key, are those conditions of practice.
Amy: The first condition of practice is basically the amount of trials that you can get per session. What can we change about what we're requiring of these kids? And the first thing is the amount. Basically that means getting more trials, because we know the basic principle of how many trials we need is that the more the better. That really is what I focus on in my therapy session. There's a few ways that I try to do that, and the first way is I reduce the amount of targets that we're actually working on.
Amy: When working with artic for example, I mean, I've got my list of cards with S initial position, and we're doing a ton of words, because our focus is that phoneme. But what my focus on with a child with CAS is not the one phoneme, it's the transition from the first phoneme to the vowel, to the next consonant, to the next vowel. If you're working so hard on this one word, you're not going to have 10 words, or 12 words, or 15 words during your session. I might have three, and maybe the first time we work on a target, I might only work on that one word that particular session.
Amy: I think, the first thing we can do is reduce the number of targets that we have and then really hit those hard because the more the better. That's what the research shows for adults with apraxia and for kids with apraxia, acquired and even developmental, or childhood apraxia. That is my first principle of motor learning tip. Reduce your amount, and then get as trials as you can. I know I have some... SLPs asked me too, "Well how many trials should I try to get? What's that magic number?" I think the answer is, there is no magic number. It's just, get more. Some research has looked at maybe getting 50 trials of a target and some look at maybe over 100. I just think the more the better, because if you can get 100 trials, I think you're doing great.
Amy: That's what I always shoot for which means... in the real world that means I'm going to pick activities that are quick, turn-taking, fun games, because I'm a game person. I want that child to be motivated to come and see me, and so frequently I will let them choose the activity. I mean, even if they want to do Legos, we build Legos. I have some older boys who that's what they want to do, so, okay, great. We're going to say this target 10 times, then we get to pick three Legos, then we'll say this target 10 times, and then we'll pick three more Legos. I find ways to basically do an activity that a child wants to do and that motivates them to get all the trials I can. Those quick turn-taking games are like... I mean, I have Checkers, and Connect 4, and Jenga. I'm looking over at my [inaudible 00:22:05] my giant stack of games over there. But these are quick, quick things. I'm not frequently doing very intricate games that won't let me get those amount of trials per session.
Marisha: Yeah. Can you give an example of a word or maybe something you did this week. If the student chose Checkers, what are some words you might be targeting and what would that look like?
Amy: Frequently, and this actually goes back to what we talked about as far as motivating that child at the beginning and setting expectations. I love to choose words that are going to be immediately meaningful to that child where they can, if we get it in the session, they're going to be able to go out and use it for their everyday life, which means that they're going to be more motivated to practice it outside of the speech therapy room. We use a lot of... I ask the parents and the children, "Hey, what's tricky for you? What's hard for you? What do you want me to help you say that will make your life a little bit easier and be able to communicate with your friends or your teacher better?"
Amy: I always have a running list of things that we can work on. This week particularly, I had a little guy, he wanted to practice his buddy's name. That's what we practice. The friend's name was Mike, and that final K sound, that K sound at the end was super, super tricky initially, and that's what he just couldn't get it, and then also it was that diphthong. There we're targeting two goals, we're doing the ai diphthong, and doing that [inaudible 00:23:43] that were just really tricky for him, then practicing making it really smooth, so we're working on prosody as well. That was a target this week.
Amy: He wanted to play Checkers, and so that's what we played. What we did is, before each turn we would have him... Sometimes I'll have little visuals, I have a pegboard and we put our finger on the pegboard for each time that we say the word. He would say, "Mike, Mike, Mike," and if he needed help and it wasn't accurate, we're not accepting it. I have him like, "Oh, that wasn't it. Look at my face. Let's try that again." That's where I bring in that DTTC hierarchy to make sure that we're practicing it accurately, because if they practice it inaccurately, then that's how that motor plan is going to be established. We don't want inaccurate productions, or at least we don't want to practice those inaccurate productions. That was the word that we were working on this week. Then I would bring in other words from our target list to work on some random practice, and that's another principle of motor learning that we'll talk about a little bit later.
Marisha: I love it. Do you mind if we take a quick little detour, because you told us just a little bit about selecting words, and from my experience, definitely working with the parent and the student, to pick words that are meaningful. How do you decide... What if they want to say, umbrella, and they're at the very beginning stages. Maybe that doesn't have to be the example, but how do you navigate picking words that are meaningful to them, but then also words that are at their level, and how do you kind of decide? Do you have any tips there?
Amy: Yeah. That goes back to your dynamic motor speech assessment, which is going to be the first thing you do when you see these kids. If you've done a good dynamic motor speech assessment, you can tell what syllable shape those kids prefer, what they're stimulable for with prompting and with cueing, and you'll also get a phonemic repertoire. You'll be able to understand, "Okay, these are the sounds that they are stimulable for, and these are the syllable shapes in which they are stimulable for all those sounds."
Amy: If I have a list of words and I know, "Okay, Johnny he prefers maybe a CV syllable shape, he's only talking in CV, consonant vowel." Maybe he's saying, ba, for umbrella. But when I prompted him, when I did that dynamic motor speech assessment, when he was looking at my face and I was giving him different prompts to see if I could get him more accurate, he was able to say, bella. Okay, I know he prefers consonant vowel, but I could get a consonant vowel, consonant vowel. That might be where I start. If I know what phonemes we can incorporate into that, then I can find a way to either maybe simplify... I know Nancy Kaufman, that's part of her apraxia technique too. We're finding ways that we can simplify it if we can, and then build upon that. Hopefully as therapy goes, they're more stimulable for more complex syllable shapes and phonemes, if that makes sense.
Marisha: Yeah. I love that we can take our assessment data and look and see what would make sense, and then we can use our creativity and problem solving skills to figure out how to bridge that gap. Sometimes, maybe if we're going completely by the book, some targets wouldn't be the best choice. But if that means we get that much more buy-in, that's some... there's a way to bridge that gap.
Amy: What's funny is, I don't want to say the name out loud because it's, I don't want to [inaudible 00:27:40] and all that. But, I had a child who wanted to say her teacher's names so bad, but oh my gosh, it had two diphthongs, a couple of consonant blends. I was like, "Oh my gosh, this is going to be [inaudible 00:27:52]. I don't think we're going to be able to do this." But I thought, " Let's give it a shot." I use backward chaining. We started out with that last syllable, got that down, no problem. Then we added the middle syllable that had a blend it and she got it. It was like, wow, okay, well let's put the first syllable on. Oh my goodness, wouldn't you know it, she got this incredibly complex word you wouldn't think she would be able to do. But because we simplified it and I used that DTTC model again, she was able to get it and her mom sent me an email later that and said her teacher cried because she was actually able to say it intelligibly, and really well, and consistently.
Amy: Don't let that let you shy away from actually trying out those complex targets just because you think, "Oh well, we're only at this syllable level." Probe and see if they can do it if you simplify it use backward chaining, just all the tricks in your toolbox to see if you can elicit.
Marisha: That's amazing. I got a little too with that one. I don't know. I think I love working with the childhood apraxia of speech. I think it's the best thing ever, because when they say those words for the first time, it's just unlike any other. It's so amazing. Yeah, okay. Thank you for going on that little detour with me. We just talked about the number of trials under the conditions of practice umbrella. Should we jump to the next one or...
Amy: Let's do it. If you're getting all the trials you can, I think distribution of practice is the next principle of motor learning that I try to focus on. You have two options there. You can either practice in a distributed way, or in a massed way. That distribution of practice just refers to how the practice is divided over time. What the research has found, when I was looking into this, is that massed practice led to greater improvement and maintenance. That is what our key is, because sometimes we can get those kids to... "Oh great. They got that word a few times, that's great." But over the next few sessions in their daily lives, are they maintaining that correct production?
Amy: What we're finding is that, for kids with CAS actually, the massed distribution where you're getting... you're just working on fewer words but a ton and ton of times, and it goes in hand with amount of practice. If you're working on those words a lot within a shorter period of time, that actually does lead to greater retention, which is interesting because it's actually not the case in other areas of research that have looked at principles of motor learning, like with non-speech tasks, with physical therapy or with even adults with acquired apraxia. Distributed practice leads to more retention.
Amy: It was interesting that it's a little different for kids because we think, "Oh, we have to distribute the practice. Here's this word and we're going to say it a few times here, and then we'll distribute it and say that word. We'll practice it just a little bit, but throughout the day." I think of it as far as like piano lessons, my daughter takes piano lessons and her teacher told her it's better to practice 10 minutes every day versus 30 minutes all at once because you'll retain it better. But that doesn't seem to necessarily be the case from my understanding anyway of the research that that is true for CAS.
Amy: Massed practice, at least initially, leads to better retention. Basically that goes hand in hand with choosing fewer target words. I think even The Informed SLP had an interest. I think they had an article about this too that looked at the literature and what it was saying. This massed practice, what they were saying is that, it might look like working on five targets over, let's say, four weeks, and then five new targets for four weeks, rather than 10 targets for eight straight weeks. You're getting more intensive, more massed practice of those four targets over those four weeks versus distributing practice of all those targets over the eight weeks. Does that make sense?
Marisha: That does make sense.
Amy: Okay. I know. I got in the weeds a little bit there, but hopefully that makes a little bit of sense.
Marisha: Yeah. If anyone is wanting to look into the Dr. [inaudible 00:32:33] article in more detail or The Informed SLP article, I'll also add those to the notes. If you're more of a visual person and you need to see it all written out, we'll share those too.
Amy: Yeah, they have some great visuals, I think, in that article as well to help explain it.
Marisha: Yeah, I love it. Thank you.
Amy: The next principle is the variability of practice. You can either have some constant practice. I like to think of... My other daughter plays softball. If you're learning how to throw to second base, or you're learning how to throw in general, and she's a right-fielder. Okay, we're just going to throw to second base 100 times. That's constant practice. You're just throwing it from one place to one target over and over and over. That's constant.
Amy: Variable practice is more like if she was going to throw it to first base, and then second base, and then to the pitcher. You're varying basically the target. One way that I try to use variable practice in my speech therapy with these kids with CAS is to vary... I think there may be just one CAS study that looks at variable practice. Actually what they vary in that study is prosody. They vary different aspects for these kids and basically they did it, I think it was... Okay, say it with a neutral voice and then say it with a question, and then a command, so it's maybe a little bit louder, and then slowed, and then fast, and then loud. These were different ways that they varied the prosody.
Amy: Let's take that word that we were practicing earlier this week, Mike. When we're getting those multiple productions and we're doing our massed practice of these productions, I will have my kids vary their prosody. Initially I might have them imitate me, like, "Oh, let's do it like a question. Let's say Mike?" A and our voice goes up at the end. All of our motions are a little bit different, but we're varying just one little aspect of production.
Amy: That's one easy way to vary production within our speech therapy sessions. Another way too is you can vary the complexity of the task. I might add... If we have other words that I know that we've just got it down, I might incorporate them into our targets and we might say, "Hi Mike," and so we're doing a more complex task. We're still working on Mike, but we're making it a little more complex and we're varying that aspect of it too. That's one way that I really like to vary how we work on particular targets in speech therapy. It's an easy way actually. I mean, if you... You're not having to really change anything about your session, you're just, "Hey, let's ask it like a question or a command."
Amy: I actually have... It's just Halloween, so I went to the Dollar Tree and I got a bunch of masks, and for each mask that I hold up we change our voice. I made a little hat with a question mark, so when I put that on my head inflection goes up at the end. I had a tiger mask and that was our mad-sounding voice. Then I had those little mustaches that stick on mustaches, and the little boy that I was working with was like, "We'll say that like my dad, my dad's voice," because he has a low voice. There are different ways in therapy that you can incorporate that.
Marisha: Oh I love that mask idea. That is so fun.
Amy: It was fun, and [crosstalk 00:36:09]-
Marisha: I have-
Amy: ... a little bit.
Marisha: I have had some masks in my Amazon shopping cart for a while. It's like, "Oh, I might actually have to buy them now," because I think it'd be fun for story [inaudible 00:36:21].
Amy: Right, exactly.
Marisha: So good. Okay. That sounds amazing, super fun. Did you have anything else for variability or should we dive into the next principle?
Amy: Like I said, those are the two ways that I find are easy to manipulate in my sessions as far as variability goes. Yeah, that's pretty much what I do as far as variability. I look at, can I change the context? Can we maybe put it into a phrase, and can we change the prosody? Those are my two go-tos.
Marisha: Love it.
Amy: The next principle is that schedule of practice. The two options here are blocked practice, so something really predictable for that child. Like, "Okay, we're going to say this word five times." There's blocked practice. It goes hand in hand with that massed practice, and increasing the amount as well. Or should we randomize the way that we practice our words, or our targets, or our phrases, or whatever we're working on? What the research has shown is that, to lead to retention, what helps these kids retain their targets is, we start off with blocked, which makes sense to me.
Amy: I mean, if you want to learn how to do something, you got to do it a whole bunch of times. Just that initial, whatever you're learning, you have to do it a whole bunch of times. Blocked practice to establish that motor pattern. To use that softball analogy again too. Maybe 50 times we're going to throw to first base. My daughter, she's going to throw it 50 times. Okay, we've got it. Then 50 times to second base, so there, we've got that one now. Okay, now let's randomize it. Her coach might say, "Okay, throw to first, throw to home, throw to," wherever she's throwing, then you're randomizing it.
Amy: You have to rely on your own knowledge of what that feels like, and so you're... it helps build... They're less reliant on your cues and what you're giving them externally and they have to rely on what they've learned internally when you give it to them more randomly. For example, if we're working on three words... if these are newer words that we're working on, I might do, that first word let's get 50 practices of this word. Let's get 20 practices of this word.
Amy: Then if I feel like, okay, they're pretty well established, I feel like we're pretty accurate with those. Now I'm going to randomize them. I might have a picture of each of those words in my therapy session that represents whatever it means. Sometimes I have the kids even make their own pictures. What I'll do while we're playing is, I will just have them on the table and I'll either point to them randomly, I'll say, "Okay, we have to say something five times, but you're not going to know what word we're going to say until I point to it."
Amy: Randomly I will point to it, and it's so funny because you'll think, "Oh, they've got these words, it's no big deal. This is going to be easy." But the minute you start to randomize it, you'll find, "Oh that was a little tricky. Okay. Let's back up, and maybe we need to back up and do a little more blocked practice with this word or maybe a little more blocked practice with this word." But I'm always trying to move to more randomized presentations of our targets, if that makes sense.
Marisha: That does make sense, because that's how it'll be in conversation too. They won't just be saying block, block, block, [inaudible 00:39:45] in completely random situations. That makes a lot of sense.
Amy: Right. Those are the aspects of, as far as things within the therapy session itself and the targets that we choose or the activities that we choose that can really influence how well these kids retain these words and phrases, and whatever we're working on within therapy. The other aspect is, we can look at the type of feedback that we're giving or the frequency of feedback that we're giving. There's been some research to look at that. The first thing basically is low frequency or high frequency of feedback.
Amy: High frequency is, okay, on every utterance I'm giving them feedback. "Oh no, that wasn't it. Yes, that was it." Or, "No, you need to..." Maybe it needs to be more specific like, "No, put your tongue here, remember? Look at my mouth." How frequently do we need to give them feedback, versus more low frequency. Really, the low frequency doesn't sound like low frequency to me because the research has defined low frequency, or some of the articles, it's about 60%. Like half of the time you're giving them that feedback.
Amy: What the research has found is that, the more frequency you give initially leads to establishing those motor plans, which makes sense, because if you're doing it wrong you need somebody to help you get there. But then once you get it, you can back off on the amount of frequency that you're giving the child. Maybe half of the time you're like, "Oh yeah, that was it. Good job." But the more you back that off, the more they're reliant on their own intrinsic sensory information, and it becomes more intuitive and then they're able to even start to self correct. They're less reliant on you and they're relying more on themselves. The frequency of feedback is something that I'm always trying to be cognizant of in my therapy sessions as well.
Marisha: That makes a lot of sense.
Amy: Then going along with that is the type of feedback. Initially you can either have what's known in the principles of motor learning area as knowledge of performance versus knowledge of results. That knowledge of performance just talks about, are you telling them exactly what they need to do or is it a yes or a no, or great, not great or like, "Oh, try again," would be knowledge of results. You're just letting them know that, "No, that wasn't quite it. Can you fix it?"
Amy: Initially you're going to want to give them knowledge of their performance like, "You know what, that was so close, but look at my lips. Your lips need to come close for that first sound m, let's have our lips come together. Keep your voice on." You're giving them very specific information about what they need to change, or add, or make different about that production, and then once they start to become more accurate you can back off of that. Then we start to give them more knowledge of results like, "Oh yes, that was it. You got it." Or, "Not quite." Then when you give them those, not quites, those knowledge of results, they're having to, again, rely on what they know, that intrinsic sensory information, to see if they can begin to correct it themselves without relying on that external input.
Marisha: Yeah. Perfect.
Amy: That's, in a nutshell, those principles of motor learning that I really focus on in my session. Just as an overview, I'm trying to get more trials if I can, which means I'm going to be reducing the number of targets that we're working on so I can do that. During my sessions I'm going to get massed practice in high intensity, not necessarily spread out over different sessions, but high intensity in my sessions to improve retention.
Amy: Then variability. I'm varying different aspects of the targets as well, so prosodic or changing the rate, changing the loudness or inflection, and then seeing if I can change the context or the... I would consider using single words and using those words within phrases, so increasing complexity, and then blocked practice, and then randomize the way that I present those targets in the session, and then just working on the different aspects of feedback that I just talked about. They all go hand in hand. It's a lot of different principles, but it's not really complex once you get used to it. I think it's not that strange to do. Just like I said even with DTTC, it just comes naturally after a while. But I think if you're focusing on fewer targets, that also becomes a little bit easier to target each one of these aspects of principles motor learning.
Marisha: Yeah, that is such a helpful breakdown. It's a good refresher for me for sure. Then this, you just reminded me of something that Dr. Strand taught when I went to the intensive course, or maybe it was even in the online piece too. But with the variability piece, we don't have to wait until students are saying the word mostly independently. She talked about having variability. You were saying this too, but I think it's helpful to emphasize. She was talking about having variability at all levels of the DTTC framework. Even if we're doing that super slow, simultaneous production, if we're working on map, we can do map, and map, and all of that. We can start incorporating that right from the very beginning which is something that I didn't think about at first.
Amy: No, I think you're absolutely right because especially considering that that prosody is such a tricky thing for kids with CAS. I've had SLPs ask me, "Okay, so when do I start working on prosody? When can I start working on it?" My answer is always, "Immediately. Yesterday, and the next best time is today." You do not have to wait at all, and because prosody is so difficult for these kids it should always be incorporated. Like you said, even if you are at that simultaneous production stage of DTTC, incorporate prosody. In fact, I didn't even know I was doing it, but I posted a therapy video on my Instagram, it's probably a few months ago. I went back and looked at it and it was a word for this kiddo, but we were at that simultaneous production phase and I was completely varying my prosody and I didn't even realize I was doing it. It just comes naturally after a while. Definitely, always incorporate, vary, prosody as soon as you can.
Marisha: You're such a rock star SLP doing all of these things. But yeah, and I think it makes it more... Because I think... I started to do that too because it can be boring just to be saying, map, map, map. It's a way to... Because these students, even if they have a hard time matching that prosody, they still try, and it always makes them giggle because you sound a little bit funny. If you add in your magical trick of using different masks, that would be so much fun. Yeah, I love these tips, so incredibly helpful. Yeah, then I'm curious too, is there anything else that you would like to share in terms of general therapy tips? Like navigating maybe some of the biggest challenges that come up when working through therapy with these kiddos?
Amy: Yeah, I think... Sometimes I tell SLPs too, you have to read the room. If you can sense that that child is just bored out of their mind, I mean, we have to be so sensitive to that. It can be hard because maybe we have this entire lesson plan ready to go and you're just, "This kid is not into it." I think for one thing we have to be flexible, which we get really good at that really quickly. I mean, that whole thing of in grad school, here's a paperclip, make a lesson plan out of it. I mean it's an annoying thing to do, but it's true. You have to be able to utilize something that is going to interest that child, and if it's a Barbie doll then okay. Well, I guess we're going to play with the Barbie doll today. How can we get trials?
Amy: That happened to me a few weeks ago, this little one wanted to play with the Barbie doll. Well, how in the world do you get trials with the Barbie doll? Well, what we did is we got painter's tape and we put dots on the table and the Barbie got to jump on the dot, and every time she did we said our word. I mean, you have to just be creative in how you're able to get all those targets. But because we really do, we have to get increased number of trials and so we have to be creative in doing it. Also like I said, read the room. I mean, if they're bored, I'm bored. Let's figure out something that's going to make them interested. Those are my two generalized tips, and that's with therapy with any child actually not just specific to CAS.
Marisha: Yeah, that makes a lot of sense. I'm curious if we could do just a quick brainstorm of some of those favorite activities that are maybe a little outside of the box. I feel like this was a go-to for me for the really little guys with... I mean, this could apply to anyone, but incorporating different motor activities or just some movement in it. I don't know if it would even... there's probably evidence against using motion when you're working on apraxia of speech because of all the other issues that we've got going on.
Marisha: But, I feel like that helped keep them engaged. One student really liked to... I was in a clinic at this time and the mom was in the room, so she said she was totally fine with it, that she loved... she was just super active climbing all over the place. We would go, I'd lift her up and down, and I got so many more productions using those types of activities than anything else I could have done [inaudible 00:50:32].
Amy: I think [crosstalk 00:50:33] actually shows, use movement. Kids retain better, they learn better when there is movement involved. Absolutely, do what works. I've even seen Cari Ebert, I've been to a couple of her seminars and she will use a swing. I've seen, kids, if you've got a sensory gym, get them in the swing and swing them back and forth and every time they'd come to your face we get to say the word. Any kind of movement helps just stimulate that overall motor processing component, I think, too of the brain. But yeah, I was going to say, I think we have to be cognizant of whether or not too there are global apraxic issues.
Amy: I did have a couple of kids who were globally apraxic, and so that overall body movement, it was hard. I think if you keep that in mind like, "Okay, we're not going to be maybe jumping on tape strips on the floor with this little one because that's just really hard and then we can't focus on speech." Keep that in mind. Keep in mind what they are able to do, because there might be a global apraxia issue going on as well in as far as just speech goes.
Amy: But, I mean, I love manipulation toys. I love, especially for my little guys. I have those Melissa & Doug vegetables that are held together. They're like two or three parts and they're held together with Velcro and there's a little plastic knife that you get to chop it into three pieces or two pieces. Once we say our target a few times we get to chop it. That's so much fun and it's got that sensory feedback, and even the fine motor skills that you can incorporate into speech. I love those types of things.
Amy: I even have a... I saved my son's Thomas the Train sets. I have so many kids that love putting together their train tracks. We get to say our targets and then here's a train track, here's another. Then more targets, and here's another train track. I love the toys that have a bunch of pieces that you can, not necessarily earn, but you get to, every time we say a target, we get to put another piece together and then that incorporates those motor movements as well. I love those.
Marisha: Yeah. I had a lot of kids who were huge fans of trains too. Dot markers are always a big hit and it's easy to get lots of repetitions with those.
Marisha: What else is-
Amy: [crosstalk 00:52:59] have things in your back pocket, I know what is going to motivate that child. I have one little girl who just wants to draw, that's all she wants to do is draw. We've got our markers and they're smelly markers and they're fun to sniff. Every time [inaudible 00:53:16] targets, we get a different colored marker. You just have to, like I said, just be creative, and know what's going to motivate that child and what they want to do. Stickers on sticker sheets. It's fun to put stickers on my table and have, for each sticker you could put your finger on each sticker, say our targets and then whatever they want to use...
Amy: I mean, I've even had little cars. We get to make a road on our table with all the stickers and we can drive down the sticker road knocking down blocks. That's always... I don't know why the preschool boys love to knock down and destroy things, but that's how I get tons of productions is, I just have these old building blocks and every time we say our targets, here's another building block and then we build this huge pyramid of blocks and knock it down with whatever vehicle they're into at the moment.
Marisha: Yeah. I love all of these ideas and I think there are a lot of things that a lot of us are already doing, but hopefully there's just a couple of new ideas.
Amy: Yeah. There's definitely magic to some of these ideas. It's just how can you use what you're already doing just to incorporate these principles, and get more trials, and get more massed practice, and how to change up the way you're giving feedback, and how you're presenting it, blocked or random. We can definitely... I mean, you can use... you don't need special stuff. I mean, use what you've got.
Marisha: Yeah. That's one thing that stands out here too. You didn't talk about using a ton of different materials. When it come to apraxia of speech, we're the main therapy, we're the best therapy material we've got. Because [crosstalk 00:55:03]-
Amy: Exactly, [crosstalk 00:55:04], right?
Marisha: The student really needs to be focused on our face and getting that feedback from us. Granted, we can feed that over time and there doesn't have to be as much focus on that. But the cool thing is, Dr. Strand was saying this too in the training. We don't need a lot of stuff. As soon as we have those different principles, which after taking that online course and listening to this for some other practical ideas, you're set, you're ready to work with these students.
Marisha: Just so exciting. I love it.
Amy: It is. It's not nearly as mysterious as it should be or as people think it is. You can do this. It's not. Yeah. I think because we don't have a lot of kids most of the time, especially if you're a generalist practitioner. If you're in the schools, you may not have very many kids with apraxia. It might be a little bit of a mystery as far as, "Oh my gosh, how do I treat this? This is unusual and different" and it doesn't have to be. Once you understand the basic principles and guidelines of treatment, you can do it.
Marisha: Yeah, I think that is a great note to end on. You can do it. Amy, thank you so much for hopping on the podcast. Again, you always have such amazing tips and tricks. If you want to hear more from Amy, I highly recommend her Instagram account because she shares... You're one of the few SLPs who actually shows therapy videos, which is incredibly helpful and you're always answering people's questions. I will link to her Instagram account if you want some more inspiration and ideas from her. But Amy, do you have any other places you'd like people to find you or any last parting words?
Amy: Well, first of all, thank you for having me back again. I'm honored that I'm the first one to return, so thank you for that. Yeah, I'm mostly on my Instagram account. I do have a website, grahamspeechtherapy.com, and then I have a Facebook page as well. Most of my activity is probably on Instagram though, so that's probably the best place to find me.
Marisha: Perfect. Thank you so much, Amy.
Amy: Absolutely. Thank you.
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