Integral Stimulation

Ref:
Clinical Management of childhood motor speech
disorders – Caruso and Strand
https://childapraxiatreatment.org/dttc/
• Term introduced by Milisen (1954)
• Emphasis on visual and auditory mode along with gestural, tactile, and
prosodic cues
• Imitative procedure
• There are various integral stimulation procedures
• Dynamic temporal and tactile cueing is one of them
 Tutorial Class
Estimated time required: 50 min
 Dynamic temporal and tactile cueing
- Dr Edythe Strand
• Evidence-based treatment
• Dynamic Temporal and Tactile Cueing (DTTC) – Child Apraxia Treatment
(link to resources)

Use this link to learn and make notes about the following

- What is DTTC?
- How is DTTC different from other CAS treatment methods?
- Who is a candidate for DTTC?
- What evidence supports DTTC?
 Watch the video of Dr Edythe Strand
• https://youtu.be/iqv-pxqPeLE
• Note: Free courses are available on the link given above. This would
be a valuable learning experience for those interested.
Other evidence-based practice
ReST rapid syllable transition
• Incorporates theories of motor control and learning and
incorporating principles of motor learning
• Goal: maximize long term maintenance and generalization of treated
speech skills
• ReST involves intensive practice in producing multisyllabic pseudo-
words (e.g: toobiger) to improve the accuracy of speech sounds
• Involves practice of transitioning rapidly and fluently from one
syllable to the next
• Practice in the control of the melody in the form of relative emphasis,
or stress, placed on each syllable with in a word
 2 components within each treatment session

Pre-practice (Or training) This is followed by a

component where the longer practice
component
stimuli are taught with incorporating those
cues to shape accurate principles of motor
production and learning that have been
immediate, shown to facilitate long
specific feedback is given term learning and
each production generalization of skill

• Knowledge of results vs. performance

• Three recent studies specifically examined treatment for
prosody.

• In the first, 3 children with CAS showed improvement in their ability to

control the relative duration of syllables in words with strong-weak
and weak-strong stress patterns. Following 3 weeks of treatment for
60 minutes 4 days per week, there was generalization to untreated
nonwords, but negligible generalization to real words.
• A study with 14 typically-developing children showed that children
could learn to produce target lexical stress in nonwords and that there
was maintenance and generalization to untrained nonwords.
• The third, very recent study was a randomized controlled trial (RCT),
involving 13 children with CAS in the ReST group , which demonstrated
improved speech accuracy of treated and untreated nonwords and
words (judged perceptually).
www.sydney.edu.au/health-sciences/rest
Link to website for training

https://youtu.be/hrv0r4Oqxs0
Link to video on ReST
 Gestural
cueing
techniques

Signed target Adapted

Jordan’s
phoneme cueing Cued speech Visual phonics
gestures
therapy techniques
Jordan’s gestures
• A set of visual symbolic gestures to demonstrate the actions involved in the
production of individual phonemes
• Supplementary therapy technique
• Manual gestures representative of the
- configuration of the vocal tract
- Transitionalizing movements of the oral structures
- points of contact of the oral structures
- voicing and devoicing
• Movement symbols for each phoneme are not taught; gestures are used for
specific phonemes that each individuals find difficult
• Figure 2. An approximate example of the Jordan’s gesture for the /r/
phoneme
 Multi sensory and Tactile
Cueing techniques

Motokinesthetic Sensory motor

PROMPT Speech Training approach Touch-Cue Method
and speech
facilitation
PROMPT
- acronym for Prompts for Restructuring Oral Muscular Phonetic Targets
- developed by Chumpelik in the late 1970s and first appeared in the
literature in 1984 (Chumpelik, 1984).
- a PROMPT that related to each of the English phonemes is specified
- For each phoneme, the following parameters were specified: jaw
height and facial-labial contraction; tongue height and advancement;
muscular tension; duration of contractions; and airstream management
at the laryngeal and oral-nasal valves
• in order to become a proficient PROMPT clinician, a new manual
motor behavior must be learned
• Meaningful linguistic units are used for PROMPTing
• The first level of training focuses on the establishment of postural support for
speech and emphasizes the attainment of trunk, neck, and head control and the
suppression of abnormal oral-motor reflexes.

• Level II of the PROMPT Treatment Hierarchy focuses on phonatory control,

which will support speech for at least 2 to 3 seconds

• Level III focuses on the control of jaw movements in speech. The degrees of
freedom of movement of the jaw are delimited to vertical actions, the only
visually observable plane of movement in which the jaw engages in normalized
speech. Horizontal and anterior-posterior sliding is inhibited by the clinician.
Maximal jaw opening for normalized speech is established, i.e., the degree of
opening of the jaw should not exceed that of the position required for /a/ in
connected speech. Control over jaw gradation is then established using age
appropriate words that contain vowels of varying heights.
• Level IV is practiced once jaw control becomes adequate. Labial rounding and
retraction are practiced at this level. Symmetry of movement on both sides of
the face, and coordinated movements of upper and lower lips, are
PROMPTed. The labial refinements are then integrated with jaw control.
• Once jaw and labial parameters of action are set, refined, and integrated,
level V is introduced. Anterior and posterior tongue action as well as control
of tongue height and location and area of contraction along the tongue body
are established and integrated with jaw and labial movements. Because the
vocal tract is a netted system of muscles, the articulators often respond as
coordinated structures (Fowler et al., 1980). For example, if the mandible is
slightly open, posterior tongue raising is more easily achieved. The interactive
nature of the structures is given careful consideration in PROMPT.
• Stage VI of the hierarchy focuses on increasing precise control of
parameters within longer sequences of speech movements. At this
level, "surface" PROMPTS that indicate key elements of movement at
points of natural stress may be used

• Finally, in stage VII, temporal aspects of speech production, such as

normalized rates and intonation contours that approximate the norms
for the appropriate age group are practiced.
• Maria Gabriela Sanchez - Como se ve una sesion Prompt – YouTube
• Prompt Therapy Method During Mass Practice - YouTube
Moto-kinesthetic Speech Training
• Developed by Edna Hill Young (1930s)
• Moto-kinesthetic stimulation works to help muscles find the way to
achieve a standard goal.
• The clinician stimulates the location of muscular functioning and the
"feeling" of the direction of the movement simultaneously by using
varying degrees of pressure and timing.
• The clinician says the word simultaneously with the application of the
tactile-kinesthetic cues. It was speculated that the auditory
pattern became associated with the feel and sequence of movement
• It is felt to facilitate accuracy and enhance learning because the oral
structures are directed through speech movements by the clinician.

• Speech practice occurs using words that are elicited during play
• Clinician has to learn new motor skill
• Bimanual dexterity of the clinician is required
Speech Facilitation
• an outgrowth of Moto-Kinesthetic Speech Training
• far less consistent with the theoretical principles of motor learning and speech
development than either Moto-Kinesthetic or PROMPT Treatment.
• Speech Facilitation differs from Moto-Kinesthetic Speech Training in two distinctive ways
1. It uses intraoral appliances extensively
- most are used to tactually stimulate lingual placement
- The appliances that are described appear to be quite obtrusive (For example, knotted dental
floss is stretched between right and left upper molars to signal a backed tongue position,
orthodontic wire guides in which small knobs are placed on tooth bands; oral acrylic
modifiers in which wire loops indicate the point of tongue contact)
The overuse of these appliances detracts from the emphasis on the facilitation of normalized,
developmentally appropriate movement sequences.
2. Speech movement training is based on developmental phoneme
acquisition trends rather than focusing on age-appropriate words
- Speech Facilitation appears to focus principally on the production of
accurate phonemes rather than on the production of sequenced
speech movements that correlate with meaningful and useful words
and phrases.
Both the use of speech appliances to signal spatial targeting and the
use of the phoneme as the unit of movement training result in Speech
Facilitation being farther removed from the principles of motor learning
and speech-language acquisition.
Touch-Cue Method
• The touch-cue method is a speech sound-sequencing and not a speech sound teaching
program per se.
• The method is a direct approach to articulation learning that systematically moves through
stages of learning consonant-vowel (CV), consonant-vowel-consonant (CVC), vowel-
consonant, and so on.
• There are three discrete stages within the touch-cue method. Within each stage a series of
therapeutic activities are included.
• The first stage is dependent on the child's ability to produce the target phoneme in
isolation, and it incorporates a series of articulation exercises of increasing difficulty.
• The second stage incorporates the learned articulatory movements into both nonsense and
meaningful words.
• Carryover of learned production strategies into solicited and spontaneous speech
characterize the third stage.
• Progression from one stage to another occurs slowly and overlearning at any one stage is
encouraged.
• The touch cues are topographic indicators designated by touching a
particular area on the lower face or neck. These cues are given
simultaneously with auditory and visual cues during the initial phase
of therapy and are not to be used separately.

Ref: A Touch-cue Method Of Therapy For Developmental Verbal Apraxia

Bashir et al, 1984
Seminars In Speech And Language-volume 5, Number 2
Melodic Intonation Therapy
• originally for non-fluent aphasia
• Intoned song-like speech phrases with unison tapping
• For children (Helfrich-Miller 1984)
- aim: to facilitate speech at propositional level
- 3 levels of therapy from grammatically simple 2-3 word phrases  4-5
word phrases with grammatical morphemes and more complex
articulators  phrases with age-adequate syntactic, morphologic, and
phonologic complexity
- not hand tapping, as in adults but signed English as the pacer to
highlight language structure
Biofeedback Treatment

• Given suggestions that CAS involves a deficit in auditory and/or

somatosensory feedback and some indication for impaired auditory
perception in CAS, several recent CAS treatment studies aimed to
enhance treatment by supplementing auditory and verbal feedback
with visual feedback.
• The rationale is that children with CAS may utilize feedback
provided through a different modality to improve their
speech movements.
• Lundeborg and McAllister used electropalatography with
one child with CAS to provide visual information about
tongue-to-palate contact patterns in the context of an intra-
oral sensory stimulation and articulation treatment with
various lingual sound (and nonsound) targets.
• Although the child demonstrated improved speech
accuracy, the intervention design (uncontrolled pre-post
design) prevents conclusions as to whether the biofeedback
was responsible for these gains.
• More recently, Preston et al. reported a treatment study using a
multiple baselines across behaviours design for 6 children with CAS
using real-time ultrasound images of the tongue as biofeedback.
Treatment focused on individualized sound and sound sequence
targets.
• All children demonstrated gains on at least two of their targets, and
gains were largely maintained at the 2-month follow-up.
• Much research remains to be done regarding biofeedback treatment
for CAS: younger children may not benefit from biofeedback and the
use of acoustic spectral biofeedback has not yet been explored in this
population.
 Nancy Kauffman’s speech praxis treatment kit
• The Kaufman Speech to Language Protocol (K-SLP) is an evidenced-based evaluation and
treatment method for childhood apraxia of speech (CAS), other speech-sound disorders, and
expressive language development. It was created by Nancy R. Kaufman, MA, CCC-SLP, and has
been evolving since 1979.

• The K-SLP methods shape a child’s best approximation of words toward full adult forms, and then
into functional, expressive, and social language. It implements the principles of motor learning and
the principles of establishing, improving, or eliminating speech and language behaviors.

Ref + more information:

Kaufman Children's Center Kaufman Speech to La
nguage Protocol • Kaufman Children's Center (kid
Alcorn Symbols
• Sophia K. Alcorn invented the Tadoma method to teach deaf-blind individuals to speak
through the feel of sound vibrations from the lips and cheeks. The method was named
for two deaf-blind students, Tad Chapman and Oma Simpson. The system still used
internationally.

Sophia Alcorn devised a system of written visual symbols to assist in developing

speech in deaf children. Known as the "Alcorn Symbols," the system is used by
teachers of deaf today.
 Northampton Vowel and diphthong Chart
• Caroline Ardelia (1848-1933)- educator of the deaf
• In 1870 she went to teach at the Clarke Institute for deaf mutes
in Northampton, Mass
• She directed the teacher training program
• The school used “Visible Speech” a system of phonetic symbols
each representing physiologic formation (the position of mouth,
tongue and so forth) of a particular sound.
• In 1882, it was decided to substitute the characters of Eng
alphabet
• The problem was to make that 26 letters represent more than 40
elementary sounds of the English language
• Along with Alice Worcester (teacher), Miss Yale devised
the Northampton Vowel and diphthong Chart which
sought to make the letters “mark themselves” for
pronunciation to greatest possible extent by their
position in words and connection with other letters
• Her pamphlet, formation and development of
elementary English sounds 1892 explained the use of the
charts which came in time to be employed not only for
teaching of the deaf but also in the so called phonovisual
method of teaching reading to children of normal
hearing
• She shaped the trend of education for deaf  teaching
of speech was introduced in every school for deaf where
previously the use of signs and finger spelling had been
the only method of communication
Phonotactic Therapy – (Shelley Velleman)
Words derive their structure not only from the sounds they include but also from the
organization of those sounds within the word.
This organization is the phonotactic level of the word: roughly, its shape including the
sequence of its elements.
Often, children with immature or disordered phonologies demonstrate phonotactic as
well as phonetic limitations.
Sometimes, the child may produce an age-appropriate variety of consonants and
vowels but be unable to use them in the configurations required by the language: final
consonants, clusters, multisyllabic words, and so forth.
In such cases, the most appropriate therapy goals may be phonotactic, rather than
phonetic, ones. Studies have shown that clinical focus on a new word or syllable shape
may generalize well beyond the specific sound or sounds targeted in that position.
• Examples of phonotactic goals
- {Child} will produce target two-consonant sequences with two consonants in
X% of trials, regardless of the accuracy of the consonants produced, in
imitation/elicited/ spontaneous single words.

- Child} will produce target iambic two syllable words with two syllables when
they are embedded in a phrase in X% of trials, regardless of the accuracy of
the consonants or vowels produced, in imitation/elicited/spontaneous speech.
- {Child} will produce target two-syllable words (e.g., CVCV) with two
syllables in X% of trials, regardless of the accuracy of the syllables produced,
in imitation/elicited/spontaneous single words.
 Sensory motor approach

 Multiple Phonemic Approach

 Vowel and diphthong remediation techniques