December, 2001

Volume 14 Numbers 2 and 3

speech (DAS). This issue of ACN considers what we know and don’t know about children with DAS, Clinicians consider AAC interven- and the role that AAC techniques tions when communication impair- play in helping these children For Consumers ments are severe and a person’s communicate more effectively. For Developmental of speech ability to communicate effectively is Consumers takes a look at defini- On the Web compromised. Typically, adults who tions of DAS and discusses the Information sources for parents and professionals benefit from AAC aids, techniques, controversies surrounding the symbols and strategies are described diagnosis. On the Web describes Clinical News Differential diagnosis: DAS and in the literature as having either resources for family members and phonologic delay (paralysis of muscles professionals interested in learning Case Example required to produce intelligible more about DAS and the use of An AAC program for children with speech); apraxia (coordination/ AAC as an intervention strategy. DAS motor planning problems that Clinical News considers the University & Research interfere with the production of differential diagnosis between DAS Three empirical studies intelligible speech); (deficits and phonologic delays in children. The AAC-RERC in syntax, semantic, phonologic and/ Continued on page 2 Across space and time: 2002 or pragmatic aspects of language); Interactive Lecture Series in AAC or aphonia (inability to produce voice as a result of removal or impairment of organs related to , such as vocal folds, tongue or larynx.) On the other hand, children who no evidence of paralysis of the benefit from AAC strategies are Developmental apraxia tongue, lips or palate). They have more typically described as having of speech (DAS) with Gary speech that is very difficult to cerebral palsy, autism, developmen- Cumley, Ph.D., Laura Ball, Ph.D. & understand; and their articulation tal delay, Down syndrome, Rett Amy Skinder-Meredith, Ph.D. problems are resistant to traditional syndrome, severe cognitive impair- phonological intervention meth- ments and so on, rather than having What is DAS? ods.1,2,3 a specific type of speech and/or A diagnosis of developmental Some children with DAS also language disorder. The tendency not apraxia of speech (DAS) is difficult have language problems. All of them to label the underlying speech to make, particularly in young have reduced expressive language disability in children who benefit children. These children are not deaf skills compared to their receptive from using AAC techniques may or aphonic, but their speech is language. Some are multi-handi- reflect how intertwined speech delayed well beyond what would be capped and have additional diag- development is in the language expected for their age or develop- noses of developmental delay, acquisition process. There is, mental/cognitive level. Such children autism, Down syndrome, mental however, one group of children that exhibit certain characteristics that retardation or other congenital AAC specialists often do label with suggest a motor component to their conditions. In addition, these children a specific type of disorder, those speech intelligibility problems, but Continued on page 2 with developmental apraxia of they are not dysarthric (i.e., there is 1 motor functions language functions

For Consumers, Continued from page 1 of developmental apraxia of speech may exhibit nonspeech characteris- (DAS) typically focus on the tics known as oral and/or limb inability or difficulty in carrying out apraxia and reduced diadochokinetic purposeful voluntary movements for rates,4,5,6 or “soft” neurological speech, in the absence of a paralysis of the speech musculature. Crary signs, mental retardation and language offers a definition that takes into impairment neuromuscular disorders.7 For the purposes of this issue, DAS is account the fact that will affect and influence defined as a moderate-severe dysarthria the development of phonology and phonological disorder that is neuro- Figure 1. Neuropathology of DAS logically-based and affects the language in children: ability to program and produce . . . the term developmental verbal adults; yet, because of the ‘undevel- 8 dyspraxia is used to represent the oped’ nature of language in children, volitional movements for speech. developmental counterpart to acquired the disorder has a more widespread Children with DAS often make apraxia of speech. The hopeful linguistic effect.13 limited progress and, when DAS is advantage gained by using this term is to project that the developmental Controversies severe, their prognosis for intelli- version is a more ‘linguistically gible speech is guarded.2,8,9,10, 11,12 encompassing’ disorder than its adult In the field of communication Similar to definitions of acquired counterpart. . .We offer the assumption disorders, there is confusion and that similar ‘motor-linguistic’ processes controversy surrounding DAS. apraxia of speech (AOS), definitions may be operating in both children and Experts do not always agree on the Upfront, Continued from page 1 descriptive label, definition, salient struggle and, when they grow up, characteristics, assessment proce- While this differential diagnosis many still have speech intelligi- dures and intervention approaches.10 may be an important component in bility problems. This is a group Factors influencing the controversy designing a speech therapy program, of people who benefit from include the complexity of the the severity of the is AAC. My experience has been disorder, as well as the limited typically what triggers the need for that children with severe DAS experiences, knowledge and skills AAC approaches, independent of are far better off when treatment that speech-language pathologists the cause. The Case Example options address their language may bring to the diagnosis and section provides a description of a and communication disorders, as treatment of children with DAS.11,12 Michigan program uses AAC well as their speech motor and Terms used to describe children techniques to serve children with speech problems. We need to do who show unusual speech produc- DAS and severe language impair- a better job of using AAC tion patterns that are suspected to be ments. University & Research techniques as a way to support motoric in origin include: develop- gives the results of three published these “partially verbal” children. mental apraxia of speech;14 develop- empirical studies of the use of AAC I wish you all a happy holiday mental verbal apraxia,15 verbal techniques with children who have season and a very safe, happy dyspraxia;16 and developmental DAS. Finally, the AAC-RERC and productive Year 2002. verbal dyspraxia.13,16,17 section announces an exciting new Sarah W. Blackstone, Ph.D. Developmental apraxia is differ- web cast series on AAC for 2002. CCC-SP, Author ent from the verbal apraxias ob- Thanks to Laura Ball, Gary served in adults with cerebral Cumley, Marlene Cummings and vascular accidents and/or traumatic Amy Skinder-Meredith who assisted brain injuries. DAS may be caused me in preparing this issue of ACN. I by a genetically transmitted disor- have not thought as long and hard der,18 problems prenatally or at birth, about DAS since 1989, when I first differences in the rate of develop- wrote about it in ACN. Like every- ment or quality of myelination one else, I work with many children (covering or sheath for the nerve who “walk but don’t talk,” who have cells in the brain), neurological a diagnosis of DAS. These children disorders, developmental delays, or

2 something else. The location and Table I. Characteristics of DAS from the literature type of neuropathology underlying DAS is not well understood beyond the fact that DAS is (1) a disruption in the central sensory-motor pro- cesses, (2) interferes with the motor learning for speech and (3) causes delays or deviances in the processes involved in planning and program- ming movement sequences for speech. Figure 1 illustrates the notion that motor speech disorders in children may fall on a continuum, which helps to account for the often observed disruption in speech motor and language functions in many children with suspected DAS.19 At this time we have only hy- potheses regarding the underlying neuropathology of DAS. Research- ers continue to debate about the origin of the disorder, or whether it has a linguistic/phonological basis or a more motor/sequencing cause.20 Researchers strive to locate children with no co-occurring deficits, to determine a specific genetic pheno- type of the disorder. For today’s children, however, these discussions do little to assist items marked with an asterisk in 70 percent) were assigned a mean speech-language pathologists or Table I in her study: rating of 5.0, indicating strong parents to select and implement agreement among the experts. Nine Three speech-language pathology efficacious treatment approaches that “experts,” employed at a (1) medical children (24 percent) received a can both remediate the severity of center, (2) public school system and (3) mean score of 4.0 or more. One speech impairment and ameliorate university speech and hearing clinic child received a rating of 3.33. Ball respectively, had a minimum of five the functional impact of that speech years of experience working with concluded that, contrary to the impairment on a child’s expressive children with severe speech and reports of some researchers, these and receptive language development, language disorders. As a group, they data show that speech-language established a list of suspected DAS behavior, social interactions, self characteristics. Subsequently, each pathologists can agree about which esteem and learning capabilities. expert independently viewed video- children have DAS, when clear taped samples of 36 children with criteria are used.21 A confluence of symptoms suspected DAS referred by SLPs in the state of Nebraska. The experts rated Traditional approaches to Another cause of confusion and each child on salient characteristics controversy relates to defining the using a rating scale of 1=definitely not intervention salient characteristics of DAS. Table DAS; 2=probably not DAS; 3=possibly Traditional interventions for DAS DAS; 4=probably DAS and 5=defi- have focused primarily on increasing I lists a number of features used to nitely DAS. The purpose was to identify DAS. In a recent study, Ball confirm a diagnosis of DAS in each or improving the articulatory profi- had three “expert” speech-language child. ciency of these children. A few pathologists decide whether 36 These experts confirmed the decades ago, intervention programs children with suspected DAS had a diagnosis of DAS in all 36 children. diagnosis of DAS.21 She used the Twenty-six of the children (nearly Continued on page 4 3 For Consumers, Continued from page 3 it also has drawbacks: functional communication needs of such as Prompts for Restructing 1. A TC approach requires that communication children and important quality of partners become proficient in learning and Oral Muscular Phonetic Targets using manual signs. life issues. AAC treatments provide 22 (PROMPT), Touch-Cue 2. A TC approach requires that a child formulate compensatory ways to communicate methods,23and Melodic Intonation signs accurately so that their signs are and express language.28 The desired Therapy (MIT)24 were developed or intelligible to others. outcomes of AAC interventions adapted from adult motor speech Many children with DAS have relate to a child’s ability to express literature as a means of improving generalized motor planning difficul- language and to communicate the intelligibility of children with ties or limb apraxia and are unable to effectively across environments. DAS. Today’s interventions also formulate accurate signs. Few people SLPs select from a variety of AAC focus on incorporating a motor outside the deaf community are strategies to augment a child’s speech perspective in intervention proficient at using or recognizing impaired speech. These include planning. Examples include inter- manual signs. Thus, when manual manual signs/gestures, low tech vention methods and procedures by signs and gestures are considered as displays with graphic symbols or Strand and McCauley14 and part of an intervention plan, one words, high tech devices with Kaufman.25 These techniques needs to assess the situation very graphic symbols or words and emphasize learning and executing carefully. Trying to communicate conversational repair strategies. motor patterns, rather than with people who either don’t know AAC treatment approaches are used emphazing linguistic or phonologi- sign language or can’t recognize your in conjunction with, not in lieu of, cal patterns of speech production. sign productions will only add to the an intense speech therapy program. frustrations children with DAS Other body movements are often Summary used simultaneously to facilitate experience in communicating. Some children who “walk but specific types of oral movements Other AAC approaches consistent with the body movement. don’t talk” have a diagnosis of DAS. Children with DAS have a higher Principles of motor learning are To remediate these children’s severe probability of failed communication emphasized. More recently, clinical speech and language disorders and interactions because of their reduced interventions based on a perspective ameliorate the myriad of secondary level of intelligibility and their of managing co-existing communi- problems caused by their speech difficulty initiating and participating cation, academic and social con- intelligibility problems, AAC successfully in interactions. They cerns are being proposed.11,26,27,28 treatment approaches are used in are at risk for developing behavior Within this framework, intervention conjunction with intense speech problems and face issues related to approaches that augment speech and therapy. However, many questions self-esteem and failing repeatedly in language deficits and enable chil- remain unanswered. Among these social and academic realms.26,27 dren to communicate using a variety are: Intervention approaches that focus 1. For children with DAS, what effect does the of AAC techniques across environ- only on improving the articulatory introduction of AAC techniques have on the ments are beginning to emerge. quality and quantity of the communication proficiency, which simply support interactions and on overall communicative Gestures and manual signs speech attempts through the use of effectiveness? 2. What modes of AAC are used most Children with severe DAS often manual signs, can not meet the effectively by which children over time? use gestures to communicate needs of children with severe DAS 3. What role should AAC interventions play in specific messages. Some develop or children with severe phonological early childhood, in elementary school years and elaborate and idiosyncratic gestural disorders.28 As a coping mechanism, during high school? 4. What are effective approaches to remediate systems. For decades, professionals these children may avoid talking, speech in children with DAS? How intensive and families have introduced more simplify their vocal responses and/ should therapy and how should progress be formal gestural systems, such as or rely on nonverbal gestures to measured over time? support and convey the intent of 5. Given the lack of data linking oral motor sign language, to help young treatment approaches to any improvement children who “walk but don’t talk” their message. in speech intelligibility/production, what, if These children need access to any role, does oral motor therapy play in the to convey meaning. This approach is treatment programs of children with DAS? known as Total Communication language and they need to exercise (TC). While TC is an effective their right to communicate. AAC option for some children with DAS, approaches directly address the

4 Dyspraxia Support Help! Enables parents/professionals to ask Table I. Ten quick and questions that require quick answers. Groupeasy and things Resource to do Centrewhen located you meet in New an Frequently asked questions (FAQs). augmented communi- Speech Topics. Articles relevant to the treatment South Wales.cator It15 has and diagnosis of DAS, including an article basic information and about the use of AAC in treatment by Dr. Gary good links to sites in the Cumley. Information sources The Apraxia-Kids Monthly. An on-line U.K., Canada, Ireland and Australia. newsletter with articles, upcoming seminars, for parents & 5. http://apraxiaontario.home latest research, new books, and articles. professionals stead.com/index.html This site is Family essays. Comments from parents and grandparents. Parents of children with DAS who hosted by the Expressive Communi- Resources. Lists of materials for families and want to learn about DAS and related cation Help Organization (E.C.H.O.) professionals in the U.S., Canada and the United interventions often find it difficult to located in Toronto, Canada. Estab- Kingdom. access good resources. The profes- lished by parents for parents, it has Interactive forums. Web pages include Talk to Others, message boards, e-mail discussion lists, sional literature on DAS is rather some very nice information. an apraxia chat group and regional apraxia dense, and can be difficult for 6. http://www.apraxia.org/index parent support groups (worldwide). parents and even professionals (e.g., about.html Hosted by the Childhood Blackstone) to follow. This section Apraxia of Speech Association of describes six websites that offer North America (CASANA), the site easily accessible information for has a useful “site map” and search families and professions. I would feature. Check out the following recommend CASANA’s site (#6) as pages when you visit this site: your first stop. It is quite well done Thus, children with DAS and very approachable. demonstrate impaired 1. http://www.asha.org/speech/ phonologic systems, as disabilities/index.cfm The American do children with Speech-Language-Hearing Associa- phonologic disorders. tion (ASHA) site has some introduc- However children with DAS’s ability tory information and a few links to Differential diagnosis: to acquire the sound system of their other sites. Pages on the site discuss Developmental apraxia language is undermined by their aspects of DAS assessment and of speech and difficulties managing the intense treatment options. phonologic delay motor demands of connected 2. http://www.taylor Amy Skinder-Meredith, Ph.D. speech.29 edmktg.com/dyspraxia/das.html This Finding children for a study who site has articles written by speech- This article considers whether a have ‘DAS’ as the primary compo- language pathologists for families. A child has a diagnosis of develop- nent to their communication disor- unique feature is a list of individuals mental apraxia of speech (DAS) or a der can be very difficult for re- from around the world with DAS. phonologic delay. The diagnosis of searchers. For example, in one Go to the site and then find the DAS is challenging because many study, 24 children with suspected worldmap and usamap pages. speech-language pathologists do not DAS were referred as participants. 3. http://www.apraxia.cc/ Hosted feel confident in differentiating They ranged in age from four to by the CHERAB Foundation (Com- DAS from a phonological delay. nine years. Of those, only six met munication Help, Education, Re- “Phonologic delay” refers to an the study criteria (no cognitive search, Apraxia Base), this site impaired phonologic system (i.e., delay, dysarthria, or pervasive focuses on children with severe the representation of the speech developmental disorder). An addi- neurologically-based speech condi- sound at a linguistic level) without tional four children had an early tions. Included on the site are pages concern for a motor planning history consistent with DAS, but, at that describe apraxia, therapies, component. As noted earlier, the time of the study, their DAS assessment and more. although developmental apraxia is appeared to have resolved into a 4. http://www.dyspraxia.com.au believed to be motoric in nature, it This site is hosted by the Australian has a widespread linguistic effect. Continued on page 6

5 Clinical News, Cont. from page 5 clinicians focus on the type of Table II. Syllable Shape processing impairment (cognitive Inventory: Child with DAS phonologic delay. Six of the 24 vs. linguistic vs. motor planning vs. children had a phonologic delay motor execution) rather than diag- only. The other eight children had nosing a child as having or not additional disabilities, which having DAS.29 The clinician needs to excluded them from the study. describe the particular set of motor Children with DAS are a hetero- behaviors that may be responsible geneous population. While they for the disruption in phonologic share a cluster of symptoms, there is performance. no agreed-upon diagnostic marker Figuring out the relative contribu- for DAS. Unlike acquired apraxia of tion of factors contributing to a speech, there is no known neurologi- fill their mouth with food (they may severe speech impairment requires a cal site of lesion or any other desire increased proprioceptive comprehensive speech evaluation, accompanying hard neurological feedback), difficulty with sucking including (1) history, (2) examination sign. Instead, there are soft neuro- from a nipple or drinking from a of the child’s neuromuscular status, logical signs, such as fine and gross cup, and immature chewing pat- (3) structural-functional examination, motor difficulties and characteristics terns. Children with DAS are more motor speech examination, and (4) a that are similar to other communica- apt to need other ancillary services, thorough description of the sound tion disorders, like phonologic such as occupational and physical system. Once dysarthria, hearing delay. These children demonstrate therapy, than children with just a and structural anomalies (such as frequent sound omissions, poor phonologic delay. cleft palate) are ruled out or factored expressive language skills, a limited Motor Speech Examination. A in, the clinician moves to differentiat- phonetic repertoire and reduced motor speech examination considers ing between a motor component and diadochokinetic rates. performance during speech as well a linguistic component. The develop- Another factor that makes as the length and phonetic complex- mental history, motor speech exami- differential diagnosis of DAS ity of sounds in words and con- nation, and description of the sound difficult is the age of the child at the nected speech. One component is system will help in differentiating time of diagnosis. A child may comparing different syllable shapes these two entities. appear to have DAS at age two, but (e.g., V, CV, CVC, CCVC, CCCVC, Developmental History. When look quite different at age three. CCCVCC, etc.). SLPs may conduct taking a history of speech develop- Differentiating between DAS and a Syllable Shape Inventory to ment in a child with suspected DAS, phonologic delays at a very young demonstrate difficulties when word we frequently hear the following: age is difficult. Many characteristics length increases. The example • Quiet baby, did not play with sounds or will be shared, especially the child’s babble much. shown in Table II represents the decreased phonetic repertoire and • When babbling occurred, it was undifferentiated syllable shape inventory of a child predominant use of simple syllable (included few or no consonant sounds). with DAS who experienced diffi- shapes. In addition, inconsistency of •Says a word, then never says it again. culty on words with more complex errors appears to be more of an • Little attempt to imitate sounds or words. syllable shapes. indicator of severity than of either • Resists attempts of adults/others to get him to Children with DAS and children DAS or a phonologic disorder. In a imitate sounds/words. with phonologic delay have more small study, Betz found that five • Limited vocabulary for age level. difficulty as the length of an utter- young children with severe phono- • Intelligibility of words is poor. ance increases. However, the •Words tend to be general in use (e.g., “num logic delay had just as many incon- num” used to represent anything good). difficulty is more marked in chil- sistent errors as five young children • Attempts to communicate through gestures, dren with DAS. For example, if the with DAS.30 vowel sounds or other means. child is asked to repeat a series of Assessment • Demonstrates frustration at not being lengthening utterances, such as understood, but seems to understand everything. base, baseball, baseball player, the How does one differentiate DAS Children with DAS may also child with DAS may produce base from a severe phonologic delay? present with a history of feeding correctly, but drop out sounds and Strand and McCauley suggest that issues, such as having a tendency to distort the vowel when producing

6 baseball. On the other hand, a child example, if the child is only speak- Table III. Formula for determining with a phonologic delay may say ing in undifferentiated vowels, the error inconsisstency base correctly and then go back to clinician may begin with differenti- the phonological process he uses on ated vowels and combine them in longer words when saying baseball CVs, VCs and CVCs. If the child is and baseball player. While children speaking in CVCs with correct with DAS may also have delayed vowels in single syllable words, the phonological processes, they are clinician may build on the CVC more likely to show other types of with more complex syllable struc- errors (e.g., vowel distortions and tures and try bisyllabic and prosodic errors); and their errors multisyllabic words and phrases. will be less consistent than the Other Areas of Assessment errors of children with phonologic scored more than 40 percent to be Davis, Jakielski, and Marquardt delays. making inconsistent errors. Assess- proposed that there are three pri- SLPs can also use a technique ing the inconsistency of errors is an mary speech characteristics that known as an integral stimulation area that would benefit from more 31 help differentiate DAS from other approach, which is modified from research to determine (1) what is types of speech delay.33 These three the Eight Step Continuum for meant by inconsistent errors and (2) 32 areas include: vowel errors, incon- acquired apraxia of speech. This at what point do we decide a child’s sistency of errors and prosodic approach allows the clinician to speech is characterized as having disturbances. assess what occurs when temporal inconsistent errors. This measure is Vowel errors. When clinicians relations are varied (e.g., simulta- not appropriate for children with do a motor speech evaluation, it is neous production vs. immediate very limited speech. important that they sample all of the imitation vs. delayed imitation). Prosodic disturbances. Another vowels and hear their productions in Integral stimulation is useful in both area clinicians should assess is different syllable shapes. A child treatment and assessment of DAS, prosody. Some researchers believe with DAS may be able to produce as described below: that a prosodic disorder is a diagnos- vowels correctly in isolation but If a child is unable to produce a word in tic indicator for a subset of children imitation, the clinician provides a simultaneous have difficulty when putting the model (e.g., “Watch and listen and we’ll say the with DAS.18,35,36 One theory is that if vowel in a CVC or longer syllable word together.”) Children with motor planning prosodic aspects of speech are difficulties do much better when they have a structure. disordered, the effect on articulation simultaneous model and the rate of speech is Children with phonologic delays decreased. Tactile cueing may also be necessary. is adverse. Another theory is that are not apt to make vowel errors. After producing the word correctly several children with DAS are struggling to times during simultaneous production, the Vowel errors consist of neutralizing plan correct articulatory movements clinician will see if the child can maintain vowels, reducing diphthongs to correct articulation with just a visual model for speech and this results in disor- (e.g., the clinician just mouths the words while monophthongs, tensing lax vowels, dered prosody. Regardless, children the child says the word). and laxing tense vowels. With the with DAS demonstrate prosodic The clinician gradually fades cues and increases exception of rhotic vowels, typically the time between the child’s production and his/ disturbances, while those with her own. Children who have severe motor developing children correctly phonologic delay typically do not. planning underlying their speech disorder produce vowels by age three. demonstrate marked differences between Clinicians can assess prosody in simultaneous production and delayed imitation. Inconsistency of errors. When several ways: In essence, when the clinician examining consistency of errors, the • Observe prosody in conversational speech: asks the child to imitate a model clinician will need to elicit a set of measure percent of utterances with abnormal stress, phrasal stress, percent of multisyllabic after a pause, the clinician is asking words multiple times. The SLP can words with abnormal stress, etc. the child to retrieve the motor plan. use the formula in Table III to judge • Observe whether child stresses the appropriate This can take a lot of practice. In the consistency of errors (i.e., ratio words and syllables. using a simultaneous production of most consistent production over • Determine if the child uses contrastive stress (e.g., I want to go home vs. I want to go home.). technique, the clinician decides what total number of productions). A • Assess whether the child can imitate the level of phonetic complexity and study by Bradford and Dodd used prosodic contour of modeled sentences. utterance length to start with. For the 25 Word Test for Inconsistency.34 They considered children who Continued on page 8

7 Clinial News, Continued from page 7 phonologic delay and DAS can be phonetically simple. For children even more challenging. • Observe what happens to the child’s prosody with DAS, it is extremely important when they are attempting to produce the correct Speech therapy to work on sequencing sounds sounds. Do they produce the word or utterance together rather than working on with equal stress, carefully articulating one Regardless of the primary deficit, syllable at a time? [Note: Sometimes this can be sounds in isolation. In other words, children with severe speech impair- an artifact of speech therapy.] work on ‘go’ as one word, not ‘g-o’. ments need intensive speech therapy Careful and thorough assessment Conversely, children with severe early on. Young children benefit from will assist the clinician in deciding phonologic delay often will general- frequent short sessions (e.g., up to the relative contribution of motor ize and use sounds they learn in four times/week for 30 minutes a planning and linguistic impairment isolation in words and phrases. session). These are preferable over to the child’s speech disorder. Language therapy Of course, it is also important to longer, less frequent sessions. In assess cognition (using a test that general, children with phonologic While working on speech with an does not require a verbal response) delay progress more quickly than unintelligible child, it is also neces- and hearing and oral structures, and children with DAS. This means that sary to address language develop- to thoroughly assess language. the child with DAS will need these ment issues. Therefore, augmenting Language learning and literacy intensive services longer. speech with picture symbols, sign deficits often occur in children with To make speech therapy motivat- language, and/or naturalistic gestures DAS. Even when children appear to ing for the unintelligible child (DAS is extremely beneficial and provides have normal language skills early or severe phonological delay), it is the child with alternative ways of on, they may demonstrate difficulty helpful to begin by working on a core expressing ideas and basic concepts. in “higher language processes,” such vocabulary that gives the child some Ready-made picture symbol books as categorizing, organizing and power and social gratification. The allow children to participate in story abstracting, in the third or fourth initial vocabulary begins with simple telling and other activities using grades.37 syllable shapes and stimulable picture symbols. As children are able As DAS is merely a cluster of phonemes. Over time, the therapy to produce more of their messages symptoms, children with DAS systematically expands the child’s verbally, use of alternative modes of comprise a heterogeneous group. phonetic repertoire and sound communication fades. Children who present with only a sequencing ability so they can make motor planning component to their different syllable shapes. An initial speech disorder are rare. When a vocabulary might include: ‘no’, ‘all child is highly unintelligible, done’, ‘hi Mom’, ‘hi Dad’, ‘go’. differentiating between a severe These words are motivating and

these students had children to acquire language, developmental apraxia literacy and social communication of speech (DAS) and skills, first in a self-contained their expressive and, in preschool classroom and subse- some cases, receptive quently, in kindergarten and first Designing an AAC program language skills were also delayed. grade classrooms with support from for children with DAS with Within the school district there the AAC team. Marlene Rayner Cummings were no intensive programs that The resulting program is known In 1996, 22 students were enrolled could meet the needs of students as the Augmentative/Alternative in the Utica Community Schools with severe DAS who did not have Communication Program and (UCS) Early Childhood Special the primary diagnosis of autism or Assistive Technology Center. Located Education program. Seven of the severe physical or cognitive impair- in Havel Elementary School in Utica, children (3 boys and 4 girls, ages 3 ments. Their social and academic Michigan, it received the Michigan to 5 years old) had unintelligible, development was considered at risk. Speech-Language-Hearing Associa- limited or no verbal speech. At the Therefore, staff designed a dynamic tion award for the “Program of the time, SLP assessments revealed that intervention plan to enable these Year” in March 2000.

8 To enroll in the program, stu- dents must: • Be three to five years of age.

• Lack expressive communication and/ or have speech that is unintelligible to at least some familiar partners.

• Have language delays, which may be due to the lack of opportunities to verbally manipulate language.

• Not evidence significant cognitive impairment, severe physical disabilities or symptoms of autism.

• Demonstrate the potential to be academically competitive. The program is designed to insure that the children receive optimum educational opportunities Figure 2. Multimodal snack time with an emphasis on communication skill development using a collabora- tive team approach. Students receive nursery rhymes and chants). Collaboration. A key component instruction in the program’s special 3. Speech-language therapy. Direct of the program is the collaborative education classroom and in regular speech-motor therapy (PROMPT) and team that supports each student in speech therapy is provided individually the classroom.* This team, in education classrooms. Daily sched- and in small groups, using augmented ules are strategically arranged to stories to support early literacy various configurations, discusses allow students to participate in core competencies and concept development individual student issues and (rhyming, patterning, sound identifica- develops program parameters, curricular content, while receiving tion). intensive training in communication, methods and strategies. literacy and assistive technologies. 4. Social work services. Direct social * Team members include family members, work services are provided in indi- classroom teacher, assistive technology Key components vidual and small group settings. assistant, teaching assistants, general education Assistive technologies and techniques teachers, school psychologist, school social worker, speech-language pathologist, occupa- Components of the program (symbol boards, speech output devices, tional and physical therapists and county/state/ include: social stories) are used to facilitate national experts. social skill development. 1. Sensory-motor therapies. Intensive Family involvement. Families of neurologically based sensory-motor 5. Early Childhood Curriculum. children with DAS face many therapies address hyper/hypo sensitivity Monthly thematic units are chosen to issues and motor planning problems. expose children to basic core vocabu- important questions and decisions. The sensory-motor program is lary, early language concepts and basic Many have been encouraged to supervised by an occupational language structures. Stories, nursery “wait and see” or to expect their therapist. rhymes, and songs augmented with symbols and low and high tech AAC children to “outgrow” their speech 2. AAC therapy. Assistive technologies devices allow students to manipulate problem. The program staff directly and AAC strategies are used to develop and use language. Kindergarteners and support the families and address language and literacy skills. AAC first graders participate in the general approaches used include: (a) aided education curriculum with support their concerns by a) discussing each language stimulation to model from the AAC program. child’s speech prognosis, b) helping expressive communication using families make decisions about the symbol supports, (b) use of symbol 6. Parent involvement and training. communication dictionaries to increase Families attend staff meetings, focus of intervention, c) being vocabulary and generate novel symbol technology trainings and AAC strategy sensitive to lifestyle and family based phrases and (c) symbol based sessions. The monthly thematic family preferences and d) helping families classroom flipbooks which allow calendar includes several family students to participate in typical “circle projects and activities, which are sent to integrate communicative supports time” routines by using visual supports into school to support student participa- across environments and partners. during verbal activities. (e.g., reciting tion and home/school communication. ABC’s, months, days of the week, Continued on page 10

9 Case Examples, Continued from page 9 Transition. After first grade, the students leave the program and return to their home school. To support each student’s smooth transition from the AT Center to the local elementary school, program staff shares expertise, resources and equipment with district teams who will be working with students in second grade and beyond. Equip- ment comes from the Assistive Technology Equipment Collection and Resource Library, which has adapted books, communication displays, computer software applica- tions, AAC devices, switches and alternative keyboards, as well as journals, books, newsletters and Figure 3. Expressing thoughts and opinions using an AAC device electronic reference materials. and a variety of assistive technolo- During the student’s last year in repeating lines and enhancing social gies are identified for each activity. participation. Examples are Song the AAC program, the transition Adult and typical peer models are Boards by Carol Goossens’, Storytime team meets three or four times to utilized to provide consistent, Songs by Patti King-Debaun and classic share written, verbal and video early childhood songs augmented with ongoing examples of communica- portfolios. Student observations, symbols placed on single switches, tion initiations, turn taking, sentence technology training and classroom AAC devices and computer software. building, etc. Communication visitations are just a few of the ways Use of single and multi-level AAC strategies employed include: staff, families and students collabo- devices. AAC devices can support rate. Use of icon displays and AAC devices. language, literacy and social interac- tions. Some examples are the: (1) Big Emphasis on communication Low and high tech AAC devices are used to augment activities that involve Mac for repeated lines, (2) Step-by-Step skills development. The program’s classic literature, nursery rhymes and communicators for simple story communication-based curriculum is finger plays to increase core vocabu- retelling, (3) Zygo Macaw to read specifically designed to support the lary, patterning and phonemic aware- stories symbol by symbol and change development of basic language ness. For example, the book Brown endings, (4) CheapTalk for snack time Bear, Brown Bear is introduced along and simple classroom routines, (5) concepts, language structures and with: (1) single symbols so students can DynaMyte for language development language use. As a result, students retell the story line and change the and interactive communication, (6) are given multiple opportunities to story’s order and endings; (2) an Dynamo for social interaction and short develop, understand and express augmented book to which children can predictable communication exchanges. language. Symbol/word-based add art and then take the book home for additional readings; (3) single switches Use of symbol-based classroom intervention materials allow students that are used to repeat lines in the story communication books. Communication to physically, auditorily and visually and increase student participation; (4) books are used to help develop academic explore, understand and manipulate symbol displays that contain additional vocabulary and support expressive communication attempts. One example early language concepts and basic animals, colors and actions to expand the story line; (5) props that students is a symbol-based classroom flipbook core vocabulary through literature, can manipulate during story retelling containing typical “circle time” nursery rhymes, songs, and finger and (6) AAC devices that allow the vocabulary (colors, letters, numbers, plays. Typical early childhood students to read the story word-for- months, weather, basic concepts, song word and line-by-line. choices, chants, shapes, classroom activities are chosen to provide rules). Students use these as visual opportunities for targeted communi- Augmented songs. Low-tech displays supports and as low-tech expressive cative interactions throughout the and AAC devices allow children to communication tools during verbal day. Communicative expectations explore language concepts, rhyming, chants and single response interactions.

10 Use of activity-based communication verbal to extremely unintelligible support decoding needs in the displays. Activity-based displays can to being understood 90% of the literacy program. The student support a child’s understanding and use of core vocabulary. Examples include time by unfamiliar listeners. He depends on verbal communica- communication displays from Engi- continues to receive extensive tion to communicate at home neering the Preschool Classroom by learning supports and now has a and with peers. Co:Writer and Carol Goossens’, as well as displays diagnosis of severe LD. Write OutLoud are used to created specifically for board games, rd support written language in bingo and other play-based communi- 3 grader. This student entered the cation activities. program at age 51/2 with minimal the classroom. Use of an augmented literacy series. AAC supports prior to his Teaching emergent literacy skills (e.g., placement in the program. He developing a sight word vocabulary and manifested many accompanying manipulating letters and sounds) is sensory, cognitive and language Elder, Pamela S., Goossens’, Carol, (1994) Communication Displays for Engineering The important. Staff uses the Learn To Read difficulties, and his expressive Literacy Series by Creative Teaching Preschool Environment. Southeast Augmenta- communication consisted of five tive Communication Publications, 2430 11th Press to provide a consistent approach Ave., N., Birmingham, AL 35234 to literacy skill development. For to ten single word approxima- Goossens’, Carol, (1998) Engineering Circle example, Level 1 supports basic tions. This student can now Time. 18th Annual Southeast Augmentative language concept development and express single and two word Communication Conference Proceedings. Level 4 has books on Science, Social Southeast Augmentative Communication Studies, Math and Fun and Fantasy. combinations. He uses natural Publications, 2430 11th Ave., N., Birmingham, Books are augmented with symbol gestures to greet others, express AL 35234 sentence strips for line-by-line text basic needs, protest and get Goossens’, Carol (1999) Song Boards For manipulation and single symbols are Engineered Classrooms. Southeast Augmenta- listener’s attention. He is pres- tive Communication Publications, 2430 11th available for word-by-word story ently using a Dynamyte with Ave., N., Birmingham, AL 35234 retelling. By the end of the program, students have typically acquired Gateway 54, a symbol-based King-DeBaun, Pati, Storytime Songbook I and II . Creative Communicating P.O. Box 3358 adequate literacy and communication communication dictionary, an Park City, UT 84060 competencies to support learning. augmented literacy program Learn To Read Series by Creative Teaching Outcomes (AlphaSmart, Co:Writer and Press, P.O. Box 2723, Huntington Beach, CA Write Out Loud) to support 92647-0723 The AAC Program and AT written language in his regular The PROMPT system, The PROMPT Institute, Center were designed with a spe- Santa Fe, New Mexico, USA, Toronto, Ontario, education classroom. Canada cific student profile in mind. Of the rd Dynavox, Dynamo Dynavox Systems, Inc., seven students with AAC needs who 2 grader. This student enrolled in 2100Wharton Street, Pittsburgh, PA 45203 8- entered the program in 1996, one the program at age 3.At that time, 00-697-7332, www.dynavoxsys.com student moved out of district. the student used 10-15 word BIGmack Communication Aid, Step-by-Step approximations and had marked AbleNet 1081 Tenth Avenue S.E., Minneapolis, Another student, whose speech is MN 55414-1312. 800-322-0956, now intelligible, is in 4th grade. delays in sensory, fine and gross www.ablenetinc.com Three students are in 3rd grade--one motor skills. The student appeared CheapTalk Enabling Devices, 385 Warburton to have typical learning potential Avenue, Hastings-on-Hudson, NY 10706. 800- has intelligible speech and two are 832-8697, www.enablingdevices.com and made significant expressive using DynaMytes with Gateway 54 Macaw Zygo Industries, Inc., P.O. Box 1008, software to support their expressive and receptive communications Portland, OR 97207-1008. 800-234-6006, http:/ /www.zygo-usa.com communication and classroom gains in the program. Currently, participation. Two students are in the student uses 3-5 word sen- 2nd grade. Both use DynaMytes tences with 40-70% intelligibility with Gateway 54 software. Here are depending on context, complexity descriptions of three of these and familiarity of the listener. students. Speech is augmented by a symbol- based communication dictionary 4th grader. This student entered the and a Dynamyte with Gateway 54. program at age three with many The AAC device is used primarily behavior, sensory and language as a repair strategy for unintelli- needs. Since then, the student has gible verbal communication and to progressed from being minimally

11 and various AAC low of a low-tech AAC approach on the and high tech aids, as quality and quantity of the childrens’ well as speech. communication interaction. The Preschool student: study had three phases: pre-treat- Researchers introduced the ment (no AAC boards available); Wolf, a voice output device, Three empirical and a remnant book, which allowed the treatment (AAC boards available); studies child to initiate and reference past and post-treatment (no AAC boards experiences with familiar and unfamil- available). Research has shown that the iar communication partners. Results introduction of AAC positively showed the student’s mean length of Researchers provided only 1 hour supports the communication interac- utterance increased, as did her and 40 minutes of training over opportunities for engaging in language three sessions to each child. In the tions and language development of and conversational discourse. children with severe speech impair- pre-treatment phase, no board was ments and can provide individuals Elementary school-aged student: available. Then, the researcher Researchers focused on supporting familiarized the children with a with greater opportunities and natural speech production and access to communicative interac- providing effective strategies and AAC communication board during play tions. However, there is limited aids to increase the student’s opportuni- and book reading situations. Boards ties for interaction. As a result, she was were available to use during the research that addresses the use of able to successfully establish communi- AAC devices with children who cation topics through the use of her treatment phase of the study. The have a diagnosis of DAS. Examples remnant book and repair her frequent board contained graphic symbols communication breakdowns using a and was designed around contex- of three studies investigating the symbol dictionary. effects of AAC interventions on tual-based activities. During the children with DAS are described Junior high school student: Before post-treatment phase, boards were treatment, this student did not initiate not available. Interactions between below. or attempt to repair his communication breakdowns. Instead he relied on his the children and the investigator Single case communication partners to take an during each phase of the study were Culp conducted a single case active role in the repair process. With videotaped for subsequent analysis. AAC aids, he began to take more study with an eight-year-old girl responsibility and attempted to repair After viewing the tapes, research- with DAS, her mother and school some of his frequent communication ers assigned each child to a fre- staff. The intervention focused on breakdowns. quency-of-use group. Assignments teaching the child’s communication In summary, results indicated were made by calculating the total partners to use different AAC modes that when AAC tools and strategies number of times each child used the (i.e., sign language, gestures, and a were introduced, these children had AAC board during the treatment communication book) and to greater opportunities to initiate and phase. Of the sixteen children, five facilitate the child’s communicative maintain interactions, as well as to were assigned to the low frequency interactions. Results were positive. repair communication breakdowns. AAC user group and seven were The girl’s communication interac- They used these strategies across assigned to the high frequency tions were enhanced when partners various communication situations, group. The four children in the supported the use of AAC tech- with both familiar and unfamiliar medium-use group were not in- niques and she used them.38 communication partners.39 cluded in subsequent analysis. Three cases Sixteen cases Researchers noted that the children in the high frequency AAC user Cumley and Swanson conducted Cumley reported on 16 school- group tended to have more severe a descriptive case study of three age children between the ages of phonological disorders than children children with DAS: (1) a three and seven who had severe in the low frequency AAC user preschooler, (2) an elementary phonological disorders and/or group. school-aged student, and (3) a junior suspected DAS.40 All had received 39 Proportional data were calculated high school student. The study ongoing speech and language and group comparisons made across investigated the effects of a intervention services through the the three phases and across the multimodal AAC intervention public schools, but had made variables of comprehensibility and approach on communication, i.e., minimal progress. The goals of the communication modality, contingent the use of gestures, manual signs study were to determine the effects 12 communication and communication showed no apparent pattern in the children’s communication breakdowns, as described: answering yes/no and Wh questions interactions during the treatment and used only speech for repairing condition. The children with the Comprehensibility and communication modalities. Researchers classified all their communication breakdowns. most severe phonological disorders communication attempts as comprehen- High frequency AAC users tended to use the AAC communica- sible (understood) or non-comprehen- Unlike the low frequency users, tion modalities provided more than sible (not understood). Then they described each attempt according to high frequency users behaved children whose speech impairments communication modality used during differently during the treatment were less severe. the videotaped communication condition. Specifically, when boards interactions (gestures, non-conventional Summary were available, they: signs, manual signs, vocalizations, Frequently parents and even verbalizations, AAC, drawing, and 1. Were more comprehensible when writing.) communication board(s) were used. some SLPs worry that the introduc- tion of AAC will inhibit the use of Contingent Communication. Research- 2. Decreased the proportion of gestural speech. These studies alleviate those ers classified partner questions as either use and increased the use of the yes/no or Wh question forms and the communication board. fears. The empirical data from children’s responses as either a Cumley’s studies provide speech- response to yes/no questions or Wh 3. Replaced some gestures with questions. communication board use. language pathologists with a ratio- nale for introducing AAC to chil- Communication Breakdowns. The 4. Were more successful answering yes/ dren with severe phonological severity of the phonological disorders no and Wh questions using a communi- affected the children’s level of cation board. disorders and/or DAS. After a very intelligibility and resulted in a high short time period, children with frequency of communication break- 5. Responded to questions more severe speech impairments benefit downs. Researchers noted all communi- frequently when the board(s) were cation breakdowns, how the children available. from using AAC techniques. This tried to repair each breakdown and means that SLPs can introduce AAC whether or not they were successful.40 6. Replaced less symbolic forms of communication (gestures) with a more approaches and determine whether Results symbolic form of communication they will benefit a child rather The results of the study sug- (graphic symbols). quickly. In addition, these studies gested that children’s phonological 7. Repaired their communication demonstrate that children can and disorders directly influenced breakdowns more successfully when will use AAC techniques for a whether children with DAS used communication boards were available, than they did using speech. variety of purposes, including AAC techniques. The more severe repairing communication break- the phonological disorder, the more The high frequency group used downs, establishing topics, answer- often children used communication primarily spoken words and gestures ing questions and using language boards if they were available. to repair their communication rather than nonlinguistic forms. It Characteristics of low and high breakdowns in the nontreatment appears that the more impaired the frequency users are described below. conditions, but, when communica- speech, the more readily children Low frequency AAC users tion boards were available, half of will rely on AAC techniques. The low frequency group consis- their successful communication The introduction of AAC boards tently used spoken words and/or repairs were accomplished using the did not adversely affect the fre- gestures as their primary mode of AAC boards. When using the boards quency with which children spoke. communication. When communica- to repair breakdowns, the high Instead, it appeared that communi- tion boards were available, the low frequency group showed a slight cation boards may have visually frequency group showed little decrease in speech and gestures as a supported the children’s use of change in the proportion of spoken primary repair strategy, proportional language and increased their speech words and/or gestures used. The to their use of boards. output. These studies show that boards did not have an adverse Conclusion AAC not only supports natural effect on the child’s use of speech. The study showed that even with speech attempts but also supports In fact, the low frequency group minimal exposure to communication the use of language and enhances demonstrated a marked increase in boards (a total of 1 hour and 40 communication effectiveness. their use of speech when the boards minutes), positive changes were were available. These individuals noted in the quality and quantity of Continued on page 14 13 of Augmentative and Lecture Series Alternative Communi- In December, the Kornriech AT cation (USSAAC) will Center hosted two lecturers: Lewis offer AAC profession- Golinker from the Assistive Tech- als, augmented commu- nology Law Center who spoke on Across space and time: nicators and their families training Medicare funding of AAC devices 2002 Interactive Lecture opportunities they can easily access and Pat Ourand of Associated Series in AAC The Kornreich from their home or office. Each of Speech and Language Services, Inc. Assistive Technology Center, the the collaborators has a unique who presented How to do assess- AAC-RERC and USSAAC contribution to bring to the table. ments for augmentative communica- The technological advances of the The Kornreich Technology Center tion. The January lecture will be 21st century already are changing plays the lead role by hosting and presented by Drs. David Beukelman how we do things. As the first providing financial and technical and Laura Ball on the topic of AAC “virtual” RERC, the AAC-RERC is support for each web cast. The techniques and people who have now using a variety of new tech- AAC-RERC assists by developing ALS: Clinical decision making. nologies to facilitate collaborations content for the lecture series and It is simple to join a web cast. among its partners who live and working to expand the diversity of The required technologies are a work from coast to coast. The seven the audience. USSAAC will offer computer and an Internet connec- partners of the AAC-RERC [Duke ASHA CEUs to participants who tion. The Real Player software is University, Pennsylvania State Univer- wish to pay for them. needed to view the web cast and sity, Temple University, University at Working together, the collabora- Shock Wave software is needed to Buffalo, University of Nebraska– tors share a common goal: to participate in the discussion with the Lincoln, University of North Carolina- provide information in the area of speaker. Both Real Player and Chapel Hill and Augmentative Commu- AAC that is high quality, up-to-date, Shockwave are available free of nication, Inc.] conduct research and relevant, useful and accessible. A charge. develop projects, provide training shared vision of the collaborators is Participation in each web cast is and disseminate pertinent informa- that the web casts be an innovative offered for free (at least for now). tion to AAC stakeholders. way to involve augmented commu- After each web cast, the lecture is The Kornreich Assistive Technol- nicators and family members in the archived and can be viewed later by ogy Center is a Division of the training, research, development and anyone wishing to see the tape. National Center for Disability treatment discussions that tend to For questions about the web cast series, please Services and is located in Albertson, e-mail Iris Fishman [email protected] The occur among professionals during Kornreich web site is http://www.kornreich.org NY. It is committed to bringing new conferences and workshops. You can link to the Kornreich web site and the educational and training opportuni- Iris Fishman, Director of the web cast archives from the AAC-RERC web ties to professionals and consumers, Kornreich AT Center, will host the page http://www.aac-rerc.com. particularly in the area of AAC. web casts and serve as moderator Within the Kornreich Center is a during the live question and answer state-of-the-art technology center period following each presentation. The AAC-RERC section is partially funded by the National Institute on Disability and equipped with the latest technology The AAC-RERC partners [David Rehabilitation Research under grant number in web casting, video conferencing Beukelman, Sarah Blackstone, Diane H133E9 0026. The opinions are those of the grantee and do not necessarily reflect those and more. These technical and Bryen, Kevin Caves, Frank of the U.S. Department of Education. human resources at the Kornreich DeRuyter, Jeff Higginbotham, Janice Assistive Technology Center will Light, David McNaughton, Janet support AAC educational web casts Sturm, Michael B. Williams and by experts. David Yoder] will be among those to Collaboration provide the lectures. A total of 1.5 hours is allotted for each session in In what promises to be a positive the lecture series. Questions to the collaboration, the AAC-RERC, the presenters are e-mailed in. Kornreich Assistive Technology Center and the United States Society

14 of continuing studies communication programs, speech and functional phonologic delay. References University of Wisconsin- Madison. Unpublished Master’s thesis, University of 1 Washington, Seattle. Velleman, S.L., & Strand, K. (1994). Develop- 16 Edwards, M. (1973). Developmental verbal mental verbal dyspraxia. In J. E. Bernthal, & N. dyspraxia. British Journal of Disorders of 31 Strand, E. & Skinder, A. (1999). Treatment of W. Bankson (Eds.), Child phonology: Communication, 8, 64-70. developmental apraxia of speech: integral Characteristics, assessment, and intervention stimulation methods. In A. Carusso & E. A. 17 Davis, B. L., Strand, E. A., & Velleman, S. with special populations (pp. 110-139). New Strand (Eds.) Clinical Management of Motor (November, 1998). Management of develop- York: Thieme. Speech Disorders in Children, New York, mental apraxia of speech: Linguistic and motor 2 Thieme, 109-148 Marquardt, T., & Sussman, H. (1991). Develop- perspectives. 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Clinical Linguistics & 19 Crary, M. A. (1993). Developmental motor Boston: Little, Brown. Phonetics, 12, 25-45. speech disorders. San Diego, CA: Singular. 4 Velleman, S., Strand, K., Pollock, K., Hall, P. 34 Bradford, A. & Dodd, B. (1996). Do all speech- 20 Velleman, S.L., & Strand, K. (1994). Develop- (November, 1992). Developmental Apraxia of disordered children have motor deficits? mental verbal dyspraxia. In J. E. Bernthal & N. Speech: Case and Questions. Paper presented Clinical Linguistics & Phonetics, 77-101. W. Bankson (Eds.), Child phonology: at the American Speech Hearing Association, 35 San Antonio, TX. Characteristics, assessment, and intervention Shriberg, L. Aram, D. & Kwiatkowski, J. with special populations (pp. 110-139). New (1997). Developmental apraxia of speech: I. 5 Love, R. J. (1992). Childhood motor speech York: Thieme. Descriptive and theoretical perspectives. disability. New York: Macmillan. JSLHR. 40:2, 273-285. 21 Ball, L. (1999). 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(1993). Vowel variability in 24 developmental apraxia of speech. In J. A. Till, Helfrich-Miller, K. R. (1984). Melodic K. M. Yorkston & D. R., Beukelman (Eds.), intonation therapy with developmentally apraxic Augmentative Communication Motor speech disorders advances in assessment children. Seminars in Speech and Language, 5, 119-125. News (ISSN #0897-9278) is and treatment (pp. 81-89). Baltimore: Paul H. published quarterly. Copyright 2001 Brookes. 25 Kaufman, N. (October, 2001). Evaluation and by Augmentative Communication, 9 treatment of children with apraxia of speech. Hustad, K. C., & Beukelman, D. R. (November, Inc. 1 Surf Way, Suite 237, 1998). Integrating residual natural speech and Northern Speech/National Rehab Continuing AAC. Paper presented at American Speech- Education Seminar, Milwaukee, WI. Monterey, CA 93940. Reproduce Language-Hearing Association Convention, San 26 Rogers-Adkinson, D., & Griffith, P. (Eds.). only with written consent. Antonio, TX. (1998). Communication disorders and children Author: Sarah W. Blackstone 10 Bernthal, J. E., & Bankson, N. W. (1993). with psychiatric and behavioral disorders. Technical Editor: Carole Krezman Articulation and phonological disorders, (3rd 27 Prizant, B., Audet, L., Burke, G., Hummel, L., Managing Editor: Harvey Pressman Edition). Englewood Cliffs, NJ: Prentice-Hall. Maher, S., & Theadore, G. (1990). Communi- One Year Subscription: Personal 11 Crary, M. A. (1993). Developmental motor cation disorders and emotional/behavioral check U.S. & Canada = $50 U.S.; speech disorders. San Diego, CA: Singular. disorders in children and adolescents. Journal of Speech and Hearing Disorders, 55, 179-192. Overseas = $62 U.S. 12 Hall, P.K., Jordan, L.S., & Robin, D. A. (1993). Institutions, libraries, schools, 28 Hustad, K., Morehouse, T., & Gutmann, M. Developmental apraxia of speech: Theory and hospitals, etc.: U.S. & Canada=$75 clinical practice. Austin: Pro Ed. (2001). AAC strategies for enhancing the usefulness of natural speech in children with U.S.; Overseas = $88 U.S. 13 Crary, M. A. (1984). A neurolinguistic severe intelligibility challenges. In J. Reichle, D. Single rate for this issue = $20. perspective on developmental verbal dyspraxia. Beukelman, J. Light (Eds.). Exemplary practices Communicative Disorders, 9, 33-49. Special rates for consumers and full- for beginning communicators: Implications for time students. Periodicals Postage 14 AAC. (pp. 433-452). Baltimore: Paul Brookes. Strand, E. A., & McCauley, R. J. (November, rate paid at Monterey, CA. POST- 2000). Differential diagnosis of severe 29 Strand, E. A. & McCauley, R. (1999). articulatory impairment in children. Paper Treatment of Children Exhibiting Phonological MASTER send address changes to presented at the American-Speech Language Disorder with Motor Impairment. In A. Caruso Augmentative Communication, Inc. and Hearing Association Convention, and E. A. Strand (Eds.) Clinical Management of 1 Surf Way, Suite 237, Monterey, CA Washington D.C. Motor Speech Disorders of Children. New 93940. Telephone: (831) 649-3050. 15 Velleman, S.L., & Strand, K. (June, 1995). York: Thieme, 73-108. FAX: (831) 646-5428. Assessment and treatment of developmental 30 Betz, S. K. (2000). Articulatory error inconsis- e-mail: [email protected] verbal dyspraxia: A new perspective. Division tency in children with developmental apraxia of

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[email protected] 48307. 586-254-8299. 586-254-8299. 48307.

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augmentative and alternative modality: Effects modality: alternative and augmentative A. Creaghead, & W. Secord (Eds.), Secord W. & Creaghead, A.

N. Disorders, University Disorders, ve School of Communicati of School

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