Developmental Verbal Dyspraxia -Nuffield Approach - Pam Williams, Consultant Speech & Language Therapist Nuffield Hearing & Speech Centre RNTNE ...

Developmental Verbal
  Dyspraxia –Nuffield
       Approach

Pam Williams, Consultant Speech
& Language Therapist
Nuffield Hearing & Speech Centre
RNTNE Hospital, London, Uk

Outline of session

„   Speech & language difficulties
    associated with DCD
„   Introduction to verbal dyspraxia
„   Definitions
„   Characteristics of verbal dyspraxia
„   Nuffield therapy approach for verbal
    dyspraxia

Speech & Language difficulties
associated with DCD

„   Children with DCD may have language
    difficulties
„   Children with DCD may have mild
    speech difficulties –speech delay &
    immature productions
„   Literature does not indicate that
    children with DCD have severe speech
    disorders

Dyspraxia

„   Describes children and adults with
    general motor co-ordination difficulties.

„   Describes children and adults with
    speech difficulties, which have a motor
    component.

Speech dyspraxia

„   1861 -Dyspraxia was used to describe
    the speech difficulties of adults who had
    had a stroke by a French neurologist.

„   1950s/60s -Dyspraxia was used to
    describe the speech difficulties of some
    children by a British speech therapist.

Speech dyspraxia in children

„   UK                 „   USA
„   Developmental      „   Developmental
    articulatory           apraxia of speech
    dyspraxia          „   Childhood apraxia
„   Developmental          of speech (CAS)
    verbal dyspraxia
    (DVD)

Apraxia vs Dyspraxia

„   From the Greek:
„   ‘A’ indicates total inability
„   ‘Dys’ indicates partial inability
„   In UK, we make distinction between
    Apraxia and Dyspraxia
„   In USA, Apraxia is used for both total
    and partial inability

Definitions (UK)

 ‘My mouth won’t co-operate with my
  brain’.
 (Stackhouse 1992 quoting Kevin aged
  13 years)

Definitions (UK)

„   ‘DVD is a condition where the child has
    difficulty in making and co-ordinating
    the precise movements which are used
    in the production of spoken language,
    although there is no damage to muscles
    or nerves’ (Ripley, Daines & Barrett
    1997)

Definitions (USA)

„   ‘CAS is a neurological childhood speech
    sound disorder in which the precision
    and consistency of movements
    underlying speech are impaired in the
    absence of neuromuscular deficits (eg
    abnormal reflexes, abnormal tone)…..

Definitions (USA)

„   …………The core impairment in planning
    and/or programming spatio-temporal
    parameters of movement sequences
    results in errors in speech sound
    production and prosody.’ (ASHA
    2007)

So what are the main problems for
children with CAS/DVD?

„   They are difficult for listeners to
    understand
„   They make pronunciation errors in their
    speech
„   They may also have unusual voice,
    resonance, intonation, rhythm features

Some children with CAS/DVD also
have…….

„   Language problems
„   Oral control difficulties
„   Feeding difficulties
„   Poor general motor co-ordination

Facts about CAS/DVD

„   CAS/DVD is rare, affecting 0.1-0.2% of
    children
„   No known cause for CAS but thought to
    be due to genetic and/or neurological
    factors
„   Diagnosis of CAS can be made once has
    some speech to analyse
„   May be suspected at a younger age

If we suspect CAS/DVD…..?

„   Children with CAS/DVD need to be assessed
    by a speech and language therapist (SLT)
„   SLT needs to differentiate CAS/DVD from
    other types of speech disorders:
„   Phonological disorder (a non-motor speech
    disorder) & Dysarthria (another motor speech
    disorder)
„   If diagnosed, SLT needs to give ‘motor-based’
    treatment

“Dyspraxia Therapy”
       What do we need to do?
„   Teach child sounds they cannot make
„   Teach child to join sounds together in
    words, phrases & sentences
„   Improve overall tone, voice, intonation,
    rhythm
„   Improve speech intelligibility

The Nuffield Centre Dyspraxia
Programme (1985; 1992; 2004)

„   Published, pictorial therapy resource
„   Popular with SLTs in UK and other
    English speaking countries
„   Language specific approach
    (Adaptations in Dutch and Swedish)
„   Based on motor learning skills
    approach
„   Building accurate speech from the
    bottom up

NDP approach

„   NDP approach involves building speech
    skills from:
„   single consonant and vowel sounds,
„   to words of increasing length and
    complexity,
„   to sentences and connected speech.

NDP – “Building the wall”

NDP approach

„   For children who already have
    developed ‘disordered speech’, this
    means stripping the speech down to the
    basic sound level; teaching accurate
    sounds and syllables and then re-
    building the speech patterns correctly

The Nuffield Centre Dyspraxia
Programme (1985; 1992; 2004)

Using the NDP

„   Ideal for children 3-7 years
„   Need to be able to sit and attend
„   Need to be able to recognise the
    pictures
„   Need to have or to be able to develop
    some ‘meta-linguistic’ skills –to
    understand about sounds, blending and
    segmenting

A motor learning skills approach

„   Working on speech through a motor
    programming approach
„   Small graded achievable steps
„   Based on repetition and practice
„   Utilises cues and feedback
„   Works from child’s strengths

Strengths & Weaknesses

„   Start from what the child can do
„   Work on target(s) (sounds/words) that
    child cannot do
„   Incorporate new skill into framework of
    current skills

What materials are available?

„   Single Consonant & Vowel sounds: picture
    symbols and sequencing activities
„   Word levels (English phonotactic
    structures:CV, VC, CVCV, CVC, Multisyllabics,
    clusters) : Sets of pictures; blending &
    sequencing tasks
„   Word combinations (phrases & sentences)
    Sets of pictures; blending & sequencing tasks

Getting started

„   Introduce 4-6 picture symbols for
    individual consonants and vowels the
    child can already say
„   Will vary from child to child, but as an
    example……

Play games to reinforce production
and recognition

„   Can you find and post the card that
    says ‘oo’?

„   You can put in a flag when you say the
    sound

Gradually introduce more symbols for
consonant and vowel sounds the
child can already say

Work on one or more sounds child
cannot say.

Teach through elicitation ideas and
support with oromotor and
discrimination activities

Accept “approximations” and
gradually refine

Reinforce new sound(s) through
games and incorporate into set
of sounds child can already say

Introducing Sequencing

„   Once child has a number of sounds that he
    can recognise from the symbols and say,
„   Repeated repetitions of a sound first and then
    gradually changes of sounds
„   Consonant-Consonant, Vowel-Vowel and
    Consonant-Vowel sequences can be practised
„   Contrasts should be very different at first,
    gradually moving to fine contrasts

At the same time……..

„   Introduce the pictures of any CV or VC words
    child can already produce (functional aspect)

„   Again reinforce with games /activities

Develop sequencing skills

Use established single sounds ‘to
build’ CV words accurately:
C+V=CV

Moving on from single sounds
and CVs
„   Therapy programme should still include
    s/sound and CV targets
„   Gradually build other word structures
„   CV+CV-> CVCV
„   CV+C -> CVC
„   Clusters (CCV)
„   CV phrases with more, no, two, hi, bye

For further information….

„   Consult the NDP manual. See chapter
    on the Therapy approach
„   Top Tips for each level of treatment
„   Detailed information and guidance on
    individual sections for each level
„   Other useful information eg how to
    teach sounds; ideas for games etc