Apraxia

Integral Stimulation Treatment
for Children with Childhood

Apraxia of Speech (CAS)
By: Janet Baker &
Brianne Nyquist
Childhood Apraxia of Speech

ASHA defines CAS as a neurological
childhood (pediatric) speech sound
disorder in which the precision and
consistency of movements underlying
speech are impaired in the absence of
neuromuscular deficits (2007).
Location
According to ASHA it is recognized that
CAS is neurologic in origin, regardless of
differing beliefs of which structures and
circuits are affected.
Typically in the Left hemisphere,
depending on handedness.
-2007
Prevalence
1 2 per 1,000
- Shriberg, Aram, and Kwiatrkowski, 1997
Mayo Clinic Data (1987-2001) state the
most common disorders in clinical practice
is dysarthrias and AOS making up 58% of
diagnosis.
10,444 patients
-Andrianopoulos, M. V. (2008)
3 Segmental and Suprasegmental

Features Consistent with CAS:
A variety of articulation errors affecting
consonants and vowels in the production of
syllables or words.
These errors vary across productions
Difficulties producing sounds which are affected

by co-articulation at the sound and syllable
levels.
Inappropriate prosody.
- ASHA Technical Report 2007
Diagnostic Features
According to ASHA there is no definitive
list of concomitant features which affect
individuals with CAS.
-2007
Speech and Non-Speech

Characteristics
Speech
Limited phonetic inventory

Frequent and inconsistent errors on vowels and consonants
Varying suprasegmental features
Increased errors during longer and more complex utterances
Small steps toward progress during treatment
Non-Speech
Decreased AMRs
Fine and gross motor skills are impaired
Typically developing receptive language
Expressive language deficits
-Duffy 2005
Treatment Guidelines for CAS

Individualized and intensive
Provide numerous opportunities
Provide visual stimuli
Provide functional activities designed to
facilitate production of targeted sounds.
Utilize activities supported by evidence
based practice
Avoid oral motor exercises of non-speech
origin (i.e. blowing bubbles, whistles).
Integral Stimulation Method

Is based on cognitive motor learning with emphasis on
cognitive-motor programming necessary for speech
production.
Involves bottom-up approach
Often referred to as the watch me, listen, do as I do
approach.
Focuses on the use of varies modalities of presentation,
but stress auditory and visual modes.
-Gildersleeve-Neumann 2007
History
The term Integral stimulation was introduced in
1954 by Milisen, who utilized it as a program for
treating articulatory disorders.
In the 70s Rosenbek suggested use of integral
stimulation to treat dysarthria and acquired AOS.
More recently, intergral stimulation methods
were then applied by Strand to children with
CAS (or developmental apraxia of speech).
Rationale for Integral Stimulation

Methods
Establish a motor plan and engrain
neuralpathways necessary for
producing speech sounds.
- Strand 1999
Application of Integral Stimulation

Treatment Planning
Determine prognosis for the childs functional
expressive communication
Setting Goals
Improve the childs ability to plan and execute
sequential movements for the production of speech.
Using repeated opportunities
First with maximal cueing then systematically withdrawing
support so the child takes on increasing responsibilities for
his/her motor planning and movements.
-Strand 1999
Sessions
Frequency
Should be frequent
Length
Long enough to allow many repetitions of practice
Type of treatment
Meaningful and relevant to the childs needs
Stimuli
Decide on size of stimuli set for each session
Phonetic context for stimuli set
Procedures
Repetitive Practice
Need repeated opportunities to learn motor skill/movement.
Distributing Practice of Targets

Mass vs. Distributed
Shaping
Feedback
Extrinsic
Knowledge of results
Knowledge of performance
Intrinsic
Tacticle and proprioceptive
-Strand 1999
Efficacy and Evidence Based

Practice
Treatment efficacy research is minimal in
the area of CAS therapy.
Strand and Debertine (2000) used the
integral stimulation approach on a 5 yr old
female with CAS to evaluate the
effectiveness of this particular approach.
Results of Efficacy study

Baseline performance was at zero before
treatment
Rapid change began following the
implementation of treatment
The child was able to consistently exhibit
improved articulation over 134 sessions.
Compelling Evidence
Strand and Debertine support that the
integral stimulation approach has efficacy
due to the fact that the child had previous
therapy (with a different approach) and
had no consistent intelligible utterances.
Application of Integral Stimulation

C was a 5 year 9 month female referred to
Edythe Strand.
Used 3 to 5 word utterances with 10%
intelligibility to an unfamiliar listening partner.
Grammatical development and language
comprehension were age appropriate
Displayed difficulties shifting from nasal to nonnasal sounds
Had no sibilants or velars.
Vowels were inconsistently distorted
Case of C continued.
Motor speech examine revealed
She was able to simulatenously produce
vowels with little distortion (but did so with
extreme effort)
All imitated CV were in error
Was able to independently produce some CV
and CVC; however, placed in longer
utterances resulted in articulatory errors.
Case of C continued.
Treatment plan was devised by Cs
mother, School SLP and a private SLP.
Important to everyone that C establish
core utterances that all communication
partners could understand (because she
was entering kindergarten)
Decided on a core list of utterances and
intergral stimulation therapy was then
implemented.
Cs Therapy
Four hour sessions a week
2 private practice
2 at school
20 functional phrases were set

5 of which were identified for intensive work
Varied temporal relationship between

stimulus and response.
Rate started slow and progressed to
normal as she improved motor planning.
Cs Progress
4 months in to therapy
Vowels were consistently more accurate
Targeted phrases were being mastered
Nasality decreased
2 years after initial session

Intelligibility estimated to be 50% to an unfamiliar
communication partner
Stimulus increased to 9
Allowed say in therapy
-Caruso & Strand (1999).
Conclusion
Integral stimulation case studies have
shown significant gains in the motor
planning and programming abilities of
individuals with CAS.
Further research
References
Andrianopoulos, M. (2008). Class notes.
Caruso, A., J. & Strand, E., A. (1999). Clinical management of motor speech disorder in
children. Thieme: New York.
Duffy, J. R. (2005). Motor speech disorders: Substrates, differential diagnosis, and management
Second edition. Philadelphia: Elsevier Mosby.
Glidersleeve-Neumann, C. (2007). Treatment for childhood apraxia of speech: A description of
the integral stimulation and motor learning. ASHA Leader, 5, 10-15.
Strand, E. A. What is the integral stimulation method? How is it used for treating
apraxia speech in children? A response by Edythe Strand. Retrieved on March 13, 2008, from
www.apraxia-kids.org
Strand, E. A., & Debertine, P. (2000). The efficacy of integral stimulation intervention with
development of apraxia of speech. Journal of Medical Speech-Language Pathology, 8, 295-300.

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Integral Stimulation Treatment

for Children with Childhood

Childhood Apraxia of Speech

3 Segmental and Suprasegmental

Difficulties producing sounds which are affected

Speech and Non-Speech

Limited phonetic inventory

Treatment Guidelines for CAS

Integral Stimulation Method

Rationale for Integral Stimulation

Application of Integral Stimulation

Distributing Practice of Targets

Efficacy and Evidence Based

Results of Efficacy study

Application of Integral Stimulation

20 functional phrases were set

Varied temporal relationship between

2 years after initial session

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