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Implementing Dynamic Temporal
Tactile Cueing: Target Selection
and Progress Monitoring
Julie Case, PhD, CCC-SLP
Jenya Iuzzini-Seigel, PhD, CCC-SLP
Julie Case, PhD, CCC-SLP

Julie Case is an Assistant Professor in the

Speech-Language-Hearing Sciences
Department at Hofstra University. Dr. Case is
an ASHA-certified bilingual speech language
pathologist with a specialization in Childhood
Apraxia of Speech (CAS). Her research
program focuses on the clinical management
of CAS, in addition to speech motor
development in children with CAS and other
speech sound disorders.
Jenya Iuzzini-Seigel, PhD, CCC-SLP

Jenya Iuzzini-Seigel, PhD, CCC-SLP is

Associate Professor of Speech Pathology and
Audiology and Director of the Communication,
Movement and Learning Lab at Marquette
University. Her research centers on the
diagnosis and treatment of pediatric
communication disorders with a specific
interest in CAS, dysarthria, and developmental
language disorder.
Disclosures
• Presenter Disclosure: Financial: Jenya Iuzzini-Seigel and Julie Case
received an honorarium for this presentation. Jenya receives funding from
NIH, Apraxia Kids, Marquette University and the Once Upon a Time
Foundation for her research. Julie receives funding from NIH and the Once
Upon a Time Foundation. Nonfinancial: Dr. Iuzzini-Seigel is on the PAC for
Apraxia Kids.
• Content Disclosure: This learning event does not focus exclusively on any
specific product or service.
• Sponsor Disclosure: There is no external sponsor for this course.
Learning Outcomes
After this course, participants will be able to:
• Describe how to select treatment targets for DTTC.
• Describe methods to measure progress over the course of
DTTC treatment.
• Describe how to measure generalization of treatment gains to
untreated words.
Jenya Iuzzini-Seigel, PhD, CCC-SLP
Julie Case, PhD, CCC-SLP
Agenda
• Dynamic assessment as a bridge to treatment
• Designing treatment stimuli
• Clinical decision-making: Case 1
• Clinical decision-making: Case 2
• Treatment monitoring
• Procedures and stimuli to examine generalization
• Summary & Questions
Dynamic Temporal and Tactile Cueing
Treatment (Strand, 2020)
• Motor-based treatment approach for children with mod-severe CAS
• Based on methods of imitation: “Watch me/listen to me/do what I do”
• Treatment targets are movements and movement patterns,
not isolated sounds​
• Provides intensive and dynamic practice to establish movement
• Integrates principles of motor learning across all stages
Dynamic Assessment as a
Bridge to Treatment
What is dynamic assessment?

• A method of assessment used to elicit a child’s

best effort and identify potential for change
• Skills may be observed and assessed before, during,
and following a teaching or cueing phase

(Strand & McCauley, 2019)

Dynamic assessment in children with
CAS
• Elicit production from child (test)
• Cue child as they make multiple attempts to
produce the target (teaching phase)
• Elicit a final production without cueing (test)
• Analyze child’s productions (with and without
cueing)
Dynamic Evaluation of Motor Speech
Skill (DEMSS; Strand & McCauley, 2019)
• Standardized, criterion-referenced measure used to examine
difficulty with motor planning and programming
• Used to support judgements of severity, prognosis, treatment
planning and target selection
Who is the DEMSS for?
• Intended to contribute to differential diagnosis for children 3
years and older
• Limited consonant and vowel inventories or with limited verbal
output
• Child must be able to attend to clinician’s face and attempt
imitation
Mechanics of the DEMSS
• Clinician provides a natural model of each item for the child
imitate
• If the child’s production is inaccurate, clinician provides model
more slowly and child repeats again
• If still inaccurate, the clinician provides systematic cues to help
the child change and possibly improve their production
• After cueing, clinician provides one final natural model of each
target for the child to imitate
DEMSS Example
DEMSS for Observation of Speech
Features
• What features does child produce initially and with cueing?
E.g.,
• Vowel errors
• Inconsistency
• Distortions
• Voicing errors
• Difficulty with coarticulatory transitions
• Stress errors or syllable segregation
• Groping

• How do features differ (appear, disappear, worsen, improve) for

different targets and when child is cued?
Watch again and note features,
inventory, word shape and
anything else pertinent during
each elicitation (before, during
and following cueing)
DEMSS Example
What did you observe about the child?
• Paid attention & watched clinician’s face throughout clip
• Demonstrated vowel errors, distortions, substitutions, & inconsistency
• Responded to and made ample progress with cueing
• Produced [k t] in word-initial and final positions and [ts] in word-final
position
• Produced correct and distorted /ɑ æ/
• Produced CVC word shape
• Responded well to verbal, visual, mime and gestural cues
• Responded well to simultaneous production with and without clinician’s
voice
Gauging severity and prognosis from DEMSS
• Child quickly improves in response to cueing
• Child is likely to respond quickly to DTTC treatment (better prognosis)

Alternatively…

• Child does not respond to cues or requires more substantial

cueing
• May indicate the child is more severe and less likely to respond quickly
to DTTC (poorer prognosis)

(Pena et al., 2006; Strand & McCauley, 2019)

DEMSS as a Bridge to Treatment
• Which sounds, syllable shapes, and prosodic contours were
present in child’s inventory?
• Which vowels were in error?
• Which words would be good treatment targets for child?
• Which types of cues were most facilitative for child and in what
contexts?
• How well did child attend to task?
• How often did child require breaks?
• Which reinforcements were most successful?
Designing Treatment Stimuli
Treatment Stimuli for DTTC
• Small stimulus set of functional, real words
• Size will vary depending on severity of child
• Use results of DEMSS + other assessment tasks to design
stimuli
• Include a range of syllable shapes and co-articulatory
transitions to offer practice variability
Using the DEMSS to Guide Stimulus
Design
• Identify established and/or stimulable syllable shapes
• Identify vowel distortions
• Consider salient features of CAS and how these can be
addressed through selected forms
• Analyze response to clinician cueing
What else goes into target selection?
• Other speech testing (e.g., artic test, phonological assessment, custom
tasks, connected speech)
• Determine comprehensive vowel and consonant inventories
• What consonants are accurate or most stimulable?
• What vowels are in error?
• Prosodic patterns
• Maximum word length
• Syllable shape inventory

• Functionality and Motivation

• Child’s interests
• Key names in child’s life (people, pets, characters)
• Important words for home and school
• Key words for self-advocacy
 Q1

Designing Treatment Targets that Focus on Mov't

*Prioritizing vowel + range of syllable shapes is integral to targeting movement gesture

❑Range of vowels + diphthongs: simple + ❑Word-shapes in the child's inventory

challenging, especially those with
distortions
❑Words with more than one consonant (consider
❑Range of syllable shapes*: place/manner/voicing):
• Complex syllable shape: include sounds in • Reduplicated consonants
child’s inventory • Consonants move from one place of
• Simple syllable shape: include stimulable articulation to another or one manner
sounds not yet productive in child's inventory
and/or voicing to another
❑Established/stimulable consonants ❑Prosody
• Consonants present in child's inventory • Range of stress patterns
• Consonants child is stimulable for ❑Function and communicative impact
Phonetics can help!
(PRACTICE RCT Research Team)
Building a Treatment Bank
TARGET Syllable Shape: Vowel: simple, Consonant: in Prosody:
WORD Range: simple - complex diphthong, repertoire, STRONGweak,
challenging stimulable weakSTRONG
Building a Treatment Bank
TARGET Syllable Shape: Vowel: simple, Consonant: Prosody:
WORD Range: simple - complex diphthong, in repertoire, STRONGweak,
challenging, stimulable weakSTRONG
distortion
Bye CV Diphthong Established NA
Up VC Simple Established NA
Pop CVC (same C) Simple, distorted Established NA
Done CVC (different C) Simple Stimulable NA
Booboo CVCV (reduplicated) Simple, distorted Established STRONGweak
Puppy CVCV (same C, different V) Simple Established STRONGweak
Happy CVCV (different C and V) Challenging Stimulable STRONGweak
Open VCVC Challenging Stimulable STRONGweak
Sample Stimuli, expanded
Syllable Structure Examples
CV no, bye, my

VC out, up, in

CVC: same C mom, pup, dad, bub

CVC: different C mine, done

CVCV: same C, different V puppy, mommy, cookie

CVCV: different C & V bunny, happy

Multisyllabic words or phrases avocado, nobody, no way

Clusters or adjacent consonants play, snack, bath time

over stress juncture
 Q5

Additional ideas for target development

(aim for a range across categories)
1. One- or two-syllable words that contain vowels/diphthongs with
distortions or in error
2. Words that contain consonants that vary in place only (e.g., take)
3. Words that contain consonants that differ in manner and/or voicing
only (e.g., sit)
4. Words or short phrases that represent child’s maximum syllable
shape and known consonants (i.e., in inventory or stimulable)
5. Words or short phrases with a harder syllable shape (e.g., cluster) but
contain same consonant in multiple word positions or different
stimulable consonants that share similar features (e.g., swim)

(Adapted from PRACTICE RCT Research Team)

Other ideas for building a word bank
Element to target Examples

Vowel/Diphthong in error Mine, Out

Consonant sequences that vary by place tuck, bed

Consonant sequences that vary by Mad, Todd, sit, cheese (depends on what
manner and/or voicing sounds are in child’s inventory)
Maximum syllable shape produced by Ladybug, tuck me in, I wanna go, stop it, I
child (containing established phonemes) need you (depending on child’s inventory)

Challenging syllable shape or sequence Swim, plate, snot

within words/phrases (containing
consonant sequences with same place or
shared feature)
Why are some movement
gestures more difficult &
complex than others?
Balance is key!
• If the vowels in a target word are particularly challenging for the
child, make sure the consonants and word-shape are more
established
• If a child can produce clusters, target a cluster using an
established word shape with known consonants and vowels
• If targeting a more difficult stress pattern, make sure
consonants and vowels are more established
• Children with moderate severity should have 2 iambic words/phrases in
their target list
Importance of functionality and motivation cannot
be overstated!
• Make sure words will have a high impact on communication
• If a word isn’t going to be used and be useful, don’t use it in treatment

• Most kids have preferred topics and interests, ask them and
their parents to make sure treatment words reflect these
What to take caution with?
• Non-stimulable sounds
• Rhotics, rhotic clusters, rhotic vowels, and rhotic diphthongs
• Flaps
• Excessively complex words
• Morphosyntactic markers like plurals, pronouns, possessives,
and past tense verbs; -ing verbs are ok
Potential treatment targets
Word Shape
Early Mid Late
CV (Simple Vowel) me, he, yeah too, two she, see, shoe
CV (Diphthong) Hi, why, bye, no, tie, go, toy show
now, how
VC (Simple Vowel) Eat, em, in, up egg, ick, off, it ell, as, all
VC (Diphthong) out, age, ouch ice

(Adapted from PRACTICE RCT Research Team)

Potential treatment targets

Word Shape
Early Mid Late
CVCV (Same C and V) papa, mama choochoo, cocoa lulu
C1VC1 (Simple Vowel) dad, poop, mom, pop kick, toot sis, sauce
C1VC1 (Diphthong) nine
C1VC2 (Simple Vowel) need, done, bed juice, book, look, move cheese, zip,
push, wish
C1VC2 (Diphthong) mine, hope, nope, down loud shake, choice

(Adapted from PRACTICE RCT Research Team)

Potential treatment targets

Word Shape Early Mid Late

Bisyllabic daddy, poopy, mommy cookie seesaw, lolly

C1V1C1V2 (simple v)
Bisyllabic Trochaic: bunny, happy, movie, taco, tiny, tidy, sipping, lego
C1V1C2V2 (+C) maybe, pony pouty

Iambic: become, begin, today balloon, below, devise

Bisyllabic upon, about able

V1C1V2 (+C)

(Adapted from PRACTICE RCT Research Team)

Potential treatment targets

Multisyllabic Trochaic Iambic Trochaic (Cluster) Iambic (Cluster)

(Singleton C) (Singleton C)
3-syll peekaboo potato, banana, skateboarding, flamingo, spaghetti
magician octopus
4-syll dinosaur

5-syll hippopotamus

(Adapted from PRACTICE RCT Research Team)

Brainstorm and then edit!
Clinical Decision-Making
Dottie
• Child is a female, aged 2;7 with recent diagnosis of CAS
• Limited vocal output with ~5 consistent word forms
• Child is highly aware of speech production difficulties and has a
low frustration threshold
• PLS-5: Rec Lang SS = 87; Exp Lang SS = 82
• Low-average cognition
• Child receives PT, OT, and ST through Early Intervention
 Dottie's Inventory from Speech Testing
• Anterior, early developing Cs
• Initial: /p*, b, m/
• Within: /ʔ, p*/
• Final: none
• Simple vowels: /ʌ*, i*, ɑ/
• Word shape inventory: CV, CVCV, VCV
• Errors: partial voicing, diphthong segmentation, vowel distortion,
excess effort
• Prosody: syllable segregation, excess and equal stress

*Mild error and/or distortion and/or contextual restrictions

Dottie's Probe Data
Designing treatment targets for this child
Stimuli must be directly related to targeting the movement
gesture
• Look at child’s current phonetic repertoire and word shape inventory
• Select a range of word shapes
• Select a range of vowels to target (be sure to include a diphthong)
• Add phonemes to vowel targets across syllable shapes to create
functional words
• Initially, select phonemes in their repertoire + 1-2 new phonemes
• More severe: words will contain same initial/final phonemes
• Less severe: words will contain wider range of co-articulatory transitions (CV
combinations), lengthier word shapes, and prosodic contour
Dottie's Treatment Words
Target Syllable Shape: Vowel: simple, Consonant: in Prosody:
Word Range: simple - diphthong, challenging repertoire, stimulable STRONGweak,
maximal weakSTRONG
Ow V Diphthong na na
Bye CV Diphthong /b/ na
Me CV Simple /m/ na
Up VC Simple /p/ na
Mom CVC Simple /m/ na
Mummy CVCV Simple /m/ STRONGweak
Puppy CVCV Simple /p/ STRONGweak
Patrick
• Child is a 5-year-old male diagnosed with CAS at age 2
• Child met all motor milestones on time and no hx of ear infections
• Parent reports 75% of speech is understood by parents and
siblings but only 50% by peers or unfamiliar listeners
• Child tends to be shy and his main interest is sports
• In school child enjoys naming letters and sounds, follows directions
well and prefers one-on-one interactions
• Rec Lang SS = 116; Exp Lang SS = 86
Patrick's Inventory from Speech Testing
Consonant inventory
• [pbtdkg* mnŋ w v* ʃ s* h ʤ* ɹ*]

Vowel inventory
• Produces all vowels and diphthongs but not consistently

Syllable Shape Inventory

• Produces varied range of syllable and word shapes
• Max Syllable Shape = CCVC (brush)
• Max Word Length = CVCVCV (potato)

Stress Inventory
• Inconsistently produces accurate stress in bisyllabic and multisyllabic words
Patrick
Treatment words for Patrick

Syllable Shape Word

VC in
VC (diphthong) ate (mastered at spontaneous)
CV how
CV (harder consonant, easier vowel) fee (mastered at spontaneous)
C1VC1 kick
C1VC2 hope
C1VC2V (diphthong) maybe
C1V1C2V2C3V3 tomato
Carmelo

• Child is 4;7 male diagnosed with CAS at 26 months

• Child has history of laryngomalacia, drooling and had difficulty
nursing. No history of ear infections.
• All motor milestones were achieved on time
• Parent reports 75% of speech is understood by parents, 50% by
peers and less than 50% by unfamiliar listener
• Child is very social and interests include baseball, tennis, and hiphop
• In school child wants to play with all children, even children he does
not know
• Rec Lang SS = 100; Exp Lang SS = 93
Carmelo's Inventory from Speech Testing
Consonant inventory
[pbtdkg mn wj l*ɹ* ʧ f*szʃ]

Vowel inventory
All vowels and diphthongs

Syllable Shape Inventory

Produces varied range of syllable and word shapes
Max Syllable Shape = CCVCVC (brushing), CVCVCCCV (butterfly)
Max Word Length = CVCVCVC (pattycake)

Stress Inventory
Child demonstrates range of stress contours in bisyllabic and multisyllabic words
Treatment words for Carmelo
Syllable Shape Word

VC On
CV Me
CVC Book
CV (harder consonant, easier vowel) Shoe

CCVC Cloud
C1V1C1V2 Cookie
C1VC2V2 Maybe
C1V1C2V2C3 Begin
C1V1C2C3V2C4 Goodnight
C1V1C1V2C2V1C2 Lollipop
C1V1C2C3V2 Push me
V1C1V1C2 Above
But wait there’s more
Progress monitoring and treatment generalization
How do we monitor progress?
Long-term measures
• Changes in standardized test scores
• Improved intelligibility in connected speech
• Changes in measures of functional speech [e.g., Intelligibility in
Context Scale (ICS; McLeod et al., 2012), FOCUS-34 (Thomas-
Stonell et al., 2012)]

Semi-regular measures
• Treatment and generalization probe data
Probe Data
• Quick and semi-regular approach to assess acquisition,
learning, and generalization of treatment gains
• Measure acquisition (motor performance) through evaluating retention
of gains for words in active treatment
• Assess retention (motor learning) through evaluating maintenance of
previous treatment gains
• Evaluate generalization to untreated exemplars (motor learning)
• Administer pre-, during, and post-treatment to assess gains and
inform treatment planning
Benefits of Probe Testing
• Quantify degree of motor learning (as compared to within
session motor performance gains)
• Quick and efficient approach to obtaining treatment data
• Does not take the clinician's attention away from treatment
session
 Q2

Probe Data: Stimulus Set

• Generate a list of treated words (using guidelines above)
• Generate a list of untreated but similar words to match treated
words and evaluate generalization
• Depending on size of stimulus set, repeat each word 3-5 times
• More severe child: smaller set
• Less severe child: larger set
• Number of repetitions: depend on severity, # of stimuli, & stamina of child
• List these words in randomized order
 Q4

Probe Data: Mechanics

• Elicit words without cueing
• Can be elicited through direct imitation while seated face-to-
face, side-by-side OR picture naming
• Make sure that child has conscious attention throughout
Record probe administration for later analysis
Probe Data: Frequency
• Probes will reveal when a child is demonstrating long-term
learning and generalization gains rather than performance
gains observed within a treatment session
• Probe treated words every 3 sessions or once/week
• Can help guide when to d/c certain targets and introduce others
• Data can be used to demonstrate progress and support continuation of services
• Probe untreated words every 3-4 weeks
• Will reveal generalization gains
Generalization
• Monitors motor learning and carryover of treatment
gains
• Evaluate speech accuracy for similar, untreated words based
on variables such as movement gesture, syllable shape, co-
articulatory prosodic contours
• Generalization is assessed less frequently to prevent
practice effects
Sample Generalization Words for Carmelo
Syllable Shape Treatment Words Generalization Words
VC On In
CV Me Knee
CVC Book Back
CV (harder consonant, easier Shoe She
vowel)
CCVC Cloud Glowed
C1V1C1V2 Cookie Cakey
C1VC2V2 Maybe Mopey
C1V1C2V2C3 Begin Became

C1V1C2C3V2C4 Goodnight Naptime

C1V1C1V2C2V1C2 Lollipop Lilypad
C1V1C2C3V2 Push me Catch two
V1C1V1C2 Above Upon
Probe
Probe Data: Measurement of Gains

• Using the recording of probe data, evaluate accuracy of probe

data
• Measure whole word accuracy including that of movement
gesture, consonant/vowels, and prosody
• Can monitor each element separately to see changes to prosody or
phoneme accuracy etc. or all together wrapped up into one measure
• When measuring generalization of treatment gains, may also
evaluate PCC/PPC as additional measure of segmental
accuracy
 Q3

How do we measure probe data?

Whole Item Accuracy (WIA; Murray et al., 2015)
0: some error/s in sounds and/or prosody, and/or transitions not smooth
1: correct in every way
3-point scoring of movements (Strand et al., 2006; Maas et al., 2019; Jing & Grigos, 2022)
0: inaccurate
1: 1-2 minor errors (e.g., mild distortion or prosodic difference)
2: completely accurate
Multilevel word Accuracy Composite Scale (MACS) (Case et al., 2023)
Rate each on a binary scale (0/1) and generate average score:
• Segmental accuracy
• Word structure
• Prosody
• Movement transitions
MACS: Overview
Category ‘0’ rating ‘1’ rating
Segmental
substitution, omission, Accurate consonant &
(sound)
distortion vowel
accuracy
inaccurate/missing
accurate
Word Structure word structure
word structure
(e.g., CVC → CV)
segmentation;
Prosody equal/inaccurate stress; accurate prosody
syllable reduction
Movement transition not smooth
accurate transition
Transition and fluid across word
MACS: Example
• Sample production: “baby” /'beɪ.bi/ as ['bi.'bi]​
• Ratings by domain:​
• Segmental – 0/1
• Word structure – 1/1
• Prosody – 0/1
• Movement transition – 0/1

MACS Score = 0 + 1 + 0 + 0 = 0.25

4 domains
 Sample Rating: Dottie

MACS
Whole Movt acc.
Word
item (3-pt
acc. scale)
Seg. Word Movt MACS
Pros.
Acc Struct. trans. Score
Puppy 0 0 0 1 0 0 .25
Bye 0 0 0 0 na 0 0
Summary
❑Let the results of your comprehensive and dynamic assessment inform target
selection.
❑Be sure to include a range of:
❑Vowels + diphthongs
❑Syllable shapes
❑Established/stimulable consonants
❑Words with more than one consonant (consider place/manner/voicing)
❑Stress patterns
❑Think about the function and communicative impact of your targets and
remember, if a word isn't useful for the child, don't use it in treatment!
❑Generate a list of treated words and similar, untreated words and collect probe
data to measure speech performance and motor learning
Q+A
Jenya.iuzzini-seigel@marquette.edu Insta: @Marquette_cml_lab
Julie.case@hofstra.edu Insta: @casespeechlab
References
• ASHA. (2007). Childhood apraxia of speech [technical report] [Technical Report]. www.asha.org/policy
• Case, J., Wang, E., & Grigos, M. I. (2023). The multilevel word accuracy composite scale: A novel approach to rating speech errors in childhood
apraxia of speech (cas). American journal of speech-language pathology, 1-18.
• Iuzzini-Seigel, J., Case, J., Grigos, M., Velleman, S., Thomas, D., & Murray, E. (2023). Dose frequency randomized control trial for dynamic temporal
and tactile cueing (dttc) treatment for childhood apraxia of speech: Protocol paper.
• Jing, L., & Grigos, M. I. (2022). Speech-language pathologists' ratings of speech accuracy in children with speech sound disorders. American journal
of speech-language pathology, 31(1), 419-430.
• Maas, E., Gildersleeve-Neumann, C., Jakielski, K., Kovacs, N., Stoeckel, R., Vradelis, H., & Welsh, M. (2019). Bang for your buck: A single-case
experimental design study of practice amount and distribution in treatment for childhood apraxia of speech. Journal of speech, language, and hearing
research, 62(9), 3160-3182.
• McLeod, S., Harrison, L. J., & McCormack, J. (2012). The intelligibility in context scale: Validity and reliability of a subjective rating measure.
• Murray, E., McCabe, P., & Ballard, K. J. (2015). A randomized controlled trial for children with childhood apraxia of speech comparing rapid syllable
transition treatment and the nuffield dyspraxia programme. Journal of speech, language, and hearing research, 58(3), 669-686.
• Peña, E. D., Gillam, R. B., Malek, M., Ruiz-Felter, R., Resendiz, M., Fiestas, C., & Sabel, T. (2006). Dynamic assessment of school-age children’s
narrative ability: An experimental investigation of classification accuracy.
• Strand, E. A. (2020). Dynamic Temporal and Tactile Cueing (DTTC): A Treatment Strategy for Childhood Apraxia of Speech. American Journal
of Speech-Language Pathology, 29(1), 30-48.
• Strand, E. A., & McCauley, R. (2018). Dynamic evaluation of motor speech skill manual. Paul H. Brookes Publishing Company.
• Thomas‐Stonell, N., Washington, K., Oddson, B., Robertson, B., & Rosenbaum, P. (2013). Measuring communicative participation using the focus©:
Focus on the outcomes of communication under six. Child: care, health and development, 39(4), 474-480.