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