Our SLP chat tonight, Wednesday, December 18, 2002, is being hosted by 
Nancy R. Kaufman, M.A., CCC/SLP. She will lead us in a chat about
developmental apraxia of speech (DAS). 

Mrs. Kaufman is the Director of the Kaufman Children's Center and has
specialized in the preschool population for 21 years. She is regarded as a
national expert in her field, a respected author and lectures locally and
nationally on the subject of apraxia of speech in children.  Mrs. Kaufman
is the author of The KSPT, Kaufman Speech Praxis Test for Children and
The Kaufman Speech Praxis Treatment Kits.

<Robin> Welcome! Tonight Nancy R. Kaufman, M.A., CCC/SLP, Director of the Kaufman
          Children's Center, will lead us in a chat about apraxia of speech.
<NancyKaufman> I will try to answer any questions you have, but first, here is some
          general information about apraxia of speech in children.
<NancyKaufman> Apraxia of speech (congenital) is the inability or difficulty in
          coordinating the oral motor movements necessary to produce and combine consonants
          and vowels to form syllables, words, phrases or sentences.
<NancyKaufman> Children with apraxia of speech may have other difficulties such as oral
          motor weakness or dysarthria.
<kathy> I came to your seminar Friday in Atlanta.  I loved it!
<NancyKaufman> Thanks! I had a great time there.
<Robin> Nancy, can we start with some basics about assessment of apraxia?
<NancyKaufman> Kids with DAS (Developmental Apraxia of Speech) usually have a lack of
          cooing or babbling as infants.
<NancyKaufman> They may point and grunt for a long time without first words.
<NancyKaufman> They may have a great repertoire of consonants or vowels but cannot easily
          combine them to form words.
<NancyKaufman> Some children may use the same syllable to represent all words.
<NancyKaufman> Some kids may have other fine motor problems.
<Robin> Where do you begin intervention?
<NancyKaufman> You begin by building on the consonant vowel patterns they have then you
          shape word approximations into target vocabulary words.
<mashaz> interesting
<NancyKaufman> For example a child may understand lots of words and their meanings but they
          haven't got a clue as to how to change what they hear into the motor act of
          speaking them.
<NancyKaufman> They literally have to be taught how to combine oral motor movements to form
<NancyKaufman> This is done through changing the words you want them to say into the
          simplest motor movements, then assist them with cues or prompts to make their best
<Robin> Can you give us an example?
<NancyKaufman> Yes, take the word "apple".
<NancyKaufman> The most difficult part of this word is the final "l".
<NancyKaufman> Younger children would automatically change this to "o".
<NancyKaufman> We would assume that the child may have an easier time attempting the word
          apple by trying it as "appo".
<NancyKaufman> Take a word like bottle.
<NancyKaufman> When kids are just learning to talk, they don't just say "bottle".
<NancyKaufman> They might say "ba".
<NancyKaufman> They might say "baba".
<NancyKaufman> So a word like bottle may have to be initially taught as "baba" to children
          with DAS.
<NancyKaufman> If they can imitate "baba", then they might be able to try the next level up
          which would be "bado".
<NancyKaufman> Here is a progression of teaching the word "bottle":
<NancyKaufman> ba, baba, bado, batto, bottle
<NancyKaufman> We don't wait until the child can imitate a full word.
<kim> Nancy -- How do you start when the sounds are more limited?
<NancyKaufman> We teach them best word approximations so that they have functional
<NancyKaufman> Now they can ask for a bottle without having to try it in its full form
          which they would not have been able to do.
<debacarlson> How do you encourage carryover from the imitative stage to spontaneous
          production stage with a child with DAS?
<NancyKaufman> We do something called scripting.
<NancyKaufman> We teach the parents to do the following:
<NancyKaufman> Lets say that the child wants to go outside but just points and grunts at
          the door.
<NancyKaufman> We then have the parents ask them the question they already know the answer
<NancyKaufman> Do you want to go outside?
<NancyKaufman> Then they tell the child to "tell me that you want to go outside".
<NancyKaufman> Then they fully support best word approximations upon imitation and with
          cues if needed to say "I want go out".
<NancyKaufman> This might sound like, "Ah wa do ou".
<NancyKaufman> Then the parents would follow through on the child's desire.
<NancyKaufman> I have this treatment approach written in a manual with cards that go with it.
<NancyKaufman> It is very hard to describe this approach in writing but I do offer workshops
          to teach the approach via videotapes.
<DeeNan> If you have a child who only tells you "Ow" (out), should you push for two words...
          like, "do ow" (go out) or "ow ti" (out side)?
<NancyKaufman> Push for a final /t/, with a cue, and assist with "I go out" which
          might have to be "Ah do ow."
<epoissant> Nancy- so you're primarily looking to target words that they will need to
          communicate within their daily lives?  How many words are typically targeted
<NancyKaufman> I will use as many functional vocabulary words as the child can remember in
          terms of their best approximations.
<NancyKaufman> You pick words that are important to that child.
<Robin> Epoissant, how old was the child you were asking about?
<epoissant> I don't have a particular child in mind. I'm just curious to know whether this
          type of intervention by parents and caregivers should be taking place throughout
          the childs day?  In sessions?
<NancyKaufman> I see the child twice a day and make videotapes of the therapy sessions.
<NancyKaufman> I also talk on the tape as though I am training someone in the approach.
<NancyKaufman> You build up a vocabulary of best word approximations for favorite foods,
          toys, etc.
<epoissant> Is it helpful to use pictures/AAC devices while teaching the targeted words?
<NancyKaufman> It doesn't matter, you just simply need a visual referent such as pictures,
          objects, etc.
<epoissant> I  see... thanks
<lisageng> I found simple sign and simple PECS for my son was easy for all to pick up.
<kathy> Once you have word approximations, do you keep a running list of the words as they
          reach perfection?
<debacarlson> I do
<NancyKaufman> So many people get stuck on perfect clarity that they are not moving the
          child ahead on the basic structure of language.
<NancyKaufman> After naming skills, we go right into naming the function of objects.
<lisageng> Kathy -keep a journal of all words and what the approximations mean -it helps
          for many reasons (baby sitters, etc.)
<kathy> Thanks Lisa
<NancyKaufman> We then go into naming action with three word combinations like,
          boy ride bike or girl eat cheese
<NancyKaufman> We are not yet interested in pronouns or function words.
<NancyKaufman> All the while we are backing up on the clarity issues.
<NancyKaufman> Every word can be broken down into a simplified version.
<NancyKaufman> Most kids with DAS don't know how to approach the motor aspects of words.
<kathy> How can I make sure that the child understands what she is imitating and will use
          the same word approximation again in the future?
<NancyKaufman> We help them by giving them the approximations, then shaping toward better
          or correct pronunciations.
<NancyKaufman> You always cue and support her until she has best approximations and is
          using them without support.
<NancyKaufman> If you have to continue full imitation and cues for functional speech and
          thus functional language this would be okay.
<NancyKaufman> You then want to reduce your cues so the child is communicating more
<lisageng> Cueing is great -I also found that even outside of therapy the kids appear to
          pick up on what works (good approximations are understood better).
<DeeNan> Your method works for older kids, too.
<Robin> Nancy, under the best circumstances, how many times a week would you see a child
          for therapy?
<NancyKaufman> Once a day every day would be the best.
<NancyKaufman> Private speech is costly so we mostly see kids twice a week for a half an
          hour but we also coordinate our effort with the public school professionals as well.
<Robin> Thats great Nancy
<NancyKaufman> Our out of state kids come twice a day everyday.
<debacarlson> I have found daily work to be great for my little girl!! Parent carryover is
          so important.
<NancyKaufman> Our parents watch every session and are fully trained in the approach.
<NancyKaufman> If they can't attend, we try to videotape and send this home.
<Robin> DeeNan, do you work with older kids?
<Robin> In the schools or in private practice?
<DeeNan> In a clinic.
<Robin> I see how important it is to involve the parents in the training.
<NancyKaufman> You should hear the parents in our waiting room.
<NancyKaufman> They all sound like speech and language pathologists!
<NancyKaufman> We train our parents fully in OT as well.
<debacarlson> That's awesome!!
<KKsmom> I'm still learning.
<kathy> I wish it were easier to get parent involvement in the public schools!
<Robin> Yes, that would be much more of a challenge, Kathy.
<NancyKaufman> Sometimes they might have to be invited.
<NancyKaufman> When my own son was in therapy at school, I didn't feel that I was
          necessarily welcome.
<NancyKaufman> However, at our center, we have one way mirrors so the parents don't have
          to be right in the room.
<lisageng> Those are the best!
<NancyKaufman> I can understand why it might be more difficult to have parent involvment
          in the schools.
<kathy> I would love to have the one way mirrors again.  Had them in grad school.
<NancyKaufman> If the children get nervous, the parents knock on the window.
<kathy> My 3 & 4 year olds don't respond well when mom is in the room.
<NancyKaufman> That's why we love the windows.
<kim>           I am the mom of a 2.5 year old who has been diagnosed with apraxia
          (at Innovative Therapists in Arizona)-- I am from Indianapolis.
<mashaz> Kim...is she getting therapy now?
<kim> Extensive therapy... two oral motor sessions with PROMPT and two with a different
          speech therapist -- we took her to Innovative Therapist in Arizona this summer and
          received a home plan as well.
<kim>           I should have mentioned that the therapy is on a weekly basis -- four sessions
<mashaz> wow...4 sessions a week!
<kim>           We are very concerned about our little girl.  She has moderate CP, auditory
          neuropathy, and apraxia.  She is very bright and catches on to things quickly
          -- but in spite of 4 sessions of therapy (2 oral motor with PROMPT) she is not
          making much progress -- she can say "up" and "hi" ... for all intents and purposes
          she presents like a hemi -- involved much more so on her right side (diagnosis is
<NancyKaufman> What type of CP does she have?
<NancyKaufman> Sometimes there is an overriding dysarthria.
<NancyKaufman> This is a problem of muscle weakness and it doesn't respond as well to
          therapy techniques.
<NancyKaufman> I would look into whether or not she has dysarthria.
<NancyKaufman> Therapy would involve more oral motor stretching, toning and strength
<kim> How is that diagnosed?
<NancyKaufman> A good person to know is Debra Beckman who knows a lot about oral motor
          skills as opposed to verbal motor.
<kim> She babbles a lot... she really wants to talk but just can't get the words or sounds
          out.  She also has trouble signing -- but is able to put letters of the alphabet in
          order!  She does use the same syllables for so many things.  We bought your cards
          but I don't think she is ready yet -- she understands a lot --even with the hearing
<kim> nancy -- I don't want to monopolize the conversation -- so I will ask just one more
          question.  We are desperate to help our daughter -- is it possible to for you to
          work with an out of state family?
<NancyKaufman> Yes, we work with many out of state families.
<NancyKaufman> We see kids from one week intensives to up to 4 weeks at a time.
<KKsmom> Our daughter right now is seeing Nancy and we are from Chicago.
<NancyKaufman> Hi KK's mom!
<kim> I will call and make an appointment with you this week - thanks so much for your time.!!
<Robin> Kim, check out Nancy's website at www.kidspeech.com.
<lisageng> Seeing Nancy is great -however her program is also highly effective for both
          parents as well as for professionals (and no I'm not Nancy's agent!)  I'm a parent
          that has personally seen how great the Kaufman approach works for my own son.
<kim> Thanks!  we purchased the cards but our little daughter needs more help -- she does
          have oral motor weakness -- can you help?
NancyKaufman> Oral-motor treatment, if you are talking about strength, toning and
          stretching, is usually done only with kids that have oral motor weakness,
          sensitivities or dysarthria (nerve disorder to the oral motor musculature).
<NancyKaufman> We might suggest stimulation activities if there is only apraxia without
          oral motor weakness.
<NancyKaufman> Stimulation involves "shocking" or "waking up" the speech musculature.
<kim> Can you help diagnose dysarthria?  What can be done if she does have this condition?
<NancyKaufman> We are not specialists with children with dysarthria but we do use the
          Beckman approach for stretching, toning and strength activities.
<NancyKaufman> If dysarthria is a primary condition, not all children gain enough strength
          to have enough clarity for the average listener to understand.
<debacarlson> Do you utilize oral motor approaches when teaching targeted sounds/words in
          children with DAS?
<debacarlson> The reason why I asked about oral motor is I am an SLP and have a 22 month
          old with DAS and had started with desensitization and then utilized oral stimulation
          to encourage sound production.  Of course, I have started her on the Kaufman Level
          One as well.
<NancyKaufman> Sometimes you can get too caught up with oral motor exercises when working
          the verbal itself would make the same improvements.
<NancyKaufman> I feel that an ecclectic approach is best but with most time spent on verbal
          motor skills ie, functional vocabulary.
<debacarlson> Yes, we now do minimal oral motor and spend most time on verbal
          approximations and spontaneous productions.
<NancyKaufman> How is it going?
<debacarlson> She now has 50 words.
<NancyKaufman> great
<Robin> excellent
<NancyKaufman> Have you been to a workshop?
<NancyKaufman>           If not, it would help a lot.
<Robin> Nancy's workshops can be found on this website's course page.
<debacarlson> I have not been able to attend one of your workshops yet but am looking
          forward to it.
<NancyKaufman> Make sure you are moving ahead on expressive language and backing up on
          motor speech.
<debacarlson> We are trying to find that balance.
debacarlson Thank you so much for your time.
<NancyKaufman> thanks for joining us!
<Robin> Yes, we are chatting nearly an hour now..any last questions for Nancy Kaufman?
<kathy> Nancy, I purchased your Basic Level Kit Friday.  I work with 3 & 4 year old kids
          with hearing aids and cochlear implants.  Children are basically nonverbal.  Could
          I use these cards to help them as well?
<NancyKaufman> Yes, I have heard from many people that this program is great for kids
          with cochlear implants.  In some ways, it resembles the Ling approach, but these
          are not nonsense syllables.
<kathy> I work with a 5 year old with a cochlear implant.  She has very few vowels and
          consonants.  I did not get very far with the Basic Level Kit.  What do I do now?
<kathy>  I don't see any oral motor weaknesses.  She only grunts and blows air out. 
          She does not attempt to make any word approximations.  She had rather sign. 
          She does hum.
<NancyKaufman> Kathy, You might wish to send me a video tape of her.
<NancyKaufman> I can get a much better idea if my approach might help.
<kathy> That would be great.  I am referring her back to her implant team also for guidance.
<NancyKaufman> My website is www.kidspeech.com for more info.
<kim> nancy -- I will send you a videotape of my daughter this week -- how long would it
          take to evaluate?
<NancyKaufman> It doesn't take long at all.
<NancyKaufman> I will view the tape, write back a letter, and speak on the phone to one
          person, either a parent of professional (there is a fee for this service).
<kim> Thanks so much!
<NancyKaufman> Feel free to call.
<Robin> Nancy, thank you so much for being here and sharing your expertise!
<kathy> Nancy, thank you so much for chatting!  I really love your work and can't wait to
          purchase some of your items!
<NancyKaufman> Thanks, I hope you do well with them.
<Robin> We have some of Nancy's kits on this website's product page.
<DeeNan> Any new kits on the way?
<Nancy> Not as of yet.  My next projects are a video/DVD on the methods and an online course.
<Robin> Thank you again and goodnight!
<DeeNan> Thanks, Nancy!
<mvh> Nancy I arrived on the scene late due to holiday errands.  You are awesome.
<NancyKaufman> thanks, mvh!
<lisageng> Bye guys -Happy Holidays!
<kathy> Enjoyed it!
<mvh> This was really very interesting!
<epoissant> Nancy- thank you very much for all the tips you've provided.  Goodnight.
<NancyKaufman> You are welcome, bye!