Who's down with DTTC??

 

Working with children with severely unintelligible children is both a challenge and a blessing.  It is pretty clear why it is a challenge, but the blessing is revealed slowly.  With every step forward for these children, you can see how the world of communication opens up.

“Communication is the essence of human life”- Janice Light

As SLPs, we need to help children who are severely unintelligible get closer to a goal of improved communication.  While the diagnosis of Childhood Apraxia of Speech (CAS) can get thrown around with these children, there are certainly different roads that bring us to the same destination: significant challenges with unintelligibility as well as a disability in overall communication.

ASHA recommends considering augmentative and alternative communication (AAC) for children with CAS (ASHA CAS Treatment, 2017), and I would go further to say that we need to consider AAC for children with less severe diagnoses as CAS, but still with challenges in communication.  When looking at the research available, there is a paucity of research that meets high level criteria for evidence based practice.  Many studies are either single subject or conducted on a few participants.  This lack of research muddles the picture when making treatment decisions, but there are options.

In my part of the U.S., PROMPT therapy is often cited by parents and practitioners as the standard of care for children who are unintelligible.  While it is important to consider options in which families are interested, we need to consider the whole picture.  In the same view, there are still clinicians who cite the value of non-speech oral motor exercises (NSOMEs), which do not have sufficient evidence in the literature to support them.  Of course, when considering the hierarchy in evidence-based treatment, clinician/expert opinion is a factor.  As SLPs, we must make the best decision for our client/student based on what we know and have experienced. 

PROMPT treatment is “multi-dimensional” and has a focus on functionality (PROMPT Institute, 2016).  Analysis of the structure, function, and integration associated with the speech mechanism is needed to determine the course of therapy.  According to the PROMPT Institute, the treatment has been used with phonological delays, developmental delays, dysarthria, motor speech disorders, and CAS.  The key is the analysis of the SAO (System Analysis Observation) which drives the treatment down the line.  Check out their 9 key components at https://www.youtube.com/watch?v=yXtNYsfNXO4

As with any treatment paradigm, there is a philosophy that underpins it which looks at the cognitive-linguistic, sensory, and social emotional outcomes.  These are strong considerations that look outside just the motoric aspect of speech.  By keeping an eye on functionality while also thinking about the external effects of unclear speech, PROMPT therapy works to improve communication for children overall.  In my experience, I have met students who have benefitted from the use of PROMPT techniques and students who have found success with other treatment styles.  The “fit” between therapist and client is incredibly important in any speech-language intervention. 

The technique of Dynamic Temporal and Tactile Cueing (DTTC) has been enormously helpful in my 10 years in the field (Strand, Stoeckel, & Bass, 2006).  DTTC focuses on shaping productions over time through techniques that focus on timing and touch cues.  In my opinion, the overall idea is to give the least support for the most beneficial outcome (i.e.; there is no reason to touch a child’s face if they are able to make a sound in chorus with you).

Strand’s technique is summarized as follows (Strand, Stoeckel, & Bass, 2006; Gildersleeve-Neumann, 2007)

·       The child watches and listens to the clinician. Simultaneous production is the target, so the child and the clinician will produce the target at the same time.

·       Next, the clinician models, then the child repeats the target while the clinician simultaneously mouths the same target.

·       The clinician models the target and provides cues and the child repeats (I will sometimes use PROMPT cues here on my own face)

·       The clinician models the target and the child repeats with no cues provided (increasing independence)

·       The clinician will prompt the target (asking a question, completing a fill-in) with the child responding spontaneously.

·       The child produces the target in more conversational-type situations.  This is a good time to use more traditional speech articulation games and activities.

A key to this process is evident in the 2006 article by Strand, Stoeckel, & Bass, “the temporal relationship used with children is constantly changing, trial by trial, depending on the child’s accuracy, in order to shape the movement, facilitate motor learning, and develop more automaticity.” As SLPs, we strive for our children to carryover their speech and become more automatic. 

The DTTC approach has worked for me in a number of ways:

·       Reducing dependence on prompts

·       Use of prosody during simultaneous production

·       Teachability to parents, teachers, and paraprofessionals

 

In each of these situations, the SLP can set up the best possible outcome for the child.

Because they are not dependent on a physical prompt, a child can reach a level of success with the least cueing needed.  Maintaining the balance of what the child “needs” to be successful allows for the “dynamic” nature of the technique to come into full view. 

Prosody is an important part of conversational speech; DTTC allows you to build that prosody in right away so the expectation is there to produce targets in a more effective way.

Because the steps in this procedure are not overly technical, teachers and family members can learn how to cue.  Additionally, the concept of reducing cues allows families to hear how their child’s productions are changing over time.

Frequency is a crucial consideration as well.  While Strand, Stoeckel, & Bass talked about getting 15-30 reps in a block of productions and 2-3 blocks completed within a session, the frequency of sessions cited in their study is hard to maintain.  School-based speech therapy certainly does not allow for multiple sessions within a day and with the busy lives of families these days it is hard to imagine that any family could follow up with a private provider daily.

Taking this into consideration, the teachability of DTTC allows for teachers and paraprofessionals to get additional blocks of practice in.  When working with unintelligible children, I advocate for practice of 30 reps once a day in the class in addition to my sessions.  For families, they know the child’s schedule at school so speech days are “no practice” days at home.  When there is no speech in school that day, it is a “must practice.”  This way families can help ensure that every day there is at least some production of target words occurring.

Overall, improving communication for unintelligible students is an uphill battle.  Beyond the considerations of family dynamics and motivation for some children, you are also dealing with a challenging course to make progress.  DTTC allows for families, classrooms, and SLPs to work in conjunction.  Prompting when needed allows for students to make growth at their pace.  PROMPT treatment looks at children through a different lens and focuses on a different assessment before working through treatment.  Whether the treatment method is PROMPT, DTTC or traditional articulation/phonological treatment, we need to think about the methods that will fit in best with our child and their goals.  Once again, the “fit” between a therapist and a client can drive some of decision making and eventual success. 

References:

American Speech-Language Hearing Association Practice Portal (2017) Childhood Apraxia of Speech: Treatment.  Accessed December 29, 2017.

Gildersleeve-Neumann, C. (2007).  Treatment for Childhood Apraxia of Speech: A Description fo Integral Stimulation and Motor Learning, The ASHA Leader (12) pg. 10-30.

PROMPT Institute (2016, November) PROMPT Case Studies: Achieving Functional Communication Outcomes. American Speech Language Hearing Association Conference, Philadelphia, PA.

Strand, E., Stoeckel, R., and Baas, B. Treatment of Severe Childhood Apraxia of Speech: A Treatment Efficacy Study. Journal of Medical Speech-Language Pathology 14 (4).