Case study analysis 1

The child is 14 years old, diagnosed with severe general motor apraxia, severe Apraxia of speech and attention deficits (Neurological diagnosis). He is learning in a special small class in a regular school. In his class there are 10 students with learning disabilities.

Patient history & description of skill

The child is 14 years old, diagnosed with severe general motor apraxia, severe Apraxia of speech and attention deficits (Neurological diagnosis). He is learning in a special small class in a regular school. In his class there are 10 students with learning disabilities.

It is very important to review his historical development in order to understand the essence of his disabilities and the rehabilitation process he had gone through. This will be expressed in the next chapters.

He was born with no complications and received a  high Apgar score of 9 and 10. He was very quiet as a baby, he didn’t babble. His motor development was not usual; at the age of a year and two months he stood up, then sat down for the first time and then crawled for the first time. He was very clumsy as a child. He couldn’t speak or say any syllables even not spontaneously. The doctors who saw him at the age of two said that he wasn’t mentally retarded since he had smart eyes and that  he wasn’t autistic either. He used to shout a lot out of frustration and to bang his head on the floor. His extreme behavior and lack of speech brought him to special kindergartens that didn’t know exactly what to do with him. At the age of four a speech language pathologist (SLP) was the first to diagnose him with Apraxia of speech.

I started working with him when he was 6 years old. At that age he still couldn’t pronounce syllables, he couldn’t walk upstairs without support, and he walked downstairs in a step to step way (STS) with poor control. He couldn’t stand on one leg or jump. However he could read. In the kitchen entrance was a big board on which he posted written words in a short sentences such as “I want to eat”. He taught himself working on the computer in reading software. His reading ability was the proof of his academic potential. He was in a special kindergarten just before entering first grade and was supposed to go to a special education school. We worked primarily on speech though after a few months we started working on gross motor abilities as well. He acquired all the syllables after six months and started building words and using them. Thanks to that he entered a regular school the year after.

When I met him I started a long therapy journey of 9 years that proceeds today. The main therapists in that journey were my self and his mother who retired from work when he was born in order to take care of him. Throughout the years the therapy program included all the fields of treatments with a focus on motor-speech and gross-motor treatment. This paper will focus on the motor-speech domain.

The child had no speech ability at the age of six years old due to Apraxia of speech. In the next 9 years he acquired motor-speech abilities and could say what ever he wanted though his pronunciation wasn’t clear. The main problem with his speech is the prosody of speech. Prosody is the patterns of stress and intonation in a language (http://dictionary.reference.com/browse/prosody). The term generally covers intonation, rhythm, and focus in speech (Rom, Segal & Tchur, 2003). Acoustically, prosody describes changes in the syllable length, loudness, pitch (frequency of a sound), and certain details of the formant structure of speech sounds. From the speech articulator’s point of view, prosody is actualy changes in the velocity and range of motion in articulators like the jaw and tongue, along with quantities like the air pressure in the trachea and the tensions in the laryngeal muscles. Phonologically, prosody is described by tone, intonation, rhythm, and lexical stress (http://en.wikipedia.org/wiki/Prosody_%28linguistics%29).

The child couldn’t control the loudness of his speech nor did he have versatility of tones in his speech. Those prosody problems didn’t allow him to deliver non semantic massages via speech which is a very important element in verbal interaction. The motor skill acquisition I choose to describe here is the ability to change voice pitch in speech (Intonation).  

The human voice is a result of a flow of air originating in the lungs. This air flows through the trachea, passes the vocal cords, epiglottis, and pharynx and then goes out of the mouth and nose cavities (Denes & Pinson, 1993). The vocal cords are responsible for sound production.  In regular breathing the vocal cords are open in the shape of a  “v” thus letting the air to flow with no interference. In order to produce sound air has to pass through the close vocal cords . The vocal cords cause vibration of the air flow which creates sound. The sound is depended on the frequency of the vibration. The pitch of sound is higher when the frequency is higher. The vocal cords are covered with a thick layer of white smooth mucus that enables good vibration. 

The pitch is determined by the:

1. Length of the vocal cords – long cords will produce low pitch.

2. Tightness of the vocal cords – tight cords will produce high pitch.

3. The accumulated air pressure proximal to the vocal cords can affect pitch.

The vocal cords are soft, non-contractible tissue. They originate at the Cricoid cartilage and inserted at the Arytenoid cartilage. They can be starched or relaxed by the adjacent muscles which are connected to the Arytenoid cartilage and get their nerve supply from the recurrent laryngeal nerve (originated in the Vagus nerve)(Grays Anatomy1964).

The motor skill required is to contract and relax those muscles consciously with intention and by that to produce different pitches, and to be able to maintain the pitch for a few seconds.

Readiness for learning

Not every task can be taught by a therapist when ever he likes. The patient has to be ready and prepared for learning. Maturation is a factor that must be considered in developmental disabilities. The emotional state after an injury can affect readiness for treatment. In this case, we tried working on intonation for 4 years with no success. Even though it seems like a situation in which you might give up, the lack of intonation was the primary language disability that didn’t enable him to integrate in society normally. Everywhere he went and started talking everybody looked at him strangely and backed away. Recently we decided it was the right time to work on the intonation again with full power because of the following reasons:

Emotions – the child was very aware of his disability. He liked very much to succeed in every task he tackled whether physical or cognitive. He used to ask after every performance “How did I do?” this awareness and motivation for success sometimes got him very nervous and tense since he was afraid of failure. One of the reasons he was stressed for success was his mother who forced him to learn and all the time compared him to regular children of his age.

At the age of 14 after so many years of struggling, the child adopted emotional defense mechanisms that helped him to deal with stressful situations. He knew it takes time to learn something new so he was ready to practice more then before. He knew that he can learn new things after practicing so he wasn’t nervous as he was before and could deal with new tasks without resistance. Before, when he tackled a very difficult task he used to throw a tantrum. Now he can deal with it and express his difficulties verbally.

Trying to work on intonation is a very difficult task even for adults with Apraxia of speech. We felt and saw that the child was ready emotionally for this task.

Intelligence – we felt that the child had within normal range intelligence. On a psychological test he took the result was that he had border intelligence, but this test didn’t take into account his developmental history. There was a section in the test that he was asked to describe verbally all kind of abstract shapes and he did this poorly. With out this factor he would have got normal range score. Considering the fact that he only began talking in a conversation level a few years ago, one would expect difficulties in describing abstract shapes. On the other hand, this child can solve mathematical problems for his matched age group. He learned a second language with his class and has average grades of B+. I can use cognitive strategies in therapy with him and that can be helpful in the learning process of intonation.

Capabilities and previous experience – the child’s capabilities in changing pitch in speech are very low. When he tries to change pitch he usually raises his voice. His speech is flat with no rhythmic changes in pitch. While analyzing his pitch with speech analyzer software we can see the fast decrement of the frequency (pitch) in any word he says. When he tries to say a simple syllable he can’t keep the frequency or the sound stable.

The capabilities of controlling the muscles action around the vocal cords are very limited. The low potential abilities make the learning process very difficult and can explain why he couldn’t progress before.  

Developmental qualities – the level of development of the intonation capability was very low over the past 14 years. In the last 4 years there were specific efforts to build up intonation abilities in a variety of ways with no success. A starting point of such a poor ability in an advanced age doesn’t have a good prognosis.

Attention – the child has mild attention deficits. He tends to loose focus while having stereotype movements. Today he can control his stereotype movements and can sublimate his impulses. He is usually anxious to finish the lesson and go back to his preferred activities.   

Learning style – the learning style theory is concerned with the differences in the process of learning. The learning style is unique for every practitioner and enables him to learn new tasks. McCarthy (Rose & Christina, 2006) defines 4 learning styles: dynamic, innovative, common sense and analytic. In this case it is hard to define a learning style since the child is not an active learner. He would rather not learn and the way he is learning is being imposed on him by his therapists. The learning styles characteristics by McCarthy regard the learner as an active learner and use the phrase “prefer”. In this case the child doesn’t “prefer” but is forced to learn. While this doesn’t sound ethical or a sensible therapeutic way, the fact is that if he hadn’t being forced to learn he wouldn’t have learned most of what he can do today and would have stayed in a special education system, frustrated with not much of a future.

I can identify features of the Dynamic, Common sense and Analytic learning styles in his way of learning.  

Motivation – motivation is “the psychological feature that arouses an organism to action toward a desired goal; the reason for the action; that which gives purpose and direction to behavior” (http://dictionary.reference.com/browse/motivation). Motivation is a basic feature in treatment. Without knowing how to motivate there is no existence even for the most knowledgeable therapist. This is the “engine” that enables treatment. In some patient populations there isn’t a crucial motivational problem because the patient corporate since he understands his problem and the benefit he will gain out of treatment. In the case of developmental disabilities, especially with mental retardation, motivation is central. This population is not motivated automatically to get treatment because they lack the understanding of the benefits from treatment.   

Rose (3) counted two sources of motivation: external and internal. In the developmental disabilities area I would add two more: therapist-patient relationship and inertia. The therapist-patient relationship can be a source of motivation for the child and it is not internal or external source by definition. The child is willing to make an effort for the therapist with no regard of the task. It has some external motivation features since he is not doing it for himself, but it is different from any other external reinforcement. The inertia can be identified as a source of motivation among children with years of experience in therapy. There are children who will cooperate in therapy even though there is no internal interest, no special relationship with the therapist or no evident external reinforcement. They are used to therapy and that is why they are cooperative.  

In this case, the child’s motivation for practice emerged from all 4 sources of motivation at different levels. He knew he had a problem with intonation and his experience of not being understood brought about an internal motivation. He has a very special relationship with me. We have a long history together and that’s why he would cooperate with me with almost anything I ask of him (therapist-patient relationship). In the therapy sessions he sometimes lost patients and I needed to use external motivational tactics to maintain motivation such as promising him that he could watch a specific T.V. show or that we will finish in a certain amount of time. The inertia source of motivation played a great role. He was used to working on a difficult task every day and he perceived it as another thing he must do, one out of many.

Since he was high motivated and cooperative the child practiced intonation with different techniques for 4 years. His motivation gave us the opportunity to try and find a solution. Using the final technique he worked every day for 20 minutes with his mother for two months (including weekends and holidays).

Social status – the main obstacle in his way to social integration at that time was the intonation problem. The impact intonation had on his social status was so great that his mother decided to put a lot of effort into this mater. This is the surroundings readiness for teaching the motor skill which is a very important factor in the way that this system works. Without the cooperation of his mother it couldn’t have worked. 

Teaching/Modeling techniques 

Teaching this specific skill took approximately four years. It wasn’t consecutive four years of treatment but periods of a few months each time along these four years. It was very hard to explain to the child how these muscles work. I couldn’t find a professional help either locally or internationally to guide us on how to make him understood how to activate these muscles. The purpose of therapy was to teach him how to discriminate between high and low pitch at the beginning of the process. Voice recording showed us a consistent pitch level in every word whether he tried to say it in a high or low pitch, and a drastic pitch decrement after each sound.  I tried many techniques with no success until I found one specific technique that gave immediate results.

This specific skill is different then other gross motor skills where the skill is visualized mostly and you need to use teaching/Modeling techniques in a direct manner. In this case teaching/Modeling techniques are one level of teaching when the other one is the indirect tactics through which the child can learn. The indirect tactics are ways in which the child acts without an intention to learn the specific task. He doesn’t know that he is learning it. I will describe the different tactics I used and the teaching/Modeling techniques used within these tactics.

Changing head position

The first technique I tried was trying to discriminate high and low pitch by changing the child’s head position. When the head was in flexion the child was asked to say the syllable “mi” in low pitch. When the head was in extension the child was asked to say the syllable “mi” in high pitch. The logic of the technique came from watching opera singers. When they attempt high pitch they usually use head and trunk extension. I assumed that it might affect the position of the Arytenoids and thus the vocal cords tension.

 At the beginning I showed him what I wanted him to do by modeling and we did it in turns so he won’t feel any pressure for success. It was perceived as a game. I praised him all the time for his good effort. After 8-10 trials I gave him augmented feedback on his success, especially for the high pitch trials. If I didn’t hear any change in pitch or an effort to change the pitch I urged him to try again. After 2-3 consecutive trials I gave him a compliment with no regards to his success in the trial but to keep him motivated.

His practicing was characterized with high tempo and high use of verbal instruction and conversation by me, so he wouldn’t lose interest. Each session took approximately 10-15 minutes divided into 1-2 minutes of practice (with different sounds) and 1-2 minutes of a break. We met once a week while working on intonation was just one of the goals. Every treatment session took 2 hours. 

This specific technique brought a slight subjective change in intonation. After a few months of practicing we could hear a slight change in the way he asked questions but not more then that. We didn’t have an objective tool to examine the treatment results, there wasn’t a pragmatic change.   

Asking questions

The second technique I used was a trial of the child asking questions. That was his main pragmatic problem at that time. At the end of a question sentence there should be an increment and then a decrement of pitch. This child couldn’t elevate his pitch and there was a quick decrement of pitch thus he couldn’t ask questions.

The technique was trying to ask questions under these conditions:

1.      Asking a lot of questions in a row (40-50) so there is an option for discovery learning (3, pp 245) since he didn’t have any idea how to do it and I couldn’t physically show him the movement.

2.      While trying to elevate the pitch in the last syllable he was asked to extend his head as he learnt to do in the “changing head position” technique. I timed the head extension with my finger just like an orchestra conductor.

3.      We asked questions regarding sports events so he would be motivated to work.

4.      We used short question sentences and short words within the sentences so he wouldn’t need to deal with the length of the word. In a motor learning point of view, this reduced the degrees of freedom (3). 

Asking questions was practiced once a week with me and 3-4 more times with his mother. Each session took 20 minutes. After a few months we could hear a change in the question pitch though it wasn’t consistent.

Playing the piano

Every therapist we asked recommended on working with musical instruments to enhance or teach intonation. We brought a piano teacher that started teaching him how to play the piano once a week. After 3 years of practicing the child learnt to play the piano with both hands (an amazing accomplishment for an apraxic child) but it didn’t change his pitch pronunciation ability. The training wasn’t pronunciation specific so it didn’t have any impact.  

Singing

Continuing the piano lessons, I tried to work through singing. I took a single line in a well known song which the child could play on the piano, and wrote it graphically so the child could see the pitch changing along the song. The child was asked to follow the graphical line and to sing the same line over and over again. When the pitch was high the child extended his head. When the pitch was low the child flexed his head. I demonstrated once at the beginning and he understood what I wanted immediately. Every session took 15 minutes. We sometimes used the piano as background music as well. We tried this technique for 2-3 months with 3-5 sessions a week

It was very promising but it didn’t enable him to learn pitch control.

Voice control

One of the problems we encountered was inability to control a stable pitch. So I built a new technique for stable pitch control. The child lay on his back with his knees bended. He learnt to breath with a diaphragm focus, I put a book on his belly and he was asked to elevate the book while inhaling and decrease the book while exhaling. After 2-3 sessions he controlled it perfectly. Then, he was asked to breathe diaphragmatically and when exhaling to say a long “ahhhhhhh”. He had trouble keeping the sound stable and it became a different sound after a second or two. After practicing for 10-15 minutes there was an improvement and after a month of practicing he could keep the sound stable for 3-4 second. It means that he could start controlling the muscles that activate the vocal cords. It didn’t change the ability to perform high and low pitch sounds but was an important achievement on the way.    

Distal Dynamic Stabilization

After 4 years of working on intonation with different techniques there was no break through (there were more therapists and techniques I didn’t mention). The Distal Dynamic Stabilization derived from a clinical reasoning that was made in order to try and find a way to teach intonation. When we increase pitch we increase simultaneously the muscles contraction around the neck and mouth. I found out that the muscles which retracts and open the jaw (Geniohyoideus, Mylohyoideus and Pterygoidus Internus )(5) participate in pitch increasing. I assumed that if I could teach the child to activate these muscles while trying to elevate pitch, then he might succeed in the task.

I tried to show him how to activate consciously these muscles by modeling and then by pressing on the belly of his muscles upward. I assumed that the muscles would contract upward in response to my stimulation but it didn’t happen. We tried this for 10-15 minutes and nothing happened. He couldn’t understand how to activate these muscles.

In the next session, a week later, I came with a better technique. The role of these muscles is to open the mouth so I asked him to open his mouth and gave a vertical upward resistance at the apex of his jaw. We got to a stable situation in which there were no movement, the mouth was semi-open while the child is pressing his jaw down and I am pressing back upward. In this situation the muscles I wanted to activate worked perfectly. Then I asked him to pronounce “mi” in high pitch and it worked immediately.

I built a program to practice this technique up to 15-20 trials a day. His mother was the executer of the program. I taught her exactly what to do. She didn’t perform as professionally as I did but it was good enough. I recorded his pitch pronunciation ability at the beginning of the program and after a month. There was a great change in empiric results and in pragmatic ability. Every question he asked was heard as a question. 

Usually, there is a proximal dynamic stabilization for a movement. The shoulder muscles give proximal stabilization to the elbow movement etc. in this case; there is a distal dynamic stabilization since through distal movement stabilization we can encourage proximal muscle work. Using the distal dynamic stabilization was very important in this case since there was no other apparent way to approach these deep muscles. In my opinion there are two explanations for the distal dynamic stabilizationmechanism. The first explanation is that the vocal cord muscles and the jaw openers muscles work as a group in that specific task. In order to perform the task all the muscles that belong to the group must work together otherwise the task can’t be performed. That group of muscles might have neuronal connections (similar to agonist-antagonist neuronal connections) thus activating part of the group with intention to activate the other part might cause an overflow from one part to the other.

The other explanation is simpler. A co-contraction of the jaw openers and the Masseter muscles creates a distal stabilization that performs a close kinematic chain. Stabilization of the distal part of the chain enable a movement in the proximal part just as doing push up exercise; the distal part, wrists, is stabilized while the proximal parts, the elbow and shoulder joints, are moving.    

Stages of motor learning

The child’s performance changed only after introducing the distal dynamic stabilization technique. We can analyze the performance changes through different theories regarding stages of motor learning:

Fitt’s three stages of learning

The child was in a cognitive stage of learning for 4 years, trying to understand the motor task. Only when the distal dynamic stabilization technique was introduced he started to progress. The physical support enabled him to understand the nature of the task.

After 2-3 treatment sessions he entered the associative stage in which he practiced the task based on the knowledge of the task he had acquired earlier. He succeeded better and better and needed less and less support in order to perform a high pitch sound. He could perform a high pitch sound in different syllables.

When he started using the high pitch sound in pragmatic circumstances such as asking questions then he started entering the autonomous stage. The control over the task was not completed thus we can identify parallel practicing of the three stages together. He still needs the basic practice of distinguishing between high and low pitch (the cognitive stage). He is also still working in the associative stage since his control over the task is not full and he can’t implement it in various situations (practicing different frequencies of pitch). I can say that he has some autonomous ability since he can ask questions clearly but he still doesn’t have full control over these muscles and can’t use intonation properly. Therefore he is practicing in all 3 different levels at the same time.        

The Neo-Bernsteinian perspective

The Neo-Bernsteinian perspective expresses movement acquisition through the amount of degrees of freedom in the task. It defines 3 stages of learning – novice , advanced and expert. At the beginning of the learning process the amount of degrees of freedom was low since the child had physical support to his jaw and was asked to change only one pitch from his basic frequency to a higher frequency. This can be regarded as the novice stage of learning. When the physical support faded and the child was required to change pitch in different sounds then the amount of degrees of freedom increased and this can be regarded as the advanced stage.  

Being able to ask questions in a changing environment and not in treatment is a situation of better control over more degrees of freedom and can be regarded as the expert stage. As in the Fitt’s model, the child is practicing in all the levels in the same time. It is not an ordinal ladder inspection but a consecutive one.  

Gentile’s two-stage model

In the first stage of Gentile’s model the learner gets the ides of the movement. The regulatory condition in our case is the physical support given by the therapist. In contrast to throwing a ball or climbing a ladder, the movement in this task is invisible since it takes place inside the thyroid cartilage. Still, there is a regulatory condition that shapes the movement. By giving the child the external support he understood the feeling of the movement and therefore the idea of it.

The next stage by Gentile is the fixation/diversification stage in which the performer is learning new skills that derive from the one he acquired (similar to the GLM theory (3)). In this case the child acquired the basic ability to distinguish between high and low pitch through one specific sound (mi) and now he is capable of doing it in different sounds (I, ki, ti), environments (home, pool, supermarket) and pragmatic applications (asking questions). 

It is interesting to see the different points of view each model has. I prefer the Fitt’s model when describing the learning process of this skill.    

Measurement of motor learning

In order to learn about the objective influence of the technique I described here, I performed a small experiment with an objective measurement. The child was recorded on the “speech analyzer” software at the beginning of the treatment period. The recordings included 20 words, the sound “I” in high pitch, the sound “I” in high pitch for 3 seconds, the sound “I” in high pitch with support and 5 question sentences.

There were two dependent variables:

1.      Pitch level

2.      Duration of pitch

The baseline measurements were taken before the treatment period began and the second test was taken after a month. The treatment program consisted of 15 minutes of daily exercises:

1. Saying “I” in high pitch with support.

2. Saying “I” in high pitch for 3-5 seconds.

3. Imitating 10 questions two times in a row.

4. Blowing on a candle without extinguishing it.

After two weeks we felt there was a great change in the child’s intonation ability. The final measurements that were taken after a month showed different results from the basic assessment. There was definitely a learning process since the change in behavior was consistent. After another month I took another measurement and found the same results that showed retention. I didn’t measure transfer objectively but we could hear the child asking questions in the right intonation in various environments, a skill he didn’t performed before.

I would rather use the transfer method of research in this case since the meaning of that skill acquisition is using the skill in the every day language; in other words, transfer the ability to different pragmatic applications. Hence, if there is a transfer then the pragmatic goal is established.  

References

Denes, P. B., & Pinson, E. P.(1993). The speech chain. W.H. freeman and company.

Grays Anatomy, descriptive and applied (33rd ed.). (1964).Longmans, Green and Co Ltd.

Rom, A.,  Segal, M., & Tchur, B. (2003). Child, what does he say? . Mofet Institute (Hebrew).

Rose, D. J., & Christina, R. W. (2006). A multilevel approach to the study of motor control and learning (2nd ed.). Pearson Education Inc.

Travis, E. L. (1957). Handbook of speech pathology and audiology. Applton-century-crofts. New York.

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