Dynamic Temporal Tactile Cueing (DTTC) for Apraxia: Caregiver Guide

Dr. Edythe Strand Explains CAS for Caregivers

Childhood apraxia of speech (CAS) is a label for a speech sound disorder that impacts one’s ability to plan sequential movements for speech productions. There are several evidenced based programs available for treating this neurological condition, one of which is Dynamic Temporal and Tactile Cueing (DTTC.)

DTTC Defined

DTTC is a therapy approach that helps kids learn how to move their mouth muscles for talking. It focuses on practicing different mouth movements. Unlike other speech therapies, DTTC is effective for kids with severe speech problems. Your speech pathologist picks specific speech motor movements to practice extensively, slowly helping kids do it on their own.

The amazing thing about this therapy is that when your child learns to make one speech motor movement, he can use that skill for other movements too. For example, learning to say the “p” sound in “up” can help with saying “p” in “pup.” And once your child gets good at saying single words, it helps him talk in longer sentences and have conversations.

Resources Caregivers Can Share With Their SLP

As a speech pathologist, my mission is to educate both caregivers and peers about resources that support children with CAS. DTTC offers an incredibly accessible program for any speech pathologist interested in improving their skill set. Child Apraxia Treatment is a program of the Once Upon a Time Foundation, a Nonprofit 501(c)3 Organization. This website directs speech pathologists to the following FREE coursework:

• Introduction to CAS: Virtual course taken at your leisure for increasing knowledge of childhood apraxia of speech characteristics and basic treatment (.15 ASHA CEUs)
• Diagnosis and Treatment of CAS Using DTTC: Everything you need to know about DTTC (.45 ASHA CEUs)
• YouTube Channel: Link that directs you to view the online courses while bypassing ASHA CEUs
• Advanced Workshops: FREE in-person 2 day workshop via application process for speech pathologists seeking advanced knowledge about DTTC (1.3 ASHA CEUs)

Hierarchy

Once Upon a Time created the above flowchart that concisely and brightly summarizes the supportive levels of DTTC towards spontaneous practice. The keys at the bottom further explain the types of cues utilized in DTTC and examples of prosody models. Ultimately, the goals are to fade cueing supports, increase speaking rates, build consistency, and expand prosody (tones) to at least two types. You can find a copy of the above image by navigating to this link and then clicking ‘Downloadable DTTC Hierarchy Infographic.’

Target Selection

Your speech pathologist begins with a dynamic evaluation, which allows your therapist to provide cues while assessing to make note of the most supportive options for therapy. Ultimately, your therapist selects anywhere from 4-6 speech motor movements for a practice round, depending on severity. Working on one movement, should generalize to other targets.

Motor Movements Defined

In your child’s session notes, you should see summaries using abbreviations for a variety of motor movements. Below, the therapist typically utilizes early movements in DTTC intervention, with a few examples listed for each.

• CV: Consonant-Vowel (me, do, show, bye)
• VC: Vowel-Consonant (eat, up, on, at)
• Reduplicated syllables (papa, Dee-Dee, cuckoo, boo-boo)
• CVC1: Consonant-Vowel-Consonant with the same first and last phoneme (mom, pop, dad, sis)
• CVC2: Consonant-Vowel-Consonant with different first and last phonemes (home, mine, mad, book)
• Bisyllabics: One consonant with two vowels (uh-oh, baby, daddy, mommy) progressing to more varied syllable shapes (happy, open, today, movie)
• Multisyllabic Words: Multiple syllables (banana, video, peekaboo, lemonade)

Supportive Movement Focus

Let’s take a closer look at each supportive stage in the DTTC hierarchy, so you can have a clearer picture of what this program looks like. Your therapist will use her clinical training and expertise to determine when your child is ready to advance to the next step.

Simultaneous

The first step is to practice saying the movement together at the same time. Following an explanation, your therapist may count down to help sync the productions. Sometimes, it’s beneficial for the therapist to fade her voice and just model the movement at this level. While varying prosody is encouraged, it is not necessary for advancement to the next step. At first, this level may take some time with up to 15 repetitions. Moving forward, trials will reduce and practice may begin at the highest level reached from the previous session.

Direct Imitation

Here, your therapist says the target and then your child imitates it immediately. Models may begin at a slower rate and then gradually increase in speed. Now, it is essential to model varied prosody with the intent of having your child imitate at least two variations. Don’t be surprised if your child masters one motor movement but struggles with a different prosody. Your therapist will adjust cues and supports accordingly. Ultimately, the aim is to practice without errors to establish a precise motor plan.

Delayed Imitation

Just as the title implies, imitations occur with a slight delay at this level. I have found that building on the delay is helpful. First, I explain this new step and then I use the word “wait” after my model paired with a hand gesture before I say “go”. I then build on repeating the word “wait” 2-3 times to lengthen the delay. As with direct imitation, we want your child to copy at least two prosody variations before moving to the final step.

Spontaneous

We have now worked our way to the final level. Once your child can produce a movement here, then he should be able to carry this over into phrases, sentences, and conversations. To prompt this practice, your therapist will ask a question, setting up your child to answer with the targeted word. Sometimes, I find it works to use a starter phrase like, “Ready, set, —” with a pause for the client to say “go” without hearing me model the word.

Incentives

During practice, your child should be free of distractions with your therapist positioned for optimal viewing of her face. If needed, then clients can earn incentives for blocks of practice in the way of: magna tiles, stickers, game pieces, bubbles, or puzzle pieces to name a few.

Feedback

Therapists begin by providing as much feedback as your child needs to be successful. Verbal feedback may include: “Open your mouth wider”, “Lips together!”, “That was it!” or “Try that again.” This feedback must fade so your child can self-monitor productions, gain independence, create accurate motor plans, and generalize skills unsupported.

Making Progress

As your child progresses in DTTC, we track their improvement in two ways. One way is by observing how well they do during sessions. Another is by doing a special test after a few sessions. During this test, your child tries to copy the movements without help. We give points based on how well they do. To “graduate” a movement, they need to get a high score. If not, we keep practicing it until they do better.

Frequently Asked Questions:

Does DTTC improve speech production in severely apraxia children?

Yes! DTTC was designed to benefit children with moderate to severe apraxia. Research and clinical experience suggest that children making little to no progress in traditional speech therapy may benefit from DTTC programming.

How is childhood apraxia treated?

Apraxia is best addressed when therapists factor the principles of motor learning (PML) as a guide during diagnosis and treatment planning. Motor learning is defined as a process of obtaining the ability to produce a skilled action. Therapists initially provide maximum supports to help the child produce motor movements and thereby develop an accurate plan to talk. Once a specific motor plan is established or created, then the child should be able to produce that motor movement in various contexts (word, phrase, sentence levels) and in multiple settings.

Does DTTC improve articulatory accuracy and verbal communication?

DTTC is one of several evidenced-based (research supported) approaches for improving verbal communication. However, it is imperative that a trained speech pathologist complete comprehensive and dynamic assessment before considering DTTC programming.