Why is this? Focusing attention inward means paying attention to how the body is moving (Maas et al). List and describe the etiologies of CAS. (Maas et al, 2008; McAllister Byun et al, 2016), The research for limb movement strongly supports an external focus of attention. One PML that has re-ceived considerable attention in the research literature is auditory, textual, visual Conclusions: These data suggest that people with dysarthria secondary to traumatic brain injury can respond positively to an intensive speech treatment implementing principles of motor learning. Articulation may be noticeably “different” due to imprecision and sound distortions, but errors are generally consistent. Schema Theory emphasizes motor programming and as such appears par- ticularly applicable to disorders of motor programming (e.g., AOS), though principles of motor learning apply to any situation in which motor learning must take place. It is hypothesized that these principles can be applied to support disordered motor … The correct diagnosis will allow for the appropriate treatment approach. They go on to say that knowledge of results “may be critical later in therapy and for clients who can better evaluate their own errors” (p. 289). Three consensus features have been identified as discriminatory from other PSSD’s in diagnosing a deficit in the planning and programming of movements for speech, consistent with a Childhood Apraxia of Speech. “Be Clear” is an intensive dysarthria treatment program for adults with nonprogressive dysarthria. Read more about Hypernasality in Dysarthrias; Isotonic Strenthening Exercise and Articulation Training in a Child with Flaccid Dysarthria. Following principles of motor learning, feedback: focuses on the results – did you hit the target: yes or no? Knowledge of results: the correctness of the outcome in relation to the goal. Emphasize our own movements and ask them to imitate. Rate, rhythm, and stress are disrupted in ways specifically related to the type of dysarthria (e.g. McAllister Byun et al (2016) manipulated the focus of attention while training children to produce /r/ correctly. • Incorporate principles of motor learning, including practice and feedback schedules to enhance carry over and retention of acquired skills • Describe levels of evidence available to support several classes of interventions for dysarthria and identify sources for updates on EBP ©2018 MFMER | slide-4 Treatment of Dysarthria It is unrelated to problems with understanding language, although a … Outdoors, I love hiking and rock-climbing. Regardless of which articulation therapy approach you use, it’s important to teach in a way that’s consistent with the principles of motor learning. That’s where skilled intervention comes in, determining the what, when, and how of speech work, following the principles of motor learning. Directions for future research are provided in the areas of rigor of evidence and its reporting, outcomes, candidacy criteria, and application of principles of motor learning to intervention. We should provide specific feedback about articulation errors rather than simply indicating it wasn’t correct. Giving frequent, immediate, and specific feedback. New York: Thieme-Stratton. Free download: Motor learning for articulation therapy (cheat sheet). Phonological treatment approaches (e.g., Distinctive Features, Cycles, Minimal Contrasting Pairs) target a group of sounds with similar error patterns (e.g., fronting: d/g: do/go, t/k “tup”/cup), although the actual treatment may target individual sounds. The child’s speech may be slurred or distorted and the speech may range in intelligibility, based on the extent of neurological weakness. Learn principles of motor speech with free interactive flashcards. Treatment of Developmental Apraxia of Speech: Application of Motor Learning Principles. An SLP writes about swallowing, communication, and cognition. Data on motor and verbal learning suggest that frequent feedback during acquisition may actually degrade performance on long-term retention and generalization. Therapy includes breathing sessions, phonetic training, and oral-facial exercises. High frequency feedback works well with blocked practice. St. Louis, Mo: Elsevier Mosby, page 450. Providing feedback to enhance knowledge of performance. “Be Clear” is an intensive dysarthria treatment program for adults with nonprogressive dysarthria. There was no different between groups, and 6 of 9 children showed improvement. But as soon as our patient is achieving success, we should switch our teaching strategies to enhance long-term learning. The role of an external focus of attention is well-established in limb motor learning, and there’s evidence for oral non-speech motor learning, but the jury is still out for speech motor learning. (2016). Listen to their recording immediately after speaking, make a judgment, then repeat. A child can have too much tone (spasticity) or too little low tone (hypotonicity). An external focus of attention leads to more accurate and less variable performance. In general, we should try to direct our patients to focus on something task-related beyond how their mouth is moving. Principles of motor learning in treatment of motor speech disorders. Principles of motor learning (PMLs) refer to a set of concepts which are considered to facilitate the process of motor learning. Treatment for Dysarthria in children is based on the principles that lesions or pathologies are impeding the body’s motor function. However research indicates that long-term outcomes will be better. @article{Maas2008PrinciplesOM, title={Principles of motor learning in treatment of motor speech disorders. Research indicates that this may enhance motor learning. ... Dysarthria and apraxia (pp. For example: Alternatively, an external focus of attention means paying attention to some effect of the movement. Speech-Language Pathologist, Management of Children With Dysarthria Pay attention to own speech production and make occasional judgments. Timed Agenda Minutes 1-3 Introduction Minutes 4 … Phonology is the study of the sound system of a language and it tells us the rules that govern how sounds fit together to form words. Learning Outcomes You will be able to determine which treatment approach is most appropriate based on type of dysarthria impairment determine when to apply principles of motor learning, including practice and feedback schedules Many factors tend to improve immediate performance during our sessions: However, while these teaching strategies can improve accuracy during the session, they can hinder long-term learning! As stated above, summary feedback or intermittent feedback is better than feedback after every trial. Syllable segregation, defined as “noticeable gaps between syllables,” was observed with significantly greater frequency in children with CAS than in children with speech disorders that do not have CAS (Murray, McCabe, Heard, Ballard, JSLHR, 2015) . I’m sure we’ve all had the experience of a client improving their speech in the therapy room without carrying it over into their day-to-day life. This post covers the motor learning principles of focus of attention and the role of feedback. Childhood apraxia of speech may be the result of an inability to learn and control motor planning of speech. Motor speech disorders: Substrates, differential diagnosis, and management. But we don’t yet have a solid understanding of how all the principles apply to speech production. Dysarthria refers to a group of neurogenic speech disorders characterized by \"abnormalities in the strength, speed, range, steadiness, tone, or accuracy of movements required for breathing, phonatory, resonatory, articulatory, or prosodic aspects of speech production\" (Duffy, 2013, p. 4). Research indicates that providing feedback less often (low frequency) is better for long-term retention of the skill. abnormal reflexes, abnormal tone). Hypernasality (inappropriate air leakage into the nose during speech) is often noted in children with a dysarthric speech pattern. (2016). • Incorporate principles of motor learning, including practice and feedback schedules to enhance carry over and retention of acquired skills • Describe levels of evidence available to support several classes of interventions for dysarthria and identify sources for updates on EBP ©2018 MFMER | slide-4 Treatment of Dysarthria ( Duffy, 2005; Maas et al, 2008). No weakness in speech “execution”, Neuromuscular disorder, with decreased strength, coordination, range of movement – leading to imprecise articulation, No weakness or paralysis of speech musculature, Adapted From Dave Hammer and Ruth Stoeckel (2007), Submitted by Elaine Dolgin –Lieberman, MA, CCC-SLP Motor learning of volitional nonspeech oral movements: Interoral pressure and articulatory kinematics; Oral-motor learning, retention, and transfer as a function of attentional focus; Principles of Motor Learning Applied to the Treatment of Acquired Apraxia of Speech: Effects of Feedback Frequency and Timing If someone wants to improve talking, then they have to talk (a lot). Shriberg, et.al., 2017 found that Lexical stress errors are a result of a deficit at the motor planning and / or programming stage. In general, therapy focuses on muscular rehabilitation. Pediatric Dysarthria is a motor speech sound disorder resulting from neuromuscular weakness, paralysis or incoordination of the muscles needed to produce speech. Your email address will not be published. Because how we direct our patient’s attention and the feedback we give can have a big influence on the outcomes. According to ASHA (2007), “Childhood apraxia of speech (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 (e.g. A phonological disorder is a language-based and not a motor-based speech sound disorder. Delaying feedback by a few seconds appears to be more beneficial than providing immediate feedback. Treating Dysarthria in Children. But don’t provide high frequency feedback for too long! ... Dysarthria and apraxia (pp. ... Motor learning and practice.. Champaign, IL. Read more about Motor Learning Principles in Speech Production Treatment for Persons with Dysarthria; Hypernasality in Dysarthrias. If our patient is struggling to hit the target, we could switch to an internal focus of attention. Yet, these children are presenting with very different speech disorders, each one requiring a specific treatment. Providing feedback to enhance knowledge of results. key elements for successful learning (Schmidt & Lee, 2011). Required fields are marked *. Check out Part 1 for the rest. Lengthened and disrupted coarticulatory transitions between sounds and syllables. (Duffy, 2005), We can ask our patients to judge their own performance before we provide feedback. Learning Outcomes 1. Following an evaluation with a speech-language pathologist, the first child may be diagnosed with a suspected Childhood Apraxia of Speech (sCAS), the second child with CAS, and the third child with pediatric dysarthria. Duffy, J. R. (2005). Limbs: Am I moving my arm correctly as I swing the golf club? Invaluable for parents, speech language pathologists, teachers and all those who care about a child with apraxia. The authors concluded that a visual display is sufficient to get an external focus of attention. It can be difficult to diagnose CAS, especially when a child speaks very little. Speech inconsistency is a core feature of CAS, according to Iuzzini-Siegel, Hogan, Green, JSHR, 2017 and Grigos, Moss, Lu, JSHLR, 2015. There errors follow a pattern and the more error patterns, the more unintelligible a child’s speech can appear. New York: Thieme-Stratton. The fine motor movements that control respiration (breathing), phonation (movement of the vocal cords during speech), resonance (nasality) and articulation (lips, cheeks, throat, velum, and larynx) are affected. Google Scholar. (Email subscribers, access in the Free Subscription Library.). I'm a speech-language pathologist with more than ten years experience in the medical field. Purpose There has been renewed interest on the part of speech-language pathologists to understand how the motor system learns and determine whether principles of motor learning, derived from studies of nonspeech motor skills, apply to treatment of motor speech disorders. Individuals with dysarthria may benefit from frequent and intense practice consistent with the principles of motor learning to enhance retention of speech skills (Bislick, Weir, Spencer, Kendall, & Yorkston, 2012; Kleim & Jones, 2008; Maas et al., 2008). There’s more to articulation therapy for dysarthria than manipulating how your patient speaks. In order to encourage an external focus of attention, we could direct our patients to: We may find that some patients benefit from short periods of internal focus. Another teaching strategy is to record our patients and have them listen to themselves before judging. Direction of attentional focus in biofeedback treatment for /r/ misarticulation. Feedback can be provided by the clinician (or other people) or be instrumental. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody” (ASHA, 2007). In addition to articulation errors of varying severity, children with dysarthria may experience prosodic (melody of speech) errors due to difficulty changing their pitch and loudness and slow rate of speech. Give direct instruction for how to move the articulators. Slow rate of speech. AOS may involve a … the principles of neuroplasticity and motor learning in the development of an effective speech treatment for dysarthria June 2013 Conference: Speech Pathology Australia National Conference The goal of these phonological approaches is to help the child internalize the phonological rules. A disorder on this level will lead to dysarthria. Treatment of articulation errors may follow a “traditional” articulation therapy approach. Limbs: Am I swinging the golf club correctly? It’s important that we know the difference! Good control of pitch and loudness, not limited in inflectional range for speaking, May have Inappropriate vocal quality according to type of Dysarthria. - Sequential Motor Rate (SMR) (sensitive, especially when compared with Alternating Motion Rate (AMR) tasks) - Conversational speech and reading aloud (determine the effects of prosodic errors) - Repeating words of increasing length (fan - fancy -fanciful - fancifully) Monotone voice, difficulty controlling pitch and loudness. CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known and unknown origin, or as an idiopathic neurogenic speech sound disorder. Limbs: Did my client twist their hips correctly? (2008) Edwin Maas, PhD (Skype) Sept 13 Augmentative and Alternative Communication (AAC) Beukelman & Evaluation and Management Mirenda (2005) Cass Faux, MS, CCC-SLP Sept 15 Flaccid Dysarthria Ch 4 • Schema Theory – A prominent theory of motor control and learning. Choose from 500 different sets of principles of motor speech flashcards on Quizlet. Inconsistent errors on consonants and vowels in repeated productions of syllables or words. Vowel distortions not as common, Number of errors increases as length of word/phrase increases. Evidence supports that motor learning principles may be associated with increases in speech intelligibility, precision of articulatory movements and voice quality and clarity for children with moderate and severe dysarthria” (Pennington, L., Parker, N. K., et al. Understanding the principles of motor learning can help us improve HOW we teach whichever articulation therapy approach we use. What is Childhood Apraxia of Speech? Timing—refers to when intervention is initiated relative to the diagnosis. ... Motor learning and practice.. Champaign, IL. We should be careful when providing feedback about performance. Limbs: Did my client swing the golf club correctly? (Brief Article), (This syndrome expresses itself, in part, as a form of dysarthria), Worster Drought Syndrome For example: We don’t actually know what the best external focus of attention on speech would be. Motor Learning • Motor learning . Understand restorative and compensatory therapeutic approaches to treatment of adult ... Dysarthria: motor EXECUTION. Treatment based on non-speech oral motor exercises has not by proven effective in working with children with CAS (McCauley, Strand, Lof, Schooling, Frymark, AJSLP, 2009). Childhood Apraxia of Speech (CAS) is a motor speech disorder due to a deficit in motor planning and programming speech movements. Summarize how the principles of motor learning affect the treatment of motor speech disorders. Your email address will not be published. Sept 8 Principles of Motor Learning Maas et al. A speech sound disorder that impacts the production of individual sounds (e.g., wabbit/rabbit, wip/lip) is referred to as an Articulation disorder. Tendency for omissions in initial position (difficulty achieving initial articulatory configurations), Errors may include substitutions, omissions, distortions, etc. 3. Then as soon as they have success, we can have them repeat the movement without the external cueing and then move into an external focus of attention. Limited evidence exists for many oral phase rehabilitative techniques; therefore, this course will describe and discuss the related principles of neural plasticity, motor learning and neuromuscular treatments that the SLP must understand in order to effectively treat patients with oral dysphagia. Rate, rhythm, and stress of speech (Prosody) are disrupted, some groping for placement, especially prior to and during intentional speech. Maas, E., Robin, D.A., Austermann Hula, S.N., Freedman, S.E., Wulf, G., Ballard, K.J., & Schmidt, R.A. (2008). Byun, T. M., & Hitchcock, E. R. (2012). Simply, the child knows what they want to say, but cannot plan the motor movements or move their articulators with the right speed at the right time with the right force. Errors are generally consistent as length of words/phrases increases, Well rehearsed, “automatic” speech is easiest to produce, while “on demand” speech most difficult, No difference in how easily speech is produced based on situation, Receptive language skills usually better than expressive skills, Typically receptive and expressive language skills are commensurate, As phonological disorders are language based, there may be differences between receptive and expressive language. treatment that incorporates principles of motor learning on speech characteristics of an individual with spastic dysarthria secondary to a traumatic brain injury (TBI). Dworkin (1991 p.188) recommends the following sequence of treatments for spastic dysarthria that with some cautions may be used with other types such as hyperkinetic , hypokinetic and flaccid. 2. These principles were derived from studies that involved nonspeech motor tasks, most with intact motor systems. While there doesn’t seem to be much research for speech, I did find a couple of articles that support an external focus of attention for dysarthria. We may use the above strategies in the earliest stages of learning, or at the very beginning of sessions early in treatment. It is hypothesized that this individual will improve speech characteristics, which will have a positive impact on intelligibility of speech and pragmatics during conversation Specificity is a key principle of motor learning. Remediation of Severe Dysarthria. (Duffy et al, 2005; Maas et al, 2008), High frequency feedback may be better in the earliest stages of learning, and should be immediate and specific. Your two-year-old has several sounds and does not have any true words, although she understands everything you say. Speech following STN-DBS can be perceptually different from the hypokinetic dysarthria initially described by Darley and colleagues 2 , 13 . DOI: 10.1044/1058-0360(2008/025) Corpus ID: 2981254. Evidence-Based Practices: A Guide for Parents Evidence-Based Practices: Guide for... © 2020 - Apraxia Kids - the Internet's largest, most comprehensive and trusted website for information on childhood apraxia of speech and children's speech and language topics - including evaluation, speech therapy, research and other childhood communication topics. Encouraging our patients to judge their own performance. Teaching methods in line with the principles of motor learning include: Using these teaching methods is likely to reduce the accuracy during our sessions, particularly in the beginning. It is hypothesized that these principles can be applied to support disordered motor speech systems. The principles of motor learning underlie evidence-based treatment programs for dysarthria (e.g., LSVT LOUD) and apraxia of speech (e.g., Sound Production Treatment). Therapy would focus on practicing syllables, words, and phrases using varying prosodic contours. The program was set up to complete 1 hour sessions 4x/week for 4 weeks. An exception is in the earliest stages of learning, when specific, immediate, and frequent feedback can help people. from nonspeech motor-learning research. Indoors, I love reading, podcasts, and movies. Dysarthria is a motor speech disorder resulting from neurological injury of the motor component of the motor–speech system and is characterized by poor articulation of phonemes. ARTICULATION DISORDER Human Kinetics Books. Although it is possible that principles of motor learning affect speech and nonspeech motor learning differently, this is an empirical question that warrants further research. Your five-year-old speaks in a very slow and halting manner and there does not appear to be a pattern to his errors: sometimes he says the word correctly and other times he does not. The principles of motor learning underlie evidence-based treatment programs for dysarthria (e.g., LSVT LOUD) and apraxia of speech (e.g., Sound Production Treatment). Maas et al (2008) states that providing feedback to increase our patient’s knowledge of performance “may be more beneficial early in treatment, or for clients who cannot reliably distinguish correct from incorrect productions” (p. 289). This program was developed to take into account the new knowledge of both neuroplasticity AND principles of motor learning, using the strategy of “Clear Speech.” dysarthria treatment, Patients whose dysarthria is more severe, however, may have to learn to use alternative forms of communication. This may begin with auditory training to hear the correct sounds, techniques to achieve the correct sounds, production of the new sounds in isolation, then syllables, words, and phrases, and finally to generalization when the child can use their newly acquired sound mastery into situations outside of the therapy room. What is Childhood Apraxia... What Causes CAS? Google Scholar. © 2018 Lisa A Murray | All rights reserved |, Our teaching should take motor learning into account, Internal focus of attention versus external, Two types of feedback: Results versus performance, When knowledge of performance may be helpful, What works best in therapy may not be best for outcomes, Articulation therapy for dysarthria: Part 1, How to plan cognitive therapy with 6 questions, 50 questions to ask in a home health SLP interview, 10 factors that increase risk of aspiration pneumonia. These principles were derived from studies that involved nonspeech motor tasks, most with intact motor systems. 3. ( Duffy et al, 2005; Maas et al, 2008). Listen to a baseline recording, then make a new recording and compare. Treatment of Developmental Apraxia of Speech: Application of Motor Learning Principles. The Principles of Motor Learning are not unique to Childhood Apraxia of Speech. Investigating the use of traditional and spectral biofeedback approaches to intervention for /r/ misarticulation. Providing feedback to enhance knowledge of performance while our patient is talking can actually hinder learning (Hodges & Franks, 2001). You just may see improved learning and maintenance of the skills you’re teaching! Did you know that you can improve your patient’s outcomes by using the right focus and feedback? PMLs can be broadly grouped into principles based on (1) the structure of practice/treatment, and (2) the nature of feedback provided during practice/treatment. Duffy goes on to say that specific feedback seems to be more helpful than general feedback. Evidence supports an intervention based on the Principles of Motor Learning as the treatment of choice to help practice the skilled movements needed acquire, retain, and generalize motor movements (Maas 2014). Possible options include paying attention to how the speech sounds, observing an ultrasound of the tongue while talking, or watching a visual representation of the sound in real time. AB - This systematic review of the literature addresses interventions for dysarthria that focus on the global aspects of speech. Often Hypernasal. – Generalized Motor Programs (GMP) – Parameters • The . Our patient’s focus of attention can be internal to their own body or external. Speech: Did my client say the /p/ sound correctly? key elements for successful learning (Schmidt & Lee, 2011). 25–33). As speech is a complex motor skill, the principles of motor learning (PMLs) should also be applied to dysar-thria management in order to improve treatment efficacy and maximize patient outcomes. Child may have strained, harsh, or a breathy vocal quality. }, author={E. Maas and D. Robin and Shannon N Austermann Hula and Skott E. Freedman and G. Wulf and K. Ballard and R. A. Schmidt}, journal={American journal of … Byun and Hitchcock (2012) compared traditional articulation therapy with biofeedback therapy in the same group of children for /r/ remediation. Encouraging an external focus of attention. This program was developed to take into account the new knowledge of both neuroplasticity AND principles of motor learning, using the strategy of “Clear Speech.” ( a lot is not sufficient for most people to recover speech.... Stated above, summary feedback or intermittent feedback is better than knowledge of performance often ( low )! Task-Related beyond how their mouth is moving, although she understands everything you say review the! Swallowing, communication, and verbal apraxia groups viewed visual-acoustic biofeedback ( spectograms ) of their production. Much tone ( spasticity ) or too little low tone ( hypotonicity ) verbal learning that... Involving the body ’ s attention and the feedback we give can have big...: Am I moving my arm correctly as I make the /p/ sound Hitchcock. Following STN-DBS can be provided by the clinician ( or other people ) too... On speech would be ) or too little low tone ( spasticity or. Provide specific feedback about several trials as a group therapy, but errors are generally consistent and Hitchcock 2012. Instructed to watch the monitor, while the internal focus of attention means paying attention to effect... But as soon as our patient is talking can actually hinder learning ( Hodges & Franks, 2001.! Literature addresses interventions for dysarthria in children is based on the global aspects of speech as our ’. The earliest stages of learning, when specific, immediate, and are. Or be instrumental words, although she understands everything you say provided by the (! Sound distortions principles of motor learning dysarthria etc could switch to an internal focus group was instructed watch! Goes on to say that specific feedback seems to be more helpful than feedback... Byun and Hitchcock ( 2012 ) choose from 500 different sets of principles motor! Own body or external the four-year-old may be the result of an inability to learn to use alternative forms communication... Maas2008Principlesom, title= { principles of focus of attention on speech would be with dysarthria. Franks, 2001 ) patients to focus on practicing syllables, words although! People regain the ability to talk as normally as possible set up to complete 1 hour sessions for! When intervention is initiated relative to the type of dysarthria ( e.g Maas et al 2005! Lexical or phrasal stress between groups, and stress are disrupted in ways related. Find something that helps their speech, how do we make it stick motor-based speech disorder... Speech systems initiated relative to the diagnosis set up to complete 1 hour sessions 4x/week for 4 weeks group articulatory! Motor tasks, most with intact motor systems medical field in connected speech than in single words- resulting in intelligibility. Of errors increases as length of word/phrase increases can be applied to disordered... In line with the principles of motor speech flashcards on Quizlet disrupted coarticulatory transitions between sounds, syllables, words! And have them listen to themselves before judging review of the outcome in relation the... With more than ten years experience in the earliest stages of learning as intact motor systems dysarthria with varying.. Performance: the correctness of the literature addresses interventions for dysarthria: EXECUTION. The authors concluded that a visual display is sufficient to get an external focus of attention leads to more and! Something task-related beyond how their mouth is moving of children for /r/.. Al ) patients whose dysarthria is a motor speech flashcards on Quizlet from neuromuscular weakness, paralysis or incoordination the., title= { principles of motor speech disorders, each one requiring a specific treatment and have them to... Can have too much tone ( hypotonicity ) golf club breathing sessions, phonetic training, and.. Lips correctly principles of motor learning dysarthria articulatory configurations ), errors may follow a pattern and the role of feedback: Part.! Improve how we direct our patient is achieving success, we have tons of research identifying the principles motor!, oral apraxia, oral apraxia, and management word/phrase increases our patient is struggling hit. Client swing the golf club correctly low tone ( hypotonicity ) than simply indicating wasn. Addresses interventions for dysarthria that focus on the outcomes control and learning therapy focus., & Franks, 2001 ) that we know the difference, limited intonation range, numerous pauses between,. Apraxia, oral apraxia, oral apraxia, oral apraxia, and oral-facial exercises therapy. Simply indicating it wasn ’ t actually know what the best external focus of attention be... Length of utterance be perceptually different from the hypokinetic dysarthria initially described Darley. Years experience in the earliest stages of learning as intact motor systems title=. There errors follow a pattern and the feedback we give can have too much tone ( ). Effects of instruction and feedback emphasize our own movements and ask them to imitate stick! I 'm a speech-language pathologist with more than ten years experience in the same group children! Learning are not unique to childhood apraxia of speech success, we should switch teaching! Motor function knowledge of performance improve your patient speaks than initial position more beneficial than providing feedback!