Dynamic Temporal and Tactile Cueing (DTTC) and Integral Stimulation

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Integral Stimulation

In the mid-1990s Robert L. Milisen published an article about a multi-layered program for articulation therapy that involved imitation and both auditory and visual models (Milisen, 1954). Since that time Milisen’s method, called integral stimulation, has shaped the treatment of functional articulation disorders, the dysarthrias and acquired apraxia of speech (AOS). It utilises a hierarchical cueing procedure that begins with a high level of support (simultaneous production of slowly spoken simple utterances with visual and tactile cues), gradually fading and amplifying the cues as required until they are faded altogether and the client produces delayed repetitions of increasingly complex stimulus items. Research Rosenbeck, Lemme, Ahern, Harris & Wertz (1973) and Strand & Debertine (2000) showed that integral stimulation intervention in treatment of individuals with AOS was efficacious.

Although they may not be aware of its precise origins, the child speech intervention version of integral stimulation is widely used by SLPs/SLTs in the treatment of child speech and language difficulties. It involves the familiar, and one could say routine procedure in which the clinician models an utterance and the child imitates it with the clinician ensuring that the child’s attention is focused, as far as possible for the individual client, on listening tothe auditory model while looking atthe therapist’s face. Integral stimulation builds from bottom up, starting with short utterances and simple phonetic segments and sequences in a hierarchy of difficulty to longer, more phonetically complex stimuli.

In working with children with CAS integral stimulation can be used on its own, but it is more effectively applied in combination with tactile and gesture cues to shape the accuracy of articulatory gestures, and prosodic cues (Strand, Stoeckel & Baas, 2006), involving melodic intonation therapy techniques (Helfrich-Miller, 1983, 1984, 1994) or contrastive stress (Velleman, 2002). A prominent feature of the application of the integral-stimulation-combined-with-prosodic-cues approach with children with CAS is that syllable, word and sentence stress are emphasised very early in therapy, that is, from the outset, and with very young children if possible.

Dynamic Temporal & Tactile Cueing for Speech Motor Learning

For non-verbal children, with very severe CAS for whom the method described above is too difficult, Strand has developed and tested (Strand, Stoeckel & Baas, 2006; see also Jakielski, Kostner & Webb, 2006) a variation of Integral Stimulation called Dynamic Temporal and Tactile Cueing (DTTC) for Speech Motor Learning. Incorporating principles of motor learning (page 40), it can be used with the non-verbal children who struggle unsuccessfully with the task of articulatory imitation and who seem unable to achieve even the remotest approximation for consonants or vowels. DTTC is an explicitly principled modified version the Eight-step Continuum for Treatment of Acquired Apraxia of Speech (Rosenbeck, Lemme, Ahern, Harris & Wertz, 1973) originally designed for adults with AOS.

DTTC allows for what Strand calls ‘a continuous shaping of the movement gesture’, with the goal of (1) improving motor planning, and (2) programming speech processing as speech and language acquisition progresses. And once again the tiny steps and essential adjustments for therapist and child of the ‘therapy dance’ have a familiar ring. The steps in DTTC are as follows.

1)     Imitation
In its implementation, DTTC begins with direct, immediate imitation of natural speech.

2)     Simultaneous production with prolonged vowels (most clinician support)
If the child cannot imitate, the therapist makes the task easier and more ‘supported’ by introducing simultaneous production. The SLP/SLT says the utterance at normal volume with the child, very slowly with touch/gesture cues as required. The utterance is slowed by sustaining the vowel (e.g., “sea” produced as si::::: and not as sssssea; "me" produced as mi:::: and not as mmmmme; "bye" produced as ba:::i::: and not by with undue emphasis on the onset consonant). This usually helps the child to imitate while allowing the clinician to run a ‘visual check’ of jaw and lip postures (e.g., no jaw slide and acceptable symmetry).

3)     Reduction of vowel length
The rate of stimuli production is increased (i.e., vowel length is reduced) to sound more natural.

4)     Gradual increase of rate to normal
Practice continues at this level to the point where the child synchronises effortlessly with the therapist at normal rate, with normal movement gestures, and without silent posturing.

5)     Reduction of therapist’s vocal loudness, eventually miming
Using delicate timing the therapist is then in a position to reduce volume eventually reaching a point where the therapist is producing a mime (mouthing the utterance) as the child actually says it aloud. Because of the intellectual closeness within the dyad this can be a tricky point in therapy, and some children will dutifully follow exactly what the adult is doing so that the two are miming at each other! This is obviously not the goal, and children may need explicit instruction to keep their voice ‘turned on’ even though the adult’s is ‘off’. The gesture and touch cues may still be needed at this point, and will be necessary in the next step, the integral stimulation method proper.

6)     Direct imitation
The SLP/SLT ensures that the child is comfortable with moving to this harder level in which the child watches the adult’s face while an auditory model is provided. The child attempts to repeat the model and if successful does so many times. If unsuccessful, the therapist may backtrack to the simultaneous level or silent mouthing/miming level described above. Eventually all miming is faded completely, and the child directly imitates and ‘repeats’ targets numerous times before the final step is introduced.

7)    Introduction of a one or two second S-R delay (least support)

Once the child is directly imitating the therapist’s model with normal rate, prosody he or she can vary, and appropriate articulatory gestures, the therapist inserts a new requirement: a one to two second delay before the child imitates, so that the child produces a very slightly delayed response (1- to 2- seconds delay). To facilitate this for the children who find the delay difficult and want to ‘jump in’, miming while the child produces the delayed response is often helpful.

8)     Spontaneous production
Finally, the therapist elicits the spontaneous utterances, for example, by asking the child questions (‘What is this called?’), using cloze tasks (‘Twinkle, twinkle ___ ___’), sentence completion (‘Mother elephant is big, her baby is ____’), and the like.

The key to implementation is the therapist’s informed observations of, and sensitivity to, what the child is ‘giving’ by way of responses. The skill and flexibility involved in continually fine-tuning the hierarchy of stimuli and the amount of support provided to the child to enable him/her to imitate spontaneously is critical, especially with the CAS population who have good and bad days with their speech processing capacities. Auditory (including prosodic), visual and tactile cues and level of demand on the child are continually modulated in each practice trial according to the child’s responses.

Related Article

Supporting Speech and Language Progress in Children with CAS or sCAS