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Apraxia PDF

Afasia, alexia, agrafia, apraxia, disartria

Apraxia is traditionally defined as a disorder of skilled movement that cannot be attributed to elementary sensorimotor deficit, aphasia or severe mental deterioration (De Renzi, 1989). This negative definition has led to integrate within the same framework a multitude o of the brain damage. Apraxia can occur in conjunction with dysarthria (muscle weakness affecting speech production) or aphasia (language difficulties related to neurological damage). Apraxia of speech is also known as acquired apraxia of speech, verbal apraxia, and dyspraxia. Children can also have apraxia, referred to as childhood apraxia of speech Acquired apraxia of speech (AOS) is a neurogenic speech disorder that is characterized by speech sound errors, slowed rate of speech production, and disrupted prosody (Square, Martin, & Bose, 2001). The speec

Apraxia - an overview ScienceDirect Topic

  1. e whether your child isdemonstrating patterns of CAS
  2. of Apraxia of Speech (AOS) 1. Slow rate of speech 2. Sound distortions 3. Sound substitutions 4. Errors that are consistent in terms of type, inconsistent in terms of location 5. Abnormal prosody (Wambaugh et al., 2006b
  3. DYSARTHRIA/APRAXIA SCREENING Oral Mechanism Exam INTELLIGIBILITY Observation: conversational speech intelligible intelligible with some difficulty unintelligible Characteristics: Spontaneous Speech: Tell me about this picture. (Disability/Perceptual) intelligible intelligible with some difficulty unintelligible RESPIRATIO
  4. Apraxia. Apraxia (also called dyspraxia) is a disorder of learned movement in which the difficulty with movement is not caused by paralysis, weakness, or incoordination of the muscles and cannot be accounted for by sensory loss, comprehension deficits, or inattention to commands.15
  5. July 23, 2014. apraxia blog. 1239. Speech therapy for apraxia requires a motor based treatment approach that works up through a hierarchy of syllable shapes with lots of repetition, repetition, repetition. Unfortunately, repeating the same syllable shapes is limiting and many times boring

Apraxia is a neurological disorder that affects a person's ability to perform everyday movements. Learn more about the symptoms, causes, and types in this article. Medical News Toda occur with speech disorders, such as dysarthria or apraxia of speech, which also result from brain damage. Who can acquire aphasia? Most people who have aphasia are middle-aged or older, but anyone can acquire it, including young children. About 1 million people in the United States currently have aphasia, and nearly 180,000 Americans acquire. The apraxia test can only be used by persons with experience in neuropsychological testing. The apraxia test adds up to 1 score ranging from 0 to 90. For both subtests a subscore is calculated. In addition, a qualitative description can be given on the basis of observing the patient. The apraxia test ttakes about 10 minutes to administer. Scorin

(PDF) Florida Apraxia Battery–Extended and Revised Sydney

Free apraxia printable Archives - SLP Mommy of Apraxi

apraxia measures including both meaningful and mean-ingless items, i.e., measures that assess apraxic impair-ments of the semantic as well as the structural processing route (see below). Although these studies do not provide any insight into which apraxic deficits (and hence which apraxia tests) predict performance of which specific aspect Understanding Childhood Apraxia By Becky Spivey, M.Ed. Childhood Apraxia of Speech (CAS) is a very specific motor speech disorder. Children with this diagnosis have difficulty planning and consistently producing sequences of speech movements using their tongue, lips, jaw, and palate. These difficulties limit a listener' and 5, high specificity (93%) and sensitivity (88%) for mild and severe apraxia could be estimated. B. Test situation The patient is seated in front of the examiner; both with the forearms placed on the table. Hemiparetic patients execute the gestures with thei r non-paretic upper limb i.e. ipsilesional. Otherwise both upper limbs are tested Apraxia. Our current clinical approach to apraxia is similar to that proposed by Liepman in the early 20th century.1 He recognised that left hemispheric lesions tend to cause bilateral upper limb apraxia and suggested a model of motor control in which the left parietal lobe stores a 'space-time form picture' of a movement. For a movement to be executed, its picture must be retrieved and. APRAXIA. Flip Book. CV / CVCV / CVCVCV Combinations. Created by Alissa A. Holloway MS-CCC, SLP © 2012 www.utahspeechtherapy.com. pay pay pay P P P. S - 2. m

Apraxia: Definition, causes, symptoms, and treatmen

SAMPLE TREATMENT GOALS ACQUIRED APRAXIA OF SPEECH There are several different recommended techniques or types of intervention which target remediation of apraxia of speech. Goals therefore can depend on what type of intervention the clinician is using at that point Children with Childhood Apraxia of Speech (CAS) Childhood apraxia of speech (CAS) is a neurological motor speech disorder in which a child has difficulty rapidly, accurately, and consistently producing and timing the movement sequences needed to produce speech. CAS is not due to having weak muscles for speech. A treatment pla Quintana (2008) suggests that there are five types of apraxia: Limb; Constructional- refers to a deficit in spatial organizational performance so clients with constructional apraxia have difficulty with copying, drawing, and constructing designs in two and three dimensions (Quintana, 2008, p. 250) APRAXIA FOLLOWING STROKE IN ADULTS A LEAFLET FOR OCCUPATIONAL THERAPISTS TO USE WITH PATIENTS/CLIENTS AND THEIR CARERS Praxis is the ability to perform skilled movements required for daily activities. This involves being able to: a) Form the idea and know what to do; b) Organise the sequence of the movement involved in the activity This review describes the means of testing, the patho- physiology, and the clinical characteristics that define five different general forms of forelimb apraxia including: (1) ideational apraxia, an inability to correctly se- quence a series of acts leading to a goal; (2) conceptual apraxia, a loss of me- chanical tool knowledge; (3) ideomotor apraxia, a loss of the knowledge of how when making transitive and intransitive movements to correctly posture and move the forelimb in space; (4.

The clinical assessment of apraxia Practical Neurolog

  1. 72. $12.50. Zip. Use these 34 open-ended interactive picture scenes for speech therapy to target a variety of early word shapes (CV, VC, CVCV). This activity is a fun, engaging, and natural way to treat articulation delays, phonological delays, and apraxia of speech during distance learning and in-person sessions! A
  2. Apraxia may be accompanied by a language disorder called aphasia. Corticobasal ganglionic degeneration is a disease that causes a variety of types of apraxia, especially in elderly adults. Treatment . Generally, treatment for individuals with apraxia includes physical, speech, or occupational therapy. If apraxia is a symptom of another disorder.
  3. Dynamic Evaluation of Motor Speech Skill (DEMSS) Manual. Developed by one of the leading experts on childhood apraxia of speech (CAS) and an expert on test development, this tool is an efficient way to assess children who have significant speech impairment, especially reduced phonemic and/or phonetic inventories, vowel or prosodic errors, poor.
  4. innervatory apraxia), ideomotor apraxia, and ideational apraxia. To this triad Rothi, Heilman, Ochipa and colleagues 5-7 added another type, termed conceptual apraxia, and DeRenzi as well as Heilman 8, 9 described a fifth type now called dissociation apraxia. In this manuscript we will focus on ideomotor apraxia (hereafter, IMA), for two reasons
  5. Apraxia is a disorder in executing learned 1 or skilled movement (exclud- ing explicitly symbolic movements 2 ) not accounted for by weakness, inco- ordination, sensory loss, incomprehension or inattention to commands. 3, 4 I

SAMPLE TREATMENT GOALS ACQUIRED APRAXIA OF SPEECH

Apraxia of Speech (AAS) Shriberg et al (2017b) CAS and AAS • Potentially share same speech process: • Inappropriate pause due to transcoding deficits in representational and motor speech processes . 10/14/2017 7 AAS vs. CAS • Both assumed to be difficulty with motor planning/programming •Apraxia is a decrease in the ability to plan and perform purposeful actions/movements •Apraxia can occur throughout the body 5 3 Primary Types of Apraxia •Limb Apraxia: Refers to the inability to make precise movements with the fingers, arms or legs on command (also called dyspraxia) •Non-Verbal Oral Apraxia: Refers to the inability t

Types of Apraxia - Apraxi

23 07, 2014. CV BINGO printable FREE!! Laura Smith. July 23, 2014. apraxia blog. 1239. Speech therapy for apraxia requires a motor based treatment approach that works up through a hierarchy of syllable shapes with lots of repetition, repetition, repetition. Unfortunately, repeating the same syllable shapes is limiting and many times boring Purpose: This article was written as an editorial to a collection of original articles on apraxia of speech (AOS) in which some of the more recent advancements in the understanding of this syndrome are discussed. It covers controversial issues concerning the theoretical foundations of AOS. Our approach was motivated by a change of perspective on motor speech that has taken place in.

Rosenbek Hierarchy of Apraxia Drills. Clinically-proven drills for apraxia that you can easily apply to any word the survivor is working on.. Why Apraxia stops us like a brick wall . Apraxia makes it difficult to form the complex mouth movements that produce speech. We use speech so often (and so effortlessly) that we forget just how complex and difficult it is to learn Apraxia is a disorder of higher motor cognition. Deficits in imitating abstract and symbolic gestures as well as deficits in appropriate tool use are common apraxic symptoms which, importantly, cannot be explained by primary sensorimotor deficits alone. In spite of the relevance of apraxia for neuro Liepman, apraxia was a unitary phenomenon, the different varieties being the result of dysfunction of the same mech­ anism at different levels. He distinguished between the following types of limb apraxia (see Hecaen, 1981): (a) Melokinetic apraxia involves the loss of kinetic engrams of special sections of the body. As a result move

Apraxia battery for adults pdf Age range: Adolescent & Adult Administration Time: 20mins Individual qualification code: CL2 Measures the presence and level of apraxia in adolescents and adults. Helps professionally assess recovery with regard to the severity of apraxia using the following subtests: Diadochocintic index Increasing the length o Apraxia has a neurologic cause that localizes fairly well to the left inferior parietal lobule, the frontal lobes (especially the premotor cortex, supplementary motor area, and convexity), or the corpus callosum. Any disease of these areas can cause apraxia, although stroke and dementia are the most common causes Download Free PDF. Apraxia and motor-skill acquisition in Alzheimersdisease are dissociable. Neuropsychologia, 1999. Jeffrey Shuren. Download PDF. Download Full PDF Package. \ PERGAMON Neuropsychologia 26 0888# 764Ð779 Apraxia and motor!skill acquisition in Alzheimer|s disease are dissociable Daniel H[ Jacobsa\ \ John C[ Adairb\ David J[G.

Childhood apraxia of speech (CAS) is a motor speech disorder that makes it difficult for children to speak. Children with the diagnosis of apraxia of speech generally have a good understanding of language and know what they want to say. However, they have difficulty learning or carrying out the complex sequenced movements that are necessary for. • Describe the hallmark features of apraxia of speech as it presents at various points of chronicity and with varying severity • Discuss how assessment and treatment methods are employed with patients experiencing apraxia of speech at various points of chronicity • Employ tools to assist in identifying an Apraxia Screen of TULIA (AST) Tim Vanbellingen and Stephan Bohlhalter 7/09 page 2 A. Test description The screening test (Vanbellingen et al., JNNP 2010) comprises 12 items extracted from the more comprehensive test of upper limb apraxia, TULIA (Vanbellingen et al., EJoN 2010) by item reduction analysis

For example, apraxia has a negative impact on the assessments do not account for the different aspects of quality of communicative gestures [25] and patients apraxia, but focus on only a single apraxic deficit, e.g., affected by apraxia rarely use spontaneous communicative disturbed imitation or impaired object use [16, 19, 24, 30, gestures in. PDF. Apraxia picture cards for speech therapy to work on Apraxia syllable shapes and words. These Apraxia picture cards are grouped by syllable shapes: CV, VC, CVC, CVCV, CVCVC, CVCVCV, and CVCVCVC words. Great for Childhood Apraxia of Speech or articulation disorders. Over 200 cards included!Cards inclu

Apraxia is a motor disorder caused by damage to the brain (specifically the posterior parietal cortex or corpus callosum) in which the individual has difficulty with the motor planning to perform tasks or movements when asked, provided that the request or command is understood and the individual is willing to perform the task. The nature of the brain damage determines the severity, and the. Apraxia or dyspraxia is a motor speech disorder which causes many problems for speech clinicians and their clients. When a child or adult has an articulation (phoneme/sound) disorder, a well trained therapist should always give an Oral Peripheral examination. This is a test for th

Lewis R. Sudarsky, in Office Practice of Neurology (Second Edition), 2003 Frontal Gait Disorder (Gait Apraxia) Frontal gait disorder is more common in older adults and has a variety of causes. The term gait apraxia is sometimes used, although the disorder is more properly a higher-level motor deficit rather than a true apraxia. Typical features include a wide base of support, short stride. This is best termed an ideational apraxia (although others use the term conceptual apraxia or even posterior ideomotor apraxia, and reserve the term ideational for another disorder). It is most commonly seen in Alzheimer's disease. Ideomotor apraxia. By contrast, ideomotor dyspraxia relates to an impaired action production system

apraxia.pdf Cerebral Cortex Parietal Lob

Adult Apraxia Worksheets & Teaching Resources Teachers

Health Condition: Moderate to Severe Apraxia of Speech With Broca's aphasia Case study: Mr. B a WAB-R: Western Aphasia Battery—Revised (Kertesz, 2006) b ABA-2: Apraxia Battery for Adults—2nd edition (Dabul, 2000) c McNeil Checklist (McNeil, Robin, & Schmidt, 1997) d ALA-2: Assessment for Living with Aphasia—2nd edition (Kagan et al., 2007 Apraxia of speech and autism. A recent study conducted by the Penn State Milton S. Hershey Medical Center has found apraxia as a common occurrence in ASD. Apraxia is a speech sound disorder that. Food and Behaviour Research A.J.Richardson 2002 Further information from: www.fabresearch.or Childhood Apraxia of Speech Childhood apraxia of speech (CAS) appears in early childhood but can continue into adulthood. Children with CAS have problems saying sounds, syllables and words. Although a child with CAS knows what they want to say, their brain struggles to correctly move their lips, jaw and tongue in order to spea

Apraxia Information Page National Institute of

TAAP: Treadmill for students with Autism and Apraxia Protocol, training to facilitate visual-gross motor development, improve posture, visual field access, and visual skills of: attention, tracking, and imitation. TAAP Training is critical to implement the TAAP Protocol in your school system/clinic.... events.r20.constantcontact.com Speech apraxia Selective impairment in ability to produce speech sounds Tactile apraxia Impairment of hand movements for the use of and interaction with an object, in the presence of preserved intransitive movements. Unimodal apraxia Any form of apraxia that is specific to actions demonstrated in a single modality, e.g. visual, but not auditory APRAXIA Flip Book CV / CVCV / CVCVCV Combinations Created by Alissa A. Holloway MS-CCC, SLP © 2012 www.utahspeechtherapy.co

Materials for Dysarthria and Apraxia of Speech by Speech

Childhood Apraxia of Speech Checklist: A Series of Characteristics to Facilitate Diagnosis Kay Giesecke, MS, CCC-SLP Specialist in CAS since 1995 Heather MacFadyen, MA, CCC-SLP Childhood Apraxia of Speech General Definition: 1. Previously known as:Previously known as: - Developmental/Verbal Apraxia, verbal dyspraxia, etc. ASHA and CASANA now us infl uences related to apraxia,27 familial speech,28,29 and neuro-logically based disorders such as dyslexia and ADHD.4,30,31 Confusion around this condition is refl ected by the vast num-ber of terms used to defi ne it, including childhood apraxia of speech, developmental apraxia, developmental dyspraxia The Apraxia Word List accompanies the Apraxia Kit CV-CVCV & VC-CVC on TPT Script Carrier Phrases to Build Functional Core Vocabulary 3. Sound associations using animal & environment sds 5. Make list of meaningful names, e.g. child's name, sister, friends, mommy, daddy 6. Preferred toys- create list of words to name & request during play 4 Apraxia is a cognitive disorder that can occur after stroke. It prevents a person from carrying out a learned movement. Various interventions are used to treat apraxia but evidence of their benefit has been lacking.To determine which therapeutic interventions.

Dynamic Evaluation of Motor Speech Skill (DEMSS) Manua

TREATMENT PRINCIPLES FOR APRAXIA OF SPEECH Lecture notes from Motor Speech Dr. Nancye Roussel I. Treatment goals will depend on the amount of co-existing aphasia: (Rosenbek handout, 1997) (1) If aphasia is absent or mild, meaningful stimuli can be used and the meaning will facilitate better movements (2) If aphasia is moderate, treatment will. What is apraxia of speech? Apraxia of speech (AOS)—also known as acquired apraxia of speech, verbal apraxia, or childhood apraxia of speech (CAS) when diagnosed in children—is a speech sound disorder. Someone with AOS has trouble saying what he or she wants to say correctly and consistently. AOS is a neurological disorder that affects the brain pathways involved in planning the sequence of. Information and resources concerning apraxia of speech including: description, types, causes, symptoms, diagnosis, treatment, and research Apraxia can occur in a number of different forms. One form is orofacial apraxia. People with orofacial apraxia are unable to voluntarily perform certain movements involving facial muscles A FREE 11-page e-book to help SLPs set better goals for adults with communication disabilities . A FREE homework packet to help your adult clients succeed in completing their home exercises. A FREE guide & video on how to mirror your tablet screen to use apps in therapy remotely. A complete list of all the Tactus apps in your local currency.

Apraxia: Review and Updat

Apraxia of speech is sometimes caused by problems with a gene or by damage to the brain, for example due to a brain lesion or stroke. It is also linked to some disorders, including Down syndrome, autism spectrum disorder, Koolen de Vries syndrome, floating harbour syndrome and 16p11.2 deletion syndrome Key Words: script training, apraxia of speech, motor learning S cript training is a relatively new, functional approach to the treatment of neurogenic communication dis-orders. Script training was initially developed by Holland and colleagues (Holland, Milman, Munoz, & Bays, 2002) to facilitate verbal communication on client-selected topics

Apraxia is a disorder in executing learned 1 or skilled movement (exclud- ing explicitly symbolic movements 2 ) not accounted for by weakness, inco- ordination, sensory loss, incomprehension or inattention to commands. 3, 4 I Hammer, D. (2013) A Multi-Sensory Approach for Childhood Apraxia and Speech Sound Disorders. Metro Speech-Language Symposium, Denver, CO. Kaufman, N. (2013) The Kaufman Speech to Language Protocol: Effective Strategies for CAS. National Conference on Childhood Apraxia of Speech, Denver, CO And if it was a speech therapist who diagnosed Apraxia, parents may not ever know that there are many other aspects to Apraxia besides just speech. In fact, Apraxia is not a speech delay, and Apraxic children rarely have educational needs that are just in the area of communication. As a neurologically-based motor planning disorder1, Apraxia can an

Short apraxia screening test

Apraxia of speech: concepts and controversie

Combined Aphasia and Apraxia of Speech Treatment (CAAST): Effects of a Novel Therapy Approach Acquired apraxia of speech (AOS) is a neurologic motor speech disorder that is characterized by slow rate of speech, difficulties in sound production, and disrupted prosody (McNeil, Robin, & Schmidt, 2009) Assessment of praxis profiles effectively contributes to diagnosis and differential diagnosis of AD and bvFTD. The Dementia Apraxia Test (DATE) is a brief and easy to administer cognitive tool for dementia assessment, has a high inter-rater reliability (Cohen's κ= 0.885) and demonstrates content val

Ideational apraxia is due to parietal lesions, most often diffuse and degenerative. 2. In ideomotor apraxia the concept or plan of movement is intact, but the individual motor engrams or programs are defective. Ideomotor apraxia is commonly tested for by asking patients to undertake specific motor acts to verbal or written commands, such as. Transcending Autism & Apraxia was founded by a mom, Dawnmarie Gaivin, who understands what it feels like to never hear her child speak and to wonder if she'd ever know his thoughts. Through Spelling to Communicate (S2C) she unlocked his voice and now she's dedicated her career to helping other families share the same joyful experience disease termed primary progressive apraxia of speech .8 This article discusses nonfluent/agrammatic variant PPA, semantic variant PPA,and primary progressiveapraxiaof speech.These disorders are first placed within a broader context by discussing the classification of degenerative speec A 50-plus year history of research on apraxia of speech (AOS) has spawned a body of literature that has been always controversial, at times contradictory, and at other times enlightening and coherent. This chapter reviews briefly the phonetic theory and neurological substrates for the disorder. We discuss neurolinguistic models and experimental evidence that have helped to set diagnostic.

Strategy Training. Protocol for the strategy training can be found in the Appendix of the study produced by van Heugten et al. (1998) (PDF link below). Clients are taught strategies to compensate of their apraxia. The client decides what ADL activities to focus on, and these activities are broken down into 3 phases: initiation, execution, and. of apraxia, a combination of two types, or all three types of apraxia (global apraxia). •Apraxia may be the primary diagnosis or a secondary diagnosis. (When apraxia is a secondary diagnosis it can be harder to detect and thus more challenging to diagnose.) •Verbal apraxia can occur in both children and adults Childhood Apraxia of Speech (CAS) is an oral-motor disorder (mouth-movement problem) that causes the child's speech to be hard to understand. It is usually detected after two years of age, when speech development is noted to be delayed. Children with CAS may have a hard time putting the tongue, lips and ja

Motor speech disorders include two primary categories, apraxia and dysarthria. In order to produce speech, every person must coordinate a range of muscles and muscle groups, including those controlling the larynx with the vocal cords, the lips, the tongue, the jaw and the respiratory system Apraxia of speech (AOS) is a neurologic speech disorder that reflects an impaired capacity to plan or program sensorimotor commands necessary for directing movements that result in phonetically and prosodically normal speech (Duffy, 2013, p. 4). AOS has also been referred to in the clinical literature as verbal apraxia or dyspraxia.For the purpose of this page, AOS will refer to acquired. View Handout-Childhood-Apraxia-of-Speech.pdf from SHS 375 at Washington State University. Childhood Apraxia of Speech [CAS] Assessment and Treatment Assessment and treatment suggestions for beginnin

(PDF) 2018 Evidence Brief: Childhood Apraxia of Speech

Rosenbeck Hierarchy treatment for Apraxia Therap

Ideomotor Apraxia, often IMA, is a neurological disorder characterized by the inability to correctly imitate hand gestures and voluntarily mime tool use, e.g. pretend to brush one's hair.The ability to spontaneously use tools, such as brushing one's hair in the morning without being instructed to do so, may remain intact, but is often lost Apraxia Therapy Lite. Download Apraxia Therapy Lite for free on your iOS or Android device for a sample of the full version. The Lite version allows you to try all 3 activities with just a small taste of the sequences, phrases, and words you'll get in the full app. Try for Free Difference between ataxia and apraxia Ataxia vs apraxia Neurological lesions have always been complicated as understanding the central nervous system and its numerous pathways is not a cake walk. Ataxia and apraxia are often confused for each other, but they are two very different neurological symptoms. Ataxia is a neurological sign wherein there is loss of coordination of muscles Examples of Materials That Can Be Adapted For Therapy a collection of resources by Judith Maginnis Kuster. The following is one section of Judith Kuster's Net Connections for Communication Disorders and Sciences (www.communicationdisorders.com).The internet is FULL of materials that can be adapted to speechlanguage therapy

A. Answer: This is a good question. If your child has trouble pronouncing words, you may have heard the terms childhood apraxia of speech (CAS) and verbal dyspraxia. Both conditions can make it hard for the brain to plan the movements needed to make speech sounds. Not all kids with CAS or verbal dyspraxia have the same symptoms Purpose This study continued Phase I investigation of a modified Phonomotor Treatment (PMT) Program on motor planning in two individuals with apraxia of speech (AOS) and aphasia and, with support from prior work, refined Phase I methodology for treatment intensity and duration, a measure of communicative participation, and the use of effect size benchmarks specific to AOS

- Quick Assessment for Dysarthria - COMPLETE KIT Speech

About Childhood Apraxia of Speech (CAS) In order for speech to occur, messages need to go from your brain to your mouth. These messages tell the muscles how and when to move to make sounds. When a child has apraxia of speech, the messages do not get through correctly. The child might not be able to move their lips or tongue in the right ways. Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g. abnormal reflexes, abnormal tone). CAS may occur as a result of known neurological impairment, in association with. Aphasia, apraxia of speech and oral apraxia are communication disorders that can result from a stroke. At times, it's hard to distinguish between them, especially since it's possible for all three to be present at the same time. Here's a breakdown of what the terms mean: Aphasia is impairment in the ability to use or comprehend words Give them the visual cues they need with the Say and Do Sound Production Flip Book and Activities for Apraxia and More! The Say and Do Flip-Book contains four identical sections of illustrated cards. The cards provide a visual model of how to produce vowels and consonants at the sound, syllable, and word levels

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