As mentioned earlier, childhood apraxia of speech is a motor speech disorder, which involves a difficulty or inability to plan and program the rapid sequence and timing of movements needed to produce speech that can be understood by others. Facial and oral structures such as the lips, tongue, soft palate, jaw and vocal folds – and the muscles that move these structures – need to be activated and move at just the right time, in just the right order, and with just the right force so that the words your child intends to say are produced accurately.
Because the main problem of CAS is speech motor planning and programming, a speech therapy approach needs to focus on the actual movement of speech structures and muscles during speech attempts (Note: the important words here are movement during speech attempts). The approach used by the therapist should aid the child in producing clearer and more accurate words, phrases, and sentences.
Because speech is a series of movements, we can use ideas in speech therapy that, more generally, help people to acquire skill in learning movement! How do people best learn to shoot a basketball and score? How do people learn to hit a golf ball with a golf club and have the ball go in the hole? How to people learn to ride a bike? How do all of these motor skills become automatic so one doesn’t have to even think much about doing them well? How does “motor learning” occur?
There is a complete and large body of research evidence on how motor learning occurs in people. The principles and theories from this research have been applied to speech motor learning, too, and form the base of ideas that are incorporated into appropriate speech therapy for children with CAS. More research is needed specifically in CAS, but experts have used “Principles of Motor Learning” as a common understanding of how to treat Childhood Apraxia of Speech. Thus, there are a number of features of speech therapy that appear to be most successful for children with apraxia of speech, regardless of the name of a particular method. These features include:
Practice and repetition – with speech.
Speech therapy for children with apraxia will include a high degree of practice and repetition. Research shows that therapy for children with apraxia of speech is more effective when the speech targets (words, phrases) are practiced with a greater degree of frequency and intensity. Children in appropriate speech therapy will be attempting syllables, words and phrases many, many times during each session while the SLP works to shape their speech attempts, and the movements underlying them, into speech that is more accurate.
Parents and caregivers will be asked to help the child practice in real life, outside of speech therapy. Intensity (practicing a lot) and frequency (practicing often) are key concepts in speech motor learning. It is for this reason, especially in the early phases of therapy, that children with apraxia should have individual speech therapy. While group speech therapy may be appropriate in addition to frequent individual therapy, children with CAS that have little speech or significantly unclear speech are not likely to make the gains they are capable of making with just group therapy.
[Special note: According to current research, spending valuable therapy time on non-speech movements (for example, blowing bubbles, licking peanut butter, tongue exercises, etc.) is not supported as effective in improving speech production. Such practices have been under scrutiny in the field of speech-language pathology for some time now. While there is no research to support the use of such procedures, some professionals do believe that such activities can lead to better speech or should happen before a child tries to practice speech and thus use the non-speech activities even without published data to support their use.]
Use of Cueing.
Appropriate therapy for children with apraxia usually includes increased sensory information to help in the control of speech movement sequences. Thus, visual, verbal, tactile or touch cueing are used in appropriate speech therapy for children with CAS. Cues from the therapist are different types of “reminders” about what your child should do when attempting a word or phrase. For example, a speech therapist points to his throat when the first sound of the word which the child is going to attempt is a sound that is made in the back of the throat (/k/ or /g/ sound). The child sees where the therapist is pointing and it triggers her memory of the position of her tongue in the back of the throat. The child is receiving a “visual cue” about where to start in producing the speech target. Seeing the therapist point to his throat helps to remind the child of how to get started with movement for the particular word. Here’s another example. The speech therapist gently uses her fingers to press the child’s lips together when he needs to make a “lip” sound as part of the target word (lips sounds are called bilabial sounds and include /m/, /b/, and /p/). Feeling the touch and his lips together, helps the child to know how to start a lip sound. This is an example of a “touch” or tactile cue. There are many examples of cues and they take advantage of sight, touch, or understanding in order to aid the child in achieving the speech movement necessary.
While experienced SLPs use cueing in speech therapy for children with apraxia, they also keep in mind that over time cueing should be reduced and then eliminated as soon as possible. A child who is only capable of their best speech when someone cues them is not developing independence. The SLP will not want your child to overly rely on cues. The therapist will want to see that the child’s own speech processing system is beginning to take on the work rather than relying on others to help. The cue “fading” process is also individualized and occurs over time.
Your child’s SLP will place thought and emphasis on how to alert or tell your child whether their speech attempts have been correct or not correct. The SLP will also be carefully weighing how much help they will give to guide your child’s speech attempts and also when they will give feedback to your child about their speech attempt. For example, the SLP could say something like, “You need to get your lips tight together when you start. Show me ‘tight lips’.” That type of information, about the specifics of how your child is forming sounds and syllables and how to specifically correct is called “knowledge of performance.” Another type of feedback is called, “knowledge of results.” With knowledge of results feedback, the SLP will say something like, “Good!” or “Almost” after your child has attempted a speech target. Feedback of results focuses on general information about whether or not your child was successful with their target word or phrase. SLPs that have experience working with children with CAS are going to be carefully thinking about:
- How much feedback?
- What kind of feedback?
- When should feedback be given?
Generally speaking, children who are just starting out in speech therapy and are severely impacted by CAS may need more immediate feedback about the specifics of their speech movements than will children who have grown in their ability to produce intelligible speech. Some research has begun so that we better understand the role of feedback in speech therapy treatment for children with CAS.
Use of rhythm.
Use of rhythm may help pace speech and help with naturalness of intonation, syllable and word stress patterns – a particular problem for children with apraxia of speech. The rate, intonation, and stress in speech are called prosody. Examples of the use of rhythm in speech therapy for children with apraxia may be clapping or tapping for each syllable or clapping harder when saying the syllable that should be stressed in a word.
Focus on speech sequences.
While some children with apraxia of speech may need help to expand the number of individual sounds they are capable of saying, the main “work” and practice the children need is in moving from sound to sound, syllable to syllable, and/or word to word. Remember that speech is a series of rapid, highly refined movements and children with CAS have difficulty planning and programming those specific movements that underlie speech. Professionals who have a great deal of experience with CAS advocate that speech targets (words, phrases) should be functional to the child. That means that the words should be useful, practical, and something that the child might actually want to say! For example, the words “hi” and “bye” are very useful (i.e.: functional) for children who are significantly affected by CAS. In daily living, every child is urged to, “Say hi!” or “Say bye-bye.” The words are one-syllable words without end consonants and so that makes producing them more simpler than words with more than one syllable or words with ending consonants.
Your child’s SLP should put a lot of thought into what speech practice targets are appropriate for your child. He or she will carefully think about all consonant and vowel sounds that your child can produce (even those which are not yet perfect but are produced somewhat well). The SLP will also give consideration to what types of “syllable shapes” your child can produce (Syllable shapes are various combinations of vowels and consonants that get combined to make a syllable, for example: Consonant-Vowel (CV), Vowel-Consonant (VC), Consonant Vowel Consonant (CVC), and so on). The SLP will think about words and ask you for words that your child might enjoy trying to say or that he or she may want or need to say frequently. Then the SLP will construct a short list of useful (aka: functional) words that your child might reasonably, given his level of apraxia and his current “inventory” of sounds and syllable shapes, be able to practice with help.
While some children will need taught individual sounds, experienced SLPs do not focus exclusively at the single sound level for children who have apraxia of speech nor do they make single sound practice the majority of the child’s therapy. Instead, they incorporate the sound being taught into short, functional words that become the child’s speech practice targets in therapy and at home. SLPs experienced in apraxia, do not “wait” for a child’s various sounds to be perfect before moving on to words and new sounds! Speech therapy is like an art form. The therapist will carefully help your child build larger and more complex syllables, words and phrases, practice them relentlessly; guide and shape them into closer and closer accurate words and phrases; and will “back up” to teach new sounds or sharpen existing sounds in the process.
Need for success.
Many children with apraxia of speech have felt defeated by the difficulty they experience at trying to talk. A great many more children have experienced speech therapy that may not have actually helped them speak or communicate. Many parents and therapists anecdotally report that children with CAS are keenly aware of how difficult “talking” is for them. And, indeed, some children communicate without words that, “mouth broken” or “mouth not work.”
It is important that SLPs who are working with your child have an immediate focus on how they can help your child experience quick success in therapy. A child with apraxia may have withdrawn from taking risks with their speech, anticipating the difficulty and the failure that they have had in previous attempts or in previous therapy. By carefully planning speech practice targets and structuring therapy for success, children with apraxia can come to trust the speech-language therapist, the therapy process, grow in confidence and begin the important and hard work that is ahead.
Equally, it is important for your child to also experience success with speech attempts at home. Parents are often eager to just do something! They frequently ask, “What can we do at home?” Parents and other caregivers are definitely an important part of the journey to their child’s speech! Especially for children with apraxia, parent involvement is crucial. That said, an SLP experienced and successful with children who have apraxia of speech will serve as the guide and coach as to how to best help at home. They want to make certain, to the best that they can, that nothing “sours” your child to the idea of speech practice. Success breeds success. The more confidence your child gains at taking risks with making speech attempts, the more he will benefit from speech therapy.
Watch below to see examples of children at different levels in speech therapy:
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