(Note: Members of the Childhood Apraxia of Speech Association Professional Advisory Board have reviewed this article.)
There is great concern among speech-language pathologists and others regarding the overdiagnosis or misdiagnosis of childhood apraxia of speech (CAS). Specifically, it is questioned as to whether children under age 3 should be given the diagnosis of apraxia of speech and if so when.Once the diagnosis is either made or suspected, the question of how to treat such a young child arises. It is recognized that many children who go on to be diagnosed with CAS will have additional speech and language therapy goals in addition to those targeting speech production. The purpose of this article is twofold: to communicate initial diagnostic procedures for identifying young children who may have CAS and to discuss speech therapy techniques that may benefit the speech production and expressive language skills of young children suspected to have CAS.
Strand (2003) argues that there are five key potential diagnostic characteristics of apraxia in young children. The five characteristics identified by Strand are:
- Difficulty in achieving and maintaining articulatory configurations
- Presence of vowel distortions
- Limited consonant and vowel repertoire
- Use of simple syllable shapes
- Difficulty completing a movement gesture for a phoneme easily produced in a simple context but not in a longer one
(Strand, 2003, p. 77)
The complexity of diagnosis in young children under age 3, according to Strand, is that the child must be able to participate sufficiently in the assessment. Unless the child can attempt to imitate utterances that vary in length and/or phonetic complexity (such as imitating /i/, then /mi/, then /mit/ or /o/, then /no/ then /nope/), it is very difficult to make a definitive diagnosis (Strand, 2003, p. 78). If a child is not able to participate with verbal attempts in this way, it is possible that the presence of certain characteristics can trigger a close watch of the child over the upcoming months. Characteristics such as restricted sound inventories and especially distorted vowels or a single centralized vowel sound might be indicative of motor planning and motor programming difficulties. Motor planning treatment principles such as those used for a child diagnosed with apraxia of speech can be instituted early, based on the presence of such symptoms.
Others advocate a long-term history with a child suspected to have CAS prior to such a label being applied. Davis and Velleman write that, clinicians should have at least a 6-12 month therapy history for an infant or toddler before a DAS label is appropriately applied. (Davis and Velleman, 2000). The characteristics which Davis and Velleman feel are most descriptive of CAS in very young children include:
- Restrictions and gaps in sound repertoire (both consonant and vowel), including the possibility that the child may have acquired some later developing sounds while be missing earlier developing sounds.
- These children may demonstrate very limited use of syllables, possible use of an extended single sound or few vocalizations at all. The children may have difficulty combining the sounds that they do have.
- Limited variation of vowels and the use of a centralized vowel in a multipurpose way.
- Vocalizations may have speech-like melody but syllables or discernable words may not be present.
- Words may seem to disappear from use more than would be expected for a typically developing child of the same age.
- Predictable utterances may be easier than novel utterances
(Davis and Velleman, 2000, p.182)
Additional nonspeech characteristics identified by Davis and Velleman that possibly combine to indicate apraxia of speech in the young child include: homemade gestures or signs, some feeding difficulties such as eating mixed textures, drooling, late development of motor skills overall, and oral motor incoordination. (Davis and Velleman, 2000).
Speech Therapy and the young child with possible apraxia
There is very little literature about treatment for apraxia or diagnostic intervention for very young children with apraxia of speech. Davis and Velleman (2000), however, have described the overarching need to initially establish two primary goals when working with young children suspected to have apraxia of speech. First, the child needs to establish a consistent form of communication and secondly the child needs to develop and consistently use oral communication. The authors encourage making communication the top priority. Clinicians should watch for attempts to communicate appropriately and respond to any appropriate mode of communication.This strategy includes responding to gestures and other attempts. Communication attempts should not be ignored with the rationale that the child is willfully refusing to talk. Davis and Velleman, also offer that, One message the child should receive (although not to the extent that it interferes with communication exchanges) is that communication is conventional. Unless there is agreement on which gesture, sound or picture will represent which meaning, communication will not be successful. (Davis and Velleman, 2000) So, for example, a child can use gestures or sign that are not correct if they use the same gesture for the same meaning consistently.
Setting Expectations: Parents as Collaborators
From the very first meeting, clinicians need to involve parents in therapy opportunities for children with apraxia; to the greatest extent they are able and willing. Parents are able to share important information from the home and community environments. Parents are important informants on the likes, dislikes, and personality characteristics of their children. Additionally, because many repetitions of speech movement patterns are necessary for motor learning to occur, parents are valuable speech practice partners for their children in their everyday life experiences together. (Stoeckel, 2001)
Hammer and Stoeckel listed the following responsibilities for the speech-language pathologist in working with parents of children with apraxia of speech:
- Educate parents re: CAS and intervention
- Educate parents re: networking/support availability
- Teach child needed skills in a flexible, productive manner
- Assure high expectations from the child
- Be able to explain goals and changes in therapy strategies
- Assure periodic observations either on-line or via videotape
- Work with parents to motivate and reinforce childs learning
(Hammer and Stoeckel, 2001)
Setting Expectations: Children as Risk-takers
While in typically developing children, early sound play and communication attempts bring a great deal of fun and excitement, by the time a young child with suspected apraxia of speech arrives in speech therapy treatment, he or she may already have experienced a great deal of failure in efforts to communicate orally. Additionally, families may also feel somewhat like failures in helping their child to communicate. (Hammer, 2003). Clinicians can help by crafting very carefully planned small steps toward success in the earliest phase of therapy.Additionally, it is important for SLPs to set early boundaries and expectations around communication exchanges as well as teach these skills to parents if necessary.
- For most of us, and especially for children with severe speech production disorders, risk taking requires trusting that the situation or person to whom we are communicating is safe and predictable. It also generally requires that the effort be worth the risk. If these conditions are met most children will attempt to use what speech or communication they have to interact. The major issue, however, is how to create this environment? One proposition is the creation of boundaries. Boundaries, in this context, refer to the physical, mental, and emotional conditions that surround the child and are based upon realistic expectations for performance.
Children with apraxia of speech need to feel as if they can trust in the therapeutic process and have success. Reasonable expectations, based on the capability of the childs speech motor system, need to be implemented and reinforced so that the child also uses what they can produce orally in communication exchanges.
Oral Communication Goals
Depending on the child, Velleman and Davis state that increasing vocalizations of any kind may be the place to start.Some suggestions they have that reduce communication pressure on the child are:
- Speech in conjunction with movement (“whee” while sliding down a slide, as example)
- Sound effects
- Verbal routines with songs, predictable books, rhymes, etc.
- Speech in unison with another person
- Props such as puppets, little people, stuffed animals, etc.
(Davis and Velleman, 2000)
Velleman adds additional ideas of where to start with very young children:
- Words with distinctive pitch patterns (e.g.: uh-oh, wow, whee, yay)
- Words with strong emotional meaning
- Words that can be paired with actions (e.g.: whee, hi, oops,
- Words with very early consonants (e.g.: [h], glides) and simple syllable shapes (e.g.: hi, uh-oh, wow, whee, yay)
- Sound effects: animal noises, vehicle sounds, etc.
(Velleman, 2002, page 66)
Also, sounds that may be in the childs current repertoire can be used to expand oral communication: words beginning with a sound in the repertoire that also have functional meanings such as “more” “mine” if the child can make an /m/ are examples.
Expanding Sounds and Syllables
Velleman and Davis (2000) discuss adding two goals when a child has begun to consistently use vocalization to communicate:
- Expansion of sounds
- Expansion of syllable structures
They further suggest, in the beginning, that the use of the sounds and structures is more important than accuracy.
Suggestions for expansion of sounds:
- Expand to include more diverse consonant and vowel sounds produced in different parts of the mouth
- Sounds with varied pitch and loudness levels
- Short and long utterances
Suggestions for expanding structures:
- Syllables rather than individual phonemes should be the focus
- Be systematic with teaching sounds and syllables in word structures. (as an example; Davis and Velleman recommend, “New word shapes, e.g., CVC “bag” when a child produces mostly CV words such as ‘moo’, the clinician should include ONLY sounds that the child can already produce, in some word position”
- (Davis and Velleman, 2000, p. 185) This strategy is described as the, “Old forms, new function – old functions, new forms” rule.
- Goals should target EITHER new structure or a new sound, not both at the same time.
Speech Movement Goals and Training
The above goals will improve the child’s need for communication, but do not yet address the underlying nature of the problem of apraxia in children – which is speech in motion or the ability to plan accurate, well timed speech movements sound to sound, syllable to syllable, in order to produce old and new words. Clinicians need to keep in mind therapy opportunities that allow young children to build flexibility and reliability into their motor systems.
Activities that use the same syllable but with a change at the end can help, according to Davis and Velleman (2000). The recommended strategy for practice is to first work on the same syllable repeated, (e.g.: ma ma ma ma). Next, introduce one change at the end of the repeated syllables, e.g.: ma ma ma moo or moo moo moo do. Alternating the syllables takes the activity one step further, i.e.: ma, moo, ma, moo or moo, do, moo, do, moo. As competence is built with these activities the most complex practice with syllables moves further so that the child produces varied syllables/sounds: ma, moo, may, my, mow. (Davis and Velleman, 2000) Further, in young children the approach will need to be fun, silly, engaging in order to elicit the childs attention, involvement and effort.
In clinical practice, it is suggested that SLPs incorporate principles of motor learning: the need for many repetitions and practice, distributed vs. massed practice opportunities, appropriate use of feedback to the child to enhance motor learning etc. Even toddlers can be involved in therapy opportunities maximizing conditions for motor learning but adapted to their needs as very young children. (Strand and Skinder, 1999; Davis and Velleman, 2000)
Ideas for gaining multiple repetitions, presented by Velleman and Davis, for children who are in the toddler age range include:
- Use of counting books but instead of counting the objects on a page, simply point to the object and repeat its “name” each time it appears on the page. For example, a counting book of animals has 4 dogs on the page for the number 4. Instead of counting “1, 2, 3, 4”, you can guide the child to point to each dog and say “pup, pup, pup, pup” or depending on their skill, “doggie, doggie, doggie, doggie”.
- While playing “house” and setting the table, each time a cup is put down saying “cup, cup, cup”.
- Pretending to eat: “yum, yum, yum”
(Davis and Velleman, 2000, p. 187)
Core vocabulary books are another way to elicit practice from the child and can also incorporate parents or other communication partners. According to Hammer, The photos should consistof meaningful people, toys, and objects in the child’s life as well as words that contain initially targeted sound sequences. This book often serves as a child’s first success at expansion of functional communication interactions with significant others. (Hammer, Apraxia-kids website)
Providing Motivation/Keeping the Childs Attention
Play presents many opportunities for these repetitive sequences and parents and therapists can be creative in this way.The idea is to trick the child into practice by making their therapy experience not just fun but also successful for them.Even very young children with apraxia have gained the understanding that speech is difficult for them and may avoid or resist expressing themselves with oral communication. An astute, engaging clinician can use low-pressure opportunities and engaging play to help children with apraxia take risks with their speech attempts. (Hammer, 2003)
Strand and Skinder offer the following ideas for providing motivation and keeping attention of young children with apraxia:
- Change positions after every 10 20 practice trials (stand up, sit backward, put hands on head, sit under the table, march, swing arms, etc)
- Change inflection (most helpful when child has some accuracy; place stress on different words, use low pitch, high pitch, exaggerate the target word or phrase)
- Use various dolls, puppets, animals that the child can speak for and change the selection after a number of practice trials.
(Strand and Skinder, 1999, p. 128)
Remember that while clinicians must make therapy fun and engaging, it is not sufficient to be able to say the child enjoyed the therapy session or that the session went well because the child cooperated. That alone will not effectively provide what the child needs, which is the opportunity for a high number of repetitions of speech targets and the clinicians thoughtful feedback about performance and results. Therapy for children with apraxia of all ages is designed to shape speech motor skill. If the child isnt saying much in the therapy session, the clinician is not going to be able to achieve this goal. (Strand and Skinder, 1999)
Other “take home” points about speech therapy for toddlers with suspected apraxia of speech include:
- The idea that children with apraxia may not follow the typical “developmental” sequence for acquiring new sounds. (Hammer, 2003; Davis and Velleman, 2000)
- Children with apraxia of speech need some early success with speech. They need to know it is worth it to trust and cooperate with the clinician. (Hammer, 2003)
- Children with apraxia seem to have periods where sometimes they seem to ‘plateau’. (Davis and Velleman, 2000)
- Play is the medium for these young children with apraxia to provide activity that builds in speech movement training. (Hammer, 2003)
- Parents need help and direct mentoring to understand their role and how they can effectively practice with the young child at home. (Hammer and Stoeckel, 2001)
- Break up sessions into several activities that have repetitive practice vs. one long activity (Davis and Velleman, 2000, Strand and Skinder 1999)
- Just as with older children with apraxia, younger children need feedback about their performance such as knowledge of results (did they get the word right) and more specific knowledge about performance (for example, “you need your lips out for that”). (Davis and Velleman, 2000; Hammer, 2003; Strand and Skinder 1999)
Apraxia or Something Else?
Once a period of therapy has commenced and the SLP has experience with a particular child suspected to have apraxia of speech, it may become clearer as to whether or not the childs primary difficulty is with speech motor planning and programming. Even if a child does not receive the apraxia diagnosis, the therapy recommendations outlined above may play a role in the treatment plan. Some have noted the possibility of a continuum of severity in childrens speech motor planning ability (McCauley, 2002). According to McCauley, A child’s failure to respond to treatment methods in which the goal is to teach the child phonologic patterns (e.g., the Cycles Approach or minimal pairs) would also suggest the possibility that greater attention to motor factors in speech learning could prove beneficial. (McCauley, 2002).
In summary, while it is difficult to diagnose children with apraxia of speech at very young ages, it is still possible to provide speech therapy to them in a manner that meets the needs of children who may have a motor-planning component to their speech production difficulties. In early phases, attention to increasing overall communication and oral communication in particular, expanding sounds and syllable shapes, gaining multiple repetitions of syllables and words for speech movement practice, functional communication, and solid parent involvement can assist young children suspected to have apraxia of speech.
Davis, B and Velleman, SL. Differential diagnosis and treatment of developmental apraxia of speech in infants and toddlers”. The Transdisciplinary Journal. Volume 10, No. 3, pp. 177 – 192, 2000.
Hammer, D.Apraxia of Speech in Young Children. Presented at the Childhood Apraxia of Speech Association/Hendrix Foundation workshop.Houston, Texas. February 2003
Hammer, D. Brief thoughts about therapy.Apraxia-Kids website. http://www.apraxia-kids.org/slps/hammer.html Accessed January 12, 2004.
Hayden, D. “How do we help children with apraxia become ‘risk-takers’ with their speech and communication?” The Apraxia-Kids Monthly. Volume 3, Number 10. December 2002.
Hammer, D and Stoeckel, R. Teaching and Talking Together: Building a Treatment Team. Presentation at the annual convention of the American Speech Language Hearing Association, New Orleans, Louisiana, November 2001.
McCauley, R. “What if a child isnt formally diagnosed with Childhood Apraxia of Speech (CAS), but appears to be having motor planning difficulties similar to children who are? The Apraxia-Kids Monthly, Volume 3, Number 7. August/September2002.
Stoeckel, R. Why is it important for parents of children with Childhood Apraxia of Speech (CAS) to be involved in their child’s speech therapy? Apraxia-Kids Monthly, Vol.2; No. 9, November 2001.
Strand, EA. Childhood apraxia of speech: suggested diagnostic markers for the young child. In Shriberg, LD and Campbell, TF (Eds) Proceedings of the 2002 childhood apraxia of speech research symposium. Carlsbad, CA: Hendrix Foundation. 2003.
Strand, EA, and Skinder, A. Treatment of developmental apraxia of speech: integral stimulation methods. In Caruso, AJ and Strand, EA (Eds.), Clinical management of motor speech disorders in children. New York: Thieme. 1999.
Velleman, S.L. Childhood Apraxia of Speech Resource Guide. Clifton Park, New York: Delmar Learning. 2003