Children with CAS may have co-existing conditions that would require different therapy approaches than those we would typically implement for CAS alone. Very often, children who struggle to speak in general may not have any or very few vowels or consonants within their repertoire and are not stimulable to produce them upon simple imitation. Some children have imprecise vowels or consonants in isolation, and therefore also have these same errors in context or connected speech. Sometimes these imprecise vowels and consonants are rooted in oral motor hypotonia, or developmental dysarthria. Therapy strategies for CAS are more focused upon helping children to combine consonants and vowels to form words, using cues and prompts to assist them and gradually fading these over time. However, when vowels and consonants are not within the child’s repertoire at all or are imprecise, more physical prompts or even tools that are used inside the oral cavity (such as a small cylinder to help with lip rounding, or a tongue tip elevator to help with alveolar consonant placement) may need to be implemented to help the children to produce isolated vowels and consonants or to produce them with better accuracy.
Language processing disorders may also co-exist with CAS. Current research is pointing to some challenges with auditory perception and processing of language as an additional aspect of CAS in some children. For example, a child may not be able to determine where each word starts and ends, and what the internal acoustic details are of the word, and thus mispronounce them. A good analogy of this is when one is in a spelling bee and asks the monitor to continuously pronounce the word of which they haven’t practiced. By hearing it repeatedly, they are trying to “listen” intently to the internal details of the words so that they can try to spell them. Children with CAS may benefit from an increase in their “listening” skills” with phonological awareness activities, sensory integration and language processing intervention strategies so that they can have additional auditory input to assist with more accurate motor-speech output.
Children with CAS may also have difficulty combining words to formulate their thoughts. Once they are able to combine consonants and vowels to form words, they now have to know how to combine words to formulate their thoughts using grammatical skills. Asking these children to repeat full, grammatically correct sentences would be met with failure as this would increase the motor-speech load and they have not had the opportunity to practice syntax and morphology.
We would want to gradually help children with CAS to combine words, first with two word combinations, moving into three words without all of the little linking words, and gradually into the use of proper grammatical skills such as adding in articles (a, an , the), auxiliary verbs (is, are, was, were, have, has), and morphological endings (endings that change verb tense such as ing, ed, plurals, etc.). Just as we use cues and prompts to help with what consonant or vowel to include, we could also use some cues as to what little linking words we desire the child to begin to include. Rather than waiting for children to have full, perfectly articulated words, however, we can help them to produce two and three word combinations with their best approximations and continue to focus upon motor-speech skills. We can control the words within the phrases we are teaching so that the child only has to complete a phrase with new vocabulary they are learning. In the K-SLP methods, these are called pivot phrases, words or phrases that remain constant while the child fills in with a novel word. These would be such phrases as, I want___, I want to, let me _____, open_______, I don’t want______, put on _____, help me to _______, put away_____, watch me ____, etc. This gives the child with CAS an opportunity to practice combining words, while being supported for their efforts, and still focusing upon bringing articulation on selected syllable shapes and vocabulary from successive approximations to perfection.
About the Author:
Nancy Kaufman is the author of the Kaufman Speech Praxis Test for Children, the Kaufman Speech to Language Protocol, K & K Sign and Say and other therapy products. She speaks internationally about apraxia of speech in children and is a member of the CASANA Professional Apraxia Advisory Board. Visit the KCC web site at http://www.kidspeech.com.