The term integral stimulation was introduced in the 1950s by Milisen, who described a program for articulatory treatment. The method involved imitation, and emphasized both visual and auditory models. Integral stimulation has long been used for articulation therapy and has also been suggested for use in treating dysarthria and acquired apraxia of speech. In practice, integral stimulation is perhaps the most common of all approaches to treating children with speech disorders. This term is still used to describe treatment that requires the child to imitate utterances modeled by the clinician. Attention is focused both on the auditory model as well as visual attention to the clinician’s face.
There are three main perspectives in treatment for children with apraxia of speech. These include: 1) Integral stimulation (“listen to me, watch me, do what I do”) which utilizes a “bottoms up” approach starting with short, phonetically simple utterances and gradually progressing to more phonetically difficult stimuli.; 2) approaches in which tactile cues as well as gestural cues are heavily employed to help the child to produce accurate movement gestures; and 3) prosodic cueing methods such as MIT or contrastive stress, which emphasize more prosody and incorporate more linguistic components and are typically used for less severe children or those further along in therapy. Of course, most treatments involve a combination of the above perspective. Individuals who use integral stimulation also employ a great deal of tactile and gestural cueing. Because it is important to facilitate improvement in the prosodic aspect of speech early on in treatment, activities to strengthen lexical and sentential stress are often brought into the integral stimulation techniques.
The non-verbal child, with very severe childhood apraxia of speech poses particular challenges for the clinician. These children frequently have no functional verbal communication, have a great deal of difficulty achieving movement gestures toward an initial articulatory configuration in direct imitation, and frequently exhibit numerous vowel distortions. One variation of integral stimulation that I have found to be extremely helpful for children with very severe apraxia is called Dynamic Temporal and Tactile Cueing for speech motor learning (DTTC). This is a strategy that I have developed over a number of years, which is based on a technique described John Rosenbek and others in 1973 (the Eight-step Continuum for Treatment of Acquired Apraxia of Speech). This approach was based a hierarchy of cueing, which varied the temporal relationship between the stimulus and the response, for adult apraxic individuals. The hierarchy begins with simultaneous production of the utterance with the patient. After the patient was able to produce the utterance simultaneously at a certain criteria, they then moved to direct imitation. Again, after reaching a certain criteria, they would add a two-second delay between the clinician’s verbal model and the patient’s response. Finally, after reaching criteria at that level, they would elicit the response either through a written cue or in response to a question, etc. This was very helpful as I worked with adults who had apraxia of speech, and it seemed logical to me to apply the treatment method to children with severe verbal apraxia. However, I was not able to achieve the same degree of success. After some thought, I realized that children have never had experience with making these movement gestures as they have never spoken. Our goal is not rehabilitation but to help these children improve motor planning and programming processing, as they acquire speech and language. As a result, I modified the eight-step continuum method to allow for a continuous shaping of the movement gesture. That is, we began with direct imitation. If the child is unsuccessful, we move to simultaneous production where the therapist says the utterance with the child first very slowly and adding tactile or gestural cues as necessary. Holding the vowel longer at first can be helpful, as well as making sure that the jaw and lip postures are correct. We continue with practice, gradually increasing the rate toward normal, until the child can easily produce the utterance with the therapist with normal rate, no groping, and accurate movement gestures. At that point, the therapist slowly fades the simultaneous cue by reducing volume to the point where there is a simultaneous mime only. When the child seems secure at that level, the therapist then moves to direct imitation. The therapist provides an auditory model, making sure the child is watching the therapist’s face. The child repeats, and if additional support is needed, the therapist may go back to simultaneous production or mouth the movement gesture as the child attempts to repeat. As the miming is faded, the child continues to practice in direct imitation. The important part of this therapy procedure is that the clinician is constantly adding or fading auditory, visual, and tactile cues as might be necessary after each practice trial. Finally, after the child is producing the utterance in direct imitation, with normal rate, accurate movement gestures, and has been able to vary prosody, then the therapist adds a one- to two-second delay before the imitative response. The child will frequently have difficulty at this point. Using a mime while the child produces the delayed response can be very helpful. Finally, the clinician will work to elicit the utterance spontaneously. Keep in mind the hierarchy is constantly changing as the therapist adds or fades cues, depending on each of the child’s responses.
[note: This article originally appeared as an “Ask the Expert” column in the Apraxia-KIDS June 2005 newsletter]
[Dr. Strand is a consultant in the Department of Neurology, Division of Speech Pathology, at the Mayo Clinic in Rochester, Minnesota, and Associate Professor in the Mayo Medical School. Her primary research and clinical interests have been in Neurologic Communication Disorders, especially childhood and acquired apraxia of speech, dysarthria, and neurologic voice disorders. She has published articles and chapters regarding the clinical management of motor speech disorders in children, including treatment efficacy. Dr. Strand is co-editor of the book (1999), Clinical Management of Motor Speech Disorders of Children. She lectures frequently throughout the country on childhood apraxia and motor speech disorders in both children and adults. Dr. Strand is a member of the Childhood Apraxia of Speech Association Professional Advisory Board.]