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Repetitive Books: An Effective Therapeutic Tool for Children Diagnosed with Apraxia of Speech

By
Michelle Soloman, M.A., CCC-SLP and Lavinia Pereira, M.A., CCC-SLP

Books are an excellent tool in treatment for speech and language disorders due to the multi-sensory approach they provide for learning. All books encourage speech and language development (Chamberlain & Strode, 2004); however, which books provide the most beneficial treatment for children diagnosed with Childhood Apraxia of Speech (CAS)? In the treatment of CAS, it is generally understood that frequent practice of sounds and words helps to improve speech (Velleman, 2005) and reduce some of the pressures associated with expressive language. Repetitive books contain various characteristics that can be part of an effective treatment strategy for children diagnosed with CAS — predictability, presence of carrier phrases, frequent practice of target sounds, familiar inflection, and an introduction to phonemic awareness.

Young children’s favorite books are usually highly predictable (Luckner, 1990). A repetitive book may be predictable in a variety of ways; the story may repeat itself, a portion of a phrase may appear on each page or the same question may be asked throughout. The predictable design of many repetitive books allows the child to grasp the content of the story with greater ease, decreasing the “cognitive load” that may come with reading a narrative type story. When the child has less to think about, often the easier it is to verbally express their thoughts.

In addition, predictable children’s books utilize a cloze procedure which allows a child to fill –in words, phrases, and character’s names, as the book content becomes more familiar. Non- repetitive books often result in the child attempting to participate in reading by either imitating the readers’ words or by answering questions presented by the reader. A predictable repetitive book allows the child to fill- in without imitating; a skill very difficult for most children with CAS (Forrest, 2003). The ability to fill- in words and phrases can lead to increased participation, turn taking, and decreased frustration for the child.

In repetitive books, there will often be a functional carrier phrase used throughout the story. For example, the popular book, “Brown Bear, Brown Bear” (Martin, B.) contains the carrier phrase “I see a ___looking at me”. These phrases allow the child to produce a longer utterance while only having to change one core word. As a result, an unlimited number of multiword utterances may be created. A child with CAS often presents with decreased intelligibility as the length of an utterance increases (Forrest, 2003). By practicing carrier phrases, the child can develop the motor plan for the portion of the phrase that repeats itself, in turn decreasing the “motor load” required for a lengthier utterance. As with predictability, these phrases allow the child to experience increased participation as well as the success of producing multi- word utterances.

The presence of carrier phrases, repeated content and recurring words in a repetitive book can result in the frequent occurrence of a particular sound (phoneme) or group of sounds. A child with CAS often presents with difficulty producing even the smallest unit of speech. If a particular phoneme is featured in a repetitive book, the child will be provided with numerous opportunities to practice the motor plan for that phoneme in a functional and interactive approach. As with other speech motor activities such as counting and reciting the alphabet, the more the child practices the motor plan necessary for production, the more automatic it becomes (Fletcher, 1995, p. 18). The increased practice can result in improved production of a sound, syllable or word and increased confidence when attempting to communicate. Error inconsistency (Jacks, Marquardt, & Davis, 2006), a characteristic often cited for children with CAS, may decrease in the context of a repetitive book due to the frequent practice.

Familiar inflection, another characteristic of repetitive books, can assist in addressing some of the difficulties with prosody that children with CAS experience. Prosody is defined as “the stress, duration, pitch, rate, and timing changes that make our speech meaningful, intelligible, and interesting. It is the melody of speech”. (Chamberlain & Strode, 2004) These features [prosodic] are often sacrificed resulting in decreased intelligibility, difficulty expressing emotion through speech inflection (Van Putten & Walker, 2003), effortful speech, robotic sounding speech and equalized stress patterns (Peter & Stoel- Gammon, 2005). As a reader recites a repetitive book it is instinctive to apply an almost sing song like or melodic tone to the books’ phrases. Each time a phrase, question or sequence of words is repeated the same inflection, rate, pitch and stress pattern may be applied when read aloud. In turn, as the child begins to fill- in words, phrases and recite patterns of the story, they may attempt to apply the same patterns resulting in improved prosody.

Repetitive books foster the development of phonemic awareness and sound symbol association. Children with Apraxia are often at risk for language and reading delays (Lewis, Freebairn, Hansen, Iyengar, & Taylor, 2004). Developing sound symbol awareness and early sight word recognition can be challenging and frustrating for the child. A repetitive book, particularly those with repeated words and short phrases can assist in the development of phonemic awareness and pre-reading skills (Lovelace & Stewart, 2007).

The predictability, use of carrier phrases, frequent practice of a target sound (s), and familiar inflection of repetitive books may help to target some of the characteristics often associated with CAS. The use of repetitive books by therapists as well as by caregivers can offer opportunities for increased participation, decreased frustration, and additional motor planning practice for speech sound production. Successful experiences communicating can improve self- esteem and provide a sense of empowerment.

Helpful Hints for Using Repetitive Books:

  • Pause to allow the child to fill in a portion of a repeated phrase.
  • Encourage the child to repeat a carrier phrase heard throughout the story.
  • Provide adequate time for the child to attempt productions.
  • Read a preferred repetitive book multiple times and provide increased opportunities for the child to verbally participate.
  • Read a story with inflection! Apply a consistent melodic tone and inflection to carrier phrases and repeated questions present throughout the book.
  • Provide opportunities for the child to take turns verbalizing.
  • Adapt a book by using additional pictures or objects that correlate to the text.
  • Call attention to the print; point to the written text as you read.
  • Provide a relaxed atmosphere for reading and positively reinforce efforts to communicate.

List of Suggested Repetitive Books

References:

Chamberlain, C. & Strode, R. (2004). Making It Fun: Practicing Speech at Home. First Apraxia- KIDS Parent Conference, Pittsburgh, Pennsylvania.
Fletcher, S.G. (1995). Articulation: A Physiological Approach. San Diego, CA: Singular Publishing Group.
Forrest, K. (2003) Diagnostic criteria of developmental apraxia of speech used by clinical speech language pathologists. American Journal of Speech-Language Pathology / American Speech-Language-Hearing Association, 12 (3), 376-80.
Jacks, A., Marquardt, T.P., Davis, B.L. (2006) Consonant and syllable structure patterns in childhood apraxia of speech: developmental change in three children. Journal of Communication Disorders, 39, 424-41.
Lewis, B.A., Freebairn, L.A., Hansen, A.J., Iyengar, S.K., & Taylor, H.G. (2004) School-age follow-up of children with childhood apraxia of speech. Language, Speech, and Hearing Services in Schools, 35, 122-40.
Lovelace, S. & Stewart, S.R. (2007) Increasing print awareness in preschoolers with language impairment using non-evocative print referencing. Language, Speech, and Hearing Services in Schools, 38 (1), 16-30.
Luckner, J., “Predictable Books: Captivating Young Readers.” In Perspectives in Education and Deafness, October/November, 1990.
Martin Jr, B., (1992). Brown Bear, Brown Bear, What Do You See? New York: Henry Holt and Company.
Peter, B. & Stoel-Gammon, C. (2005) Timing errors in two children with suspected childhood apraxia of speech (sCAS) during speech and music related tasks. Clinical Linguistics and Phonetics, 19 (2).
Van Putten, S.M. & Walker, J.P. (2003) The Production of emotional prosody in varying degrees of severity of apraxia of speech. Journal of Communication Disorders, 36 (1), 77-95.
Velleman, S. (2005). Update on Childhood Apraxia of Speech. Worldtide, Northampton, MA.


About the Authors:

Michelle Solomon M.A., CCC-SLP, PC and Lavinia Pereira, M.A., CCC-SLP, PC are the creators of First Sound Series, a series of interactive children’s books that foster the development and growth of speech and language skills. Please visit www.firstsoundseries.com for additional information and to purchase materials.

Lavinia Pereira, M.A., CCC-SLP, PC and Michelle Solomon, M.A., CCC-SLP, PC, both earned their degree in Speech-Language Pathology from New York University. Currently, Lavinia is in private practice on Manhattan’s Upper East Side and holds a position as a clinical supervisor of graduate students. Michelle is currently in private practice with two office locations on Manhattan’s Upper East Side. In addition, she instructs licensed speech therapists on therapy technique. Both Lavinia and Michelle specialize in the assessment and treatment of motor speech disorders.