The article, “Meeting the Challenge of Suspected Developmental Apraxia of Speech Through Inclusion” (Topics in Language Disorders, 1999, (3), pages, 19 – 35 by Ruth Bahr, Ph.D., Shelley Velleman, Ph.D., and Mary Ann Ziegler, MS), details the difficulty of service delivery for children with suspected Developmental Apraxia of Speech (DAS). The authors discuss three frequently used models for service delivery in schools including 1.) pull out speech therapy, 2.) speech therapy in group sessions, and 3.) a self-contained language classroom model.
As many parents of children with apraxia have experienced, the researchers note that when the first option, a pull-out model is used, the size of the speech therapist’s caseload seems to play a determining factor in the frequency and intensity of sessions recommended or initially offered. This is problematic for children with severe intelligibility problems. The authors state that the second common option, group treatment, need not differ in quality from an individual treatment approach, except that because more children are being treated at once, people seem to use this model to increase contact time with students in need of intensive treatment. Unfortunately, children with severe intelligibility problems need more intensity versus less. The third common option, a self-contained language classroom, is described as problematic because children with suspected DAS have intact receptive language. This model then places them in a classroom with children whose language ability is not age appropriate. The focus is primarily on language comprehension versus speech/oral motor articulation.
This study emanated from Pinellas County School District in Florida. This school district’s speech pathologists had noted the need for new and innovative services for children with DAS. They contacted researchers at the University of South Florida’s Communication Disorders program to discuss this issue. At the time, Pinellas County tended to serve students with severe language disabilities in self-contained classrooms, pairing a special educator and an SLP to co-teach, with curriculum presented through a language-based approach. This language classroom was of concern. It appeared to the staff that children with unintelligible speech often had the cognitive ability to benefit from the regular curriculum. The children differed, in their individualized need, from children with severe language impairment who needed a modified curriculum. Yet due to the children’s lack of intelligibility, the speech therapists were concerned as to how to meet the children’s academic needs within regular mainstream classes.
With the researchers, staff at Pinellas identified the following aspects that represented an optimal treatment model for children with severe intelligibility issues:
- a general education curriculum because the children are able to cognitively handle age-appropriate concepts
- age-appropriate peers, providing social and emotional benefits
- normal speech and language models for everyday interaction in the classroom
A full day, year round classroom was established with a regular education teacher and an SLP staffing it. After screenings to determine the children who would be targeted for this classroom (children with severe intelligibility issues, normal cognitive, social and receptive language ability, etc.), they identified a group of children who would begin the program. Next, a treatment approach was decided.
“Co-teaching principles were used for educational planning and implementation…Student learning occurred in large and small groups, as well as individually within learning centers. All children in the classroom participated in the speech production activities as these were integrated into their daily activities. In this way, children were able to assist each other with the speech tasks. If individual children were not able to perform the activities within the group context, then the SLP would work with them separately during one of the child’s learning center times… Classroom activities ranged from oral motor, oral sensory to activities that emphasized the more phonological aspects of the disorder.”
A sampling of activities included:
- Oral motor: focused on tactile stimulation followed by phoneme practice. Tactile exercises served ONLY AS WARM UP to phoneme practice. Use of the Metaphon approach, touch cues, etc.
- Main focus of treatment on syllable structure control and organization within a variety of linguistic contexts. (Focused on supporting children’s enhanced awareness of movement from one spatial target to the next.)
- Flip book or pacing boards to which visual cues were attached, play routines, book reading and rhyming games that adapted easily to the repetitive practice needed by children with DAS.
- Prosody activities: drumming, clapping, marching, rhythm, pitch activities of high and low voices, volume control, stress pattern work, etc.
Effectiveness of the program:
- An immediate and noticeable drop in frustration level of the students with apraxia as reported by teachers and parents. The authors write,
- “…for the first time, teachers gave students appropriate feedback on the sounds and words they were either making or attempting to make. The adults that the students encountered really cared about understanding the children. Such recognition increased the students’ knowledge that what they were attempting to say was important”.
- “This classroom operated as a typical inclusion program, with the teacher and SLP working together through co-teaching practices to communicate the necessary kindergarten concepts and to monitor and internalize aspects of better executed speech production. The curriculum incorporated the sound class or phoneme for the week in every way possible. Oral motor stimulation was conducted with each and every child in the classroom through the course of the day. As needed, a child would be pulled out for individual work on a sound.”
- APP-R scores and informal ratings of intelligibility by the SLP suggested that these children were very difficult to understand at the beginning of the year. By winter break, others in the school began reporting that they were beginning to understand the children’s speech (i.e.: cafeteria workers, custodian, etc.)
By the end of the year, eight of the nine children with DAS were promoted to first grade. Their intelligibility in everyday conversation had improved to the point that the SLP felt that they no longer needed intensive services. These eight children were then recommended to continue to receive some pull out services from their regular first grade classrooms. Monitoring, after the first year since leaving the program, indicated that six of nine apraxic children had only minor articulation errors remaining and that they were progressing well academically. Six went on to second grade and three were referred to a Speech Language Disorder program because their language difficulty became more evident as speech intelligibility improved.
Final comments from the researchers state that, “the success of this program suggests that inclusion models can make a huge difference in both the social adjustment and communication skills of students with severe intelligibility problems who meet clearly specified criteria for inclusion.”
The key difference between the experimental classroom for children with DAS and many existing specialized classrooms for children with speech and language problems was that the experimental classroom was specifically designed with repetitive speech production and oral motor opportunities in mind. Additionally, it provided the added bonus of typically developing peers as speech models. It is nice to see this blend of specialized assistance for the unique needs of kids with DAS mixed with the known and obvious benefits of inclusion with typically developing peers. A big congratulation to the speech and language professionals in the Pinellas County School District! It’s refreshing to learn of people who recognize the unique issues and challenges presented by our kids with DAS and move to DO SOMETHING about it.