The goal of intervention for a child with apraxia is to enable the child to gain volitional control of his/her articulators in order to produce age-appropriate, co-articulated, intelligible speech (co-articulation refers to the way we talk when we connect our words together in a speech-melody, rather than pronouncing each word individually). To that end, I believe one must consider the following in the development of speech and language goals for a child with apraxia:
- How intelligible are the childs utterances? How does this level of intelligibility compare to that of his/her peers? How functional is the childs expressive communication (what types of things can the child do with his/her expressive communication can he/she label things, ask for things using a question form, get his/her wants and needs met, share an idea, clarify his/her message)? Children with apraxia often experience a deficit in the ability to use their language for varied purposes or communicative intents.
- Are the childs language complexity, word order, and/or utterance length affected by his/her apraxia? In most cases, children who have apraxia produce utterances that are shorter and less complex than those of their peers.
- Which are the phonemes (sounds) and phoneme sequences that the child can produce with the most automaticity (the ability to produce the phoneme or phoneme sequence without having to “think about” its production)? Which are the most difficult phonemes and phoneme sequences for the child to produce? The most difficult phoneme sequences are those that are the most likely to cause the childs phoneme production to fall apart in connected speech because they are the most inconsistent in terms of production. The child produces more than one error for these phonemes at different levels of production (syllable, word, phrase, etc.). For example, the child may produce the following phoneme errors for /f/ in the beginning or initial position of words: the substitutions of /d/, /b/, /n/, and /p/, along with omissions in some phoneme sequences. This pattern shows clearly that the child lacks a consistent motor plan for the production of /f/. When /f/ occurs in a word he/she tries to produce, he/she has to struggle motorically and ends up producing varied phoneme errors (substitutions, distortions, omissions, and additions) in the place of /f/, depending on the co-articulatory context (the phonemes that immediately precede and follow the /f/). These inconsistently produced phonemes should always be addressed in the childs treatment plan.
- How well does the child understand words and sentences? Many children score within normal limits on receptive vocabulary tests, giving the impression that their receptive language is good. But because of the limited expressive language they produce, it is not always possible to determine their true language processing and production skills because of their inability to respond intelligibly during administration of language comprehension and/or processing assessment instruments. When the apraxia is severe, the child has very limited experience in the use of vocabulary and language structures appropriate to his/her age. This lack of experience can lead to a lack of understanding of the language contained in question forms (the child may not know what kind of information is required for each WH form), directions, clarification, and sequencing of events. This can result in secondary delays in the childs ability to understand the language of adults and peers. A child learns vocabulary and expressive language by using them. That which he/she cannot produce is harder for him/her to understand.
- What are the childs immediate needs in terms of communication? In some cases, these needs might be met by carrier phrases or functional phrases that will expand the child’s communicative repertoire. For example, if you teach the child to co-articulate “Iwanta” (I want a ) intelligibly, all he/she will need to do is add a word to that phrase and he/she will be able to communicate many things to others. The best way to determine these needs is through parent and teacher interview, observation of the child, and knowledge of the words and phrases that are generally developed first for typically-developing communicators.
If the child is older, it is even more important to determine if his/her utterance length and complexity and communicative intent (ability to communicate a wide range of things to others) are commensurate with his/her peers. Children with apraxia can become very adept at monitoring their own co-articulatory productions as they get older, so they sound quite intelligible. In actuality, they may be shortening their utterances so it is not obvious that they do not have volitional control of phoneme production as co-articulatory demands increase. This can affect their choice of vocabulary, their written language, and their ability to use language for abstract purposes such as persuasion, comparison and contrast, idioms, etc. When this happens, their language sounds younger than their peers (sometimes you have to listen very carefully to catch this). It is important to address this early on in a childs therapy by having him/her produce words and sequences that do not occur frequently in the English language. The child should practice these less common and generally higher-level words and phrases in order to gain complete co-articulatory competency. Examples of this would be words such as plural, rural, extraction, exists, contrary, etc. The phoneme sequences addressed will depend on each childs individual phoneme-production profile. In essence, the clinician teaches the child co-articulatory production of these later-developing phoneme sequences so the child has mastery over all possible phoneme sequences. This way the child will not avoid these co-articulatory challenges as he/she gets older.
How does the child compare to his/her peers in terms of social skills? Is his/her eye contact, physical distance, vocal modulation, nonverbal communication, etc., typical for his/her age? Many times a child will experience delays in these skills because he/she will not be able to develop these interactive, pragmatic language skills at the level of his/her peers because of social inexperience caused by the apraxia.
For an older child, how well does he/she read? Can he/she hear all the phonemes in a word or phrase? Those phonemes which a child cannot produce are often difficult for him/her to hear and/or differentiate from other phonemes. Children with apraxia may experience delays in their ability to read because of secondary delays in morphology, syntax, comprehension, expressive language and phonological processing skills.
Does the childs connected speech sound normal, or does he/she have difficulty varying the prosodic features of his/her utterances? Prosody refers to features of an utterance such as intonational patterns, syllable and/or word stress, volume, and rate. Deficits in prosody are often an indication that a child is not able to co-articulate at the utterance level produced. When this happens, he/she produces some phonemes, phoneme sequences, and/or words individually, stopping the speech-melody and causing the child to sound “robot-like” or “different.”
These are some of the main factors that need to be considered when developing goals and objectives for a child with apraxia.
(Lori Hickman, M.S., CCC-SLP, has been a practicing speech-language pathologist since 1983, having graduated with her Master’s in Speech Sciences from Portland State University in Oregon. Ms. Hickman has dedicating her career to date to speech-language pathology in the schools, as well as assessment and treatment of children with severe communication disorders such as CAS. Ms. Hickman is the author of The Apraxia Profile, an assessment instrument as well as therapeutic materials for children with CAS. In 2000, she wrote the book Living In My Skin: the Insider’s View of Life With a Special Needs Child, a book based on interviews of hundreds of parents of children with special needs, providing professionals, extended family, friends, and communities with an inside look at the day-to-day challenges that families of children with special needs face.)