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The “Successive Approximation” Method of Therapy for Children with Apraxia of Speech

By
Nancy Kaufman, M.A., CCC-SLP

Children with childhood apraxia of speech cannot easily execute and/or coordinate oral-motor movements to combine the consonants and vowels necessary to form words. Asking children to imitate whole words would be setting them up for failure. Just like any other task that is difficult to master, the task of speaking can be broken down into a more simplified one, in this case word approximations.

By examining how children first learn to speak, we can observe that many of the early vocabulary begins with word approximations such as, baw for ball, or bah for bottle, or even wawa for water. Children with CAS who have performed little babbling or practice as infants, may not be able to change what they hear and understand, into the motor act of speaking those words. By simply offering children with CAS the opportunity to attempt word approximations using the consonants and vowels already in their repertoire, successful attempts at words are achieved, reinforced, and rewarded by the listeners comprehension, and thus their response to the childs needs and desires. Through shaping, cueing, and fading techniques, children with CAS can gradually move into whole words, phrases and sentences.

One can evaluate the consonant and vowel patterns of children by asking them to imitate, moving in a hierarchy from simple to complex vowel and consonant combinations to obtain a profile of the childs motor-speech proficiency. Then, through practice of this hierarchy of consonant and vowel patterns, the children gain verbal praxis skills for the ultimate goal of successful verbal communication.

Beyond the workout of practicing consonant-vowel patterns in real words is the important aspect of functional communication. As soon as the child has any type of an approximation for a word, it should be encouraged and reinforced by the appropriate response of the listener (i.e., giving the child juice for attempting doos or oos for juice). In this approach, however, we do not necessarily wait for the child to use an approximation independently, though that is certainly the optimal goal. We actually assist them with imitation, cues, prompts or any possible way to help them make their best word approximation attempt. We also help to script the children directly into two or three-word combinations almost immediately, even if every word is only approximated, such as in I want .., being scripted as Ah wah

This approach encompasses aspects of behavior modification (shaping, cueing, fading) for successful approximations, as well as our knowledge of phonological processes, which are the way young children tend to simplify adult forms of words. Such phonological concepts as final consonant deletion, cluster reduction, vowel neutralization, to name a few processes, are what we rely upon to decide how a word can be simplified based upon typical speech development. Every word can be reduced to its shell (this concept of word shells was introduced to me by Ms. Carole Goff, M.A., CCC/SLP). For instance, the word bottle, can be broken down like this:

bottle

bah-do

bah-o

bah-bah

bah

Choosing the childs highest successful imitation and reinforcing it (ideally giving the child the bottle), offers them a chance at successful verbal communication rather than only accepting the full word which may not yet be a possibility. This approach also encompasses techniques gleaned from the research and work accomplished by many speech and language pathologists who work with individuals exhibiting acquired apraxia of speech. These techniques include using melody and gestures to take the pressure off of the volitional muscle control system. Occupational therapy/sensory integration techniques of direct stimulation to the oral musculature and using gross-motor activity to propel the entire motor system to activate verbal-motor skills are also valuable to this approach.

The Kaufman Speech Praxis Treatment Approach is also becoming highly successful for children with CAS on the spectrum of autism. Dr. Vincent Carbone, Ed.D., BCBA and Ms. Tamara Kasper, MS/CCC-SLP, BCaBA, are currently researching and adapting the KSPT techniques specifically through Applied Verbal Behavior, employing methods from B.F. Skinner (1959) and Sundberg and Partington (1998). The changes for children with autism are largely due to the fact that it can be more difficult to move along the hierarchy of word approximations, as there is more work involved in extinguishing and replacing the first learned word approximation and shaping it toward the ultimate goal of the full word. Dr. Carbone also utilizes the method of stimulus-stimulus pairing to move non-verbal (yet vocal) children into the ability to imitate CV patterns, which prepares them for the KSPT approach.

Through the workout, scripting, and ultimately improving word retrieval, grammatical skill development and general formulation skills, children with CAS can become effective verbal communicators.


[Nancy R. Kaufman, , M.A., CCC/SLP is the Director of the
Kaufman Childrens Center for Speech, Language, Sensory-Motor and Learning Potential, Inc. (KCC), located in West Bloomfield, Michigan. Nancy has specialized in working with children exhibiting apraxia of speech for over twenty five years. She is the author of The Kaufman Speech Praxis Test for Children, and The Kaufman Speech Praxis Treatment Kits for Children. She lectures locally, nationally, and internationally. Families from around the country, Canada, and the UK travel to the KCC to participate in intensive and specialized programs. Specialists in the field of Applied Verbal Behavior (AVB) have recently adopted the Kaufman Approach into their protocol for children on the spectrum of autism. Nancy is also a member of the CASANA Professional Advisory Board.]

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