Many issues surround the decision as to how to treat a child with a motor speech disorder. Perhaps first and foremost is how the clinician views that disorder. My particular point of view is that the term apraxia of speech is a misnomer. My experience and research has indicated that there may in fact be two or three forms of motor speech disorders in children that clinicians historically have lumped under the label of apraxia of speech. In my work, I have called these congenital dysarthria, planning apraxia of speech, and executive apraxia of speech. These terms are intended to show a continuum of clinical impairment ranging from those dominated by motor deficits to those that are more language based. All have a “motor planning” component to them. This continuum between motor to language processes influences much of my thinking on how to evaluate and treat children with developmental motor speech disorders. With that in mind let me address one treatment program that has worked well for a number of children over the years.
The program is sometimes called the “multi-focal program.” This is because it addresses three aspects of motor speech disorders that I have seen repeatedly over the years:
- oral motor deficits and motor deficits in speech production,
- disorganization in the phonologic system,
- disorganization in the expressive language system.
The multi-focal program incorporates each of these into each and every therapy session. The balance across the three components is determined by the imbalance in capabilities demonstrated by the child. For example, if a child has significant motoric impairments there may be greater emphasis on the initial component. From a different perspective, a child with significant phonologic deficits with minimal oral motor problems may receive a greater emphasis on the second component and so on and so forth.
The first component, motor speech, utilizes a bite block to stabilize the mandible combined with vowel or consonant-vowel syllables to facilitate lip and tongue movement independent of mandibular support. We have found this to be helpful in both child and adult patients with motor speech disorders. For example, once a bite block is placed the child may be asked to imitate the cardinal vowels of /i/, /a/,/u/. This forces the tongue to move without mandibular support to the high-front, high-back and low-mid position in the oral cavity we then may add the consonants /t/, /k/ or /d/ and /g/ introducing the co-articulatory effect of a front and back consonant. These CV units(consonant-vowel) are then strung together and converted to CVC (consonant-vowel-consonant) syllables to vary syllable shape during the early component of the treatment session. We have learned over the years that younger children tend to not tolerate bite blocks as well as older children and therefore these are often used for a shorter duration of time with the younger child.
The second component, phonological reorganization, address the overt characters of sound omissions substitutions etc. One philosophy is that the child develops disorganized production phonology as a result of impaired motor learning processes. From this perspective we have tried to use a therapy technique that reorganizes the phonological system. One of my favorite techniques has been “phonemic contrasting.” In phonemic contrasting, the child learns a very important lesson about speaking. The child learns that in order for words to have different meanings to the listener they must be produced differently. For example, if the child is deleting final consonants and says the word “boo” when he means to say the word “boot”, we have not only a phonologic change, (final consonant omission) but also a semantic change (obvious change in word meaning). In phonemic contrasting, words are paired based on the contrast that you are trying to teach the child. In this system, the focus on individual sounds is minimized and it is the contrast between meaningful word pairs that is emphasized. In the example given the contrast would be final consonant production. Therefore, if the child said “bood” he or she would be considered to have produced a correct response because a final consonant was produced; even though an incorrect final consonant. What we have found with this technique is:
1.) Clinicians can work on many different sound categories in the same treatment sessions focusing on a single contrast, and
2.) Though children may not produce the initial correct sounds in these targets, they soon reorganize the phonologic system and correct sounds emerge.
The third component, syntactic reorganization, is used for two purposes. The first is to give the child some “carry over practice” in a more complex linguistic framework than single words. The second is to give the clinician an opportunity to stimulate more advanced grammar in expressive language. A variety of techniques can be used. One that I have used repeatedly is a modification of the Fokes Sentence Builder. In this technique, sentences are constructed by physically aligning 3×5 cards in the right order. The target words from the second component of therapy (Phonemic Contrasting) can be used as part of the sentence construction. Once simple sentence frames are constructed clinicians can then turn the cards over or reorganize them if memory or sequencing activities are indicated in the treatment plan. Subsequently, we give the child all the cards and ask them to tell a story to terminate the treatment session.
These treatment sessions can be conducted in as little as thirty to forty-five minutes. We have found them to be effective in children with motor speech disorders of varying types. A brief comment on changing from one stimulus to the other; we have found that it is advantages to use a “stairstepping” model for introducing new stimuli. That means that we never change the motor target, phonologic target, and the grammatic target in the same session. Only one new target is introduced in any given session. Once the child masters that target it is then introduced in a new context such as a more advanced grammatical structure or a more difficult sentence type. In this regard only, the information that you want the child to focus on is changed in any give session.
In the preceding paragraph, I used the word context. I think that context is very important in developing effective therapy program for children with developmental speech disorders. My view is that apraxia is a disorder of motor organization/motor execution that is influenced by motoric and/or linguistic context. Clinicians who can master the ability to identify the context contributing to either success or non-success in speech production for these child can subsequently structure therapy using appropriate context to facilitate improved responses.
Michael Crary is author of Developmental Motor Speech Disorders and numerous other publications.