Speech Therapy for Younger Children

Speech Therapy for Younger Children

Apraxia: Speech Therapy and Treatment for Toddlers and Young Children

Original article written by Sharon Gretz, M.Ed.

Revised and updated by Megan Overby, PhD, CCC-SLP(Note: Members of the Apraxia Kids Professional Advisory Council have reviewed this article.)

Introduction

There are questions whether children under age 3 should be given the diagnosis of apraxia of speech. If a diagnosis is made (or suspected), the issue of how to treat such a young child arises, especially because many children who later receive a confirmatory diagnosis of CAS will have additional speech and language therapy goals in addition to those targeting speech production. The purpose of this article is twofold: to review current recommendations for initial diagnostic procedures when identifying young children who may have CAS and to briefly discuss some speech therapy techniques that may benefit the speech production and expressive language skills of young children suspected to have CAS.

Diagnostic Indicators

Much work needs to be done in characterizing the early speech sound development of infants and toddlers later diagnosed with CAS, but studies (Highman, Hennessey, Leitao, & Piek; 2013; Highman, Hennessey, Sherwood, & Leitao, 2008; Overby & Caspari, 2015; Overby, Caspari, Schrieber, in review) offer some preliminary diagnostic indicators for children aged two and younger.

Not all infants and toddlers later diagnosed with CAS will present with these possible indicators, nor is it known how many of these possible indicators, or which ones, are most concerning. Nevertheless, at age 2 and younger, a risk of CAS may be associated with:

  • Few consonant and vowel sounds so that the child seems less vocal and more quiet than typically developing infants and toddlers
  • No recognizable consonant by 12 months of age
  • Lack of canonical babbling onset between 7 – 12 months of age
  • Three or fewer recognizable consonants by 16 months of age
  • Five or fewer recognizable consonants by 24 months of age
  • Lack of “back” sounds (such /k/ and /g/) and favoritism of sounds that are anterior (bilabials and alveolars, such as /m/ and /d/) by 24 months of age
  • Favoritism of stops and nasals over a diverse manner, with possible absence of fricatives or glides by 24 months of age
  • Dependency on vowels at 13 – 18 months with little use of consonant-vowel syllable shapes

All young children are highly variable in their speech sound development. Therefore, the diagnosis of CAS in a child who is younger than three, or who has little expressive ability, should be made only by a speech-language pathologist with specific experience in assessing the speech sound skills of young children.

Other descriptive speech sound characteristics of CAS in infants and toddlers later diagnosed with the disorder have been suggested (Davis & Velleman, 2000, p. 182; Fish, 2016), including:

  • The child may have acquired some later developing sounds while be missing earlier developing sounds.
  • Limited variation of vowels and the use of a centralized vowel in a multipurpose way.
  • Vocalizations may have speech-like melody but syllables or discernable words may not be present.
  • Words may seem to disappear from use more than would be expected for a typically developing child of the same age.
  • Predictable utterances may be easier than novel utterances

Nonspeech characteristics that could also indicate apraxia of speech in the young child include: homemade gestures or signs, some feeding difficulties such as eating mixed textures, drooling, late development of motor skills overall, and oral motor incoordination.

If there is uncertainty about a diagnosis of CAS in a very young child, active monitoring of the child’s speech sound development over the course of a few months may yield additional information. However, because the trajectory of speech sound development in children with CAS appears to be much slower than that of children with typical development or with other types of speech sound disorders (Overby & Caspari, 2015; Overby, Caspari, & Schrieber, in review), early intervention for children with suspected CAS is important.

As children mature, they are better able to participate in assessment of their speech sound skill. More information about the child’s speech sound capabilities can be obtained when the child can attempt to imitate utterances varying in length and/or phonetic complexity (such as imitating /i/, then /mi/, then /mit/ or /o/, then /no/ then /nop/) (Strand, 2003). Strand (p. 77) offers five potential diagnostic characteristics of apraxia in young children who are able to make such imitative attempts:

  • Difficulty in achieving and maintaining articulatory configurations
  • Presence of vowel distortions
  • Limited consonant and vowel repertoire
  • Use of simple syllable shapes
  • Difficulty completing a movement gesture for a phoneme easily produced in a simple context but not in a longer one

Speech Therapy and the Two-Year Old with Possible Apraxia

There is little literature about treatment in very young children with apraxia of speech and no studies have compared the effectiveness of treatment approaches in this population. Nevertheless, for children who are two years old and under, but are considered high-risk for CAS because, for example, they have no consonants and are not babbling, treatment should not be delayed. Although therapy should always be individualized to each child, some experts (Fish, 2016; Velleman, 2003) suggest intervention for very young children could include:

  • Learning to imitate gross motor skills
    • Large motor movements (such as clapping)
    • Actions with objects (banging two blocks together)
  • Imitating vocal play (e.g., raspberries, squeals)
  • Imitating oral-facial movements (e.g., licking lips, blowing kisses)
  • Vocalizing visible early sounds such as /m/, /b/, or /d/ (e.g., /mmmm/, “muh” or “buh”)
  • Vocalizing to get attention (e.g., “uh” and pointing to a cookie)
  • Sound effects: animal noises (e.g., “grr”, vehicle sounds)

As children gain the ability to say a sound or sounds, therapy can focus on simple words such as:

  • Words with distinctive pitch patterns (e.g., “uh-oh,” “wow,” “whee,” “yay”)
  • Words with strong emotional meaning
  • Words or vocalizations that can be paired with actions (e.g., “whee”, “hi,” “oops”)
  • Sound effect words (e.g., “woof’, “beep,” etc.)
  • Verbal routines (e.g., songs, rhymes, favorite predictable books)
  • Speech or singing in unison with others
  • Words with very early consonants (e.g., [h], glides) and simple syllable shapes (e.g., “hi,” “uh-oh,” “wow,” “whee,” “yay,” “me”)

Regardless of how many sounds the infant/toddler has, speech therapy should include:

  • Support to the family
  • Use of props such as puppets, stuffed animals, etc.
  • Use sounds already in child’s repertoire to build simple productions (e.g., if a child has /m/, can he learn to say “ma,” “me,” or even “muh” as an approximation of “more”)
  • Maximizing the child’s gaze to the speaker’s mouth by putting toys or objects of interest near the speaker’s mouth during imitation tasks

In summary, two primary treatment goals for young infants and toddlers with suspected apraxia of speech are, according to Davis and Velleman (2000, p. 184):

  • Helping the child establish a consistent form of communication. Clinicians should watch the child for attempts to communicate appropriately and respond to any appropriate mode of communication the child may use, including non-verbal expressions such as gestures, facial expressions, sound effects, leading, or pictures. Communication attempts should not be ignored.
    • It is important that the child and his communication partner(s) agree what a gesture, sound, picture, or word approximation represents or means.
  • The child needs to develop and consistently use oral communication. Using alternative communication such as sign language, gestures, or computer-based icon programs can be very helpful in moving a young child toward oral communication by relieving frustration and establishing a consistent, reliable means of communication (Fish, 2016). Efforts should be made to develop the child’s ability to use oral sounds to communicate, using the goals suggested above, as soon as the child is capable of doing so.

Speech Therapy and the Older Toddler with Possible Apraxia

Once a child has consistently begun to use vocalization to communicate, it is more important for a child to use sounds and to work towards expanding his sound and syllable repertoire than to be accurate in producing them. Experts (Davis & Velleman, 2000; Fish, 2016; Overby, Caspari, & Schreiber, in review) suggest therapy goals for a child with the ability to vocalize should focus on:

  • Expansion of sounds
  • Expansion of syllable structures

Suggestions for expansion of sounds are:

  • To acquire a diverse set of consonant and vowel sounds. This means the child should be able to say sounds produced in different parts of the mouth. Acquiring sounds in the posterior part of the mouth can be difficult and may require a lot of effort by the child and the clinician.
  • Producing sounds with varied pitch and loudness levels

Suggestions for expanding structures:

  • Focusing on syllables rather than individual phonemes
  • Fish (2016) and Velleman (2003) suggest a hierarchy of syllable shapes:
    • CV (“me”)
    • Reduplicated CV.CV (“bye-bye” or “no-no”)
    • Vowel harmonized CV.CV (“TV”) or consonant harmonized (“mommy”)
    • Variegated CV.CV (“bunny”)
    • Harmonized CVC (“pop”)
    • Variegated CVC (“top”)
    • Harmonized CVCVC (“pop up”)
    • Non-harmonized CVCVC (“peanut”)
    • Words containing clusters
  • Goals should target EITHER new structure or a new sound, not both at the same time
  • Syllables should represent, when possible, a variety of nouns, verbs, adjectives, and other meaningful productions

Working at any one level of syllable shape does not mean drilling the same word over and over. The idea is to help the child learn new motor movements by building on current skills. So, for example, one could first work on the same syllable repeated, (e.g., “ma ma ma ma”). Next, introduce one change at the end of the repeated syllables, e.g., “ma ma ma moo” or “moo moo moo do”. Alternating the syllables takes the activity one step further, i.e., “ma, moo, ma, moo” or “moo, do, moo, do, moo.” As competence is built with these activities, practice with syllables moves further so that the child produces varied syllables/sounds: “ma, moo, may, my, mow”. In young children, the approach will need to be fun, silly, and engaging in order to elicit the child’s attention, involvement, and effort.

Speech Movement Goals and Training

Goals, such as those described above, are only one component of the speech therapy program for CAS. A speech therapy program must address the underlying nature of the problem of apraxia – which is the ability to plan accurate, well timed speech movements from sound to sound, and syllable to syllable, in order to produce old and new words. Clinicians need to provide therapy opportunities that allow young children to build flexibility into their motor systems.

In clinical practice, it is suggested that speech-language pathologists incorporate principles of motor learning: the need for many repetitions and practice, distributed vs. massed practice opportunities, appropriate use of feedback to the child to enhance motor learning, etc. (Maas, Robin, Hula, Freedman, Wulf, Ballard, & Schmidt, 2008). Even toddlers can be involved in therapy opportunities maximizing conditions for motor learning but adapted to their needs as very young children (Davis & Velleman, 2000; Strand & Skinder, 1999;).

Davis and Velleman (2000, p. 187) offer ideas for gaining multiple repetitions from toddlers:

  • Use of counting books but instead of counting the objects on a page, simply point to the object and repeat its “name” each time it appears on the page. For example, a counting book of animals has 4 dogs on the page for the number 4. Instead of counting “1, 2, 3, 4”, you can guide the child to point to each dog and say “pup, pup, pup, pup” or if the child is more skilled, “doggie, doggie, doggie, doggie”.
  • While playing “house” and setting the table, each time a cup is put down saying “cup, cup, cup”.
  • Pretending to eat: “yum, yum, yum”

Functional vocabulary books are another way to elicit practice from the child and can also incorporate parents or other communication partners. According to Hammer (Apraxia Kids website), the vocabulary book should consist of photos or pictures of meaningful people, toys, and objects in the child’s life as well as words that contain initially targeted sound sequences. This book often serves as a child’s first success at expansion of functional communication interactions with significant others.

Fish (2016) also provides a list of activities to elicit repetitive practice that can be motivating and fun. A few activities include:

  • Hop to it” where the child hops to the target, saying the target with each hop
  • “Paper chain” in which the child repeats the target word or phrase written on strip of paper, and then glues or staples the paper together to form a link in a paper chain
  • “Feely box” where there are small objects (with the target sound in the name) inside a closed box with hole large enough for the child’s hand, and the child tries to find the object

Providing Motivation/Keeping the Child’s Attention

Play presents many opportunities for these repetitive sequences and parents and therapists can be creative in this way. The idea is to help the child into practice by making their therapy experience not just fun but also successful for them. Even very young children with apraxia have gained the understanding that speech is difficult for them and so may avoid or resist expressing themselves with oral communication. An astute, engaging clinician can use low-pressure opportunities and engaging play to help children with apraxia take risks with their speech attempts (Hammer, 2003).

Experts (Fish, 2016; Strand & Skinder, 1999) offer the following ideas for providing motivation and keeping attention of young children with apraxia:

  • Ideally, incorporate movement into treatment, or at least after 10-20 practice trials (rocking, bouncing, marching, swinging arms, etc.)
  • Change inflection (stress on different words, low pitch, high pitch, exaggerate the target word or phrase)
  • Use various dolls, puppets, animals that the child can speak for; change the selection after a number of practice trials
  • Incorporate music into treatment (make up tunes or use familiar ones to practice a word)

Remember that while clinicians must make therapy fun and engaging, it is not sufficient to be able to say the child enjoyed the therapy session or that the session went well because the child cooperated. That alone will not effectively provide what the child needs, which is the opportunity for a high number of repetitions of speech targets and the clinician’s thoughtful feedback about performance and results. If the child isn’t saying much in the therapy session, the clinician is not going to be able to achieve this goal (Strand & Skinder, 1999).

Other “take home” points about speech therapy for toddlers with suspected apraxia of speech include:

  • Children with apraxia may not follow the typical “developmental” sequence for acquiring new sounds (Davis & Velleman, 2000; Hammer, 2003; Overby et al., in review)
  • Children with apraxia of speech need some early success with speech. They need to know it is worth it to trust and cooperate with the clinician (Hammer, 2003).
  • Children with apraxia seem to have periods where sometimes they seem to ‘plateau’ and show little growth (Davis & Velleman, 2000; Overby et al., in review)
  • Play is the medium for these young children to learn speech movement training (Hammer, 2003).
  • Parents need help and direct mentoring to understand their role and how they can effectively practice with the young child at home (Hammer & Stoeckel, 2001).
  • Break up sessions into several activities that have repetitive practice vs. one long activity (Davis & Velleman, 2000; Strand & Skinder 1999).
  • Just as with older children with apraxia, younger children need feedback about their performance such as knowledge of results (did they get the word right?) and more specific knowledge about performance (for example, “you need your lips out for that”) (Davis & Velleman, 2000; Hammer, 2003; Strand & Skinder 1999).

Parents as Collaborators

At the outset, clinicians need to involve parents in therapy opportunities for children with apraxia, to the greatest extent they are able and willing. Parents can share essential information from the home and community environments and are important informants on the likes, dislikes, and personality characteristics of their children. Additionally, because many repetitions of speech movement patterns are necessary for motor learning to occur, parents are valuable speech practice partners for their children in their everyday life experiences together (Stoeckel, 2001).

Hammer and Stoeckel (2001) listed the following responsibilities for the speech-language pathologist in working with parents of children with apraxia of speech:

  • Educate parents re: CAS and intervention
  • Educate parents re: networking/support availability
  • Teach child needed skills in a flexible, productive manner
  • Assure high expectations from the child
  • Be able to explain goals and changes in therapy strategies
  • Assure periodic observations either on-line or via videotape
  • Work with parents to motivate and reinforce child’s learning

Setting Expectations: Children as Risk-takers

In typically developing children, early sound play and communication attempts bring a great deal of fun and excitement, but by the time a young child with suspected apraxia of speech arrives in speech therapy treatment, he or she may already have experienced a great deal of failure in efforts to communicate orally. Additionally, families may also feel somewhat like failures in helping their child to communicate (Hammer, 2003). Clinicians can help by creating carefully planned small steps toward success in the earliest phase of therapy. Additionally, it is important for clinicians to set early expectations around communication exchanges. Sometimes children with CAS must be encouraged to take “risks” in talking.

Children with apraxia of speech need to feel as if they can trust in the therapeutic process and have success. Reasonable expectations for oral communication, based on the capability of the child’s speech motor system, need to be implemented and reinforced so that the child uses and practices what he/she can produce (Hayden, 2002).

Apraxia or Something Else?

Once a period of therapy has commenced and the speech-language pathologist has experience working with a child, she can better determine if the primary difficulty lies in speech motor planning and programming. According to McCauley (2002), if a child does not respond well to treatments in which the goal is to teach phonologic patterns (e.g., the Cycles Approach or minimal pairs) or to traditional articulation training, the clinician should consider whether there are possible motor factors in speech learning.

Even if a child does not receive an apraxia diagnosis, the therapy recommendations outlined above may be useful in the child’s treatment plan. A speech-language pathologist experienced in the differential diagnosis of CAS from other disorders can be of assistance to families seeking diagnostic information about their child.

Conclusion

In summary, while it is difficult to diagnose children with apraxia of speech at very young ages, there are some emerging possible diagnostic indicators that, with additional research, may facilitate the diagnostic process. Furthermore, even without a clear diagnosis, it is still possible to provide speech therapy to young children who are at-risk for a motor-planning component to their speech production difficulties. Attention to increasing overall communication and oral communication, expanding sounds and syllable shapes, gaining multiple repetitions of syllables and words for speech movement practice, focusing on functional communication, and encouraging parent involvement are key treatment considerations for young children suspected to have apraxia of speech.

References

Davis, B., & Velleman, SL. (2000). Differential diagnosis and treatment of developmental apraxia of speech in infants and toddlers. The Transdisciplinary Journal, 10(3), 177 – 192.

Fish, M. (2016). Here’s how to treat childhood apraxia of speech (2nd ed). San Diego, CA: Plural Publishing.

Hammer, D. (2003). Apraxia of speech in young children. Presented at the Childhood Apraxia of Speech Association/Hendrix Foundation workshop. Houston, Texas.

Hammer, D. Brief thoughts about therapy. Apraxia-Kids website. https://www.apraxia-kids.org/slps/hammer.html

Hayden, D. (2002). How do we help children with apraxia become ‘risk-takers’ with their speech and communication? The Apraxia-Kids Monthly, 3(10).

Hammer, D., & Stoeckel, R. (2001). Teaching and talking together: Building a treatment team. Presentation at the annual convention of the American Speech Language Hearing Association, New Orleans, Louisiana.

Highman, C., Hennessey, N., Leitao, S., & Piek, J. (2013). Early development in infants at risk of childhood apraxia of speech: A longitudinal investigation. Developmental Neuropsychology, 38(3), 197–210.

Highman, C., Hennessey, N., Sherwood, M., & Leitao, S. (2008). Retrospective parent report of early vocal behaviors in children with suspected Childhood Apraxia of Speech (CAS). Child Language Teaching and Therapy, 24(3), 285–306.

Maas, E., Robin, D., Hula, S., Freedman, S., Wulf, G., Ballard, K., & Schmidt, R. (2008). Principles of motor learning in treatment of motor speech disorders, American Journal of Speech-Language Pathology, 17, 277-198.

McCauley, R. (2002). What if a child isn’t formally diagnosed with Childhood Apraxia of Speech (CAS), but appears to be having motor planning difficulties similar to children who are? The Apraxia-Kids Monthly, 3(7).

Overby, M. & Caspari, S. (2015). Volubility, consonant, and syllable characteristics in infants and toddlers later diagnosed with childhood apraxia of speech: A pilot study. Journal of Communication Disorders, 55, 1654-1669.

Overby, M., Caspari, S., & Schreiber, J. (in review). Volubility, consonant emergence, and syllabic structure in infants and toddlers later diagnosed with CAS, SSD, and typical development: A retrospective video analysis. Journal of Speech, Language, and Hearing Research.

Stoeckel, R. (2001). Why is it important for parents of children with Childhood Apraxia of Speech (CAS) to be involved in their child’s speech therapy? Apraxia-Kids Monthly, 2(9).

Strand, EA. (2003). Childhood apraxia of speech: suggested diagnostic markers for the young child. In Shriberg, LD and Campbell, TF (Eds), Proceedings of the 2002 childhood apraxia of speech research symposium. Carlsbad, CA: Hendrix Foundation.

Strand, EA, and Skinder, A. (1999). Treatment of developmental apraxia of speech: integral stimulation methods. In Caruso, AJ and Strand, EA (Eds.), Clinical management of motor speech disorders in children. New York: Thieme.

Velleman, SL. (2003). Childhood apraxia of speech resource guide. Clifton Park, New York: Delmar Learning.

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (CASANA)
www.apraxia-kids.org

Practicing Speech Sounds, Syllables, or Words Multiple Times with Preschoolers

By

Robin Strode, M.A., CCC-SLP

We believe in making speech practice fun and play-like whenever possible. One way to do this is to think about what types of activities your child enjoys and how to incorporate speech practice into those activities. This encourages your child to be emotionally invested in the practice and more “in control”. You’ll get better cooperation this way and find practicing a lot less stressful. Below are some examples of different activities for speech practice. Keep practice sessions short and fun when possible. As much as possible, do what fits into your lifestyle and daily schedule. Let siblings and friends participate in the activities with everyone practicing the speech targets. You don’t have to use the practice sheet the therapist gave you. Write the words on 3 x 5 cards and have your child draw a picture on each (they don’t have to be great), or you do this. Then use these in fun activities or games during the day.

Get on the Move: Use Movement Activities to Encourage Speech Practice.

  • For example, write or draw pictures of the speech sounds, syllables or words on 3 x 5 cards. Scatter these around a room or outside. Have your child run or hop or skip to a card (let your child pick what type of physical movement he/she wants to do to go get the cards). The child says the word on the card three times, then runs, hops or skips back to you. He/she says the word three more times, then can put the card into a basket or small paper bag. Do this for all the cards.
  • Do the same in a hide-and-seek activity. “Hide” the cards and let your child search for one at a time. When he finds one, he says the word three times, then brings it back to home base (you). He tells you the word three times, then goes to find another card. Play again, but this time let him hide the cards and you search for them. When you bring a card back to him you both must say the word three times.
  • Throw or bounce a ball back and forth, practicing a word each time before the ball is thrown. Do the same for throwing a basketball through the hoop.
  • Go to the playground or park. Push your child several times on a swing, catch the swing, have your child say a word three times, then resume pushing. Play on the slide. When your child is sitting at the top of the slide put your arm across the top of the slide in front of him to make a barrier and say “stop”. Have him say a practice word after you three times. Lift your arm and cheerfully say “go” and let him slide down.
  • Play “Red Light-Green Light”. This is a fun game to play with several children. The children line up across the lawn from you. The object is to be the first one to arrive at the base (you) without getting caught. You turn your back and say “green light,” at which time the children can take big steps toward you. When you say “red light” they must stop moving completely before you turn around. Anyone caught moving has to go back to the starting line. Each person must say a speech practice word before you can turn around to say “green light” to resume the game.
  • Make an obstacle course with a word card in front of each obstacle. For example: have a large cardboard box laying on its side that is open on both ends that the child can climb through, a pillow she can roll over, a chair she can crawl under, a wrapping paper roll she can jump over, etc. She has to say the word on the card before attempting each obstacle. This is great for motor planning also.
  • Write a movement activity on each card below the practice word. Put all the cards in a paper bag. The child reaches in and pulls one out, says the word several times, then performs the activity (e.g., “say your practice word 2 times, then turn in a circle 2 times). You take a turn too.

Use Pretend Play Activities to Encourage Speech Practice.

  • Do you have left over party bags or boxes? Hide a practice card in each one and play birthday party. Use a dialogue thats appropriate for a pretend party. Make a cake out of playdoh, letting your child practice a word in order to put a candle on the cake. Then let him/her open one present at a time. He says the practice word 3 times to put it in his present pile.
  • Set up a play scenarios such as, Lets pretend Barbie is going to the beach. Lets pack a suitcase for her. (This can be a small suitcase or a shoe box). Get out a bunch of Barbie clothes and equipment. The game goes this way. Each person gets a turn – on your turn you pick a speech word, say it 3 times, then you get to put something in the suitcase. Each player does this multiple times. You can use 2 suitcases and see what the other one packs. You can make this funny, I think Barbie would want to swim in this long ball gown, so Im going to pack that.

Use Board Games or Building with Blocks to Encourage Speech Practice.

  • Play Hi-Ho Cherry-O, Shoots and Ladders, Bingo, any child board game. Each player picks a speech card or points to a speech word on the practice sheet, says the word, then gets to roll the dice, pick a game card, do the spinner, etc.
  • Blocks, Legos and Duplos are great for this – you take turns saying words to get to add another piece onto the structure. You can also do this with puzzles.

Preacademics

  • Buy a book with simple coloring and preschool activities. These are available at Wal-Mart, K-Mart, or the grocery store. Let your child pick a picture in the book. When she says a word 3 times she can color one part of the picture. Then you take a turn to say a speech word and color a section of the picture. Take turns until the picture is completed. Hang proudly on the refrigerator. This is fun to do with dot-to-dot pages also.
  • Make an alphabet book. Write an alphabet letter at the top of each page of a spiral notebook. Add pictures (clip art, cut from magazines, hand drawn) with a written word under each for each speech practice word. This is cumulative – you keep adding new words to the book each week. This is a great way to review speech words and build literacy early skills.

Use the Computer

  • Help your child type a speech practice sound, syllable, or word on the computer using a fun, large font. Have her say the word 3 times, then copy and paste it on the computer. She can do this multiple times, saying the word each time its pasted. Print this out and mail it to Grandma. You can use different fonts, different colors, or print it on colored paper to add interest.
  • Use a clip art program to print multiple copies of a picture of a target word on a page. Each time he pastes a picture on the page he has to say the word 3 times.

Make a Photo Album

  • Use a small photo album that holds single pictures on each page. Take pictures that represent speech targets, using the child in as many of the pictures as possible. Write the target sound, syllable, word, or phrase on a file folder label and put it on the bottom of each picture. That way everyone who looks at the book with the child will know what word to practice. This also encourages early literacy skills. For syllables you could have pictures to represent mo for more, wa for want, ba for ball. For reduplicated syllables have a picture of 2 balls for ba-ba, people (mama, dada, nana), or animals (moo-moo, woof-woof, neigh-neigh). If child is practicing initial /b/ words for example, take a picture of a big ball with a friend whos a boythere you have words such as big, ball, boy, and bye. Our children love looking through their picture books and showing them to friends and family. This is a great way to build a core vocabulary and to practice repeatedly on words that are important to your child such as his name, his friends names, or his favorite activities, toys and foods.

Make it Predictable: some children like to know their practice schedule and how long they will spend practicing.

  • Set up a routine practice time each day. Draw boxes on a piece of paper, one for each word the child will practice. Tell him the rules”I’ll put a star in a box each time you practice one of your words. When you have 3 stars in a box, well color that box. When all the boxes are colored, we’re finished!”

Reward System: Set up a reward system. All of us enjoy a reward for a job well done.

  • Use the box system above, but now draw a happy face when your child has finished practicing his words for the day. When he has 5 to 7 happy faces he can pick a prize from a special toy box. Have a variety of small prizestoys from McDonalds, a matchbox car, a coupon for lunch out, a piece of Barbie clothes, a coupon for a trip to the park or library, sunglasses, toy jewelry, crafts activities, stickers, markers, etc., etc. One child I worked with loved tools so I bought a set of toy tools and tool belt for the toy box. Every time he earned a trip to the toy box he could pick any one of the tools he wanted. He became excited about practicing his “speech homework” because he was working toward something meaningful and fun for him.
  • This system works well when your time for practicing is limited or your child is reluctant to practice.

Practice in New Places: you can practice anywhere.

  • The car is a great place to practice. Put the speech words on 3 x 5 cards, punch a hole in one corner of each card and put them a special key ring for your child. Every time you stop at a red light see if you and your child can say one of the words 3 times before the light changes. Make it into a game called “Beat the Light.”
  • Mealtime is a great way to incorporate the whole family into practice. Have your child “hide” a card under napkins as you set the table. She has to say the word 3 times to hide the card. When everyone sits down to eat, each person lifts their napkin to find a card. Your child tells them what the word is and they must repeat it after her one to 3 times before they can eat dinner.
  • Put practice cards on doorways around the house. To go through the doorway each person must say the “magic” word 3 times.

Truly respect that speech is difficult for him, but that you have faith in his abilities. Let him know you will help him through any difficulties. For example, tell him you will write down any “hard” words to give to the therapist to come up with special tricks to make them easier. Always praise your child for attempting speech targets, even when he wasn’t fully correct. You can tell him “good try,” “I like the way you were watching me,” or “Wow, you got really close that time.” Then model (say) the word again using helpers such as touch cues and have him try again.

Just remember that if we make practicing fun, playful and rewarding both you and your child will enjoy it.


(Robin Strode, M.A., CCC-SLP, has been a practicing speech-language pathologist for 28 years, currently specializing in serving preschool children with a large variety of special needs. She and her partner, Catherine Chamberlain, have presented numerous workshops throughout the United States on the topics of Developmental Verbal Apraxia and Oral-Motor Facilitation of Speech Skills. They also serve as consultants to speech-language pathologists, teachers, schools, and families. She and Ms. Chamberlain have written seven joint publications for LinguiSystems, including three best sellers: Easy Does It for Apraxia and Motor Planning, Easy Does It for Apraxia: Preschool, and Easy Does It for Articulation: An Oral-Motor Approach. Additionally, Ms. Strode is a member of the Childhood Apraxia of Speech Association’s Professional Advisory Board.)

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (CASANA)
www.apraxia-kids.org

A Dozen Tips for Supporting Early Speech Development in Children with Severe CAS

By

Margaret Fish, M.S., CCC-SLP

(Note: Apraxia-KIDS thanks the author and Pediastaff, where this article originally appeared, for permission to reprint.)

Young children with suspected childhood apraxia of speech (CAS) and children with very severe CAS present unique challenges to speech-language pathologists. When children begin to develop some volitional control over the production of syllables, the speech-language pathologist can help to shape increasingly complex speech movement sequences and support the child’s acquisition of a complete phonemic repertoire. For children who do not imitate speech reliably, however, other treatment strategies need to be utilized. Following are several strategies to support the development of more reliable volitional imitation and early speech in children who are nonverbal or minimally verbal.

Support Attainment of the Precursors of Motor Learning

The lack of speech imitation in children past the age of two years creates a great deal of anxiety for parents and caregivers. We as SLPs want to see those first words emerge, too; however, when children have not developed precursors to motor learning (Strand & Skinder, 1999), including (a) trust and motivation; (b) focused attention and effort; (c) an understanding that the goal of treatment is the practice of movement, and (d) an understanding of the tasks at hand, our efforts to elicit speech imitation may be futile. This does not mean that children need to be able to sit quietly and attentively in a chair for a period of several minutes before attempts to elicit speech are introduced. It does mean that the SLP needs to be sensitive to where the child is developmentally, and work to support the child’s focus, attention, direction following, simple imitation, and motivation to try challenging things. Speech therapy becomes much more productive if time is taken earlier on and throughout the treatment process to facilitate these precursors to motor learning.

Reinforce Vocalizations and Oral Movements

Before children begin to imitate vocalizations, they vocalize by cooing and babbling. It is important to provide positive reinforcement for children’s vocal productions, even when these productions are not volitional or imitative. Telling a child, “I love all those lip sounds you’re making!” may lead to an increase in babbling, and these sounds gradually can be shaped into volitionally produced, meaningful words.

Attach Meaning to Vocalizations

When we attach a meaning to a child’s sound productions, we help the child learn that their verbal behavior elicits certain responses. The child who says, “ma,” in the context of playing with a ball may be babbling, or may be trying to say, “ball” or “more.” By treating the vocalization as a meaningful word, the therapist links the child’s speech with a favorable response of receiving a desired toy. We can respond to the child’s production by enthusiastically saying, “Oh, you want the ball. Here you go!” thereby increasing the likelihood that the child will produce the same utterance again in hope of a similar response. Teaching parents and caregivers to begin to recognize their child’s sounds as meaningful is equally important to the therapy process.

Talk About Speech Movements

Children need to understand that the purpose of their therapy visits is to work on movement and sounds. When children stick out their tongues, talk about it; bring it to their attention and make movement and sound become the forefront of the sessions. Comments by the parents and clinician, such as, “Wow, I see your tongue,” “I love to hear all your noisy sounds,” or “I see you smacking your lips. You’re a great lip smacker,” help the child to recognize the importance of sounds and oral movement. Bringing movement to the forefront helps set the stage for what the speech therapy is all about, thus supporting attempts at further speech movements.

Facilitate Imitation

Prior to speech imitation readiness, children need to develop other types of motor imitation skills. When children engage in back and forth imitation, they are learning the important skill of “you do what I do,” an essential skill in the process of speech praxis treatment. Rather than pushing imitation of sounds and words, determine what types of movements the child is able to imitate and work from there. Refinement of imitation is a gradual process, and can be facilitated by beginning with whole body movement (rocking back and forth), imitation of actions during play (banging a drum, stacking blocks), smaller movement imitation (clapping, wiggling fingers, shaking head), imitation of oral/facial movements (sticking out tongue, smacking lips), vocal imitation (basic sound and syllable play), and, finally, imitation of true words. Although parents may be eager for their children to begin saying real words, it is important to help them understand the importance of developing a strong base of imitation prior to asking the child to say words, and to have them engage in these types of imitation routines at home.

If the child does not readily imitate body or vocal movements, one way to get the imitation turn-taking routine going is to imitate what the child is doing. When the child bangs on a table, makes tongue-clicking sounds, or vocalizes a neutral vowel, the therapist and parent can match the movement or sound, usually to the delight of the child. After the turn-taking routine is established with the child in the lead, the therapist or parent can change it by doing something a little different. If the child is banging on the floor, the therapist may bang on a chair instead. If the child is making tongue clicks, the therapist may, instead, make lip-smacking sounds. Praising the child for these imitative attempts is equally important to support the establishment of purposeful, volitional imitation skills upon which speech praxis treatment is based.

Use Toys That Reinforce Early Sound Effects and Simple Exclamations

Prior to the development of “true words,” children typically produce silly sounds and sounds effects, such as coughing, grunting, chewing noises, raspberries, and snoring. Animal and vehicle noises also are among the sounds children master in the context of play and book reading. Encourage production of these sounds by incorporating toys and activities that elicit these sounds. Toy animals, animal puzzles, vehicles, foods, cooking gadgets, and building tools, all serve to elicit repetitive modeling of playful sounds that the child can be encouraged to imitate. Linking a movement to a sound offers an additional cueing mechanism for the child. For example, each time the buttons on the microwave are pushed when “making” playdough cookies, the therapist or parent can say, “beep, beep, beep.”

Pause with Expectation

For children who are quite delayed in babbling and sound imitation, lack of vocal responsiveness becomes an expectation. After children have begun to develop some ability to imitate some vocalizations, a shift should occur on the part of the therapist and family that helps the child recognize that being passive during turn-taking routines is no longer the expected response. Pausing and looking at a child expectantly lets the child know that some response is expected. Offering positive reinforcement when the child takes the risk of making a vocal response further solidifies shared enjoyment in the turn-taking process, paving the road to continued effort and continued success.

It is beneficial to model the target sound effects and target words during therapy using a focused stimulation approach (Ellis Weismer & Robertson, 2006). During focused stimulation, the therapist or parent produces the target sound or word frequently and in a way that brings a heightened awareness of specific phonemes or sounds. Treatment targets can be emphasized by (a) pausing just before the target word is produced (e.g., “Here’s a … ball, and here’s another … ball … and here’s another …ball”); (b) increasing the duration of the vowel of the target word or prolonging a consonant (e.g., “Yummy banana. Mmmmmmm” or “The airplane is going higher. It goes uuuuup, uuuuup, uuuuup.”); and (c) securing the child’s visual attention prior to modeling the target word or sound. Using amplification tools, such as an echo microphone, Toobaloo®, or even a paper towel or wrapping paper roll, may help to focus the child’s attention and generate interest in repetition of sounds and words.

Reduce the Number of Target Utterances Per Session

Strand and Skinder (1999) recommend limiting the number of target utterances in the stimulus set introduced during a therapy session to no more than five or six utterances. In this way, blocked practice of a small number of treatment targets could be accomplished. This repetitive practice of a small number of targets supports the child’s ability to master new movement plans in the earlier stages of learning.

Use Tactile and Proprioceptive Input

Ayres (2005) suggests that many children with apraxia demonstrate reduced tactile and proprioceptive processing. By providing additional tactile and proprioceptive cues, the child’s ability to make sense of the somatosensory input is enhanced. PROMPT® treatment, described by Hayden (2008), incorporates specific tactile cues that offer the child a more salient way of sensing what a movement sequence should feel like, thus helping the child to connect the feeling of the movement gesture with the accompanying acoustic information. Strand and Skinder (1999) also recommend incorporating tactile cues as needed to support imitation when visual and verbal cues alone are not enough to help the child perform the targeted speech movements. In addition, body movements, gestures, and manual signs can be associated with speech movement gestures to create associations between speech movements and other movement cues.

Practice Skill Refinement

It is important to help children move from broad to more narrow distinctions between sounds. For children who do not reliably turn on their voice to produce sounds, praise will be provided when a child produces an undifferentiated vowel sound volitionally. As treatment progresses, purposeful movement of the lips or tongue will be facilitated, and then gradually building up to making distinctions between lip versus tongue sounds, nasals versus non-nasals, stops versus continuents, one versus two syllables, and voiced versus voiceless phonemes. Grading and differentiating of vowels based on tongue position (high/low/mid; front/central/back) and lip shape (open/round/retracted) also should be facilitated. These distinctions are gradual and take time, and children’s achievement of these motor speech skill refinements should be praised each step of the way.

Incorporate Music, and Books into Treatment

Music and carefully chosen books support attainment of speech in children with severe CAS, because they offer opportunities for repetitive practice of target utterances. Music also provides opportunities to practice varied and exaggerated intonation patterns, simple sound effects, and early developing sounds and words. Reduction of rate during songs offers the child the time to achieve initial articulatory configurations of target sounds and words. Making up little tunes with repetition of simple treatment target sounds and words to accompany the activities in the speech session can help to engage the child in the repetitive practice necessary for initial learning of treatment targets. Creation of simple, personalized books can support opportunities for repetitive practice of a simple sound effect or a small number of target utterances. For example, a book with pictures of people or things dropping, falling, and crashing, could be the perfect tool for practice of the exclamation, “uh oh.” Fish (2010) provides several book and song lists, including lists of books to target sound effects and early word production.

Provide Access to AAC

Children need a means of communication. When speech is slow in coming, the use of manual signs and gestures, low tech picture boards, and/or voice output communication devices will help support a child’s ability to express a wider range of ideas, and to establish greater social communication skills. Parents may need to be reassured that the verbal mode of communication will continue to be addressed, but that helping children find a way to establish positive communication patterns is very important for overall development.

References:

Ayres, A. J. (2005). Sensory integration and the child: Understanding hidden sensory challenges. Los Angeles, CA: Western Psychological Services.

Ellis Weismer, S., & Robertson, S. (2006). Focused stimulation approach to language intervention. In R. McCauley and M. Fey (Eds.), Treatment of language disorders in children (pp. 175-201). Baltimore, MD: Paul H. Brookes.

Fish, M. (2010). Here’s how to treat childhood apraxia of speech. San Diego, CA: Plural Publishing.

Hayden, D. A. (2008). P.R.O.M.P.T. prompts for restructuring oral muscular phonetic targets, introduction to technique: A manual (2nd ed.). Santa Fe, NM: The PROMPT Institute.

Strand, E. A., & Skinder, A. (1999). Treatment of development apraxia of speech: Integral stimulation methods, In A. Caruso & E. Strand (Eds.), Clinical management of motor speech disorders in children (pp. 109-148). New York, NY: Thieme.


Featured Author: Margaret A. Fish, M.S., CCC-SLP

Margaret Fish is a speech-language pathologist working in private practice in Highland Park, Illinois. She has 30 years of clinical experience working with children with severe speech-sound disorders, language impairments, and social language challenges. Her primary professional interest is in the evaluation and treatment of children with childhood apraxia of speech (CAS). Margaret is the author of the recently released book, Here’s How to Treat Childhood Apraxia of Speech by Plural Publishing. Her workshops and writing focus on providing practical, evidence-based evaluation and treatment ideas to support children with CAS.

Speech Therapy for Younger Children

Apraxia: Speech Therapy and Treatment for Toddlers and Young Children

Original article written by Sharon Gretz, M.Ed.

Revised and updated by Megan Overby, PhD, CCC-SLP(Note: Members of the Apraxia Kids Professional Advisory Council have reviewed this article.)

Introduction

There are questions whether children under age 3 should be given the diagnosis of apraxia of speech. If a diagnosis is made (or suspected), the issue of how to treat such a young child arises, especially because many children who later receive a confirmatory diagnosis of CAS will have additional speech and language therapy goals in addition to those targeting speech production. The purpose of this article is twofold: to review current recommendations for initial diagnostic procedures when identifying young children who may have CAS and to briefly discuss some speech therapy techniques that may benefit the speech production and expressive language skills of young children suspected to have CAS.

Diagnostic Indicators

Much work needs to be done in characterizing the early speech sound development of infants and toddlers later diagnosed with CAS, but studies (Highman, Hennessey, Leitao, & Piek; 2013; Highman, Hennessey, Sherwood, & Leitao, 2008; Overby & Caspari, 2015; Overby, Caspari, Schrieber, in review) offer some preliminary diagnostic indicators for children aged two and younger.

Not all infants and toddlers later diagnosed with CAS will present with these possible indicators, nor is it known how many of these possible indicators, or which ones, are most concerning. Nevertheless, at age 2 and younger, a risk of CAS may be associated with:

  • Few consonant and vowel sounds so that the child seems less vocal and more quiet than typically developing infants and toddlers
  • No recognizable consonant by 12 months of age
  • Lack of canonical babbling onset between 7 – 12 months of age
  • Three or fewer recognizable consonants by 16 months of age
  • Five or fewer recognizable consonants by 24 months of age
  • Lack of “back” sounds (such /k/ and /g/) and favoritism of sounds that are anterior (bilabials and alveolars, such as /m/ and /d/) by 24 months of age
  • Favoritism of stops and nasals over a diverse manner, with possible absence of fricatives or glides by 24 months of age
  • Dependency on vowels at 13 – 18 months with little use of consonant-vowel syllable shapes

All young children are highly variable in their speech sound development. Therefore, the diagnosis of CAS in a child who is younger than three, or who has little expressive ability, should be made only by a speech-language pathologist with specific experience in assessing the speech sound skills of young children.

Other descriptive speech sound characteristics of CAS in infants and toddlers later diagnosed with the disorder have been suggested (Davis & Velleman, 2000, p. 182; Fish, 2016), including:

  • The child may have acquired some later developing sounds while be missing earlier developing sounds.
  • Limited variation of vowels and the use of a centralized vowel in a multipurpose way.
  • Vocalizations may have speech-like melody but syllables or discernable words may not be present.
  • Words may seem to disappear from use more than would be expected for a typically developing child of the same age.
  • Predictable utterances may be easier than novel utterances

Nonspeech characteristics that could also indicate apraxia of speech in the young child include: homemade gestures or signs, some feeding difficulties such as eating mixed textures, drooling, late development of motor skills overall, and oral motor incoordination.

If there is uncertainty about a diagnosis of CAS in a very young child, active monitoring of the child’s speech sound development over the course of a few months may yield additional information. However, because the trajectory of speech sound development in children with CAS appears to be much slower than that of children with typical development or with other types of speech sound disorders (Overby & Caspari, 2015; Overby, Caspari, & Schrieber, in review), early intervention for children with suspected CAS is important.

As children mature, they are better able to participate in assessment of their speech sound skill. More information about the child’s speech sound capabilities can be obtained when the child can attempt to imitate utterances varying in length and/or phonetic complexity (such as imitating /i/, then /mi/, then /mit/ or /o/, then /no/ then /nop/) (Strand, 2003). Strand (p. 77) offers five potential diagnostic characteristics of apraxia in young children who are able to make such imitative attempts:

  • Difficulty in achieving and maintaining articulatory configurations
  • Presence of vowel distortions
  • Limited consonant and vowel repertoire
  • Use of simple syllable shapes
  • Difficulty completing a movement gesture for a phoneme easily produced in a simple context but not in a longer one

Speech Therapy and the Two-Year Old with Possible Apraxia

There is little literature about treatment in very young children with apraxia of speech and no studies have compared the effectiveness of treatment approaches in this population. Nevertheless, for children who are two years old and under, but are considered high-risk for CAS because, for example, they have no consonants and are not babbling, treatment should not be delayed. Although therapy should always be individualized to each child, some experts (Fish, 2016; Velleman, 2003) suggest intervention for very young children could include:

  • Learning to imitate gross motor skills
    • Large motor movements (such as clapping)
    • Actions with objects (banging two blocks together)
  • Imitating vocal play (e.g., raspberries, squeals)
  • Imitating oral-facial movements (e.g., licking lips, blowing kisses)
  • Vocalizing visible early sounds such as /m/, /b/, or /d/ (e.g., /mmmm/, “muh” or “buh”)
  • Vocalizing to get attention (e.g., “uh” and pointing to a cookie)
  • Sound effects: animal noises (e.g., “grr”, vehicle sounds)

As children gain the ability to say a sound or sounds, therapy can focus on simple words such as:

  • Words with distinctive pitch patterns (e.g., “uh-oh,” “wow,” “whee,” “yay”)
  • Words with strong emotional meaning
  • Words or vocalizations that can be paired with actions (e.g., “whee”, “hi,” “oops”)
  • Sound effect words (e.g., “woof’, “beep,” etc.)
  • Verbal routines (e.g., songs, rhymes, favorite predictable books)
  • Speech or singing in unison with others
  • Words with very early consonants (e.g., [h], glides) and simple syllable shapes (e.g., “hi,” “uh-oh,” “wow,” “whee,” “yay,” “me”)

Regardless of how many sounds the infant/toddler has, speech therapy should include:

  • Support to the family
  • Use of props such as puppets, stuffed animals, etc.
  • Use sounds already in child’s repertoire to build simple productions (e.g., if a child has /m/, can he learn to say “ma,” “me,” or even “muh” as an approximation of “more”)
  • Maximizing the child’s gaze to the speaker’s mouth by putting toys or objects of interest near the speaker’s mouth during imitation tasks

In summary, two primary treatment goals for young infants and toddlers with suspected apraxia of speech are, according to Davis and Velleman (2000, p. 184):

  • Helping the child establish a consistent form of communication. Clinicians should watch the child for attempts to communicate appropriately and respond to any appropriate mode of communication the child may use, including non-verbal expressions such as gestures, facial expressions, sound effects, leading, or pictures. Communication attempts should not be ignored.
    • It is important that the child and his communication partner(s) agree what a gesture, sound, picture, or word approximation represents or means.
  • The child needs to develop and consistently use oral communication. Using alternative communication such as sign language, gestures, or computer-based icon programs can be very helpful in moving a young child toward oral communication by relieving frustration and establishing a consistent, reliable means of communication (Fish, 2016). Efforts should be made to develop the child’s ability to use oral sounds to communicate, using the goals suggested above, as soon as the child is capable of doing so.

Speech Therapy and the Older Toddler with Possible Apraxia

Once a child has consistently begun to use vocalization to communicate, it is more important for a child to use sounds and to work towards expanding his sound and syllable repertoire than to be accurate in producing them. Experts (Davis & Velleman, 2000; Fish, 2016; Overby, Caspari, & Schreiber, in review) suggest therapy goals for a child with the ability to vocalize should focus on:

  • Expansion of sounds
  • Expansion of syllable structures

Suggestions for expansion of sounds are:

  • To acquire a diverse set of consonant and vowel sounds. This means the child should be able to say sounds produced in different parts of the mouth. Acquiring sounds in the posterior part of the mouth can be difficult and may require a lot of effort by the child and the clinician.
  • Producing sounds with varied pitch and loudness levels

Suggestions for expanding structures:

  • Focusing on syllables rather than individual phonemes
  • Fish (2016) and Velleman (2003) suggest a hierarchy of syllable shapes:
    • CV (“me”)
    • Reduplicated CV.CV (“bye-bye” or “no-no”)
    • Vowel harmonized CV.CV (“TV”) or consonant harmonized (“mommy”)
    • Variegated CV.CV (“bunny”)
    • Harmonized CVC (“pop”)
    • Variegated CVC (“top”)
    • Harmonized CVCVC (“pop up”)
    • Non-harmonized CVCVC (“peanut”)
    • Words containing clusters
  • Goals should target EITHER new structure or a new sound, not both at the same time
  • Syllables should represent, when possible, a variety of nouns, verbs, adjectives, and other meaningful productions

Working at any one level of syllable shape does not mean drilling the same word over and over. The idea is to help the child learn new motor movements by building on current skills. So, for example, one could first work on the same syllable repeated, (e.g., “ma ma ma ma”). Next, introduce one change at the end of the repeated syllables, e.g., “ma ma ma moo” or “moo moo moo do”. Alternating the syllables takes the activity one step further, i.e., “ma, moo, ma, moo” or “moo, do, moo, do, moo.” As competence is built with these activities, practice with syllables moves further so that the child produces varied syllables/sounds: “ma, moo, may, my, mow”. In young children, the approach will need to be fun, silly, and engaging in order to elicit the child’s attention, involvement, and effort.

Speech Movement Goals and Training

Goals, such as those described above, are only one component of the speech therapy program for CAS. A speech therapy program must address the underlying nature of the problem of apraxia – which is the ability to plan accurate, well timed speech movements from sound to sound, and syllable to syllable, in order to produce old and new words. Clinicians need to provide therapy opportunities that allow young children to build flexibility into their motor systems.

In clinical practice, it is suggested that speech-language pathologists incorporate principles of motor learning: the need for many repetitions and practice, distributed vs. massed practice opportunities, appropriate use of feedback to the child to enhance motor learning, etc. (Maas, Robin, Hula, Freedman, Wulf, Ballard, & Schmidt, 2008). Even toddlers can be involved in therapy opportunities maximizing conditions for motor learning but adapted to their needs as very young children (Davis & Velleman, 2000; Strand & Skinder, 1999;).

Davis and Velleman (2000, p. 187) offer ideas for gaining multiple repetitions from toddlers:

  • Use of counting books but instead of counting the objects on a page, simply point to the object and repeat its “name” each time it appears on the page. For example, a counting book of animals has 4 dogs on the page for the number 4. Instead of counting “1, 2, 3, 4”, you can guide the child to point to each dog and say “pup, pup, pup, pup” or if the child is more skilled, “doggie, doggie, doggie, doggie”.
  • While playing “house” and setting the table, each time a cup is put down saying “cup, cup, cup”.
  • Pretending to eat: “yum, yum, yum”

Functional vocabulary books are another way to elicit practice from the child and can also incorporate parents or other communication partners. According to Hammer (Apraxia Kids website), the vocabulary book should consist of photos or pictures of meaningful people, toys, and objects in the child’s life as well as words that contain initially targeted sound sequences. This book often serves as a child’s first success at expansion of functional communication interactions with significant others.

Fish (2016) also provides a list of activities to elicit repetitive practice that can be motivating and fun. A few activities include:

  • Hop to it” where the child hops to the target, saying the target with each hop
  • “Paper chain” in which the child repeats the target word or phrase written on strip of paper, and then glues or staples the paper together to form a link in a paper chain
  • “Feely box” where there are small objects (with the target sound in the name) inside a closed box with hole large enough for the child’s hand, and the child tries to find the object

Providing Motivation/Keeping the Child’s Attention

Play presents many opportunities for these repetitive sequences and parents and therapists can be creative in this way. The idea is to help the child into practice by making their therapy experience not just fun but also successful for them. Even very young children with apraxia have gained the understanding that speech is difficult for them and so may avoid or resist expressing themselves with oral communication. An astute, engaging clinician can use low-pressure opportunities and engaging play to help children with apraxia take risks with their speech attempts (Hammer, 2003).

Experts (Fish, 2016; Strand & Skinder, 1999) offer the following ideas for providing motivation and keeping attention of young children with apraxia:

  • Ideally, incorporate movement into treatment, or at least after 10-20 practice trials (rocking, bouncing, marching, swinging arms, etc.)
  • Change inflection (stress on different words, low pitch, high pitch, exaggerate the target word or phrase)
  • Use various dolls, puppets, animals that the child can speak for; change the selection after a number of practice trials
  • Incorporate music into treatment (make up tunes or use familiar ones to practice a word)

Remember that while clinicians must make therapy fun and engaging, it is not sufficient to be able to say the child enjoyed the therapy session or that the session went well because the child cooperated. That alone will not effectively provide what the child needs, which is the opportunity for a high number of repetitions of speech targets and the clinician’s thoughtful feedback about performance and results. If the child isn’t saying much in the therapy session, the clinician is not going to be able to achieve this goal (Strand & Skinder, 1999).

Other “take home” points about speech therapy for toddlers with suspected apraxia of speech include:

  • Children with apraxia may not follow the typical “developmental” sequence for acquiring new sounds (Davis & Velleman, 2000; Hammer, 2003; Overby et al., in review)
  • Children with apraxia of speech need some early success with speech. They need to know it is worth it to trust and cooperate with the clinician (Hammer, 2003).
  • Children with apraxia seem to have periods where sometimes they seem to ‘plateau’ and show little growth (Davis & Velleman, 2000; Overby et al., in review)
  • Play is the medium for these young children to learn speech movement training (Hammer, 2003).
  • Parents need help and direct mentoring to understand their role and how they can effectively practice with the young child at home (Hammer & Stoeckel, 2001).
  • Break up sessions into several activities that have repetitive practice vs. one long activity (Davis & Velleman, 2000; Strand & Skinder 1999).
  • Just as with older children with apraxia, younger children need feedback about their performance such as knowledge of results (did they get the word right?) and more specific knowledge about performance (for example, “you need your lips out for that”) (Davis & Velleman, 2000; Hammer, 2003; Strand & Skinder 1999).

Parents as Collaborators

At the outset, clinicians need to involve parents in therapy opportunities for children with apraxia, to the greatest extent they are able and willing. Parents can share essential information from the home and community environments and are important informants on the likes, dislikes, and personality characteristics of their children. Additionally, because many repetitions of speech movement patterns are necessary for motor learning to occur, parents are valuable speech practice partners for their children in their everyday life experiences together (Stoeckel, 2001).

Hammer and Stoeckel (2001) listed the following responsibilities for the speech-language pathologist in working with parents of children with apraxia of speech:

  • Educate parents re: CAS and intervention
  • Educate parents re: networking/support availability
  • Teach child needed skills in a flexible, productive manner
  • Assure high expectations from the child
  • Be able to explain goals and changes in therapy strategies
  • Assure periodic observations either on-line or via videotape
  • Work with parents to motivate and reinforce child’s learning

Setting Expectations: Children as Risk-takers

In typically developing children, early sound play and communication attempts bring a great deal of fun and excitement, but by the time a young child with suspected apraxia of speech arrives in speech therapy treatment, he or she may already have experienced a great deal of failure in efforts to communicate orally. Additionally, families may also feel somewhat like failures in helping their child to communicate (Hammer, 2003). Clinicians can help by creating carefully planned small steps toward success in the earliest phase of therapy. Additionally, it is important for clinicians to set early expectations around communication exchanges. Sometimes children with CAS must be encouraged to take “risks” in talking.

Children with apraxia of speech need to feel as if they can trust in the therapeutic process and have success. Reasonable expectations for oral communication, based on the capability of the child’s speech motor system, need to be implemented and reinforced so that the child uses and practices what he/she can produce (Hayden, 2002).

Apraxia or Something Else?

Once a period of therapy has commenced and the speech-language pathologist has experience working with a child, she can better determine if the primary difficulty lies in speech motor planning and programming. According to McCauley (2002), if a child does not respond well to treatments in which the goal is to teach phonologic patterns (e.g., the Cycles Approach or minimal pairs) or to traditional articulation training, the clinician should consider whether there are possible motor factors in speech learning.

Even if a child does not receive an apraxia diagnosis, the therapy recommendations outlined above may be useful in the child’s treatment plan. A speech-language pathologist experienced in the differential diagnosis of CAS from other disorders can be of assistance to families seeking diagnostic information about their child.

Conclusion

In summary, while it is difficult to diagnose children with apraxia of speech at very young ages, there are some emerging possible diagnostic indicators that, with additional research, may facilitate the diagnostic process. Furthermore, even without a clear diagnosis, it is still possible to provide speech therapy to young children who are at-risk for a motor-planning component to their speech production difficulties. Attention to increasing overall communication and oral communication, expanding sounds and syllable shapes, gaining multiple repetitions of syllables and words for speech movement practice, focusing on functional communication, and encouraging parent involvement are key treatment considerations for young children suspected to have apraxia of speech.

References

Davis, B., & Velleman, SL. (2000). Differential diagnosis and treatment of developmental apraxia of speech in infants and toddlers. The Transdisciplinary Journal, 10(3), 177 – 192.

Fish, M. (2016). Here’s how to treat childhood apraxia of speech (2nd ed). San Diego, CA: Plural Publishing.

Hammer, D. (2003). Apraxia of speech in young children. Presented at the Childhood Apraxia of Speech Association/Hendrix Foundation workshop. Houston, Texas.

Hammer, D. Brief thoughts about therapy. Apraxia-Kids website. https://www.apraxia-kids.org/slps/hammer.html

Hayden, D. (2002). How do we help children with apraxia become ‘risk-takers’ with their speech and communication? The Apraxia-Kids Monthly, 3(10).

Hammer, D., & Stoeckel, R. (2001). Teaching and talking together: Building a treatment team. Presentation at the annual convention of the American Speech Language Hearing Association, New Orleans, Louisiana.

Highman, C., Hennessey, N., Leitao, S., & Piek, J. (2013). Early development in infants at risk of childhood apraxia of speech: A longitudinal investigation. Developmental Neuropsychology, 38(3), 197–210.

Highman, C., Hennessey, N., Sherwood, M., & Leitao, S. (2008). Retrospective parent report of early vocal behaviors in children with suspected Childhood Apraxia of Speech (CAS). Child Language Teaching and Therapy, 24(3), 285–306.

Maas, E., Robin, D., Hula, S., Freedman, S., Wulf, G., Ballard, K., & Schmidt, R. (2008). Principles of motor learning in treatment of motor speech disorders, American Journal of Speech-Language Pathology, 17, 277-198.

McCauley, R. (2002). What if a child isn’t formally diagnosed with Childhood Apraxia of Speech (CAS), but appears to be having motor planning difficulties similar to children who are? The Apraxia-Kids Monthly, 3(7).

Overby, M. & Caspari, S. (2015). Volubility, consonant, and syllable characteristics in infants and toddlers later diagnosed with childhood apraxia of speech: A pilot study. Journal of Communication Disorders, 55, 1654-1669.

Overby, M., Caspari, S., & Schreiber, J. (in review). Volubility, consonant emergence, and syllabic structure in infants and toddlers later diagnosed with CAS, SSD, and typical development: A retrospective video analysis. Journal of Speech, Language, and Hearing Research.

Stoeckel, R. (2001). Why is it important for parents of children with Childhood Apraxia of Speech (CAS) to be involved in their child’s speech therapy? Apraxia-Kids Monthly, 2(9).

Strand, EA. (2003). Childhood apraxia of speech: suggested diagnostic markers for the young child. In Shriberg, LD and Campbell, TF (Eds), Proceedings of the 2002 childhood apraxia of speech research symposium. Carlsbad, CA: Hendrix Foundation.

Strand, EA, and Skinder, A. (1999). Treatment of developmental apraxia of speech: integral stimulation methods. In Caruso, AJ and Strand, EA (Eds.), Clinical management of motor speech disorders in children. New York: Thieme.

Velleman, SL. (2003). Childhood apraxia of speech resource guide. Clifton Park, New York: Delmar Learning.

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (CASANA)
www.apraxia-kids.org

Practicing Speech Sounds, Syllables, or Words Multiple Times with Preschoolers

By

Robin Strode, M.A., CCC-SLP

We believe in making speech practice fun and play-like whenever possible. One way to do this is to think about what types of activities your child enjoys and how to incorporate speech practice into those activities. This encourages your child to be emotionally invested in the practice and more “in control”. You’ll get better cooperation this way and find practicing a lot less stressful. Below are some examples of different activities for speech practice. Keep practice sessions short and fun when possible. As much as possible, do what fits into your lifestyle and daily schedule. Let siblings and friends participate in the activities with everyone practicing the speech targets. You don’t have to use the practice sheet the therapist gave you. Write the words on 3 x 5 cards and have your child draw a picture on each (they don’t have to be great), or you do this. Then use these in fun activities or games during the day.

Get on the Move: Use Movement Activities to Encourage Speech Practice.

  • For example, write or draw pictures of the speech sounds, syllables or words on 3 x 5 cards. Scatter these around a room or outside. Have your child run or hop or skip to a card (let your child pick what type of physical movement he/she wants to do to go get the cards). The child says the word on the card three times, then runs, hops or skips back to you. He/she says the word three more times, then can put the card into a basket or small paper bag. Do this for all the cards.
  • Do the same in a hide-and-seek activity. “Hide” the cards and let your child search for one at a time. When he finds one, he says the word three times, then brings it back to home base (you). He tells you the word three times, then goes to find another card. Play again, but this time let him hide the cards and you search for them. When you bring a card back to him you both must say the word three times.
  • Throw or bounce a ball back and forth, practicing a word each time before the ball is thrown. Do the same for throwing a basketball through the hoop.
  • Go to the playground or park. Push your child several times on a swing, catch the swing, have your child say a word three times, then resume pushing. Play on the slide. When your child is sitting at the top of the slide put your arm across the top of the slide in front of him to make a barrier and say “stop”. Have him say a practice word after you three times. Lift your arm and cheerfully say “go” and let him slide down.
  • Play “Red Light-Green Light”. This is a fun game to play with several children. The children line up across the lawn from you. The object is to be the first one to arrive at the base (you) without getting caught. You turn your back and say “green light,” at which time the children can take big steps toward you. When you say “red light” they must stop moving completely before you turn around. Anyone caught moving has to go back to the starting line. Each person must say a speech practice word before you can turn around to say “green light” to resume the game.
  • Make an obstacle course with a word card in front of each obstacle. For example: have a large cardboard box laying on its side that is open on both ends that the child can climb through, a pillow she can roll over, a chair she can crawl under, a wrapping paper roll she can jump over, etc. She has to say the word on the card before attempting each obstacle. This is great for motor planning also.
  • Write a movement activity on each card below the practice word. Put all the cards in a paper bag. The child reaches in and pulls one out, says the word several times, then performs the activity (e.g., “say your practice word 2 times, then turn in a circle 2 times). You take a turn too.

Use Pretend Play Activities to Encourage Speech Practice.

  • Do you have left over party bags or boxes? Hide a practice card in each one and play birthday party. Use a dialogue thats appropriate for a pretend party. Make a cake out of playdoh, letting your child practice a word in order to put a candle on the cake. Then let him/her open one present at a time. He says the practice word 3 times to put it in his present pile.
  • Set up a play scenarios such as, Lets pretend Barbie is going to the beach. Lets pack a suitcase for her. (This can be a small suitcase or a shoe box). Get out a bunch of Barbie clothes and equipment. The game goes this way. Each person gets a turn – on your turn you pick a speech word, say it 3 times, then you get to put something in the suitcase. Each player does this multiple times. You can use 2 suitcases and see what the other one packs. You can make this funny, I think Barbie would want to swim in this long ball gown, so Im going to pack that.

Use Board Games or Building with Blocks to Encourage Speech Practice.

  • Play Hi-Ho Cherry-O, Shoots and Ladders, Bingo, any child board game. Each player picks a speech card or points to a speech word on the practice sheet, says the word, then gets to roll the dice, pick a game card, do the spinner, etc.
  • Blocks, Legos and Duplos are great for this – you take turns saying words to get to add another piece onto the structure. You can also do this with puzzles.

Preacademics

  • Buy a book with simple coloring and preschool activities. These are available at Wal-Mart, K-Mart, or the grocery store. Let your child pick a picture in the book. When she says a word 3 times she can color one part of the picture. Then you take a turn to say a speech word and color a section of the picture. Take turns until the picture is completed. Hang proudly on the refrigerator. This is fun to do with dot-to-dot pages also.
  • Make an alphabet book. Write an alphabet letter at the top of each page of a spiral notebook. Add pictures (clip art, cut from magazines, hand drawn) with a written word under each for each speech practice word. This is cumulative – you keep adding new words to the book each week. This is a great way to review speech words and build literacy early skills.

Use the Computer

  • Help your child type a speech practice sound, syllable, or word on the computer using a fun, large font. Have her say the word 3 times, then copy and paste it on the computer. She can do this multiple times, saying the word each time its pasted. Print this out and mail it to Grandma. You can use different fonts, different colors, or print it on colored paper to add interest.
  • Use a clip art program to print multiple copies of a picture of a target word on a page. Each time he pastes a picture on the page he has to say the word 3 times.

Make a Photo Album

  • Use a small photo album that holds single pictures on each page. Take pictures that represent speech targets, using the child in as many of the pictures as possible. Write the target sound, syllable, word, or phrase on a file folder label and put it on the bottom of each picture. That way everyone who looks at the book with the child will know what word to practice. This also encourages early literacy skills. For syllables you could have pictures to represent mo for more, wa for want, ba for ball. For reduplicated syllables have a picture of 2 balls for ba-ba, people (mama, dada, nana), or animals (moo-moo, woof-woof, neigh-neigh). If child is practicing initial /b/ words for example, take a picture of a big ball with a friend whos a boythere you have words such as big, ball, boy, and bye. Our children love looking through their picture books and showing them to friends and family. This is a great way to build a core vocabulary and to practice repeatedly on words that are important to your child such as his name, his friends names, or his favorite activities, toys and foods.

Make it Predictable: some children like to know their practice schedule and how long they will spend practicing.

  • Set up a routine practice time each day. Draw boxes on a piece of paper, one for each word the child will practice. Tell him the rules”I’ll put a star in a box each time you practice one of your words. When you have 3 stars in a box, well color that box. When all the boxes are colored, we’re finished!”

Reward System: Set up a reward system. All of us enjoy a reward for a job well done.

  • Use the box system above, but now draw a happy face when your child has finished practicing his words for the day. When he has 5 to 7 happy faces he can pick a prize from a special toy box. Have a variety of small prizestoys from McDonalds, a matchbox car, a coupon for lunch out, a piece of Barbie clothes, a coupon for a trip to the park or library, sunglasses, toy jewelry, crafts activities, stickers, markers, etc., etc. One child I worked with loved tools so I bought a set of toy tools and tool belt for the toy box. Every time he earned a trip to the toy box he could pick any one of the tools he wanted. He became excited about practicing his “speech homework” because he was working toward something meaningful and fun for him.
  • This system works well when your time for practicing is limited or your child is reluctant to practice.

Practice in New Places: you can practice anywhere.

  • The car is a great place to practice. Put the speech words on 3 x 5 cards, punch a hole in one corner of each card and put them a special key ring for your child. Every time you stop at a red light see if you and your child can say one of the words 3 times before the light changes. Make it into a game called “Beat the Light.”
  • Mealtime is a great way to incorporate the whole family into practice. Have your child “hide” a card under napkins as you set the table. She has to say the word 3 times to hide the card. When everyone sits down to eat, each person lifts their napkin to find a card. Your child tells them what the word is and they must repeat it after her one to 3 times before they can eat dinner.
  • Put practice cards on doorways around the house. To go through the doorway each person must say the “magic” word 3 times.

Truly respect that speech is difficult for him, but that you have faith in his abilities. Let him know you will help him through any difficulties. For example, tell him you will write down any “hard” words to give to the therapist to come up with special tricks to make them easier. Always praise your child for attempting speech targets, even when he wasn’t fully correct. You can tell him “good try,” “I like the way you were watching me,” or “Wow, you got really close that time.” Then model (say) the word again using helpers such as touch cues and have him try again.

Just remember that if we make practicing fun, playful and rewarding both you and your child will enjoy it.


(Robin Strode, M.A., CCC-SLP, has been a practicing speech-language pathologist for 28 years, currently specializing in serving preschool children with a large variety of special needs. She and her partner, Catherine Chamberlain, have presented numerous workshops throughout the United States on the topics of Developmental Verbal Apraxia and Oral-Motor Facilitation of Speech Skills. They also serve as consultants to speech-language pathologists, teachers, schools, and families. She and Ms. Chamberlain have written seven joint publications for LinguiSystems, including three best sellers: Easy Does It for Apraxia and Motor Planning, Easy Does It for Apraxia: Preschool, and Easy Does It for Articulation: An Oral-Motor Approach. Additionally, Ms. Strode is a member of the Childhood Apraxia of Speech Association’s Professional Advisory Board.)

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (CASANA)
www.apraxia-kids.org

A Dozen Tips for Supporting Early Speech Development in Children with Severe CAS

By

Margaret Fish, M.S., CCC-SLP

(Note: Apraxia-KIDS thanks the author and Pediastaff, where this article originally appeared, for permission to reprint.)

Young children with suspected childhood apraxia of speech (CAS) and children with very severe CAS present unique challenges to speech-language pathologists. When children begin to develop some volitional control over the production of syllables, the speech-language pathologist can help to shape increasingly complex speech movement sequences and support the child’s acquisition of a complete phonemic repertoire. For children who do not imitate speech reliably, however, other treatment strategies need to be utilized. Following are several strategies to support the development of more reliable volitional imitation and early speech in children who are nonverbal or minimally verbal.

Support Attainment of the Precursors of Motor Learning

The lack of speech imitation in children past the age of two years creates a great deal of anxiety for parents and caregivers. We as SLPs want to see those first words emerge, too; however, when children have not developed precursors to motor learning (Strand & Skinder, 1999), including (a) trust and motivation; (b) focused attention and effort; (c) an understanding that the goal of treatment is the practice of movement, and (d) an understanding of the tasks at hand, our efforts to elicit speech imitation may be futile. This does not mean that children need to be able to sit quietly and attentively in a chair for a period of several minutes before attempts to elicit speech are introduced. It does mean that the SLP needs to be sensitive to where the child is developmentally, and work to support the child’s focus, attention, direction following, simple imitation, and motivation to try challenging things. Speech therapy becomes much more productive if time is taken earlier on and throughout the treatment process to facilitate these precursors to motor learning.

Reinforce Vocalizations and Oral Movements

Before children begin to imitate vocalizations, they vocalize by cooing and babbling. It is important to provide positive reinforcement for children’s vocal productions, even when these productions are not volitional or imitative. Telling a child, “I love all those lip sounds you’re making!” may lead to an increase in babbling, and these sounds gradually can be shaped into volitionally produced, meaningful words.

Attach Meaning to Vocalizations

When we attach a meaning to a child’s sound productions, we help the child learn that their verbal behavior elicits certain responses. The child who says, “ma,” in the context of playing with a ball may be babbling, or may be trying to say, “ball” or “more.” By treating the vocalization as a meaningful word, the therapist links the child’s speech with a favorable response of receiving a desired toy. We can respond to the child’s production by enthusiastically saying, “Oh, you want the ball. Here you go!” thereby increasing the likelihood that the child will produce the same utterance again in hope of a similar response. Teaching parents and caregivers to begin to recognize their child’s sounds as meaningful is equally important to the therapy process.

Talk About Speech Movements

Children need to understand that the purpose of their therapy visits is to work on movement and sounds. When children stick out their tongues, talk about it; bring it to their attention and make movement and sound become the forefront of the sessions. Comments by the parents and clinician, such as, “Wow, I see your tongue,” “I love to hear all your noisy sounds,” or “I see you smacking your lips. You’re a great lip smacker,” help the child to recognize the importance of sounds and oral movement. Bringing movement to the forefront helps set the stage for what the speech therapy is all about, thus supporting attempts at further speech movements.

Facilitate Imitation

Prior to speech imitation readiness, children need to develop other types of motor imitation skills. When children engage in back and forth imitation, they are learning the important skill of “you do what I do,” an essential skill in the process of speech praxis treatment. Rather than pushing imitation of sounds and words, determine what types of movements the child is able to imitate and work from there. Refinement of imitation is a gradual process, and can be facilitated by beginning with whole body movement (rocking back and forth), imitation of actions during play (banging a drum, stacking blocks), smaller movement imitation (clapping, wiggling fingers, shaking head), imitation of oral/facial movements (sticking out tongue, smacking lips), vocal imitation (basic sound and syllable play), and, finally, imitation of true words. Although parents may be eager for their children to begin saying real words, it is important to help them understand the importance of developing a strong base of imitation prior to asking the child to say words, and to have them engage in these types of imitation routines at home.

If the child does not readily imitate body or vocal movements, one way to get the imitation turn-taking routine going is to imitate what the child is doing. When the child bangs on a table, makes tongue-clicking sounds, or vocalizes a neutral vowel, the therapist and parent can match the movement or sound, usually to the delight of the child. After the turn-taking routine is established with the child in the lead, the therapist or parent can change it by doing something a little different. If the child is banging on the floor, the therapist may bang on a chair instead. If the child is making tongue clicks, the therapist may, instead, make lip-smacking sounds. Praising the child for these imitative attempts is equally important to support the establishment of purposeful, volitional imitation skills upon which speech praxis treatment is based.

Use Toys That Reinforce Early Sound Effects and Simple Exclamations

Prior to the development of “true words,” children typically produce silly sounds and sounds effects, such as coughing, grunting, chewing noises, raspberries, and snoring. Animal and vehicle noises also are among the sounds children master in the context of play and book reading. Encourage production of these sounds by incorporating toys and activities that elicit these sounds. Toy animals, animal puzzles, vehicles, foods, cooking gadgets, and building tools, all serve to elicit repetitive modeling of playful sounds that the child can be encouraged to imitate. Linking a movement to a sound offers an additional cueing mechanism for the child. For example, each time the buttons on the microwave are pushed when “making” playdough cookies, the therapist or parent can say, “beep, beep, beep.”

Pause with Expectation

For children who are quite delayed in babbling and sound imitation, lack of vocal responsiveness becomes an expectation. After children have begun to develop some ability to imitate some vocalizations, a shift should occur on the part of the therapist and family that helps the child recognize that being passive during turn-taking routines is no longer the expected response. Pausing and looking at a child expectantly lets the child know that some response is expected. Offering positive reinforcement when the child takes the risk of making a vocal response further solidifies shared enjoyment in the turn-taking process, paving the road to continued effort and continued success.

It is beneficial to model the target sound effects and target words during therapy using a focused stimulation approach (Ellis Weismer & Robertson, 2006). During focused stimulation, the therapist or parent produces the target sound or word frequently and in a way that brings a heightened awareness of specific phonemes or sounds. Treatment targets can be emphasized by (a) pausing just before the target word is produced (e.g., “Here’s a … ball, and here’s another … ball … and here’s another …ball”); (b) increasing the duration of the vowel of the target word or prolonging a consonant (e.g., “Yummy banana. Mmmmmmm” or “The airplane is going higher. It goes uuuuup, uuuuup, uuuuup.”); and (c) securing the child’s visual attention prior to modeling the target word or sound. Using amplification tools, such as an echo microphone, Toobaloo®, or even a paper towel or wrapping paper roll, may help to focus the child’s attention and generate interest in repetition of sounds and words.

Reduce the Number of Target Utterances Per Session

Strand and Skinder (1999) recommend limiting the number of target utterances in the stimulus set introduced during a therapy session to no more than five or six utterances. In this way, blocked practice of a small number of treatment targets could be accomplished. This repetitive practice of a small number of targets supports the child’s ability to master new movement plans in the earlier stages of learning.

Use Tactile and Proprioceptive Input

Ayres (2005) suggests that many children with apraxia demonstrate reduced tactile and proprioceptive processing. By providing additional tactile and proprioceptive cues, the child’s ability to make sense of the somatosensory input is enhanced. PROMPT® treatment, described by Hayden (2008), incorporates specific tactile cues that offer the child a more salient way of sensing what a movement sequence should feel like, thus helping the child to connect the feeling of the movement gesture with the accompanying acoustic information. Strand and Skinder (1999) also recommend incorporating tactile cues as needed to support imitation when visual and verbal cues alone are not enough to help the child perform the targeted speech movements. In addition, body movements, gestures, and manual signs can be associated with speech movement gestures to create associations between speech movements and other movement cues.

Practice Skill Refinement

It is important to help children move from broad to more narrow distinctions between sounds. For children who do not reliably turn on their voice to produce sounds, praise will be provided when a child produces an undifferentiated vowel sound volitionally. As treatment progresses, purposeful movement of the lips or tongue will be facilitated, and then gradually building up to making distinctions between lip versus tongue sounds, nasals versus non-nasals, stops versus continuents, one versus two syllables, and voiced versus voiceless phonemes. Grading and differentiating of vowels based on tongue position (high/low/mid; front/central/back) and lip shape (open/round/retracted) also should be facilitated. These distinctions are gradual and take time, and children’s achievement of these motor speech skill refinements should be praised each step of the way.

Incorporate Music, and Books into Treatment

Music and carefully chosen books support attainment of speech in children with severe CAS, because they offer opportunities for repetitive practice of target utterances. Music also provides opportunities to practice varied and exaggerated intonation patterns, simple sound effects, and early developing sounds and words. Reduction of rate during songs offers the child the time to achieve initial articulatory configurations of target sounds and words. Making up little tunes with repetition of simple treatment target sounds and words to accompany the activities in the speech session can help to engage the child in the repetitive practice necessary for initial learning of treatment targets. Creation of simple, personalized books can support opportunities for repetitive practice of a simple sound effect or a small number of target utterances. For example, a book with pictures of people or things dropping, falling, and crashing, could be the perfect tool for practice of the exclamation, “uh oh.” Fish (2010) provides several book and song lists, including lists of books to target sound effects and early word production.

Provide Access to AAC

Children need a means of communication. When speech is slow in coming, the use of manual signs and gestures, low tech picture boards, and/or voice output communication devices will help support a child’s ability to express a wider range of ideas, and to establish greater social communication skills. Parents may need to be reassured that the verbal mode of communication will continue to be addressed, but that helping children find a way to establish positive communication patterns is very important for overall development.

References:

Ayres, A. J. (2005). Sensory integration and the child: Understanding hidden sensory challenges. Los Angeles, CA: Western Psychological Services.

Ellis Weismer, S., & Robertson, S. (2006). Focused stimulation approach to language intervention. In R. McCauley and M. Fey (Eds.), Treatment of language disorders in children (pp. 175-201). Baltimore, MD: Paul H. Brookes.

Fish, M. (2010). Here’s how to treat childhood apraxia of speech. San Diego, CA: Plural Publishing.

Hayden, D. A. (2008). P.R.O.M.P.T. prompts for restructuring oral muscular phonetic targets, introduction to technique: A manual (2nd ed.). Santa Fe, NM: The PROMPT Institute.

Strand, E. A., & Skinder, A. (1999). Treatment of development apraxia of speech: Integral stimulation methods, In A. Caruso & E. Strand (Eds.), Clinical management of motor speech disorders in children (pp. 109-148). New York, NY: Thieme.


Featured Author: Margaret A. Fish, M.S., CCC-SLP

Margaret Fish is a speech-language pathologist working in private practice in Highland Park, Illinois. She has 30 years of clinical experience working with children with severe speech-sound disorders, language impairments, and social language challenges. Her primary professional interest is in the evaluation and treatment of children with childhood apraxia of speech (CAS). Margaret is the author of the recently released book, Here’s How to Treat Childhood Apraxia of Speech by Plural Publishing. Her workshops and writing focus on providing practical, evidence-based evaluation and treatment ideas to support children with CAS.



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