Choosing stimuli is probably one of the most important decisions a therapist makes when beginning treatment for childhood apraxia of speech. Thoughtful rationale for specific stimulus items can make a big difference in the rate and amount of early improvement in speech production, especially for children who exhibit severe deficits. This answer will specifically address the non-verbal or very severely apraxic child.

In order to decide what to work on within a session, one first must consider what we are really trying to do through therapy. For apraxic children, I think we are working to give the child the opportunity to practice planning, programming and executing accurate movement gestures (which is the neural processing that is not working efficiently for these children) for speech. That leads to the conclusion that the stimuli we choose must be speech. The stimulus set is used as a vehicle to practice the neural processing that is inefficient for them. We work to help them improve the accuracy of the movement gestures for the chosen words or phrases, first with maximum support (auditory, gestural, visual, tactile cues) and gradually fading that support as they achieve greater accuracy and more automaticity.

There is some controversy over whether to use nonsense verses real words. I always choose to use real words, which are functional, meaningful and very useful in the child’s environment. Early therapy is difficult, and slow. Helping the child master a few useful utterances gives him or her verbal power and helps them trust us and trust the process.

When choosing initial stimuli, I use the results of the motor speech examination to guide me, looking at the phonemic inventory, syllable shapes, and degree of vowel differentiation and accuracy. I then choose stimuli to build on each. These stimuli are typically chosen taking into account phonetic capabilities, earlier more visible and more easily tactically cued phonemes, as well as targeting specific vowel and syllable shapes. Improving vowel accuracy is extremely important early in therapy. I often target only one or two new vowels (that are not yet produced correctly by the child) along with utterances including vowels they can produce. Sometimes a child can produce a vowel in one co-articulatory context, but not others. That is a good early target, expanding the coarticulatory contexts in the initial stimulus set so that the child get practice in a number of articulatory contexts (e.g. me; knee; beep;).

Because the cognitive motor learning literature points out that mass practice facilitates motor performance (accuracy of the movement in the training session itself), I would suggest starting with a very small stimulus set. However, the motor learning literature also shows that if the set size is too small, it will inhibit motor learning or generalization. Therefore, with non-verbal and severely apraxic children I would recommend focusing on a core functional vocabulary of approximately 5-6 utterances at the beginning. As each individual utterance reaches criteria, that one is moved to generalization and a new one introduced. As the child improves his or her motor planning/programming abilities, mastery of utterances becomes faster, and then 2 utterances may be added as another is discontinued. Eventually, the set size will grow.

A case example may serve to illustrate the clinical thinking that may go into deciding on initial stimuli. AB is a 6 year old who is non-verbal due to severe apraxia of speech. There is no dysarthria or significant receptive language impairment. His only consonant is /m/ and he produces little vowel differentiation. The initial core vocabulary included the bilabial nasal /m/ plus two different vowels (“me” and “my”) that he could approximate with cuing. I also included the lingual alveolar nasal /n/ (“no”) as he did not yet produce that phoneme. This also served to expand the vowel inventory and give him some verbal power. I included “hi” and “bye” in the initial set to give him extra practice with /aI/ and to give him some social language. This also allowed us to begin work on bilabial plosing which he did not yet exhibit. This stimulus set allowed the therapist to improve AB’s ability to perform movement gestures for five different CV contexts, focusing on vowel differentiation, as well as correct movement gestures for /n/ and /b/ in at least one coarticulatory context. We also encouraged his mom to model and elicit “uh oh” frequently at home to facilitate further vowel differentiation.

As AB mastered each stimulus item, new items were introduced. We expanded bilabial plosing to different coarticulatory contexts and varied the voicing feature and added CVC and CVCV contexts as he improved (e.g. Pooh; dad; home; hi mom; me too; etc.). After a couple of months we were able to expand the stimulus set to 7, then after 6 months or so, to 10. Keep in mind that the stimuli are a vehicle to practice the motor planning/programming of movement gestures. Eventually, as severely apraxic children improve, we are frequently able to take a more phonologic approach to continued treatment and choose stimuli accordingly.

[Dr. Strand is a consultant in the Department of Neurology, Division of Speech Pathology, at the Mayo Clinic in Rochester, Minnesota, and Associate Professor in the Mayo Medical School. Her primary research and clinical interests have been in Neurologic Communication Disorders, especially childhood and acquired apraxia of speech, dysarthria, and neurologic voice disorders. She has published articles and chapters regarding the clinical management of motor speech disorders in children, including treatment efficacy. Dr. Strand is co-editor of the book (1999), Clinical Management of Motor Speech Disorders of Children. She lectures frequently throughout the country on childhood apraxia and motor speech disorders in both children and adults. Dr. Strand is a member of the Childhood Apraxia of Speech Association Professional Advisory Board.]

Books are an excellent tool in treatment for speech and language disorders due to the multi-sensory approach they provide for learning. All books encourage speech and language development (Chamberlain & Strode, 2004); however, which books provide the most beneficial treatment for children diagnosed with Childhood Apraxia of Speech (CAS)? In the treatment of CAS, it is generally understood that frequent practice of sounds and words helps to improve speech (Velleman, 2005) and reduce some of the pressures associated with expressive language. Repetitive books contain various characteristics that can be part of an effective treatment strategy for children diagnosed with CAS — predictability, presence of carrier phrases, frequent practice of target sounds, familiar inflection, and an introduction to phonemic awareness.

Young children’s favorite books are usually highly predictable (Luckner, 1990). A repetitive book may be predictable in a variety of ways; the story may repeat itself, a portion of a phrase may appear on each page or the same question may be asked throughout. The predictable design of many repetitive books allows the child to grasp the content of the story with greater ease, decreasing the “cognitive load” that may come with reading a narrative type story. When the child has less to think about, often the easier it is to verbally express their thoughts.

In addition, predictable children’s books utilize a cloze procedure which allows a child to fill –in words, phrases, and character’s names, as the book content becomes more familiar. Non- repetitive books often result in the child attempting to participate in reading by either imitating the readers’ words or by answering questions presented by the reader. A predictable repetitive book allows the child to fill- in without imitating; a skill very difficult for most children with CAS (Forrest, 2003). The ability to fill- in words and phrases can lead to increased participation, turn taking, and decreased frustration for the child.

In repetitive books, there will often be a functional carrier phrase used throughout the story. For example, the popular book, “Brown Bear, Brown Bear” (Martin, B.) contains the carrier phrase “I see a ___looking at me”. These phrases allow the child to produce a longer utterance while only having to change one core word. As a result, an unlimited number of multiword utterances may be created. A child with CAS often presents with decreased intelligibility as the length of an utterance increases (Forrest, 2003). By practicing carrier phrases, the child can develop the motor plan for the portion of the phrase that repeats itself, in turn decreasing the “motor load” required for a lengthier utterance. As with predictability, these phrases allow the child to experience increased participation as well as the success of producing multi- word utterances.

The presence of carrier phrases, repeated content and recurring words in a repetitive book can result in the frequent occurrence of a particular sound (phoneme) or group of sounds. A child with CAS often presents with difficulty producing even the smallest unit of speech. If a particular phoneme is featured in a repetitive book, the child will be provided with numerous opportunities to practice the motor plan for that phoneme in a functional and interactive approach. As with other speech motor activities such as counting and reciting the alphabet, the more the child practices the motor plan necessary for production, the more automatic it becomes (Fletcher, 1995, p. 18). The increased practice can result in improved production of a sound, syllable or word and increased confidence when attempting to communicate. Error inconsistency (Jacks, Marquardt, & Davis, 2006), a characteristic often cited for children with CAS, may decrease in the context of a repetitive book due to the frequent practice.

Familiar inflection, another characteristic of repetitive books, can assist in addressing some of the difficulties with prosody that children with CAS experience. Prosody is defined as “the stress, duration, pitch, rate, and timing changes that make our speech meaningful, intelligible, and interesting. It is the melody of speech”. (Chamberlain & Strode, 2004) These features [prosodic] are often sacrificed resulting in decreased intelligibility, difficulty expressing emotion through speech inflection (Van Putten & Walker, 2003), effortful speech, robotic sounding speech and equalized stress patterns (Peter & Stoel- Gammon, 2005). As a reader recites a repetitive book it is instinctive to apply an almost sing song like or melodic tone to the books’ phrases. Each time a phrase, question or sequence of words is repeated the same inflection, rate, pitch and stress pattern may be applied when read aloud. In turn, as the child begins to fill- in words, phrases and recite patterns of the story, they may attempt to apply the same patterns resulting in improved prosody.

Repetitive books foster the development of phonemic awareness and sound symbol association. Children with Apraxia are often at risk for language and reading delays (Lewis, Freebairn, Hansen, Iyengar, & Taylor, 2004). Developing sound symbol awareness and early sight word recognition can be challenging and frustrating for the child. A repetitive book, particularly those with repeated words and short phrases can assist in the development of phonemic awareness and pre-reading skills (Lovelace & Stewart, 2007).

The predictability, use of carrier phrases, frequent practice of a target sound (s), and familiar inflection of repetitive books may help to target some of the characteristics often associated with CAS. The use of repetitive books by therapists as well as by caregivers can offer opportunities for increased participation, decreased frustration, and additional motor planning practice for speech sound production. Successful experiences communicating can improve self- esteem and provide a sense of empowerment.

Helpful Hints for Using Repetitive Books:

• Pause to allow the child to fill in a portion of a repeated phrase.
• Encourage the child to repeat a carrier phrase heard throughout the story.
• Provide adequate time for the child to attempt productions.
• Read a preferred repetitive book multiple times and provide increased opportunities for the child to verbally participate.
• Read a story with inflection! Apply a consistent melodic tone and inflection to carrier phrases and repeated questions present throughout the book.
• Provide opportunities for the child to take turns verbalizing.
• Adapt a book by using additional pictures or objects that correlate to the text.
• Call attention to the print; point to the written text as you read.
• Provide a relaxed atmosphere for reading and positively reinforce efforts to communicate.

List of Suggested Repetitive Books

• Boynton, S.- Red Hat, Yellow Hat
• Brown, M.- Goodnight Moon (Board Book)
• Campbell, R.- Dear Zoo: A Lift The Flap Book (Dear Zoo)
• Carle, E.- Have You Seen My Cat?
• Carle, E. – 1, 2, 3 to the Zoo
• Carlstrom, N.W.- Jesse Bear, What Will You Wear? (Jesse Bear)
• Cartwright, S.- Who’s Making That Mess? (Usborne Lift-the-Flap Book)
• Christelow, E.- Five Little Monkeys Jumping on the Bed (Board Book)
• Eastman, P.D.- Are You My Mother?
• Ernst, L.C.- Up to Ten and Down Again
• Guarino, D.- Is Your Mama A Llama?
• Kalan, R.- Jump, Frog, Jump!
• Pereira, L. & Solomon, M. – Oh! A Bubble…
• Shaw, C.B.- It Looked Like Spilt Milk
• West, C.- “Buzz, Buzz, Buzz” Went Bumblebee
• West, C.- I Don’t Care! Said the Bear
• Williams, S- I Went Walking
• Williams, L- The Little Old Lady Who Was Not Afraid of Anything
• Wood, A.- The Napping House

References:

Chamberlain, C. & Strode, R. (2004). Making It Fun: Practicing Speech at Home. First Apraxia- KIDS Parent Conference, Pittsburgh, Pennsylvania.
Fletcher, S.G. (1995). Articulation: A Physiological Approach. San Diego, CA: Singular Publishing Group.
Forrest, K. (2003) Diagnostic criteria of developmental apraxia of speech used by clinical speech language pathologists. American Journal of Speech-Language Pathology / American Speech-Language-Hearing Association, 12 (3), 376-80.
Jacks, A., Marquardt, T.P., Davis, B.L. (2006) Consonant and syllable structure patterns in childhood apraxia of speech: developmental change in three children. Journal of Communication Disorders, 39, 424-41.
Lewis, B.A., Freebairn, L.A., Hansen, A.J., Iyengar, S.K., & Taylor, H.G. (2004) School-age follow-up of children with childhood apraxia of speech. Language, Speech, and Hearing Services in Schools, 35, 122-40.
Lovelace, S. & Stewart, S.R. (2007) Increasing print awareness in preschoolers with language impairment using non-evocative print referencing. Language, Speech, and Hearing Services in Schools, 38 (1), 16-30.
Luckner, J., “Predictable Books: Captivating Young Readers.” In Perspectives in Education and Deafness, October/November, 1990.
Martin Jr, B., (1992). Brown Bear, Brown Bear, What Do You See? New York: Henry Holt and Company.
Peter, B. & Stoel-Gammon, C. (2005) Timing errors in two children with suspected childhood apraxia of speech (sCAS) during speech and music related tasks. Clinical Linguistics and Phonetics, 19 (2).
Van Putten, S.M. & Walker, J.P. (2003) The Production of emotional prosody in varying degrees of severity of apraxia of speech. Journal of Communication Disorders, 36 (1), 77-95.
Velleman, S. (2005). Update on Childhood Apraxia of Speech. Worldtide, Northampton, MA.

About the Authors:

Michelle Solomon M.A., CCC-SLP, PC and Lavinia Pereira, M.A., CCC-SLP, PC are the creators of First Sound Series, a series of interactive children’s books that foster the development and growth of speech and language skills. Please visit www.firstsoundseries.com for additional information and to purchase materials.

Lavinia Pereira, M.A., CCC-SLP, PC and Michelle Solomon, M.A., CCC-SLP, PC, both earned their degree in Speech-Language Pathology from New York University. Currently, Lavinia is in private practice on Manhattan’s Upper East Side and holds a position as a clinical supervisor of graduate students. Michelle is currently in private practice with two office locations on Manhattan’s Upper East Side. In addition, she instructs licensed speech therapists on therapy technique. Both Lavinia and Michelle specialize in the assessment and treatment of motor speech disorders.