Evidence-Based Practices: Guide for Parents

Evidence-Based Practices: Guide for Parents
Stephanie M. Nixon, Ph.D., CCC/SLP


What is evidence-based practice?

You may have heard speech/language pathologists using this word when describing why they are using a specific treatment approach with your child.  What it means is that a speech/language pathologist is making decisions about your child’s care based on scientific evidence and professional experience while considering your child’s specific needs.

This helps speech/language pathologists (and other professionals) decide what interventions or strategies could help the child based on that child’s specific needs.  There is not necessarily one approach that works for all children, especially not for all children with childhood apraxia of speech.  There are some approaches that have not been studied at all or have been studied with research methods that don’t allow for very strong conclusions.

What is scientific evidence?

Scientific evidence is empirical data that is collected and interpreted using the scientific method.  This is evidence that serves to support or counter a scientific theory or hypothesis and is derived from controlled studies.

Is all scientific evidence high quality?

No.  There are levels of evidence that indicate the quality.

What are the levels of evidence?



In simpler terms, an opinion from professionals that is based on professional experience as opposed to systematic research is the lowest form of evidence.  Pulling together multiple randomized controlled trials into guidelines or a meta-analysis is the best form of evidence. Anecdotes are not evidence, even more so when these anecdotes are offered by (or on websites of) people with a commercial interest.

What are some factors that can decrease the quality of evidence?

When looking at a CAS treatment research study, look for study limitations (e.g., small sample size, inconsistent implementation of treatment approach, lack of a control group or condition, pre-treatment differences between groups, analysis performed by non-blinded outcome assessors, etc.).

Do we have much of the Level 1 standard research for Childhood Apraxia of Speech treatment?

No. We have a few meta-analysis studies and systematic reviews available. For example, Murray, McCabe and Ballard wrote a systematic review in 2014 that is worth examining. However, the studies included in even that study consisted mostly small sample sizes of patients.  Most of our treatment research with children who have CAS is based on small sample sizes (i.e., small numbers of patients).  That said, this research has still given some answers about the best approaches for working with children who have CAS.  By looking at the “evidence” a Speech/Language Pathologist can determine which approaches are most likely to work and which approaches to avoid.

What characterizes a strong treatment research study?

The gold standard for a therapy approach study is a randomized controlled trial and/or meta-analysis.  When evaluating a study, clinicians look at the sample size and the consistency of the therapy process for the children.  When considering sample size, think about it like this – the more children that participated in an therapy study, the more unique children participated.  So if an approach seems to work for most of those cases, it is safer to think it could work for other children with like diagnoses.

When considering the consistency of the therapy process used in research, the clinician wants to be sure that each child receiving “test” and “control” therapies received the same elements of those therapies.  If the same therapeutic process was not followed with each child, then it could negatively influence the outcome of either group (and therefore explain any outcome differences not as a result of the intended treatment but unintended procedural differences).

Another aspect to consider is the presence of other factors that could explain changes and whether these are controlled. For example, if a child also received treatment elsewhere, or if a child started school, or had a medical procedure. Of course maturation (getting older) is another factor: if a treatment study takes place over 6 months and children improve, then it might not be the treatment but it might be maturation/development.

What if an approach with research support isn’t working for my child?

Sometimes clinicians have to use professional experience and opinion combined with the available research to try something slightly different, particularly if the approaches with the strongest “evidence-base” aren’t working for a child.  Clinicians have to monitor progress and adapt when a child is not meeting her/his goals and objectives.  The approach should still have some evidence base – even if it’s minimal.  Evidence base includes knowledge of theoretical foundations of how children learn, how speech production works. Based on this knowledge, clinicians can generate ideas/hypotheses (sophisticated educated guesses) about what might work for a given child.

Additional information on evidence based practices can be found at the following websites:










Murray, E., McCabe, P., Ballard, K.J. (2014). A systematic review of treatment outcomes for children with childhood apraxia of speech. American Journal of Speech-Language Pathology, 23, 486-504.


About the Author:

Stephanie M. Nixon, Ph.D., CCC/SLP is an outpatient speech-language pathologist at Children’s National Health System in Washington, DC.  Dr. Nixon received her Ph.D. in Communication Science and Disorders at the University of Pittsburgh and her MS in Communication Science and Disorders at Arizona State University.  Dr. Nixon has worked for Children’s National since May 2008.  Her clinical focus areas include speech sound disorders, Childhood Apraxia of Speech, higher order language skills, reading decoding, and reading comprehension.

How State Insurance Commissions Can Help With Insurance Funding

Our organization works with parents to assist them in understanding how to file insurance appeals regarding speech therapy. One tip that is perhaps underutilized is having consumers request the assistance of their State Insurance Commission in resolving issues. Filing a complaint can actually be accomplished with some ease because most states have online submission for complaints. The National Association of Insurance Commissioners has a website which can assist consumers in various ways. One section allows consumers to click on their state and directs them to the complaint form for the Insurance Commission in their state. CLICK HERE and follow the links to your state.

How can involving State Insurance Commissions help? First of all, most state Insurance Commissions are consumer-friendly and exist to provide help to consumers from their state. Secondly, they can actually investigate, intercede and get involved. Finally, the state Insurance offices will keep data on the types of complaints that are filed, regarding what topics, and what issues. Having such data on the number of consumer calls regarding speech therapy reimbursement problems could be valuable information to assist in national advocacy efforts aimed at improving speech therapy benefits.

So, if you are experiencing a problem with securing insurance approval for speech therapy why not file a complaint? Speech-language pathologists and pediatricians can also help by suggesting the idea to parents experiencing difficulties and in some states the providers are permitted to file a complaint themselves.

Friendships and Our Children

Reflections on Friendship

What steps can we take to invite and support real friendships for our sons and daughters who live with disabilities? We seem to see other children moving along in a sea of friendship, and we see our children struggling with isolation. The natural ebb and flow of play, enjoyment and affection seems out of reach, and we worry about the prospect of a life-long pattern of separateness. What can we do?

To begin, I’m not sure that I know anything about making friends. The older I get, the more I think that we discover each other. Then if we’re lucky, pay attention, stay faithful, and don’t mess up, we have a friend for life.

We hope that our children who live with disabilities will receive the blessings of friendship. As we seek that blessing, it may be useful to examine how the ordinary patterns of discovery and friendship work, and see if we can follow those patterns, but perhaps in a way that is more focused and intentional.

How did our most important friendships come into being? Where were we when we discovered each other? Among the dozens, hundreds, even thousands of people we’ve met in our lifetimes, how is it that some of us are still friends after all these years?

Being There

At the simplest level, we were there in the same place at the same time. If I’m not there if I’ve been sent away for special [you fill in the blanks] friendship doesnt have much of a chance.

Now I was there at a Janis Joplin concert at the Fillmore Auditorium in San Francisco in 1967 with about a thousand other people. We were close-packed. It was, after all, the Summer of Love. We were young, feeling groovy, and we loved the same music. But nobody from that concert is in my life today. In fact, nobody from that concert was in my life the next morning. We can spend a lifetime going from one activity to another and still be alone the next day (and for the rest of our lives), or we can try another tack.

If we think about it, we see that one basic condition for the development of friendship (love-at-first-sight being a wonderful possible exception) is that we keep going back to the same place over time.

But just going back may not be enough. Twenty years after that night at the Fillmore, I was attending a large church in Winnipeg. The church was packed for four services every Sunday. But one could go back for a month (or a year) of Sundays and still not find friendship, because the ordinary pattern of the service didn’t really lend itself to making connections. You had to make connections around the edges of the service.

The edges are always there: times when were arriving and departing, waiting for the first notes to sound from the organ, coffee after the service. But if you are shy or dont know how to make time in those brief moments, you still might miss the boat.

In 1993, a fellow named Fred conducted a little survey inside this big congregation. Fred made an interesting discovery: there were seventy-six small associations within the church, each focused on something different. Coffee might be just a brief moment for the people who made their way downstairs after the service, but the people who made the coffee were pretty solidly connected to each other. They were a bit political, so we drank fair trade coffee.

As the coffee-makers gathered every Sunday, they talked. They got to know each other well. They appreciated each others contributions, gifts and interests: Mary makes wonderful lemon cookies. Frank just found a new connection for fair trade tea. Mark and Jess discovered that they both love sailing.

While we were making coffee (or doing any of the things that focused the other seventy-five small associations), we had a chance to discover each other. We shared time, space, conversation, and most importantly, we shared a common interest. This is even more powerful when the interest is passionate. When we share a passionate interest, we begin to feel that we share an identity.

In our community, the people who were working to save the Englishman River Estuary came from all walks of life. They represented a wide range of ages, incomes and backgrounds, but they all shared a passion for this beautiful place. As they worked together on something they felt passionate about, many of them discovered new friendships across those ‘natural’ boundaries.

Passionate interests don’t have to be big deals, but it helps if they’re about more than ‘consuming’ something. Making music brings people closer together than listening to music. Listening to music (especially if we keep going back and the place is small enough) brings people closer than merely buying (or these days, downloading) music.

So what does this have to do with our children?

Understanding where and how adult friendships flourish tells us that there are some things we can do to make friendship more likely for a child with disabilities:

  • Children need to be present with other children.
  • Children need to be in a place that allows time for them to connect.
  • It helps to have a bridge-builder on the scene. The school playground allows time for children to connect, but in the absence of conscious bridge-building, an isolated child can remain isolated for a very long time.
  • Introductions help. We have the power to introduce children in ways that define them as alike or as other. Shared interests and gifts make children alike. Defining children by their disabilities makes them other, so it helps to focus on shared interests and gifts and let disability fade into the background.
  • One of the important ways in which children might be alike is that they share a passionate interest. It also helps when we have the time to identify, mobilize and celebrate gifts and contributions. Community exposure isnt enough.
  • Even when a child is present, there are places that are more or less conducive to connection. Places that are primarily based on consumption or competition are not particularly fruitful (see 14,000 Islands, Navigating the Boundary with Community, at http://www.communityworks.info/articles/14000.htm).
  • Competition can quickly define us as “other”, so it makes sense to look for places where cooperation is the hallmark.

Robert Fulghum, (Everything I Need to Know I Learned in Kindergarten) suggested a civilized reengineering of the game of (Musical Chairs). In this version, the object is not to exclude people, but to find ways to include them, even when there are no chairs left. People do remarkable and often quite pleasant things to find room on their laps for one another. He has seen groups find seats for everyone even when there are no chairs left they support one another in the air, like a suspension bridge. He once watched the entire student body of a college make room for one another in their human latticework.

Following Natural Opportunities for Connection

If we think back and remember where we met our best friends, we see that many of those friendships emerged in the context of doing something interesting together over time. We went to school together. We worked in the same company. We were members of the Naturalists Society. We sang in a summer stock production of Annie Get Your Gun.

We may begin with one shared interest and discover others. The last time we were in Tennessee I said to Jake, who is becoming a real friend, You know that if we lived in the same town, we’d be getting into trouble together. What I mean is that I’d be connecting with more of the elements of Jakes life (he’s a BMW motorcycle rider), and he with mine (I’m a sometimes-sailor).

Repeating the connection makes a difference. When Peter moved out to BC, I introduced him to my old friend, John. As I look back, I remember that I kept creating occasions for the three of us to get together, and we’ve done so for years. Peter and John are good friends now, and their friendship has a life that is independent of me.

The depth and quality of the introduction makes a big difference. We don’t just introduce our friend to another person, we share our enjoyment; we give a good account; we announce the ways in which we think they might connect.

Numbers have something to do with this: Most of us have met thousands of people in our lives, but only a handful of them have become good friends. We need to create many opportunities for connection.

The Promise

Once we discover each other, we still need to pay attention, deepen the invitation, and be good to each other. Friendship is a gift, but once we open the gift, we need to be on purpose if friendship is to endure.

The highest form of friendship is something that might be called a covenant relationship (my friend Don talks about the fact that good friends make unreasonable commitments to each other). When we marry, when a child is born or when we adopt a child, we make a promise. And we see that there is often an unspoken promise at the heart of a deep friendship. Wendell Berry reminds us in Standing by Words:

As the traditional marriage ceremony insists, not everything we stay to find out will make us happy. The faith, rather, is that by staying, and only by staying we will learn something of the truth, that the truth is good to know, and that it is always both different and larger than we thought. We must accept the duration and effort, even the struggle, of formal commitment. We must come prepared to stay.

As we make the journey with our children and our friends who live with disabilities, we seek that promise, and we hope to find it extending beyond the boundaries of the family.

The Circle of Friends

Almost two decades ago our friend Judith Snow described what seemed to be a new form of a promised relationship the Circle of Friends. Judith tells us that hers was not the first circle. She says that people have been building circles for thousands of years. But Judiths Joshua Committee the group of committed friends who helped her get out of a nursing home and begin a new life, and who have been with her for twenty years may have been one of the first where overcoming the challenges associated with disability played such an important role.

Judith says, I think that what I have isn’t a disability. If I have anything, it is an invitation. She says that what we call a disability is a powerful invitation to be more intimate, more cooperative, more inventive, and to make new kinds of promises.

Judith’s Circle (you can find books about this at http://www.inclusion.com) has become a model for the development of circles all over the world. There are others: Mennonite Central Committees pattern for Supportive Care in the Congregation, the Personal Support Networks described in Al Etmanskis book. Each of these examples reminds us about a couple of important things:

First, there are times when we need to be more consciously on purpose about expressing the invitation times when the quick-acting rules of attraction or the recognition of shared identity is slowed down by the presence of a disability.

Amber can’t talk, and when she’s excited about something her body moves in a way that is easy to interpret as distress. So we need to be on purpose about introducing her and inviting people to experience who she is underneath her disability interpreting her expressions and movements, and revealing her interests and gifts.

Second, it may take more-than-one-of-us to make and keep the promise, especially when we’re challenged by time and space and other responsibilities. One of the beautiful things about Judith’s Circle is that it includes a natural way of renewing itself. When Doris and Alan moved out of town, the people who remained in the circle were in a position to invite new partners.

The Pattern of Friendship

We know that friendship goes far beyond simple attraction and hanging out. It’s far more complex. A couple of years ago, Faye began speaking about something she calls the Family Pattern (http://www.communityworks.info/familypattern.htm). Originally we intended this to describe what a family (ideally) offers to each of its members and especially to its children. But the Family Pattern could also be a picture of what good friends can offer each other, and what circles of friends might offer to our sons and daughters who live with disabilities.

  • We sense (or promise) that our relationship will endure, that we’ll be there through thick and thin, mistakes and misunderstandings, even times when we’re unattractive, disagreeable, or out of sorts..
  • We recognize, mobilize and celebrate each others’ gifts. We look for places where our friend’s gifts might blossom and we build bridges to those places.
  • We see the essential beauty in each other, and we celebrate that.
  • We carry dreams for each other and encourage each others’ dreams.
  • We share our time, our worldly goods, and our ‘standing’ in the community. We share the things that delight us (I lose a lot of books that way).
  • We connect each other with trusted (trustworthy) people.
  • We’re watchful we look out for each other’s well being and best interests.
  • Sometimes we offer direction. Our First Nations friends in British Columbia have four different words for the idea of ‘encouragement’, and one of those words means pointing out when someone is on a path that might be harmful.

Ordinary Ways and Tender Work

In Bob Perske’s words, I have the will to believe that all of the qualities, experiences, and blessings of friendship can be available to our children and our friends with disabilities. But because we are working to overcome the distance associated with disability and the fact that the ordinary rules of attraction may not be immediately in play, we know that we will have to be on purpose about this. The good news is that all of the ways are the known ways of friendship, family and community. They’re not disability-specific or special, but they are more intentional.

  • Because the ordinary balance of time and energy may be stretched by the presence of disability, we may have to think in terms of inviting and supporting an intentional circle of companionship. But the ways of doing this are familiar literally of the family.
  • Because mutuality might be harder to see at the outset (it’s likely to start out as a mystery), we will need to be more conscious and self-reflective. Once again, the ways of doing this are nothing special (see Key Circle Questions, at http://www.communityworks.info/articles/circle.htm).
  • Because it is tender work, we need to move in a way that allows people to feel safe, loved, loving and very gently engaged. Friendship is a discovery, not a requirement, and it helps to remember the value of small beginnings. At the outset, were not asking for a lifetime commitment: Murray, you know that Amber is interested in peace-making. Could you come for coffee and help us think about how she might get connected with the Monday night group?

The good news is that to find friendship, we don’t need a program. All of this is within the reach of families and friends. As Wendell Berry reminds us in Home Economics:

We hear again the voices out of our cultural tradition telling us that to have community people don’t need a ‘community center’ or ‘recreational facilities’ or any of the rest of the paraphernalia of ‘community improvement’ that is always for sale. Instead, they need to love each other, trust each other, and help each other. That is hard. All of us know that no community is going to do these things easily or perfectly, and yet we know there is more hope in that difficulty and imperfection than in all the neat instructions for getting big and getting rich that have come out of the universities and agribusiness corporations in the past fifty years.

(David and Faye Wetherow live in British Columbia, Canada, and share their lives with an adopted daughter. They conduct planning and training sessions for individuals and families, government and community agencies, schools, parent associations and self-advocacy groups throughout the United States and Canada. They can be contacted through CommunityWorks at http://www.communityworks.info.)

Applying for Social Security Disability Benefits for a Child with Apraxia

If your child has apraxia of speech – either as a primary condition or associated with another condition – then he or she may be eligible to receive disability benefits through the Social Security Administration’s (SSA’s) Supplemental Security Income (SSI) program and/or Social Security Disability Insurance (SSDI) program.

Apraxia may significantly impact your son or daughter’s ability to function on a level similar to his or her peers. Specialized therapy, assistive technology, and other necessary services can be very costly.  If  you cannot afford to support their specific needs, you may qualify for Social Security Disability benefits on his or her behalf.

A few things to remember:

  • A diagnosis does not automatically make your child eligible.
  • The impact of the diagnosis or disability on your child’s ability to function in a number of life areas will be considered.
  • Only children who are found to be “severely” affected by their disability, as per guidelines of the SSA, are eligible.
  • Your child and family will need to meet financial requirements.

Basic Eligibility for Benefits

A child under the age of 18 typically qualifies for Supplemental Security Income (SSI) rather than Social Security Disability Insurance (SSDI). This is because the SSDI program requires past employment and a specific amount of taxes paid into the system. However, if a child’s parent currently receives SSDI, the disabled child may be eligible for dependent benefits under that parent’s name. If you feel that your child may qualify for dependent benefits under a parent or guardian, contact the representative who handles the eligible parent’s claim.

SSI, on the other hand, pays benefits to elderly or disabled individuals (including children) who have access to very limited income. There are no work-related requirements for SSI.  SSI provides both cash and health insurance benefits.

There are two sets of eligibility criteria for receiving SSI: (1) financial criteria, based on the income and resources of the child and family; and (2) medical criteria about the child’s impairment or combination of impairments.

Financial Criteria

To qualify, applicants must meet very specific financial requirements. In the case of a child, a parent or guardian’s income will be evaluated. Learn about the specific financial limits, here: http://www.socialsecurity.gov/ssi/spotlights/spot-deeming.htm.  If the child is eligible based on the families income, that is only the first step.  The child must then be found to have a severe disability.

SSA considers your financial resources are items like employment income, bank accounts, stocks, bonds, and property. Your personal belongings, the family home and care usually do not count.

(Special note:  Many states do have what are called “Medicaid Waivers“.  These waivers are unique to each state and often have waiting lists, however, they often set aside financial requirements for those with very severe disabilities so that the child is able to receive medical insurance benefits.)

Medical Criteria

In addition to the financial requirements listed above, there is also a basic definition of disability that your son or daughter must meet. This is defined by the SSA as follows:

  • He or she has a medically determinable physical or mental impairment (or combination of impairments); and
  • The impairment(s) results in marked and severe functional limitations; and
  • The impairment(s) has lasted (or is expected to last) for at least one year or to result in death

Medical Requirements

If your child meets the basic definition of disability, his or her condition will be evaluated based on very specific medical requirements. These requirements can be found in the SSA’s guide of potentially disabling conditions, known as the blue book.  Although Childhood Apraxia of Speech—or CAS—is not listed in the SSA’s blue book, your child may still qualify for disability benefits.

There are two ways in which your child may qualify for SSI without meeting a blue book listing:

  1. Match the specific medical criteria listed under a separate but similar listing.  Professionals may find that CAS most closely matches blue book listing 111.09- Communication Impairment Associated with a Documented Neurological Disorder. Under this listing, the SSA requires the following criteria:
  • Documented speech deficit which significantly affects the clarity and content of the speech; or
  • Documented comprehension deficit resulting in ineffective verbal communication for age; or
  • Impairment of hearing as described under the criteria in 102.10 or 102.11.

If CAS occurs with another medical condition, your child may qualify for disability based on the other condition, but the SSA will also take into account all issues, including those created by CAS.

  1. Provide evidence that, despite not meeting a blue book listing, your child’s impairment causes significant difficulty completing age-appropriate activities of daily living.

Preparing to Apply for Benefits

The first step toward applying is to schedule your appointment with the SSA. It will probably take some time before there is an available appointment date. While waiting for your appointment collect all of the necessary documentation, including:

  • medical records
  • school records,
  • And any other information that points to the limitations and challenges your child faces on a daily basis.

It can be very helpful to have your child’s physician write a summary letter or report to outline in one place all of the ways that your child is impacted by their disability.  You can provide them with a list of the issues and also this document describing criterian from the SSA publications for medical professionals.  This is the time to truly describe any activity impacted by your child’s disability (for example:  is unable to communicate pain, hurt, or illness; has no intelligible speech to communicate; etc.)

Also take the time to review the child disability starter kit.

What to Expect from the Application and Review Processes

Once you complete the initial application, it might be months before your receive a decision. You should be prepared to face the possibility that your child might be denied. If this happens, you have a chance to appeal. You have 60 days from receiving the denial to file an appeal.

Although the application process can seem complicated and overwhelming, disability benefits are often a necessary lifeline for many families. Once you are awarded benefits, you will be able to better support your child’s needs.

For more information about applying for disability benefits, visit Social Security Disability Help.


Apraxia Therapy – Evidence for Frequent and Intensive Speech Therapy Services

frequency and intensity

Children with childhood apraxia of speech (CAS) are often described as needing frequent and intensive speech therapy services in order to address the speech motor planning and programming issues that are at the heart of their speech difficulty. Typically, the need for speech therapy will extend over a number of years. Families and caregivers may need to advocate for the appropriate speech therapy services for a child with apraxia.

Children with CAS who receive appropriate speech therapy are capable of making meaningful and substantial gains in speech intelligibility and communication. As their speech becomes more and more intelligible, the frequency of services can be adjusted according. Each child’s individualized needs and circumstances must be considered. In addition to their speech motor planning and programming needs, children with CAS often have other speech and/or language needs that need factored into therapy goals. For example, some children may also require training with augmentative communication devices in addition to speech therapy specifically targeting their speech production.

Included below are the most relevant citations available in the professional published literature for communication sciences and disorders and in prevailing expert opinion that describe the need for frequency and intensity for children with CAS. Additionally, there are quotes and excerpts from the American Speech Language Hearing Association (ASHA). ASHA is the professional organization and licensing body for speech-language pathologists.

The American Speech-Language-Hearing Association (ASHA)

In 2007, ASHA issued its “Position Statement on Childhood Apraxia of Speech” and the “Technical Report on Childhood Apraxia of Speech” in order to update speech-language clinicians regarding the science of CAS and its consensus expert guidance for speech-language pathologists. ASHA is the national professional, scientific, and credentialing association for 186,000 members and affiliates who are audiologists; speech-language pathologists; speech, language, and hearing scientists; audiology and speech-language pathology support personnel; and students. This position statement is an official policy of the American Speech-Language-Hearing Association (ASHA). Here are relevant citations regarding speech therapy frequency and intensity:

“It is the policy of ASHA that the diagnosis and treatment of CAS are the proper purview of certified speech-language pathologists with specialized knowledge in motor learning theory, skills in differential diagnosis of childhood motor speech disorders, and experience with a variety of intervention techniques that may include augmentative and alternative communication and assistive technology. It is the certified speech-language pathologist who is responsible for making the primary diagnosis of CAS, for designing and implementing the individualized and intensive speech-language treatment programs needed to make optimum improvement, and for closely monitoring progress.”
[Position Statement: Childhood Apraxia of Speech, American Speech-Language-Hearing Association (ASHA); http://www.asha.org/policy/PS2007-00277.htm; Accessed 08/01/2017]

Given the need for repetitive planning, programming, and production practice in motor speech disorders, clinical sources stress the need for intensive and individualized treatment of apraxia, especially for children with very little functional communication. There is emerging research support for the need to provide three to five individual sessions per week for children with apraxia as compared to the traditional, less intensive, one to two sessions per week (Hall et al., 1993Skinder-Meredith, 2001Strand & Skinder, 1999). Ideally, this should be done in as naturalistic an environment as possible to facilitate carry-over and generalization of skills. Although home practice is critical for optimal progress, it cannot take the place of individual treatment provided by a speech-language pathologist who has expertise in motor speech skill facilitation. For the diverse backgrounds of children seen for early intervention, including their stages of psychological/emotional development, the Committee sees value in endorsing a treatment plan for optimum progress based on provision of intensive therapy.

Individual differences among children will also underlie rationale for changing the form, content, and intensity of treatment throughout the course of intervention. If toddler and preschool-age children are seen for early intervention that targets their speechmotor deficits, the frequency of treatment may be able to be reduced over time. As long as the primary goal is to improve the motoric aspects of the child’s speech production (i.e., more time for motor practice), individual therapy should be the preferred approach regardless of age. For children whose severity of involvement has decreased and whose treatment goals have begun to move toward language and pragmatic skills enhancement, a combination of both individual and small group therapy may also be optimal for some children, providing that a treatment focus is maintained on speech production.”
[Technical Report: Childhood Apraxia of Speech; American Speech-Language-Hearing Association, 2007; http://www.asha.org/policy/TR2007-00278.htm; Accessed 08/01/2017]

From the ASHA Practice Portal:  Childhood Apraxia of Speech

Dosage refers to the frequency, intensity, and duration of service and the culmination of those three variables (Warren, Fey, & Yoder, 2007). Treatment dosage for CAS is consistent with principles of motor learning (McNeil, Robin, & Schmidt, 1997). Given the need for repetitive production practice in motor speech disorders like CAS, intensive and individualized treatment is often stressed. A number of research studies support the need for three to five individual sessions per week versus the traditional and less intensive one to two sessions per week (Hall et al., 1993; Skinder-Meredith, 2001; Strand & Skinder, 1999). For younger children, the frequency and length of sessions may need to be adjusted; shorter, more frequent sessions are often recommended (e.g., Skinder-Meredith, 2001).

Format refers to the structure of the treatment session (e.g., group and/or individual). The appropriateness of treatment format (individual vs. group vs. both) depends on the primary goal for the child at a particular point in the treatment process. For example, if the primary goal is to improve the motor aspects of speech, individual sessions that emphasize motor practice might be the preferred approach. However, once the child has made progress on goals targeting motor speech production, goals might then include language and the enhancement of pragmatic skills. At that point, a combination of individual and group treatment may be appropriate.
[Practice Portal: Childhood Apraxia of Speech; American Speech Language Hearing Association; http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935338&section=Treatment; accessed 08/01/2017]


Other citations on frequency and intensity from published journals and books:

Individual therapy is recommended because it offers more opportunities for intensive practice and child and parent feedback. Group therapy is a complex learning environment with more potential distractions and fewer opportunities for practice of speech targets with individualized cueing and feedback. Young children with suspected CAS may have difficulty focusing on the clinician and may not have sufficient practice opportunities to develop and establish new speech motor patterns within a group setting.”
[Pukonen, M., Grover, L., Earle, C.,  Gaines, R., and Theoret-Douglas, C. (2017). A proposed model for identification of childhood apraxia of speech in young children. Canadian Journal of Speech-Language Pathology & Audiology; 41(1), 10 – 32.]

“It is commonly agreed that children with CAS need intensive speech therapy (McCauley & Strand, 2008). Edeal and Gildersleeve-Neumann (2011) found that frequent and intense practice of speech resulted in more rapid response to treatment in two children with CAS. Treatment approaches for children with CAS typically involved therapy at least twice a week, often more. Strand et al. (2006) provided sessions two times a day, five days a week. Iuzzini and Forrest (2010) provided 20 therapy sessions over 10 weeks. Martikainen and Korpilahti (2011) provided therapy three times a week for six weeks.”
[Kiesewalter, J., Vincent, V., and Lefebvre, P. (2017). Wee words: a parent-focused group program for young children with suspected motor speech difficulties. Canadian Journal of Speech-language Pathology & Audiology; 41(1), 58 – 70.]

The principle of motor learning that has the greatest evidence supporting its use in children with CAS is that of treatment intensity—where a higher number of sessions and practice trials per session results in the greatest gains within one block of treatment. The minimum intensity that has been shown to work is two sessions a week (Namasivayam, Pukonen, Goshulak, et al., 2015; Thomas, McCabe, & Ballard, 2014) with most articles employing sessions 3–5 times a week and 100 production trials per session (Edeal & Gildersleeve-Neumann, 2011; Murray et al., 2015).
[Murray, E., and Iuzzini-Seigel, J. (2017).  Efficacious treatment of children with childhood apraxia of speech according to the international classification of functioning, disability and heath. Perspectives of the ASHA Special Interest Groups SIG 2; 2(2); 61 – 76.]

“Evidence level of reviewed studies ranged from moderate to strong (ASHA, 2004). With regard to research phase, only one study was considered to be phase III research, which corresponds to the controlled trial phase. The remaining studies were considered to be phase II research, which corresponds to the phase where magnitude of therapeutic effect is assessed. Results suggested that higher treatment intensity was favourable than lower treatment intensity of specific treatment technique(s) for treating childhood apraxia of speech and speech sound (phonological) disorders”
[Kaipa, R & Peterson A.M. (2016) A systematic review of treatment intensity in speech disorders. International Journal of Speech-language Pathology; 18(6)      ]

“There is evidence that speech therapy provided in frequent sessions multiple times per week can yield superior outcomes over traditional, less frequent service delivery (Allen, 2013; Namasivayam et al., 2015; Kaipa and Peterson, 2016), and some motor-based speech treatments are specifically designed with intensive schedules in mind (Ramig et al., 2001; Strand et al., 2006; Murray et al., 2014).”…..“Intensive therapy programs with visual feedback may be one option for increasing speech accuracy for some school-age children with CAS. All participants showed an increased ability to perform the desired speech movements for perceptually accurate productions during treatment, but this approach did not immediately result in generalized improvements to untrained items or to connected speech for all children.”
[Preston, J., Leece, M. & Maas, E. (2016). Intensive treatment with ultrasound visual-feedback for speech sound errors in childhood apraxia of speech. Fronteirs in Human Neuroscience   ]

“The primary purpose of the present study was to explore the effects of treatment intensity on outcome measures for children with CAS undergoing motor speech intervention. A secondary purpose was to assess the magnitude of change as a function of treatment intensity across outcome measures in this population.

Results indicate that both higher intensity groups (RND lists 1 and 2; tables 2 and 3) yielded significant results for changes in articulation (GFTA-2 standard score) and functional communication (FOCUS scores). However, lower intensity treatment (table 1) did not yield any statistically significant results. Importantly, there were no significant changes in speech intelligibility scores (for word or sentence level) across either treatment intensity. In general, higher intensity treatment produced large effect sizes for the articulation (GFTA-2 standard score) and functional communication variables (FOCUS scores) and moderate effect sizes for sentence-level speech intelligibility (BIT for higher intensity RND list 1; figure 3). On the other hand, lower intensity treatment yielded relatively smaller effect sizes than higher intensity treatment for articulation and functional communication, but for word-level speech intelligibility (CSIM) both lower and higher intensity (RND 1) treatments resulted in similar magnitude of effect sizes. For sentence-level speech intelligibility (BIT scores) only one higher intensity treatment group (RND 1) showed moderate effect sizes.

Children with CAS who received 2×/week (higher intensity) individual MSTP intervention for 10 weeks demonstrated significantly better outcomes for articulation and functional communication compared with those who received 1×/week (lower intensity) intervention.”
[Namasivayam, A., Pukonen, M., Goshulak, D., Hard, J., Rudzicz, F., Rietveld, T., Maassen, B., Kroll, R., & van Lieshout, P. (2015), 50(4);     ]

Intensive treatment delivery in impairment-based intervention appears crucial for obtaining positive treatment outcomes. These treatments provided therapy at least 2-3 times a week, with sessions of up to 60 min. The dose of treatment, defined as the “number of properly administrated teaching episodes during a single intervention session” (Warren et al., 2007, p. 71), should probably also be high (Edeal & Gildersleeve- Neumann, 2011). This review suggests that at least 60 trials per session represents a “high” dose. Williams (2012) suggested that, with phonological therapy for speech sound disorder, ≥50 trials per session over ≥30 sessions is effective, although dose and intensity need to increase as impairment severity increases.”
[Murray, E., McCabe, P., & Ballard, K. (2014). A systematic review of treatment outcomes with childhood apraxia of speech. American journal of speech-language pathology, 23(3), ]

While both children appeared to benefit from other aspects of their treatment, the data indicate that learning and maintenance of skills for both children was greater for speech targets treated with more intensity—that is, a higher frequency of production. The effect size for treatment condition was large for motor performance tasks in both children..Data show that the speech targets treated with the HiF condition led to higher in-session accuracy and greater generalization effects for both children than for speech targets treated with the lesser number of repetitions in the ModF condition. The treatment differences observed may be due to the greater intensity and pace of the HiF condition in which the subjects had more opportunity for practice of speech sounds and received more cues when needed. Not only did speech targets treated with a higher number of productions and a greater level of intensity show higher levels of accuracy overall during the course of the treatment, but high levels of accuracy were achieved in fewer sessions than targets treated with fewer productions. Speech targets treated with a high number of productions showed less variability, meaning accuracy did not vary from session to session as much as it did for targets treated with fewer productions. Speech targets treated with more productions generalized better to untrained words and showed more stability overall. Both children also demonstrated better retention of the targets treated with more productions during the posttreatment probes.”
[Edeal, D. & Gildersleeve-Neumann, C. (2011).  The importance of production frequency in therapy for childhood apraxia of speech. American Journal of Speech-Language Pathology; 20; 95 – 110.]

“How Many Treatment Sessions Are Required to Improve My Childs Speech?”
For the phonologically disordered children, an average of 29 individual, 45-minute treatment sessions (range of 21 to 42 sessions) were required for parents to increase their ratings from having less than half of their child’s speech understood by an unfamiliar listener to having about three-fourths of their child’s speech understood. In stark contrast, the eight children with apraxia speech whose parents stated that three-fourths of their child’s speech could be understood following treatment, required 151 individual treatment sessions (ranging from 144 to 168 sessions) to achieve a similar level of parental estimated speech intelligibility. In other words, the children with apraxia of speech required 81% more individual treatment sessions than the children with severe phonologic disorders in order to achieve a similar functional outcome.”
[Campbell, T. (1999). Functional treatment outcomes in young children with motor speech disorders. In Caruso, A. & Strand, E. (Eds.). Clinical management of motor speech disorders in children (p 394).  New York, NY: Thieme Medical Publishers Inc.]

Regardless of the primary deficit, children with severe speech impairment need intensive speech therapy early on. Young children benefit from frequent shorter sessions (e.g., up to four times/week for 30 minutes each session). These are preferable over longer, less frequent sessions. In general, children with phonologic delay progress more quickly than children with DAS. This means that the child with DAS will need these intensive services longer.”
[Skinder-Meredith, A. (2001). Differential diagnosis: developmental apraxia of speech and phonologic delay. Augmentative Communication News; 14 (2 & 3).]

Several decisions need to be made regarding the frequency, length, and the type of treatment sessions. Given that most researchers in motor learning agree that motor skill is acquired only through practice (Rose, 1997; Schmidt, 1988, 1991), sessions should be frequent and long enough to allow the practice that is needed. How those sessions are scheduled, however, is important. Magill (1998) suggested that for continuous skill a distributed practice schedule is preferable, whereas for discrete skill, mass practice is better. Fletcher (1992) discussed this concept with respect to speech and suggested that distributed practice will likely yield better speech motor performance and speech motor learning for this serial motor learning task. This brief review of the concept of mass versus distributed practice leads to the suggestion that for children with significant motor planning or programming problems, distributed practice will likely result in better motor learning. For example, if 2 hours of therapy per week are recommended, sessions should be scheduled four times per week for half hour, versus two times a week for an hour. Given that we know frequent repetitive practice is necessary to learn skilled movement, however, it seems logical to assume that individual treatment sessions go much further in offering the child the opportunity to practice the movement gestures with enough frequency for the motor learning to be retained.”
[Strand, A. & Skinder, A. (1999) Treatment of developmental apraxia of speech: integral stimulation methods (120-121). In Caruso, A. & Strand, E. (Eds.) Clinical management of motor speech disorders in children.  New York, NY: Thieme Medical Publishers Inc.]

To summarize, although there are differences in definitions of intensive remediation for children with CAS, there appears to be emerging consensus within the literature that therapy should be conducted at least three to five times weekly, in sessions lasting between 30 and 60 minutes each, and that the intervention should be conducted on an individual basis.”
[Hall, P. , Jordan, L. & Robin, D. (2007) Developmental apraxia of speech: theory and clinical practice, 2nd Edition. p. 200, Texas: Pro-ed Publishers.]

Intensive Services are Needed for the Child with DAS. Children with DAS are reported to make slow progress in the remediation of their speech problem. They seem to require a great deal of professional service, typically done on an individual basis. Therefore, clinicians working with DAS must accommodate this need and schedule as much intervention time with the child as the child and/or his/her circumstances can allow. Thus, the clinician may be thrust into the position of becoming an advocate on behalf of the child to assure that services are provided as frequently as possible. In some cases, the clinician may need to help the family find the financial resources or assistance thy may need to cover the costs of professional service; a child with DAS can quickly become an expensive child to his/her family or school system because of the amount of therapy they typically require.”

“The definition of intensive varies from clinician to clinician and from work setting to work setting. Rosenbek (1985), when discussing therapy with adult apraxics, defines the work as meaning that the patient and the clinician should have daily sessions; Macaluso-Haynes (1978), Haynes (1985), and Blakeley (1983) also advocate daily remediation sessions. Blakeley (a983, p.27) stated that I do not expect to provide speech education for children with developmental apraxia of speech on a cursory basis for it may be the most important part of their entire education.”
[Hall, P. , Jordan, L. & Robin, D. (1993) Developmental apraxia of speech: theory and clinical practice, p. 125, Texas: Pro-ed Publishers.]




Encoding, Memory, and Transcoding Deficits in Childhood Apraxia of Speech (Annotated Summary)

Annotation of Article by Sharon Gretz, M.Ed.

Article: Encoding, Memory, and Transcoding Deficits in Childhood Apraxia of Speech

Clinical Linguistics & Phonetics, May 2012; 26(5):  445 – 482
Shriberg, L.D, Lohmeier, H.L., Strand, E.A., and Jakielski, K.J.

In this study, researchers were examining whether the deficits of children with CAS were limited to speech motor planning & programming (what the author calls “transcoding deficits”) or if the children also had difficulties in auditory perception (termed “encoding” in this paper) and/or memory (ability to store and access representations).  Various analyses and properties of a task called the “Syllable Repetition Task”, as well as other measures, were used to examine 369 children in four distinct groups.  The groupings of subjects were:

  • typical speech-language,
  • speech delayed – typical language,
  • speech delayed – language impairment,
  • and a group with childhood apraxia of speech


Origins of CAS

While there is extensive research about adult acquired apraxia of speech, research in CAS is still young, happening primarily in the last 20 years.  While adult AOS is due primarily to illness or injury, the origins of CAS are more complicated.  Various genes have been associated with CAS including FOXP2, FOXP1, FOXG1, CNTNAP2, ELP4, RAI1 and others.  Because the origins of CAS are by and large different than those for adult AOS, it can be expected that profiles or patterns of deficits would also show differences between adults and children.  First of all, adults who acquire apraxia of speech had a lifetime of a typical path of speech and language formation, development, acquisition and refinement.  We can contrast this to children who are identified with CAS.  Children with CAS are in the acquisition process and the system is already disrupted.  As the authors point out, the integrity and development of one system will influence and have ramifications to other related systems- each in and of themselves in the process of growth and development.  Some systems serve as building blocks for other systems.  Further, the influence of disrupted gene expression in the brain may include not only areas involved with speech processing but other related structures and neural circuits.  Classification systems used for adult motor speech may not relate well to child motor speech disorders.

Speech Processing System

Research often breaks down speech processing into four domains:

  • Auditory encoding – auditory information is taken in, interpreted, and transformed into representations of sounds/phonemes, syllables, and words.
  • Memory – allows one to store and access the representations
  • Transcoding – takes the representations and transforms them into plans and programs for speech movements
  • Execution – the neurological processes of actually performing – executing – the programmed speech movements

While speech motor planning is the “noticeable” deficit in CAS, research appears to suggest that encoding and/or memory impairments may also be present, represented by difficulties with reduced perception & production of vowels, syllables, rhymes, and phonemic sequences; problems in reading & spelling.

Transcoding deficits would reflect motor planning and programming difficulties but there is not total agreement in the research community as to what sort of speech behaviors represent planning or programming.  In current CAS research there are no firm markers that are sufficiently specific or sensitive to identify with certainty those children with apraxia of speech.  The authors of this study describe a speech behavior within a Syllable Repetition Task that they believe does tap into motor planning/programming processes.

The Syllable Repetition Task developed by Shriberg et al. includes 18 items and can be scored in 5 minutes. The procedure allows for assessment of the processes underlying nonword repetition in a simple context that can be used for speakers with mild to severe articulation errors.  Nonwords are used to remove linguistic load from the test items and can be a window through which to observe new word learning. The authors used various metrics developed and associated with SRT performance to index deficits in encoding, memory and transcoding.

Research Questions:

  1. Do children with apraxia only have speech motor planning/programming deficits (transcoding) or do children with CAS have deficits in multiple domains of the speech processing system?
  2. Can findings from a syllable repetition task (SRT) contribute significant diagnostic information on whether or not the individual has CAS?

In this study, researchers include 40 participants with CAS – 20 with genetic conditions and 20 subjects with idiopathic CAS (CAS of unknown origins).  The comparison groups were:

  • typical speech/language children,
  • children with speech delay and typical language, and
  • children with speech and language delay.

As the authors write, “the CAS participants … constitute one of the largest reported samples and the most diverse in age range and diversity of origins.”  In the CAS neurogenetic group, 55% of the sample was males as compared to 65% from the idiopathic CAS group, representing roughly equal gender prevalence in the genetic group.

Notes About Measurements & Scoring Within the Study:

Below is general information about some of the measurements reported in the study:

  • Competence scores denoted relative mastery.
  • Encoding scores (correct auditory-perceptual representations) were calculated using the mean percentage of within-class manner substitutions that occurred in the 3 and 4 syllable tokens. Higher scores reflect higher competence in encoding.
  • Memory scores reflect a ratio between percentages of sounds correct in longer three syllable-length items as compared to shorter two syllable-length items. Lower SRT memory scores point to greater difficulty in accurately repeating 3 syllable length items as compared to 2 syllable length items.
  • Transcoding scores were defined as percentage of responses to each of the 18 SRT items that included one or more sound additions, with the score subtracted from 100 (so that lower scores would denote less competence in speech motor planning/programming)


  • Competence scores of participants with CAS were lower in both younger subjects (ages 3 – 6) and older subjects (7+ years) as compared to the comparison groups with speech delay, and especially for suprasegmentals and within the older subjects. Competence scores on segmental measures were generally lower in the CAS genetic group than the CAS idiopathic group.
  • Participants in the typical speech/language group had the highest competence and processing scores and subjects in the CAS group had the lowest competence and processing scores.
  • Subjects with CAS have lower SRT scores than the other three groups on 11 of 12 comparisons.
  • Particularly relevant to the study questions, the adjusted mean transcoding score (purported to represent motor planning & programming) for the CAS group was significantly different than adjusted mean scores for the other three comparison groups.
  • CAS subjects had significantly lower scores on all measures than the Group 1 (typical speech/language subjects); lower SRT competence and memory scores than Groups 2 & 3 (speech delay/normal language, speech delay/language delay); and significantly lower encoding scores than the Speech delay/normal language comparison group, but not the speech & language delay group 3.

Did the SRT indexes help with diagnostic accuracy of the CAS individual speakers?


  • Out of all of the SRT measures, the transcoding scores had the highest diagnostic accuracy for discriminating subjects with CAS (74% accurate in discriminating those with CAS from those with speech delay, with and without language impairment).
  • Transcoding scores of 80% ruled out CAS with 93.9% accuracy.
  • Transcoding scores of less than 80% were 8.3 times more likely from subjects with CAS than from subjects with speech delay

Transcoding score Differences within the CAS group

  • Significantly more CAS subjects with idiopathic origins had low transcoding scores indicating the possible importance of etiology in CAS (neurogenic vs. idiopathic) in future explanatory accounts of the disorder.


– Based on the comparisons in this study, CAS is more consistent with an explanation of deficits across multiple speech processing domains, with the most significant deficit in transcoding.

– Transcoding scores were moderately sensitive to CAS, yet some participants from the comparison groups also had low transcoding scores.

– SRT scores can provide significant diagnostic information for CAS, but are not diagnostically conclusive.

– No one diagnostic marker is likely to identify CAS in individuals of all ages, cognitive abilities, competencies, or etiologies.


  • Findings from this study indicate that deficits in auditory-perceptual encoding, memory, and transcoding are core features of CAS in idiopathic and genetic contexts, although transcoding (motor planning/programming) was most significant.
  • Those with CAS will have quantitative differences in speech, voice and prosody than those with other speech sound disorders rather than conclusive differences and to identify them will require a battery of standard assessment items in these areas.



We Are Not Defined By Our Struggles

What follows is a long, emotional post. Around a year ago, I graduated from a great school, Emory University, on the same week as Apraxia Awareness Day, and I just happened to have worn a blue dress. I was diagnosed with apraxia when I was around 4 years old, back in the nineties.

There was very little known about the disorder, so little that a local college actually used me as a case study for 13 years. I and my parents had to consistently battle with school, friendships, confidence, communication, and bullies.  I had never witnessed an Apraxia Awareness Day until this year.

To look at all this unity, not only makes me beyond emotional, but you all are giving voices to the voiceless and the struggled voices. Growing up, I often felt defined by my voice and speech – the “girl with the funny accent.”  But I eventually learned something very important.

alyson taylor

In these graduation pics, I’m not defined by my blue dress- I got a black graduation robe like everyone else. And I am not defined by my “funny” speech or accent, because at least I have a voice like everyone else whether it be orally, written, or even emotional facial expressions. I suppose the point I’m trying to bring across in this emotional post is celebrate and raise awareness for apraxia, those diagnosed, and their accomplishments; but also remember that we are not defined by our struggles and should find our strengths even within our weaknesses.

¿Qué Hace Que La Terapia Del Habla Sea Diferente En El Tratamiento De Los Niños Con Apraxia del Habla Infantil?

Como mencioné anteriormente, el apraxia del habla infantil es un desorden motor del habla que implica una dificultad o inhabilidad de planear y programar la secuencia y la sincronización rápida de movimientos necesarios para producir habla que pueda ser entendida por otros. Las estructuras faciales y orales como los labios, lenguaje, paladar blando, mandíbula y pliegues vocales- y los músculos que mueven dichas estructuras – necesitan ser activados y moverse en el momento justo, con un orden específico y con la fuerza exacta para que las palabras que su hijo/a quiere decir sean producidas con exactitud.

Debido a que el problema principal en el AHI es la planeación y programación motriz del habla, la terapia del habla debe estar enfocada en el movimiento en sí de las estructuras y músculos del habla durante los intentos de producción  de habla (Nota: las palabras importantes son “movientes durante los intentos de producción del habla). El enfoque usado por el terapeuta debe ayudar al niño/a producir en forma más clara y correcta palabras, frases y oraciones.

¡Porque el habla consistente en una serie de movimientos, nosotros podemos usar en terapia del habla ideas que, generalmente, son usadas para ayudar a las personas a adquirir habilidades en el aprendizaje de un movimiento! ¿Cómo aprenden las personas de mejor manera a lanzar la bola de basquetbol y encestar? ¿Cómo aprenden las personas de mejor manera a pegarle a una bola de golf y a hacer que la bola se vaya en el hoyo?  ¿Cómo aprenden las personas a montar bicicleta? ¿Cómo ocurre el “aprendizaje motriz”?

Hay un cuerpo extensiva y complete de evidencia acerca de cómo ocurre el aprendizaje motriz en las personas. Los principios y teorías que se tienen como resultado de dichas investigaciones ha sido aplicado al aprendizaje motriz del habla también y forman la base de las ideas que se han incorporado al tratamiento apropiado de terapia del habla para los niños/as con AHI. Se necesitan más investigación específicamente en el AHI,  pero los expertos han usado los “Principios de Desarrollo Motor” como una base de conocimiento común acerca de cómo tratar el Apraxia del Habla Infantil.  Por ende, hay un número de características de terapia del habla que parecen ser más exitosas para ayudar a los niños/as con apraxia del habla, sin importar el nombre que tenga el método de tratamiento. Dichas características incluyen:

Práctica y repetición – con habla.

La terapia del habla para los niños/as con apraxia incluye un alto nivel de práctica y repetición. Las investigaciones muestras que la terapia para los niños/as con apraxia del habla es más efectiva cuando los objetivos del habla (palabras, frases) son practicados con un mayor grado de frecuencia e intensidad. Los niños/as en terapia del habla apropiada trataran de producir sílabas, palabras y frases  muchas, muchas veces durante cada sesión mientras el terapeuta del habla trabaja en moldear y dar forma a los intentos de habla y los movimientos subyacentes, para que el habla sea más clara y los movimientos más exactos.

A los padres y a las personas que cuidan al niño/a se les pedirá ayuda para que el niño/a practique en la vida real, por fuera de terapia del habla. La intensidad (practicar mucho) y la frecuencia (practicar muy a menudo) son los conceptos claves en el aprendizaje motor del habla. Es por esta razón, especialmente en la fase inicial del tratamiento, que los niños/as con apraxia del habla deben recibir terapia individual. Aunque que la terapia en grupo puede ser apropiada cuando se da sumada a la terapia individual frecuente, los niños con AHI que tienen poca habla o cuya habla es muy ininteligible, tienden a no desarrollar todo su potencial y alcanzar los objetivos de los que serían capaces si se les da solo terapia en grupo.

[Nota especial: De acuerdo con las investigaciones actuales, dedica tiempo valioso de terapia a movimientos orales pero no del habla (por ejemplo, soplar burbujas, lamer mantequilla de maní, movimientos linguales, etc.) no es considerado como un enfoque efectivo para el tratamiento que mejore la producción del habla. Dichas prácticas han estado bajo escrutinio en el campo de la terapia del habla y el lenguaje durante algún tiempo. Aun cuando no existen investigaciones que apoyen dichos procedimientos, muchos profesionales creen que dichas actividades pueden llevar a mejorar el habla o que estas se deben usar antes de que el niño o la niña trate de practicar el habla y por esto usan las actividades orales sin que haya datos publicados de investigaciones que soporten su uso.]

Uso de Claves

La terapia apropiada para los niños/as con apraxia usualmente incluye el uso de mayor información sensorial para ayudar en el control de las secuencias de movimientos del habla. Por lo tanto,  las claves / ayudas visuales, verbales y táctiles son usadas en la terapia que es apropiada para la terapia del habla en niños/as con AHI. Las claves que el terapeuta bringa son diferentes tipos de “recordatorios” acerca de lo que su niño/a debe de hacer cuando esté tratando de decir una palabra o una frase. Por ejemplo, el terapista se toca la parte superior de su garganta cuando el primer sonido de la palabra que el niño/a va a tratar de decir es un sonido que se produce en la parte de atrás de la boca (como los sonidos /k/ y /g/). El niño/a ve donde el terapista esta señalando y esto dispara una memoria sobre la posición de su lengua en la parte posterior de la boca. El niño/a está recibiendo una “clave visual” acerca de donde se está produciendo este objetivo de habla. Ver al terapista señalándose la garganta le recordará al niño/a como empezar el movimiento para una palabra en articular. Otro ejemplo, es cuando el terapista delicadamente pone un poco de presión en los labios del niño/a para generar un contacto de los dos labios cuando el niño/a  intenta producir una palabra objetivo que contiene un sonido “labial” (los sonidos que se producen con los labios se llaman sonidos bilabiales e incluyen /m/, /b/, y /p/). El sentir el contacto de los labios juntos y la presión ayudan al niño/a a saber cómo empezar a producir un sonido labial. Este es un ejemplo de una clave “táctil”. Hay muchos ejemplos de claves que aprovechan y usan la vista, el tacto y de la comprensión para asistir al niño/a en lograr los movimientos necesarios para el habla.

Mientras que el fonoaudiólogo o terapeuta del habla experto utiliza claves en la terapia para los niños/as con AHI, ellos también tienen en cuanta que con el tiempo las claves deben de ir disminuyendo hasta que sean eliminadas pro completo lo antes posible. Un niño/a que es capaz de producir su potencial de habla solo cuando alguien le proporciona claves no está adquiriendo independencia. Su fonoaudiólogo / terapeuta del habla no querrá que su niño/a dependa excesivamente en las claves. El terapeuta querrá  ver que el sistema de procesamiento del habla de su niño/a está empezando a  trabajar en vez de depender de otros para ayudarle. El proceso de “minimización o desvanecimiento” es también individual y ocurre con el tiempo.

Feedback o Retroalimentación.

El terapeuta de su niño/a pensará cuidadosamente y hará énfasis en cómo decirle a su niño/a si sus intentos de habla son exactos o correctos o si por lo contrario no lo son.  El terapeuta del habla también  balanceara con cautela cuanta ayuda le dará al niño/ a para guiarle en la producción de sus intentos de habla y además cuando  le proporcionarán feedback o retroalimentación a su niño/a acerca con respecto a su intento de producción de habla. Por ejemplo, el terapeuta del habla puede decir alfo como “Necesitas apretar tus labios juntos antes de empezar. Muéstrame tus ‘labios apretados’.”  Este tipo de información, acerca de la forma específica en que su niño o niña está formando sonidos y silabas y como corregir en forma específica la producción se conoce como “conocimiento de desempeño”. Otro tipo de retroalimentación se conoce como “conocimiento del resultado”. En el conocimiento de resultados el terapeuta dice algo como “Bien” o “Casi” después de que su niño/a luego de que su niño/a  produce un objetivo de habla.  La retroalimentación de resultados se enfoca en la información general con referencia a su niño/a fue o no fue exitoso en la producción de su palabra o frase objetivo. Los terapeutas del habla con experiencia en el tratamiento de apraxia pensaran con mucho cuidado:

  • ¿Cuánta retroalimentación brindarán?
  • ¿Qué clase de retroalimentación?
  • ¿Cuándo se debe dar la retroalimentación?

Generalmente hablando, los niños/as  que inician terapia del habla y/o aquellos con casos severos de AHI necesitan más retroalimentación inmediata y especifica acerca de los movimientos para la producción del habla que los niños/as que han mejorado en su habilidad de producir habla inteligible. Algo de investigación se han empezado a dar para que podamos comprender mejor el rol de la retroalimentación en el tratamiento de los niños/as con AHI.

Uso de ritmo.

El uso de ritmo puede ayudar a controlar el flujo del habla y a ayudar con la naturalidad de la entonación, con los patrones de acentuación de las palabras y las silabas – las cuales son particularmente problemáticos para los niños/as con apraxia. El ritmo, la entonación y el acento en el habla se conocen como la prosodia. Ejemplos del uso del ritmo en la terapia del habla para los niños/as con apraxia pueden ser aplaudir o golpear para marcar cada silaba o aplaudir más fuerte cuando se produce una silaba que debe ser acentuada en una palabra.

Enfoque en la secuencias del movimiento de habla.

Mientras que algunos niños/as con apraxia del habla necesitan ayuda para expandir el numero individual de sonidos que son capaces de producir, el principal “trabajo” y la práctica de estos niños/as se enfoca en el movimiento del habla que ocurre de sonido a sonido, sílaba a sílaba y / palabra a palabra.  Recuerde que el habla es una serie de movimientos rápidos y altamente refinados y los niños/as con apraxia del habla tienen dificultades con la planeación y programación de los movimientos específicos subyacentes a la producción del habla. Los profesionales que tienen mucha experiencia con AHI defienden el que los objetivos del habla (palabras, frases) deben ser funcionales para el niño/a. ¡Esto significa que las palabras deben ser útiles, prácticas y algo que el niño/a realmente quiera decir! Por ejemplo, las palabras “hola” y “chao / adiós” son muy útiles (funcionales) para los niños/as muy comprometidos con AHI. En la vida diaria, a todos los niños/as se les insiste en que saluden “¡Di hi!” o “¡Despídete, di bye, bye!” En ingles, estas palabras son de una sola silaba y no contienen consonantes al final delas palabras por lo cual el pronunciarlas es más fácil que producir palabras con más de una sílaba o palabras que contienen consonantes al final.

La terapeuta del habla de su niño/a debe pensar muy buen cuales van a ser los objetivos de habla que son apropiados para su niño/a. Él o ella cuidadosamente pensará en cuidadosamente en todas las consonantes y vocales que su niño/a puede producir (aun aquellas que en ese momentos no sean perfectas pero que su niño/a produce algo bien). El terapeuta del habla también considerará cuales son los tipos de sílabas que su niño/a puede producir (Los tipos de silaba son diferentes formas y dependen de la combinación de las vocales y las consonantes para la formación de las sílabas; por ejemplo, Consonante-Vocal (CV), Vocal-Consonante (VC), Consonante Vocal Consonante (CVC), and así sucesivamente). El terapeuta del habla  pensara acerca de las palabras y también le pedirá a usted cuales palabras usted cree que su niño/a disfrutaría el tratar de decir o cuales él o ella necesita decir con bastante frecuencia. Luego, el terapeuta del habla creará una lista corta de palabras útiles (alias: funcionales) que su niño/a podría razonablemente practicar con ayuda, dado su nivel de apraxia y del “inventario” de sonidos y de los tipos de sílabas que pueda producir.

Mientras que algunos niños/as necesitan aprender sonidos aislados uno por uno, los terapeutas de habla expertos no se enfocan exclusivamente en la producción de sonidos individuales en el tratamiento de los niños/as con apraxia ni tampoco hacen que la mayor parte de la terapia consista en la práctica de sonidos individuales. En cambio, ellos incorporan los sonidos que se deben enseñar en palabras cortas y funcionales que se vuelven los objetivos de terapia y en la casa. ¡Los terapeutas con experiencia en apraxia, no “esperan” a que los sonidos que el niño producen sean perfectos antes de pasar a palabras o a sonidos nuevos!  La terapia del habla es como una forma de arte. El terapeuta cuidadosamente ayudará a su hijo/a a construir sílabas, palabras y frases más complejas y las practicará implacablemente, las guiará y moldeará para que se acerquen con mayor y mayor precisión las palabras y frases objetivo y “retrocederá / dará marcha atrás” para enseñar sonidos nuevos o perfeccionar los sonidos en proceso.

Enfoque en la secuencias del movimiento de habla

Muchos niños/as con apraxia del habla se han sentido derrotados por las dificultades que ellos experimentan cuando tratan de hablar. Un gran número mayor de niños/as han recibido terapia del habla que realmente no los ha ayudado a hablar o a comunicarse. Muchos padres y terapistas reportan en forma anecdótica que los niños/as con AHI están profundamente al tanto de lo difícil que el “hablar” es para ellos/as. Y, ciertamente, algunos niños comunican sin palabras que “boca rota” o que “la boca no les sirve o les funciona.”

Es muy importante que los terapeutas del habla que trabajen con hijo/a se enfoquen inmediatamente en como pueden ayudar a su niño/a tener éxito rápidamente en terapia. Un niño/a con apraxia puede dejar de tomar riesgos con su habla, anticipando la dificultad  y el fracaso que han tenido en intentos anteriores al hablar o en terapia del habla anterior. Mediante la planeación cuidadosa de los objetivos de terapia a practicar y la estructuración de terapia para lograr que el niño/a sea exitoso, los niños/as con apraxia pueden llegar a confiar en el terapeuta del habla y  en el proceso de terapia, aumentan la confianza y seguridad en sí mismos y comienzan el importante y duro trabajo por venir.

Igualmente, es importante para su niño/a que experimenten el éxito con sus intentos de habla en casa. ¡Los padres frecuentemente están ansiosos de hacer algo! Ellos frecuentemente preguntan, “¿Qué puedo hacer en casa?” ¡Los padres y otros guardianes son definitivamente una parte importante de la travesía para mejor el habla del niño/a! Especialmente para los niños/as con apraxia, la participación de los padres es crucial.  Dicho lo anterior, un terapeuta del lenguaje y el habla con experiencia y que haya tenido éxito con niños/as que tienen apraxia del habla servirá como guía y como instructor para darles herramientas para ayudarlos en casa de la mejor manera. Ellos quieren asegurarse, en la medida que les sea posible, que nada va a “amargar” a su niño/a en los que refiere a la práctica del habla. El éxito produce éxito. Entre mayor confianza el niño/a gane al tomar riesgos al hablar o hacer intentos de habla, mayor será el beneficio que tendrá de la terapia del habla.

¿Será que mi hijo/a con Apraxia del Habla Infantil (AHI) llegará a hablar normalmente?

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La pregunta contenida en el título de este artículo, que se relaciona con el pronóstico y los logros a largo plazo, es una que casi todos los padres se hacen a sí mismos y a los profesionales en algún momento después de su hijo/a recibe el diagnóstico de Apraxia del Habla Infantil (AHI). Esta pregunta puede surgir durante la evaluación inicial del niño/a o más adelante durante el tratamiento. Es una pregunta importante que requiere consideración tanto por parte de los padres como para las fonoaudiólogas/ patólogas del lenguaje y el habla involucradas en el caso. Desafortunadamente, no hay investigaciones publicadas hasta la fecha que específicamente nos den repuesta a esta esta pregunta. Por ende, la repuesta, en el mayor de los casos, será una suposición educada basada en los síntomas particulares del niño/a y la experiencia clínica de la patóloga del lenguaje en el diagnóstico y tratamiento del AHI.

Muchos niños/as con AHI llegan a desarrollar un habla normal pero algunos no. Puede ser difícil predecir cuales niños/as probablemente desarrollarán habla normal antes o en la adultez y en cuales casos es poco probable que los niños/as  lo hagan. Hay indicadores que la patóloga de lenguaje puede utilizar para distinguir estos dos grupos. En mi experiencia, la mayoría de los indicadores importantes son específicos de cada caso y relacionados con factores internos y externos de cada niño/a. Estos factores incluyen la severidad del AHI, el progreso inicial del niño/a cuando empieza el tratamiento y la presencia y severidad de los síntomas co-ocurrentes. Los síntomas concomitantes que pueden afectar el pronóstico más significativamente, en mi experiencia, incluyen retrasos del lenguaje, impedimentos cognitivos, y el apraxia oral o de las extremidades. Aunque la interacción de estos desordenes con el AHÍ es desconocida, entre mayor sea la severidad de los síntomas concomitantes, mayor será el reto para que el niño/a pueda alcanzar a desarrollar habla como la de un adulto. Otros indicadores que son específicos a cada niño/a y requieren atención son la motivación del niño/a, el nivel de atención, la continuidad del progreso y el acceso a recibir servicios de terapia. Entre más favorables sean los factores anteriormente mencionados, más positivo será el pronóstico del niño/a.

Yo he trabajado con niños/as con AHI tanto en el área de investigación como en la práctica clínica por más de 20 años. Durante este tiempo, he visto niños/as con AHI cuya habla ha llegado a mejorar hasta llegar a un habla normal (o casi normal) con intervención. Aun niños/as con AHI moderada o severa pueden alcanzar  un nivel de habla normal con servicios de intervención apropiados y extensivos; sin embargo, he encontrado que el pronóstico más favorable para aquellos niños/as con menor cantidad y/o menor severidad de síntomas co-ocurrentes. Los niños/as  que presentan menos síntomas concomitantes y/o cuyos síntomas co-mórbidos son de menor severidad, tienden a progresar hasta desarrollar habla normal antes o en la adolescencia cuando se les brinda terapia del habla suficiente y apropiada, aun cuando el apraxia del habla (AHI) fuera más severa en el momento del diagnóstico. Después de darles de alta  de terapia, uno puede notar errores sutiles en la articulación cuando el adolescente está cansado o estresado; de otra manera, el habla permanece bien articulada e inteligible para el oyente.

También hay otros niños/as con AHI severa o moderada cuyo pronóstico para lograr habla normal en el transcurso de su desarrollo hasta llegar a la adultez es desfavorable. En mi experiencia, estos niños/as inicialmente presentan con múltiples y más severos síntomas co-ocurrentes. Estos niños/as frecuentemente continúan progresando en terapia del habla hasta la adolescencia y, aun cuando ellos/as no alcanzan a desarrollar habla completamente normal, ellos/as logran mejorar y el habla es a menudo su fuente primordial de comunicación. El discurso conexo (es decir la producción en frases largas y complejas de corrido) permanece con un reto constante, como también lo son la producción correcta de aspectos suprasegmentales del habla (la prosodia o melodía del habla, la acentuación, la velocidad del habla, etc.) Para la los niños/as que presentan mayor severidad en el diagnóstico, los sistemas de comunicación alternativa pueden ser usados en combinación con la producción del lenguaje oral para aumentar la capacidad de comunicación. El usar una combinación en las técnicas de comunicación puede ser de gran ayuda particularmente para los adolescentes / adultos jóvenes que se ven enfrentados a una gran diversidad de situaciones comunicativas.

En general, es importante recordar que los niños/as con AHI pueden mejorar y progresar con el tratamiento de terapia del habla. El pronóstico en lo que se refiere al desarrollo de habla normal depende de una variedad de factores; muchos de estos factores son específicos para cada niño/a y están sujetos a cambiar con el tiempo. ¡Continúe creyendo en la habilidad que tienen los niños/as de progresar y trate de celebrar cada logro ya que es un paso positivo en el camino!

Qué causa el Apraxia del Habla Infantil (AHI) y Se puede prevenir?

Primero, es importante para los padres que entiendan que es muy probable que ustedes no hayan hecho nada para “causarle” a su hijo/a  una discapacidad en el habla. No se trata de cuanto le hablaron a su hijo/a o de si los pusieron en una guardería infantil, por ejemplo. Su hijo/a no tiene apraxia porque usted se separó de su esposo/a o por haberse mudado a una ciudad nueva. Mientras conocemos el rol tan importante que cumplen los padres en el desarrollo de un niño saludable, al menos que hubiera algún tipo de abuso, negligencia o aislamiento, usted no es el directamente responsable de la causa de que su hijo/a tengo un problema del habla.

Actualmente sabemos que el apraxia del habla infantil (AHI)  ocurre en las siguiente condiciones:

  • Impedimentos neurológicos causados por infección, enfermedades o accidentes antes o después del nacimiento o por anomalías aleatorias o fallas en el desarrollo fetal. Esta categoría incluye a los niños/as con resultados son positivos a nivel cerebral en el IRM (Imagen por Resonancia Magnética).
  • Desórdenes complejos en el desarrollo neurológico. Sabemos que el apraxia del habla infantil (AHI) puede ocurrir como una característica secundaria de otras condiciones como son condiciones de origen genético, metabólico  y/o trastornos mitocondriales. En esta categoría estaría el apraxia del habla infantil (AHI) concomitante con Autismo, Frágil X, Galactosemia, algunas formas de Epilepsia y translocaciones cromosómicas que involucran duplicaciones y supresiones cromosómicas.
  • Desorden Idiopático del Habla (un desorden de “causa desconocida”) – con esta condición, actualmente no sabemos “porque” el niño/a tiene AHI. Los niños/as no tienen anomalías neurológicas observables u otras condiciones del neurodesarrollo fácilmente observables.


Los padres frecuentemente preguntan si sus hijos tienen Apraxia del Habla debido a complicaciones médicas durante el embarazo o el parto. En la actualidad no existen estudios que indiquen una relación directa entre las complicaciones durante el embarazo o el parto y un aumento específico en el riesgo de tener apraxia del habla. Por ejemplo, un cordón umbilical enredado en el cuello de un feto puede, en teoría, cortar el flujo de oxígeno y posiblemente llevar a un daño neurológico, resultando eventualmente en el diagnóstico de AHI. Sin embargo, dicha condición puede NO resultar en AHÍ o incluso en una lesión neurológica. Algunos niños nacen sanos aun cuando haya habido una complicación durante el embarazo o el parto. Mientras que es posible que una complicación pueda resultar en un daño neurológico que contribuya a un desorden motor del habla como AHI, las investigaciones no nos han dicho como o cuando esto sucede. Algunos especulan que algunas formas de AHI y otras condiciones que  se dan durante la infancia pueden darse, en parte, debido a condiciones ambientales como la exposición a toxinas y/ o contaminantes antes o después del nacimiento. Otros especulan que déficits en la nutrición o malabsorciones pueden causar AHI. Sabemos que, por lo general, las toxinas y los déficits nutricionales causan algunos problemas en el desarrollo pero, hasta el momento, estas teorías en lo que se relaciona específicamente con AHI son solo especulaciones.

Dicho esto, la buena salud de un niño puede contribuir con su habilidad de  beneficiarse de la exposición a oportunidades de aprendizaje y de terapia que este diseñada para ayudarles. Un que esté saludable es más capaz de tomar ventaja de las oportunidades de aprender. Los niños que se enferman frecuentemente con infecciones de oído o sinusitis, amigadlas o adenoides  inflamadas, asma, alergias o que tienen desórdenes del sueño, dietas pobres, dificultades se atención o problemas de comportamiento, van a tener mucha mayor dificultad de beneficiarse de la ayuda que les es brindada. Ayudar a su niño a estar saludable y por ende más “presente” durante las oportunidades de aprendizaje que le rodean, es una forma en que los padres pueden ayudar.

Muy probablemente en el futuro aprenderemos que el AHI es causado por múltiples factores y condiciones, no una sola. En la medida en que la evidencia de las investigaciones demuestre que el AHI es causada por algunos factores que puedan ser manipulados para reducirlos o eliminarlos se determinará si el AHI es o no es prevenible. Hasta que llegue ese momento, lo que si conocemos es que la terapia del habla proveída frecuentemente y teniendo en cuenta los principios del tratamiento motor de habla ofrece la oportunidad de mayor impacto e importancia para que los niños con AHI mejoren su habilidades a nivel de articulación y habla. Los niños que puedan mantener un nivel de salud óptima muy probablemente se beneficiaran directamente cuando se les brinda la ayuda adecuada.