Principles of Motor Learning for Treatment of Childhood Apraxia of Speech (CAS)
When learning about treatment for Childhood Apraxia of Speech (CAS), we hear that we need to use the principles of motor learning (PML), so what does that mean? These principles or processes are how we all learn new motor skills or plans. Speech is a motor skill that can improve using these principles. Treatment may be designed differently depending on the child (with differences in severity, attention and motivation ), but applying the PML will provide a roadmap to support and treat children with CAS.
When learning about treatment for Childhood Apraxia of Speech (CAS), we hear that we need to use the principles of motor learning (PML), so what does that mean? These principles or processes are how we all learn new motor skills or plans.
Speech is a motor skill that can improve using these principles.
Treatment may be designed differently depending on the child (with differences in severity, attention and motivation ), but applying the PML will provide a roadmap to support and treat children with CAS.
Following is a guide for using principles of motor learning that I use when I treat children with CAS (based on research):
1) PRACTICE, PRACTICE, PRACTICE:
Imagine learning to swim. You didn't jump in the water and swim right away, you had to practice moving your body in different ways to float and stay afloat, then to move forward, all the while breathing at the same time. The same goes for children with CAS. Regular practice is the most important aspect for generalization of speech production.
It's all about getting enough practice trials per session to make the motor speech movements second nature and automatic. But remember, quality matters as much as quantity. Be attentive to the child's response, and adjust cues accordingly. As they progress, you can gradually fade those cues.
2) MASSED PRACTICE VS. DISTRIBUTED PRACTICE:
Think of this as the difference between cramming for an exam and studying consistently over time. For CAS, research suggests that frequent, shorter sessions spread out over time are more effective for progress and generalization.
Starting with massed practice (practicing all at once- think one session weekly for a longer time period) to build a strong foundation, then transitioning to distributed practice (therapy spread out across sessions- think 4, half hour sessions weekly). I know sometimes we don't have the luxury of changing a schedule like that in schools- but see principle number 3 for ways to change up practice within time constraints.
3) BLOCKED VS. RANDOM PRACTICE:
Blocked practice is practicing one target extensively before moving on, then later randomizing practice by mixing several targets together. An example is initially you might choose 5 words including bilabials plus vowels (like poo, ba, me, ma, and pee) and focus on those only. As the child improves, you can randomize the targets for example adding a vowel consonant productions in (i.e. “up, oop, um”)
The severity of CAS can be your guide here. For severe cases, more blocked practice might be necessary, but you can modify it by mixing targets within blocks. This variation allows you to get more repetitions of target movements within each blocked practice.
4) VARY CONTEXTS AND PROSODY
Facilitate practice in different contexts. Vary the types of consonants or vowels and the positions that they are in . For example, change the initial set, going from CV (consonant-vowel) to CVC (consonant-vowel-consonant). Increase complexity of movements as the child gains the accurate motor movement sequences.
Experiment with prosody, loudness, and emotional intonation. This variability engages different muscles, enhancing motor planning processing and efficiency – our ultimate goal.
5) FEEDBACK MUST BE EVER-CHANGING
Feedback is dynamic throughout a child’s therapy program. Feedback can be intrinsic (what the child perceives) or extrinsic (what we provide for the child). Extrinsic feedback can be knowledge of results (was that right or wrong) or knowledge of performance (specific guidance on what specifically needs improvement).
Initially, provide more feedback to guide the child, but gradually fade it as they become more accurate and independent in their speech movements. We don’t want too much support for too long otherwise the child could become dependent on the supports. We want to fade supports so children know how to produce the movements independently.
Often the type of feedback can change depending on the target and the accuracy of that target.
Using the Principles of Motor Learning:
Using the Principles of Motor Learning is like having roadmap in the world of CAS therapy. These principles guide speech therapy leading our children toward improved communication skills. So, practice often and adapt to the child's needs whether it be with feedback, type of practice or contexts.
Visual Speech Sound Cues
Cueing in speech therapy can really make a huge difference in the speed of progression!
Cues in speech sound therapy (articulation, phonology and childhood apraxia of speech) are important to provide assistance with accurate speech sound production.
Cues can include:
1) Visual (pictures and hand cues)
2) Auditory (Verbal Model)
3) Tactile (touching)
I use all three of these cues together to optimize the time have in therapy with my students. I usually begin with visual speech sound cue cards that represent the consonant or vowel sound that the child is working on. These sounds each have a name and a “hand cue” to go with it. For example the /p/ sound can be called the “Popcorn Sound” and I use an open hand a the the lips and push it away from my lips when I say /p/.
The Popcorn Sound
By providing the child with the auditory model paired with the movement of the hand cue and the visual picture the child is more likely to make an association with the correct way to make the sound!
Visual picture cues paired with the auditory model can be incorporated into classroom reading programs, drill articulation work and play-based therapy. The visual cues are environmental sounds that the child is familiar with (like the /k/ sound for “coughing” or the /sh/ sound as the “quiet” sound).
Speech Sound Cue Cards
The /k/ or the “Coughing Sound” and the /sh/ or the “quiet sound” with descriptions of hand cues.
The Speech Sound Cue cards work well with children exhibiting Childhood Apraxia of Speech CAS). A motor based approach for CAS is critical for facilitating motor planning and sequenced motor movements with combined sounds. Pairing a consonant with a vowel card (i.e. the “quiet sound” /sh/ with the vowel sound /u/ as in “shoe”) and modeling the motor sequence helps the child make that neural connection. Moving your finger (or the child’s finger) from the consonant to the vowel cue card incorporates the fluid movement intended for the sound sequence.
Children with CAS many times exhibit vowel distortions where the hand cues imitating the lip and jaw shapes can assist with the correct vowel movements.
Children with Phonological Processing Disorders (or when a child makes a predictable patterns of speech sound errors) also benefit from therapy using speech sound cue cards. For example, if a child is working on “Fronting” (producing velar sounds in the front of the mouth), the velar speech sound cue cards can be used together to target the /k/ and /g/ sounds. Often I target several words in play-based therapy for children with phonological processing disorders and have the speech sound cue cards in the vicinity of the toys we are using to refer to when the child’s target word comes up.
For easy storage of the cue cards, I punch a hole in the corner of each card and put them on a circular ring binder clip. The target sounds can be easily removed for use in therapy. I’m always on the go, so this storage method works for me. I’ve also seen therapists store the cards in a binder in baseball card plastic pockets for easy access.
The Speech sound cue cards can also be utilized as a tool for emerging literacy, early acquisition of speech and for traditional articulation therapy
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Animals shoving and pushing each other targeting the phonological process of “Stopping”.