Treatment of Childhood Apraxia of Speech
Childhood Apraxia of Speech (CAS) is a speech disorder that affects a child's ability to plan and execute the precise movements required for clear speech. Treatment differs from other speech sound disorders in that the focus must be on the motor speech movement and not on individual sounds. Treatment should be multi-sensory and targets should be selected based on the child’s interests and needs.
About 15 years ago, I got my first case of Childhood Apraxia of Speech (CAS) that was diagnosed by a developmental pediatrician as “verbal dyspraxia”. From that moment, I did some big digging into what CAS really is. Since then, I have had many children that I have worked with with CAS (most whom I diagnosed) and although complex, I really love working with kids with CAS because of the difference I can make! Kids with CAS are close to my heart and I want you to feel as comfortable as I do know with techniques for treatment. Understanding it better can help us make a significant impact on the lives of our young clients.
I recently took a refresher course by Alonna Bondar that I would highly recommend if you need more information on CAS, choosing targets and applying treatment techniques. There are also some videos on YouTube by Edyth Strand that provide some really practical therapy and treatment information!
1) What is Childhood Apraxia of Speech?
CAS is a speech disorder that affects a child's ability to plan and execute the precise movements required for clear speech. It's like the brain and mouth are not on the same page when it comes to talking. Unlike other speech sound disorders, CAS isn't caused by muscle weakness or muscle coordination problems but rather by neurological issues that disrupt the planning process.
2) How CAS Differs from Other Speech Sound Disorders
Unlike phonological disorders or articulation disorders, CAS is not about substituting one sound for another. It's about the brain struggling to coordinate all the movements required to produce the planning of speech sounds and combinations of sounds. CAS can sometimes be mistaken for other speech sound disorders like phonological disorders or articulation disorders. The key difference lies in the motor planning aspect. In CAS, the child knows what they want to say, but their brain has trouble coordinating the precise movements necessary for speech. This makes CAS unique and requires a different approach in therapy (see the earlier Blog Post: Principles of Motor Learning in CAS).
3) Early Signs of Apraxia of Speech
Limited babbling before 12 months
5 or less consonants between 17-24 months
Limited vocalizations
Simple syllable shapes (vowel or consonant-vowel only)
Late or difficult development of first words
Words that appear then disappear
(Bondar 2023, Bjorem Speech Informal Motor Speech Assessment 2020, Davis and Velleman 2000)
4)What characteristics distinguish Childhood apraxia of speech from other speech sound disorders?
Awkward transition from one sound and/or one syllable to another
Groping behavior while attempting word or sound production
Vowel Distortions
Errors with prosody (stress, loudness, intonation, pitch and rhythm
Inconsistent voicing errors
Inconsistency of word or phrase production over repeated trials
Struggling with longer and more complex words
Inconsistent errors when trying to repeat words
(ASHA 2007, Strand 2020, Bondar 2023)
5) How do we know a child is ready for CAS Treatment?
Does the child have an internet to communicate? Are they using some type of communication to make wants and needs known (i.e. pointing, grunting, pulling the hand of a caregiver)
Is the child able to focus on an activity (i.e focus on a favorite toy).
Can the child imitate motor movements (i.e opening their mouth, pursing their lips)
Is the child able to request items with gestures like pointing or reaching?
Will the child look at an object near your face?
6) Techniques for Children with CAS
Let’s get to the fun part! Treatment! When working with kids who have CAS, we've got to be creative and choose the approach and feedback that best fits the individual child. Whatever treatment approach is used the key is working on MOTOR MOVEMENT. Multisensory approaches work well for children with CAS. Here are a few techniques that have worked for me (and many others based on the research!) this is not ALL of the treatment procedures, I am highlighting some that proven to be successful for my students:
DTTC (Dynamic Temporal and Tactile Cueing):
This is a dynamic approach that combines touch and sound cues. It helps kids improve speech motor planning by guiding them through the correct movements.
With DTTC, there is a specific hierarchy and cueing methodology to facilitate the acquisition and generalization of movement accuracy for speech. It is structured to slowly lengthen the amount of time between the clinician’s production of a motor movement and the child’s production of the word or motor movement. Initially the child says the word at the same time with the clinician, then the child voices the word while the clinician only produces the mouth shapes of the word and later is cued to say the word with no cues.
DTTC is designed for children with more severe CAS and is not intended for long-term use.
For more detailed information regarding the DTTC hierarchy please see the references below
(https://www.bjoremspeech.com/collections/free-resources/products/dttc-hierarchy-flow-chart-for-apraxia-therapy, American Journal of Speech-Language Pathology, Strand, Edyth, Vol. 29, 30–48 • February 2020, Apraxia Course, Bondar, Alonna 2023)
Speech Sound Cue Cards:
Visual aids can be a game-changer! Using cue cards with pictures and written prompts can help children understand and produce specific sounds. You can find the speech sound cue cards that I developed for my students with CAS that provide visual (pictorial and hand cues), and auditory cues to aid in motor movement.
Using cue cards with pictures and written prompts can help children understand and produce specific sounds. Using a finger or pointer or marker on a wipe board to move from one sound cue card to another showing the child movement while elongating the sound (if possible) works well for a visual representation.
Promote Functional Communication:
Encourage children to communicate using signs, gestures, or alternative communication methods while working on speech goals. This helps reduce frustration and builds their communication skills.
7) Appropriate Target Selection
Choosing the right targets is key for the child to feel successful in the therapy program. Initially, if a child has very little verbal productions, begin with sounds and sound effects such as animal sounds (“baa, moo, neigh"), sounds like a car sound or “beep” and “uhoh” or” eeekk”. These sounds are fun to produce and promote the child’s engagement. It is important to reinforce the child’s attempts at vocalizations and imitate their vocalizations and assign some meaning to them.
Start with functional verbal words that are relevant to the child's daily life and communication needs if the child is at this level. As progress is made, gradually work your way towards more complex sounds and words. Words like “on, up, pop, bye, ma, poo” are great powerful words for kids to start with, but what is meaningful to the child is the best way to choose the targets. Use words that are meaningful to that child such as favorite toys, family names, friends names and favorite foods.
Using games that have lots of pieces to them can provide many trials and motivation for CV, VC and CVC words like “out, in, up, pop, push, my, me and see”.(Games like Pop-up Pirate, Banana Blast and Jumpin’Jack are great for this!).
Remember, progress may be slow, and that's okay. Every small victory is a step in the right direction. Celebrate those wins, no matter how tiny they may seem! CAS is a unique and challenging speech disorder that requires a specialized approach. By understanding the nature of CAS, spotting it early, and using appropriate techniques, we can make a world of difference in the lives of our young clients.
For more information: (https://www.bjoremspeech.com/collections/free-resources/products/dttc-hierarchy-flow-chart-for-apraxia-therapy, American Journal of Speech-Language Pathology, Strand, Edyth, Vol. 29, 30–48 • February 2020, Apraxia Course, Bondar, Alonna 2023)
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.