By: Margaret A. Fish, M.S., CCC-SLP

Editor’s Note:  PediaStaff would like to thank CASANA/Apraxia-Kids for introducing us to this wonderful CAS expert!
Young children with suspected childhood apraxia of speech (CAS) and children with very severe CAS present unique challenges to speech-language pathologists. When children begin to develop some volitional control over the production of syllables, the speech-language pathologist can help to shape increasingly complex speech movement sequences and support the child’s acquisition of a complete phonemic repertoire. For children who do not imitate speech reliably, however, other treatment strategies need to be utilized. Following are several strategies to support the development of more reliable volitional imitation and early speech in children who are nonverbal or minimally verbal.
Support Attainment of the Precursors of Motor Learning
The lack of speech imitation in children past the age of two years creates a great deal of anxiety for parents and caregivers. We as SLPs want to see those first words emerge, too; however, when children have not developed precursors to motor learning (Strand & Skinder, 1999), including (a) trust and motivation; (b) focused attention and effort; (c) an understanding that the goal of treatment is the practice of movement, and (d) an understanding of the tasks at hand, our efforts to elicit speech imitation may be futile. This does not mean that children need to be able to sit quietly and attentively in a chair for a period of several minutes before attempts to elicit speech are introduced. It does mean that the SLP needs to be sensitive to where the child is developmentally, and work to support the child’s focus, attention, direction following, simple imitation, and motivation to try challenging things. Speech therapy becomes much more productive if time is taken earlier on and throughout the treatment process to facilitate these precursors to motor learning.
Reinforce Vocalizations and Oral Movements
Before children begin to imitate vocalizations, they vocalize by cooing and babbling. It is important to provide positive reinforcement for children’s vocal productions, even when these productions are not volitional or imitative. Telling a child, “I love all those lip sounds you’re making!” may lead to an increase in babbling, and these sounds gradually can be shaped into volitionally produced, meaningful words.
Attach Meaning to Vocalizations
When we attach a meaning to a child’s sound productions, we help the child learn that their verbal behavior elicits certain responses. The child who says, “ma,” in the context of playing with a ball may be babbling, or may be trying to say, “ball” or “more.” By treating the vocalization as a meaningful word, the therapist links the child’s speech with a favorable response of receiving a desired toy. We can respond to the child’s production by enthusiastically saying, “Oh, you want the ball. Here you go!” thereby increasing the likelihood that the child will produce the same utterance again in hope of a similar response. Teaching parents and caregivers to begin to recognize their child’s sounds as meaningful is equally important to the therapy process.
Talk About Speech Movements
Children need to understand that the purpose of their therapy visits is to work on movement and sounds. When children stick out their tongues, talk about it; bring it to their attention and make movement and sound become the forefront of the sessions. Comments by the parents and clinician, such as, “Wow, I see your tongue,” “I love to hear all your noisy sounds,” or “I see you smacking your lips. You’re a great lip smacker,” help the child to recognize the importance of sounds and oral movement. Bringing movement to the forefront helps set the stage for what the speech therapy is all about, thus supporting attempts at further speech movements.
Facilitate Imitation
Prior to speech imitation readiness, children need to develop other types of motor imitation skills. When children engage in back and forth imitation, they are learning the important skill of “you do what I do,” an essential skill in the process of speech praxis treatment. Rather than pushing imitation of sounds and words, determine what types of movements the child is able to imitate and work from there. Refinement of imitation is a gradual process, and can be facilitated by beginning with whole body movement (rocking back and forth), imitation of actions during play (banging a drum, stacking blocks), smaller movement imitation (clapping, wiggling fingers, shaking head), imitation of oral/facial movements (sticking out tongue, smacking lips), vocal imitation (basic sound and syllable play), and, finally, imitation of true words. Although parents may be eager for their children to begin saying real words, it is important to help them understand the importance of developing a strong base of imitation prior to asking the child to say words, and to have them engage in these types of imitation routines at home.
If the child does not readily imitate body or vocal movements, one way to get the imitation turn-taking routine going is to imitate what the child is doing. When the child bangs on a table, makes tongue-clicking sounds, or vocalizes a neutral vowel, the therapist and parent can match the movement or sound, usually to the delight of the child. After the turn-taking routine is established with the child in the lead, the therapist or parent can change it by doing something a little different. If the child is banging on the floor, the therapist may bang on a chair instead. If the child is making tongue clicks, the therapist may, instead, make lip-smacking sounds. Praising the child for these imitative attempts is equally important to support the establishment of purposeful, volitional imitation skills upon which speech praxis treatment is based.
Use Toys That Reinforce Early Sound Effects and Simple Exclamations
Prior to the development of “true words,” children typically produce silly sounds and sounds effects, such as coughing, grunting, chewing noises, raspberries, and snoring. Animal and vehicle noises also are among the sounds children master in the context of play and book reading. Encourage production of these sounds by incorporating toys and activities that elicit these sounds. Toy animals, animal puzzles, vehicles, foods, cooking gadgets, and building tools, all serve to elicit repetitive modeling of playful sounds that the child can be encouraged to imitate. Linking a movement to a sound offers an additional cueing mechanism for the child. For example, each time the buttons on the microwave are pushed when “making” playdough cookies, the therapist or parent can say, “beep, beep, beep.”
Pause with Expectation
For children who are quite delayed in babbling and sound imitation, lack of vocal responsiveness becomes an expectation. After children have begun to develop some ability to imitate some vocalizations, a shift should occur on the part of the therapist and family that helps the child recognize that being passive during turn-taking routines is no longer the expected response. Pausing and looking at a child expectantly lets the child know that some response is expected. Offering positive reinforcement when the child takes the risk of making a vocal response further solidifies shared enjoyment in the turn-taking process, paving the road to continued effort and continued success.
It is beneficial to model the target sound effects and target words during therapy using a focused stimulation approach (Ellis Weismer & Robertson, 2006). During focused stimulation, the therapist or parent produces the target sound or word frequently and in a way that brings a heightened awareness of specific phonemes or sounds. Treatment targets can be emphasized by (a) pausing just before the target word is produced (e.g., “Here’s a … ball, and here’s another … ball … and here’s another …ball”); (b) increasing the duration of the vowel of the target word or prolonging a consonant (e.g., “Yummy banana. Mmmmmmm” or “The airplane is going higher. It goes uuuuup, uuuuup, uuuuup.”); and (c) securing the child’s visual attention prior to modeling the target word or sound. Using amplification tools, such as an echo microphone, Toobaloo®, or even a paper towel or wrapping paper roll, may help to focus the child’s attention and generate interest in repetition of sounds and words.
Reduce the Number of Target Utterances Per Session
Strand and Skinder (1999) recommend limiting the number of target utterances in the stimulus set introduced during a therapy session to no more than five or six utterances. In this way, blocked practice of a small number of treatment targets could be accomplished. This repetitive practice of a small number of targets supports the child’s ability to master new movement plans in the earlier stages of learning.
Use Tactile and Proprioceptive Input
Ayres (2005) suggests that many children with apraxia demonstrate reduced tactile and proprioceptive processing. By providing additional tactile and proprioceptive cues, the child’s ability to make sense of the somatosensory input is enhanced. PROMPT® treatment, described by Hayden (2008), incorporates specific tactile cues that offer the child a more salient way of sensing what a movement sequence should feel like, thus helping the child to connect the feeling of the movement gesture with the accompanying acoustic information. Strand and Skinder (1999) also recommend incorporating tactile cues as needed to support imitation when visual and verbal cues alone are not enough to help the child perform the targeted speech movements. In addition, body movements, gestures, and manual signs can be associated with speech movement gestures to create associations between speech movements and other movement cues.
Practice Skill Refinement
It is important to help children move from broad to more narrow distinctions between sounds. For children who do not reliably turn on their voice to produce sounds, praise will be provided when a child produces an undifferentiated vowel sound volitionally. As treatment progresses, purposeful movement of the lips or tongue will be facilitated, and then gradually building up to making distinctions between lip versus tongue sounds, nasals versus non-nasals, stops versus continuents, one versus two syllables, and voiced versus voiceless phonemes. Grading and differentiating of vowels based on tongue position (high/low/mid; front/central/back) and lip shape (open/round/retracted) also should be facilitated. These distinctions are gradual and take time, and children’s achievement of these motor speech skill refinements should be praised each step of the way.
Incorporate Music, and Books into Treatment
Music and carefully chosen books support attainment of speech in children with severe CAS, because they offer opportunities for repetitive practice of target utterances. Music also provides opportunities to practice varied and exaggerated intonation patterns, simple sound effects, and early developing sounds and words. Reduction of rate during songs offers the child the time to achieve initial articulatory configurations of target sounds and words. Making up little tunes with repetition of simple treatment target sounds and words to accompany the activities in the speech session can help to engage the child in the repetitive practice necessary for initial learning of treatment targets. Creation of simple, personalized books can support opportunities for repetitive practice of a simple sound effect or a small number of target utterances. For example, a book with pictures of people or things dropping, falling, and crashing, could be the perfect tool for practice of the exclamation, “uh oh.” Fish (2010) provides several book and song lists, including lists of books to target sound effects and early word production.
Provide Access to AAC
Children need a means of communication. When speech is slow in coming, the use of manual signs and gestures, low tech picture boards, and/or voice output communication devices will help support a child’s ability to express a wider range of ideas, and to establish greater social communication skills. Parents may need to be reassured that the verbal mode of communication will continue to be addressed, but that helping children find a way to establish positive communication patterns is very important for overall development.
References:
Ayres, A. J. (2005). Sensory integration and the child: Understanding hidden sensory challenges. Los Angeles, CA: Western Psychological Services.
Ellis Weismer, S., & Robertson, S. (2006). Focused stimulation approach to language intervention. In R. McCauley and M. Fey (Eds.), Treatment of language disorders in children (pp. 175-201). Baltimore, MD: Paul H. Brookes.
Fish, M. (2010). Here’s how to treat childhood apraxia of speech. San Diego, CA: Plural Publishing.
Hayden, D. A. (2008). P.R.O.M.P.T. prompts for restructuring oral muscular phonetic targets, introduction to technique: A manual (2^nd ed.). Santa Fe, NM: The PROMPT Institute.
Strand, E. A., & Skinder, A. (1999). Treatment of development apraxia of speech: Integral stimulation methods, In A. Caruso & E. Strand (Eds.), Clinical management of motor speech disorders in children (pp. 109-148). New York, NY: Thieme.
 
Featured Author: Margaret A. Fish, M.S., CCC-SLP
Margaret Fish is a speech-language pathologist working in private practice in Highland Park, Illinois. She has 30 years of clinical experience working with children with severe speech-sound disorders, language impairments, and social language challenges. Her primary professional interest is in the evaluation and treatment of children with childhood apraxia of speech (CAS). Margaret is the author of the recently released book, Here’s How to Treat Childhood Apraxia of Speech by Plural Publishing.  Her workshops and writing focus on providing practical, evidence-based evaluation and treatment ideas to support children with CAS.