By: Margaret A. Fish, M.S., CCC-SLP
Speech sound disorders, including articulation disorder, phonological disorder, dysarthria and childhood apraxia of speech (CAS), make up the bulk of caseloads of many speech-language pathologists. The incidence of childhood apraxia of speech, however, is relatively low, affecting approximately 3 – 5 percent of preschoolers with speech impairments (CASANA, 2005). It is not unusual for a speech-language pathologist to feel unprepared when presented with a child with known or suspected CAS. Many speech-language pathologists report that their graduate school instruction in identification and treatment of children with CAS was limited. In addition, treatment techniques that are effective for children with articulation or phonological disorders generally are not effective with children with CAS.
It is important to recognize that the core impairment for children with CAS is not the execution of speech movements (as seen in children with dysarthria) or in the ability to learn the phonological rules of a language (as seen in children with phonological disorder). The underlying challenges for children with CAS are in “planning and/or programming spatiotemporal parameters of movement sequences” (ASHA, 2007). When we consider the complexity of these spatiotemporal parameters, including muscle selection, direction, distance, and speed of articulatory movement, amount of force that is applied to the articulators, and degree of muscle contraction, it becomes more clear how an impairment in planning and programming articulatory movements can have such a significant impact on a child’s speech intelligibility and speech prosody, particularly stress and intonation of syllables and words.
Below are several principles to consider when designing and implementing treatment programs for children on your caseload with known or suspected CAS.
Reduce rate of production.
Rate reduction can have a significant impact on motor learning (Maas et al., 2008). By using a slower rate of production, the child is able to plan and program the articulatory movement sequences more accurately. After a motor plan for a target utterance is achieved at a reduced rate, a gradual increase in rate should be encouraged to support generalization.
Work on sequences of speech movements/coarticulation
Children with CAS struggle with planning and programming movement sequences. Therefore, treatment should focus on supporting the child’s ability to produce increasingly complex articulatory sequences, rather than individual phonemes. Begin at least at the syllable level; CV (no, hi) or VC (up, out). If these types of sequences are challenging, increase the amount of multisensory cueing and reduce the rate of production. Once established, begin to combine these simple syllables into two-word phrases and two-syllable words (e.g., CV.CV word “baby” or phrase “no way”) and then into increasingly complex word shapes and phrases.
Facilitate repetitive practice in early stages of learning
Repetitive practice of target utterances is essential in the early stages of learning for children to develop volitional control of speech movement sequences. Large numbers of practice trials help to establish new movement patterns. For children with severe CAS, Strand and Skinder (1999) recommend choosing a small number of target utterances per session to allow for a sufficient number of practice opportunities for each utterance. When the number of target utterances per session is limited to 3, 5 or 10, it is especially critical to be creative and find quick, but motivating activities that allow for as many repetitive practice opportunities as possible. After accurate production of a target utterance has been established, however, it is important to help children develop greater flexibility by shifting to a more random practice schedule. That is, rather than practicing the same utterance repetitively, the utterance is practiced among other target utterances randomly within the session.
Select target utterances carefully
Careful selection of target utterances is essential to successful treatment of CAS.

• Children with CAS typically need to establish a broader speech sound repertoire of both consonants and vowels, as well as to increase the complexity of speech movement sequences or word shapes. It would be too challenging, however, for a child to work on both a new phoneme and a new word shape simultaneously. Davis and Velleman (2000) recommend that when working on new phonemes, be sure to incorporate them into well-established word shapes. On the flip side, when working to develop a more complex word shape, choose targets with well-established phonemes.
• It is important to select functional utterances rather than simply looking through a set of word cards containing the target phonemes or target word shapes. Choose utterances that are socially and cognitively appropriate for the individual child. Consider the child’s favorite foods, toys and activities, important persons within the child’s home and school, and utterances that will support the use of a wide range of communicative functions (e.g., requesting, protesting, greeting, rejecting, asking questions, asserting oneself).
• Premade picture sets and articulation books and games tend to include an over-representation of nouns. Support expressive language development by establishing target vocabulary that represents different parts of speech (nouns, verbs, adjectives, adverbs, prepositions, interjections, etc) to increase opportunities for establishing early phrase and sentence production.

Use multisensory cues
Provide multisensory cues (visual, auditory, tactile/kinesthetic/proprioceptive, cognitive) to help children establish accurate production of target utterances. After the child has developed greater volitional control of a target utterance, however, gradually begin to fade the cues to support the child’s ability to produce the utterance spontaneously.
Address speech prosody right from the start
It is important to address prosody early on and throughout the process of treatment. When prosody is not addressed, a child’s speech may sound robotic. Encourage natural sounding speech by helping children to recognize and accurately produce stress on the correct syllable(s) of words and the appropriate word(s) within sentences. Stress changes are produced by changing the loudness, pitch and duration of the stressed syllable of the word or word within the sentence. Children may be able to recognize and imitate the increased duration component that leads to recognizable changes in stress and attempt to achieve this through visual, cognitive, and auditory cues.
Work on those vowels
Treatment should address vowel accuracy and help children to establish a complete vowel inventory. It is not unusual for a child with severe CAS to be limited to the neutral vowel, /?/ “uh” (cup). Because of their acoustic and motoric contrasts, the vowels /i/ (see), /u/ (boo), /o/ (go), and /a/ (mom) are good choices to address early in treatment. In addition, these vowels can be incorporated into both open and closed syllables, including early developing CV, CVC, and CV.CV word shapes. Diphthongs can be challenging. After each pure vowel comprising the diphthong has been established individually, begin to facilitate vowel diphthong production by combining the two known pure vowels using reduced rate and multisensory cueing.
Consider the needs of the whole child
Because CAS can occur as part of a larger set of challenges, it is important to consider the relative contribution of the child’s speech praxis difficulties in the context of other cognitive and communicative challenges (linguistic, social, emotional, learning, pragmatic language, etc). For example, a child with severe social language challenges may need to establish communicative intent prior to working on speech praxis drills.
Address language and literacy in the context of speech praxis treatment
Language and literacy challenges frequently coexist with CAS. Be aware of possible language, phonological awareness and literacy difficulties exhibited by the child, and be sure to address these challenges throughout the treatment process.
Work closely with families
It is essential to work closely with families to establish opportunities for home practice of the skills being worked on within the speech therapy sessions. If parents can observe or participate in sessions, this is ideal. When this is not possible, sessions can be videotaped and shared with parents.
References
American Speech-Language-Hearing Association (2007). Childhood apraxia of speech [Technical Report]. Retrieved October 13, 2010, from http://www.asha.org/policy.
Author, (2005). What is childhood apraxia of speech? Childhood Apraxia of Speech Association of North America (CASANA). Retrieved October 13, 2010 from http://www.apraxia-kids.org.
Davis, B. L., & Velleman, S. (2000). Differential diagnosis and treatment of developmental apraxia of speech in infants and toddlers. Infant-Toddler Intervention, 10, 177-192.
Maas, E., Robin, D., Austermann Hula, S., Freedman, S., Wulf, G., Ballard, K., & Schmidt, R. (2008). Principles of motor learning in treatment of motor speech disorders. American Journal of Speech-Language Pathology, 17, 277-298.
Strand, E. A., & Skinder, A. (1999). Treatment of developmental 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
We thank Margaret Fish for providing us with this article for our Website.
Margaret (Dee) Fish is a licensed speech-language pathologist with over 25 years experience working with children in a variety of clinical and educational settings. She currently works in private practice in Highland Park, Illinois. Her primary areas of professional interest are children’s speech sound disorders, language disorders, and social language challenges of children with highly unintelligible speech. She conducts local, state, and national workshops on the topics of childhood apraxia of speech, children’s language development, and social language development, with an emphasis on providing practical treatment ideas for therapists and parents based on strong theoretical foundations and available clinical research. Margaret is the author of the recently released book, Here’s How to Treat Childhood Apraxia of Speech by Plural Publishing.