School-based speech-language pathologists face unique challenges in treating students diagnosed with childhood apraxia of speech (CAS). Demanding caseloads often require creative intervention strategies to meet the needs of children with this complex motor speech disorder. According to the ASHA technical report by the Ad Hoc Committee on Apraxia of Speech in Children, "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., 1993; Skinder-Meredith, 2001; Strand & Skinder, 1999).
However, the report goes on to state, "as long as the primary goal is to improve the motoric aspects of the child's speech production...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..." (ASHA, 2007).
SLPs who work with preschool-age children with CAS need to prepare parents at the outset of treatment for potential changes in treatment over the long term. We can help parents understand that when their child enters school, he or she may be best served by a mix of individual and small-group sessions with a lesser degree of intensity or by group treatment only, if the speech motor issues have been significantly resolved.
School-age children with apraxia do require intensive, individual intervention. The technical report states that "there are treatment constraints (e.g., limited funding, limited staff availability) in certain settings that make it challenging to secure intensive, individual therapy..." and that "resources need to be made available to insurance companies, school districts, and specialized programs to provide children with CAS the best opportunity to develop functional communication" (ASHA, 2007). For a percentage of early school-age children with CAS, SLPs needs to consider the best treatment options for persistent residual language issues, phonological error patterns, prosody deviancies, and pragmatic communication deficits.
In my presentations on apraxia, especially to clinicians and parents, I emphasize that a child's diagnosis of apraxia of speech does not mean that he or she needs or is entitled to intensive one-on-one treatment throughout the course of intervention. In an outpatient setting, my goal is to reduce gradually the number of sessions per week as speech motor issues subside. I hope to reach a point at which less intensive treatment can meet speech and language needs by the time the child enters elementary school.
The SLP plays a critical role in collaborating with other team members, training them how to accommodate for the child, and helping the child demonstrate goal achievement across settings. Parents, general education teachers, and other professionals are crucial members of the team. The technical report on CAS indicates that home practice is critical for optimal progress (ASHA, 2007). Even when I see children for three to five individual sessions per week, I consider it "a drop in the ocean" when I think about how much impact my 1.5 to 2.5 total hours of treatment will have without parent or caregiver follow-through.
In the school setting, classroom teachers are a readily available resource for carryover practice collaboration. However, SLPs must find a way to involve parents/caregivers closely without having easy access to their time and attention.
Ideally, parents and caregivers would observe the intervention sessions from start to finish, or at least part of the session. For a child who has ongoing apraxic features, we can't just provide worksheets or activities for home practice without parents' understanding of how to use cues, prompts, pictures, and other strategies to facilitate sound precision and sound, syllable, and word sequencing. However, we are fortunate that videotaping is readily available. We need to "risk" sharing videotaped samples of treatment in action for the sake of the child's potential improvement.
With the unique challenges that school SLPs face in treating CAS, partnerships with outpatient/private SLPs as well as parents and caregivers are critical to provide the best service that we can offer for this challenging motor speech disorder.