Treatment section of the Childhood Apraxia of Speech Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Reduced intelligibility and comprehensibility (i.e., the ability to convey intended messages within communicative contexts; Yorkston, Strand, & Kennedy, 1996) are seen as especially debilitating for many children with CAS (e.g., Hall, 2000a, 2000b).
Treatment goals for children with CAS focus on facilitating overall communication and language skills by
- increasing speech production and intelligibility or, when indicated,
- using augmentative and alternative forms of communication (AAC), such as gestures, manual signs, voice output devices, and context-specific communication boards.
Motor speech disorders require repetitive planning, programming, and production practice; therefore, intensive and individualized treatment of childhood apraxia is often necessary.
To the extent possible, treatment takes place in naturalistic environments, is provided in a culturally appropriate manner, and involves as many important people in the child's life as possible to facilitate carryover and generalization of skills. Involving significant others in treatment also facilitates home practice by helping these individuals understand and target goals with the child outside the treatment setting.
Many children with CAS also exhibit phonologic impairment and language impairment, and the relative contribution of motoric to linguistic deficits is considered when planning treatment. If a child has mild motoric deficits and significant phonologic deficits, then linguistic approaches may need to be prioritized. One may also want to bring in some principles of motor learning to facilitate movement accuracy (McCauley & Strand, 1999).
Treatment approaches that focus directly on improving speech production can be classified as follows.
- Motor-programming approaches utilize motor-learning principles, including the need for many repetitions of speech movements to help the child acquire skills to accurately, consistently, and automatically make sounds and sequences of sounds.
- Linguistic approaches focus on CAS as a language learning disorder; these approaches teach children how to make speech sounds and the rules for when speech sounds and sound sequences are used in a language.
- Combination approaches use both motor-programming and linguistic approaches.
- Sensory cueing approaches involve the use of the child's senses (e.g., vision, touch), as well as gestures to cue (or self-cue) some aspect of the targeted speech sound. Cueing is often used in conjunction with other approaches, such as motor programming (Hall, 2000b).
- Rhythmic (prosodic) approaches, such as melodic intonation therapy (Helfrich-Miller, 1984, 1994), use intonation patterns (melody, rhythm, and stress) to improve functional speech production.
The goal of treatment approaches that focus on speech production is to help the child achieve the best intelligibility and comprehensibility possible. However, when there are concerns that oral communication is not adequate, various augmentative and alternative modes of communication may also be used to provide functional communication, while at the same time supporting and enhancing verbal speech production (Cumley & Swanson, 1999; Yorkston, Beukelman, Strand, & Hackel, 2010). In addition to increasing communication success, AAC approaches may stimulate the development of language skills that cannot be practiced orally (Murray, McCabe, & Ballard, 2014).
From the perspective of the World Health Organization's (WHO) International Classification of Functioning, Disability, and Health (ICF; WHO, 2001), motor and linguistic approaches are focused on "body functions/structures" within the ICF framework (McLeod & McCormack, 2007), while AAC approaches are directed at "activities/participation" (Murray et al., 2014).
Below are brief descriptions of both general and specific treatments for addressing childhood apraxia of speech. This list is not exhaustive, and the inclusion of any specific treatment approach does not imply endorsement from ASHA.
The majority of treatment approaches for CAS emphasize movement patterns versus sound patterns. Many of those listed below incorporate traditional speech sound techniques, such as progressive approximation techniques to shape the best/most accurate productions possible and phonetic placement techniques to provide verbal information and instruction about positioning of the mouth, tongue, lips, or jaw during speech attempts. Additionally, a core set of child-specific functional stimuli (e.g., words or phrases) is often incorporated into various treatment approaches (Strand, Stoeckel, & Baas, 2006; Iuzzini & Forrest, 2010).
For other approaches and techniques that may be useful in the treatment of CAS, see
treatment section of the speech sound disorders: articulation and phonology page.
Treatment selection depends on a number of factors, including the severity of the disorder and the communication needs of the child. Because symptoms typically vary both from child to child and within the same child with age (Lewis, Freebairn, Hansen, Iyengar et al., 2004; Shriberg et al., 2003), multiple approaches may be appropriate at a given time or over time.
Apraxia in other systems may also play an important role in treatment. For example, the presence of limb apraxia may preclude using manual signs for functional communication, although sign language cues can still be used by others to support verbal speech, if the primary goal is to help cue words and word sequences. The presence of oral apraxia may support the need for either more aggressive or alternative approaches to the use of phonetic placement cues in speech treatment.
Augmentative and Alternative Communication (AAC)
AAC involves supplementing or replacing natural speech or writing with aided symbols (e.g., picture communication, line drawings, Blissymbols, speech-generating devices, and tangible objects) or unaided symbols (e.g., manual signs, gestures, and finger spelling). Whereas aided symbols require some type of transmission device, production of unaided symbols requires only body movements. See ASHA's Practice Portal page on Augmentative and Alternative Communication.
Motor Programming Approaches
Motor programming approaches are based on motor programming/planning tenets. They provide frequent and intensive practice of speech targets; focus on accurate speech movement; include external sensory input for speech production (e.g., auditory, visual, tactile, cognitive cues); carefully consider the conditions of practice used (e.g., random vs. blocked practice of targets); and provide appropriate types and schedules of feedback regarding performance (Maas et al., 2008). For a discussion of the principles of motor learning as they apply to CAS and a review of motor-based treatment approaches for CAS, see Maas, Gildersleeve-Neumann, Jakielski, and Stoeckel (2014).
Kaufman Speech to Language Protocol (K-SLP)
K-SLP is an approach rooted in behavioral principles. K-SLP focuses on the child's motor-speech skills, shaping the consonants, vowels, and syllable shapes/gestures from what he or she is capable of producing toward higher levels of motor-speech coordination. Speech and language are broken down into smaller units (consonants, vowels, syllables, and words) and built back up into the target behavior (age-appropriate motor-speech and expressive language skills) using cues, fading cues, cueing before failure (errorless teaching); using powerful and strategic reinforcement (motor learning principles); gaining many responses within a session; and using a variety of tasks to avoid overgeneralization. In this way, successive approximations of target vocabulary are reinforced, giving the child a functional avenue by which to become an effective vocal communicator (Kaufman, n.d.).
Nuffield Dyspraxia Program (NDP3®)
NDP3® is a motor skills learning approach that emphasizes motor programming skills and focuses on speech output. It is described as a "bottom-up" approach, in which the aim is to "build" accurate speech from core units of single speech sounds (phonemes) and simple syllables. New motor programs are established using cues and feedback and through frequent practice and repetitive sequencing exercises. Phonological skills are incorporated into the treatment approach through the use of minimal word pairs (Williams & Stephens, 2010).
Training Syllable Sequences
Repetitions of varied sequences of real or nonsense syllables are used to train motor planning flexibility (Velleman, 2003; Velleman & Strand, 1994). Similarly, Rapid Syllable Transition Treatment (ReST) applies principles of motor learning to maximize long-term maintenance and generalization of speech skills in children with CAS. ReST involves intensive practice in producing multisyllabic, phonotactically permissible pseudo-words to improve accuracy of speech sound production, rapid and fluent transitioning from one sound or syllable to the next, and control of syllable stress within words. Pseudo-words are used to allow the development and practice of new speech patterns without interference from existing error speech patterns (Murray, McCabe, & Ballard, 2012).
Linguistic approaches for treating CAS emphasize linguistic and phonological components of speech, as well as flexible, functional communication (Velleman, 2003). These approaches focus on speech function and target speech sounds and groups of sounds with similar patterns of error in an effort to help the child internalize phonological rules. It is important to note that linguistic approaches to CAS are intended as a complement to motoric approaches, not a replacement for them.
Cycles training is a linguistic approach that targets phonological pattern errors. It is designed for highly unintelligible children who have extensive omissions, some substitutions, and a restricted use of consonants. The goal is to increase intelligibility within a short period of time. Treatment is scheduled in cycles ranging from 5 to 16 weeks. During each cycle, one or more phonological patterns are targeted. After each cycle is completed, another cycle begins that targets one or more different phonological patterns. Recycling of phonological patterns continues until the targeted patterns are present in the child's spontaneous speech (Hodson, 2010; Prezas & Hodson, 2010). The goal is to approximate the gradual normal phonological development process. There is no predetermined level of mastery of phonemes or phoneme patterns within each cycle; cycles are used to stimulate the emergence of a specific sound or pattern, not produce mastery of it.
Integrated Phonological Awareness Intervention
Integrated phonological awareness intervention (IPA) is designed to simultaneously facilitate speech production, phonological awareness, and letter-sound knowledge in preschool and young school-age children with speech and language impairment. Specific approaches to facilitate the development of phonological awareness include developing knowledge that positively influences phonological awareness development (e.g., teaching nursery rhymes and focusing on sound properties of spoken language) and integrating phonological awareness activities into treatment sessions (e.g., phoneme awareness and letter game activities; McNeill, Gillon, & Dodd, 2009b; Moriarty & Gillon, 2006).
Many treatments for CAS incorporate sensory input (e.g., visual, auditory, proprioceptive and/or tactile cues) to teach the movement sequences for speech. Sensory cues can be used separately or in combination (i.e., multisensory approach). Feedback is an important aspect of motor learning. These external cues may facilitate speech production by providing additional feedback to the child if he or she cannot benefit from, or does not receive, sufficient intrinsic sensory feedback.
Integral Stimulation (IS)
Integral Stimulation (IS) is a method for practicing movement gestures for speech production that involves imitation and emphasizes multiple sensory models (e.g., auditory, visual, tactile). Treatment follows a "listen to me, watch me, do what I do" sequence, in which the child hears and sees how the clinician produces a target sound sequence or word/phrase and then imitates (Strand & Skinder, 1999). Dynamic Temporal and Tactile Cueing (DTTC) is an IS method that uses a cueing hierarchy (auditory, visual, and tactile) and systematically decreases supports as the child achieves success at each level of the cueing hierarchy (Strand & Debertine, 2000; Strand et al., 2006). Movement gestures are shaped, beginning with direct imitation, moving to simultaneous production with tactile or gestural cues if direct imitation was unsuccessful, and then fading the simultaneous cue and again moving to direct imitation. The key element of this approach is that the clinician is constantly adding or fading auditory, visual, and tactile cues as needed after each practice trial.
Tactile methods of speech facilitation are those that provide direct tactile input for correct speech production. Using these methods, the SLP applies pressure or otherwise touches the child's face, neck, and head to provide a tactile cue for correct production or speech movement gesture. For example, PROMPT© (Prompts for Restructuring Oral Muscular Phonetic Targets) is a dynamic tactile method of treatment based on touch pressure, kinesthetic, and proprioceptive cues (Hayden, Eigen, Walker, & Olsen, 2010). Using this approach, the SLP uses his or her hands to cue and stimulate articulatory movement and to help the child limit unnecessary movements. The Touch-Cue Method is another tactile approach used for CAS (Bashir, Grahamjones, & Bostwick, 2008).
Visual cueing methods provide visual "cues" as to the shape, placement or movement of the articulators. Visual cues can be gestural (e.g., simple hand signs) or more technologically advanced methods such as electropalatography readouts, ultrasound images (e.g., Preston, Brick, & Landi, 2013), computerized speech viewing programs, and other forms of biofeedback that provide visual cues about speech movement performance.
Prosodic facilitation treatment methods use intonation patterns (melody, rhythm, and stress) to improve functional speech production. Melodic intonation therapy (MIT; Albert, Sparks, & Helm, 1973) is a prosodic facilitation approach that uses singing, rhythmic speech, training with common phrases, and rhythmic hand tapping. Using these techniques, the clinician guides the individual through a gradual progression of steps that increase the length of utterances, decrease dependence on the clinician, and decrease reliance on intonation (Martin, Kubitz, & Maher, 2001).
Factors to consider in the treatment of CAS for children who are bilingual include the following.
- Bilingual treatment may facilitate greater improvement than English-only treatment in a child with CAS (Gildersleeve-Neumann & Goldstein, 2014). See
bilingual service delivery.
- Beginning treatment by first targeting phonemes that are shared between the languages spoken by a child may yield the greatest improvement in intelligibility across languages in the shortest amount of time. Cross-linguistic transfer is also most successful when stimuli are chosen that are shared between the two languages (Yavas & Goldstein, 1998). Additionally, cross-linguistic transfer can be used to target goals in one language while targeting properties of a second language. For example, treatment addressing multisyllabic words in Spanish may facilitate transfer to the phrase level in English (Gildersleeve-Neumann & Goldstein, 2014).
- Errors that are only present in one language are unlikely to improve intelligibility in the other language when addressed in treatment. For example, if final consonants are targeted in English to improve intelligibility, but occur rarely in the child's primary language, intelligibility in that language will not be positively influenced by addressing accurate final consonant productions in English.
- Clinicians consider the contexts in which a child uses each language and identify vocabulary words that are likely to facilitate carryover, functional use, and repeated practice and exposure in each language.
- Treatment incorporates activities that facilitate cross-linguistic transfer of skills and improved intelligibility, including providing activities for home practice in the language used by the family.
- Goals and targets in each language are chosen based on the properties and word shapes of each language. English has more monosyllabic words with consonant clusters and, thus, targets in English should be representative of this word shape.
Throughout treatment, SLPs monitor progress in each language and note if improvements are consistent and if there is any generalization across languages. Children may appear to show a preference for speaking in one language, but this may be a preference for the easier motor task associated with words in one language and not necessarily a preference for communication in a specific language (Gildersleeve-Neumann, n.d.). This pattern does not suggest a need to recommend limiting communication to a single language for the child and family.
Criteria for determining eligibility for services in a school setting are detailed in the Individuals with Disabilities Education Improvement Act (IDEA; 2004). For information about eligibility and dismissal from speech-language pathology services in the schools, see
treatment considerations in schools section of the speech sound disorders: articulation and phonology.
For some children, speech difficulties persist throughout their school years and sometimes into adulthood. Pascoe, Stackhouse, and Wells (2006) define persisting speech difficulties (PSD) as "… difficulties in the normal development of speech that do not resolve as the child matures or even after they receive specific help for these problems" (p. 2).
Anecdotal evidence from clinical observations suggests that, for children with CAS, persisting difficulties can include residual prosody issues, persistent speech sound distortions, and ongoing struggles handling unfamiliar multisyllable words.
For more detailed information about treatment options for children with persisting speech difficulties, see
treating children with persisting speech difficulties in the speech sound disorders: articulation and phonology page.
Children with persisting speech difficulties may continue to have problems with oral communication, literacy, and social aspects of life as they transition to post-secondary education and vocational settings. The potential impact of persisting speech difficulties highlights the need for continued support to facilitate a successful transition to young adulthood. See
Service Delivery section of the Childhood Apraxia of Speech Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
In addition to determining the type of speech and language treatment that is optimal for children with CAS, consider other service delivery variables that may have an impact on treatment outcomes, such as dosage, format, provider, setting, and timing.
Dosage refers to the frequency, intensity, and duration of service and the culmination of those three variables (Warren, Fey, & Yoder, 2007). Treatment dosage for CAS is consistent with principles of motor learning (McNeil, Robin, & Schmidt, 1997). Given the need for repetitive production practice in motor speech disorders like CAS, intensive and individualized treatment is often stressed. A number of research studies support the need for three to five individual sessions per week versus the traditional and less intensive one to two sessions per week (Hall et al., 1993; Skinder-Meredith, 2001; Strand & Skinder, 1999). For younger children, the frequency and length of sessions may need to be adjusted; shorter, more frequent sessions are often recommended (e.g., Skinder-Meredith, 2001).
Format refers to the structure of the treatment session (e.g., group and/or individual). The appropriateness of treatment format (individual vs. group vs. both) depends on the primary goal for the child at a particular point in the treatment process. For example, if the primary goal is to improve the motor aspects of speech, individual sessions that emphasize motor practice might be the preferred approach. However, once the child has made progress on goals targeting motor speech production, goals might then include language and the enhancement of pragmatic skills. At that point, a combination of individual and group treatment may be appropriate.
Provider refers to the person providing the treatment (e.g., SLP, trained volunteer, caregiver). SLPs treat the speech-motor and linguistic aspects of CAS. Other professionals (e.g., physical therapist or occupational therapist) may also be involved in the treatment of children with apraxia; SLPs need to be mindful of the potential for fatigue and the possible need to vary treatment activities accordingly. It is also important for SLPs to collaborate with other professionals regarding treatment alternatives, including opportunities for co-treatment (Davis & Velleman, 2000; Velleman & Strand, 1994).
Timing refers to timing of intervention relative to diagnosis. When a child is diagnosed with CAS, he or she is likely to present with a significant speech disorder that warrants immediate intervention. Prompt treatment is also indicated for children suspected of having CAS or with a provisional diagnosis of CAS, given that progress in treatment can often assist in making a definitive diagnosis.
Setting refers to the location of treatment (e.g., home, community-based). A naturalistic treatment environment is important for facilitating generalization and carryover of skills, and home practice is essential for helping the child make optimal progress.