Treatment section of the Apraxia of Speech (Childhood) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Reduced intelligibility (i.e., the degree to which the listener understands the individual’s speech) and comprehensibility(i.e., the degree to which the listener understands the individual’s speech within a communicative context; Yorkston, Strand, & Kennedy, 1996) can be especially debilitating for many children with CAS (see, 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 AAC, such as gestures, manual signs, voice output devices, and context-specific communication boards.
International Classification of Functioning, Disability, and Health (ICF) for examples of functional goals consistent with ICF for various clinical disorders.
Motor speech disorders require repetitive planning, programming, and production practice; therefore, intensive and individualized treatment of childhood apraxia is often necessary (see, e.g., Maas, Gildersleeve-Neumann, Jakielski, & Stoeckel, 2014; Namasivayam et al., 2015; Skinder-Meredith, 2001).
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 caregivers in treatment helps them understand and practice goals with the child outside the treatment setting.
Many children with CAS also have phonological impairment and language impairment. The relative contribution of motoric and linguistic deficits is considered when planning treatment (see treatment approaches below). If a child has mild motoric deficits and significant phonological deficits, then linguistic approaches may need to be prioritized while also bringing in some principles of motor learning to facilitate movement accuracy (Maas et al., 2008; Maas, et al., 2014. Macdonald-D’Silva, van Rees, Ballard, & Arciuli, 2014; McCauley & Strand, 1999).
Treatment approaches that focus directly on improving speech production can be classified as follows:
- Motor programming approaches—use 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.
- Rhythmic (prosodic) approaches, such as melodic intonation therapy (MIT; Albert, Sparks, & Helm, 1973; Helfrich-Miller, 1984, 1994)—use intonation patterns (melody, rhythm, and stress) to improve functional speech production.
Treatment approaches that target speech production focus on helping the child achieve the best intelligibility and comprehensibility possible. However, when there are concerns that oral communication is not adequate, AAC may also be used to provide functional communication while at the same time supporting and enhancing verbal speech production (Bornman, Alant, & Meiring, 2001; Cumley & Swanson, 1999; Yorkston, Beukelman, Strand, & Hakel, 2010). In addition to increasing communication success, AAC approaches may stimulate the development of language skills that cannot be practiced orally (Cumley & Swanson, 1999; Murray, McCabe, & Ballard, 2014). See ASHA’s Practice Portal page on
Augmentative and Alternative Communication.
International Classification of Functioning, Disability and Health (ICF) web page for examples of treatment goals consistent with ICF for various clinical disorders.
Below are brief descriptions of both general and specific treatments for addressing CAS. This list is not exhaustive, and the inclusion of any specific treatment approach does not imply endorsement from ASHA. See Murray et al. (2014) and Maas et al. (2014) for recent reviews of the evidence base.
The majority of treatment approaches for CAS emphasize movement patterns versus sound patterns. Many of those listed below incorporate the following techniques:
- Shaping the best/most accurate productions possible.
- Sensory cueing approaches that involve using the child’s senses (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). These approaches 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. Many treatments for CAS incorporate sensory cueing (e.g., motor programming approaches; Hall, 2000b).
- 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 (see, e.g., Preston, Brick, & Landi, 2013; Preston, Leece, & Maas, 2016; Preston, Leece, McNamara, & Maas, 2017; Preston, Maas, Whittle, Leece, & McCabe, 2016), computerized speech viewing programs, and other forms of biofeedback that provide visual cues about speech movement performance.
- Verbal/auditory cues
provide instruction on how to move the articulators during production attempts
(“spread your lips wide”) in order to assist the child in making more accurate
movement gestures for speech.
- Tactile facilitation methods 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. PROMPT© (Prompts for Restructuring Oral Muscular Phonetic Targets) is one tactile method of treatment that is based on touch, pressure, kinesthetic, and proprioceptive cues (Dale & Hayden, 2013; Hayden, Eigen, Walker, & Olsen, 2010). The Touch-Cue Method is another tactile approach in which touch cues are given simultaneously with auditory and visual cues during the initial stages of therapy (Bashir, Grahamjones, & Bostwick, 2008).
A core set of child-specific functional stimuli (e.g., words or phrases) is often incorporated into various treatment approaches (Iuzzini & Forrest, 2010; Strand, Stoeckel, & Baas, 2006).
Treatment selection depends on factors such as 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 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 make it difficult for the child to use manual signs for functional communication. 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.
Motor Programming Approaches
Motor programming approaches are based on motor programming/planning principles. These approaches
- 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, and cognitive cues);
- carefully consider the conditions of practice (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 et al. (2014).
Examples of motor programming approaches include the following:
- Dynamic Temporal and Tactile Cueing (DTTC) is an integral stimulation ("look, listen, do what I do") 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. It is suggested for very young children with severe CAS.
- Nuffield Dyspraxia Program( 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).
- Rapid Syllable Transitions (ReST) is a method that involves repetition of varied sequences of real or nonsense syllables to train motor planning flexibility (Velleman, 2003; Velleman & Strand, 1994). It uses 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 (McCabe et al., 2014; McCabe, Murray, Thomas, & Evans, 2017; Murray, McCabe, & Ballard, 2015; Thomas, McCabe, & Ballard, 2014; Thomas, McCabe, Ballard, & Lincoln, 2016).
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. They 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 as a replacement for them.
Examples of linguistic approaches include the following:
- The Cycles approach (Hodson, 1989) is a linguistic approach that targets phonological pattern errors. It is designed for children whose speech is highly unintelligible and 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, the SLP targets one or more phonological patterns. 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 typical 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 (IPA) is designed to simultaneously facilitate phonological awareness, letter–sound knowledge, and speech production in preschool and young school-age children with speech and language impairment. Specific approaches to facilitate the development of phonological awareness include (a) developing knowledge that positively influences phonological awareness development (e.g., teaching nursery rhymes and focusing on sound properties of spoken language) and (b) integrating phonological awareness activities into treatment sessions (e.g., phoneme awareness and letter game activities; McNeill, Gillon, & Dodd, 2009a, 2010; Moriarty & Gillon, 2006).
Prosodic facilitation treatment methods use intonation patterns (melody, rhythm, and stress) to improve functional speech production. Melodic intonation therapy (MIT; Albert et al., 1973) is a prosodic facilitation approach that uses singing, rhythmic speech, and rhythmic hand tapping to train functional phrases and sentences. 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).
Augmentative and Alternative Communication (AAC)
Augmentative and augmentative communication (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.
The following information and treatment considerations are summarized from
Considerations When Working With a Bilingual Child With CAS (Portland State University, n.d.):
- Bilingual treatment may facilitate greater improvement than English-only treatment in a child with CAS (Gildersleeve-Neumann & Goldstein, 2014).
- Targeting errors that are present in only one language is unlikely to improve intelligibility in the other language. For example, if final consonants are targeted in English to improve intelligibility but occur rarely in the child’s primary language, intelligibility in the primary language will not be positively influenced by targeting final consonant productions in English.
- Beginning treatment by targeting phonemes shared by both languages may yield the greatest improvement in intelligibility across languages in the shortest amount of time.
- Selecting stimulus targets that affect both languages can result in cross-linguistic transfer of skills (Yavas & Goldstein, 1998).
- Clinicians (a) consider the contexts in which a child uses each language and (b) 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; thus, targets in English should be representative of this word shape.
- Throughout treatment, SLPs monitor progress in each language and note whether improvements are consistent and whether there is any generalization across languages. If the child is not making progress, then the SLP modifies goals and approaches, as needed.
- 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. This pattern does not suggest a need to recommend limiting communication to a single language for the child and family.
For general information about treating a bilingual or multilingual child with a speech sound disorder, see the
Treatment section of ASHA’s Practice Portal page on Speech Sound Disorders: Articulation and Phonology. See also ASHA’s Practice Portal page on
Bilingual Service Delivery.
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 the
Considerations for Treatment in Schools section of ASHA’s Practice Portal page on Speech Sound Disorders: Articulation and Phonology. See also ASHA's resources on
eligibility and dismissal in schools,
IDEA Part B Issue Brief: Individualized Education Programs and Eligibility for Services, and
2011 IDEA Part C Final Regulations.
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 the
Children With Persisting Speech Difficulties section of ASHA’s Practice Portal page on Speech Sound Disorders: Articulation and Phonology.
Children with persisting speech difficulties may continue to have problems with oral communication, literacy, and social aspects of life as they transition to postsecondary 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 ASHA’s resource on
Service Delivery section of the Apraxia of Speech (Childhood) 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. These include dosage, format, provider, timing, and setting.
Dosage refers to the frequency, intensity, and duration of service and the culmination of those three variables (Warren, Fey, & Yoder, 2007).
A high treatment dosage (total amount of treatment) for CAS is consistent with principles of motor learning (Maas et al., 2008, 2014; McNeil, Robin, & Schmidt, 1997). Given the need for repetitive production practice in motor speech disorders like CAS, intensive and individualized treatment is often stressed (Hall et al., 1993; Namasivayam et al., 2015; Skinder-Meredith, 2001; Strand & Skinder, 1999). It is unknown whether the critical variable is the number of sessions per week or the overall amount of treatment (total number of sessions).
For younger children, the frequency and length of sessions may need to be adjusted (e.g., shorter, more frequent sessions are often recommended; Skinder-Meredith, 2001). Given the potential for fatigue, treatment activities may need to be varied accordingly.
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 the child’s speech sound disorder. Other professionals (e.g., physical therapist or occupational therapist) may also be involved in the treatment of children with apraxia. It is important for SLPs to collaborate with other professionals about treatment alternatives and to participate in co-treatment when appropriate (Davis & Velleman, 2000; Velleman & Strand, 1994).
See ASHA’s resource on
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. Early treatment is also indicated for children suspected of having CAS or with a provisional diagnosis of CAS, given that progress in treatment can help 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.