The incidence of apraxia of speech (AOS) refers to the number of new cases of AOS identified in a specific time period.

The prevalence of AOS refers to the number of individuals who are living with AOS in a given time period.

There are currently no large, population-level studies of the incidence and prevalence of AOS in adults. Additionally, reduced accuracy of AOS diagnosis due to a variety of factors (e.g., comorbid speech and language disorders, difficulty detecting more mild cases of AOS) may impact the precision of frequency estimates. The following statistics are predominately based on single studies within a limited number of hospital systems. As such, they may not reflect the true incidence and prevalence of AOS in adult populations.

• It is estimated that 44% of patients with chronic aphasia have some degree of AOS (Ziegler et al., 2022).
• In one retrospective chart review, AOS was reported in 11% (12 out of 107) of patients with acute ischemic stroke who were evaluated by speech-language pathologists (SLPs). 100% of the patients diagnosed with AOS had concomitant aphasia and 50% had concomitant dysarthria (Flowers et al., 2013).
• AOS as the primary or only acquired communication disorder is not common.
  • Duffy (2020) reported that AOS was documented as the primary, but not necessarily the only, communication disorder in about 5% of all patients with motor speech disorders seen by SLPs at the Mayo Clinic.
  • Over a 14-year period, only 5 cases of AOS without comorbid dysarthria or aphasia were confirmed by SLP services at the Mayo Clinic (Graff-Radford et al., 2014).
• Based on medical data from one U.S. county, Primary Progressive Apraxia of Speech (PPAOS) is estimated to be diagnosed in 0.14 out of every 100,000 people every year (Turcano et al., 2024).

The following signs and symptoms are not unique to AOS and can also be present in dysarthria or aphasia. AOS diagnosis requires a constellation of symptoms that indicate deficits in motor planning and programming.

Several key features of AOS have gained broad consensus for differential diagnosis (Allison et al., 2020; Ballard et al., 2014; Duffy, 2020; McNeil et al., 2009):

• phonetic distortions (i.e., imprecise articulation) and distorted substitutions or additions
• reduced overall speech rate
• prosodic abnormalities (e.g., equal stress across adjacent syllables)

Please see the Differential Diagnosis section for further information. AOS can improve, remain stable, or worsen over time depending on its specific cause (e.g., poststroke AOS vs. primary progressive AOS) and time elapsed since onset.

Articulation

• Voicing errors—having voicing on when producing voiceless phonemes (e.g., saying /d/ for /t/) or having voicing off when producing voiced phonemes (e.g., saying /p/ for /b/).
• Prolonged phonemes.
• Inconsistent errors—A particular phoneme is not always produced incorrectly or with the same error, even in repeated productions of the same word.
• Syllable telescoping—collapsing or merging syllables (e.g., “disaur” instead of “dinosaur”).
• Performance on specific speech tasks.
  • Automatic speech (e.g., counting from 1 to 10, saying familiar words such as “hello” or familiar phrases such as “I love you”) may be easier to produce than generative (i.e., novel or spontaneous) language.
  • Nonwords (e.g., “puhtuhkuh”) are more difficult to produce than real words (e.g., “buttercup”).
  • Low-incidence words (e.g., “hydroplane”) are more difficult to produce than high-incidence words (e.g., “animal”).
• Sound production accuracy decreases as complexity increases (e.g., more syllables per word, more words per sentence).

Rate and Prosody

• Slowed rate of speech, with unintentional pauses within and between words/syllables.
• Syllable segmentation.
• Reduced pitch and loudness variability.
• Syllable stress errors, which may be inconsistent or may be characterized by excess and equal stress.

Fluency

• Disrupted fluency with successful and unsuccessful attempts at self-correction.
• Difficulty initiating speech.
• Groping—visible struggle or effort to move the mouth, lips, or tongue into the correct position before the person is able to phonate.
• False starts and restarts.
• Sound and syllable repetitions.

Potential Co-Occurring Diagnoses

Pure AOS (i.e., AOS in the absence of dysarthria or aphasia) is rare. Individuals with AOS often have other motor speech disorders or comorbid linguistic deficits. These comorbidities typically depend on the site of the lesion and include the following:

• Aphasia—language comprehension and/or production deficits.
• Dysarthria—motor speech disorder characterized by neuromuscular weakness or impaired coordination or control.
  • The type of dysarthria co-occurring with AOS varies depending on the etiology and/or site and extent of any resulting brain lesion(s). Unilateral upper motor neuron dysarthria likely co-occurs most often in AOS due to stroke.
• Nonverbal oral apraxia—difficulty programming orofacial musculature for nonspeech movements (e.g., whistling, blowing).
• Limb apraxia—difficulty programming purposeful limb movements.
• Varying degrees of unilateral (typically right-sided) weakness and/or spasticity.
• Apraxia of swallowing—difficulty programming muscles of the head and neck for coordinated swallowing.

AOS can be caused by any process or condition that compromises regions of the brain that are responsible for planning and programming motor movements for speech. Causes most often include

• stroke,
• traumatic brain injury,
• tumor,
• surgical trauma (e.g., tumor resection), or
• neurodegenerative progressive disease.

AOS in Progressive Conditions

AOS can occur as part of a neurodegenerative progressive condition. Primary progressive apraxia of speech (PPAOS; Josephs et al., 2012) is a disorder characterized by AOS symptoms that are the earliest, only, or predominant symptoms of a progressive syndrome. PPAOS is most often associated with progressive movement disorders (e.g., corticobasal degeneration, progressive supranuclear palsy; Duffy, 2006; Duffy & McNeil, 2008; Duffy et al., 2007, 2020). AOS and PPAOS can develop alongside other neurodegenerative conditions (e.g., progressive supranuclear palsy).

Individuals with PPAOS require periodic reassessment as they progress through the disease course, which can initially present with mild AOS symptoms but may progress to mutism, as well as the development of other motor or cognitive symptoms (Josephs et al., 2014).

The purpose of PPAOS treatment is typically to maximize communication and participation in life activities at each stage of the disease. Maintenance and/or compensatory therapy is often used to address these needs. Restorative approaches may possibly help to slow decline or improve speech for a short time (Duffy, 2020). Goals in the early stages might begin with efforts to improve speech (using strategies that are helpful for nondegenerative AOS) and maintain comprehensibility, followed by establishing compensatory strategies, including augmentative and alternative communication (AAC; Duffy & McNeil, 2008; Jung et al., 2013).

Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of AOS. The professional roles and activities in speech-language pathology include clinical services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).

Assessment and Diagnosis

• Screening to determine the need for further assessment and/or referral for other services.
• Diagnosing the presence of AOS and establishing its severity and prognosis as well as its impact on participation, quality of life, mental health, and carer burden.
• Referring to, and collaborating with, other professionals to determine the etiology of AOS, if unknown, and to facilitate access to comprehensive services.
• Conducting culturally and linguistically relevant comprehensive assessment, modifying standardized assessment procedures as necessary.
• Working with the interdisciplinary team to make decisions about candidacy for services.

Counseling, Education, and Advocacy

• Providing adjustment counseling for people with AOS and their care partners about communication-related issues and any subsequent mental health challenges.
• Educating professionals on the needs of people with AOS and the role that SLPs play in meeting those needs.
• Advocating for individuals with AOS and their families at the local, state, and national levels.

Treatment

• Serving as a key member of an interdisciplinary team that includes individuals with AOS and their care partners.
• Providing timely access to augmentative and alternative communication (AAC), as needed, and training individuals with AOS and their care partners in the use of AAC.
• Providing intervention and management, including improving activity and life participation using evidence-based practice to guide intervention.
• Developing culturally and linguistically appropriate treatment plans, including intervention and support services and clear documentation of progress.
• Determining appropriate service delivery approaches and discharge criteria.

As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs who serve this population should be appropriately trained to do so. SLPs who diagnose and treat AOS must be skilled in differential diagnosis of motor speech disorders and comorbid language disorders and have experience with appropriate intervention techniques.

Hearing screening (e.g., pure-tone audiometry) may be considered in individuals with suspected hearing loss. For further hearing assessment, refer to an audiologist. Individuals who use and have access to prescription eyeglasses should wear them during any screening, treatment, and evaluation tasks. Any potential influence of unaided hearing or vision loss on assessment results should be clearly documented. Clinicians may also account for and document any assessment challenges caused by positioning, fine or gross motor deficits, or masks worn by patients or clinicians.

Screening

Screening should be conducted in the language(s) used by the person, with sensitivity to cultural and linguistic diversity.

Screening for apraxia of speech (AOS) typically involves listening for specific abnormal articulatory, phonatory, and prosodic speech features that are associated with AOS during conversation and other speech tasks. The clinician may consider tasks such as

• automatic speech (e.g., counting from 1 to 10) and
• spontaneous production and repetition of syllables, words, and phrases of varying length and complexity.

Other tasks may be administered at the clinician’s discretion. Clinicians may note signs of other forms of apraxia (e.g., nonverbal oral apraxia, limb apraxia, gait apraxia) and their potential impact on treatment (e.g., use of gestures, ability to imitate oral movements). SLPs may recommend appropriate referrals for nonspeech apraxia.

AOS frequently co-occurs with aphasia. Because of this, clinicians should consider screening for expressive and receptive language deficits to identify additional treatment targets. Clinicians should also consider the potential impact of aphasia on motor speech assessment and treatment.

Please see the Practice Portal page on Aphasia for further information.

Comprehensive Assessment

Comprehensive assessment can use standardized and nonstandardized measures (see ASHA’s resource on assessment tools, techniques, and data sources). Assessment may lead to referral to other disciplines, including physical therapy, occupational therapy, neurology, or clinical psychology.

Comprehensive assessment of AOS involves the assessment of speech production, oral–motor structure and function, and motor speech planning and programming. Specific attention is paid to the impact of speech deficits on

• intelligibility—the degree to which listeners understand the person’s speech,
• comprehensibility—the degree to which listeners understand the individual based on speech and nonspeech factors (e.g., context, body language, facial expressions), and
• efficiency—the rate at which the individual can communicate an intelligible or comprehensible utterance.

Comprehensive assessment typically captures the following background information:

• case history (i.e., medical history, personal characteristics, and social factors), including any history of childhood AOS or motor or communication disorders, including comorbid disorders
• baseline status
• self-reported areas of concern
• identification of contextual barriers and facilitators
• sensory and motor status

Oral–Motor Mechanisms and Nonspeech Oral Motor Movements

Assessment of these systems can help differentiate AOS from dysarthria and oral apraxia. Clinicians assess the structure, function, and integrity of the respiratory, phonatory, resonatory, and articulatory systems. Assessment considers the strength, speed, and range of movement of the oral–motor system. It also considers steadiness, tone, accuracy, and coordination of movements for speech and nonspeech tasks.

Speech Characteristics

A careful evaluation of abnormal speech features is essential for differential diagnosis. This includes an auditory analysis of the speech features associated with speech subsystems (i.e., respiration, phonation, resonance, and articulation). Speech characteristics may be described in terms of

• acoustic features (e.g., “inconsistent pitch variability”),
• articulation (e.g., “imprecise” consonants),
• vocal quality (e.g., “hoarse”), and
• intelligibility (e.g., “approximately 50% intelligible in conversation”).

Speech characteristics may be evaluated using various

• levels of complexity (e.g., word vs. conversational level),
• contexts (e.g., in noise, with or without established context), and
• sample types (e.g., reading, imitative, spontaneous).

Motor Speech Planning/Programming

AOS is a result of impaired motor speech planning and programming (Duffy, 2020). Assessment considers the following domains in the production of phonemes, syllables, monosyllabic/multisyllabic words, and sentences (differing motoric complexity):

• articulation and consistency of speech production
• respiration
• prosody
• resonance
• voicing
• syllable stress
• automaticity of speech
• whether the speech is produced in imitation or is self-generated

Assessment of motor speech planning/programming also examines the following:

• Conversational speech and narrative tasks (e.g., picture description)—These are used to assess integrated functioning of all the speech subsystems.
• Vowel prolongation.
• Acoustic and physiologic assessments—These instrumental procedures can help quantify abnormalities in voice onset time, speech rate, prosody and stress, articulation, and trial-to-trial variability.
• Diadochokinetic rates—the speed and accuracy with which the individual can repeat a series of sounds, measured in repetitions per second. These include the following:
  • Alternating motion rates (AMRs)—AMRs are used to evaluate the speech and regularity of planning a single syllable and then repeatedly executing that one motor plan (e.g., /papapa/).
  • Sequential motion rates (SMRs)—SMRs are used to evaluate the ability to motor-plan for three different syllables (e.g., /pataka/) and quickly transition between them. Abnormal production of SMRs is common in AOS (Duffy, 2020).

Many people with AOS do well with AMRs but have difficulty with SMRs. AMRs in AOS may be rhythmic but slow and may be distorted (due to voicing incoordination). SMRs in AOS often cause a breakdown in fluency.

Assessment of motor speech/planning may include an analysis of the speech features associated with each speech subsystem (i.e., respiration, phonation, resonance, and articulation), as follows:

• acoustic features (e.g., “inconsistent pitch variability”)
• articulation (e.g., “imprecise” consonants)
• vocal quality (e.g., “hoarse”)
• intelligibility (e.g., “approximately 50% intelligible in conversation”)

Differential Diagnosis

AOS often co-occurs with other neurogenic communication disorders such as dysarthria and aphasia. Differentiating between AOS, dysarthria, and aphasia can be difficult due to similarities in disorder characteristics (Duffy, 2020; Graff-Radford et al., 2014; Haley & Jacks, 2023).

AOS does not involve changes in muscle tone or strength, nor does AOS involve the language comprehension or production deficits that characterize aphasia.

Accurate assessment is important for differential diagnosis. The chart below provides a basic comparison between the characteristics of AOS, dysarthria, and aphasia.

*See the Distinguishing AOS From Aphasia section below for further details.

This chart does not capture all the nuances of differential diagnosis of AOS, which are elaborated below.

Distinguishing AOS From Dysarthria

The dysarthria subtypes that are most difficult to distinguish from AOS are ataxic dysarthria and unilateral upper motor neuron dysarthria. Unilateral upper motor neuron dysarthria often co-occurs with AOS when the lesion occurs in the left hemisphere, whereas ataxic dysarthria is associated with cerebellar damage.

Speech subsystem assessment is helpful when distinguishing AOS from dysarthria. Unlike AOS, dysarthria is generally not influenced by the automaticity of speech production, stimulus modality, and linguistic variables (Duffy, 2020).

Poorer performance on SMRs is associated with AOS, whereas poorer performance on AMRs is associated with ataxic dysarthria (Duffy, 2020). See ASHA’s Practice Portal page on Dysarthria in Adults.

Distinguishing AOS From Aphasia

AOS and aphasia frequently co-occur and can be difficult to distinguish between. Duffy (2020) notes distinctions between AOS and aphasia reflected in the comparison chart above. However, some characteristics such as prosody and speech sound errors following a neurological injury may not be easily classified.

Prosodic errors and groping for articulatory postures can be seen in both aphasia and AOS, although they may present differently. However, because AOS and aphasia frequently co-occur, groping and prosody are likely not the most useful distinguishing features for differential diagnosis.

Although speech sound errors can arise from different processing impairments (motor planning deficits in AOS vs. linguistic breakdowns in aphasia), error patterns are often similar, particularly in very mild or very severe presentations. Additionally, severe aphasia may mask the clinical features of AOS, and severe AOS may limit the assessment of language. See ASHA’s Practice Portal page on Aphasia.

Assessment Considerations: Cultural and Linguistic Factors

Although the impact of AOS on speech characteristics is the same across languages (i.e., disrupted articulation and prosody), the impact on communication may be different. For example, speakers of tonal languages may require special consideration when working with AOS, as prosodic deficits may change the meaning of a given word.

SLPs consider the influence of cultural and linguistic factors on the individual’s communication style and the potential impact of impairment on function when selecting screening and assessment tests. The assessment is conducted in the language(s) used by the person with AOS, with the use of interpretation services as necessary (see ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators).

Comprehensive documentation includes descriptions of any accommodations and modifications made to standardized assessment to account for cultural and linguistic variations. If a standardized test is modified or if accommodations not allowed for in the assessment are provided, standardized scores are invalid and inappropriate to report.

The goal of treatment for AOS is to increase the individual’s independence in communication and social participation.

Interventions are designed to

• capitalize on the unique strengths of the individual;
• facilitate the development, redevelopment, or maintenance of skills;
• teach appropriate accommodations and compensations, as needed;
• improve (or maintain, in the case of degenerative disease) speech production, intelligibility, naturalness, and efficiency; and
• incorporate augmentative and alternative communication (AAC), when indicated.

Barriers to successful communication and participation can be minimized for individuals with AOS by

• modifying the environment (e.g., reducing background noise, maintaining eye contact, and decreasing the distance between the speaker and the listener),
• informing listeners about the individual’s communication needs and their preferred method of communication, and
• teaching strategies (e.g., repeating, rephrasing, using gestures, writing) for repairing communication breakdowns.

See Person-Centered Focus on Function: Acquired Apraxia of Speech [PDF] for an example of functional goals consistent with the International Classification of Functioning, Disability and Health framework (World Health Organization, 2001).

Treatment Considerations

Clinicians work to foster partnerships that allow clients and their care partners to become active participants in collaborative goal setting and the development of client-centered therapy plans. Please see Focusing Care on Individuals and Their Care Partners.

When designing a treatment program for an individual with AOS, consider the following factors.

Client Autonomy and Personal Preferences

• Treatment may begin with meaningful and self-selected speech stimuli (e.g., words and phrases), as appropriate.
• When patients choose their practice conditions (e.g., which target to practice first), their motor skill learning is improved (Wulf & Lewthwaite, 2016).

Principles of Motor Learning

Principles of motor learning impact the structure of practice and feedback. Clinicians can modify practice by the amount and schedule of practice time and the variability and complexity of the targets during practice. For example, blocked, constant practice is associated with skill acquisition, whereas random, variable practice is associated with retention and transfer (Maas et al., 2008). Feedback can be modified in its frequency and focus, moving from frequent knowledge of performance feedback (e.g., “You put your lips together”) during skill acquisition to variable knowledge of results feedback (e.g., “That was correct”) during retention and transfer. Clinicians may also incorporate principles of neuroplasticity during treatment planning, including specificity of training, repetition, intensity, and salience (Kleim & Jones, 2008; Ludlow et al., 2008). Clinicians consider each of these principles, their intersection with each other, and differences in their application between nonspeech and speech tasks when choosing interventions, selecting targets, and recommending schedule and dosage.

Individual client factors that may influence motor learning include

• the severity of the underlying subsystem impairment,
• the natural history and prognosis of the underlying neurologic disorder,
• the presence and severity of co-occurring conditions (e.g., aphasia, cognitive impairment, dysarthria),
• the client’s response to cueing,
• the client’s accuracy and ability to modify motor performance, and
• client and care partner preferences and opportunities for supported practice.

Task Difficulty

• Stimulability is often used to determine initial therapy targets; however, more difficult targets may promote better generalization (Ballard, 2001; Maas et al., 2008; Odell, 2002).
• Motor performance and learning may be enhanced by setting positive expectations that a learner will be able to complete a task (i.e., moderating perceived task difficulty; Wulf & Lewthwaite, 2016).

Task Hierarchy

Therapeutic tasks may start at a level where the individual can have some degree of success (see, e.g., Guadagnoli & Lee, 2004). The complexity of initial stimuli is chosen based on the client’s performance in the assessment and stimulability testing alongside considerations of treatment approaches.

Examples of Stimulus and Task Variables That Affect Responses*

*Source: Duffy (2020)

Feedback

• Skill acquisition may be enhanced by feedback that is frequent and specific.
• Skill retention and generalization may be greater when feedback
  • is intermittent rather than constant (e.g., feedback is provided on 60% of trials, not 100% of trials),
  • is general rather than specific (e.g., “That was correct” vs. “You made the correct sound because you closed your lips fully”), and
  • involves input from the person receiving treatment (e.g., deciding when they want to receive feedback from the clinician).
• Providing feedback following correct responses rather than incorrect responses may enhance learning (Wulf & Lewthwaite, 2016). However, individuals with AOS may have reduced awareness of their errors and may not always be accurate when self-assessing their errors (Wambaugh, Shuster, et al., 2016). Thus, it may be necessary to address error awareness in treatment.
• Self-monitoring and self-correction can facilitate learning and maintenance of skills. Clinicians may teach individuals how to monitor or judge their speech production. For some patients, simply refraining from providing immediate feedback may provide an opportunity to self-reflect, identify errors, and attempt to self-correct.

Feedback is an important aspect of motor learning. These external cues may support motor relearning in individuals with AOS who do not receive sufficient internal sensory feedback to recognize errored movements or productions. Many treatments for AOS incorporate sensory cueing. Cueing may occur in only one modality or using a combination of multiple modalities (i.e., multisensory approach) and often seeks to build proprioception (i.e., the ability to sense the body’s—including articulatory muscles—position in space).

Auditory/Verbal Cueing

Auditory/verbal cueing methods provide instruction on how to move the articulators to produce the desired sounds (e.g., “Press your lips together”). Auditory/verbal cueing approaches may also involve providing models of speech productions or playing recordings of a client’s speech productions in order to provide feedback or encourage self-feedback.

Tactile Cueing

Tactile cueing methods use direct tactile input to guide accurate speech production. The SLP provides a tactile cue by touching or applying pressure to the person’s face, neck, and head. Alternatively, clinicians may ask clients to touch their own face, neck, or head to build awareness and for self-correction of errors in articulatory placements, voicing, or resonance.

Visual Cueing

Visual cueing methods provide visual cues for shape, placement, or movement of the articulators. Visual cues can be provided via low-tech methods (e.g., simple hand signs, direct visualization of target productions, or visual feedback via a mirror) or more technologically advanced methods that use biofeedback, such as

• acoustic/spectrographic feedback displays, which use visual representations of frequency and/or loudness to provide feedback on speech sound production (see, e.g., Hitchcock et al., 2023);
• electromagnetic articulography, which uses miniature receiver coils placed on and in the mouth to record and provide a visual display of tongue, mouth, palate, and jaw movements;
• electropalatography, which provides visual feedback through the use of a palatal device with electrodes to record and visualize contact of the tongue on the palate (Howard & Varley, 1995; Mauszycki et al., 2016); and
• ultrasound visual biofeedback, which provides a visual display of tongue movement and position during speech.

Treatment Approaches

Treatment can be

• restorative—aimed at improving or restoring impaired function,
• compensatory—aimed at compensating for deficits not amenable to retraining, and/or
• maintenance—aimed at maintaining speech functioning in cases of degenerative conditions (e.g., progressive AOS).

Restorative approaches focus on reestablishing motor plans/programs and improving the ability to select and activate them and set program parameters (e.g., speed) in specific situations (Knock et al., 2000). These treatment approaches include articulatory–kinematic approaches, sensory cueing, rate and/or rhythm control, and various combinations thereof.

Compensatory approaches involve the use of strategies or external aids to facilitate successful communication (e.g., using gestures, writing, or drawing to communicate).

Some interventions may be used in both restorative and compensatory approaches. For example, AAC is used to provide functional communication options while supporting, enhancing, and potentially improving speech production (Lasker et al., 2008; Yorkston et al., 2010).

Maintenance therapy services are designed to maintain a level of function or prevent further functional decline. Maintenance therapy may be episodic (i.e., delivered over a short period of time with periodic reassessment of needs as the disease progress). Payer coverage policies for maintenance services may vary. Treatment targets, goals, outcome measures, and documentation may look very different for cases of degenerative AOS compared to other AOS populations.

Treatment Options

Below are brief descriptions of treatment options for addressing AOS, grouped by approach. This list is not exhaustive, and the inclusion of any specific treatment does not imply endorsement from ASHA. As previously mentioned in this page, treatment of AOS generally incorporates feedback and cueing. See the Feedback section above for more information. See the Treatment section of the Apraxia of Speech (Adult) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective about the various treatment options for AOS.

Treatment selection depends on

• the severity of the disorder;
• the communication needs, preferences, and goals of the individual;
• the individual’s
  • prognosis,
  • insight, and/or
  • ability to repair breakdowns;
  • social determinants of health; and
  • the presence and severity of co-occurring conditions (e.g., cognitive–linguistic deficits, aphasia, dysarthria).

Apraxia in other systems may play a role in treatment. For example, limb apraxia may impact access to AAC or the ability to perform gestures or use sign language.

Script Training

Script training is a functional approach to treating neurogenic communication disorders (Holland et al., 2002). It is used to facilitate verbal communication on specific topics selected by the person with AOS. Script training targets a select number of personally relevant topics. Phrases are practiced so that they become automatic and can be inserted into conversations relatively fluently (Henry et al., 2018; Youmans et al., 2011). Script training may be conducted using audio/video recordings as a method of visual and auditory cueing, as in the case of Video-Implemented Script Training for Aphasia (VISTA).

Articulatory–Kinematic Approaches

Articulatory–kinematic approaches are based on principles of motor planning/programming. 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, and tactile cues);
• consider practice schedules, such as random versus blocked practice (see, e.g., Wambaugh, Nessler, et al., 2014, 2016); and
• provide appropriate types and schedules of feedback regarding performance.

See Bislick et al. (2012) and Maas et al. (2008) for discussions of motor learning principles as they apply to the treatment of motor speech disorders.

Integral Stimulation

Integral stimulation is a technique that uses imitation and sensory stimulation (e.g., auditory, visual, proprioception) to aid movement practice for speech production. This technique follows a “listen to me, watch me, do what I do” approach, in which the person is instructed to listen to and watch how the clinician produces a targeted sound sequence or word/phrase and then joins in simultaneous production of the target. The clinician eventually removes their model so that the individual may practice the movements independently. Integral stimulation is used as a component of many treatment approaches (e.g., sound production treatment [SPT], described previously). It was first described as part of Rosenbek et al.’s (1973) eight-step continuum.

SPT

SPT (Wambaugh, 2001; Wambaugh et al., 1998) is intended to improve the production of sound targets that are problematic for a particular speaker (i.e., speech targets in SPT are individualized and can cover sounds or sound combinations of words of varying lengths and even phrases or sentences). It uses a response-contingent treatment hierarchy that incorporates modeling and repetition, including integral stimulation (i.e., “Watch me, listen to me, and say it with me”), and practice of minimal-contrast word pairs (e.g., “wake” and “lake”). Auditory, visual, and tactile cues are used alongside articulatory placement cues and graphemic cues. SPT is one of the most systematically investigated treatments for AOS (see, e.g., Bailey et al., 2015; Wambaugh & Mauszycki, 2010; Wambaugh, Nessier, Wright, & Mauszycki, 2014; Wambaugh, Shuster, et al., 2016).

Speech Motor Learning Treatment

Speech motor learning treatment addresses the underlying ability to plan and program the production of motor speech targets. This treatment progresses through phonetic contexts that gradually increase in difficulty and length.
Treatment begins at the nonword level, using combinations of targeted consonants and vowels to form practice stimuli. Treatment progresses from the imitation of nonwords to self-initiated production of the same nonwords and, ultimately, to real words and phrases containing the trained nonwords. This hierarchical approach increases in complexity and length over time to support generalization. For further information, see van der Merwe (2011).

Motor Learning Guided Approach

The motor learning guided (MLG) approach is a treatment protocol designed to promote long-term retention of motor learning and programming. The MLG approach features an imposed 2- to 3-second delay between productions, in which participants are asked to reflect on their performance prior to their next production. The MLG approach also reduces the frequency of clinician feedback and uses knowledge of results (i.e., whether a production was accurate or not) rather than knowledge of performance (i.e., how to alter articulatory placements to improve performance). This frequency and type of feedback is designed to promote greater self-awareness and self-correction of errors.

Phonomotor Treatment

Phonomotor treatment is a model that has been mostly used for aphasia treatment but is beginning to be investigated for AOS treatment. It is intended to help individuals with AOS critically evaluate specific aspects of sound production. Treatment begins with sounds in isolation and may progress to syllables and syllable strings.

Phonomotor treatment uses

• visual cues (line drawings) and visual feedback (using a mirror);
• verbal instruction of articulatory placement;
• modeling, repetition, and written cues;
• verbal feedback from the clinician; and
• Socratic questioning techniques (e.g., “How did your tongue move when you made that sound?”).

Rate and Rhythm Control Approaches

Rate and rhythm control approaches (also called prosodic facilitation approaches) target intonation patterns (melody, rhythm, and stress) to improve speech production. Although these approaches are aimed at improving prosody, they may also result in improved articulation for individuals with AOS (Mauszycki & Wambaugh, 2011).

Contrastive Stress

Contrastive stress is varying the emphasis or stress on different parts of the sentence to change the meaning. For example, the meaning changes significantly if one modifies the words that are stressed in the phrase “I want to go to the store.”

Clinician: “Who wants to go to the store?”
Individual with AOS: “I want to go to the store”
Clinician: “You want to go where?”
Individual with AOS: “I want to go to the store”

Contrastive stress can be used in AOS treatment in target phrases or sentences to improve the person with AOS’s ability to produce speech with varying intonation contours (Wertz et al., 1984).

Melodic Intonation Therapy

Melodic intonation therapy (MIT) is a therapy program originally designed for individuals with severe nonfluent aphasia that uses melodic concepts (i.e., pitch, rhythm, and stress) to improve expressive language (Sparks et al., 1973). MIT has potential for motor speech problems treatment (Zumbansen et al., 2014) and may have application for AOS treatment.

Individuals begin by producing simple phrases with a specific intonation provided by the clinician and then gradually increasing syllable length and length of utterance. Visual and tactile cues are given by the clinician, and phrases of social and functional importance to the individual (e.g., “I love you”) are practiced. Reliance on intonation is gradually decreased over time.

Metrical Pacing Treatment

Metrical pacing treatment uses sequences of tones that are based on natural rhythm and prosody to guide speech production. Individuals are asked to produce target utterances at the same time as computer-generated pacing signals. The signals can be varied by rate (corresponding to speech rate) and metrical structure (syllable number and stress pattern) to simulate natural stress patterns of speech (Brendel & Ziegler, 2008).

Rhythmic Pacing Strategies

Rhythmic pacing strategies use various rate control techniques to provide temporal cues that help pace speech production by using constant rhythmic cues. Techniques include hand or finger tapping and use of a pacing board or metronome (Dworkin et al., 1988; Mauszycki & Wambaugh, 2008; Wambaugh et al., 2012).

AAC Systems

An AAC system is an integrated group of components used to enhance communication. AAC uses a variety of techniques and tools to help the individual express thoughts, ideas, wants, needs, and feelings. AAC can supplement existing expressive spoken communication or can be an alternative to spoken language.
It is important to determine the individual’s willingness to use the AAC approach when considering AAC. See Lasker and Bedrosian (2001) for a discussion on promoting the acceptance of AAC by adults with acquired communication disorders. See ASHA’s Practice Portal page on Augmentative and Alternative Communication (AAC) for additional information.

Combined Aphasia and Apraxia of Speech Treatment

Combined Aphasia and Apraxia of Speech Treatment (CAAST) combines SPT with response elaboration training (RET; Kearns, 1985). CAAST allows clinicians to simultaneously address expressive language skills associated with aphasia and sound errors associated with AOS.

Clinicians encourage individuals to expand and then repeat verbal responses to a stimulus (e.g., describing a picture). Any sound errors during repeated productions of expanded responses can then be addressed using the SPT response-contingent hierarchy (Wambaugh et al., 2018; Wambaugh, Wright, et al., 2014).

Please see ASHA’s Practice Portal page on Aphasia for further information on aphasia treatment.

Treatment Considerations: Factors Influencing Treatment Decisions

Service Delivery

In addition to determining the optimal speech and language treatment for an individual with AOS, the clinician considers other service delivery variables that may have an impact on treatment outcomes, such as format, modality, provider, dosage, timing, and setting.

Format

Format refers to the structure of the treatment session (e.g., group and/or individual). The appropriateness of the treatment format depends on the primary goal at a particular point in the treatment process. For example, initial treatment may involve intensive drills to improve speech production and/or practice in using AAC aids. However, once the individual has made progress on these goals, group treatment may be incorporated to provide opportunities for practice.

Telepractice can be used to treat AOS, when appropriate. However, telepractice introduces challenges. For example, video/sound quality and signal delay can impede the provision of timely feedback.

Although there are reviews of teletherapy in other populations, there are limited studies regarding the use of teletherapy to treat AOS. Generally, telepractice appears to be feasible for AOS treatment, but modifications to the treatment materials and protocol may be necessary.

Telepractice may be a viable option for treating AOS. However, clinicians may need to adjust feedback and cueing strategies because telepractice can limit the clinician’s ability to use tactile and kinesthetic cueing.

See ASHA’s Practice Portal page on Telepractice for further information.

Provider

Provider refers to the person providing the treatment (e.g., SLP, trained volunteer, caregiver). SLPs treat the speech motor and communication aspects of AOS and train individuals in the use of AAC. It is important to involve care partners and other communication partners in the treatment process to help them understand the individual’s communication needs, learn strategies to facilitate communication, and support home practice if needed. Other professionals (e.g., physical therapist or occupational therapist) may be involved in the treatment of comorbid deficits. It is important for SLPs to collaborate with other professionals regarding treatment and to take advantage of opportunities for co-treatment when appropriate.

Dosage

Dosage refers to the frequency, intensity, and duration of service. Treatment dosage for AOS should be consistent with principles of motor learning (Maas et al., 2008; Rosenbek et al., 1973; Wambaugh, Nessler, et al., 2014). Intensive and individualized treatment is often stressed because of the need for repetitive production practice in motor speech disorders such as AOS. See Ballard et al. (2015) for a discussion of average dosage.

Timing

Timing refers to the initiation of intervention relative to diagnosis. Generally speaking, treatment begins as early as possible after onset. Treatment can also be appropriate when an extended amount of time has elapsed since onset, particularly if an individual has not received any treatment for AOS during that time.

Setting

Setting refers to the location of treatment (e.g., home, community-based). A naturalistic treatment environment that incorporates a variety of communication partners may facilitate generalization and carryover of skills.

ASHA Resources

• Aphasia
• Apraxia of Speech in Adults
• Assessment Tools, Techniques, and Data Sources
• Childhood Apraxia of Speech
• Dynamic Assessment
• Focusing Care on Individuals and Their Care Partners
• Person-Centered Focus on Function: Acquired Apraxia of Speech [PDF]
• Speech Sound Disorders: Articulation and Phonology

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• American Stroke Association: Aphasia vs. Apraxia
• National Institute on Deafness and Other Communication Disorders (NIDCD): Apraxia of Speech  
• United States Society for Augmentative and Alternative Communication

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Acknowledgements

Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Acquired Apraxia of Speech page:

• Kirrie J. Ballard, PhD, CCC-SLP
• Lauren Bislick, PhD, CCC-SLP
• Lisa Bunker, PhD, CCC-SLP
• Heather M. Clark, PhD, CCC-SLP
• Shannon Cook Mauszycki, PhD, CCC-SLP
• Joseph R. Duffy, PhD, CCC-SLP
• Katarina Haley, PhD, CCC-SLP
• Adam Jacks, PhD, CCC-SLP
• Edwin Maas, PhD
• Malcolm R. McNeil, PhD, CCC-SLP
• Christina Nessler, MS, CCC-SLP
• Edythe A. Strand, PhD, CCC-SLP
• Rene Utianski, PhD, CCC-SLP
• Darlene S. Williamson, MA, CCC-SLP

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Acquired Apraxia of Speech. [Practice Portal]. https://www.asha.org/practice-portal/clinical-topics/acquired-apraxia-of-speech/.