What is Childhood Apraxia of Speech
Just imagine. You are trying to say something. As you struggle to get the word out, the word emanating from your mouth sounds nothing at all like what you have intended. That is what many children with Childhood Apraxia of Speech (CAS) struggles with.
Welcome to the world of children with childhood apraxia of speech. In fact, this groping movement and inconsistency in producing the target sound is one of the key characteristics of the disorder.
The Mayoclinic defines childhood apraxia of speech as an uncommon speech disorder in which a child has difficulty making accurate movements when speaking.
Speech Therapy for Childhood Apraxia of Speech
When a speech therapist works with your child for CAS, she will note down his current repertoire and also create a list of functional words that are important for him. These include words that your child may yet be able to say.
Even though some of these words are not within his inventory, they can still be worked on by simplifying the words. This simplification is not something that is one-size-fits all either. Rather, it is based on what is within reach for each child.
For each word, there are many levels of simplification. The child is moved up along the various levels as she progresses such that she is getting closer and closer to the target word.
Speech therapy for childhood apraxia of speech is based very much on motor learning theory. And the key principle of motor learning theory is that of repetition in context. Therefore, in order for your child to get better, it is important for her to make repeated attempts at saying a target word.
However, frequent failure is demoralising for children. This may result in a child who may even stop trying. This throws a spanner in therapy as repetition is the key to overcoming childhood apraxia of speech. To avoid this situation, it is thus important for parents to help their children by using cues. These cues are then slowly faded as the child gains mastery in the words he is learning.
Now that you know how cues may help in therapy for CAS, here are some that you can try as you help your child along:
Visual/Tactile Cues
In my experience working with children, I find that the young ones in early intervention are usually really aversive to people touching their faces. As such, I tend to rely more on visual and auditory cues.
Visual cues are great as they help your child to see which articulators are involved as well as how the sounds are produced. This can be done by using hand signals such as Cued Articulation (or other systems such as the ones devised by Pamela Marshalla) around your mouth. It does not matter what system you use, just as long as you and your team are all consistent. I have included a video from Svetlana Ava that shows the various hand signs of Cued Articulation.
Another visual cues that you can use are oral postural cues. This means emphasising the placement of your own articulators (i.e. your mouth, tongue, lips etc) for the initial, medial or final consonant, syllables or full words/phrases.
For some sounds like /t/ and /k/ which are a little harder to see from the outside, I might use a hand puppet of a mouth to show the child where exactly the tongue is placed. The Super Duper Inc’s Jumbo Mighty Mouth puppet is especially useful for this purpose. Alternatively, there are apps like Speech Tutor and videos online that you can use to show your child what goes on inside the mouth when we make a certain sound.
Auditory Cues
Another form of non-invasive cues are auditory cues. These come: in many different forms.
Explanation cues
You can help your child to position his articulators by telling him how to do so. Let say we are working on the /f/ sound. You may tell your child to bite his lips and blow like in the /f/ sound.
Pictorial cues
Another form of cues combines both visual and auditory cues. This is usually effective for more visual learners because it involves more senses by linking sounds to pictures.
Let’s take the /t/ sound for example. You may liken it to the sound of a clock, and help the child link it to an image of a clock.
In addition, it also makes cueing easier, as you can just say “make the clock sound” instead of “tap your tongue on the bump behind your top front teeth”.
For more such examples, refer to Easy Does it for Apraxia by Strode and Chamberlain.
Physical Cues
Physical cues involve physically manipulating your child’s articulators to help him achieve the correct position for the production of the targeted sound. The easiest sounds to cue using physical cues are usually the bilabials (lip sounds such as /b/, /p/, /m/). For these sounds, you can help the child to put his lips together either with your hands, or by using tools. Some tools that may be useful to elicit various oral positions are Talk Tools. You can also read more about how to cue the different sounds in Sara Rosenfeld-Johnson’s book.
In recent literature, the evidence suggests that oromotor exercises like horn-blowing and chewing do not translate to speech production. However, some of the tools may still be useful to help your child arrive at the correct oral placement. From there, it is essential that you quickly transition your child to the production of the sound so that he can translate the learnt motor plan to speech.
As mentioned earlier, I find that many children dislike having their face touched, so I generally reserve the physical cues for the most severe clients, after everything else have failed.
Troubleshooting
If the child is still unable to achieve the word, there are other ways to troubleshoot.
If the child leaves out the final consonant
Some children have the tendency to leave out the final consonant. So you can help them to add in the last sound by dragging out the first syllable. Let’s say you are working on the word “beet”. You may model “beee—t” and then ask your child to try it out.
If the child makes errors on multisyllabic words
Multisyllabic words are particularly difficult for children with CAS, as their main challenge is in sequencing sounds. One way we can help them out is by a process known as “backward chaining”. We can do so by getting them to say the final sounds first.
So for example, in the word “banana”, we can get the child to say “nana” first. And once they can say “nana”, we can then go on and get them to say “banana”.
If the child makes errors on diphthongs (two vowel sounds that go together such as boy)
Diphthongs are made up of two vowel sounds. Some examples are “boy” and “bike” This means that they are more difficult than individual vowels as it requires sequencing. One way that we can make diphthongs easier is by dragging out one vowel before joining it to the next. For example, in the word bike, you can get your child to say “baa-eek” instead.
If the child makes errors with the number of syllables or prosody
First place some blocks on the table. Then you can touch the blocks as you say each sound. If you want to increase the rhythm, you may place the blocks closer together on the table. This gives a visual representation of the number of sounds as well as help them visualise the prosodic nature of the word.
If the child has voicing errors
Some children tend to voice everything. And you can help them to devoice by removing the vowel in between. For example, if you are working on the word “dot”, you might get the child to say /d/ and /t/ together first. Once he can do so successfully, get him to add in the vowel.
Conclusion
The use of cues is effective in helping children with childhood apraxia of speech achieve better accuracy when talking. However, it is also important to gradually fade these cues as they improve so that children can gain mastery.
In a way, cues can be likened to teaching a child how to ride a bike. Once the child achieves balance, we have to stop holding on; otherwise she will never learn how to ride independently.
Overcoming childhood apraxia of speech is not easy, but your determination and sweat can determine how far your child goes.
See also: What Parents can do to Help Their Child with Childhood Apraxia of Speech
