How to Effectively Treat Childhood Apraxia of Speech?
This blog aims to help SLP’s who work with children with childhood apraxia of speech. To make it simple and easy to understand I have divided this article in to two parts.
PART I: Evidence-based approaches in treating CAS
PART II: Five steps to make treating CAS easy, predictable and more successful.
PART III: Evidence-based approaches in treating CAS
There are several approaches designed to treat CAS; however, only two stand out and are found to be most effective with supporting evidence:
A. Motor Programming Approach
B. Linguistic Approach
A. The Motor programming approach has the following principles, which makes it the most evidence-based practice in treating CAS.
Frequent Practice: CAS is a motor planning disorder and frequent practice will benefit in producing the targeted sounds consistently and effectively with more clarity.
Accurate speech movement and feedback: Children need accurate feedback to correct any errors in their speech. Feedback provided must be accurate and constructive. For example, if you are trying to work with the sound /ta/, and the child produces /tha/, then you need to give the child an appropriate feedback so that he would be able to correct the /tha/ to targeted /ta/. Avoid saying “it’s not /tha/, it’s /ta/; instead, you can say “yes, you’ve tried it right, now for the next trial, try to put your tongue behind your upper teeth and say “ta”.
A positive feedback can give you more success, because you’re building up the child’s confidence by letting him know that he’s right.
Multi-sensory Inputs: Use visual, auditory, tactile (as well as proprioceptive and vestibular) inputs to help children produce the targeted speech sounds.
Considerations for Practice: Duration, intensity and frequency of therapy sessions need careful considerations to provide adequate support for children and their families.
The above-mentioned principles are part of the motor programming approach and have the most evidence to it.
B) The Linguistic Approach (Shelly Velleman), has incorporated the following language based principles in treating CAS, that makes it the go to approach for SLPs.
Linguistic and Phonological Aspects
Functional communication or using whatever the child has learned, in a more natural setting.
PART II: Five Steps to Make Treating CAS Easy, Predictable and More Successful
I have incorporated the motor programming and linguistic approaches into my practice and have come up with five steps that make treating CAS easy, predictable and more successful. The illustration below will make it more easy to understand.
Rapport building: One significant step to gain the child’s trust before introducing any therapy strategies is rapport building, and is extremely important in a speech therapy session. Using the child’s favourite toys and activities can catalyse building trust and the joy of learning. When a child is able to trust his therapist and enjoy the learning process, the targeted skills or sounds can be achieved much faster than otherwise.
Imitation: Most skills that we teach children with speech sound disorders require the ability to imitate. CAS is a motor planning disorder and is crucial to help children understand the placement of articulators through oral motor imitation. The following steps can help teach imitation progressively.
Start from easy tasks and progress to difficult ones. I would recommend that you begin with gross motor imitation because, larger muscles groups are easier to work with, as compared to the teeny-tiny muscles of the mouth.
Ensure to elicit voluntary sound production prior to the next step.
Combine into Meaningful Words: Start with vowel or a consonant that is already existing or easy to imitate. Using gestures along with vocalisations can be an added benefit as it becomes easy for children to achieve the targeted sounds.
Combine sounds with images and pictures to make them meaningful units; then, combine single sounds into words by using vowel-consonant combinations.
Once children start using about 50 words, introduce short phrases.
Sentence Level: Once children start using about 50 words, introduce short phrases. Use the short phrases and expand them into sentences by adding other words to it (preferably one additional word at a time). Reading practice can be of great help at this juncture as syntax and morphological structures get easily added into the child’s vocabulary.
5. Introduce High-Demand Tasks
The final step is to build conversations. Start with book reading and summarising a short stories. Follow this by introducing the child to social communication groups with other children to build advanced and high demand speech tasks. If your clinic does not have a social communication group take the help of grown-ups (colleagues or parents).
While you are working from step one through step five, give careful considerations to the C-L-R-E-P-P. I would like to remind you that this is what I use in my speech therapy sessions. I don’t claim them to be evidence based, but I have seen children progress pretty well, with the following considerations.
C – L – E – R – E – P – P
C– Cognition
Choose your activities based on the child’s cognitive skills. Neither keep it too simple as it would lead to boredom; nor too complex, where the child is unable achieve the target.
L – Learning capacities
Each child has their own learning capacity, some learn fast, while others take a long time to learn. Allow children to learn at their comfortable pace.
E – Effort
Children with CAS find achieving speech targets very effortful, and can get frustrated and/ or lose motivation before achieving their target. Therefore, ensure activities or the targets that you have aimed at, are not too effortful, or way above the child’s abilities to achieve.
R & E– Regulation & Engagement
Regulation and engagement go hand in hand, so you must keep the child regulated engaged with you throughout the session.
P – Prosody
Children with CAS are most likely to have difficulties in prosody and intonation, as a result, their speech may sound robotic.
Varying pitch, loudness and rate of speech can help improve prosody and must be considered as part of therapy right from the start.One of the studies that I was going through recently, stated that if music is introduced early on life; children are able to acquire prosody and intonation much easier.
P – Parent Involvement and Prosody
Parent involvement is a must and what was done in the session must be carried forward at home by caretakers/ parents in different settings, for repeated practice. It could be during a clean-up time at home, play and fun time, or even in their cars when they are driving back home.
Functional speech has to be elicited in natural environments by caregivers/ parents consistently for consistent progress.
In conclusion, using evidence based approaches along with practical steps listed above can make your speech therapy sessions a rewarding experience to you and the children you work with.
I have used the above strategies in my sessions and found it extremely useful, I hope you do too!
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