Effective Treatment For Childhood

EFFECTIVE TREATMENT FOR
CHILDHOOD APRAXIA OF
SPEECH
“… a neurological childhood
(pediatric) speech sound disorder in
Presentation for which the precision and consistency
OHIO SPEECH-LANGUAGE-HEARING of movements underlying speech are
ASSOCIATION impaired in the absence of
March 19, 2011
neuromuscular deficits (e.g.,
abnormal reflexes, abnormal tone).
ASHA Ad Hoc Committee on Apraxia of Speech in Children
Presented by
Margaret (Dee) Fish, M.S., CCC-SLP
Highland Park, Illinois
•  Muscle selection
CAS may occur as a result of known
neurological impairment, in association with •  Direction of movement of the articulators
complex neurobehavioral disorders of
known or unknown origin, or as an
idiopathic neurogenic speech sound •  Distance the muscles need to move
disorder. The core impairment in planning
and/or programming spatiotemporal •  Speed of muscle movement
parameters of movement sequences
results in errors in speech sound production
•  Amount of force applied to the articulators
and prosody.”
ASHA Ad Hoc Committee on Apraxia of Speech in Children
•  Degree of muscle contraction
Effec%ve Treatment of CAS
Margaret A. Fish, M.S., CCC‐SLP
OSLHA March 19, 2011 1
1 1
2 2
3 3
4 4
5… 5…
  Consonants: limited repertoire, omissions, subs*tu*ons (more 2
  Inconsistent errors in produc*on of consonants and vowels with and 3 feature errors) [e.g., ton/sun (one feature) versus bun/sun
repeated produc*ons of syllables and words;
(three feature]
  Lengthened and disrupted coar2culatory transi2ons between
sounds and syllables;   Vowels: limited repertoire, subs*tu*ons, distor*ons, omissions
  Inappropriate prosody, especially in the realiza*on of lexical or
  Variability of phoneme errors (e.g., /s/ produced as /s, t, p, h/)
phrasal stress.
ASHA Ad Hoc Commi;ee on Apraxia of Speech in Children
  Connected speech more unintelligible than expected given
7
phoneme repertoire or results of single‐word ar*cula*on test
  Use of simple word shapes   Differences in suprasegmental features (linguis*c and contras*ve
stress, rate, pitch, loudness)
  Increased errors with increased word shape complexity
  Limited vocaliza*ons/babbling during infancy   Voicing errors (e.g., b/p ) and resonance errors (e.g., m/b)
  Automa2c speech may be beIer than voli2onal produc*ons
  Difficulty producing voli*onal oral movements
  Groping or silent posturing
  Possible feeding difficul*es during infancy (unrelated to significant
  Regression (loss of sounds and words) muscle tone weakness)
  Poor diadochokine*c rates, accuracy, rhythmicity
  Possible limb and/or hand praxis difficul*es
9 10

•  No sensory deficits, muscular weakness, or peripheral organic

  Recep*ve language (typically) exceeds expressive language disorder
•  Delayed development of connect play schemes
  Morpho‐syntac*c difficul*es •  Receptive-expressive language gap
•  Limited repertoire of consonants and vowels
  Late in aIaining first words •  Limited canonical babbling
•  Limited word shapes; tendency to produce isolated consonants and
  At risk for literacy difficulty vowels
•  Limited intonation patterns
•  Limited vocal output
Adapted from Davis, B.L. & Velleman, S.L. (2000).

11
•  More frequent loss of previously produced words
1.  Children with CAS have difficulty with planning and
•  Difficulty combining different syllables
programming the specific spa%otemporal parameters of
•  Groping for sounds speech movement sequences (described above) to reach
•  Use of idiosyncratic signs for functional communication the ini%al ar%culatory configura%ons and subsequent
•  Possible uncoordinated feeding patterns movement sequences.
•  Possible drooling
•  Motor milestones attained later than expected 2.  Because children do not speak one phoneme at a %me, it is
•  More difficulty with volitional than automatic nonspeech oral motor important to help facilitate not only the child’s ar%culatory
behaviors configura%on for each individual phoneme but, more
•  Presence of oral motor incoordination importantly, the child’s ability to transi%on from an ini%al
ar%culatory configura%on into and through the ar%culatory
•  Word order errors in simple phrases
configura%ons for the phonemes that follow.
Adapted from Davis, B.L. & Velleman, S.L. (2000).
3. Some researchers theorize that children with CAS do not have strong 6. When we plan remedia%on, we need to consider the “whole child”
internal representa%ons of the tac%le, kinesthe%c, and including related and coexis%ng challenges, temperament, family
propriocep%ve sensa%ons related to speech movements to support system, etc.
the planning and programming of the spa%otemporal parameters
of movement sequences for the desired auditory output. 7. Prosody challenges can further impact a child’s speech intelligibility
and influence how the child is perceived by others.
4. Children with CAS benefit from a mul%sensory approach to
treatment (incorpora%ng visual, auditory, tac%le, and cogni%ve 8. Children with CAS frequently exhibit language differences (syntax
cues) to acquire new motor speech plans, as well as ongoing and morphology).
prac%ce to habituate these plans.
9.  Vowel subs%tu%ons and distor%ons have a tremendous impact on
5. Giving and fading of cues and feedback in “real %me” helps support speech intelligibility.
a_ainment of and then generaliza%on of newly learned motor
skills.
10.  Children need opportuni%es to communicate in some mode(s)
What does research say about…
Whole prac*ce is preferable to Parts prac*ce
when working on speech
Parts prac*ce •  Begin at least at the syllable level (CV or VC)
•  Move to phrase level as quickly as possible
Whole prac*ce
•  Facilitate flexibility

Syllable/Word Shapes Sample words
Syllable/Word Shapes Sample words
CVC with assimila%on “pop” “toot” “cake”
C or V “sh” “mmm” “sss” “zzz”
“eye” “ah” “o”
*CVC without assimila%on “top” “hat” “home”
CV “no” “whee” “bye”
CV‐CV‐CV “banana” “dinosaur”
VC “up” “in” “ouch”
“bye daddy” “we go now”
CV‐CV with reduplica%on “mama” “dada” “boo‐boo” CV‐CVC “bu_on” “finish” “hopping”

“go home” “boy sit”
CV‐CV with assimila%on “mommy” “puppy” “bubb(le)” CVC‐CVC “cupcake” “helping” “goodnight”

“Mom sit” “push bus”
*CV‐CV with varied “bunny” “happy” “dino” Clusters (2 or 3; ini%al or “spin” “splash”
phonemes “hi ma” “we go” “no way” final) “hops” “jumped”
Mul%syllabics “alligator” “motorcycle” “jack‐o‐lantern”
What does research say about:
•  When teaching new movement pa_erns,
__________ prac*ce is recommended
Blocked prac*ce
“Hi Mom” “Hi Mom” “Hi Mom” “Hi Mom”
•  When trying to habituate skills, __________
prac*ce is recommended
Random prac*ce
“I got ball” “Give me” “Roll down” “Got it”
MOVEMENT ACTIVITIES 17
Soccer bowling-kick the target pictures down

•  Choose toys and ac%vi%es that allow for a with ball
repe%%ve theme or ac%on (e.g., puzzles, vehicles, Basketball-earn opportunities to toss ball in
hoop
animals, toy people) Long jump-jump over increasingly longer picture
•  Choose toys and ac%vi%es the child will want to do sets
repe%%vely (e.g., blowing bubbles, finding things in Picture hop-hop from picture-to-picture while
producing target
a bin of beans, sending cars down a racetrack)
Animal walk-produce targets while walking like
•  Find mul%ples of toys (a few of the same animals, different animals
toy foods, potato head pieces, etc.) Treasure hunt-use flashlight to locate hidden
pictures
•  Choose games that are quick and easy
Mailman-pretend to “mail” pictures
•  Use open‐ended ar%cula%on games
INCREASE LIKELIHOOD OF GETTING
ARTISTIC ACTIVITIES GREATER # OF TURNS
Block designs-early blocks to create designs

Large number dice-write larger numbers on
Tall tower-earn blocks to create tower blank dice (available from Superduper)
Dominoes-set up target pictures like a dominoes Large number spinner-place stickers with larger
game numbers over original numbers on a spinner
Stickers-earn little stickers for each target Magnet chips-place magnetic chips under
Progressive drawing-earn a new part of a pictures and produce target for each chip
picture (drawn by therapist) and try to guess collected
what it is Double dice roll- just roll two dice instead of
Earn it now – make it later-earn parts for one; add up the numbers to determine number
craft project that will be sent home with the of targets
instructions to make later
MISCELLANEOUS
Motor skills are:
Go Fish-ask “do you have a ____?” to
receive matching pairs Acquired more quickly
Memory-find matching pairs
A_ained more accurately
Simon Says-”Simon says…say your
word 6 times while tapping your and
head”
Louder/softer-Say it loud/soft, like Are be_er retained
you’re happy/sad, like you’re papa
bear/baby bear, etc.
WITH __________, ______ _________ SESSIONS
SERVICE DELIVERY VARIABLES WILL CHANGE OVER TIME
•  Number of treatment minutes per week DEPENDING ON THE FOLLOWING…
•  Severity of speech challenges
•  Age of the child
•  Number of sessions and length of each
•  Child’s mo%va%on
session
•  A_en%on capaci%es
•  Physical stamina
•  Individual, dyad, small group, classroom •  Types of goals being addressed in addi%on to the speech
praxis goals (language, social language, literacy/pre‐
literacy, play)
•  Push in or pull out •  Co‐exis%ng needs (motor, cogni%ve, medical, academic,
social, emo%onal) and %me needed to service these areas
4. SELECTING VOCABULARY
•  Phoneme repertoire
–  Consonants
Speech Linguistic Motivational Environmental Social Skills & •  Use consonant phonemes within child’s repertoire or for
Capacities Abilities Factors Factors Needs
which child is stimulable
•  Consider “early eight” (Shriberg, 1993) /m, b, j, n, w, d, p,
h/ for initial selection
•  Help child produce consonants in a certain manner (e.g.,
stops, fricatives) if that manner is absent from repertoire
•  Help child produce consonants of a certain place (e.g.,
bilabials, velars) if that place is absent from repertoire
•  Phoneme repertoire ESTABLISHING FLEXIBILITY
–  Vowels
TRY TO ESTABLISH FLEXIBLE PRODUCTION OF
•  Use vowel phonemes within child’s repertoire or for
which child is stimulable PHONEME SEQUENCES
•  Consider /ʌ (bus), i (tea), u (moo), ɑ (mama), o (no), e •  USING A WIDE RANGE OF COMBINATIONS INITIALLY AT
(neigh)/ for initial selection THE CV LEVEL USING PHONEMES WITH
–  CONSONANTS WITH DIFFERENT PLACE MANNER AND VOICING
•  Use established pure vowels to teach diphthongs (e.g., (e.g., me, bee, D, see, he, we)
out, hi, toy) –  VOWELS OF DIFFERENT SHAPES (TONGUE HEIGHT/TONGUE
POSITION/ORAL SHAPE) (e.g., bee, bah, bow, boo, bye)
•  MOVING TO TARGETS WITH INCREASINGLY COMPLEX
AND VARIED SYLLABLE SHAPES
•  AND TARGETS WITH VARIED PROSODIC FEATURES
Syllable Stress Patterns

When introducing new phonemes, •  Trochaic patterns (Sw “bunny,” SwSw “motorcycle”) are
more common in English than iambic stress patterns (wS
incorporate them into old syllable shapes “because,” wSwS “binoculars”) (Velleman, 2002)
BUT •  Consider choosing words with trochaic stress patterns

prior to words with iambic stress patterns
When introducing new syllable shapes •  At phrase level, use trochaic phrases for trochaic words
incorporate old phonemes and iambic phrases for iambic words
–  “Do you have a monkey?” trochaic
–  “I see a big balloon.” iambic
Davis & Velleman (2000)
FACILITATING CONTEXTS FACILITATING CONTEXTS
•  Connect same ending and beginning
•  Use naturally co-occurring phonetic consonants
environments (Davis & MacNeilage, 1990; –  (e.g., hot tea, black car, soup pot, bus stop)
1995) •  Final consonants – choose words where a
– Alveolar consonants tend to co-occur with high voiceless obstruent follows a lax vowel (Kehoe &
front vowels Stoel Gammon, 2001)
–  (e.g., sit, look, guess, nap)
– Labial consonants tend to co-occur with central
vowels •  Choose word with high front vowel in second
syllable
– Velar consonants tend to co-occur with high back
–  (e.g., mommy, baby, bunny)
vowels
COGNITIVE-LINGUISTIC AGE VOCABULARY
Choose words/phrases that are age appropriate/ Choose word that encompass a wide range of parts of
cognitively appropriate speech, not just easily picture-able nouns (e.g.,
verbs, pronouns, descriptive terms, prepositions,
conjunctions, interjections)
SYNTAX/MORPHOLOGY HOME ENVIRONMENT
•  Functional carrier phrases •  Names of family and friends

•  Consider phrases when targeting word shapes •  Routines and activities
(e.g., V.CV “I do,” CV.CV “cow go”)
•  Favorite foods/toys
•  Consider what we know about early semantic •  Situations causing conflict
relations (Brown, 1973)
•  Combine morphology/word shape goals (e.g.,
CVC + 3rd person singular “s” marker = “goes, buys,”
CVCC + regular plural = “pushed”
SCHOOL ENVIRONMENT COMMUNITY
•  Names of teachers/classmates
•  Restaurant
•  Activity centers
•  Sports or other activities
•  Thematic units
•  Textbook terms •  Prayers for places of worship
•  Upcoming oral presentations •  Birthday party
–  show and tell •  etc…
–  oral report
–  weather reporter
•  Games
•  Child’s interests •  Establish communicative intent
– Give child choices
– Ask parents or teachers •  Support use of a wider range of language
functions: greeting/closing, requesting (objects,
actions, attention, information, permission,
•  Novel Toys assistance), rejecting, protesting, disagreeing,
commenting, sharing information, responding to
•  High-affect play questions, asserting
•  Support conversational skills
 SPECIFIC CUEING TECHNIQUES

 SPECIFIC CUEING TECHNIQUES
 Rate Variations – modeling reduced rate is

valuable  Tapping/clapping out syllables
 Choral speaking (simultaneous production)  Syllable manipulatives (blocks, paper squares)
 Direct or delayed imitation  Metaphors (sound names)
 Mirror  Phoneme placement cues
 Mime  Mouth pictures
 Hand motions/positions/manual signs  Visual syllable words
 Written letters and words  Tactile cues
 Backward chaining
Cueing Technique Visual Auditory Tactile Cognitive Cueing Technique Visual Auditory Tactile Cognitive
Rate Variations X X X Tapping/Clapping Out Syllables X X X
Choral Speaking/Simultaneous X X Syllable Manipulatives X X X

Production
Direct or Delayed Imitation X X Metaphors (Sound Names) X
Child at Mirror X X Phoneme Placement Cues X
Miming X Mouth Pictures X
Hand Motions/Positions/ X X Visual Syllable Words X X

Manual Signs
Written Letters/Words X Tactile Cues X
Adapted from Fish, M. (2010) Here’s How to Treat Childhood Apraxia of Speech. San Diego, CA: Adapted from Fish, M. (2010). Here’s How to Treat Childhood Apraxia of Speech. San Diego, CA:
Plural Publishing, Inc. Plural Publishing, Inc.
Samples of Hand Cues

Ideally we want our early treatment to be /p, b, m/ Index finger along lip line
mul%sensory in nature to provide the most salient /t, d, n/ Tip of finger at philtrum
possible cues that support motor learning.
/k, g/ Fingertips under chin near throat
CONSIDER /h/ Palm in front of mouth
/s, z/ Fingertips at corners of retracted lips
an Integral S*mula*on Approach (e.g., Dynamic /ʃ, tʃ, ʤ/ Index finger and thumb at cheek pads
Temporal and Tac%le Cueing) /l/ Index finger pointing toward upper teeth
and/or /r/ Index finger and thumb near back of throat
PROMPT
Sample Metaphors
/b/ submarine /s/ shy shake
/p/ popcorn /z/ shy bee
/m/ humming /ʃ/ sleeping baby
/w/ crying baby /tʃ/ choo choo train Providing clear feedback helps facilitate a
/d/ drum /ʤ/ noisy choo choo train
shared attention and mutual understanding
between the child and the clinician of WHAT
/t/ tick-tock clock /θ/ and /ð/ brave snake to do and WHY. This is important for motor
/n/ noisy nose /r/ bear learning to take place.
/l/ singing /k/ cough
/f/ windy /g/ drinking
/v/ race car /h/ panting dog
Extrinsic Intrinsic
Feedback Feedback Frequency of
• Sensory information • Sensory information Reinforcement
provided by outside within the learner
source
o Knowledge of o Auditory
Performance o Proprioceptive As
o Knowledge of o Tactile
Skill Level
Results
• Necessary to acquire • Necessary for
new skill carryover Reduces the risk of feedback dependency
Adapted from Fish, M. (2010). Here’s How to Treat Childhood Apraxia of Speech. San Diego, CA:
Plural Publishing, Inc.
 Provide frequent feedback
 Progressively fade extrinsic feedback
 Provide immediate feedback
  Provide intermittent reinforcement and feedback
 Provide KNOWLEDGE OF PERFORMANCE
  Begin to provide extrinsic feedback in form of KNOWLEDGE
 Tell what was not correct about the movement OF RESULTS – was the target correct or incorrect
 Tell what should be done differently next time   Begin to delay feedback
 Limit the amount of information provided - don’t overload
M
•  Pure Vowels
High a
n
d
i
•  Diphthongs
b
l
Mid e
•  Rhotic Diphthongs and Triphthongs
H
e
i
g
•  **Semivowels**
Low h
t
Vowel production requires no articulatory contact, just certain •  Begin with “uh” and /i, u, o, a/. . . WHY?
configurations of the tongue, and to some extent, the lips, with
the jaw going along for the ride; therefore the child with CAS
may exhibit … •  Begin at syllable level if possible
•  Vowel distortions
•  Use established pure vowels to teach diphthongs
•  Limited vowel repertoire, resulting in…Numerous vowel
substitutions •  Model prolonged vowels in utterances using rate
reduction to increase proprioception
•  Difficulty with diphthongs and rhotics
•  Homonymy – “buh” for bee, ba, bow, boo, bye, bah, ball, etc.
•  Use multisensory cues; gestural cues (big hand/ Children with CAS frequently demonstrate:
arm movements) and tactile cues (e.g.,
P.R.O.M.P.T) can be particularly beneficial •  excessive/equal stress (Shriberg et al, 1997)
•  Use facilitating contexts (see Target Utterance •  inappropriate linguistic/lexical stress

Selection section)
•  inappropriate contrastive stress
•  Teach vowels with varied tongue placements
(anterior/central/posterior; high/mid/low) and lip •  inappropriate intonation patterns
shapes (rounded/retracted/neutral) to support
flexibility
Address Prosody by:
How are variations in
  Teaching exclamations
Stress (Linguistic stress & Contrastive stress)   Emphasizing words with emotional content
  Counting
and   Teaching questions vs. declaratives.
  Using Statement - Question – Response
  Teaching Syllable stress
Intonation   Identify
  Imitate w/ focus on the duration element
  Produce in single words and sentences
accomplished?
STATEMENT – “The dog is brown.” 1.  Choose and alternate target word (e.g.,

QUESTION – “What color is the dog?” “mmhmm” for yes, “uh uh” for no, “Papa”
RESPONSE – “The dog is brown.”
QUESTION – “What is brown?” for Grandpa, “Nana” for Grandma, “bah
RESPONSE – “The dog is brown.” bah” for sheep
STATEMENT – “Mark ate oatmeal cookies.” 2.  Accept approximations/simplifications

INCORRECT SENTENCE – “Sarah ate oatmeal cookies.”
RESPONSE – “No, Mark ate oatmeal cookies”
INCORRECT SENTENCE – “Mark ate chocolate chip cookies.”
RESPONSE – “No, Mark ate oatmeal cookies.” 3.  Consider nonstandard articulatory
INCORRECT SENTENCE – “Mark ate oatmeal cupcakes.” placement
RESPONSE – “No, Mark ate oatmeal cookies.”
Mommy Cupcake I want ball
“dah no”
ma cake a wa baw
“di no” mama cu cake I wan baw
mommy cupcake I want ball

“di no so”
“di no saur”
Sample Carrier Phrase Corresponding Language Activity Sample Carrier Phrase Corresponding Language Activity
More ________ Snack time, bubbles, ball play, etc. It’s a ___________ “Feely box” – place hand inside box, feel what’s
inside and tell what it is
_________ in/on/up Animal characters going on a school bus. I have (a) _________ Describe clothing or physical characteristics of
TV toy characters climb up mountain. You have (a) __________ self and other person
Hi/Bye ________ Toy characters meeting each other along the I got a ___________ Go Fish game or Memory game – tell what you
path during a hike got when you turn over a pictures
One/two ________ Picture match game; memory game I found a _____________ I Spy – using a flashlight, find “hidden” toys
Big/little ___________ Toy sort I want (a) _________ Tell what piece you need to complete a sticker
I want (a) _______ picture, block structure, or craft project
(color word) ___________ Make a potato head toy or a jack-o-lantern
_______
picture
Do you have a _________? Go Fish game
________ go Animals, characters or toy people going down
slide 71 72
Is it (a) ________? 20 questions
SYLLABLE SHAPES SAMPLE PHRASES
V‐CV GRAMMAR GOALS SAMPLE WORDS
Third Person Singular ‘s’ hits, takes
CV‐CV
Plural hats, bikes
CV‐CVC
CV‐CV‐CV CV-CVC Syllable Shape

GRAMMAR GOALS SAMPLE WORDS
CVC‐CVC
Present Progressive ‘ing’ taking, hopping
Regular Past Tense pa_ed, needed
Promoting Retention and Transfer

Promoting Generalization and Retention
•   practice opportunities
–  # of trials/session •  Change feedback from descriptive
–  # of minutes/week (knowledge of performance) to correct/
incorrect (knowledge of results)
•   flexibility by using many phonemic contexts
•  Choose functional vocabulary
•   cueing
•  Enlist help of family/teachers to practice
•   rate
in wider range of settings
•   pausing between syllables and words
•  Use developmental norms to determine target •  Facilitate improved overall motor imitation – may not be
phonemes for children with few or no phonemes. able to begin with vocal or verbal imitation, so back up
•  Large motor
•  With objects
•  Use sounds within the child’s repertoire •  More subtle gestures/signs
irrespective of developmental norms. •  Oral-facial
•  Vocal
•  Reinforce vocalizations to support a general
increase in a child’s vocalizations •  Imitate the child’s movements to support an
enjoyment of “you do what I do”
•  Help make vocalizations meaningful – Give •  Choose toys that reinforce early sound effects and
meaning to child’s early vocal attempts, just like we simple exclamations.
would do with a younger child
•  Emphasize key words, and repeat these words •  Choose activities with vocabulary containing:
frequently during play •  Simple sounds and syllable structures
•  Pause •  Phonemes within child’s repertoire
•  Say key words more slowly •  Sounds and words that get the child’s attention
•  Get child’s visual attention
•  Greater vocal intonation or vocal change •  Use amplification tools: Echo-microphone, Toobaloo,
paper towel roll.
•  Use small vocabulary set – begin with five or fewer
targets per session •  Use motion (bouncing, swinging).
•  Model slow, exaggerated articulation.
•  Use music •  Address complex phonemic sequences (e.g., moving from
velar to alveolar in same word)
•  Use repetitive books and counting books. •  Support production of complex clusters
•  Introduce multisyllabic words with varied prosodic contours
•  Describe what child is doing with the speech motor •  Tune into omission errors (e.g., medial consonants, weak
system early on in order to link the kinesthetic/ syllables) in connected speech
proprioceptive to the auditory. •  Pull treatment targets from textbooks
•  Solicit input from the child about settings, specific words,
•  Incorporate AAC into treatment as needed. upcoming situations that may be challenging – make it
functional
•  Work with rate and help child recognize the contribution of rate
on intelligibility Name: Charlie Sample
•  Provide opportunities to work on phrasing to support rate Age: 5 years, 10 months
control Grade: Kindergarten
•  Address prosody if stress and intonation continue to be an area Primary Diagnosis: Autism
of challenge Secondary Diagnoses: Oral apraxia, Verbal apraxia,
•  If intelligibility is poor at this age, work on functional phrases Hypotonia (limb and oral/facial)
and sentences to support the child’s intelligibility in meaningful
environments
•  Support child’s attainment of a complete phonetic repertoire
•  Help child recognize when others do not understand him and
practice strategies for these communicative breakdowns
Background Information from referral source at age 5 years, 3
months:  Phonetic Inventory:
  Receptive Language: • [m, p, b, h, d (with tongue protrusion), n (with tongue
•  PPVT-IIIB administered. S.S. = 77, A.E. = 3 yrs, 0 mo. protrusion)]
•  Followed one-part and some two-part instruction, though • [ah, uh]
inconsistent • Volitional production of bilabials more consistent than /h,
•  Responded to yes-no questions n, d/, which often need to be elicited through mulitsensory
•  Responded to simple “wh” questions with gestures and words cueing.
  Expressive Language (verbal):  Word shapes: V “uh” for up, C “p” for pop, CV “ma” for
•  Vocabulary – 10 words or less more, CVCV (with reduplication) “papa” for daddy, “baba” for
•  Syntax – Single words only bubble
  Expressive Language (with communication device):
•  Vocabulary – navigates independently between screens using AAC
device utilizing extensive vocabulary
•  Syntax – uses 1-4 word utterances with AAC device
85 86
 Imitation: able to imitate several oral movements. Difficulty

with lip rounding (even with mirror cuing) and with alternating Eligible for Speech-Language Therapy? Yes____ No____
among any of the oral movements completed correctly
Amount of Service _____ minutes/week
 Social interaction: limited engagement with peers.
Engaged with adults to request, reject, greet, close, label
Number of Sessions per week _____
 Emotional regulation: Fair to good. Some challenges
related to obsessive preferences, which limit his willingness to Session Length _____ minutes
participate in a wider range of activities
Group, individual or both __________
 Reading: beginning to read phonetically and sight words
87 88
Long Term Speech and Language Goals
1.
2.
3.
4.
Goals and Objectives Related to Speech and Speech Praxis
1.
a.
b.
c.
2.
a.
b.
c.
3.
a.
b.
c. 89 90
Contact Information
Margaret (Dee) Fish, M.S., CCC-SLP

1471 Oakwood Avenue
Highland Park, IL 60035
847-433-6340
deespeech@gmail.com
91
References
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Effective Treatment for Childhood Apraxia of Speech
OSLHA Annual Convention, March 19, 2011

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EFFECTIVE TREATMENT FOR

• Degree of muscle contraction

• No sensory deficits, muscular weakness, or peripheral organic

Adapted from Davis, B.L. & Velleman, S.L. (2000).

CV‐CV with reduplica%on “mama” “dada” “boo‐boo” CV‐CVC “bu_on” “ﬁnish” “hopping”

CV‐CV with assimila%on “mommy” “puppy” “bubb(le)” CVC‐CVC “cupcake” “helping” “goodnight”

Soccer bowling-kick the target pictures down

Block designs-early blocks to create designs

Syllable Stress Patterns

BUT • Consider choosing words with trochaic stress patterns

COGNITIVE-LINGUISTIC AGE VOCABULARY

• Functional carrier phrases • Names of family and friends

SCHOOL ENVIRONMENT COMMUNITY

• Support conversational skills

 SPECIFIC CUEING TECHNIQUES

 Rate Variations – modeling reduced rate is

Rate Variations X X X Tapping/Clapping Out Syllables X X X

Choral Speaking/Simultaneous X X Syllable Manipulatives X X X

Child at Mirror X X Phoneme Placement Cues X

Miming X Mouth Pictures X

Hand Motions/Positions/ X X Visual Syllable Words X X

Samples of Hand Cues

/p/ popcorn /z/ shy bee

/m/ humming /ʃ/ sleeping baby

/f/ windy /g/ drinking

/v/ race car /h/ panting dog

• Use facilitating contexts (see Target Utterance • inappropriate linguistic/lexical stress

STATEMENT – “The dog is brown.” 1. Choose and alternate target word (e.g.,

STATEMENT – “Mark ate oatmeal cookies.” 2. Accept approximations/simplifications

“di no” mama cu cake I wan baw

mommy cupcake I want ball

CV‐CV‐CV CV-CVC Syllable Shape

Promoting Retention and Transfer

• Model slow, exaggerated articulation.

 Imitation: able to imitate several oral movements. Difficulty

Margaret (Dee) Fish, M.S., CCC-SLP

Childhood Apraxia of Speech Association of North America (CASANA). (1997). Retrieved

Davis, B. L., & MacNeilage, P. F. (1990). Acquisition of correct vowel production: A

Gildersleeve-Neumann, C. (2007). Treatment for Childhood Apraxia of Speech: A Description

Kehoe, M. M., & Stoel-Gammon, C. (2001). Development of syllable structure in English-

Square, P. (1999). Treatment of childhood apraxia of speech: tactile-kinesthetic, rhythmic, and

Watts, N. (2004). Assessment of vowel summary. ACQuiring Knowledge in Speech, Language

You might also like

•  Degree of muscle contraction

•  No sensory deficits, muscular weakness, or peripheral organic

BUT •  Consider choosing words with trochaic stress patterns

•  Functional carrier phrases •  Names of family and friends

•  Support conversational skills

 SPECIFIC CUEING TECHNIQUES

 Rate Variations – modeling reduced rate is

•  Use facilitating contexts (see Target Utterance •  inappropriate linguistic/lexical stress

STATEMENT – “The dog is brown.” 1.  Choose and alternate target word (e.g.,

STATEMENT – “Mark ate oatmeal cookies.” 2.  Accept approximations/simplifications

•  Model slow, exaggerated articulation.

 Imitation: able to imitate several oral movements. Difficulty