The Nuffield dyspraxia programme targets children with speech sound disorder resulting

from motor deficits. It showed successful results in treating children with severe speech
disorders mainly dyspraxia. It is created for children aged between 3 and 7 years, and it
can be adjusted for older ages. It is built on the motor speech approach which aims to
voluntarily control speech actions. The motor speech approach sheds light on the
important of practicing the steps on a daily basis. This approach focuses on building new
motor programs and practicing them for the purpose of expanding the child’s inventory
of expressive phonemes. Repetition and practice are essential for constant and precise
production. NDP3 is designed by building articulatory skills through small steps
depending on the bottom-up theory where mastering high levels depends on mastering
lower levels. This programme aims to build in a hierarchy of steps starting from isolated
sounds to complex words. It focuses on building accurate speech motor programs,
starting with single-consonant and vowel sounds and simple syllables and then moving to
more complex words, sentences, and eventually connected speech. First, the treatment
starts with expanding the child’s phonetic inventory starting from the sounds he can
produce, then other sounds, and later to CV structures which are the building blocks for
later complex structures. The Nuffield approach sheds light on the importance of motor
skills learning approach in therapy.

Speech sound disorders is an umbrella term. It can be organic or functional in nature.

Organic speech sound disorders result from an underlying motor/neurological, structural,
or sensory/perceptual cause. Our focus in this presentation is on the motor part. Motor
speech disorders include two primary categories, apraxia (deficits in motor planning) and
dysarthria (deficits in motor execution). According to ASHA, apraxia of speech is
sometimes called acquired apraxia of speech, verbal apraxia, or dyspraxia.
https://www.asha.org/public/speech/disorders/apraxia-of-speech-in-adults/

Before diving into the deficits of children with dyspraxia, I’ll explain these important key
words:

When a person decides to communicate verbally, the message first has to be converted
from an abstract idea to meaningful linguistic (language) symbols. The language message
must then be transformed into a code that can be handled by a motor (movement) system.
This transformation of the code occurs in three different phases. Speech motor planning,
motor programming and execution are the three different phases in the preparation and
the actual production of speech movements.

Motor planning adds specific properties to abstract phonological symbols. Phonemes are
changed into sounds which have different place and manner of articulation features. For
example, the motor plan for /b/ sound includes lip closure, velar lifting and vocal cords
closure. In speech motor programming, tactics or specifications regarding muscle tone,
movement direction, velocity, force, range and mechanical stiffness of joints are added to
those motor plans. Once the motor programs are specified, these are sent to the muscles
for execution which are transformed into actual movements

In this programme, they focused mostly on children with dyspraxia. They show deficits at
the levels of:

- Motor planning: They show inconsistent production of the same word and many
articulatory and phonological errors. It can be targeted through sequencing
activities at early stages.
- Motor programming: it can be enhanced through starting with the basic building
blocks: isolated sounds and CV structures. Then, moving on to more complex
structures using the previous basic units. Then, working on unfamiliar words.
Then, performing other sequencing activities in order to generate a motor program
for the sequence.
- Motor programs: To establish motor programs, we should proceed in small steps
with using specific instructions related to the movements. Targeted motor
programs should be practiced daily until production is correct and automatic.
 - Motor execution:
- Phonological representations: Dyspraxic children have inaccurate phonological
representations. To improve phonological representations, slps should use,
auditory support, discrimination of child’s errors, picture cues for the word
meaning, and phonological awareness.
- Auditory discrimination: Auditory modules can support auditory processing
- Phonological awareness: It is developed through the use of symbols to cue
production, simple blending and segmentation tasks, classifying to onset/rime and
syllable segmentation.

At each level, self-monitoring and motivation are important for the success of
therapy.

FOCUSING ON EACH STEP OF THE THERAPY:

1. single sounds

Children with speech impairments have problems in producing speech sounds even in
isolation, in which the problem is phonetic and not phonological. Thus, even by
imitation, only a limited number of phonemes are produced. First, the SLP starts by
associating sounds that are already in the child’s phonetic repertoire with symbol picture.
Then, the SLP uses strategies such as modeling, imitation, verbal, tactile, manual cues
and auditory discrimination to obtain the sounds that the child can’t produce (are not in
his phonetic repertoire). The SLP can reinforce the child’s trials with feedback, for
example, “That worked well because you remembered to round your lips” or “Careful!
Your tongue didn’t touch your teeth that time.” Then, the SLP targets sounds that the
child can’t produce spontaneously and by imitation through the use of the other
techniques. For example, a child who can imitate /m/ but not /b/ would be helped to
produce /b/ by saying /m/ while the SLP gently blocked his nostrils. In addition, the SLP
could use one or more of a variety of cues, including verbal cues such as “this sound
needs to come out through your mouth”; manual cues such as those in Cued Articulation;
orthographic cues such as written letters, and diagrammatic cues such as articulograms to
represent features of a particular sound. At this level, motor program is establish for each
sound.
Activity: Bingo game

Materials: 2 bingo cards (one for each player), picture cards, tokens/marker

Procedure: Each player is given a bingo card and tokens. The game starts with taking
turns while each player. When it is the child’s turn to pick a picture from the stack, he
should say the speech sound and cover the corresponding picture on the bingo card with a
token. The same procedure is applied when it is the therapist’s turn. The player who
covers all the pictures on the bingo card first wins.

2. single sound sequencing

Single consonants sequencing

Single vowel sequencing

Sequencing activities are challenging because it requires the child to retrieve two
different motor programs and apply motor planning skills to achieve accuracy in speech
sounds production. Therefore, SLPs should start by choosing two sounds that differ in
two or more features with slow production rate. Thus, sounds with close features should
be controlled and introduced gradually. For example, for a child who replaces /k/ with /t/
but has now learned to say /k/ as a single sound, contrastive sequencing might start
with /m-k/, then /b-k/, /p-k/, and finally /t-k/. In this case, they moved from nasal sound
to stop then from voiced to voiceless, then from bilabial to alveolar. Speed of production
can gradually be increased, with rhythmic and stress patterning incorporated

Procedure:

- First step is to introduce separately the sound lottos that will be used in the sequencing
worksheets.

- Ensure the correct production of sound lottos individually.

- The therapist presents the sequencing activities while demonstrating the method.

- The method: the therapist follows the sound lottos in these activities as he/she points
while producing the sound of each. This will create a sound sequence in each sheet.
- After demonstration, allow the child to try as a first time. this part is done to make sure
that the child understood the concept of the activity. When it’s certain, start using the
sequencing activities for therapy.

3. transition from single sounds to CV words

It is considered difficult since it requires the development of new motor program by

combining two existing motor programs so that they join smoothly, without the gap in
production left in sequencing tasks.

- C+V=CV build up worksheets

At this step, the child is able to produce the sounds presented in the sound lottos. The
sound lottos are set in puzzle forms.

- The two sounds targeted are combined together through the puzzle forms as a visual
support to ensure the blending of the two sounds into the targeted syllable.

- The therapist should point at the puzzle forms while producing their corresponding
sounds.

- As he/she combines the two puzzle pieces together, the final CV production is formed

C+V=CV hiding worksheets

At first, the therapist demonstrates and explains how two sounds are combined in order to
create the CV syllable.

- This step follows the build-up step. Thus, the child has passed by the transition phase 1.

- The sound lottos have been presented previously in separate lottos and then in puzzle
pieces.

- In this step, the therapist hides the CV syllable keeping the C and V open.

- The child should blend the two sounds and create the CV by himself/herself.
4. CV syllables

First, SLP starts with CV words that the child can produce. Then, she moves to the ones
he can’t produce. For example, for a child who has recently learned to produce the
syllable sea accurately, having previously produced it as tea, staged sequencing practice
might move from a vowel change (e.g., sea, saw, sea, saw) to an easy placement change
(e.g., sea, bee, sea, bee) to a harder manner change (e.g., sea, tea, sea, tea).

CV lottos

CV-CV sequencing

Procedure: same as that of isolated sounds

5. CVCV words

Objectives:

a. develop suitable motor programs for words of different complexities

b. understand the notion of syllables
c. clarify phonological representations

- CV + CV= CVCV transition sheets

- CVCV noun pictures

- Symbol cues

6. CVC words

CV+C= CVC build-up transition worksheets

CVC picture cards

7. stories

8. articulograms