According to the American Speech-Language and Hearing Association, childhood apraxia of speech (CAS) is a neurodevelopmental speech sound disorder in children, characterized by difficulties with precise lip, tongue, and jaw movements required for speech production due to an interruption in the brain-muscle connection. There is no question of whether the child knows what they want to say, but rather, on how the brain tells the articulatory muscles to move.
It can be tricky to diagnose a child with CAS due to its symptoms that are shared by other speech disorders. To diagnose a child with apraxia, clinicians look for:
- distorted phonemes
- slow speech rate
- equalization of syllable stress
- audible or silent groping (trying to move the mouth in the correct way to say a word)
- error inconsistency (the same word pronounced differently every time)
- increased error due to word or phrase length
All of these features of a child's speech can aid in diagnosing a child with CAS. Once a child is diagnosed, it is easier to proceed with the proper speech therapy needed. Luckily, because CAS is not due to muscle weakness, many treatments and therapies can help a child learn the correct muscle movements for proper speech articulation.
The image below shows all the muscles needed for speech production, with all the manners of articulation clearly labeled. These muscles are what are targeted during speech therapy for CAS.
Types of Therapy for CAS
Two main types of speech therapy are deemed the most successful for children with CAS. These treatments are individualized and continually reviewed and reevaluated to ensure they are the most beneficial. Articulatory-kinematic treatments, or therapy that focuses on motor skills through repetition, cueing, and extensive practice, are modified slightly depending on the patient to suit their interests and needs best (Damico et al, p. 380).
PROMPT: Prompts for Restructuring Oral and Muscular Phonetic Targets
One therapy type that has been proven to improve speech in children with CAS is PROMPT. PROMPT is "a tactually grounded, sensorimotor, cognitive-linguistic intervention model... for treatment of children (6 months and above)", according to Morgan Fish et.al in Here's How to Treat Childhood Apraxia of Speech. This type of therapy, created by Deborah Hayden, focuses on breaking words down into individual phonemes, or individual sounds, isolating each sound for repetitive practice before moving on to multisyllabic words or phrases, which can be challenging for children with CAS. PROMPT is different for every child, because the therapist facilitating this therapy method screens the child cognitively and socially to make sure it is best designed to meet each child's needs.
PROMPT usually targets the jaw, lips, cheeks, and throat to practice correct pronunciation and strengthen the mind-muscle connection.
Over time, PROMPT is meant to be faded or changed for each child as they get more confident in their ability to pronounce words correctly and form the proper facial structures needed for speech production.
PROMPT being facilitated. Photo sourced from: https://speechinmotion.com/blog/f/what-is-prompt-therapy
DTTC: Dynamic Temporal and Tactile Cueing
Developed by Edythe Strand, DTTC is a form of integral stimulation that is designed for children as young as 2 or 3 years of age, as long as they can interact with the clinician. DTTC is different from PROMPT, which focuses on individual phonemes, because DTTC emphasizes speech movements and meaningful utterances instead (Fish, p. 187).
In DTTC, the clinician will model certain words or sounds with the expectation that the child will mimic them. Using different visual, auditory, and temporal cues to help the child pronounce the right sound, once the child becomes more successful in their speech production, the therapist will fade the cues to encourage more independent speech.
Temporal cues might be rhythm, tapping, or emphasis on melodic stress within a multisyllabic word to aid in pronunciation.
Visual cues could be touching the area of the face where the sound is made on the clinician's own face, with the hope that the child will mimic the motion.
Auditory cues are when the clinician samples the sound at different speed rates, to allow the child to hear it more than once, and in different contexts.
DTTC was created to help children with CAS learn important words or phrases necessary for conversation. It is usually a short-term therapy, not intended for prolonged use, but rather to give children the building blocks needed for speech-sound articulation (Damico et al.382).
DTTC is being facilitated. Photo sourced from: https://www.mcrorypediatrics.com/post/dynamic-temporal-tactile-cueing-evidence-based-treatment-for-childhood-apraxia-of-speech
Keeping Kids Engaged
It's no secret that kids can sometimes have short attention spans. However, kids with CAS must benefit as much as possible from their speech therapy sessions. This is why turning therapy into an educational but entertaining activity can keep kids engaged in the material for longer, while simultaneously improving their speech.
We want children to be as comfortable as they can during their speech therapy sessions, as to optimize their learning and development. To do this, we can ensure that the session takes place in a well-lit, reasonably quiet place. It would also be beneficial to use pictorial support, or even the reinforcement of an AAC device, so that the child is seeing and hearing the sound/word that needs to be replicated, in multiple ways. Multimodal therapy is also a great way to keep kids engaged, because they can pick up on verbal and nonverbal cues, giving them more to pay attention to, and hopefully, that much more material to learn from (Damico et al, p. 380).
A quote from The Handbook of Language and Speech Disorders by Jack Damico et. al is very important when talking about speech therapy for AOS or CAS. "Treatment in both adults and children with apraxia of speech may benefit from principles that integrate motivation and autonomy along with traditional motor learning principles." This quote reinforces the idea that keeping kids engaged by incorporating their interests, multiple methods of information input, and pretend play not only gives them autonomy within the session but also motivates them to work at reaching their goal.
Kids also want to have fun just as much as they want to learn. Intertwining therapy and play can be beneficial for children with CAS, and also helps to keep them fully engaged while in their therapy session. There should be a happy medium between administering the principles of motor learning and pretend play within speech therapy for CAS (Fish, p.123). There are many ways to disguise repetitive practice into an educational game to help children with proper muscle formation and articulation. Visual representations always help, such as a 10x10 grid, and each time a word is said correctly, the child gets to mark it down with a sticker. This disguise helps children hit their target utterances while simultaneously taking the pressure off the child and instead creating a fun game out of it.
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