Children with childhood apraxia of speech (CAS) are frequently noted in the literature as having disordered prosody. Prosody refers to intonation, stress pattern, loudness variations, pausing, and rhythm. We express prosody mainly by varying pitch, loudness, and duration. We also may use greater articulatory force to emphasize a word or phrase. Children with CAS are frequently reported to have prosodic errors as well as many speech sound errors. Often, these prosodic errors and articulation errors are thought of as two separate entities. The purpose of this article is to highlight potential relationships between speech characteristics of CAS, as well as the efforts to improve speech sound accuracy, and their impact on prosody.

Children with CAS have been reported to sound:

• robotic-like, producing each syllable one at a time and with equal stress
• aprosodic (i.e., decreased intonation patterns, monotone)
• dysprosodic (i.e., using prosody that doesnt match the expected intonation pattern)
• slow and choppy
• too fast

English-speaking children with CAS have also been observed to use word stress patterns that are similar to children younger than they are who are developing typically (i.e., 2-4 years of age). More specifically, children with CAS are more successful producing words with a strong-weak stress pattern (e.g., baby) than a weak-strong stress pattern (e.g., guitar). Children with CAS may have more success with strong-weak stress pattern words because one; they have had more practice with them and two; they may be easier to produce.

However, as previously mentioned, children with CAS frequently produce other types of prosodic errors, as well. When considering the types of sound errors children with CAS typically make, it is easy to see why we perceive disordered prosody. If we think about the effort required for correct articulation, it is also makes sense that prosody suffers. The following table summarizes common speech characteristics or errors of CAS and how they interact with prosody.

Table 1. Effects of CAS Speech Characteristics on Prosody

In addition to articulatory effort and speech errors interfering with prosody, there is also the aspect of speech development to consider. Children with CAS are often characterized as having been quiet babies. Children who were quiet and did not babble missed the opportunity to practice/achieve rhythmic organization through babbling. Babbling provides the opportunity to organize phonation, articulation and respiration in a rhythmic style as evidenced by the childs prosody when vocalizing.

There are also several effects that speech therapy can have on prosody, not all of them positive. Many techniques speech therapists use promote correct articulation at the expense of natural sounding prosody. The following table summarizes common therapy techniques and their effect on prosody.

Table 2. Potential effects of therapy on prosody

Historically, speech therapists have not generally been trained to think about what to do with a child with CAS once he or she has obtained all of their sounds and syllable shapes and have increased intelligibility. The focus of treatment is often on improving the motor plans and sequences needed for speech production to increase intelligibility. In other words, the clinician will carefully construct treatment phrases to increase syllable shapes (e.g., bow, boat, boats), sound sequences (e.g., cat and tack), and phrase lengths (e.g., I want more, I want more milk, I want more milk please). During treatment it is easy to fall into accentuating targets unnaturally and thus modeling inappropriate prosody, as in the first example provided in table 2. In addition, motor skill learning principles applied to speech therapy encourage decreasing rate and giving numerous opportunities to practice the motor speech skill. Children will produce utterances in the way they are modeled. That means they will use extra articulatory force, produce multisyllabic utterances syllable by syllable, and prolong syllables, etc. if that is what is modeled. Thus, speech therapists need to be mindful of how therapy is impacting the naturalness of the childs speech as they work on accuracy of sequencing articulatory gestures for clear articulation. Often these unnatural models are necessary for the child to hear, see and feel the appropriate articulatory configurations initially. However, as soon as the child has learned it, the model needs to become more natural.

Treatment efficacy studies that examine what happens to prosody when we increase awareness and effort on correct articulation would be of great benefit. Many treatment techniques do address naturalizing prosody after obtaining accuracy of the speech sounds (e.g., PROMPT, Melodic Intonation Therapy, and Integral Stimulation). It would be worthwhile to examine what the best way is to ensure normal prosody while working on accuracy of sounds. For example, at what point should drilling a more natural sounding motor plan come into place? How long should we focus on correct articulation at the expense of normal prosody? For every child the answer will most likely be different. The important message here is that prosody and articulation are not two separate entities. Thus, speech therapists need be aware of changes in prosody as attention is being placed on articulation. Outside of speech therapy, music and other rhythmic activities, such as dance, could also benefit the childs prosodic development.

We also need to set realistic expectations. A child with CAS may have residual prosodic differences even after they have learned to produce all sounds and sound sequences correctly. For example, some parents have noted that their child is intelligible, but sound as if they have a foreign accent. At some point, we need to dismiss a child from speech therapy even if they dont sound perfect. However, we also need to believe they have reached their full potential. If prosody has not been addressed in speech therapy, we are not done yet.

Prosody generally refers to intonation, stress pattern, loudness variations, pausing, and rhythm. We express prosody by varying pitch, loudness, and duration. A person who does not vary any of these parameters will sound robotic. We frequently come across characteristics of childhood apraxia of speech (CAS) as including robotic speech or some other element of disordered prosody. What may account for this observation?

It has been my belief that when a child with CAS is focusing on correct articulation, some aspect of prosody inevitably suffers. Treatment techniques commonly used with children with CAS often encourage clear articulation at the cost of normal prosody. One example would be a child who is focusing on the correct sequencing of syllables for a multisyllabic word or utterance. This child may be trained to compensate by speaking one syllable at a time, causing the speech to sound choppy and monotone. Another technique is to work on decreasing the rate of speech so that the child has time to plan the movement sequence for speech. Children with CAS have been observed to incorporate a target phoneme at slower than normal speech rate but not able to produce it at normal speech rate. This in turn, can alter word stress. For example, in the word ‘teacher’, the first syllable should be stressed. However, if ‘r’ takes a lot of effort and time to produce correctly, we’ll hear the second syllable as being stressed.

It’s interesting to note that such disturbances are often not evident in spontaneous speech. My observation has been that younger children who have a lot of sound omissions and are not paying attention to correct articulation tend to have more normal prosody than children who are attempting correct articulation. Once speech becomes more automatic, prosody tends to improve. It is important to note that while decreasing rate is extremely important, the therapist should also try to keep intonation as normal as possible.

(Amy Meredith, Ph.D., CCC-SLP is currently an Assistant Professor at the Washington State University. She is an experienced clinician who has worked in the public school, hospital, and private practice settings. Her primary clinical and research interest is in children with motor speech disorders. She has published and presented her research on children with apraxia at national conferences. She has also given numerous workshops for practicing speech-language pathologists on assessment and treatment of childhood apraxia. Dr. Meredith is a member of the professional advisory board for Apraxia Kids)

For Preschool Children

1. Rhythm
   • Drums, clapping, marching, etc.
   • Use to beat out number of syllables per word or to keep time with songs, rhymes, etc. Provides rhythmic “frame” for word and syllable production. [BEWARE of “excess equal” stress! Do not encourage robotic production, with each syllable equally stressed.]
   • Use big (loud, higher pitch) and small (quieter, lower pitch) drum to represent stressed versus unstressed syllables.
2. Pitch
   • Animal sound keyboard: Imitate “daddy” chirp, bark etc. (lowest note) versus “baby” (highest) versus “mommy” (middle).
   • Songs, finger plays etc. Play activities and books with animal “voices”, “daddy” versus “baby” voices, etc.
3. Volume control
   • Telling secrets, baby sleeping, etc. — whisper
   • BINGO, John Jacob Jingleheimer Schmidt, etc. (songs with loud and soft) “Wheels on the Bus” with loud vs. soft voice for different verses
4. Duration
   • Songs, finger-plays, walking games (e.g., “Lion Hunt”) etc. with longer duration words accompanying slower actions.

For School-Age Children

1. Stress Patterns
   • Word Stress:
     • Identify the number of syllables in a word (by clapping, with blocks, etc.).
     • Identify the stressed syllable in orally presented multisyllabic words.
     • Imitate multisyllabic words with appropriate stress.
     • Produce familiar (from steps 1-3) multisyllabic words with appropriate stress.
   • Phrase Stress:
     • Correctly match a spoken phrase with its meaning: EX.: “black+board” with stress on “black”, matches “what the teacher writes on”
     • with stress on “board”, matches “a board which has been painted black”.
     • Other examples include: white house, light house, greenhouse, hot house, big top, fish tank, black bird, blue bird, hot dog.
     • Correctly stress a phrase to match the given meaning (production).
   • Sentence Stress:
     • • • Identify the stressed word in spoken sentences. (Stress may need to be exaggerated initially.)
         • Given a wh-question, identify which word should be stressed in a written sentence. For example:
           “Who ate the cheese?” –> “The mouse ate the cheese”.
           “What did the mouse eat?” –> “The mouse ate the cheese”.
           “What did the mouse do to the cheese?” –> “The mouse ate the cheese”.
         • Correctly repeat the sentence when modeled after marking the word to be stressed.
         • Given a wh-question, correctly stress the reply.
         • Given a written paragraph from a textbook, identify words which should be stressed (i.e., the most critical pieces of information.) if the paragraph were to be read aloud.
         • Given a written paragraph from a textbook, read it aloud after marking correct stress.
   • Carry over these skills to:
     • Reading aloud in the classroom when forewarned of which portion of written text (s)he will be asked to read (so that (s)he can independently pre-read it and select words to be stressed).
     • Appropriately stress words in controlled conversation (i.e., in therapy).
     • Appropriately stress words in conversation when asked to clarify an utterance.
     • Appropriately stress words in conversation.
2. Pitch (Sentence-Level)
   • Identify rising pitch vs. falling pitch at the ends of orally presented sentences:
     • In yes/no questions (rising) versus wh-questions and statements (falling pitch).
     • In lists (including counting) — rising pitch on all but last item, falling on last. Signal when the last item is produced (based upon pitch cue).
   • Given written sentences, indicate where the speaker should produce rising pitch vs. falling pitch in the above environments.
   • Given written sentences, produce rising pitch vs. falling pitch in the above environments, first in imitation, then spontaneously.
   • Given written paragraphs, mark words that should receive rising versus falling pitch, then read them aloud accordingly.
   • Use pitch appropriately in controlled conversation (i.e., in therapy).
   • Use pitch appropriately in conversation when asked to clarify an utterance.
   • Use pitch appropriately in conversation.
3. Pauses
   • Identify pauses within orally presented sentences.
   • Given written sentences, identify locations where pauses should occur (at edges of noun phrases, verb phrases, clauses, etc.).
   • Repeat sentences with appropriate pauses (based upon prior identification).
   • Read sentences with appropriate pauses (based upon prior identification).
   • Use pauses appropriately in controlled conversation (i.e., in therapy).
   • Use pauses appropriately in conversation when asked to clarify an utterance.
   • Use pauses appropriately in conversation.