“Will my child ever learn to make the “r” sound?” This is a question I hear from many parent(s) of children with CAS, likely reflecting very real parental concerns about how their child’s speech will sound as they enter the teen years, or even young adulthood.

The question is a logical one. The answer is a difficult one. As a speech-language pathologist I must consider a number of factors when discussing the “r” issue with parents. These include the over-all severity of the CAS, the number of characteristics of the disorder the child exhibits, the changes that have occurred within the speech skills over time, and the rate and ease with which these changes have occurred. Additional factors include the availability of appropriate services (particularly as the child enters middle school and beyond), the motivation of the child to cooperatively continue in the remedial process, and perhaps even the number and severity of the co-occurring problems that the child may be exhibiting in addition to the CAS.

We also need to remember that the “r” is a sound with many facets. Many of us use both a consonant “r” as well as more vowel-like “er” sounds in our particular versions of spoken American English. However, we need to recognize that there are also regional and dialectical variations of the “r” and its use. Children with CAS will need to strive for production of the “r” sounds that are consistent with those of their families and /or geographic home.

While I am approaching the “r” issue cautiously, it has been my clinical experience that many children with CAS do, in fact, develop the “r” sound or sounds. This is based on two types of evidence. The first of these are the clinical observations that I have made, and the anecdotal reports that have been shared with me by other clinicians of “older” children with CAS—pre-teens and early teens—that the “r” sounds are acquired, but always with remedial help.

The second type of evidence is a research base that would support the possibility of “r” acquisition in this population of children. It is largely based on an M.A. thesis project, and later an ASHA paper, completed by Melissa Jackson under my direction nearly 20 years ago. The purpose of the study was to look longitudinally at the speech sound characteristics of four children with CAS, as recorded during formal assessments at our university clinic. One child was a pre-schooler. However, the other three children were older and are of more interest regarding the “r” issue. For one child we had 5 years of data from ages 6 through 10.5 years, another for 6 years through ages 4 to 10 years, and the final child (exhibiting a very severe speech apraxia) was followed for 8 evaluations from age 4 through 10.5 years. Among the questions asked in the project was if the patterns of speech for the children with speech apraxia changed with increases in age and remediation, and how these patterns of sound acquisition compared with those of children with normally developing speech. The results found that the children with CAS did acquire the speech sounds of their language, and in an order similar to children acquiring them normally. This included the “r” sounds. However for the children with CAS the sounds were acquired at a slower rate and at older ages, than do children with normally developing speech skills. In fact, one child correctly produced the “r” sounds at the age of 9; the other two were inconsistently correct in their productions of the “r” sounds at age 10 years, but they could correctly produce them. Most importantly, however, is that these skills were acquired while the children were receiving fairly intensive remedial services, emphasizing the need for continued therapy. In fact, the three children discussed above all continued to receive speech and language services well beyond the oldest ages noted in the study.

It must be remembered that even with remedial services targeting the “r” sounds, progress in correct production is likely to be slow. There are several stages within the therapy process. The first is to achieve, or elicit, the sound itself, whether it is the “r”, or the “sh”, or perhaps the “g”. There are many techniques that a speech-language pathologist can use to facilitate the child’s learning of what needs to be done with the speech-producing mechanism in order to correctly produce the sound all by itself. Often, sensory input will help, so that the child is given auditory, visual, gestural, or tactile cues to help learn what to do to create the sound. There are a number of specific treatment techniques which use various sensory modalities in this phase of remediation. Because of the individuality of each child with CAS there is often no way to determine which specific sensory modality, or modalities, will be most helpful in achieving success in this phase of therapy. Many different ones may need to be introduced to the child. After the child can produce the sound by itself or in simple syllables with the target sound (in this case the “r”) plus a vowel, a second stage of therapy may well incorporate motor-programming therapy approaches. The goal for the targeted sound in this stage is for the child with CAS to acquire voluntary, consistent, and correct control over the speech-producing mechanism so that the speech sound, and sound sequences in which it occurs, can be produced consistently correctly. In order for this to occur, there must be many, many repetitions of speech tasks which are carefully ordered to include gradual increases in the difficulty and length of the speech tasks. Children with CAS often find this process to be an arduous one, requiring much practice and investing much effort over a prolonged period of time—which may reach into a number of years of therapy.

The message is one of optimism. There seems to be a distinct probability that the “r” sounds will be acquired by children with CAS. However, CAS is known for its individuality as far as how the disorder is expressed by any individual child. A particular child with CAS may not acquire the sound, despite good efforts in therapy, just as some children with seemingly normally developing speech skills may find the “r” sounds to be a particularly difficult challenge. But, we all must be patient; the child with CAS may be 10, or 12, or 14 years of age before the “r” sounds make their appearance. And most importantly of all, the child needs to receive speech remedial services, and to cooperatively invest in this process, in order to facilitate this acquisition.

References:

Jackson, M.R.F. (1986) Phonological characteristics of developmental verbal apraxia: A longitudinal study. M.A. thesis completed at The University of Iowa.
Jackson, M.R.F. & Hall, P.K. (1987). A longitudinal study of articulation characteristics in developmental apraxia of speech. Paper presented at the annual meeting of the American Speech-Language-Hearing Association, New Orleans, LA.

[Penelope K. Hall is an associate professor in the Department of Speech Pathology and Audiology at the University of Iowa. She has long-term clinical and research interests in Childhood Apraxia of Speech, having recently completed the second edition of the Hall, Jordan & Robin text, Developmental Apraxia of Speech: Theory and Clinical Practice. She also serves on the Apraxia Kids Advisory Board.]