The easy answer to the question, “What type of speech and language goals should be considered when planning an IEP for a child with apraxia?” is that any area of communication deficit that the child with CAS exhibits should be addressed in his/her treatment program. What complicates the answer is that many areas of communication can be affected when a child has CAS, so a clinician must be very observant in order to ascertain which areas of communication are affected for each child. The components of any speech-language treatment program will vary depending on the individual child. But there are a number of general guidelines that should help parents know if their child is getting appropriate services.

• fluency (stuttering)
• voice (volume, hoarseness, etc.)
• vocabulary (understanding and use of words)
• language processing (understanding of other people’s communication to him/her)
• language production (use of age-appropriate word order and language structures, such as verbs, pronouns, etc., which are referred to as syntactical and morphological skills)
• articulation (ability to produce phonemes or sounds in single words)
• co-articulation (ability to produce phonemes or sounds in connected speech)
• hearing

When a clinician is developing goals for an Individualized Education Plan (IEP), they will look at goals in two ways long-term goals and short-term objectives. The long-term goal(s) should address what the child should be able to do as a result of intervention over a specified period of time (for IEPs, this is generally one year). Short-term objectives include the types of activities that will be used to support and achieve the long-term goal. Both long-term goals and short-term objectives should be objectively measurable. Each should specify WHO will do WHAT under WHICH CIRCUMSTANCES. The long-term goal will often specify how the goal will be measured to ascertain a child’s progress.

One suggestion for speech production long term goals for children with CAS is to write them in terms of the child’s speech intelligibility AND his/her mean length of utterance in morphemes (morphemes are like words, but are a more sensitive measure of a child’s language complexity. For example, if a child said “cat,” that would be counted as one morpheme. But if the child said “cats,” that would be counted as two morphemes, because the pluralization (s) of the word “cat” represents a higher level of language complexity). Speech intelligibility and mean length of utterance are the two features of a child’s communication that are often the most compromised when he/she has childhood apraxia of speech, and as such are the best measures of the child’s functional communication deficits pre-treatment, and of the child’s progress as a result of treatment.

It is essential for the clinician to establish long-term goals that require a true gain in skills rather than gains that would naturally be expected as a result of maturity and/or the clinician’s increased ability to understand the child as a result of becoming familiar with his/her speech. There are expected ranges for both mean length of utterance and speech intelligibility in children. The long-term goal should be written to represent criterion for success that would represent at least one year’s growth (or the amount of time the long term goal is being written for). Remember, however, that statistical differences in children’s utterance length do not occur in an amount of time under three months (Hickman, 1983), so a clinician must be cautious in viewing comparison measurements of utterance length that are taken closer than 6 months to each other. Speech-intelligibility and language complexity, however, are features that can be measured more frequently.

The short term objectives support the long-term goal, or are a representation of some of the means for supporting and achieving the long term goal. Objectives often include benchmarks indicating dates by which a child will have met the objective at a specified level. These objectives should not be all-inclusive. In other words, every single aspect of the child’s treatment program does not have to be listed as an objective, but the objectives and the long term goals should be written in a way that allows measurement of the important factors for each child’s success.

Finally, parents are an important part of the goal development. Goals and objectives should make sense to parents in terms of their child’s needs. It is also important to remember that the most outstanding goals and objectives in the world do not guarantee that the services/intervention provided will be effective. For that reason, I believe it is very important for parents to observe speech therapy sessions as often as possible, and maintain frequent communication with the SLP In this way, parents can be aware of how the goals and objectives developed are actually being addressed therapeutically.

References:

Hickman, L. A., (1983) Sex Differences in the Language Development Rates of Two-Year Olds. Masters Thesis, Portland State University.

(Lori Hickman, M.S., CCC-SLP, has been a practicing speech-language pathologist since 1983, having graduated with her Master’s in Speech Sciences from Portland State University in Oregon. Ms. Hickman has dedicating her career to date to speech-language pathology in the schools, as well as assessment and treatment of children with severe communication disorders such as CAS. Ms. Hickman is the author of The Apraxia Profile, an assessment instrument as well as therapeutic materials for children with CAS. In 2000, she wrote the book Living In My Skin: the Insider’s View of Life With a Special Needs Child, a book based on interviews of hundreds of parents of children with special needs, providing professionals, extended family, friends, and communities with an inside look at the day-to-day challenges that families of children with special needs face. She is also a member of the Apraxia Kids Professional Advisory Board and has contributed articles to the Apraxia-Kids web site.)

The goal of intervention for a child with apraxia is to enable the child to gain volitional control of his/her articulators in order to produce age-appropriate, co-articulated, intelligible speech (co-articulation refers to the way we talk when we connect our words together in a speech-melody, rather than pronouncing each word individually). To that end, I believe one must consider the following in the development of speech and language goals for a child with apraxia:

• How intelligible are the childs utterances? How does this level of intelligibility compare to that of his/her peers? How functional is the childs expressive communication (what types of things can the child do with his/her expressive communication can he/she label things, ask for things using a question form, get his/her wants and needs met, share an idea, clarify his/her message)? Children with apraxia often experience a deficit in the ability to use their language for varied purposes or communicative intents.
• Are the childs language complexity, word order, and/or utterance length affected by his/her apraxia? In most cases, children who have apraxia produce utterances that are shorter and less complex than those of their peers.
• Which are the phonemes (sounds) and phoneme sequences that the child can produce with the most automaticity (the ability to produce the phoneme or phoneme sequence without having to “think about” its production)? Which are the most difficult phonemes and phoneme sequences for the child to produce? The most difficult phoneme sequences are those that are the most likely to cause the childs phoneme production to fall apart in connected speech because they are the most inconsistent in terms of production. The child produces more than one error for these phonemes at different levels of production (syllable, word, phrase, etc.). For example, the child may produce the following phoneme errors for /f/ in the beginning or initial position of words: the substitutions of /d/, /b/, /n/, and /p/, along with omissions in some phoneme sequences. This pattern shows clearly that the child lacks a consistent motor plan for the production of /f/. When /f/ occurs in a word he/she tries to produce, he/she has to struggle motorically and ends up producing varied phoneme errors (substitutions, distortions, omissions, and additions) in the place of /f/, depending on the co-articulatory context (the phonemes that immediately precede and follow the /f/). These inconsistently produced phonemes should always be addressed in the childs treatment plan.
• How well does the child understand words and sentences? Many children score within normal limits on receptive vocabulary tests, giving the impression that their receptive language is good. But because of the limited expressive language they produce, it is not always possible to determine their true language processing and production skills because of their inability to respond intelligibly during administration of language comprehension and/or processing assessment instruments. When the apraxia is severe, the child has very limited experience in the use of vocabulary and language structures appropriate to his/her age. This lack of experience can lead to a lack of understanding of the language contained in question forms (the child may not know what kind of information is required for each WH form), directions, clarification, and sequencing of events. This can result in secondary delays in the childs ability to understand the language of adults and peers. A child learns vocabulary and expressive language by using them. That which he/she cannot produce is harder for him/her to understand.
• What are the childs immediate needs in terms of communication? In some cases, these needs might be met by carrier phrases or functional phrases that will expand the child’s communicative repertoire. For example, if you teach the child to co-articulate “Iwanta” (I want a ) intelligibly, all he/she will need to do is add a word to that phrase and he/she will be able to communicate many things to others. The best way to determine these needs is through parent and teacher interview, observation of the child, and knowledge of the words and phrases that are generally developed first for typically-developing communicators.

If the child is older, it is even more important to determine if his/her utterance length and complexity and communicative intent (ability to communicate a wide range of things to others) are commensurate with his/her peers. Children with apraxia can become very adept at monitoring their own co-articulatory productions as they get older, so they sound quite intelligible. In actuality, they may be shortening their utterances so it is not obvious that they do not have volitional control of phoneme production as co-articulatory demands increase. This can affect their choice of vocabulary, their written language, and their ability to use language for abstract purposes such as persuasion, comparison and contrast, idioms, etc. When this happens, their language sounds younger than their peers (sometimes you have to listen very carefully to catch this). It is important to address this early on in a childs therapy by having him/her produce words and sequences that do not occur frequently in the English language. The child should practice these less common and generally higher-level words and phrases in order to gain complete co-articulatory competency. Examples of this would be words such as plural, rural, extraction, exists, contrary, etc. The phoneme sequences addressed will depend on each childs individual phoneme-production profile. In essence, the clinician teaches the child co-articulatory production of these later-developing phoneme sequences so the child has mastery over all possible phoneme sequences. This way the child will not avoid these co-articulatory challenges as he/she gets older.

How does the child compare to his/her peers in terms of social skills? Is his/her eye contact, physical distance, vocal modulation, nonverbal communication, etc., typical for his/her age? Many times a child will experience delays in these skills because he/she will not be able to develop these interactive, pragmatic language skills at the level of his/her peers because of social inexperience caused by the apraxia.

For an older child, how well does he/she read? Can he/she hear all the phonemes in a word or phrase? Those phonemes which a child cannot produce are often difficult for him/her to hear and/or differentiate from other phonemes. Children with apraxia may experience delays in their ability to read because of secondary delays in morphology, syntax, comprehension, expressive language and phonological processing skills.

Does the childs connected speech sound normal, or does he/she have difficulty varying the prosodic features of his/her utterances? Prosody refers to features of an utterance such as intonational patterns, syllable and/or word stress, volume, and rate. Deficits in prosody are often an indication that a child is not able to co-articulate at the utterance level produced. When this happens, he/she produces some phonemes, phoneme sequences, and/or words individually, stopping the speech-melody and causing the child to sound “robot-like” or “different.”

These are some of the main factors that need to be considered when developing goals and objectives for a child with apraxia.

(Lori Hickman, M.S., CCC-SLP, has been a practicing speech-language pathologist since 1983, having graduated with her Master’s in Speech Sciences from Portland State University in Oregon. Ms. Hickman has dedicating her career to date to speech-language pathology in the schools, as well as assessment and treatment of children with severe communication disorders such as CAS. Ms. Hickman is the author of The Apraxia Profile, an assessment instrument as well as therapeutic materials for children with CAS. In 2000, she wrote the book Living In My Skin: the Insider’s View of Life With a Special Needs Child, a book based on interviews of hundreds of parents of children with special needs, providing professionals, extended family, friends, and communities with an inside look at the day-to-day challenges that families of children with special needs face.)

Many individuals close to childhood apraxia of speech hear the words “motor planning” and think of speech. However, motor planning affects everything that requires movement; a child’s function at home, at school and in every extra-curricular or leisure activity that they are involved in. Motor planning is the ability to plan and carry out motor tasks. For children with deficits, physical activities are hard to learn, difficult to retain and generalize, and may look hesitant or awkward in performance.
When considering the effect of motor planning on a child’s performance in school, an immediate concern is typically hand writing. Hand writing is definitely affected by motor planning, but so are many other activities that children need to perform independently to be successful at school. It is important to remember that just as speech is so difficult for many children with apraxia of speech, other complex motor tasks may be difficult as well. A good example is the task of shoe tying.

When a child learns a new task, they usually learn it in steps:

1. cross the laces
2. wrap the top lace under and pull tight
3. make a loop with one lace
4. make a loop with the other lace
5. cross the loops over each other
6. push the top loop around through the hole underneath and pull tight

It is easy to see that when one breaks down the task into steps, there is a lot of room for error and confusion until the motor plan for the activity becomes set or automatic, and does not need constant cueing and reminders. It can become frustrating for the child and for the parent or teacher when there is difficulty learning basic tasks like dressing or gathering books to take home.

Occupational therapists are trained first and foremost in the analysis of everyday activities, and in a school setting- teaching their clients or students how to be independent for school activities. These activities are considered the “occupation” of the child and go well beyond just the academic performance. They can also include being able to sit in one’s seat, organize books and papers, attend to the teacher, and function in the classroom. The child also needs to be able to function outside the classroom to be successful at school. This includes being able to do the other things that happen during a school day, like going to the bathroom- managing the snaps or buttons on their pants, going through the cafeteria line without bumping into people, carrying a tray to a seat, opening containers, eating independently, packing up belongings at the end of the day and getting ready to go home.

When there is a breakdown in motor planning, children can appear clumsy, unorganized, and inattentive and not be able to complete tasks in a timely manner. It is important if any of these issues are noted, to speak to the occupational therapist and follow through with recommendations at home and at school. Children with motor planning deficits learn through demonstration, repetition and successful attempts. As with speech motor planning difficulties, appropriate therapeutic intervention usually is very helpful in managing motor planning problems, and should be addressed as early as possible.

[Ann Marie Feretti, OTR/L, CHT is the owner of Helping Hands Occupational Therapy PC. She earned her degree in Occupational Therapy at the University of Alberta in Western Canada, and is now pursuing an advanced Master’s degree at Boston University. In addition to being an occupational therapist, Ann Marie is also a certified hand therapist and has published articles and lectured in this specialty area, especially in the area of traumatic hand injuries and burns. Ann Marie has been able to link her expertise in hand therapy to the needs of the children in the Bronx/New York City school districts to provide occupational therapy services to local children and families.]

This article originally appeared in “Ask The Experts”, October 2005 Apraxia-KIDS Monthly Newsletter