By Shelley Velleman, Ph.D., CCC-SLP

Key factors to consider in therapy approaches for childhood apraxia of speech:

1. It’s a dynamic disorder, and it’s far more a disorder of combining elements than of producing the elements themselves. In other words, the main problem is in putting elements together “on line”. The person may be able to make a certain consonant sound and a certain vowel sound, but the hard part is putting them together into a syllable. For older/less impaired children, it may be a problem of putting words into sentences or even of making a paragraph out of sentences. With respect to reading, the child may know which letters “say” which sounds, but be unable to blend them together into a word; or the child may recognize a whole (“sight”) word but be unable to understand how the letters combine to make that word.
2. Many factors — especially communication pressure and performance load (meaning + complexity of grammar + difficulty of sounds + difficulty of vocabulary, etc.) — can have an impact on the person’s ability to produce certain sounds/words/sentences at a given time. Just because the child said something once does not mean (s)he can say it again, especially if it is important to do so. The more (s)he wants to say it, the harder it will be to do so. This results in the child appearing to be inconsistent, resistant, or even stubborn.
3. There are often language symptoms (about 50% of the time). Researchers disagree whether these are part of the syndrome or not (I think they are), but all agree that they often co-occur with the articulation symptoms. These may be very basic and appear early (e.g., early grammar will be delayed or disordered), or they may not show up until the child is older. Some children’s language symptoms do not appear until they begin to try to use language as a tool (e.g., reading to learn as opposed to learning to read), in 4th or 5th grade. Sometimes reading is affected.
4. Prosody differences (stress and intonation, especially stress) are a key symptom of the disorder. Many children get to the point where their speech is quite intelligible, yet they still sound different because their stress or intonation patterns are unusual. Usually, speech is slow and choppy. Some children sound quite robotic.
5. There may be other types of apraxia present, including oral apraxia (affecting nonspeech movements of the mouth) or limb apraxia (affecting the hands). Occupational or physical therapists should be involved if so.
6. It’s not the same as other phonological delays. The symptoms can be quite complex, and may change suddenly and unpredictably. The child often will not follow the developmental sequences which are listed in textbooks for other children.

Therefore, therapy approaches should:

1. Be dynamic. Movement patterns and building larger elements should be emphasized. Working on producing consonant sounds in isolation, for example, is a bad idea. It may produce quick results, but it will not contribute to intelligible speech. (The only exception to this is consonant sounds which have a meaning, such as “mmm” and “shh”.) Syllables should be the basic unit, building up from there. The activities which will actually address the heart of the problem are activities where the oral-motor planning system has to plan how to get from one articulatory position to another. This may begin with repeating simple meaningful syllables (baa-baa-baa, moo-moo-moo), moving up to alternating syllables which include either the same consonant or the same vowel (baa – bee – baa – bee; bee – D – bee – D). Working on articulatory movement patterns (as in Moving Across Syllables) is also very helpful.
2. Include activities with lower communication pressure, to increase the automaticity of syllables/words already in the child’s repertoire (e.g., through singing, book-reading, and other verbal routines), as well as activities with higher communication pressure.Augmentative/alternative communication (signs or picture boards) can often help in two ways:
   1. reduce the communication pressure, so the child actually finds it easier to speak
   2. decrease everyone’s frustration.

   Using sign or picture boards does not discourage the child from speaking. It helps.

3. Include monitoring and (if appropriate) treatment of language symptoms. Teach grammatical word endings in an order that is phonologically easiest, even if this doesn’t follow developmental order.
4. Address prosodyvery directly, beginning at a young age. Early activities can include anything with rhythm, pitch, or loudness changes. Music is great! Be sure to vary rhythm, so the child doesn’t get locked into one equal-stressed rhythm pattern. Older children should be explicitly taught about the importance of prosody in speech, including:
   • stress patterns which signal nouns vs. verbs (CONtrast vs. conTRAST), different types of phrases (light HOUSEkeeper vs. LIGHTHOUSE keeper), or sentence meanings (I DIDN’T know vs. I didn’t KNOW).
   • intonation, which signals the type of sentence (yes-no question,with pitch rising at the end, versus statements and wh- questions, with pitch falling at the end) and also the speaker’s emotions.
5. Include movement activities (e.g., to music). Co-therapy with occupational or physical therapists is often very helpful.
6. We recommend therapy as intensively and as often as possible. Five short sessions (e.g., 30 minutes) a week is better than two 90-minute sessions. Regression will occur if therapy is discontinued for a long time (e.g., over the summer).

At least some of the therapy, on a regular basis (e.g., once a week) must be provided by an ASHA-certified (“CCC-SLP”), licensed (in those states with licensure) speech-language pathologist. Other professionals who work with the child in other sessions must be supervised by the certified person (e.g., meet with her/him weekly to discuss progress and strategies).

Most of the therapy (e.g., 2-3 times a week) must be provided individually. If group therapy is provided, it will not help unless the other children in the group have the same diagnosis and are at the same level phonologically. Adequate services cannot be provided in whole-classroom activities. Language stimulation, exposure, etc. may have an impact on some social language skills, but are not sufficient. If you are told,”(S)he’ll get it by listening to the other kids”, do not believe it. If (s)he could get it through exposure, (s)he’d have it already.

Key references:

*Ayres, A. J. (1985). Developmental Dyspraxia and Adult-Onset Apraxia. Torrance, CA: Sensory Integration International.

Crary, M. (1993). Developmental Motor Speech Disorders. San Diego: Singular Publishing Group, Inc.

Hall, P., Jordan, J., & Robin, D. (1993). Developmental Apraxia of Speech. Austin, TX: Pro-Ed.

Kirkpatrick, J., Stohr, P., & Kimbrough, D. (1990). Moving Across Syllables. Tucson, AZ: Communication Skill Builders.

Shriberg, L. D., Aram, D. M., & Kwiatkowski, J. (1997). Developmental Apraxia of Speech: III. A subtype marked by inappropriate stress. Journal of Speech Language and Hearing Research, 40(2), 313-337.

Shriberg, L. D., Aram, D. M., & Kwiatkowski, J. (1997). Developmental Apraxia of Speech: I. Descriptive and theoretical perspectives. Journal of Speech Language and Hearing Research, 40(2), 273-285.

Shriberg, L. D., Aram, D. M., & Kwiatkowski, J. (1997). Developmental Apraxia of Speech: II. Toward a diagnostic marker. Journal of Speech Language and Hearing Research, 40(2), 286-312.

*Stackhouse, J. (1992). Developmental verbal dyspraxia: A longitudinal case study. In R. Campbell (Eds.), Mental Lives (pp. 84-98). Cambridge, MA: Blackwell Publishers.

Velleman, S. L. (1994). The interaction of phonetics and phonology in developmental verbal dyspraxia: Two case studies. Clinics in Communication Disorders, 4(1), 67-78.

Velleman, S. L., & Strand, K. (1994). Developmental verbal dyspraxia. In J. E. Bernthal & N. W. Bankson (Eds.), Child Phonology: Characteristics, Assessment, and Intervention with Special Populations (pp. 110-139). New York: Thieme Medical Publishers, Inc.

Note – Because these references were not written with parents and family members of children with apraxia of speech in mind, please refer to the links with asterisks for material that is easier for non-professionals to understand.

Reviewed 1-11-19