As children with apraxia are in therapy for a period of time, they may experience phases of system “overload,” when the demands for speech motor complexity appear greater that the capacity to handle them. It can be quite frustrating to the parent and therapist alike to all of the sudden be faced with yet another aspect of communication breakdown just when the child appeared to be making such good progress! The book Stuttering and Related Disorders of Fluency (2nd Edition), edited by Richard F. Curlee, Ph.D., contains two particular chapters that may be helpful. Chapter 7 is titled “Treating Children Who Exhibit Co-Occurring Stuttering and Disordered Phonology” and Chapter 9 is titled “Perspectives on Stuttering as a Motor Speech Disorder.”

My first recommendation, when disfluency erupts in children with apraxia who have not demonstrated prior disfluent speech, is: “Don’t panic.” As difficult as it is to hear a child struggle intensely with fluency control, I have seen many children with very severe rapid onset of disfluency “move out of it” either as quickly as it began, or over time without any “direct” focus. A response of tension and anxiety from the listener can further contribute to increased speaking tension for the child. That doesn’t mean that there are not some adjustments that can be made in therapy as well as in the home, especially when the disfluency persists over time.

Therapy considerations should include a “backing off” of “direct” sound/sound sequencing work and utterance complexity expansion, to allow time for solidification of past speech motor gains. Generally, for children with apraxia, there are many other areas that can be addressed during this break time. These include prosody (e.g., stress and inflection), specific language forms, and pragmatics. For some children, this may be the optimal time to “teach” them such strategies as self-dialogue play. The idea here is to avoid adding additional demands to the speech-motor system for a period of time, with the length of time quite dependent upon each individual situation.

It is important that therapists and parents attempt to use an easy, relaxed manner of speaking to the child, as much as possible during this time. In our clinic, we use “phrased speech,” where pauses at phrase junctures are used. This allows for continued natural inflection (as opposed to slowing all the words down, which usually results in minimal inflectional variation), while slowing the overall rate of speaking down. This is not just a “go home and do it” recommendation, as parents may be quite variable in their personal rate of speech. The strategy of “phrased speech” should be practiced in the therapy setting whenever possible for it to become more automatic and natural sounding. In a way, it mirrors what we are asking the children to do with speech motor sequences.

In our preventative stuttering therapy program at Children’s Hospital of Pittsburgh, we used a wireless microphone feedback approach to teach parents strategies of fluency enhancement. The therapist provided on-line feedback for the use of this strategy and others through an ear bud as the parent was playing with his/her child. We found the carryover of strategy usage to be much better than just suggesting a slower rate to parents, and hoping that it happens. Even with this more intensive approach to parent training, it remains quite a challenge for parents to adjust their rate of speech, which is certainly understandable.

If in fact, it is determined that the child demonstrates co-occurring CAS and stuttering, there are a number of options that can be considered as each individual and situation may be unique and warrant a different approach.  These approaches may include the following:

1. Indirect concurrent approach (Conture, Louko, & Edwards, 1993)
   • No direct training, evaluations or corrections
   • Indirect modeling slow rate, etc. for fluency
   • Indirect modeling of correct productions for articulation
2. Direct concurrent/alternating approach (Unicomb, et al, 2013)
   • First two sessions just direct therapy for fluency (e.g. Lincombe)
   • Future sessions – alternating LP and speech/articulation
3. Blended
   • Incorporate fluency strategies into “speech” intervention activities.
4. Sequential
   • Treat one disorder at a time.
   • If just focus on fluency, then add demands of speech sound production/sequencing will it negatively impact fluency?
   • If just focus on speech sound production/sequencing and delay fluency treatment, might there be social, emotional and educational consequences of continued dysfluencies?

Word retrieval problems can also play a role here. We know that children with apraxia of speech are at higher risk for processing, formulation, and word retrieval deficits. The child may attempt to “hold the conversational floor” as he searches for a word. Again, modeling that it is okay to take time to respond, to answer questions, etc. helps the child not to feel time pressure to verbalize immediately.

You don’t have to be an expert in stuttering to handle fluency breakdowns as they occur for children with apraxia. I certainly have seen enough children move through this phase without any “direct” attention to the disfluency, to know that it can resolve. On the other hand, it cant be taken too lightly if viewed as a signal to us that the speech motor system may be overloaded or in need of a pause time from direct input. Hopefully some of the suggestions presented here will help move children more easily through this sometimes disconcerting phase of verbal skill acquisition.

(David Hammer, M.A., CCC-SLP, is the former co-director of the Stuttering Center of Western Pennsylvania, a joint affiliation between Children’s Hospital of Pittsburgh & the University of Pittsburgh and the former VP of Programs of Apraxia Kids. Additionally, he served as Coordinator of Speech and Language Services at Children’s Hospital North in Pittsburgh. He has lectured extensively and given “hands-on” workshops on childhood apraxia to speech and language associations, early intervention and school systems, conferences and conventions throughout the United States.