Treatment Approaches for Childhood Apraxia of Speech

Overview

This lecture explains treatment methods for Childhood Apraxia of Speech (CAS), focusing on motor-based approaches, especially Dynamic Temporal and Tactile Cueing (DTTC), and briefly on other articulatory, prosodic, tactile/gestural methods and treatment evidence.

Main Treatment Categories for CAS

• Treatment categories: articulatory, tactile–gestural, prosodic, and augmentative communication (AAC).
• Most programs combine several approaches (articulatory plus prosodic; sometimes tactile–gestural).
• AAC, natural gestures, and sign can support communication early, until speech is functional.
• Core principle: use motor learning principles to guide all clinical decisions (stimuli, practice, feedback, cues).

Integral Stimulation: General Articulatory Approach

• Integral stimulation = “watch me, listen to me, do what I do” (direct imitation; visual + auditory models).
• Watching the clinician’s face is highly facilitative but may need to be taught systematically.
• Prerequisites: joint attention to the face, basic imitation skills, sustained attention for short periods.
• Mirrors: used sparingly; risk child watching wrong movements or playing instead of focusing.
• Mirror may be used briefly to establish initial placement, then replaced with other placement cues.

Dynamic Temporal and Tactile Cueing (DTTC)

Purpose and Best Candidates

• DTTC = integral-stimulation–based articulatory method focused on shaping accurate movement gestures.

• Developed because existing methods worked but were inefficient for severe CAS.

• Most appropriate for:

  • Severe CAS, primary deficit in motor planning/programming.
  • Child can attend to clinician’s face for at least a few seconds.
  • Child can attempt direct imitation (not necessarily accurate).
  • Preferably good access to frequent therapy and parent participation.

• Not appropriate when:

  • No joint attention, no communicative intent, no gestural communication yet.
  • Cognitive level too low to attempt volitional movement changes or maintain attention.

Core Assumptions and Goals

• CAS primary impairment: motor planning for volitional speech (movement parameters).
• Shift focus from individual phonemes to whole movement gestures for syllables.
• Goals:
  • Increase accuracy and efficiency of motor planning/programming.
  • Increase automaticity to make speech less effortful.
  • Help child take increasing responsibility for assembling, retrieving, executing plans.

Temporal Hierarchy and Cueing Logic

• Hierarchy built on temporal relationship between model and response; cues are added then faded.
• Clinician continually adjusts cues based on child’s most recent response.

DTTC Hierarchy: Steps

Within-Step Procedures

• Always begin by letting child try; then add help only if needed.
• In any step:
  • Start with maximum necessary cues.
  • Increase rate slowly toward normal once spatial accuracy improves.
  • Once accurate at normal rate, introduce prosodic variation.
  • Fade cues as soon as possible; reintroduce temporarily if performance drops.

Use of Prosody within DTTC

• Prosodic variation is introduced first in simultaneous level, then required in direct imitation.
• Changing stress, pitch, loudness, and rate increases variability of motor plans for same word.
• In delayed level, child may initially lose prosodic variety; practice continues until both are stable.

Simplifying Motor Demands (Voice-Off Strategy)

• When a target word is too difficult (e.g., “baby,” “wonderful”):
  • Remove voicing and airflow: practice only oral movement silently.
  • Example: exaggerate mouth movement for “baby” with no sound.
  • Once accurate: move to whisper, then gradually add full voice.
• This reduces planning load by eliminating respiratory and laryngeal demands initially.

Practice Structure within DTTC

• Begin with blocked (massed) practice: longer blocks, many repetitions of the same target.
• As accuracy improves,:
  • Shorten blocks.
  • Reduce repetitions per block.
  • Move toward more random practice across targets and within conversational contexts.
• Probe for spontaneous production periodically; remove a word from training once spontaneous and stable.

Examples from Video Clips (Clinical Strategies)

• Reinforce “trying,” not only correct productions, to lower anxiety and encourage risk-taking.
• Use meaningful, functional words (e.g., “no way,” “mom,” “bike”) tied to real contexts.
• Periodically ask real-life questions (e.g., “Do you like it when people pick on you?”) to maintain communicative relevance.
• Manage attention: brief novel physical tasks (e.g., stand with hands on clinician’s) can recapture focus.
• Accept relaxed posture (slouching on couch) if the child is attending; adjust only when attention is lost.
• For some children, strong external reinforcement (e.g., brief video clips) may be necessary; gradually increase practice-to-reward ratio.
• Initially exaggerate articulatory movements with very severe children, then refine to more natural range.

Other Motor-Based Approaches

Rapid Syllable Transition (ReST)

• ReST = articulatory approach focused on multi-syllabic pseudo-words and prosody.

• Goals:

  • Improve transitions between sounds/syllables.
  • Improve control of stress patterns and overall prosody.
  • Maximize long-term maintenance and generalization.

• Core features:

  • Intensive practice producing nonwords like “tʊbiga” (“tubiga”).
  • Rapid, fluent transitions between syllables.
  • Systematic practice of different lexical stress patterns (e.g., TU-bi-ga vs. tu-BI-ga).

• Session components:

  • Pre-practice:
    • Teach stimuli using various cues.
    • Provide immediate, specific feedback (knowledge of performance) for shaping accuracy.
  • Practice phase:
    • Emphasize motor learning principles.
    • Use knowledge of results feedback and appropriate timing.
    • Fade cues systematically.

• Evidence: published efficacy data; works well for children about 7–10 years with mild–moderate CAS.

• Possible clinical use: start severe children with DTTC, then move to ReST later for prosody and naturalness.

Prosodic-Focused Approaches

Melodic Intonation Therapy (MIT)

• Originally for adults with acquired apraxia; adapted for children with CAS.
• Uses melody and rhythm to support speech.
• For children:
  • Progress from short, simple phrases to more complex utterances.
  • Use signed English symbols to keep time instead of tapping hand like adults.

Contrastive Stress Activities

• Used especially with older children, or when lexical/phrasal stress is impaired.

• Two main uses:

  • Increase variability of practice by altering intonation, rate, volume on accurate utterances.
  • Directly teach lexical and phrasal stress patterns.

• Example for phrasal stress:

  • Show picture “Bob hit ball.”
  • Ask “Who hit the ball?” ⇒ “BOB hit the ball.”
  • “Did Bob kick the ball?” ⇒ “No, Bob HIT the ball.”
  • “Did Bob hit the truck?” ⇒ “No, Bob hit the BALL.”

• Example for word-level (syllable) stress:

  • Use arm/hand movements to mark stressed syllables: “TE-le-phone,” “BA-by.”
  • Emphasize length, loudness, slightly higher pitch on stressed syllable.
  • Clinically, increasing vowel length is the easiest visible cue; pitch and intensity often follow.

• For older children learning long words (science, geography terms):

  • Visually segment word into syllables and bold the stressed one.
  • Teach children to:
    • Break words into syllables.
    • Identify stressed syllable by listening.
    • Practice repeatedly until automatic.
  • Teach parents to support this practice at home.

Tactile and Gestural Approaches

PROMPT (Prompts for Restructuring Oral Muscular Phonetic Targets)

• Designed for CAS; motor-based, movement-focused.
• Uses highly specific tactile–kinesthetic cues on the child’s face and mouth.
• Hands and fingers guide articulators through movement sequences for syllables and words.
• Cues support place, manner, and sequential movement; feedback is primarily tactile/kinesthetic.

Evidence for Treatment Efficacy in CAS

Systematic Reviews

• Earlier ASHA review summarized CAS treatment literature up to that time (in CAS technical report and position statement).
• Murray, McCabe, Ballard (2015) systematic review:
  • Searched peer-reviewed treatment articles (1970–2012) for children with CAS.
  • Included all levels of evidence due to few randomized controlled trials in speech pathology.

• Conclusions:

  • Three approaches best supported for clinical use:
    • DTTC (motor).
    • ReST (motor).
    • Integrated Phonological Awareness (linguistic plus phonological).
  • Effective studies shared:
    • At least two sessions per week.
    • Dose above ~60 practice trials per session.

• Approach-specific findings:

  • DTTC: effective for more severe CAS (design purpose).
  • ReST: effective for ~7–10-year-olds with mild–moderate CAS.
  • Integrated Phonological Awareness: effective for 4–7-year-olds with CAS and co-occurring language impairment.

Practical Therapy Guidelines and “Pearls”

General “Do’s” and “Don’ts”

• Do:

  • Maximize the number of practice trials per session (high dose).
  • Base stimuli selection on vowel content and syllable shape, especially early and in severe cases.
  • Practice whole syllables/words as continuous movement gestures.
  • Use quick, low-distraction reinforcers to keep practice density high.
  • Apply motor learning principles: blocked to random practice, appropriate feedback, variability.

• Don’t:

  • Overuse games/pictures that draw attention away from the clinician’s face and reduce practice opportunities.
  • Separate phonemes within a syllable (e.g., “b–a–k” for “bike”); single-sound movements differ from syllable movements.

Attention and Motivation

• Build joint attention and face-watching before intensive speech work if necessary.
• Use novel, simple tasks (e.g., standing, hands-on-hands) to reset attention when child is distracted.
• Accept natural, comfortable body positions as long as attending; intervene only if attention breaks.
• Occasionally let child choose a challenging “special” word (e.g., “wonderful”) to increase motivation and self-worth.

Use of Data and Progress Monitoring

• Focus in-session time on shaping movement, not taking continuous data.
• Recommended:
  • Every other session (depending on frequency), sample 5–10 random productions of current targets in direct imitation.
  • Use these brief probes to monitor progress and decide when to move items out of training.

Role of Parents

• Ensure parents understand:
  • Nature of CAS as a specific motor-planning speech sound disorder.
  • Overall treatment goals and rationale for chosen techniques.
  • How to support practice at home without adding unhelpful prompts.
• Parents can help with:
  • Reinforcing attention to faces.
  • Encouraging communicative attempts and use of new words in real contexts.
  • Supporting at-home practice for multisyllabic and prosody tasks.

Key Terms & Definitions

• Childhood Apraxia of Speech (CAS):

  • A speech sound disorder where the primary problem is motor planning/programming for volitional speech movements.

• Integral Stimulation:

  • “Watch me, listen to me, do what I do” approach emphasizing visual and auditory modeling and direct imitation.

• Dynamic Temporal and Tactile Cueing (DTTC):

  • Motor-based CAS treatment using a temporal hierarchy from simultaneous to delayed and spontaneous production, with dynamic cueing.

• ReST (Rapid Syllable Transition):

  • Motor-based treatment using intensive practice of multisyllabic pseudo-words with varied stress and rapid transitions.

• Melodic Intonation Therapy (MIT):

  • Prosodic treatment using melody and rhythm to support speech, adapted for children from adult apraxia practice.

• PROMPT:

  • Tactile–kinesthetic treatment using specific manual cues on the face and mouth to guide articulatory movements.

• Blocked (Massed) Practice:

  • Many repetitions of the same target in a row; useful early for severe impairment.

• Random Practice:

  • Mixed practice of different targets in a varied order; supports better generalization and retention.

• Prosody:

  • Rhythm, stress, and intonation pattern of speech.

• Lexical Stress:

  • Pattern of emphasis on particular syllables within words.

• Knowledge of Performance vs. Knowledge of Results:

  • Performance: feedback about how the movement was done.
  • Results: feedback about whether the attempt was correct/incorrect.

Action Items / Next Steps

• Review current CAS caseloads and:

  • Re-examine choice of stimuli (vowels, syllable shapes, functional words).
  • Increase number of practice trials per session where feasible.

• Incorporate motor learning principles:

  • Adjust blocked vs. random practice and feedback type/timing for each child.

• For severe CAS cases:

  • Consider DTTC, ensuring prerequisites (attention, imitation, joint attention) are met.

• For older/mild–moderate CAS cases:

  • Explore ReST, and explicit prosody/contrastive stress activities.

• Collaborate with families:

  • Explain CAS in accessible terms, treatment rationale, and specific home-support strategies.

• For personal development:

  • Consult ASHA CAS technical report/position statement and the Murray et al. systematic review for more detail on evidence.