Childhood

Apraxia Of
Speech
Rahaf Shihadeh
Marah Talat
Eman Samara
Mariam Omran
Majd Al-Anati
Overview
 Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder that
reflects an impaired capacity to plan or program sensorimotor commands necessary for directing
movements that result in phonetically and prosodically normal speech, in the absence of neuromuscular
deficits.

Motor speech
Cognitive
planning, Neuromuscular
linguistic
programming execution
process
and control

 The core impairment in planning and/or programming spatiotemporal parameters of movement

sequences results in errors in speech sound production and prosody. 
Causes
CAS can be congenital, or it can be acquired during speech development.

Both congenital and acquired CAS can occur:

 As an idiopathic neurogenic speech sound disorder (i.e., in children with no observable
neurological abnormalities or neurobehavioral disorders or conditions).
 As primary or secondary signs within complex neurobehavioral disorders (e.g., autism,
epilepsy, and syndromes).
 In association with known neurological events (e.g., early childhood stroke, infection,
trauma, brain cancer/tumor resection).
 Prevalence

 Childhood apraxia of speech (CAS) is an

uncommon speech disorder.

 It was estimated to occur in 1 to 2 children

per 1,000 (0.1%–0.2).

 It was estimated to be higher in male

children than in female children with a 2–3:1
ratio.
Childhood apraxia of Speech: Demographics

 More than 80% of children with CAS have at least one family member with reported speech
and/or language disorders (Velleman, 2003).

 CAS demonstrates higher rates of family history than other speech sound disorders, which
suggests a genetic basis in at least some cases (Lewis et al., 2003).

 Up to 3% to 4% of children with speech delay are given the diagnosis of CAS (Delaney & Kent,
2004).

 CAS symptoms are common among children with Down syndrome (Kumin & Adams, 2000).

 Approximately 60% of children with autism spectrum disorder have speech problems;
about 13% report primarily symptoms of apraxia of speech (Marili, Andri- anopoulos, Velleman, &
Foreman, 2004).
 The term childhood apraxia of speech implies a shared core of features (both speech
and prosodic) regardless of the time of onset and whether it is congenital or acquired
or has a specific etiology.

 Early reports delineating the symptoms were based on acquired apraxia of speech in
adults.

• Similarities and differences between the specific articulatory problems noted in adults
with acquired apraxia of speech and children with childhood apraxia of speech were
compared.

• The most important similarity between these two groups of clients pertains to the lack
of sequential volitional control of the oral mechanism.
 There remains a clinical necessity to
delineate the speech characteristics of CAS
children from those evidenced by children
with developmental speech sound
disorders.

 Both groups of children have certain

characteristics in common:

 The onset is early in the developmental

period.
 The course is long term, often extending into
adulthood.
 Speech
Characteristi
cs
 Complaints nearly always center on articulation
and rate and rarely on breathing, phonation, or
resonance.
Patient
Many patients recognize errors and attempt to
Perceptions correct them.

and Many say that the problem worsens under

conditions of stress or fatigue.
Complaints
Patients deny difficulties with verbal
comprehension, reading comprehension, and
the linguistic aspects of writing.
Speech Findings
Articulation:
I. Consonant and vowel distortions (imprecise articulation)
II. Distorted substitutions
III. Distorted additions
IV. Distorted sound prolongations
V. Distorted voicing distinctions “blurring of voiced-voiceless boundaries”

Apraxic speakers produce more consonant distortions than substitutions and that
half of their perceived substitutions are also perceived as distorted.
Rate and prosody

I. Slow overall rate regardless of phonemic accuracy, especially for utterances more than
one syllable in length.
II. Prolonged but variable vowel durations in multisyllabic words or words in sentences.
III. Prolonged but variable interword intervals regardless of phonemic accuracy.
IV. Syllable segregation.
V. Errors in stress assignment with a tendency to equalize stress across syllables and
words.
VI. Decreased phonetic accuracy as rate increases, sometimes crossing phonemic
boundaries.
VII. Altered stress occasionally leads to perception of foreign accent.

No prosodic abnormalities in mild AOS, but very evident in moderate and severe AOS
Fluency:

I. Successful or unsuccessful
attempts to self-correct
articulatory errors that cross
phonemic boundaries.
II. False articulatory starts and
restarts.
III. Effortful visible and audible trial-
and-error groping for articulatory
postures.
IV. Sound and syllable repetitions.
Influential task variables:

I. Syllabicity effects: increased error rates for low frequency syllables, syllables
with more phonemes.
II. Error rates higher for volitional vs. automatic/reactive utterances.
III. Error rates higher for nonsense syllables than meaningful words of comparable
length and complexity
IV. Imitation of utterances particularly difficult
Characteristics of Severe Apraxia of Speech
1. Limited repertoire of speech sounds.
2. Speech may be limited to a few meaningful or unintelligible utterances.
3. Imitation of isolated sounds may be in error.
4. Errors may be limited in variety and highly predictable.
5. Automatic speech may not be better than volitional speech.
6. Error responses may approximate target if stimuli are chosen carefully.
7. Usually accompanied by significant aphasia but can occur in the absence
of aphasia.
8. Usually accompanied by nonverbal oral apraxia.
Multidisciplinary Team
 Professionals to collaborate with
when working with CAS

•Since CAS is a speech sound disorder, the

most appropriate professional to diagnose
and treat it is a speech-language
pathologist (SLP).

• Is SLP is enough?
Depending on your child’s needs, other
professionals may also be part of your
team.
 What other Professionals
May Be Involved?

1- DEVELOPMENTAL PEDIATRICIAN

• is a pediatrician with advanced training in

neuro-developmental disorders and “atypical”,
out of the ordinary child development. 
• This type of professional can help recommend
specialists and coordinate and advocate for
services that the child may need. 
2. PEDIATRIC NEUROLOGIST

A Pediatric Neurologist may be helpful if

there are overall neurological concerns
in addition to speech. If you are
concerned about whether there is:
• a problem of brain structure
• seizures
• other brain related activities

Some medical tests that can be done

include MRIs to examine brain structure
and extended EEGs to investigate the
electrical system of the brain.
3. CLINICAL GENETICIST

•A Clinical Geneticist may become involved if there is

suspicion of an underlying genetic condition.

•In the last few years, since the Human Genome Project
was implemented, a new concept in genetics has
appeared.  It is called copy number variant (CNV). 
• CNV refers to the finding that individuals can have
small parts of chromosomes that are missing,
duplicated, rearranged, or in some way different from
what is expected. 
• There are some CNVs identified in research
publications that have childhood apraxia of speech as
one characteristic.
• For these reasons If there are extended family
members who also have histories of speech and/or
language problems or if there are medical concerns
about your child, parents should speak to their
pediatrician about referral to a geneticist. 
4. OCCUPATIONAL THERAPIST
An OT can evaluate your child’s overall ability to
function in many aspects of life, including fine
motor control.

Often, children with apraxia of speech have:

• difficulty in managing the fine motor
movements and coordination with their
hands that are necessary for skills such as
printing and writing, dressing, manipulating
toys or objects and other self-help skills.

• Additionally, some occupational therapists

are great resources for evaluating children
with difficulty eating.

• Sensory processing difficulties are often

reported by parents of children with CAS,
such as difficulty with noises or in touching
various textures and more. A highly trained
occupational therapist can help evaluate
and treat sensory difficulties.
5. PHYSICAL THERAPIST
A PT can evaluate overall physical
functioning, body coordination and
motor control of larger muscles of
the body (gross motor control) and
how the child is able to function in
their environment. 

6. A DEVELOPMENTAL SPECIALIST OR
PSYCHOLOGIST
A Psychologist or Developmental
Specialist can help to examine a child’s
cognitive abilities and whether they are
developing as expected. 
 Gather Your Team

Each member of your child’s team has their

own area of expertise and strengths. Your
child’s team will depend on their needs and the
resources available. If you have concerns about
your child’s development in addition to their
speech, other professionals may be called on to
get involved in helping your child. 
1-Parents/Caregivers

•You are the expert on your child and know

your child the best

•You provide invaluable information about

your child's motivations, moods, and
challenges.

•You're the one who knows everything that

is going on for your child and can help fill-in
that information for other team members.
 2-SLP(s)

Your child might be working with more than one

SLP. One SLP might be an expert on CAS and
another might have more experience with AAC
(augmentative and alternative communication) or
language.
3-Teacher(s)

If the child is in school, their

teacher(s) are likely to also be a
critical part of the team. Since
many children with CAS also
experience academic challenges.
4- Other Therapists
• Audiologist – PT – OT …
Assessment
 Assessment is accomplished using a variety of standardized and nonstandardized
measures and activities.

 Comprehensive assessment typically includes:

General
observations Speech Stimulability
Oral
Case history of production and response
examination
neurological and analysis to cueing
signs
Case History
Prior speech and
Early vocal
Family history language
behaviours
treatment

Feeding problems
Hearing status (currently or Other treatment
Previously)

Medical or other
Ear infections diagnosis
(Reports)
General observation of neurological signs

It is important to make differential diagnosis between CAS and dysarthria.

We should observe and note neurological signs such as significant muscle tone
abnormalities, asymmetry, extraneous limb movements, abnormal gait
patterns, exist of pathological reflexes. As these signs consist with the diagnosis
of Dysarthria.
Oro-motor examination
Assessing Structure:
Structure refers to the anatomy (e.g., the mouth, teeth, lip,
tongue, pharynx, and larynx).

CAS is associated with intact oral structures for speech (ASHA,

2007).

Body structure deficits may be present if a child has a comorbid

diagnosis such as cleft palate or dysarthria (Murray et al., 2015).

Oral structures need to be assessed using an oral-motor

assessment, such as the Oral and Motor Speech Protocol
(Robbins & Klee, 1987).
Assessing Function:
Function refers to the physiology of the body.

The CAS diagnosis is associated with functional deficits rather than structural deficits
(Iuzzini-Seigel, J., & Murray, E. 2017). Examination of the function of oral peripheral
mechanism.

Imitation of signal and combined nonspeech oral movements, note:

Groping (may indicate CAS)

Inability to imitate single oral/facial movements (may indicate oral apraxia)

Incoordination or lack of rhythmicity of movement sequences slow, clumsy or

inaccurate (may indicate CAS) (Fish, 2016)
Speech production and analysis
Diadochokinetic rates and coordination.
Articulation test.
Syllable test.
Speech sample.
Prosody and suprasegmental features of speech.
Diadochokinetic rates and coordination

Ask the child to produce the syllables /pa/, /ta/, /ka/ 5-10 times each at first slowly, then
naturally, and then as fast as they can.

The child then produces /pa.ta.ka/ 5 times at first slowly, then naturally, and then as fast as
they can.

Note the following:

Reduced misarticulate sounds
Reduced accuracy with increase rates
Reduced rhythmicity of the syllable sequences
Articulation test

Consonant repertoire:
List each consonant that the child produces (even if distorted, substituted incorrectly, or
ordered incorrectly).
Vowel repertoire:
List each vowel (pure vowels, diphthongs) the child produces (even if distorted,
substituted incorrectly, or ordered incorrectly).
 Phonetic accuracy
Consonant accuracy:
Consonant accuracy was assessed by computing the percentage of consonants produced correctly
compared to the number of consonants attempted during each session to get the percent
consonants correct (PCC).
PCC is calculated by = number of correct consonants (excluding distortions) / total number of
consonants * 100.
• Rating system according to Shriberg and Kwiatkowski (1982):
Mild: 85-100%
Mild-moderate: 65-85%
Moderate-Severe: 50-65%
Severe: Below 50%

Vowel accuracy:
This tests the child’s ability to produce the targeted vowels and calculate the percentage of
correctly produced vowels per totally examined vowels (i.e. Percent Vowels Correct PVC).
PVC is calculated by = number of correct vowels / total number of vowels * 100.
Place, manner and voicing errors

SODA (substitution, omission, distortions and addition)

Phonological patterns.
Have children produce test words both
spontaneously and imitatively:

Some children with CAS are able to produce the

word or utterance spontaneously, but not imitate
the same utterance after a model.

Other children can imitate words when provided

with enough cueing but cannot produce the same
words without a model.

This gives indication that the child is

demonstrating a challenge in planning of speech
movement sequence (Fish,2016).
Consistency of consonant and vowel errors

This is observed by asking the child to repeat test items more than once.
Inconsistency is a common finding in children with CAS. So, asking the child to
produce a word only once doesn’t provide enough information if the child
demonstrate ‘inconsistent errors’ or not.
If the formal test you are using doesn’t require the child to produce the test
items more than once. You can add this informally. Only repeat the words that
exhibit motor planning challenges as a starting point (Fish, 2016).
Syllable testing
Syllabic accuracy
 Syllabic accuracy measures the participant ability to produce accurate syllable number, shape and
sequencing.

 For the analysis of syllable number and structure accuracy, a study that was preformed in Egypt
(2010), they used a specially designed syllable accuracy task ‘‘The Arabic Syllable Accuracy Word
Task’’ (ASAWT).

 Participants were asked to repeat 32 different consonant vowel (CV) structures with increasing
task demands.
 Task levels were arranged into 8 categories guided by the hierarchy of phonotactic difficulty.

 (1) Simple open monosyllable (CV) as in /ba/, /ti/, /me/, /do/.

 (2) Reduplicated open syllables (CVCV—same syllable repeated) as in /mama/, /baba/, /nunu/, /titi/.

 (3) Harmonized non-reduplicated disyllabic open syllable forms CVCV as in /teta/, /duda/, /keka/,
/bobi/

 (4) Non-harmonized non-reduplicated disyllabic open syllable forms /toka/, /futa/, /tani/, /hati/.

 (5) Harmonized closed monosyllable CVC /bab/, /dad/, /tut/, /bib/.

 (6) Non-harmonized closed monosyllable CVC /kan/, /gab/, /bet/, /hat/

 (7) CVCVC polysyllable words (non-reduplicated, non-harmonized) /dulab/, /ketab/, /Rarab/,

/mezan/

 (8) Words with initial, medial, and/or final close-to-clusters (using short vowels /gebna, /benti/,
/wedni/, /kofta/
The following scores were then calculated:

(a) Syllable number accuracy

Syllable number accuracy is the proportion of words in which the correct number of syllables is
maintained regardless of the correctness of consonants. For example, if 5 words should have been
produced with 2 syllables and only 4 were produced with 2 syllables, then syllable number
accuracy for disyllables is 4/5 = 80%.

(b) Syllable shape accuracy

Syllable shape accuracy is the proportion of words produced in which the syllable shape is
maintained regardless of the correctness of consonants.

For example, if the target word / ketab/ is produced as /tetab/, the syllable shape is accurate even
though the substitution of the posterior velar /k/ by the anterior alveodental /t/ stop is an error.

The percent of correct syllable shape to the totally produced syllable was calculated to get the
syllable shape accuracy.
Prosody and suprasegmental features of speech

Some of the suprasegmental characteristics that can be impacted in children with

CAS include ( stress, intonation, rhythm, resonance and rate).

 Note whether the child is using excessive equal stress, placing stress on an
incorrect syllable or using flat intonation (Fish,2016).

 Syllable stress inventory: list the syllable stress patterns produced by the child,
even if they are produced incorrectly.
Speech sample
Obtain speech sample to analyse the child’s speech through connected speech.

Consonant and vowel repertoire.

Consonant and vowel accuracy.
Place, manner and voicing errors.
SODA (substitution, omission, distortions and addition).
Phonological patterns.
Rate of speech: Children who are suspected of CAS, may have slow rate as they
struggle to connect phonemes smoothly and efficiently.
Intelligibility of speech: This is measured by comparing the total number of
intelligible words in a speech sample by the total number of words in in the
speech sample.
Stimulability
To assess dynamic motor speech, let the child repeat words after the clinician and
cueing such as simultaneous imitation and touch cues are used to determine
what a child can do with support (Strand, McCauley, Weigand, Stoeckel, &Baas,
2013)
Intervention
CAS has difficulty in:
1.Combine an isolated consonant or vowel phoneme to form a CV or VC syllable.
2.Add a final consonant to produce a CVC production (e.g., shop).
3. combine two CV syllables into a CV.CV word (e.g., bunny).
4.combine two consonants to produce clusters (e.g., stay, eats) .
5.Establishing an initial articulatory gesture and then transitioning smoothly into the next
articulatory gesture.
 An example would be a child who is able to say [mɑ] for “mom” and [mi] for “me,” but
who is not able to connect the syllables to produce [mɑ.mi] “mommy.”
Foundation to treat childhood apraxia of speech P.R.I.S.M:

• Phoneme Sequencing

• Repetitive Practice

• Intensity of Treatment

• Selection of Target Utterances

• Multisensory Cues and Feedback

 Syllable Shapes

Phoneme Priorities in choosing

Sequencing phoneme sequence

Tips for Improving Flexibility

in Phoneme Sequencing.
Syllable Shapes
 Syllable shape: refers to the
ordering of consonants (C)
and vowels (V) within a
syllable.

 word shape : is refers to the

ordering of Cs and Vs within a
word.
Priorities in choosing phoneme sequence
 If the children with CAS tend to omit initial consonants , it may be appropriate to
introduce the VC shape prior to the CV shape.
 If the children with CAS find the production of final consonants so challenging that
the CV.CV.CV syllable shape( e.g. “banana” or “we go now” ) may be easier to learn
to produce than a CVC syllable shape( e.g. top).
 If the child with CAS have limited motor control over their speech output may find
combining two phonemes too challenging, it would be appropriate to work on
meaningful isolated consonants and vowels (e.g., /m/ for yummy, /ʃ/ for quiet , etc..).
 Tips for Improving Flexibility in Phoneme Sequencing

1. choose target words that contain phonemes the child is able to produce.

2. choosing targets with well-established syllable shapes when facilitating

production of new phonemes.

3. Establishing phonetic variety in terms of place, manner, and voicing is

crucial to establishing flexible phoneme sequencing skills.
Repetitive Enhancing Motivation
Practice
Enhancing Motivation

1. know they are successful.

2. understand the power of language.

3. Understand how motor skills will affect their ability to communicate.

4. having fun.
Intensity of Considerations Related
Services to Treatment Intensity
Considerations Related to Treatment Intensity

 Severity of the child’s speech praxis challenges

 Age of the child
 Attention capacities of the child
 Physical stamina of the child
 Types of goals being addressed in speech and language treatment
 Coexisting needs that may require other types of treatment (motor, cognitive,
learning, medical, social, emotional)
Selecting Target
Utterances
Influence of Current Speech Capacities on Target
Utterance Selection
1. To expand and stabilize specific syllable shapes, choose words with phonemes the
child already can produce easily.

2. To expand the child’s phonemic repertoire, choose targets with well-established

syllable shapes
When choosing target utterances for therapy, there are five main speech-related
areas to consider:
1. Syllable Shapes

2. Phonemes

3. Prosody (Trochaic and iambic stress patterns)

When introducing two-syllable words into treatment, begin with words with trochaic stress before moving to words
with iambic stress because trochaic words tend to be easier for children to produce than iambic words.

4. Flexibility and contextual limitations and Facilitating contexts

 Primary Types of Cues

Multisensory
Cueing
Multisensory Cues
 visual is a visual model or image of the way the mouth looks during production of the
target utterance .

 auditory is an auditory model of the target utterance.

 tactile/kinesthetic/proprioceptive: is what the child feels

during production of the target utterance.
- Tactile cues relate to the sense of touch on the skin.
- Kinesthetic awareness is the body’s internal sense of movement.
- Proprioception is the internal sense that helps a person recognize the amount of effort or
force with which the body is moving, the speed of movement, and how the different body
parts are moving in relation to one another in space.

 metacognitive is an associative cue that helps the child focus on a specific aspect of
the target utterance.
https://youtu.be/u4DNZYHOeCI
Evidence-Based
Treatment Programs
for Children with CAS
 Treatment approaches that target speech production focus on helping the child
achieve the best intelligibility and comprehensibility possible.

 However, when there are concerns that oral communication is not adequate, AAC
may also be used to provide functional communication while at the same time
supporting and enhancing verbal speech production.

 In addition to increasing communication success, AAC approaches may stimulate the

development of language skills that cannot be practiced orally.

 These approaches use multisensory cues within the context of treatment to facilitate
the accurate production of new motor speech plans.
 Motor
programming
approaches

Rhythmic Treatment Linguistic

(prosodic)
Approaches approaches
approaches

Combination
approaches
 Dynamic Temporal and
Tactile Cueing (DTTC)

Motor Nuffield Dyspraxia

programming Program(NDP3®)
approaches
Rapid Syllable Transitions
(ReST)
 Motor programming approaches are based on motor programming/planning
principles. These approaches:

1. Provide frequent and intensive practice of speech targets.

2. Focus on accurate speech movement.
3. Include external sensory input for speech production (e.g., auditory, visual, tactile,
and cognitive cues).
4. Carefully consider the conditions of practice (e.g., random vs. blocked practice of
targets).
5. Provide appropriate types and schedules of feedback regarding performance.
Dynamic Temporal and Tactile Cueing
 DTTC was designed to facilitate the child’s ability to transition from an initial articulatory configuration to
the articulatory configurations for the phonemes that follow.
 The steps to using the DTTC approach are as follows:
1. The child immediately following the clinician’s model (direct imitation).
2. If the child is inaccurate (slow, or clumsy in production):

- simultaneous production: the clinician will produce the utterance with the client , modeling the target
utterance at a reduced rate (rate variations).
- Additional cues may be added as needed.
- As the child achieves that accuracy at a normal rate and with varied prosody, the clinician begins to
fade the cues back to direct imitation.

3. When the child is able to produce the utterance correctly ( normal rate and with varied prosody):
- delayed imitation: the clinician slowly begins to increase the time interval between the model and the
child’s production of the target until the child can achieve accurate production of the target without a
model.
Nuffield Dyspraxia
Program(NDP3®)
 Nuffield Dyspraxia Program( NDP3®) is a motor
skills learning approach that emphasizes motor
programming skills and focuses on speech output.
 It is described as a "bottom-up" approach in which
the aim is to "build" accurate speech from core
units of single speech sounds (phonemes) and
simple syllables.
 New motor programs are established using cues and
feedback and through frequent practice and
repetitive sequencing exercises.
 Phonological skills are incorporated into the
treatment approach through the use of minimal
word pairs (Williams & Stephens, 2010).
Rapid Syllable Transitions (ReST)
 ReST was designed to facilitate improved phoneme accuracy and consistency, speed and fluidity
of transitions from one syllable to the next, and appropriate lexical stress in children with CAS.

 ReST is recommended for children with mild-to-moderate CAS who are able to sustain attention
to structured tabletop work.

 ReST incorporates intensive practice (≥100 trials per session) in production of:

- two- to three-syllable (e.g., CV.CV [badə]; CV.CV.CV [bədafi])

- pseudo-words in and short carrier phrases and sentences (e.g., I want a [badə]) phonotactically
permissible pseudo-words.

- The importance of using pseudo-words is to practice motor planning and programming on word-
like forms without interference from previously incorrectly learned plans.
DTTC: https://www.youtube.com/watch?v=drg8qszcCKI
ReST: https://www.youtube.com/watch?v=5IGvgrLPj94
 Cycles approach

Linguistic
Approaches
Integrated Phonological
Awareness
 Linguistic Approaches
 Linguistic approaches for treating CAS emphasize linguistic and phonological
components of speech as well as flexible, functional communication (Velleman,
2003).

 These approaches focus on speech function.

 They target speech sounds and groups of sounds with similar patterns of error in an
effort to help the child internalize phonological rules.

 It is important to note that linguistic approaches to CAS are intended as a complement

to motoric approaches, not as a replacement for them.
Cycles approach
 The Cycles approach is a linguistic approach that targets phonological pattern errors.

 It is designed for children whose speech is highly unintelligible and who have extensive omissions,
some substitutions, and a restricted use of consonants.

 The goal is to increase intelligibility within a short period of time.

 Treatment is scheduled in cycles ranging from 5 to 16 weeks.

 During each cycle, the SLP targets one or more phonological patterns. After each cycle is completed,
another cycle begins that targets one or more different phonological patterns.

 Recycling of phonological patterns continues until the targeted patterns are present in the child's
spontaneous speech.

 The goal is to approximate the gradual typical phonological development process.

 There is no predetermined level of mastery of phonemes or phoneme patterns within each cycle;
cycles are used to stimulate the emergence of a specific sound or pattern, not produce mastery of it.
 Integrated Phonological Awareness Intervention

 Integrated Phonological Awareness (IPA) is designed to simultaneously facilitate

phonological awareness, letter–sound knowledge, and speech production in
preschool and young school-age children with speech and language impairment.

 Specific approaches to facilitate the development of phonological awareness include

(a) developing knowledge that positively influences phonological awareness
development (e.g., teaching nursery rhymes and focusing on sound properties of
spoken language) and (b) integrating phonological awareness activities into
treatment sessions.
Prosodic Facilitation
 Prosodic facilitation treatment methods use intonation
patterns (melody, rhythm, and stress) to improve
functional speech production.

 Melodic intonation therapy is a prosodic facilitation

approach that uses singing, rhythmic speech, and
rhythmic hand tapping to train functional phrases and
sentences.

 Using these techniques, the clinician guides the individual

through a gradual progression of steps that increase the
length of utterances, decrease dependence on the
clinician, and decrease reliance on intonation .
Combination approaches
 Uses both motor programming and linguistic approaches.
Prompts for Restructuring Oral Muscular Phonetic Targets
 A PROMPT-trained clinician uses tactile/kinesthetic/proprioceptive input to the
speech subsystems (e.g., phonation, mandible, labial-facial, lingual) to facilitate
production of phonemes, words, and phrases.

 Prompts are provided externally to the jaw (to facilitate the accurate degree of
jaw opening, provide jaw stability, and reduce extraneous jaw excursions); the
muscles of the face, including the cheeks and lips (to facilitate independent lip
closure, rounding, and retraction); and the mylohyoid tissue under the chin (to
facilitate placement, width, and timing of contraction in the tongue musculature)
(Hayden, 2004a).

 Additional tactile cues are provided to facilitate voicing and nasality.

 Prompts are faded as the child develops greater control over the planning and
execution of speech movements and coarticulation.
https://youtu.be/yXtNYsfNXO4
 A core set of child-specific functional stimuli (e.g.,
words or phrases) is often incorporated into various
treatment approaches.

 Treatment selection depends on factors such as the

severity of the disorder and the communication
needs of the child.

 Because symptoms typically vary both from child to

child and within the same child with age, multiple
approaches may be appropriate at a given time or
over time.

 Apraxia in other systems may also play an important

role in treatment. For example, the presence of limb
apraxia may make it difficult for the child to use
manual signs for functional communication.
 This case study is used to illustrate the changing
nature of treatment over time for a child with CAS.

 At each stage of development, the child’s present

level of performance will be described, along with
recommendations for treatment that are priorities
for the child at that moment in time.

 Basic treatment goals and possible methods for

treatment are listed; these change depending on
the child’s age and performance levels.

 The treatment goals listed in this case study are

basic goal areas that will be addressed for this
child.
Marissa, Age: 2 Years, 5 Months
Marissa, Age: 2 Years, 9 Months
Marissa, Age: 3 Years, 3 Months
Marissa, Age: 4 Years, 4 Months
Thank You!
Any Questions?
  References:
1. Duffy, J. (2013). Motor Speech Disorders ( Substrates, Differential Diagnosis, and Management)- 3rd Edition. Elsevier.

2. Childhood apraxia of speech. American Speech-Language-Hearing Association. https://www.asha.org/practice-

portal/clinical-topics/childhood-apraxia-of-speech/. Accessed April 2, 2021.

3. Bauman-Wrangler, J. (2016). Articulatory and phonological impairments: A clinical focus 3d Ed. Boston: Pearson,
Allyn& Bacon.

4. Luzzini-Seigel, J., & Murray, E. (2017). Speech Assessment in Children With Childhood Apraxia of Speech. Perspectives
of the ASHA Special Interest Groups, 2(2),

5. Aziz, A. A., Shohdi, S., Osman, D. M., & Habib, E. I. (2010). Childhood apraxia of speech and multiple phonological
disorders in Cairo-Egyptian Arabic speaking children: Language, speech, and oro-motor differences. International
Journal of Pediatric Otorhinolaryngology, 74(6), 578–585.

6. Fish, Margaret A,. (2016), Second edition. Here's how to treat childhood apraxia of speech

7. Feldman, H. (2019, November 7). What other Professionals May Be Involved? Apraxia Kids.

8. Waldrup, B. (2020). Team Approach for Children with Childhood Apraxia of Speech. Child Apraxia Treatment.

9. American Speech-Language-Hearing Association. Childhood Apraxia of Speech. ASHA.