Have you recently started to treat a child with Childhood Apraxia of Speech (CAS)? Are you feeling lost and in need of an initial roadmap? CAS is a dynamic disorder that changes with age and severity, and frequently presents with concurrent language and literacy difficulties.1 Treatment can be challenging for an SLP with limited experience. Furthermore, treating Childhood Apraxia of Speech requires specialized knowledge in the area of motor-speech disorders and the principles of motor learning.
So, have you researched and planned an efficient, effective, and direct route for treating CAS? Do you have guideposts, a compass, or a GPS to help you navigate this journey? Well, turn on your GPS! Here is an initial roadmap to get you started on this trip!
Entrance Ramp Ahead: The Journey Starts Here
Prior to assessing and treating children with CAS, research and plan ahead. It is an absolute necessity to read and utilize a number of key documents prior to beginning any assessment or treatment. There are many important articles to read, but build your assessment and treatment map by reading the following:
- American Speech-Language-Hearing Association’s 2007 seminal documents on CAS: ASHA’s Position Paper on CAS and ASHA’s Technical Report on CAS4,5
- ASHA’s Childhood Apraxia of Speech (CAS) Practice Portal14
- Article published in American Journal of Speech-Language Pathology: Review of the Principles of Motor Learning in Treatment of Motor Speech Disorders2
- Article published in Language, Speech, Hearing, Services in Schools: School-age Follow-up of Children with Childhood Apraxia of Speech1
Stop: Practice Speech, Not Non-Speech Oral Motor Exercises
Research has shown that non-speech oral motor exercises (NSOMEs) are not effective for the treatment of CAS.3 CAS is a motor speech disorder and requires intense practice of speech production.
Yield: SLPs with Experience Evaluating and Treating CAS
ASHA recommends the diagnosis and treatment of CAS should be conducted by certified speech-language pathologists with “specialized knowledge in motor learning theory, skills in differential diagnosis of childhood motor speech disorders, and experience with a variety of intervention techniques that may include augmentative and alternative communication.”4 For information on identifying a speech-language pathologist who is experienced in diagnosing and treating CAS, please refer to How to Find a Speech-Language Pathologist When Your Child Has Apraxia of Speech.
One Lane Ahead: ASHA’s 2007 Technical Report recommends that children with CAS receive individual motor speech therapy.
ASHA’s Technical Report on CAS states, “Given the need for repetitive planning, programming, and production practice in motor-speech disorders, clinical sources stress the need for intensive and individualized treatment of apraxia… Although home [classroom] practice is critical for optimal progress, it cannot take the place of individual treatment… As long as the primary goal is to improve the motoric aspects of the child’s speech production (i.e., more time for motor practice) individual therapy should be the preferred approach.”5 Weekly, 3-5 individual motor speech sessions are recommended.
Merging Traffic: Collaboration
Children with CAS frequently receive treatment from more than one SLP. It is important that early intervention, hospital-based, and school-based SLPs collaborate with a child’s private SLP. Motor speech targets and treatment strategies should be consistent across settings.
Slow Traffic Ahead: Use a Motor Speech Approach
Although other treatment methods are being researched, at this time children with CAS have shown improvement in their speech production skills in response to the use of motor speech treatment approaches. One such research intervention is Dynamic Temporal and Tactile Cuing.6,7 DTTC has been studied for its effectiveness in improving the speech skills of children with CAS.8 DTTC is based on a cueing hierarchy that is dynamic in nature. In this hierarchy, the clinician systematically decreases his or her support, moving from simultaneous target productions with a slow rate of speech to direct models, indirect models, and finally spontaneous productions. A general goal of treatment for CAS is to move the child from motor performance to actual motor learning. Other well-researched motor-based programs include Rapid Syllable Transitions (ReST) and Nuffield Dyspraxia Programme.9
No Idling, Stopping, or Standing: Deliberate, Purposeful, Individualized, and Intense Practice is Required
The motor act of speaking is complex! Production of speech requires a fine level of coordination across many different muscle groups and an ability to handle complex spatiotemporal demands. As a result, motor speech treatment should be intense and incorporate deliberate speech practice. Carefully plan schedules and types of practice and feedback. Motor speech targets should be carefully chosen and individualized for each child. These targets need to be chosen not only for phonetic and phonological properties, but also for the functional communicative power mastery will afford the child.
Watch Curves: Childhood Apraxia of Speech is a Dynamic Disorder
CAS is a dynamic disorder that changes across the continua of age and severity.1,10,13 As a child ages, the relative contribution of CAS to his or her speech and communication difficulties may change. Upon entering school, literacy skills will also need to be monitored closely.
Bumpy Road Ahead: Use Concepts of Grit and Growth Mindset
Implement strategies to increase the trait of grit, as well as a growth mindset in your clients.11-13 Motor speech practice is difficult work that encompasses long-term goals for clients and their family members and SLPs. Use strategies to build grit and a growth mindset to support and build resilience in your clients to face the difficult work ahead. For example, praise the process of learning new and challenging motor speech targets not just the results. Utilize grit and growth mindset language including Dweck’s concept of the “amazing power of yet.”
Fuel and Lodging Ahead: Savor the Research!
There are ways to simultaneously keep up with and embrace the research that is regularly published. You can start a journal club to stay abreast of the research and to help you find ways to consistently implement evidenced-based treatments. Since the 2007 ASHA documents on Childhood Apraxia of Speech were published, there has been much more research into the nature and treatment of CAS. There is a lot of research to stay current on! Starting a CAS journal club is one way to fuel your brain, get respite, and stay current–ensuring that your treatment is evidenced-based.
- Lewis, B. A., Freebairn, L. A., Hansen, A. J., Iyengar, S. K., & Taylor, H. G. (2004). School-age follow-up of children with childhood apraxia of speech. Language, Speech, and Hearing Services in Schools, 35, 122-140
- Maas, E., Robin, D. A., Austermann Hula, S. N., Freedman, S. E., Wulf, G., Ballard, K. J., & Schmidt, R. A. (2008). Principles of motor learning in treatment of motor speech disorders. American Journal of Speech-Language Pathology, 17, 277-298.
- Lof, G. L., & Watson, M. (2004). A nationwide survey of non-speech oral motor exercise use: Implications for evidence-based practice. Language, Speech and Hearing Services in Schools
- American Speech-Language-Hearing Association. (2007a). Childhood apraxia of speech [Position Statement]. Available from www.asha.org/policy
- American Speech-Language-Hearing Association. (2007a). Childhood apraxia of speech [Technical report]. Available from www.asha.org/policy.
- Strand, E. A. & Debertine, P. (2000). The efficacy of integral stimulation intervention with developmental apraxia of speech. Journal of Medical Speech-Language Pathology, 8, 295-300.
- Strand, E. A., Stoeckel, R., & Baas, B. (2006). Treatment of severe childhood apraxia of speech: A treatment efficacy study. Journal of Medical Speech-Language Pathology, 14(4), 297-307.
- Maas, E., Gildersleeve-Neumann, C. E., Jakielski, K. J., & Stoeckel, R. (2014). Motor-based intervention protocols in treatment of childhood apraxia of speech (CAS). Current Developmental Disorders Reports, 1, 197-206.
- Murray, E., McCabe, P., & Ballard, K. J. (2012). A comparison of two treatments for childhood apraxia of speech: Methods and treatment protocol for a parallel group randomised control trial. BioMed Central Pediatrics, 12(1), 112-121.
- Aggarwal, P., Mitchell, L., & Van Zelst, A. The changing face of CAS, Presented at the Childhood Apraxia of Speech Association Conference, Danvers, MA 2012
- Duckworth, A. L., Peterson, C., Matthews, M. D., & Kelly, D. R. (2007). Grit: Perseverance and passion for long-term goals. Journal of Personality and Social Psychology, 92(6), 1087-1101.
- Dweck, C. Mindset: The new psychology of success. Ballentine Books, New York, New York, 2006
- Van Zelst, A. & Mitchell, L. (2015) Building spunk and grit: Promoting resilience and success in CAS treatment. American Speech-Language Hearing Association Convention, Denver CO
- ASHA’s Childhood Apraxia of Speech (CAS) Practice Portal. Available at: www.asha.org/Practice-Portal/Clinical-Topics/Childhood-Apraxia-of-Speech/