Examples of CAS treatment
Well, the goal of treatment and the focus of treatment is the major difference between treating a child that has particular difficulty with praxis for speech, and treating a child with a different kind of speech sound disorder. The focus for childhood apraxia of speech has to be on movement accuracy. So the techniques we use will be a little bit different, in that we’re drawing the child’s attention and effort, we’re providing feedback, all related to the accuracy of movement. Now it’s a little more complicated than that, given that these children with apraxia of speech sometimes have other problems, too, which we address. But if I had to talk about what’s the primary difference, it would have to be that the focus of treatment is on movement accuracy.
Treatment for childhood apraxia of speech also differs in that it’s important that therapy be frequent, and that during each therapy session, a lot of actual practice occurs. It’s important to have the child watching the clinician’s face, as that’s very facilitative for children with apraxia of speech. One other thing that therapists try very hard to do when treating children with apraxia of speech is to bring in what we call principles of motor learning. These are just basic principles that relate to how practice is organized, how and when we provide feedback, and different kinds of schedules of practice.
The next segments will show some examples of therapy with children who have childhood apraxia of speech. This clip shows an early treatment session, in which I am looking for appropriate items for him to practice. At this point, I’m paying attention to how much cueing he needs, rather than carrying out the therapy strategies for improving his speech. At this point, I reward him for any tries, letting him know it’s OK to make mistakes. I also reward him for certain movements, such as the lip rounding for the W, even though he still distorts the vowel. Try “no way!” No ay. Good job. Can you tell me, “wwwhen?” When. Eh! [LAUGHTER] Try “when.” It’s OK if you can’t do it right. I just want to see you try. Good trying! I’m going to do it with you. When. Good one. My turn. When. Oo-eh. Good for you. This clip shows a therapy strategy in which the clinician and the child say the word or phrase at the same time. Notice how he does better when he looks at the clinician. After he is fairly accurate, we move to imitation. This is harder for him, so we can either go back to saying the word together, or as you’ll see in this clip, have him repeat the word while watching me mouth the word at the same time. Gestures and slowed rate are other cues used in this clip. Notice how slowly we move toward normal rate with continued practice. Oo-ay. No way. No oo-ay. Good job. Very good. Do you like to eat dirt? Oo-ay! Good trying. That was very good. Say, “no way.” No way. Good job! Do you like it when people pick on you? No ay — way.
In this next clip, we see the same child a couple of days later, where we are working to vary the rate and rhythm so that speech becomes more natural and more automatic. In this clip, we also see a therapy strategy of adding a delay before he imitates, so that he is less reliant on cues. Note the large number of responses that are obtained. This is an essential key to motor learning. Way. No way. No wayyy. No wayyy. No way. No way. No way. No way. No way. No way. No way. No way. No way. No way. OK, let’s see if you can wait. No way. No way. Good. No way. No way. Good. I was mouthing it. That helped you, huh. No way. No — no way. Yeah. Can we put your hand down, buddy, so I can see what you’re doing with that mouth? Thank you. No way. No way. Good job. No way. No way. Get lips real round for O. No way. Good one. My turn. No way. Nuh — [LAUGHTER] Do it again. No way. No way. Good job, I didn’t help you at all! Let’s try a different one. Tell me, “I’m home.” I ome. I. I. This time we’re saying, “I’m,” cause we’re — I’m. — gonna say, I am home. I’m home. Make those lips round. I’m — At this point, you will see him start to go on automatic pilot, where he’s just repeating, but not really thinking about what he’s doing. At this point, we need him to slow down and bring back his focused attention. OK, stop. Let’s go “whew.” Huhh. Very good.
In this clip, the child is asked to attempt a phrase that is newer and harder for him. I need to bring back his attention to my face so he can benefit from the visual cues. We often have the child stay in an initial position for the first sound a little longer, to help him get a better feel for it. — say as much. So we’re gonna do something here. Stand up. Put your hands like this, next to me. Eyes up here. Get your lips ready. We’re going to go — just leave them there. Good job. Stay there. Oooo-i-nuh. Very good. Let’s just say “why” a few times. You ready? Ooo-i. Good. We’re just — not “wine,” honey. Why-eee. Finish with the “ee.” Why-ee. Good. Why-ee. It’s really interesting, because you say “I” really good, but Y is a lot harder, huh. Ooo-i-nuh. Good. We’re just going to say “why.” I’m going to show you one thing. I want you to open your mouth a little bit. Don’t smile. Just go, ooo ai eee. Then smile, good. Ooo ai eee. Good, let’s do it again. Ooo ai eee. Yeah! See, if you sit way up here and watch me, we get better. OK, watch it. Ooo ai eee. Good one. Ooo ai eee. Good. Ooo ai eee. Ooo ai eee. Does mama ever say, “Cause I said so!” when you ask her why? How do you sign why? You have a sign for — yeah. Very good. Now you can say it, huh. Ooo ai eee. Good. Let’s do it faster. Ooo-i-ee. Ooo-i-ee. You’re starting nice and round. Ooo-ai-ee. Oo-ai-ee. All right, let’s try it. Ooayee. Good job. You can rest your mouth. Go like this. [BLOWING] Yeah. Now go, “why not.” Why not. That was beautiful.
Although this child can say the “I” vowel in some words, like “bye,” he has more trouble in more complicated words, like “bike.” This is common in childhood apraxia. Note that we never separate sounds within a syllable, such as “buh-ike,” because movements for a single sound are different than the movement for that sound in a syllable. My bike. My bak. Oh, that was a good “my.” We need to do aieee in bike, too. I want to see your jaw move. Baieek. Let’s do “bike” five times. Baieek. Baieek. Baieek. Baieek. Baieek. Good. Bike. Bak. Oh, bak? I’m hearing kind of bahk. Let’s try it. Aieee. Aiee. Baiee. Baiee. Baieek. Baieek. That was it. Byeek. Bike. Good one. Byeek. Do you have a bike? No. Yeah. I thought you got a bike for your birthday. Did you forget? Your probably didn’t get to bring it with you, did you, to Rochester. So that will be fun. When you go home, you can ride your — Bak. Bak? I don’t know what that is! You want to ride your — Baik. Better. Good job! Logan, what would you like to ride? You like to ride your — Baik. Good. You have a red — Baik. Did I remember that right? Yeah. Is your bike red? Good. You have a red — Bahk. Can you fix that? I bet you can. I bet you can. Think about it. My bak. Oh, you’re going to say “my bike” this time. We can just say “bike” for a while. Baieeek. Baieeek. You have a red — Baieeek. Good. Whose bike is it? Myee baieek. Good job! Whose bike is it? Myee byeek.
This is a child who needs more rewards for practicing. He is very motivated by watching a favorite character on the video. We give him short video breaks after each period of practice. This keeps his attention to our face. Over time, we can increase the amount of practice trials between the video breaks. Notice that we over exaggerate the movements at first. This is sometimes necessary for children with more severe apraxia. We work to quickly refine the movement as they become more accurate. Good job. Who can say, owwt? Aut. Owwwt. Aht. Almost. Owwt. That was it! James can! Who can say — Out. That’s it. That’s it. Owt. Yeah, you knew you didn’t quite have your vowel. Out. Yeah. Owwwt. Good one. Out. Good job. Out. Out. Out. Out. Out. Out. Out. Out. Can you the right here at Edie? Look at Edie so we can do it three times. Home. Good job, you made your lips round. Ohh. Home. Good job. Mommy is at — we’ll watch more in just a minute. Let’s do three more. No, ah. Two more? OK, how about two and two? OK? OK. Home. Good job. Hommme. Hommme. Good one. Hommme. Good job. Home. Good. Lips round. Hommme. Let’s go a little slower.
This sample shows a child trying a word that seems too difficult at this point in therapy, but I reluctantly included it, because he really wanted to say it. He was accurate within one session, and proved me wrong. Who do we look at? You! Yeah, right here, buddy. Yes, ooh, good hugs. OK, watch Edie’s mouth. We’re going to do it together. We’re going to say “wonderful.” Won der ful. Good job. Let’s do it slower. Can we go real slow? [INAUDIBLE], look at Edie, please. Won — Am I doing that? No. What am I doing? I want to do something different. Let’s take the voice away. And we’re just going to make some movements. Let’s get the stickers — Like — Like that, yeah. Just like we did before. We just made movements. No talking. Let’s just do this. Good job. That’s how we do it. Let’s do it again. That’s it. That’s it. Go slower, though. Won der ful. Oh, you did it! Did you think you could do it? No. No. Did you do it? Yes! Wonderful words. Da. You want to say that, huh. Let’s do it together. Wonderful. Oo — Whoops — Won der ful. Beautiful. Do it again. Won der ful. Oh, you stayed with me! We’re saying won-der-ful. Won-der-ful. My turn. Won- der-ful. Won- der- ful. Good job. Won- derful. Won der ful. Wonder- ful. Won der ful. Good job. Ww — Oh, oh — Wonderful. Won der ful. Get lips round. Won der ful. Won der ful.
Keep in mind, there are many different approaches and techniques which are appropriate for children with childhood apraxia. You have seen only a few. A key element of any therapy, though, is to be sure the child gets lots of practice, and that visual and touch cues, as well as gestures, that may be necessary at first are faded out as quickly as possible. Finally, it is important that parents understand what is happening in therapy, and how they can help their child at home.