Childhood Apraxia of Speech: Hierarchy of Support offers tips and tricks for helping children with CAS by giving consistent speech cues.

Using a hierarchy of support (consistent cues) has been one of my most used strategies for children with CAS. It is important to be intentional about the frequency and types of cues you are giving. By doing so, children have a consistent measure of support. This support fades as children’s speech production skills increase.

Before we begin, if you’d like to learn more about this series by reading my introductory post on CAS or scrolling to the bottom of the page for other posts on this topic.

Cueing: A Client Example

One of my recent clients with CAS came to me at age four. He made a variety of vowel and consonant sound errors. At that time, he was difficult to understand. In fact, I think his parents were the only people who could understand him. For those interested, I described more details about his story in my last post.

This client sometimes felt frustrated while speaking. He had started to notice that his speech was difficult to produce. He also noticed that people couldn’t understand him. Because of this, he was starting to talk less and less.

As a result, his parents and I developed a plan. We wanted him to increase his speech sound production skills. We also wanted to give him cues and pointers that were helpful. Our ultimate goal was that we wanted to hear this boy’s voice and what he had to say.

Thankfully with speech therapy, this client made a considerable amount of progress. Now, most people can understand what he says. He is still working on quite a few speech sounds, but speech no longer causes him a great deal of frustration. He likes to talk, and his parents and I like to hear him do so!

What worked?

So, how did we provide support? What plan did we develop? There were a variety of facets. We included regular speech therapy appointments and a homework program, gave this client opportunities to talk, and encouraged him by telling him what he said was important.

Over time, his speech sound skills increased. At first, he came several times a week for speech therapy. After his skills increased, he continued to come once a week to speech therapy.

Cues helped this child reduce his frustration level early on. Cues also helped him build his speech sound production skills. Over time, I was able to reduce those cues and he was still able to produce target sounds (even without cues).

Cues: A Definition

What are cues? A cue could be a sign, a prompt, or a reminder. There are many prompts you can give a child as you help her/him produce speech sounds. For example, you may ask a child to watch your mouth while you produce the sound. In addition, you may produce the speech sound together.

Chances are, you are already giving cues to your child. But how do we know that the cues we are giving are helpful? How can we cue children without giving too much or too little support?

As a child’s speech sound production skills increase, we need to give fewer cues. This increases independence and generalization because children are not dependent on our cues. In other words, we want to give a lot of support at first. As a child’s skills increase, we want to then reduce the support of cues. This will increase confidence and independence on the child’s part.

Childhood Apraxia of Speech: Hierarchy of Support

The hierarchy of support offers guideposts for those of us working with CAS to offer cues. It starts with offering the most help. This way, children can learn these skills with support and feel success. After that, the support decreases (in steps) as children’s skills increase.

Using this hierarchy of support is one of my most valuable tools in working with children with CAS. Giving supportive cues facilitates learning and independence in speech sound production.

Below, I’ll outline some of the steps in this hierarchy and examples of each. Also, the tasks in this hierarchy get more and more difficult. This is because as we see success on each step, we make sure to move forward to harder tasks. This is based on DTTC, a research-based approach to CAS; and is adapted for the order in which I use it in my clinic.

Steps in the Hierarchy of Support

1. Watch and Listen – Say The Word Together

This step offers the highest level of support.

For this step, I ask my client to watch me say the word. It is important my client is attending to my mouth movements. Then, we say the word together.

2. Watch and Listen – I Say, You Say (Watch my Mouth)

This step offers less support than Step 1. I begin this step once my client has a high level of accuracy with Step 1.

I will say the word, and then my client will say the word. Again, I make sure my client is attending to my mouth so she/he can see how I’m producing the sound.

3. I say, You Say (With Cues)

After Step 2, I reduce support even more for Step 3.

I’ll say the word and give a cue. I might give a visual cue, such as a picture of how the mouth should look for the sound. Another visual cue I might use would be my mouth puppet. This way, my client can manipulate the puppet and show me how to produce the sound. There are many other cues (besides visual cues). Even so, for simplicity (and brevity), we’ll stick with this one for now.

With cues (such as a visual prompt), I’ll say the target word and then the child will say the target word.

4. Model, Repeat (No Cues)

This step is a simple model (I’ll say the word or sound), and then my client will repeat. I do not use other cues for this step.

In short, this step is I say it, you say it.

5. I ask A Question, You Answer (With Target)

Step 5 is an exciting step as we work away from using an initial adult model. This is an important step to increase generalization. When we reduce cues, children can work closer towards generalization. What is generalization? This is when children start using speech sounds in less structured settings. This is an important step to working towards using these sounds in conversational speech.

For this step, let’s pretend a child’s target word is “stop.”

My cue might be: “On a stoplight, green means go. What does red mean?”

A child could answer “stop,” and then we’d be ready for the next target word.

I ask a question (typically without the target word in it), and the client answers the question with the target word.

6. Target Utterances In Role Play in Games

Step 6 is for when children use their new speech sounds when answering questions (Step 5). It is important that there is a high level of accuracy on Step 5 before moving on to Step 6.

For younger clients, we might target sounds in role play or games. For older students, I might show them a picture loaded with target sounds and ask them to tell me about it. For students who are fluent readers, we might read a book together that has many of their target sounds.

To summarize, this steps involves using target sounds in less structured tasks (play, picture scenes, story retell).

Final Considerations for Parents

Although it isn’t necessary to follow this leveled support for all clients, I’ve found this is a helpful tool. In outlining these steps, I’ve removed some steps I don’t use. Therefore, other clinicians might have steps that look different than these. Ultimately there are many roads to a successful speech therapy session. Most of all, my goal in today’s post is to share one path that has worked well for my sessions.

Remember, these aren’t hard and fast rules. I may skip steps or not use these steps at all. Each child (and each speech pattern) can be quite different. As such, any good speech therapy plan will start with an evaluation of a specific child’s needs. After that, a speech language pathologist (SLP) will develop a plan targeting those areas.

If you are a parent of a child with CAS, I’d encourage you to talk to your child’s SLP about cueing. An SLP can provide helpful pointers on cues to use. If you are using cueing at home, it is important to check in with your child’s SLP. This way, you can make sure you use cues that compliment those used in speech therapy sessions.

Children with CAS can make significant gains in speech sound production skills. The best way to see progress is by using a combination of consistent speech therapy and practice at home. For parents with a child with CAS, an SLP can be one of your most important allies.