This post is part of a series on CAS. If you are just joining this series, you may want to read my introductory post, called Apraxia 101.
I remember one of my first clinical experiences in graduate school. I was working with a young child with Childhood Apraxia of Speech (CAS), and I thought the session went fairly well. As I walked out of the room (with a two-way mirror and my professor on the other side), and my clinical professor asked me a question I was unprepared for and will never forget.
“What is your evidence for using the treatment methods you used? Why did you do what you did? Where have you found research to inform your treatment strategy?”
As a new clinician, I froze for a second. Then I did my best to answer. I explained what I’d done and why I’d done it. Research articles came to mind. Advice from seasoned clinicians came to mind. I’ll never forget what she said next.
“As a Speech Language Pathologist, you will frequently be asked by other professionals and parents questions like this. You know what you are doing and why. But just as important, you need to be prepared to explain it at any time to others.”
Thankfully that was her way of saying I’d passed that test. Since then I have been asked these questions many times. Most frequently, I’m asked why I do what I do for clients with CAS.
Evidence Based Practice for Childhood Apraxia of Speech (CAS)
Evidence based practice for CAS is an important topic for many Speech Language Pathologists (SLPs). It is important to know the work we are doing with children is based on research. In addition, it is important that we are taking data to make sure we are monitoring progress.
The suggestions in this article are based on the research of DeThorne et al (2009), and the work of many SLPs who specialize in CAS.
What is Evidence Based Practice?
Evidence Based Practice is the idea that quality service (best practices) are a three pronged approach:
– External scientific evidence (journals, studies)
– Clinical expertise/expert opinion (What are you doing that has worked in the past? What is working for other SLPs?)
– Client/Patient/Caregiver Perspectives (What does the client want? What does the client’s family want?)
Ultimately, there are many ways to gather evidence. This post focuses on what research suggests for CAS treatment strategies. In addition, these are all strategies I have tried in my clinic and find helpful!
1. Minimize Pressure To Speak
Most children don’t like to feel pressured to talk. Especially if talking is hard for them. Starting by playing and having fun in a low-pressure situation is usually a great place to start.
If you are an SLP, chances are you might be a perfectionist (many of us are). You may put pressure on yourself to work on speaking right away. But as we learned in the previous article on this blog, taking time to build trust and rapport is the first step.
If you are a parent, chances are you’d love an SLP whose paramount goal is to make your child feel comfortable. Things may start slowly. Have patience with the process. Remember it may feel slow at first, but this step is key.
The goal is to have children speak when they are ready, and at a time that feels comfortable for them. Building trust and rapport lays the groundwork for that to happen.
2. Imitate
Working on sounds means that SLPs often ask children to imitate both sounds and words.
Before working on these structured tasks, it is helpful for SLPs to imitate the children we work with. For example, if I’m playing with a shape sorter with a client, and my client says “oooh,” I might show my interest in the toy by saying “ooh” also. In addition, I might expand on that by adding a comment about the toy to build on that communication.
If you’d like to read more on how to work on imitation, we also have previous posts on that topic.
3. Exaggerated Intonation/Slowed Tempo
This tip suggests using a pattern of exaggerated intonation (the rising and falling of your tone of speech) and a slower tempo when talking to children. This isn’t baby talk. Instead, it is using vocal expression (melody, tempo) to draw attention to our communication. This provides specific features children can cue into which helps highlight speech sounds.
4. Varied Feedback
Children with CAS often aren’t able to copy speech sounds straight off by hearing them. They need a variety of cues to learn the motor movements needed to produce new sounds. Some examples:
– Visual feedback: providing pictures or models of what the mouth does to produce sounds
– Tactile feedback: touch cues to help with sounds
– Auditory cues: hearing the sounds, saying the sound first and having the child listen
5. Avoid Oral Motor Therapy
This is a speech therapy don’t. To summarize, oral motor approaches (nonspeech movements) don’t positively impact speech sound production. You can read more about that in my speech therapy mistakes series.
6. Provide access to AAC
AAC is an acronym for Augmentative and Alternative Communication.
AAC is (American Speech-Language Hearing Association’s Definition):
Augmentative and alternative communication (AAC) includes all forms of communication (other than oral speech) that are used to express thoughts, needs, wants, and ideas. We all use AAC when we make facial expressions or gestures, use symbols or pictures, or write.
People with severe speech or language problems rely on AAC to supplement existing speech or replace speech that is not functional. Special augmentative aids, such as picture and symbol communication boards and electronic devices, are available to help people express themselves. This may increase social interaction, school performance, and feelings of self-worth.
For some clients, this might be pictures or gestures to communicate. This is highly individualized based on each client’s needs. Supplementing with AAC can also increase language skills as they develop.
Childhood Apraxia of Speech: Evidence Summary
I hope you found these suggestions applicable to your work with your child (or client) with CAS.
If you want to start with just a few concrete suggestions, I’ve found 1. and 4. have made the biggest difference in my own sessions. First, when minimizing pressure on a child to speak (especially a child new to my clinic), that child is often more comfortable. Each child needs a different amount of time to warm up, but it is worth the wait to make sure they are comfortable before working on speech sound production. Also, I’ve found that different feedback or cueing works better for different children. I’ve had good results with touch cues and hand signs for different sounds, and many of my clients have made excellent progress with this feedback. However, it depends on the client!
If you have a child who has Childhood Apraxia of Speech and you are looking for a Speech Language Pathologist in the Rogue Valley, feel free to contact me for more information. I work with clients with a variety of needs, and CAS is one of my areas of expertise. I’d love to help!