Supporting Speech and Language Progress in Children with CAS or sCAS


Cite this article as:
Bowen, C. (2011). Supporting speech and language progress in children with CAS or sCAS. Retrieved from http://www.speech-language-therapy.com/ on [insert the date that you retrieved the file here].


Early days in intervention

In the initial stages of assessment, diagnosis and intervention, the parents of and others close to children with Childhood Apraxia of Speech (CAS) or suspected CAS (sCAS) are embarking on a huge learning curve.

Parents may feel 'swamped' with information from SLPs/SLTs and from other sources – some reliable, and some not-so-reliable.

It is a time for hard work for parents as they keep the child busy with focused, relevant, enjoyable activities that work from the child’s strengths and interests.

 


12 things families can do


From the outset, parents are encouraged, and helped by the clinician, to do these 12 things:

1. Organise the environment to facilitate communication

Organize the environment to facilitate communication, by using communicative temptations, sabotage, reinforcement of new vocabulary, and experiences - especially with toddlers.


COMMUNICATIVE TEMPTATIONS


There are many ways to arrange the environment so that a child is encouraged (but not compelled or manipulated) to request, demand, indicate what he or she wants, for example, you might:

  • put videos on a high shelf to "tempt" your child to request them;
  • give the child paper to draw on and “forgetting” to provide a crayon;
  • show the child his or her face in a hand mirror "accidentally" holding the mirror the wrong way round.

Sara 1;6

Sara, aged 18 months, loved unzipping little pencil cases to see what was inside, and she loved tiny teddies (small teddy bears from a local craft shop). We had 6 pencil cases and put one tiny teddy in the first one, two in the second, three in the next, etc. We gave her the first pencil case and she extracted the teddy. When she took the two teddies out of the next one, we modelled “more” because there were more teddies in it. We did the same with the next pencil case, modelling “more”. Meanwhile, the other three pencil cases were in view but out of reach. Sara pointed to one and her mother modelled (said) “more?” and asked her, “Do you want MORE teddies?” As soon as Sara approximated “more” she was given the next pencil case. And so on and so forth.

Ben 1;9

Ben, aged 21 months, enjoyed rolling small balls through a “tunnel” made of PVC tubing placed on a sloping lawn. Ben's mother would get all the balls out and leave them on the lawn where he could see them, and put the tunnel out of reach so that he would ask for it. At other times, she would have the tunnel in place and the balls out of sight. He played the game many times, initiating it himself. At first he was rewarded for saying “getta getta” (for “get it for me”) but he was soon saying “getta”, “me”, “nunnoh” (tunnel), “more” and “ball”. This was extremely empowering for his mother.


SABOTAGE


Remembering that this is an age-group that enjoys slapstick and adults being ridiculous, other ideas might include:

  • putting something in the “wrong” place unexpectedly as a joke, e.g., socks on hands, gloves on feet;
  • get into the back seat to start the car and then “realise your mistake” exaggeratedly;
  • suck on a balloon instead of blowing.

Matthew 1;11

Matthew 23 months liked to help to set the table, and his job was to get spoons out of a drawer and put one in everyone's place (for himself, and for his parents, brother and sister). His mother put half a dozen elastic bands around the spoons and put them in the drawer for the next time he did his chore. Matthew brought her the bunch of spoons, and showed her. She used humour and modelled “off” as she helped him remove them one by one. He loved it so much that he wanted the elastic bands put on and off again, repeatedly, and was soon approximating “off” and “on” and “band”.


REINFORCING 'NEW' VOCABULARY


Chenguang 2;6

Chenguang was aged 2;6 and loved to go to the grocery store in Chinatown with her mother. She had recently started to say the names of some of the foods, including approximations for "rice", "ginger", "chicken" and "veggies". Her mother took photos of the items that interested Chenguang and that she was attempting to say, and the toddler enjoyed looking at them on her mother's phone and naming the foods.

John 1;5

John, aged 17 months, had a new word, “car”. His parents stacked the environment with cars, some within his reach and some in funny places to tempt him to ask for them. For example, his father tucked a little car into his collar at the nape of his neck. John pointed at it excitedly and his father pretended not to know the car was there. After John had said “car” insistently several times his father modelled “car” several times in context ("Oh my goodness! A car!  A car in a funny place. What were you doing there silly car?" etc) and gave it to John, who by that time had said “car” himself, several times more. His father put another car in a silly place, and so on.

Sophia 2;1

Sophia was 2;1 and had recently acquired the word "me". Her parent's made up a question and answer game in which they asked questions like "Who's clever?", "Who's got a nice tummy?", "Who likes toast?", "Who's funny?", with Sophia responding with "Me!" each time.


EXPERIENCES


Provide 'experiences' that will foster language growth, building them around things the child likes and looks forward to, incorporating turn-taking, repetition and predictability.

Sam 1;10

Sam 22 months liked walking to the park and much of his therapy was around the things he found on the way there and did there, and his stick collection!

Zaahir 2;0

 

Zaahir aged 2;0 spent a sunny Australian afternoon in a paddling pool under a shady tree his grandfather's garden. He invented a game of pouring milk cartons of water over himself, saying "woosh" repeatedly, with his grandfather saying "oh, no!" every time.

Soon, Zaahir caught on to the idea that he was "making" his grandfather say "oh, no!". He loved this "power" and the predictability of his communicative partner's responses, and would tip some water on his grandfather every now and then to elicit a really big, "OH, NO!" and then burst into apreciative squeals and chuckles. Quite an experience!


MORE COMMUNICATIVE TEMPTATIONS


The following communication temptations, some of which are suitable for, or can be adapted for, young children, are from Weatherby and Prizant (1989) and Weatherby, Yonclas, and Brian (1989).

  • Eat a desired food in front of the individual without offering any to the individual.
  • Activate a wind-up toy, let it deactivate, and hand it to the individual.
  • Give the individual four blocks to drop in a box, one at a time for use (or use some other action that the individual will repeat, such as stacking the blocks or dropping the blocks on the floor); then immediately give the individual a small animal figure to drop in the box.
  • Look through a few books or a magazine with the individual.
  • Open a jar of bubbles, blow bubbles, then close the jar tightly and give the closed jar to the individual.
  • Initiate a familiar and an unfamiliar social game with the individual until the individual expresses pleasure, then stop the game and wait.
  • Blow up a balloon and slowly deflate it; then hand the deflated balloon to the individual or hold the deflated balloon up to your mouth and wait.
  • Hold a food item or toy that the individual dislikes out near the individual to offer it.
  • Place a desired food item or toy in a clear container that the individual cannot open while the individual is watching; then put the container in front of the individual and wait.
  • Place the individual's hands in a cold, wet or sticky substance such as Jell-O, pudding, or paste.
  • Roll a ball to the individual, after the individual returns the bail three times, immediately roll a different toy to the individual.
  • Engage the individual in putting together a puzzle. After the individual has put in three pieces, offer the individual a piece that does not fit.
  • Engage the individual in an activity with a substance that can be easily spilled (or dropped, broken, torn, etc.), suddenly, spill some of the substance on the table or in front of the individual.
  • Put an object that makes noise in an opaque bag and shake the bag, hold up the bag and wait.
  • Give the individual materials for an activity of interest that necessitates the use of an instrument for completion (e.g., piece of paper to draw on or cut, bowl of pudding or soup); hold the instrument out of the individual's reach and wait.
  • Engage the individual in an activity of interest that necessitates the use of an instrument for completion (e.g., pen, crayon, scissors, stapler, wand for blowing bubbles, spoon); have a third person come over and take the instrument, go sit on the distant side of the room while holding the instrument within the individual's sight, and wait.
  • Wave and say "bye" to an object upon removing it from the play area. Repeat this for a second and third situation, and do nothing when removing an object from a fourth situation.
  • Hide a stuffed animal under the table. Knock, and then bring out the animal. Have the animal greet the individual the first time. Repeat this for a second and third time, and do nothing when bringing out the animal the fourth time. These four trials should also be interspersed with the temptations above when presented.

Wetherby, A. & Prizant, B. (1989). The Expression of Communicative Intent: Assessment Guidelines. Seminars in Speech and Language,10, 70-91.

Wetherby, A., Yonclas, D. & Brian, A. (1989). Communicative Profiles of Handicapped Children: Implications for Early Identification. Journal of Speech and Hearing Disorders, 54, 148-158.

2. Make some of the therapy invisible (indirect)

Make some of the therapy as "invisible" as possible (don’t get 'the book' out every time). This involves teaching parents:

  • to work indirectly (the way SLPs/SLTs do) with the child
  • to narrate their worlds using verbs and nouns
  • to use repetition, uttering the same words or expressions each time they perform a routine task (e.g., getting into a car seat)
  • to comment on what the child is doing rather than asking questions
  • to appreciate the importance of turn-taking routines, rituals and games
  • to pause to allow the child adequate 'thinking time' and 'planning time' and 'word retrieval time'
  • to know that the goal is to 'constantly teach' without appearing to, and NOT to 'constantly test', or constantly have the child perform all his or her verbal or conceptual accomplishments
  • to use prosody as a facilitator, employing child directed speech (also called 'parentese' or 'motherese')
  • to appreciate the role of 'baby talk' used at the right moment
  • to allocate half an hour per day adult-child time, talking, playing and being together 1-to-1
  • to know what is meant by a 'functional vocabulary'
  • to follow the child's lead (communicatively)
  • to get down to the child’s level
  • to reward communication attempts with communication

3. Make some of the therapy visible (direct)

Make some of the therapy as "visible" as possible (very grown up and formal). This involves helping parents to organise a time when, for 5 to 7 minutes per day parent and child sit together at a table, or on the floor, and play simple turn taking games. Call it ‘talking time’ or similar and do it in the same place each time if possible (like therapy). Set up an expectation in the child that this is a time for communication, when parents will:

  • Read a story, or look at a pictures, or look at an interesting object, or make something
  • Name objects (e.g., objects in an object box such as 6 things starting with B)
  • Sign
  • Run through the brag book (see below)
  • Do "pretend play" (e.g., fishing, driving, cooking)
  • Keep it short, sweet and "instructional", ending on a positive note
  • Model, model, model throughout (see the modelling and recasting link at #7 below)

4. Identify nursery rhymes, stories,  etc.

Identify nursery rhymes, songs, stories, games, etc that can be used to progress certain targets. For example Marvin K Mooney for "go", Where is the Green Sheep? for "sh", One Duck Stuck for /k/ and Are You My Mother? for question forms and/or the pronoun "my".

5. Recognise teaching moments

Recognise "teaching moments" within everyday happenings and activities.

6. Let the child listen

Provide input without always pushing the child to respond. Sometimes he or she should simply be given space to listen and think.

7. Model and recast

Employ modelling and recasting techniques optimally.

8. Choose functional targets

Choose target words and syllables that will be functional or powerful for the child in order to motivate him or her to TRY  to communicate verbally.

9. Make it fun

Use FUN finger-plays, songs, and drill-play.

10. Avoid over cueing

Avoid over cueing. Too many cues can confuse.

11. Balance new with old

Balance new content vs. older content, and activities with many cues vs. activities with few cues.

12. Enjoy success

Practice things the child is "good at" - this is not a waste of time! It encourages confidence and a feeling of mastery.


Very Young Children


In supporting very young children with CAS or sCAS, SLPs/SLTs explain the therapy while enlisting and valuing parents’ support and input. They observe the following guidelines:

  1. If using metalinguistic cues and imagery, they include appropriate instructions in the Speech Book so that anyone who looks at it with the child can see what to do.
  2. Notes are also included in the child’s Brag Book and the Speech Book to let the “other” adults outside the immediate family know that the emphasis should be on meaningful word production and syllable production (e.g., bee, boo, moo, neigh, go). Isolated sounds are really only a goal if they carry meaning (sh for be-quiet, ss as a snake sound, ee-ee for a mouse, etc). It is explained that isolated sound production may be used briefly as a means to an end, but that “bababa”, “beebeebee”, “tatata”, etc are more desirable than practice drills for [b], [t], etc.
  3. The importance of emphasising rhythm, “melody”, stress, loudness, rate, and appropriate nasality is discussed. This is important because it may promote more natural sounding speech earlier – rather than the “programmed” sound that is characteristic of many children with CAS.
  4. It is explained that, in therapy based on the principles of motor learning, the desired goal is many repeats of targets (syllables, syllable sequences, single words or word sequences).
  5. It is explained to parents that SLPs/SLTs need their (the parents’) ingenuity to make therapy and homework happen in ways that are beneficial, motivating and fun for toddlers and preschoolers.
  6. Parents are reassured that with appropriate support most children will “bring the homework to parents”, understand what therapy is for, and take some ownership of their own practice needs.

10 tips for SLPs/SLTs


In intervention for children with severe CASor sCAS including children who are non-verbal or who have few word approximations:

  1. Establish a core vocabulary of ‘power words’.
  2. Make a ‘brag book’ of words, signs and sound effects that the child can say.
  3. In choosing phonetic stimuli favour those that are already spontaneously produced, most stimulable, and most visual.
  4. Following the principles of motor learning, start with CV and VC and CVC combinations (include isolated vowels), but avoid isolated consonants unless they carry meaning, e.g., [sh] be quiet, [z] bee, [s] snake, [m] yes/yum.
  5. Establish the most beneficial facilitators for the individual child (ask parents – or TELL them!)
  6. Establish an appropriate stimulus/response relationship.
  7. Set criteria for subsequent changes in stimuli (How many correct trials should there be before moving to different stimuli?).
  8. Choose reinforcers carefully, knowing that achieving the necessary intensity of drill is difficult, and that it is often hard to maintain the child’s interest, attention and cooperation.
  9. Aim to get sufficient responses within a practice session: that is MANY REPEATS.
  10. Watch linguistic load. Keep it simple. Don’t use complex carrier phrases or cloze.
  11. Use AAC to augment verbal attempts and to facilitate expressive language.
  12. Keep therapy fresh – sameness and boredom kill motivation (everyone’s!).

Brag book


________’s Words / “core vocabulary book”

Remember this is a BRAG BOOK of what the child CAN do! Include the child's words, word approximations and communicative 'sound effects'.

  1. Start with photos of the child and family members. Include ‘verb photos’ of the child.
  2. Then put p- b- m- w- h- words the child can say (including poo, wee, bum, etc. and ‘silly words’).
  3. Then include all the other words / approximations and sound-effects in the child’s repertoire.
  4. Put ‘favourite words’ / ‘good words’ in several times.
  5. Print target words in lower case (remind parents) next to the images so anyone can pick up the book and enjoy it with the child knowing the exact target word. Write approximations if necessary.
  6. As the collection of pictures grows, rearrange pictures so that they are loosely organised by theme and initial sound.
  7. Think in terms of ‘sound patterns’ (phonology) from very early on.
  8. Make sure there are some 'easy', fun words at the beginning of the book, and at the end.
  9. Include songs, rhymes, cloze, etc where the child CAN provide the punch line, etc.
  10. Have parents bring the brag book to every therapy session so that new words can be added straight away.

Homework and CAS


Family Support

No matter how ‘in tune’, creative, flexible, encouraging and motivating Speech-Language Pathologists/Speech and Language Therapists are in therapy sessions the necessary carryover is unlikely to happen without practice between sessions, and for this to happen there must be, within within everyone's capabilities, solid family support and the child's cooperation.

Collaborative

Homework has to be understood and implemented properly (one-to-one and as demonstrated by the clinician) and as often as suggested (by the SLP/SLT). The process of setting, demonstrating, explaining and rehearsing homework is collaborative, and parents’ suggestions and feedback are welcome.

Ideally, parents are involved from the outset as as team members. Some of the initial tasks they can perform might be: compiling power word lists, collecting speech samples, and making ________’s Brag Book (see above).

Routine

Homework becomes a regular, routine activity for families of children with CAS. It can be done in small ways that mount up to facilitate significant change.

Explicit practice for parents

Explicit practice, during which parents are "trained" to deliver current homework is valuable. It helps parents build confidence in their skills, and it impresses on the child that their parents are part of the treatment team. While getting into a homework routine, is helpful to narrow down times of speech focus at home, and then expand so parents and child are not overwhelmed.


Links


Apraxia-KIDS - CASANA

American Speech-Language-Hearing Association. (2007). Childhood Apraxia of Speech [Technical Report]. Available from www.asha.org/policy WEB

Strand, E. A., & McCauley, R. J. (2008, Aug. 12). DifferentialDiagnosis of Severe Speech Impairment in Young Children. The ASHA Leader, 13(10), 10-13.


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