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Part I

Introduction
Over the years, since the first accounts of the disorder,
there has been disagreement over the underlying nature of
the disorder. Some have proposed that CAS is linguistic in
nature; others have proposed that it is motoric and some
have put forth the tenet that it is BOTH linguistic and
motoric in nature. However, currently nearly all sources
describe the key presenting impairment involved with CAS as
some degree of disrupted speech motor control. The reason
for this difficulty is still under investigation by speech
scientists.

Weakness, paresis, or paralysis of the speech musculature

does not account for the impaired speech motor skills in
CAS. Differences in various theories of speech motor
control notwithstanding, it is believed that the level of
impairment in the speech processing system occurs somewhere
between phonological encoding and the motor execution
phase, such as a disruption in motor planning and/or
programming. Some believe that children with CAS have
difficulty accurately storing or volitionally accessing
Speech motor plans and programs and the spatial-temporal
specifications within them. To some degree or another,
these impairments result in difficulty rapidly and
accurately moving between sequences of articulatory
configurations that are required for continuous and
intelligible speech production. Some researchers posit
that children with CAS additionally have disordered
sensory-motor related features such as reduced or aberrant
proprioception and thus an inability to realize the
relationship and spatial position of the articulatory
structures to one another. For some of the most severely
affected children, even initiating speech movement gestures
may prove extraordinarily difficult.

There appears to be some consensus and research evidence

that children who display these sorts of speech motor
impairments also typically have problems in certain aspects
of expressive and/or receptive language, even if subtle.
There is currently no agreement as to whether these
linguistic impairments are central to the disorder or are
separate issues that co-occur or are co-morbid. Some

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individuals have described CAS as a disorder that changes

and unfolds over time.

Childhood Apraxia of Speech

The use of the prefix "A" (i.e.: absence) and "dys" (i.e.:
partial) attached to the root word praxis may also provide
confusion. In most instances, use of either of the terms
apraxia or dyspraxia appear to be based on personal
preference, one's graduate educational institution, and/or
one's geographic location rather than a substantially,
meaningful or practical difference. The term apraxia,
however, is the choice used nearly exclusively to describe
the adult form of the disorder. Praxis, in either case,
refers to "skilled movement."

Definitions
Praxis:
"The generation of volitional movement patterns for the
performance of a particular action, especially the ability
to select, plan, organize, and initiate the motor
Pattern which is the foundation of praxis" (Ayres 1985).

Spatial-Temporal Coordination
• Critical to fluent, adult-rate speech-language production
• Dominates the development of speech-motor control over
the first six years of life.
• Gradual increase in overall execution speed of motor
programs over the ages 3-11 years.
• Segment durations are conditioned or adapted according to
the linguistic content of the utterance (Netsell 1981)

Motor sequencing:
Ordering the individual gestures that make up the whole
motor plan and coordinating them with each other. Includes:

 Determining the order of the elements

 Figuring out how to get from one to the other (Ayres
1985): transitions

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Apraxia:
"A disorder in carrying out or learning complex movements
that cannot be accounted for by elementary disturbances of
strength, coordination, sensation, comprehension, or
attention" (Strub & Black 1981).

"..A group of phonological disorders resulting from

disruption of central
Sensorimotor processes that interfere with motor learning
for speech... Paralysis or weakness might be present, but
is not sufficient to account for the nature and severity of
the observed speech disorder" (Crary 1984).

"Viewed as a syndrome...developmental verbal apraxia might

be defined as a severe and persistent phonological disorder
coupled with an expressive syntactic disorder with variable
neurological and articulatory findings." (Aram 1984)

Unitary Disorder:
 One consistent symptom or set of symptoms is always
present

Syndrome/Symptom Complex:
 A pattern of symptoms, with a common underlying cause,
is used for diagnosis
 No one symptom alone is adequate to identify the
syndrome
 Different children may have varying symptoms of the
same disorder
“a reduced capacity to form systemic mappings [between
articulatory movements and their auditory consequences]
might underlie the oral motor and early speech learning
difficulties in DAS [CAS] and put the child at a
disadvantage for the acquisition of the motor aspects of
phonology, that is, the phoneme-specific mappings”… “higher
level [phonological] knowledge … must be acquired by the
child via the problematic speech production and perception
skills” (Maassen 2002, pp. 261, 265)

Thus, apraxia or dyspraxia is a disorder of:

1. Volitional movement (Dewey et al. 1988, Maassen et al.

2003, Nelson, 1995)
2. Spatial-temporal coordination (Sussman et al. 2000,
Nijland et al. 2002)

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3. Motor sequencing (Crary & Anderson, 1991)

4. Carrying out or learning complex movements (Crary &
Anderson, 1991)
5. Central sensorimotor processes (Crary 1984)
6. Accommodation to context (coarticulation, etc.; Maassen
et al. 2001, Nijland et al. 2003, Nijland et al 2002).

Types of Apraxia
A person may have one or more types of apraxia at the same
time. We describe three types of apraxia:

1. limb
2. oral
3. verbal

Limb apraxia: limb apraxia is associated with volitional

movements of the arms and legs. The client may be unable to
wave good bye or make a fist on command (volitionally) even
though the muscular strength and range of motion necessary
to complete the tasks are present and the client is able to
automatically (non volitionally) perform the tasks.

Oral apraxia:

The client with oral apraxia may be unable to protrude the

tongue or smack the lips volitionally. Oral apraxia is
sometime confused with the third type, verbal apraxia since
they both involve oral facial muscles but they are not the
same.

Verbal apraxia:

Verbal apraxia is a disorder of motor programming for the

production of speech. The client with verbal apraxia has
difficulty positioning and sequencing muscles involved in
the volitional production of phonemes. Clients may exhibits
one, two or three types of apraxia.

The Terminology

Developmental apraxia of speech

Developmental verbal dyspraxia
childhood apraxia of speech

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Childhood Apraxia of Speech (CAS) is the current preferred

terminology to describe the disorder. Other terms still in
"use" and from the relatively recent past include
"developmental apraxia of speech" and "developmental verbal
dyspraxia". Use of the descriptor "developmental",
however, unfortunately provides a false implication to
other professional groups that the speech difficulties of
affected children are akin to "delays" in development; are
transient and can be simply outgrown without direct
intervention.

Early signs & symptoms:

 Limited or little babbling as an infant (void of many
consonants). First words may not appear at all,
pointing and “grunting” may be all that is heard.
 The child is able to open and close mouth, lick lips,
protrude, retract and lateralize tongue while eating,
but not when directed to do so.
 First word approximations occurring beyond the age of
18 months, without developing into understandable
simple vocabulary words by age 2.
 Oral scanning or groping may occur with attempts at
speaking.
 Continuous grunting and pointing beyond age 2.
 Lack of a significant consonant repertoire: child may
only use / b , m , p , t , d , h /.
 All phonemes (consonants and vowels) may be imitated
well in isolation, but any attempts to combine
phonemes are unsuccessful.
 Words may be simplified by deleting consonants or
vowels, and/or replacing difficult phonemes
(consonants and vowels) with easier ones.
 Single words may be articulated well, but attempts at
further sentence length become unintelligible.
 Receptive language (comprehension) appears to be
better than attempts at expressive language (verbal
output).
 One syllable or word is favored and used to convey all
or many words beyond age 2.
 A word (may be a real word or a nonsensical utterance)
is used to convey other words beyond age 2.
 The child speaks mostly in vowels.

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 Verbal preservation: getting “stuck” on a previously

uttered word, or bringing oral motor elements from a
previous word into the next word uttered.
 The child has difficulty moving the tongue where they
want it to go.

 “Pop-outs” or automatic words and phrases are spoken

clearly, but they cannot be imitated when directed or
may not be heard again.
 Other fine motor problems may be present.

CAS is a “symptom complex”

 No one feature is adequate for diagnosis
 Symptoms can include motor, linguistic, neurological.
 Inconsistency is expected across children and within
same child
 Symptoms change over time (Lewis et al. 2004;Shriberg
et al. 2003)

CAS as a Secondary Diagnosis

• Approximately 60% of children on the autism spectrum have

motor speech symptoms; about 13% report primarily symptoms
of apraxia; 10% primarily dysarthria; remainder mixed
(Marili, Andrianopoulos, Velleman & Foreman, 2004)
• Symptoms of CAS are common among children with Down
syndrome (Kumin & Adams 2000; Rupela & Manjula, in
submission)

Key characteristics of CAS

When considering characteristics of the disorder, Speech
and Language Pathologists need to keep in mind that
children with other speech sound disorders share some
characteristics from the list. Other characteristics may
be more common and contribute more specifically to the
differential diagnosis of CAS, distinguishing CAS from the
other pediatric speech sound disorders. Additional
research is needed to identify a diagnostic marker with an
acceptable degree of specificity and sensitivity (i.e.:
identifies children with CAS while ruling out those who do
not have CAS). Until such research data is available, the
list below may be useful for identification of children
suspected to have CAS.

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Key characteristics:

• Limited repertoire of vowels; less differentiation

between vowel productions; and vowel errors,
especially distortions
• Variability of errors
• Unusual, idiosyncratic error patterns (sometimes
defying transcription!)
• Errors increase with length or complexity of
utterances, such as in multi-syllabic or phonetically
challenging words.
• Depending on level of severity, child may be able to
produce accurately the target utterance in one context
but is unable to produce the same target accurately in
a different context.
• More difficulty with volitional, self-initiated
utterances as compared to over-learned, automatic, or
modeled utterances
• Impaired rate/accuracy on diodochokinetic tasks
(Alternating movement accuracy or maximum repetition
rate of same sequences such as /pa/, /pa/, /pa/ and
multiple phoneme sequences such as /pa/ /ta/ /ka/ )
• Disturbances of prosody including overall slow rate;
timing deficits in duration of sounds and pauses
between and within syllables contributing to the
perception of excess and/or equal stress, "choppy" and
monotone speech.
• At some point in time, groping or observable physical
struggle for articulatory position may be observed
(possibly not present on evaluation, but observable at
some point in treatment).
• May also demonstrate impaired volitional non speech
movements (oral apraxia)

Etiology
Theories about causes:

While there is agreement about the defining characteristics

of DAS, it is not known exactly what causes CAS. There are
several theories about the cause of CAS including:

1. Some believe that children with CAS have problems

producing speech because of auditory deficits, albeit in
the presence of normal hearing tests. The belief is that

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these deficits adversely affect the child’s ability to

detect and/or encode speech sounds from conversational
speech.

2. Another theory is that CAS may be caused by a

child’s difficulty in learning and building an adult-like
language system.

3. Yet another viewpoint is that CAS is caused by

problems in a child's organization and sequencing of speech
components such as sound, syllables, and melody. The
belief is that the child has mentally stored these speech
components, but do not possess the skills to consistently
organize and sequence the movements of the articulators
into words and sentences.

To begin with, developmental verbal apraxia is a spectrum

disorder. What this means is that there are no definite
behaviors that identify its presence. Instead, a child is
identified as having apraxia if he/she exhibits a number of
characteristics that are believed to be highly indicative
of apraxia. Because of this, no two children with apraxia
are alike.

Additionally, although many hypotheses have been proposed

for the etiology (cause) of apraxia, in reality, apraxia
has a number of etiologies. Some of them are: genetic
predisposition to motor sequencing disorders (family
history), problems prenatally or at birth, differences in
the rate of development or quality of myelination (covering
or sheath for the nerve cells in the brain, which increases
dramatically in the preschool years), neurological
disorders, developmental delay, etc

Finally, there are many features/traits in a child's life

that will differ with each child, that have a great deal of
influence in terms of the outcome for a child with apraxia.

Demographics:

• 86% of kids with CAS have at least one family member w/

speech-language disorders
• 59% have at least one affected parent
• Higher rates of family history than for other speech-
sound disorders: suggests genetic basis in at least some
cases (Lewis et al. 2003)

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FOXP2 (The gene is required during early embryonic

development for formation of brain regions associated with
speech and language): Translocation on chromosome 7q31
A few individuals (e.g., the “KE” family) with this genetic
difference have the symptoms of oral and verbal apraxia.
However, they also have oral-facial anomalies and non-
verbal deficits. Thus, FOX-P2 may be the cause of some
cases of CAS, but certainly not all of them.

Prevalence
• Prevalence 1-2 children per thousand (Shriberg et al.,
1997a); up to 3-4% of children with speech delay are given
this diagnosis (Delaney & Kent, 2004)

Prognosis of Apraxia

Factors Which Effect Long-term Outcome in Apraxia:

Etiology of the Child's Apraxia

Is the cause of the child's oral motor deficits primarily
motor, linguistic, or phonological in nature? Because the
cause of apraxia varies, so will the prognosis. Two
children with similar presenting symptoms initially, may
have different outcomes because one child's etiology may
allow for new motor skill development more readily than the
other child's etiology. The difficulty for the clinician
lies in the fact that only rarely do we know the etiology
(cause) of a child's apraxia.

Family History
When other family members have a similar speech history, it
is reasonable to conclude that the child's long term
outcome may be similar to that family member's (providing,
of course, that their etiologies are truly the same).

Severity of Apraxia
In general, the more severe the child's apraxia, the longer
they will need to receive treatment.

Presence of Oral as well as Verbal Apraxia

Children who exhibit an oral apraxia as well as a verbal
apraxia often require treatment longer than those children
who exhibit only a verbal apraxia.

Overall Health
Children whose overall health is good are more accessible

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to learning of all kinds than children who have periods of

time when they are less "learning available" because of
illness (middle ear infections, upper respiratory
infections, etc.).

Cognitive Skills
Children with measured learning potentials in the average
to above average range have a more favorable prognosis than
children with cognitive delays.

Attention/Ability to Focus
Children with attentional issues will often require
intervention for longer periods than children with average
to above average attentional skills. This is because the
SLP can focus on the child's productions rather than on
maintaining their attention, and because children with
attentional issues tend to have more difficulty monitoring
their own speech (which is very important for "carry-over"
of skills to the conversational level).

Child's Reaction to Their Intelligibility Deficit

Children who are seemingly unaware of, or unbothered by the
difficulty other people have understanding them often
require longer treatment.

Ability to Self-Monitor
Children who have average to above average abilities to
monitor their own speech productions tend to make progress
more quickly than children who are unable to "self-monitor"
and continue to need the SLP or others to give them
feedback regarding their productions. Self-monitoring is an
important skill for children with apraxia to learn. This is
the process by which they take skills learned in therapy
and begin to use them in their spontaneous speech. The only
way this can occur is for the child to begin to "hear"
his/her own productions and "edit" them. If a child cannot
perceive an error, it will be impossible for him/her to
correct it.

Age at Which Intervention Begins

The younger the child is when treatment begins, the better
his/her long term prognosis.

Appropriateness of Therapy
Because children with apraxia are different in terms of the
etiology of the apraxia, the therapeutic approach utilized
in their treatment needs to be tailored to their individual

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needs. A "one-size-fits-all" approach does not work for

children with apraxia. Knowledge of the current approaches
to the management of apraxia is necessary for the SLP to
adjust sessions according to the child's needs.

Frequency of Therapy
The more frequently the child receives appropriate therapy,
the better his/her long term prognosis.

Co morbidity
The presence of other disorders with apraxia (such as
hearing loss, dysarthria, etc.) will generally indicate a
poorer prognosis than when apraxia presents as the only
disorder/delay for a child. A "pure apraxia," however, is
not the norm. When a child is neurologically different in
one way, it often means they will exhibit
learning/motor/behavior issues in other areas of their
development. Additionally, children with apraxia do not
have the opportunity to interact with peers and adults in a
typical way, and so are at greater risk for
developing/exhibiting social, behavioral, language, etc.
delays and disorders because of the apraxia.

Motivation
A child who has a positive response to working with a
therapist on increasing his/her speech intelligibility has
a better prognosis than the child who is resistant or
ambivalent towards his/her therapy.

Parent Involvement, Education, Support

A parent's knowledge/understanding of their child's apraxia
increases their ability to respond in ways that encourage
the child's communication skills. They are also much better
equipped to advocate in effective ways for the child with
other people in the child's life.

Parents should be wary of any prognostic statement which is

absolute in either direction. It is not possible for a
clinician to say with absolute certainty that a child will
completely recover; conversely, he/she will not be able to
tell you that your child will never talk.

To date, there are no definitive studies of the outcome of

children with apraxia. This is due to the lack of
agreement/identification of this group of children, and

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also due to the fact that there are no two children with
apraxia who are exactly alike in terms of their apraxic
characteristics, so establishing a control group to
determine efficacy and results of long-term therapy is very
difficult.

Progress and Long Term Outcomes

With appropriate early intervention and ongoing support,
most children with CAS can improve their speech production
skills and develop functional speech. The period of time
this outcome requires is individualized and most likely
based on the unique characteristics of the child and the
level and quality of the intervention provided. Previous
literature had cited "slow or little progress" as a
"characteristic" of apraxia. Currently it is recognized
that while treatment is intensive and extends over a number
of years, these children are very capable of making
wonderful gains and developing intelligible speech.
Progress, is of course, individualized, however
unproductive therapy should not go on indefinitely. If the
child is not making noticeable and meaningful progress over
several months of treatment, the SLP needs to regroup and
examine the reason.

If a child fails to make significant and adequate progress

despite receiving speech therapy intervention, the
following questions need addressed:

• Is the diagnosis correct?

• Is the frequency of therapy adequate for the child's
needs?
• Is the intensity appropriate? For example, is therapy
offering the child dozens and dozens of "practice
moments" or is the child sitting, listening and not
practicing speech much at all?
• Is the therapy tailored toward motor speech methods
and techniques to the extent required for adequate
progress?
• Is the therapeutic environment safe and motivating to
this child? Is clinician - child rapport adequate?
• Are other issues interfering with progress? (i.e., can
the child sustain enough attention to participate?
Has the child had health related problems? Is the
family following through with practice at home or is
the child willing to practice at home? Could other
diagnoses contribute to lack of adequate progress?)

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If after addressing these issues, progress is still not

adequate, ask for consultation from a colleague with more
experience with this particular disorder.

Some long-term residual issues that may persist even after

the child attains intelligibility include sound distortions
and prosody deficits (rate, timing, stress, intonation).
If these issues are present, therapy strategies can
continue to target them. Additionally, speech therapy may
need to continue to address linguistic or pragmatic needs
presented by some children.

A prognosis is, at best, an estimate of how your child's

speech skills will improve with therapy. An exact outcome
is impossible for any SLP to predict. There are several
reasons why a child's treatment outcome is very difficult
to predict.

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Part II

Evaluation, Assessment and

Diagnosis of Childhood Apraxia of
Speech
While there are a number of packaged evaluation kits
available, many clinicians use common evaluation techniques
to assess children with suspected CAS. Young children with
CAS can be especially challenging to evaluate and may be
non-risk takers with their speech attempts. In some cases,
especially with very young children, an extended period of
evaluation in order to elicit sufficient speech samples to
make diagnosis is warranted. Overall, tasks used in the
assessment process in order to differentiate CAS from other
speech sound disorders should include:

 Speech production tasks graded from simple to more

complex (from simple syllables to challenging
multisyllabic words)
 The effect of increased length on accuracy (i.e.: me,
meet, meeting)
 The effect of context on speech accuracy (more; more
milk, want more)
 Observation of performance on repeated productions of
the same target
 Documentation of differences between elicited or
imitated productions vs. volitional and spontaneous
productions
 An analysis of types of errors, including omissions,
distortions and substitutions
 Observations concerning prosody (stress, intonation,
rate)
 Observations of nonspeech movement sequencing (show me
how you bite. Show me how you blow. Bite, then blow)

Common articulation tests alone will not provide the

information needed for differential diagnosis, although
such tests can provide some information necessary to the
process. Additionally, traditional child language tests

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can provide helpful information about the child's

communication profile but will not provide the type of
information necessary to make a differential diagnosis. If
clinicians work in settings in which they administer
expressive/receptive language testing in order to determine
eligibility for services and the clinician suspects the
child could have CAS, referral for in depth evaluation of
speech production should occur.

Additional Assessment Considerations

While the previous assessment and evaluation discussion
centered on the speech production difficulties of children
with suspected CAS, several other considerations for
planning and conducting assessments should be considered.
The literature documents co-morbid language related
deficits, thus both expressive and receptive language
evaluation should be a part of the evaluation process of
documenting a complete communication profile for the child
with CAS. Narrative language skills should be a part of
that battery, as appropriate, given the current functioning
of the child. A structural-functional evaluation should be
performed as well in order to document any observations of
abnormalities in structures, sensation, strength, range,
symmetry, etc. For children who are school age or
approaching school age, the evaluation of phonemic
awareness and early literacy related skills should be
included in assessments. A propensity for literacy related
deficits in phonemic awareness, reading, spelling and
written expression has been substantiated in children with
CAS in recent research and should be considered, regardless
of the child's current level of speech production
capability.

Apraxia Assessment Tools

The Verbal Motor Production Assessment for Children (VMPAC)

(Deborah Hayden, M.A., CCC-SLP and Paula Square, Ph.D.,
CCC-SLP)

Identify children with motor issues that have negative

effects on the development of normal speech motor control.
Pinpoint where the child begins to have difficulty, with
items arranged from basic to complex. This test leads you

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step-by-step through the evaluation; helpful Clinician's

Notes provide explanation.

The Apraxia Profile (Lori Hickman, M.S., CCC-SLP)

Use to assist in the differential diagnosis of

developmental verbal apraxia, identify the presence of oral
apraxia, and reveal the most problematic oral-motor
sequences and movements.
Document a child's oral-motor sequencing deficits and
establish the level of oral movements and sequences
produced successfully. Obtain helpful information to share
with parents, teachers, and other professionals.

Kaufman Speech Praxis Test(By Nancy Kaufman, M.A., CCC-SLP)

the KSPT identifies the level of breakdown in a child's

speech so that treatment can be established and improvement
tracked. Easy to administer and score, the test measures a
child's imitative responses to the clinician, locates where
the child's speech system is breaking down, and points to a
systematic course of treatment.

The Screening Test for Developmental Apraxia of

Speech (STDAS-2) Robert Blakeley, Ph.D.

The Screening Test for Developmental Apraxia of Speech

(STDAS) assists in the differential diagnosis of
developmental apraxia of speech. This screening instrument
points out the need for additional and more specific speech
and neurological evaluation.

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Speech Therapy for Children with CAS

While children with CAS have many similarities to one
another, they also display frank differences in
communication profiles. Thus, this is a heterogeneous
population. It will be important for clinicians to
determine the contribution of speech motor processing to
the child's speech difficulty. Children with a diagnosis
of CAS will initially need to work, much of the time, at
this level in the system. For children with significant
speech motor-planning deficits there should be an
assumption that the child, at least for a period of time,
will need frequent and intensive individual speech therapy.

Frequency and Intensity

One factor that appears to have agreement among experts in
speech-motor programming treatment approaches is that early
in the therapy process, children with apraxia of speech
will need intensive services, most often on an individual
basis. A number of factors influence the frequency of
therapy, including:

• The severity of the child's speech-motor impairment

and functional communication disorder
• The child's age and ability to tolerate therapy
• The child's willingness to practice with
parents/caregivers.

Clinicians are likely to find themselves in the role of an

advocate to insure that these children, especially those
who are severely impaired, receive the appropriate
intensity and frequency of treatment.
In the early phases of treatment for children with moderate
to severe CAS, appropriate frequency may range from 3 - 5
individual speech therapy sessions per week. As children
improve and develop speech motor control over volitional
utterances, frequency can be reduced accordingly, as long
as they maintain and generalize improvements.

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Additionally, intensity refers to actual time spent in

individual therapy sessions that provides children with CAS
opportunities for numerous repetitions of speech movement
targets. In keeping with motor learning theory, many
repetitions are required in order for motor skills to
become volitional and automatic. Speech therapy needs to
provide these children with many, many repetitions and
response opportunities of targeted utterances. This
response intensiveness is in contrast to treatment
approaches in which the child is mainly asked to listen vs.
respond or to share response time with multiple other
children. By the end of a speech therapy session, no
matter the length of the actual session, the child with CAS
should have produced dozens and dozens of target
utterances. This high degree of intensity for responses is
not likely to occur in group therapy settings.

Children with apraxia of speech are often described in the

professional literature as needing frequent and intensive
speech therapy in order to address the motor planning and
programming issues which are at the heart of their speech
difficulty. In the annexure C there are the most relevant
citations available that describe the need for frequency
and intensity. When children with apraxia receive
appropriate speech therapy they can and do make progress!
As their speech becomes more and more intelligible,
frequency of services can be adjusted according. Children
must be looked at for their individualized needs and
circumstances. In addition to their motor planning and
programming needs, children with apraxia often have other
speech and/or language needs that must also be factored
into therapy. Some children may also require training with
augmentative communication devices in addition to therapy
specifically targeting their speech production. (For
supported citation see annexure c)

General Treatment Principles

Motor-programming Approach
If one understands CAS as a disorder of the speech motor
system, then guidance for treatment can be found in
understanding motor programming/planning tenets. Again,
each child with CAS will have their own individual profile
and will have different needs at different points in their
development as competent speakers and communicators.

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Clinicians will still need to determine what contribution

motor speech deficits have in the child's overall speech
difficulty as well as address other potential language and
communication deficits. Overall, methods that employ a
motor programming approach will:

• Provide frequent and intensive practice of speech

targets
• Focus on the actual skill being trained (accurate
speech movement)
• Include enhanced external sensory input (not just
auditory, but also visual, tactile, cognitive cues for
speech production)
• Give careful consideration to types of practice
(random vs. blocked practice of target items)
• Provide appropriate feedback (knowledge of results or
knowledge of performance

1-Multi-sensory Input for Speech Practice

Overall, most treatment methods in the professional
literature describe variations of therapeutic multisensory
input to the affected child. Use of multisensory
strategies may incorporate input that is visual, auditory,
proprioceptive and tactile in order to teach the child the
movement sequences for speech. It is not yet understood
exactly why such “inputs” assist in the articulatory
accuracy or “speech motor learning” of children with CAS.
One theory is that children with CAS do not benefit from
sensory-motor feedback for their speech attempts in the
same way as typically developing children do. Perhaps the
feedback is faulty, reduced, or otherwise inadequate to
provide meaningful assistance to the motor learning
process. Essentially then, each speech attempt would be
akin to the “first time”, with children with CAS failing to
incorporate the sensory results of their speech effort into
their next speech attempt. Feedback is an important aspect
of motor learning. If a child cannot benefit from or does
not receive intrinsic sensory feedback, theoretically it is
possible that external or imposed feedback can help
facilitate speech production skills. Another possibility
is that over time visual or tactile cues may map an
association for the child and thus trigger a type of “motor
memory” for the articulatory goal.

Tactile methods of speech facilitation include methods that

provide direct tactile input to the child’s face or

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articulators in order to “cue” them for the correct

production. With these sorts of methods, the speech-
language pathologist may apply pressure or otherwise touch
the child’s face, neck, and head, to provide a tactile cue
for correct production or speech movement gesture. (See
information on the PROMPT therapy method)

Visual methods provide visual “cues” as to the shape,

placement or movement of the articulators. Hand signs or
cues often provide a visual cue. More technologically
advanced methods such as electropalatography readouts,
various computerized programs such as “Speechviewer” and
other forms of biofeedback can also provide the child with
visual feedback for speech movement performance. A visual
cue may help to elicit an appropriate movement
configuration upon a learned association.

Asking the child to slow down and to maintain articulatory

configurations for a longer duration than is typical
provides additional proprioceptive feedback in order for
the child to have more opportunity to “feel” the position
of the articulators (See information on The Dynamic
Temporal and Tactile Cueing for Speech Motor Learning
Method - DTTC). In some therapy methods such as the PROMPT
and the DTTC methods, the clinician may provide touch to
the jaw, face, etc. in order to provide additional
proprioceptive input. Enhanced proprioceptive input,
theoretically, may help the child benefit and learn from
the motor experience and make adjustments to stored motor
programs and plans based on such feedback and experience.

It is important to note that in all of these sensory

modalities, direct and systematic training of articulatory
movement sequences receives a high degree of emphasis.
While the SLP may be called on to teach isolated phonemes
at some point as well, this is not the key emphasis of
therapy for children with CAS. Rather, the emphasis is on
well-controlled sequences of movement patterns required for
accurate production of a continuous string of phonemes
(i.e.: continuous speech). Additionally, for children that
have a significant deficit in speech motor planning and
programming a “minimal pairs” (auditory discrimination)
approach is not a primary element of treatment to elicit
improved speech motor planning. The reason for this is
that the treatment method should match the understanding of
the underlying nature of the child’s disorder. If the
child’s disorder is motoric (as opposed to linguistic),

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then a motor speech approach should be adopted. More

linguistically or phonologically based approaches may also
have a benefit for some children who ALSO have a linguistic
or more traditional auditory perceptual or phonological
deficit to their overall profile but such methods do not
replace the need for speech motor strategies.

2-Establish Functional Communication

Many children with CAS struggle so significantly and are so
severely affected that they have difficulty attaining any
semblance of a functional vocabulary. Thus, one initial
goal for treatment of such children should be to aid in
establishing such a vocabulary. A careful inventory of
the child's current consonant and vowel inventory may
provide a clue as to beginning words (or approximations)
that may be possible. Word choices should take into
account words and functions that a child would want to
communicate.

3-Successive approximations
One method of therapy, "successive approximations" may
help to establish functional verbal communication. Word
approximations are shaped and molded, with the assistance
of cuing and input from the SLP, until there is independent
accuracy in the word production.

By examining how children first learn to speak, we can

observe that many of the early vocabulary begins with word
approximations such as, baw for ball, or bah for bottle, or
even wawa for water. Children with CAS who have performed
little babbling or practice as infants, may not be able to
change what they hear and understand, into the motor act of
speaking those words. By simply offering children with CAS
the opportunity to attempt word approximations using the
consonants and vowels already in their repertoire,
successful attempts at words are achieved, reinforced, and
rewarded by the listeners comprehension, and thus their
response to the childs needs and desires. Through shaping,

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cueing, and fading techniques, children with CAS can

gradually move into whole words, phrases and sentences.

One can evaluate the consonant and vowel patterns of

children by asking them to imitate, moving in a hierarchy
from simple to complex vowel and consonant combinations to
obtain a profile of the child’s motor-speech proficiency.
Then, through practice of this hierarchy of consonant and
vowel patterns, the children gain verbal praxis skills for
the ultimate goal of successful verbal communication.

Beyond the workout of practicing consonant-vowel patterns

in real words is the important aspect of functional
communication. As soon as the child has any type of an
approximation for a word, it should be encouraged and
reinforced by the appropriate response of the listener
(i.e., giving the child juice for attempting doos or oos
for juice). In this approach, however, we do not
necessarily wait for the child to use an approximation
independently, though that is certainly the optimal goal.
We actually assist them with imitation, cues, prompts or
any possible way to help them make their best word
approximation attempt. We also help to script the children
directly into two or three-word combinations almost
immediately, even if every word is only approximated, such
as in I want .., being scripted as Ah wah

This approach encompasses aspects of behavior modification

(shaping, cueing, fading) for successful approximations, as
well as our knowledge of phonological processes, which are
the way young children tend to simplify adult forms of
words. Such phonological concepts as final consonant
deletion, cluster reduction, vowel neutralization, to name
a few processes, are what we rely upon to decide how a word
can be simplified based upon typical speech development.
Every word can be reduced to its shell (this concept of
word shells was introduced by Ms. Carole Goff, M.A.,
CCC/SLP). For instance, the word bottle, can be broken down
like this:

bottle

bah-do

bah-o

bah-bah

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bah

Choosing the child’s highest successful imitation and

reinforcing it (ideally giving the child the bottle),
offers them a chance at successful verbal communication
rather than only accepting the full word which may not yet
be a possibility. This approach also encompasses techniques
gleaned from the research and work accomplished by many
speech and language pathologists who work with individuals
exhibiting acquired apraxia of speech. These techniques
include using melody and gestures to take the pressure off
of the volitional muscle control system. Occupational
therapy/sensory integration techniques of direct
stimulation to the oral musculature and using gross-motor
activity to propel the entire motor system to activate
verbal-motor skills are also valuable to this approach.

The Kaufman Speech Praxis Treatment Approach is also

becoming highly successful for children with CAS on the
spectrum of autism. Dr. Vincent Carbone, Ed.D, BCBA and Ms.
Tamara Kasper, MS/CCC-SLP, BCaBA, are currently researching
and adapting the KSPT techniques specifically through
Applied Verbal Behavior, employing methods from B.F.
Skinner (1959) and Sundberg and Partington (1998). The
changes for children with autism are largely due to the
fact that it can be more difficult to move along the
hierarchy of word approximations, as there is more work
involved in extinguishing and replacing the first learned
word approximation and shaping it toward the ultimate goal
of the full word. Dr. Carbone also utilizes the method of
stimulus-stimulus pairing to move non-verbal (yet vocal)
children into the ability to imitate CV patterns, which
prepares them for the KSPT approach.

Through the workout, scripting, and ultimately improving

word retrieval, grammatical skill development and general
formulation skills, children with CAS can become effective
verbal communicators.

4-David Hammer's approach

Just as communication therapy for children with apraxia of
speech presents unique challenges, it certainly is a
challenge to present views on treatment in a few
paragraphs. There are many complexities involved when we
discuss therapy strategies due to the wide range of

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children whom we service. These include, but certainly are

not limited to,

 The maturation level of the child

 The child's general cognitive abilities
 Possible dual diagnoses
 Other deficit areas such as fine motor skills
 And parent motivation.

When we discuss intervention strategies, we must take into

account individual strengths as we develop a multi-sensory,
multi-modality communication therapy course of action.

For children who have the cognitive capacity to understand

picture stimuli, David finds that an essential component to
early therapy is the development of a "core vocabulary"
book. This involves the inclusion of photographic pictures
into a "Grandma's Brag Book" (small photo album). The
photos should consist of meaningful people, toys, and
objects in the child's life as well as words that contain
initially targeted sound sequences. This book often serves
as a child's first success at expansion of functional
communication interactions with significant others. The use
of sign language has proven to enhance vocal output, reduce
frustration, and provide differentiation for words that
"sound the same" in the early course of treatment.

Touch cueing and physical prompting are also critical

elements of David’s treatment approach. Each of these
techniques is modified to fit the particular needs and
tolerance level of the child. An ongoing goal is to fade
all cues as soon as possible to allow for the child to
develop the oral/verbal movement and sequencing patterns
necessary for intelligible speech. Oral-motor work is never
done without a sound production goal in mind. Sounds are
not taught in isolation for any length of time with almost
immediate progression to consonant-vowel or vowel consonant
forms. Focus on suprasegmental features (e.g. rhythm,
stress, intonation, etc.) should be ongoing from the start
of therapy to enable the most naturalistic speech
production possible.

If we begin intensive individual intervention in the

optimal age range, the challenges in therapy are:

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(1) To discover ways to motivate toddlers and preschool-age

children into repetitive practice of sound sequences while
having fun at the same time

(2) To let the child seemingly set the stage for the
sessions while, at the same time, achieving therapy goals
and

(3) To make sure that optimal practice of speech sound

production is accomplished so that speech motor patterns
become more automatic.

These are not impossible tasks if we remain creative

thinkers, flexible therapists, and great listeners to the
children and their parents. David says” I can't stress
enough the importance of family involvement (including
siblings attending treatment sessions), and close
collaboration with all professionals involved in the
child's programming. This ensures consistent encouragement
and feedback which "nudges" the child with apraxia of
speech in the direction of self-motivated speech practice”.

Once a core vocabulary has been established, it may be

useful to incorporate "carrier phrases", i.e., short
sentence constructions in which core vocabulary can be
inserted. For example, "I see _____", "Where is
_________", "I want ______". Additionally, "power phrases"
may be introduced as therapy targets. These are short
phrases that may serve high utility to the child ("No way",
"Get out", "Me too") and provide the child with functional
communication.

5-Systematic and Hierarchical Structure for

Early Success
Many methods employed for successful speech therapy for
children with CAS are both systematic and hierarchical. A
strong emphasis is placed on understanding the current
level on which the child is successful and then
incrementally building and shaping improved articulation
accuracy and movement sequencing through systematically
altering the phonetic length, articulatory adjustment,
contexts, type of external cues and so on. Clinicians need
to be careful to insure that children with apraxia have
early success in their speech therapy sessions. One way to
enhance this probability is to make sure that starting work

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is focused at the level at which the child can be

successful and then incrementally begin to build new CVC
forms, new speech movement patterns, new contexts, etc.

6-Shelley Velleman's approach

(for method see annexure B)

Key factors to consider in therapy approaches for childhood apraxia of

speech:

1. It's a dynamic disorder, and it's far more a disorder of

combining elements than of producing the elements
themselves. In other words, the main problem is in putting
elements together "on line". The person may be able to make
a certain consonant sound and a certain vowel sound, but
the hard part is putting them together into a syllable. For
older/less impaired children, it may be a problem of
putting words into sentences or even of making a paragraph
out of sentences. With respect to reading, the child may
know which letters "say" which sounds, but be unable to
blend them together into a word; or the child may recognize
a whole ("sight") word but be unable to understand how the
letters combine to make that word.

2. Many factors -- especially communication pressure and

performance load (meaning + complexity of grammar +
difficulty of sounds + difficulty of vocabulary, etc.) --
can have an impact on the person's ability to produce
certain sounds/words/sentences at a given time. Just
because the child said something once does not mean (s)he
can say it again, especially if it is important to do so.
The more (s)he wants to say it, the harder it will be to do
so. This results in the child appearing to be inconsistent,
resistant, or even stubborn.

There are often language symptoms (about 50% of the time).

Researchers disagree whether these are part of the syndrome
or not (I think they are), but all agree that they often
co-occur with the articulation symptoms. These may be very
basic and appear early (e.g., early grammar will be delayed
or disordered), or they may not show up until the child is

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older. Some children's language symptoms do not appear

until they begin to try to use language as a tool (e.g.,
reading to learn as opposed to learning to read), in 4th or
5th grade. Sometimes reading is affected.

4. Prosody differences (stress and intonation, especially

stress) are a key symptom of the disorder. Many children
get to the point where their speech is quite intelligible,
yet they still sound different because their stress or
intonation patterns are unusual. Usually, speech is slow
and choppy. Some children sound quite robotic.

5. There may be other types of apraxia present, including

oral apraxia (affecting nonspeech movements of the mouth)
or limb apraxia (affecting the hands). Occupational or
physical therapists should be involved if so.

6. It's not the same as other phonological delays. The

symptoms can be quite complex, and may change suddenly and
unpredictably. The child often will not follow the
developmental sequences which are listed in textbooks for
other children.

Therefore, therapy approaches should:

1. Be dynamic. Movement patterns and building larger

elements should be emphasized. Working on producing
consonant sounds in isolation, for example, is a bad idea.
It may produce quick results, but it will not contribute to
intelligible speech. (The only exception to this is
consonant sounds which have a meaning, such as "mmm" and
"shh".) Syllables should be the basic unit, building up
from there. The activities which will actually address the
heart of the problem are activities where the oral-motor
planning system has to plan how to get from one
articulatory position to another. This may begin with
repeating simple meaningful syllables (baa-baa-baa, moo-
moo-moo), moving up to alternating syllables which include
either the same consonant or the same vowel (baa - bee -
baa - bee; bee - D - bee - D). Working on articulatory
movement patterns (as in Moving Across Syllables) is also
very helpful.

2. Include activities with lower communication pressure, to

increase the automaticity of syllables/words already in the
child's repertoire (e.g., through singing, book-reading,
and other verbal routines), as well as activities with

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higher communication pressure.

Augmentative/alternative communication (signs or picture

boards) can often help in two ways:

1. reduce the communication pressure, so the child

actually finds it easier to speak
2. decrease everyone's frustration.

Using sign or picture boards does not discourage the child

from speaking. It helps.

3. Include monitoring and (if appropriate) treatment of

language symptoms. Teach grammatical word endings in an
order that is phonologically easiest, even if this doesn't
follow developmental order.

4. Address prosody very directly, beginning at a young age.

Early activities can include anything with rhythm, pitch,
or loudness changes. Music is great! Be sure to vary
rhythm, so the child doesn't get locked into one equal-
stressed rhythm pattern. Older children should be
explicitly taught about the importance of prosody in
speech, including:

• Stress patterns which signal nouns vs. verbs (CONtrast

vs. conTRAST), different types of phrases (light
HOUSEkeeper vs. LIGHTHOUSE keeper), or sentence
meanings (I DIDN'T know vs. I didn't KNOW).
• Intonation, which signals the type of sentence (yes-no
question, with pitch rising at the end, versus
statements and wh- questions, with pitch falling at
the end) and also the speaker's emotions.

5. Include movement activities (e.g., to music). Co-therapy

with occupational or physical therapists is often very
helpful.

6. We recommend therapy as intensively and as often as

possible. Five short sessions (e.g., 30 minutes) a week is
better than two 90-minute sessions. Regression will occur
if therapy is discontinued for a long time (e.g., over the
summer).

At least some of the therapy, on a regular basis (e.g.,

once a week) must be provided by an ASHA-certified ("CCC-
SLP"), licensed (in those states with licensure) speech-

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language pathologist. Other professionals who work with the

child in other sessions must be supervised by the certified
person (e.g., meet with her/him weekly to discuss progress
and strategies).

Most of the therapy (e.g., 2-3 times a week) must be

provided individually. If group therapy is provided, it
will not help unless the other children in the group have
the same diagnosis and are at the same level
phonologically. Adequate services cannot be provided in
whole-classroom activities. Language stimulation, exposure,
etc. may have an impact on some social language skills, but
are not sufficient. If you are told,"(S)he'll get it by
listening to the other kids", do not believe it. If (s)he
could get it through exposure, (s)he'd have it already.

Key components of successful

intervention
1-Knowledge of Results - Knowledge of Performance

The child with CAS will require "feedback" in order for

motor learning to occur. Two types of feedback to consider
in treatment are "knowledge of performance" and "knowledge
of results." Knowledge of performance refers to feedback
provided by the SLP that gives the child specific
information on how a movement is performed or correction to
the specific movement (i.e., 'your tongue needs to be up
more", "build up that air inside with your lips closed
tight"). Knowledge of results refers to feedback from the
SLP regarding how well the overall speech attempt was
performed (i.e., "Yes, you did it!", "That wasn't it, try
it again.").

Some experts suggest that knowledge of performance is more

appropriate in early treatment phases and knowledge of
results more appropriate as the child gains some control in
their speech motor processing system. Clinicians, however,
should give careful attention to feedback and make clinical
judgments and evaluation related to the degree of external
feedback provided, assessing the child's internal feedback
capacity and "self monitoring". The end goal is for the
child's system to develop intrinsic feedback and self-
monitoring. There is risk to providing too much or too
little external feedback. If too little is provided, the
child may fail to make progress because their system is not

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currently providing them with sufficient internal feedback.

If too much feedback is provided, the child's system will
never be taxed to develop internal feedback loops and will
possibly fail to take over the responsibility for
independent processing. So, careful attention is warranted
to the extent and type of external feedback provided by the
clinician. This is a gentle process of providing
appropriate feedback and backing off and observing the
child's ability to be accurate with volitional speech
movement sequences using their own internal system of
feedback.

2- Effort, Attention and Motivation:

Children with CAS need to exert a great deal of their

cognitive and attention resources to the speech task,
especially during the early phases of speech therapy as
they build volitional control over their speech motor
system. SLPs need to assess consistently their environment
and the potential distracters for the child that will
reduce the child's ability to put forth the necessary
attention and intrinsic resources to their speech practice.
For example, noise and visual distracters or movement can
reduce the child's ability to put forth their greatest
allocation of attention to the speech production practice.
As children develop their speech motor skills, these issues
may become less important.

Attention is a key skill for children who require the type

of multisensory strategies described for children with
apraxia of speech. In particular, for a child to benefit
from increased sensory input like visual cueing, they must
be able to provide eye contact and attend to the SLP's face
when instructed to do so. Children who are unable to give
even the most basic level of attention to the SLPs face may
need preliminary work to increase their ability to do so in
order that they may benefit from an intensive speech motor-
programming based approach.

Children with CAS have likely experienced a great deal of

failure in their communication attempts. Many either
withdraw from communication interactions or develop
behaviors related to their frustrating situation.
Additionally, many children have experienced a lack of
success at previous speech therapy attempts. Thus, the SLP
needs to provide special care and concern to actively

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engage such youngsters and insure that they experience

early success in therapy - even during the first session.
Experienced clinicians pay attention to:

• Understanding the child's personality as well as their

history of communication failure and success
• Demonstrate understanding directly to the child by
validating their experience and sharing the desire to
help speech become easier for them.
• Remember that each child is different in what
motivates them and what interests them. By including
such interests in therapy, children may be enticed to
participate with more willingness.
• Work with caregivers to communicate a safe environment
for the child and to create trust in the process.

3- Helping child with CAS

Various studies conducted with children with limited

phonological awareness or poor reading skills point to some
suggestions. For instance, a study by Hatcher, Hulme, &
Ellis who divided seven year olds who were poor readers
into three groups and provided different arrangements of
phonological awareness training, reading instruction, or no
other training outside of the routine classroom work, found
that the only group that made significantly more progress
than the control group, was the group that focused on both
phonological awareness plus explicit reading strategies. In
her article reporting the results of this study, Stackhouse
writes, "phonological awareness training alone does not
necessarily facilitate literacy development. Literacy
development is dependent on children's ability to link
their phonological awareness skills to letter knowledge and
reading experience." (Stackhouse, 1997, p.162) An earlier
study by Bradley and Bryant of 65 children with below
average ability on phonological awareness tasks as
nonreaders before entering school demonstrated that
phonological awareness training needs to be combined with
explicit letter knowledge teaching for these children to
make actual gains in literacy development.

Further, a complete language assessment needs to be done.

Such an assessment must not only look at and define the
symptoms of the speech, reading, and spelling problems but
also the underlying nature of those problems. A full
assessment would include: speech, language and oral-motor

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abilities; auditory skills (such as auditory

discrimination, memory and organization); rhyme detection
and production; syllable and phoneme segmentation; reading
comprehension and expression; spelling and awareness of
reading and spelling strategies. It is also important to
include more difficult items in reading and spelling tests
(for instance, multisyllabic words) in order to determine a
particular child's difficulty. At the end of a thorough
assessment, Stackhouse suggests that:

"...having identified through the assessment

(a) a profile on speech, language, and reading tests
(b) the level and modality of breakdown
(c) the severity of the difficulties and their
manifestation in 'real life'
(d) the coping strategies adopted
then remediation can be planned" (Stackhouse, 1985, p.109)

4- The Role of the Speech and Language Pathologist:

The literature and studies reviewed for this paper indicate

that there needs to be awareness and vigilance to the
literacy development of children with spoken language
problems, especially those who have apraxia of speech.
"There is a danger that as intelligibility reaches an
acceptable level, the child is discharged from the speech
therapist's care only to be left struggling with residual
speech difficulties and related spelling problems,"
concludes Joy Stackhouse. (Stackhouse, 1985, p.115) While
the role of the speech and language pathologist is not to
teach reading and spelling per se, Snowling & Stackhouse
indicate that, "the role is one of identification and
promoting the underlying skills that contribute to literacy
development." (Stackhouse, 1997, p.190) It is hoped that by
receiving early, intensive communication therapy for
apraxia of speech or phonological deficits, these children
may, in fact, heighten their phonological awareness and, in
part, strengthen a potentially intrinsic weakness.

Stackhouse suggests that some possibly relevant tools,

techniques and activities include:

• phoneme-grapheme matched cards (cards with pictures

that represent sounds)

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• color coded systems as visual reminders of language

structures or of sound groups
• sound categorization activities using multi-sensory
approaches
• syllable and sound segmentation activities
• rhyming work
• explicit teaching of reading and spelling rules

5- Reading instruction

Research accumulated over time indicates that many children

need explicit teaching using a phonics approach with
phonological awareness; sound-letter correspondence and
decodable text with kindergartners and first graders.
Research appears to indicate that whole language can
enhance comprehension and that a balance of comprehension
and decoding skills should be focused on but that whole
language should not be the only strategy used with
nonreaders. This data may be especially important to
children with apraxia of speech and residual problems.(see
annexure D)

6- Parents Participation:

Parents can support the work of speech pathologists and

teachers by following through on home activities that are
suggested. For young children, these include nursery rhymes
and rhyme games; making games with syllable beats in words;
drawing attention to the printed word while reading to
children; using books with rhymes and word patterns. Most
importantly, parents need to be proactive by knowing what
is happening in their child's school program. Developing
effective communication with teachers and therapists will
help promote skill development and also help to identify
potential roadblocks at the earliest possible time, before
a significant problem has developed.

7- Augmentative and Alternative Communication and

Apraxia

Augmentative and Alternative Communication (AAC) may be

appropriate for children with a diagnosis of CAS. Some
children benefit from using sign language for some period

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of time when their speech is not yet fully intelligible.

There are many benefits to sign language and other AAC
forms detailed in other articles on the website, however
several benefits include:

• Allows for continued language, vocabulary, literacy

and educational development
• Enables participation in the curriculum
• Increases likelihood that a familiar listener can
"catch" the meaning intended from an unintelligible
utterance, thus providing communication motivation for
the child
• Provides another form of sensory input that can be
used as paired association method for triggering
"speech motor memories"
• Reduces the communication pressure felt by the child
who has experienced a great deal of failure and
anxiety in communication attempts, allowing their
personal resources to be directed back to the
communication process

The use of AAC requires a skilled evaluator and trainer to

insure the child's needs and abilities are properly
considered. For SLPs who do not feel adequately trained or
skilled in AAC methods, evaluation, and treatment, arrange
for or request technical assistance. If providing support
to an AAC user, SLPs should familiarize themselves with the
benefits and current research literature on AAC.

8- Appropriate time to Consider Augmentative and

Alternative Communication (AAC) for Children with
Apraxia of Speech

The American Speech-Language-Hearing Association defines

AAC as ... "a set of procedures and processes by which
individuals communication skills (i.e., production as well
as comprehension) can be maximized for functional and
effective communication. In other words, AAC includes any
form of communication other than speech that allows the
user to communicate in his or her surroundings."

Light (1988) identified four primary functions, or

purposes, of communication. These include:

(1) expression of wants and needs,

(2) exchange of information,

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(3) social closeness, and

(4) social etiquette.

Typically-developing children use speech to function within

these areas. When speech is not adequate to achieve the
child’s communicative purposes, it is necessary for the
child to find a way to close any gaps. In terms of
expressing wants and needs, AAC is a nice bridge between
the need to communicate a message and actually getting your
meaning across to another person. Children can use natural
gestures, sign language, a communication book, a symbol
(picture, photograph, line drawing, etc.), and/or a speech-
generating device to convey their intents. Exchange of
information becomes essential in a school setting. The
teacher requires that the child interacts within the
classroom by asking/answering questions, participating in
collaborative learning groups, and using increasingly more
complex language. This exchange of information demonstrates
to the teacher that the child has achieved levels of
knowledge expected at various stages in development. For
example, a child that is unable to say an s is going to
have a difficult time indicating that he/she has learned
the concept of plurals. This same child would easily be
able to demonstrate the use of plurals using AAC. As
children mature, the requirements to communicate multiply
with the opportunities. Social environments become more
diverse and filled with more communication partners. Making
communication interactions functional and effective takes
on greater importance because of the addition of these
social influences.

There is a chance that families will encounter speech-

language pathologists who choose to focus on speech, while
overlooking overall communication. A focus on speech is not
wrong in and of itself. We all want our children to use
natural speech. However, everyone on the child’s team
(including parents and peers) needs to step back and really
look at that child’s ability to communicate functionally
within his/her various environments. Focus on what the
child is currently able to communicate. Consider, if the
progress in therapy is slow, how long are you willing to
wait for the child to communicate? Is it ok to go through
Kindergarten entirely without talking? First grade? There
is a real difference between intelligibility (how
understandable a child is using speech alone) and
comprehensibility (which take speech into account along
with context). Some AAC strategies put context into an

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interaction, and that may be sufficient to support the

Child’s communication. These strategies might include
alphabet (first letter) supplementation, indicating the
topic being discussed, indicating a change in topic, etc. An
evaluation to determine a particular child’s needs is
invaluable to determine the best AAC supports.

When discussing AAC, one of the first concerns voiced by

parents and caregivers is that use of AAC might prevent the
child from talking, or further delay development of natural
speech. In response, there is a reference to the excellent
Cumley (2001) article included on the Apraxia-KIDSSM web
site. His research demonstrated that AAC does not deter a
child from using speech to communicate, if and when it is
effective for him/her. Moreover, as speech increasingly
becomes the primary mode of communication (with development
of functional natural speech), AAC tools and strategies
will be gradually phased out of the child’s communicative
strategies. In fact, the child will phase out use of AAC on
his/her own, when speech becomes more effective and
efficient.

9-Using Sign Language for Children with

Apraxia of Speech
Often when someone raises the idea of using sign language
for a child with apraxia, parents may experience confusion
and even fear. After all, "The child can hear just fine!
Why would we use sign language for a hearing child?" Or
"But won't using the sign mean my child won't need to talk?
Won't it keep him/her from speaking?" Conversely, some
parents report that their child's speech language
pathologist has told them that the child will rely on sign
and thus not learn to speak. This article attempts to
address many of these myths about signing.

First of all, in our mainstream culture it is true that we

see most images of sign language associated with people who
are deaf or hard of hearing. However, that doesn't mean
that for some children - those with apraxia - that sign
cannot help! For children with apraxia the sign can be
used to assist and augment their verbal communication, sort
of as a bridge to communication while they are learning to
speak clearly. The use of signing with children who have
apraxia has nothing to do with their ability to hear or

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understand the spoken word. Most children with apraxia

have very good receptive language skills.

Secondly, it is rare that a child's speech output is

diminished by using sign language. To the contrary,
therapists and parents alike nearly always report a
heightened willingness to try new words and say more.
Nearly all parents are actually quite relieved when their
child starts to use some signs to help with communication.
It makes life easier for the child and the parent!

For just a few children with apraxia of speech, sign may

not be indicated. These children have additional severe
motor planning difficulties with their arms and hands,
making it extremely difficult for the child to use a fairly
consistent manual sign to represent a word. However, it is
possible that even these children can benefit from sign if
the adult uses the sign as a form of visual cueing
(explained in more detail below). And it is not necessary
that the child's sign is "perfect," just that they can be
fairly consistent with whatever approximation of a sign
they can achieve.

Reasons for considering Sign & Verbal Attempts:

Below are some reasons why we might want to consider using

sign and verbal attempts for a child with apraxia:

1. Reduce Frustration: Reduce frustration and have basic

needs understood. Children who have access to sign
language are at least able to communicate at some level,
which usually results in decreased frustration on their
part and yours.

2. Symbolic Communication: Sign can be important to young

children with little or no speech because it is symbolic
communication. They are learning that they can label
things and use the signs to communicate. This is important
for all children. Those with typically developing speech
are doing so with speech attempts - words. Our children
with speech apraxia also need a way to do this so that this
part of the process of acquiring language is not further
delayed.

3.Expansion of Expressive Speech: For children who have

apraxia and who are really struggling to sequence sounds
into words, sign can be a mechanism to insure that their

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expressive language development isn't further impeded.

Speech production is just that: producing speech.
Expressive language is the ability to understand and
properly use the rules of the language to construct
sentences. So a child with apraxia is at risk, due to the
speech production struggle, of also falling seriously
behind in expressive language since they have no means to
try out and practice how words go together to create
meaningful and proper messages. Using sign assists
children to keep expanding their expressive language.
While they may not be able to speak a word or put two words
together, they can still, by using sign, be doing this same
thing in a different way.

4. Successful Communication: Children with apraxia who use

sign, may also use it as an assist for the listener when
accompanied by their vocal attempts. They may be capable
of, for example, three word sentences in which each word is
an approximation, not properly articulated, and thus the
listener may not understand their message. When the child
uses sign, along with the vocal attempt, the listener (if
they know the signs) can have a better chance of
understanding the message and thus, the child is successful
at communication. Our children very much need to feel
successful in their attempts to use their voice to
communicate. If when attempting to use their voice to
communicate, no one ever understands, it is not uncommon
for them to just stop trying to use their voice. When they
are understood (perhaps because they also used sign) they
are delighted to realize they were successful and are more
likely to keep on trying.

5.Controls Rate of Speech: when the adult uses sign, and

even when the child uses sign, it has the tendency of
slowing down the rate of speech for most people (obviously
not for interpreters perhaps!). For some children with
apraxia, this is very helpful for them to have the
additional time to allow for motoric transitions between
words, etc. It gives them a better chance, in many cases,
of also being able to imitate you. Many adults speak fast
and that can have a negative effect on a child with
apraxia's ability to imitate you.

6. Serves as Visual Cues: It is pretty much universally

agreed that multisensory input is helpful to children with
apraxia of speech. The literature is full of examples of
"cues" from various modalities that, when consistently

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paired with verbal attempts, can trigger for the child

access to the motor plan they need to produce the word,
sound, or sound sequence correctly. One very powerful
modality for many children with apraxia is visual (thus the
term "visual cues"). When the adult is also using sign to
"cue" the child, and an association between the visual cue
and the word or sound has been made over time, just the
sight of the "cue" can help the child produce the correct
word. Sometimes a sign for an alphabet letter may be used
in conjunction with a location to cue a sound (sign for "K"
being held at the throat). As children's speech becomes
more intelligible, they almost always drop their use of the
signs. However, many parents and therapists will continue
to use a sign themselves for the purpose of providing a
visual cue for sound or word production when the child is
struggling.

7. Kinesthetic Reinforcement: Some people believe that

the use of manual sign helps kinesthetic reinforcement of
volitional movements and sequencing when accompanying the
verbal attempt.

Speech-language pathologists who successfully use sign

language with children who have apraxia do not have the
child using the signs in isolation. Instead, they are
encouraging the child to use signs along with verbal
attempts. Therapists and parents need to work together in
partnership on all aspects of a child's therapy, including
the use of manual sign language to augment speech attempts.

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Part III

Working with Families and Caregivers

For many reasons, it is in the child's best interest when
SLPs are committed to working with and beside parents and
caregivers. Creating professional-parent partnerships
whenever possible enhances the opportunities for children
with CAS. Parents can be valuable "therapy extenders",
with proper guidance from the SLP. It is not likely enough
to simply spend a minute at the end of a therapy session
verbally telling the parent what occurred. It is not
likely enough to send home a homework sheet and think it is
going to be helpful. As often as possible, parents should
observe a significant portion of a speech therapy session
so that they can receive direct instruction on how to
elicit appropriate speech practice at home. Some therapy
settings provide ample space and room for this to occur.
For example, settings that have observation rooms with one-
way mirror windows are a real bonus for providing parents
with the opportunity to view therapy sessions. Creativity
may be needed in other settings in which observation is not
as simple. Some SLPs use video cameras to periodically
record therapy sessions so the parent can view them.
Minimally, some parents report taking baby monitors to the
therapy room so they can at least hear the treatment
session in progress.

While having oneself observed is not always comfortable,

the real help it can provide to the family hopefully
overrides any such discomfort. SLPs need to go beyond
verbally reporting the help that parents can provide at
home to also modeling it directly. It is through this
modeling and direct guidance that parents will learn what
their child is capable of producing independently or with
cueing and that which the child is not yet capable.

As previously explained, the amount of practice will

directly influence the child's ability to achieve motor
learning for speech. Without practice outside of the

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therapy room, many children will not receive the adequate

degree of practice. Thus, if SLPs encounter parents who
are not able or unwilling to learn how to practice with
their child, a discussion of the ramification on long-term
progress is certainly appropriate.

Many parents today try to educate themselves on problems

affecting their children. Thus, SLPs will encounter parents
who may have read more recent information on apraxia in
children than the SLP has! It is important to understand
that most parents are eager to engage with the SLP as
partners in helping the child. It is perfectly fine to
acknowledge when the SLP has not had much experience with
apraxia; has an equal eagerness to learn about the disorder
and its treatment; and express an overall willingness to
include the parents as partners. Parents appreciate when
the SLP can acknowledge that which they do not know and an
expression of willingness to learn and seek training in
order to help their child.

There may be times when the SLP is concerned that the

parent is not, for whatever reason, following through
consistently or providing appropriate support to the child
at home. During such instances, a meeting without the
child presents and outside of scheduled therapy time may
need to occur. It is important to sensitively and honestly
share concerns for the child's progress with the parent so
that realistic understanding exists. The SLP may also need
to provide referrals to other appropriate professional
resources for specific children. For example, if the SLP
suspects that the child has an underlying pervasive
disability, disorder, or syndrome it would be important to
refer the family to an appropriate developmental
pediatrician or pediatric neurologist.

Overall, it is in the best interest of the child when the

SLP is able to involve the parent or caregiver as a partner
in the therapy process. All efforts should lead to that
hopeful result.

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Part IV

A Case Study of Childhood Apraxia of

Speech
Case #1

Jamie, a six year-old boy, moved into town and entered

first grade. He was very unintelligible (hard to
understand), but seemed to have a lot to say.

His teacher said he did well on many of the math papers,

but struggled with letters and sounds. Jamie had been
receiving speech therapy for the past year and a half in
his previous school, but his mother reported little
noticeable progress.

We did a more complete educational evaluation, including a

speech-language assessment. We found that Jamie had some
fine-motor weaknesses and sensory integration delays, which
were identified by the occupational therapist. The fine-
motor weaknesses explain why he had such difficulty with
such things as gripping his pencil and writing his letters
on the line in an appropriate way. The sensory integration
difficulties also explained why he was resistant to wearing
clothes of different textures, was knocking into walls as
he walked, and didn't seem to sense when crumbs were left
on his mouth after snack. The occupational therapist ("OT")
began therapy once a week in a small group in the therapy
room. Later in the year, much of the therapy was done in
the class.

The special education teacher did a learning disabilities

assessment and found there was difficulty in most areas
related to sequencing. Jamie could not put pictures of a
story sequence in order, repeat words in order, or copy
letters in order. His letter-sound understanding ("S" says
"sss") was adequate. He could read some memorized words,
but could not sound out a new word, even when he knew each

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sound in the word. His math skills seemed to be age

appropriate and his attention span was good. Special
education help was initiated, with the special education
teacher going into the first grade class to help Jamie
during Language Arts.

In terms of the speech-language assessment, I found that

Jamie's difficulties were a pretty classic case of
"dyspraxia", also known as "Developmental Dyspraxia of
Speech" or apraxia. While he had been previously identified
as having a severe articulation disorder, the word
dyspraxia never appeared in any of his previous evaluation
reports. How did I know? Jamie was able to produce nearly
all the vowel and consonant sounds in isolation. If I said,
"Jamie, say 'ah' (as in *apple*), he could do it. He could
say "apple" if he concentrated. He could say "pie". But if
I asked him to say "apple pie", this is what I heard:
"paboo bie". If I asked him to say it three times, I would
get three answers. Another attempt might sound like "pappie
bah". There was no consistency. He often produced single
words clearly, but fell apart in phrases and conversation.
Words with more than one syllable were also much more
difficult for him to pronounce. Sounds that were produced
in one word (the "s" in "bu*s*") were left off in other
places ("s" in the phrase "I *s*ee"). Moreover, his global
difficulty with sequencing, fine-motor, and sensory
integration was typical for children with dyspraxia. He
could tell what he said wasn't sounding right, and was
visibly frustrated, but couldn't *sequence* the sounds and
syllables to match what I said.

This might explain why his previous therapy, which

consisted of ear training and traditional articulation
therapy (where he worked on one sound at a time in single
words) wasn't producing any significant change. He was also
getting oral-motor therapy designed to strengthen his
muscles. I'm guessing the previous therapist knew his mouth
wasn't doing something right. However, when I saw Jamie,
his tongue, lips, and other muscles were not weak or
lacking control during nonspeech tasks. Perhaps the therapy
had done its job, I couldn't tell. While some children with
dyspraxia have difficulty with verbal as well as nonverbal
oral movements, Jamie did not. He was able to open his
mouth, stick out his tongue, and perform a variety of other
commands with normal timing and precision. His chewing,
drinking and swallowing were normal. His tongue did not

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protrude at rest, his jaw did not slide during speech

tasks, and he did not drool.

Lastly, Jamie's sentence structure (syntax) was fragmented.

He said things such as "Morrow I bay di my dend" (Tomorrow
I play with my friend) and I noticed some word-retrieval
difficulties in conversation and on picture-naming tests.
That is, he recognized a word's meaning when he heard it,
but could not remember it when asked to name a picture.
This too, is not uncommon with dyspraxic children.

In terms of therapy, I began a very structured, systematic

approach. I incorporated a variety of methods, such as the
PROMPT technique(which is represented by Deborah Hayden
also described in this study ) and drills which work at the
syllable level, then are incorporated into phrases and
conversation. Words that were too difficult for Jamie to
produce but of high interest, were broken down into easier
"versions" so he could at least approximate a consistent
way of saying what he wanted. I also began using the
Phonemic Synthesis program, which helps children auditorily
learn to blend sounds and sequence them. This helps their
speech, decoding, spelling, and word retrieval. Initially,
individual sounds within a syllable or word were cued with
gestures to help Jamie sequence them. As he improved, each
word in a phrase was cued. Without a great deal of home
practicing, all of my efforts would have been of little
benefit. However, Jamie and his mother were diligent and it
paid off.

By the middle of second grade (a year and a half later),

Jamie's speech was significantly improved. By the beginning
of fourth grade, he was done with articulation therapy and
occupational therapy. However, Jamie still needed some
special education support in Language Arts and work on
developing his expressive language. As is sometimes the
case, Jamie will most likely need some kind of speech
and/or special education assistance for awhile. But he is a
"normal" boy and looks and sounds like the rest of his
friends at this writing.

Note:

(The above is a case study which is based on several actual children

I have seen over the years with the diagnosis of dyspraxia or
apraxia. The name is fictitious.)

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Patti Hamaguchi has a private pediatric speech therapy practice in

Cupertino, California. She has a master's degree in Speech-Language
Pathology from the College of New Jersey and holds the CCC
(Certificate of Clinical Competency) from ASHA.

Case history # 2

Omer is an 8 years old boy student of academic group in

autism institute was brought for the speech and language
assessment by her mother with the complain of poor
functional language and poor intelligibility. For further
evaluation an interview was conducted. Mother reported
that his prenatal and post natal birth history was
normal. No complication was seen during this period. At
the age of 1-1/4 he had seizure. He delayed in his speech
and language milestones. He is able to convey his message
verbally. But doesn’t initiate to start conversation. For
the speech and language evaluations following tests were
administered:

Oral facial examination:

To assess the structural and functional integrity of the

oral mechanism oral facial examination was administered.
Facial features was symmetrical. Range of motion of
opening and closing mouth was normal. Movement of tongue
was normal. Pharynx was also in normal condition. In
short oral musculatures were intact.

Diadochokinetic Syllable Rates:

To assess the ability to make rapidly alternating speech

movement this test was administered. The score is 10.3
and standard deviation 2.8. The rate of errors were high,
he found very difficult this task.

Articulation Scale:

• To find the score of sound production, stimulability,

intelligibility, oral motor function and adverse
affect on educational performance articulation Scale
was administered. The total score was fall within the
range of 17-24, which is moderate. Errors were
inconsistent. He has no difficulty in individual sound

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production. All phonemes (consonants and vowels) were

imitated well in isolation, but any attempts to
combine phonemes are unsuccessful.Errors increased
with length or complexity of utterances, such as in
multi-syllabic or phonetically challenging words.

Functional Communication rating scale:

His score was 4 in interaction and intention that is

severely affected. As mother has already reported he
doesn’t initiate for conversation.

Findings

Omer has difficulty in the production of clusters of

vowels and consonants, specially with the CCVCC, and in
the complex context. During assessment Omer did not
initiate to start conversation and when prompted he gave
good response, speech was intelligible in isolation but
within sentence structure complex utterances were not
intelligible, he exhibited a number of characteristics
that are believed to be highly indicative of apraxia.

Therapy intervention:

So far the initial stage of treatment Omer was

recommended for frequent and intensive one on one speech
therapy programs with Phonotactic Therapy techniques (see
annexure B) PROMPT (Prompts for Restructuring Oral
Muscular Targets, also watch video presentation online).
Targets were the development of simple CVC syllable
production with 90% accuracy. He started to receive 5
days, 30 minutes therapy session. After 40 sessions the
results were very positive and mother reported the
positive results in his speech. All important components
are being considered for successful therapy treatment. He
is currently receiving the therapy treatment according to
the prescribed schedule and prognosis is very positive.

Note: (the above case study has been taken from Autism
Institute Karachi.)

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Conclusion:
Childhood Apraxia of speech, also known as verbal apraxia
or dyspraxia, is a speech disorder in which a child has
trouble saying what he or she wants to say correctly and
consistently. It is not due to weakness or paralysis of the
speech muscles (the muscles of the face, tongue, and lips).
The severity of apraxia of speech can range from mild to
severe.

Developmental apraxia of speech (DAS) occurs in children

and is present from birth. It appears to affect more boys
than girls. This speech disorder goes by several other
names, including developmental verbal apraxia,
developmental verbal dyspraxia, articulatory apraxia, and
childhood apraxia of speech. DAS is different from what is
known as a developmental delay of speech, in which a child
follows the "typical" path of speech development but does
so more slowly than normal.

The cause or causes of DAS are not yet known. Some

scientists believe that DAS is a disorder related to a
child's overall language development. Others believe it is
a neurological disorder that affects the brain's ability to
send the proper signals to move the muscles involved in
speech. However, brain imaging and other studies have not
found evidence of specific brain lesions or differences in
brain structure in children with CAS. Children with CAS
often have family members who have a history of
communication disorders or learning disabilities. This
observation and recent research findings suggest that
genetic factors may play a role in the disorder.

Children with either form of apraxia of speech may have a

number of different speech characteristics, or symptoms.
One of the most notable symptoms is difficulty putting
sounds and syllables together in the correct order to form
words. Longer or more complex words are usually harder to
say than shorter or simpler words. Children with apraxia of

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speech also tend to make inconsistent mistakes when

speaking. For example, they may say a difficult word
correctly but then have trouble repeating it, or they may
be able to say a particular sound one day and have trouble
with the same sound the next day. Children with apraxia of
speech often appear to be groping for the right sound or
word, and may try saying a word several times before they
say it correctly. Another common characteristic of apraxia
of speech is the incorrect use of "prosody" -- that is, the
varying rhythms, stresses, and inflections of speech that
are used to help express meaning.

Children with developmental apraxia of speech generally can

understand language much better than they are able to use
language to express themselves. Some children with the
disorder may also have other problems. These can include
other speech problems, such as dysarthria; language
problems such as poor vocabulary, incorrect grammar, and
difficulty in clearly organizing spoken information;
problems with reading, writing, spelling, or math;
coordination or "motor-skill" problems; and chewing and
swallowing difficulties.

The severity of both acquired and developmental apraxia of

speech varies from person to person. Apraxia can be so mild
that a person has trouble with very few speech sounds or
only has occasional problems pronouncing words with many
syllables. In the most severe cases, a person may not be
able to communicate effectively with speech, and may need
the help of alternative or additional communication methods.

Professionals known as speech-language pathologists play a

key role in diagnosing and treating apraxia of speech.
There is no single factor or test that can be used to
diagnose apraxia. In addition, speech-language experts do
not agree about which specific symptoms are part of
developmental apraxia. The person making the diagnosis
generally looks for the presence of some, or many, of a
group of symptoms, including those described above. Ruling
out other contributing factors, such as muscle weakness or
language-comprehension problems, can also help with the
diagnosis.

To diagnose developmental apraxia of speech, parents and

professionals may need to observe a child's speech over a
period of time. In formal testing for both acquired and
developmental apraxia, the speech-language pathologist may

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ask the person to perform speech tasks such as repeating a

particular word several times or repeating a list of words
of increasing length (for example, love, loving, lovingly).
For acquired apraxia of speech, a speech-language
pathologist may also examine a person's ability to
converse, read, write, and perform non-speech movements.

Children with developmental apraxia of speech will not

outgrow the problem on their own. Speech-language therapy
is often helpful for these children and for people with
acquired apraxia who do not spontaneously recover all of
their speech abilities.

Speech-language pathologists use different approaches to

treat apraxia of speech, and no single approach has been
proven to be the most effective. Therapy is tailored to the
individual and is designed to treat other speech or
language problems that may occur together with apraxia.
Each person responds differently to therapy, and some
people will make more progress than others. People with
apraxia of speech usually need frequent and intensive one-
on-one therapy. Support and encouragement from family
members and friends are also important. The PROMPT
technique presented by Deborah Heydn is useful in the
therapy.

In severe cases, developmental apraxia of speech may need

to use other ways to express themselves. These might
include formal or informal sign language, a language
notebook with pictures or written words that the person can
show to other people, or an electronic communication device
such as a portable computer that writes and produces speech.

Researchers are searching for the causes of developmental

apraxia of speech, including the possible role of
abnormalities in the brain or other parts of the nervous
system. They are also looking for genetic factors that may
play a role in DAS or CAS. Other research on CAS is aimed
at identifying more specific criteria and new techniques
that can be used to diagnose the disorder and distinguish
it from other communication disorders. Research on acquired
apraxia of speech includes studies to pinpoint the specific
areas of the brain that are involved in the disorder. In
addition, researchers are studying the effectiveness of
various treatment approaches for acquired and developmental
apraxia of speech.

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Velleman, S.L. (2003). Childhood apraxia of speech resource

guide. Clifton Park, NY: Delmar Learning.

Web Reference: http://www.apraxia-

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Recommended:

live video lecture on PROMPT Technique by Deborah Heyden

must watch it.

http://video.google.com/videoplay?docid=-
2545150313323194177&sourceid=searchfeed

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