A Systematic Approach for Viewing and Treating Apraxia of Speech: Part Five – Choosing Therapy Targets
Part Five: Choosing Therapy Targets:
When I originally began working with apraxic children I often chose therapy targets based on which sounds were easier to produce in isolation. I then targeted those sounds in a variety of syllable shapes based on the research I had done on other apraxia approaches.
But I quickly learned that I had to change my approach. The reasoning for this change started when I began working with a specific severely apraxic child – lets call him Johnny. When I began therapy with Johnny he could only produce the /ah/ vowel. That was it – nothing else. I began by using the one vowel he had to shape others vowels until he had a few vowels. I then used the sustained phonation modeling technique to help him put the vowels he could produce together to produce vowel-vowel movement patterns. I then began targeting some consonants and I started with nasals because they are usually the easiest to target in isolation. Once he could produce his nasals I again used the sustained phonation modeling technique to help him put his nasals together with the vowels he could produce in consonant-vowel movement patterns. After teaching nasals I then moved on to teaching stops because they are usually the next easiest to produce in isolation. We spent quite a while working on stops because although he could produce them in isolation, he had a great deal of difficulty producing them in a movement pattern. I eventually moved on to fricatives and was surprised how quickly he picked up multiple fricatives and was able to produce them in consonant-vowel movement patterns. I then moved him on to liquids, affricates, and lastly I went back and taught him stops again – and this time he was able to produce them in consonant-vowel movement patterns very quickly. This is where I began to change my way of picking therapy targets and moving through them.
I realized how important sustained phonation is to factor in when choosing targets for therapy. I actually think it is better to follow the progression of sounds that are easier to produce with sustained phonation than it is to follow the progression of sounds that are easier to produce in isolation. So I typically follow that format now and have seen a great deal of success.
I use this continuum to help guide me through choosing target sounds:
Sustained Phonation Target Continuum
I then move the sounds as quickly as I can from isolation into syllables or movement patterns using this continuum to help guide me:
Movement Patterns Target Continuum
Currently Johnny is able to produce all sounds in isolation (vowels and consonants), all sounds in vowel-vowel movement patterns, and all sounds in consonant-vowel movement patterns. We have recently moved onto the vowel-consonant movement pattern and he can produce these movement patterns with only vowels and nasals. My next step will be to work on fricatives in vowel-consonant movement patterns. I hope the progression of therapy makes sense now.
I realize that this will probably be a whole paradigm shift for therapists who work with apraxic kids (especially teaching liquids like l/r BEFORE teaching stops like p/b/t/d/k/g). I had to adjust my whole way of thinking when it came to choosing targets for therapy. However I have noticed that although it may take my clients a little longer to produce a fricative or a liquid in isolation as it would a stop – they can move those sounds into actual movement patterns a lot faster and in turn can use them in words and phrases much faster. I have now used this approach with many of my severely apraxic kids and have seen phenomenal results.
I believe these results come from one specific fact…
We must give our apraxic kids enough time and direction with their speech movements so that they can remember and repeat the movements later. And sustained phonatory modeling is the best technique I have found for providing this time and direction.
We are so used to treating regular speech kids – we often rely on our knowledge there to guide our decisions when treating apraxic kiddos. But keep in mind – what is the most difficult think for apraxic kids??? I believe it is the movement from one sound to the next. Any time you can slow down that movement and provide more cues, direction, and modeling – the easier time the child has learning.
Think back to Part One of my apraxia posts. I compared speaking for kids with apraxia to driving around trying to find where you are going without any map or directions. Now – if you drive slowly, looking at the scenery, the signage, the roads, the details surrounding the drive – how much better will you remember how you got to your destination and repeat your trip again? A lot better right? Now compare that to zipping along a road as quickly as you can without having the time to take in the details. How much harder would it be for you to remember and repeat the trip?
So – I like to compare producing sounds without sustained phonation (p/b/t/d/k/g/ch/j) to driving quickly without taking in the details of the drive. This will likely impede your clients’ ability to remember and repeat the movement later. Likewise, I also like to compare producing a sound with sustained phonation (vowels/m/n/f/v/s/z/sh/th/l/r) to driving slowly and taking in the details of the drive. When you use a sustained phonatory model it gives your clients extra time to visualize, hear, and feel the movement that occurred. This will increase their ability to remember how they produced the movement and to repeat it later.
** For more information about my systematic approach to viewing and treating apraxia of speech remember to FOLLOW ME on my 7 post journey. Remember to add your comments, feedback, and suggestions so that we can work together to conquer apraxia of speech!!!
These blogs make so much sense,,,can’t wait to see the rest! Thank you so much for sharing your journey and making the journey for our apraxic clients a little less difficult,
Thank you. I hope they make sense.
I’m a bit confused, because we don’t use phonation for voiceless sounds such as /f/ ???
You make a great point. I guess the name I chose for the treatment was misleading. I guess I should call it the sustained phoneme modeling technique. It’s not so much about voicing as it is about phonemes that you can hold out/sustain (vowels, nasals, fricatives, liquids) and those that you can’t (stops and affricates). Does that help?
I am new to your blog, but am really enjoying your free resources. Thanks for putting yourself out there and sharing all that you have learned and created to help other SLPs and their clients. I work in the school system and am often approached by teachers of students with apraxia, particularly in early elementary grades, who are having difficulty assessing these students’ knowledge of letters, sounds, and phonological awareness skills. Do you have any advice or recommendations regarding students with apraxia and classroom testing accommodations?
Hi, Thank you for you info. I’m going to try it with a student of mine. How many minutes a week do you typically work with a child who has apraxia of speech? I’m in a school setting. Thank you
It depends on the financial abilities of the client – but usually around 60 minutes a week – divided into 2 or 3 sessions throughout the week.
Hi! Thank you for these great treatment notes and materials. My question is this: once a student has mastered CV and VC syllables – how would I go about progressing to 2 and 3 syllable words? For a CVCV word – do select one CV combination to serve as the first syllable in the pair – keep it unchanging, and then systematically change the second CV until I covered all the consonant and vowel combinations? I don’t know why, but this transition from CV to CVCV confuses me… Thanks for your input!
I would say that you need to do both. I practice the same CV combinations in a repetition form (CVCV – i.e. mama) where all the consonants and vowels are the same. This helps the child get a good amount of practice moving from the one consonant to the one vowel. It is much easier practice. Then, when the child gets successful – start combining different consonants and vowels. This is important to help facilitate the production of real words and sentences. I hope that makes sense. You need to be able to move around and practice different levels of difficulty. For example, I would start the session practicing similar CVCV combinations – as a warm up – and then move into combining different CV combinations during the main portion of the session. I would start by keeping the consonant the same but switching the vowel (i.e. mommy, daddy, baby), then I would work on combinations where the vowels are the same and the consonants are different (i.e. meanie, mayday, tyedye), and then I would eventually move to combinations where both the vowel and consonant change (i.e. body, money, today). I hope that makes sense. Good luck.