Apraxia Therapy: Early Apraxia Therapy (Where to Begin) Part 3

I frequently receive requests for information from parents or therapists of very young children - usually between the ages of 18 and 30 months. The children have very few, if any, words. They make few sounds. They have a history of reduced or absent babbling. They have difficulty imitating and difficulty making volitional utterances. They are beginning to become aware that they are different. They want to communicate and yet struggle. Frustration is increasing on the part of both parents and children. The child may begin to act out in negative ways. What do you do? Where do you start?

You have three immediate goals:

Reduce frustration.
Establish and increase frequency of volitional utterances.
Increase number of daily speech utterances through structured practice.

Early Apraxia Treatment - Reducing frustration.

Read about how to address this goal in part one of my Early Apraxia Therapy (Where to Begin) series.

Early Apraxia Treatment - Establishing and increasing frequency of volitional utterances.

Read about how to address this goal in part two of my Early Apraxia Therapy (Where to Begin) series.

Early Apraxia Treatment - Increase number of daily speech utterances through structured practice.

Childhood Apraxia of Speech is a disorder of the motor planning of speech movements. The brain knows what the child wants to say. The mouth is capable of making the movements necessary. The planning of those movements gets jumbled in between. Children with apraxia need repetition, repetition, repetition in order to establish proper motor planning routines and make those routines smooth and automatic. One of the most efficient ways to increase the sheer number of repetitions your child makes is through drill. You can do drill activities with very young children, but first you need to figure out what to drill. I will outline a sequence of steps that will show you how to determine which sounds to target first for a specific child and help you find the resources and methods for doing those drill activities with young children.

Take a speech sound inventory - Young children with apraxia often have a “limited phonemic repertoire”. This is just a fancy way of saying that they can’t make very many sounds. Even if they are trying to mimic a wide variety of words, the sounds they are actually producing often are not the sounds that should be in the words they are trying to imitate. Listen carefully to your child when they are verbalizing. Take videos of several times when your child is “chatty”. Then go back and really listen to those utterances. Transcribe them if you can. What sounds do you hear? What vowels? What consonants? Write those down. For example, check out thisspeech sample of a child with apraxia at 23 months of age. You can see the transcript of the words Ava was saying and the actual sounds she produced. You'll want to do this several times so that you can be sure that you have a fairly complete collection of the types of utterances your child can make.
Analyze the speech sound data you collected - Take your lists of the transcribed words your child makes (if you are a parent, you don't have to use fancy transcription symbols like I did -just note vowels and consonants as best you can). From those lists, make a final list of all the consonant sounds your child can produce. If you can, note next to each consonant whether you heard it at the beginning of the word (in initial position) or at the end of the word (in final position) or both. Your list of consonants may be very small. When I started working with Ava, her only consonant was /d/. You may hear several consonants. If so, try to identify the one or two consonants your child uses most often. Or, the one or two consonants they can imitate best.
Choose speech practice target sounds - This may seem counterintuitive, but you want to begin by working with the sounds your child is most successful with. You are going to begin practicing with the one or two sounds that they already use the most and/or that they can imitate the best. You are going to do this for two reasons. First, you want them to experience success. Early apraxia therapy is all about turning speech from a frustrating activity the child feels like a failure at to a fun activity they can enjoy and consistently participate in at some level. Second, it is likely that they are only using those "best" consonants in a single word, or that they cannot produce them at will in many situations. You want to take that sound that they are currently only using in one word, at home, with you and turn it into a sound they can use in many words (with different vowels to mean different things) in many different situations (school, with other family members, at the park, etc.).
Make therapy practice materials - Go to my free speech articulation materials page and download a free card set or two. Choose a card set that features the sounds you identified in the previous step. If your child uses the sound at the beginning of their words, download the initial card set for that sound. If your child uses the sound at the end of their words, download the final card set for that sound. The card set is designed to pair that consonant your child can produce successfully with multiple vowels. If they leave off a sound (for example, "pah" for "pop"), accept that as correct and move on. If there are cards in the set that your child cannot produce because they can't imitate that vowel sound at all, don’t use them. Right now you want your child to think that this game is fun. You want them to experience success.

Scroll down to the bottom of the free card set page for some tips on doing speech practice with young children and 30 ideas of games and activities to do with those cards.
Practice, practice, practice - Keep practice sessions short. Treat it as play. Tell your child that you're going to play a speech game and then follow through with making it fun. If your child is struggling, ask for just one more, and then put it aside and come back to it later, with a different game. Remember that all of these speech repetitions are cumulative. You are using a variety of strategies throughout the child's entire day to increase the number of speech utterances they produce. Structured practice with picture cards can easily double a the number of speech utterances a child produces in a day in a very short amount of time. It is a valuable tool. It also allows your child to practice using very simple combinations of sounds to produce a wide variety of words that they will hopefully begin to be able to incorporate into their own spontaneous use.