Principles of motor learning in Childhood Apraxia of Speech (CAS)

ByLondon Speech and Feeding
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We use powerful motor learning principles to help children with CAS (Childhood Apraxia of Speech) learn how to produce better, clearer speech sounds in words, phrases and sentences.

What are these principles?

Principle 1: MASSED PRACTICE

This is where you see a child for lots of sessions in a shorter period of time, so for instance six weeks of three times weekly for 30 minutes.

This leads to motor performance or automaticity.

Principle 2. DISTRIBUTED PRACTICE

This is what I use, as most of my clients are not able to come and see me that often on a weekly basis. It is hard to travel in London and life is hectic. So I favour one session a week over say a term or two terms and a session is usually 45 minutes long.

This leads to improved Motor Learning and good generalisation.

During either Massed or Distributed Practice, we choose between 4 variables:

Principle 3: Constant vs Variable

Principle 4: Blocked vs Random

To explain:

Constant Practice is where we repeat the practice of a small handful of target words.

We practise the same target sound in the same word position, e.g. at the beginning of a word: ‘bee’, ‘bye’, ‘bow’, ‘baa’ or ‘key’, ‘car’, ‘cow’, ‘Kaye’ etc.

We keep the rate, pitch and intonation constant.

Variable Practice is where we vary the rate, volume, pitch and intonation of the targets

We use a larger number of sounds, and words that are motivating to say for the child.

For example, if a child loves Peppa Pig then I might choose the words: ‘Peppa’, ‘Daddy Pig’, ‘George’, ‘Mummy Pig’ and a couple of other favourite characters. My child might struggle with a number of sound sequences there but we will target them one by one.

We can also select simpler words like ‘cape’ and ‘cake’ or ‘tick’ and ‘tip’.

Blocked Practice is where we practise one target word for say five minutes then we move to another target word for the next five minutes and then we revert back to the first target word again and so on, so blocks of practice.

Random Practice means we practise several target words at the same time.

How do I decide on what to use?

Good question!

I always opt for distributed practice (weekly for up to 45 minutes).

Within that, I tend to find it most successful to start out with constant practice when a child is finding a certain sound sequence really hard and we need to just ‘nail it’. Bearing in mind I only pick sounds that my student can actually make in isolation, so we are not working on articulation! (where we focus on trying to elicit single sounds correctly – or even at all sometimes) Here in CAS work, we are working with sounds the student can make but is having trouble to add together, into a sequence that is needed to make a word sound right.

As soon as I feel we have some traction I will go to variable practice, i.e. I pick words that are either funny or interesting for the child and it can be a slightly larger number.

I tend to use blocked practice in the beginning or when working on vowels. That’s because it is more important we get our vowels right. They carry a word and are very important for overall speech intelligibility. Once we are on a roll, I tend to go more for random practice.

Example

Here in the video clip, we try and work the /e/ vowel in short words likes ‘bell’, ’fell’, ‘dell’, ‘sell’, ‘smell’ and I am using an AAC device to give a child’s voice as auditory feedback as well as using the PROMPT approach to help my student shape his vowels.

So this is:

  1. Distributed (1 x week for 45 minutes)
  2. Constant – we are practising the /e/ vowel in the same position in six different words
  3. Blocked – we did this: several repetitions of each word and after the sixth we moved to another sound, and then later we came back to this.

Please feel free to contact me if your child has speech sound difficulties. It is my passion. I love supporting children with apraxia.

Sonja McGeachie

Early Intervention Speech and Language Therapist

Feeding and Dysphagia (Swallowing) Specialist The London Speech and Feeding Practice

The London Speech and Feeding Practice

Find a speech and language therapist for your child in London. Are you concerned about your child’s speech, feeding or communication skills and don’t know where to turn? Please contact me and we can discuss how I can help you or visit my services page.

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    1. Interdental lisp

    Protruding the tongue between the front teeth while attempting ‘S’ or ‘Z’ is referred to as interdental lisp; it can make the speech sound ‘muffled’ or ‘hissy’. Often, we associate a lisp with the person sounding a bit immature. The good news is that this type of lisp is the easiest to correct and, in my practice. I have a 100% success rate with this type of lisp.

    1. Lateral lisp

    In a lateral lisp the person produces the ‘S’ and ‘Z’ sounds with the air escaping over the sides of the tongue. This renders the ‘S’ as sounding ‘slushy’ or ‘wet’. This type of lisp is a bit harder to correct than the interdental lisp. In my experience this can be fixed but it might need a bit longer, more intensive therapy than the interdental lisp.

    1. Palatal lisp

    With a palatal lisp the ‘S’ sound is attempted with the tongue touching the palate, much further back than it should be. The ‘S’ sounds ‘windy’ and ‘hissy’. This is a quite rare lisp production but it is also not difficult to correct.

    These types of speech difficulties come under the category of ‘speech delay of unknown origin’ and may persist into adolescence and adulthood as ‘residual errors‘.

    Some thoughts on Treatment in general:

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    Waiting well past 4½ years is not advisable as the longer we wait and do nothing the stronger engrained the erroneous tongue/speech habit will become. The ‘right’ age for therapy for one child may be different from the ‘right’ age for another child even within the same family. So do make an appointment with a speech and language therapist to assess and see whether your child might be ready to start therapy.

    Do lots of children lisp—is it normal?

    Until the age of about 4–4.5 years old it can be a perfectly normal developmental phase for some children to have the interdental lisp. But when we see and hear a lateral or palatal lisp we ought to act and see a speech and language therapist for sure.

    After the age of 4.5 or 5 years old most speech therapists would agree on at least having a look to see if treatment could be started. The longer we wait the harder it is to retrain the brain pathways to adopt new speech habits.

    What happens during the first Speech and Language Consultation?

    The first consultation takes about an hour and involves screening relevant areas of communicative function. We take a detailed history, examine the anatomy of the child’s mouth and tongue movements. We check for tongue tie, teeth formation, palate structure and function, as well as swallowing patterns.

    Then we begin straight away to try and see if any of the alveolar sounds (T/D/L/N) can be produced correctly with the right tongue placement as that would be the starting point from where to shape a good, clear ‘S’ sound.

    The first consultation usually ends with home practice being given, explained to parents and another appointment being made for follow up.

    Therapy – what does a session look like?

    Each therapy session consists of:

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    It tends to take about one term with weekly sessions to help a student make good ‘S’ sounds in phrases and sentences. If the student can do the home practice every day in between the weekly sessions, then in most cases I am able to pronounce the lisp as ‘fixed’ after about one term.

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    Prosody refers to the ‘music’ of speech — the rhythm, pitch, stress, and volume that convey meaning and emotion beyond the literal words themselves. Think about a monotone statement like ‘Really?’ compared to one with a rising inflection, expressing genuine curiosity.

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    3. It makes it easier to express our emotions:

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    I aim to make all my sessions fun and have intrinsic rewards built into the speech practice where possible.

    Home practice tips:

    Therapy shouldn’t exist in a bubble. Working on prosody during sessions is crucial, but it’s equally important to integrate these skills into everyday interactions. Parents and caregivers can model appropriate prosody during playtime, story time, or even simple conversations. This consistent reinforcement helps our children to generalise their newfound skills and use them naturally in their daily lives.

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    • Read aloud with enthusiasm: Model expressive reading, varying your voice for different characters and emphasising key words. This makes reading time engaging and helps children understand the power of prosody.

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    The London Speech and Feeding Practice

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    Verbal dyspraxia

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    Children with verbal dyspraxia can make great progress!

    We provide frequent and appropriate speech movement opportunities and with time and the right support, children will move forward and begin to speak more fluently and with greater intelligibility. It is important to know this can take time.

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    We design carefully tailored programmes focusing on words that have a lot of power (e.g., NO, GO, UP, IN, OUT, LET’S GO, STOP).

    We offer shared enjoyment, and laughter. This helps a child find their voice. Other ways of finding our voices include singing or humming, or even yelling/shouting!

    The most difficult phase of verbal dyspraxia is initiation, that is to start talking, to start producing a word. Frequent “automatic” repetition supports children with initiation because it removes the element of “thinking to start”. I often ask a child to repeat a word 5-10 times (with rewards at the end. A little game works well). You can see that with repetition the act of initiating is taken out of the equation as you are “on a roll “as it were.

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    Treatment Approaches – A Typical Session

    There are various great ways to treat speech sound disorders and I use all the approaches available selectively; I decide what works with each individual child and I also vary the approach depending on the child’s frame of mind at any given time during my session.

    Some of the approaches are more “drill-based” and require a child to be able to pay attention and really participate actively in the therapy, and this is what I am showing you today with this video clip.

    My little student here has been working with me for some time and from only saying a handful of words which were not very easy to understand he has come a long way. He does have some features of Verbal Dyspraxia which I shall briefly outline here:

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    • Repeating sound sequences or words sequences is hard, for example: “say p-t-k in sequence” or “say fish chips fish chips fish chips
    • When saying the same word again and again, different mistakes can be heard
    • Intonation difficulties: speech sounds monotonous
    • Vocabulary is very limited

    Some therapy approaches are more play based, for example the Core Word method: here we pick a few words at a time which are very significant to the child and therefore highly motivating to try and say. These could be characters of Pokemon or Minecraft for example, or simple words like “GO!”

    When you watch the video you will see that I use a lot of visual prompting, such as showing him where the tongue is moving to or from. I do this with my index finger and this approach is called Tactile Cueing or “Cued Articulation”. Part of the approach is to give a visual prompt and then reduce the prompt as the learner is more able to produce the correct sounds. Once he can produce the sound on its own, we quickly move to the sound within a word.

    I do mix and match my approaches and in fact here I am drilling but I also use the Core Word which for him (YELLOW) — it’s his favourite colour and I happen to have quite a few good games where a YELLOW something or other can be asked for….. WHO KNEW!? 🙂

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    ByLondon Speech and Feeding
    Target Activities and Games For Kids

    Why imitation is so important and how can speech and language therapy help children who struggle to imitate?

    Imitation or copying starts in early infancy. When we observe a young baby and his parent or familiar adult we can see clearly and frequently that the baby will be intently looking at adult’s face and try to copy their facial expressions, smiles and all those funny baby sounds we often make with young babies.

    These sounds are called “motherese” and are the beginnings of a little conversation between the parent and the baby. The “conversation can go back and forth for a long time and include sounds, as well as facial expressions.

    A little later on, once the baby can crawl and sit up unaided the copying then goes on to include toys and objects. Mum or Dad will show their toddler how to use a drum or how to put a little train on the wooden tracks and the toddler will try and copy this. They may not succeed and be a little clumsy perhaps but the act of copying anything and everything their favourite adult does is typically seen throughout the day.

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    Copying in Children with Autism

    We know that children with autism often struggle to imitate. We see children on the spectrum typically having great difficulty to copy adults or children; this can be seen in very reduced play with their peers in nursery for example.

    Children with autism tend to have reduced joint attention and engagement with others and need to develop the ability and awareness to copy others in order to then engage more jointly with others.

    Speech and Language Therapy can help with Parent Child Interaction work and Coaching, here is how:

    During my coaching work with parents I teach step by step how to help a child who struggles to imitate:

    We look at all the researched skills and actions that adults can take to help their little one to copy, starting with close observation of their child’s interests, then following and including their child’s play and copying/imitating their child in how they play. I teach steps in a graduated way so that it is easy to see the progress and joyful to have the results at the end.

    The results are clear to see over time: our children on the spectrum learn to imitate actions, with objects and gestures, then sounds and words. Alongside this increased imitation skill the child can then develop more joint attention and engagement.

    I would always recommend Parent Child Interaction Training as a first port of call as we learn so many great techniques which are well researched by the Hanen Programme, www.hanen.org. Do drop me a line if you would like to find out more.

    Find a speech and language therapist for your child in London. Are you concerned about your child’s speech, feeding or communication skills and don’t know where to turn? Please contact me and we can discuss how I can help you or visit my services page.