Thursday, May 22, 2014

Apraxia Therapy: Early Apraxia Therapy (Where to Begin) Part 2

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:
  1. Reduce frustration.
  2. Establish and increase frequency of volitional utterances.
  3. 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.

Typically, very young children with apraxia have difficulty producing sounds when they want to. You want to help them be able to intentionally vocalize. If they already can vocalize at will, you want to increase the number of those utterances and the contexts in which they can produce those utterances. Note that for the purpose of this goal, you should not care if the utterance is phonetically accurate. For example, if the child is trying to say, “baby”, and the utterance they make doesn’t sound anything like “baby,” that is all right. If they produce something different each time, that is all right too. You simply want them to be able to reliably produce an utterance in response to a stimulus.

Every time a child with apraxia makes a vocalization (any vocalization) on purpose they are practicing formulating a message in their mind, creating a motor-speech plan, and successfully coordinating breath, phonation, and movement of the speech articulators to produce sound. For these children, that sequence of events is a huge success and a necessary beginning. You need this to happen before you can begin to fine tune the specific sounds that emerge. There are many ways to establish and increase practice opportunities for volitional utterances. I will describe four methods below.
  1. Echoing - One of the simplest ways to establish or increase the number of volitional utterances is to echo any utterances your child does make back at them. Remember that every single time your child deliberately makes a sound to communicate they are coordinating intent with breath, phonation, and movement of speech muscles and structures. This is essential practice in early apraxia therapy. So, if your child happens to make a sound (not a frustration sound, but any other sound) echo it back at them. You want to try to create a fun feedback loop or simple game out of bouncing that word/sound/exclamation/utterance back and forth. For example, there was a time when my daughter's only word was "da?" (for "that?"). She would use it to label items she already knew the name for, to request the name for unknown items, and to request items she couldn't reach. She and I could have an entire conversation consisting of bouncing that one word back and forth. She would point to an unknown item (let's say... a marble, just for the sake of this example). The conversation would unfold as follows:
    • Ava: "Da?" (What's that?)
    • Mama: "Da?" (You mean this?)
    • Ava: "Da!" (Yep!)
    • Mama: "Da?" (You sure you mean this?)
    • Ava: "Da!" (Yep mama. Tell me already!)
    • Mama: "Marble."

    So, instead of her making a single utterance and then receiving either the marble or the label for the marble and being done, Ava practiced making an utterance three times in the context of a true, turn-taking conversation. Over time, this simple technique can result in dozens, or hundreds of extra utterances a day. You can listen to an example of a father using this technique with his 21 month old daughter in the first apraxia speech sample audio clip of this post.
  2. Interactive book reading - Sit down with your child and a picture book. Your goal is to use the book interactively to elicit speech from your child. Read the same book each night so that the child sees the book as a familiar and fun activity. You do not want to read the book to your child, although you can make reading the text on each page part of what you do. You want to engage your child in commenting on the action in the pictures by pointing and asking questions. For example, if a story involves a character who falls, every time you read that page, point to the character and say, “Uh oh!” Then encourage your child to mimic you. Go back and forth several times. Have fun with it. Other utterances that can be worked into reading many children’s books include “hi,” “oh no,” “shhhh,” “bye bye,” “mama,” “daddy,” etc. Again, it doesn’t matter so much that your child mimics those words correctly. You simply want them to experience the turn taking and joint attention that comes with playing the game.

    You can watch a video of this type of interaction in my Case Study of Apraxia – Audio Samples from 21-30 months post. I am reading a book with my 21 month old daughter with apraxia. I also highly recommend the Big Book of Exclamations by Teri K. Peterson. The author is a speech pathologist who designed the book to provide many, many opportunities for interactions and vocalizations. Read my review of The Big Book of Exclamations for more information on this great book.
  3. Pair actions and vocalizations - Often children with apraxia find vocalizing easier when their efforts are paired with motion. Encourage your child to say “whee” while sliding down a slide or swinging on a swing. Play horsie and bounce them on your knee or on an exercise ball while saying “ba bump, ba bump, ba bump”. Blow bubbles and encourage them to say “pop” as they pop each one with their finger. Crash cars together and have them mimic “bam!” Give them a ball of play dough and let them poke holes in it imitating “squish” each time. Line up blocks along the end of a table and have them say “uh oh” each time they push one off. Then they can say “up” each time they put one back up setting up for the next round. Possibilities are endless. Again, it doesn’t so much matter what sound they make. What matters is that they do make a sound. You want them to enjoy making the sound. Making a sound is part of the game. Without a sound, the game isn’t as much fun.
  4. Strategic Withholding - Create speech opportunities in daily life. Structure interactions to require speech. It is so easy with a minimally verbal child to start anticipating their needs and eliminate the need for them to even try to vocalize. Instead, deliberately place a few favorite things out of reach so they have to ask for your help to reach them. Give them a small serving of their favorite food so they’ll need to ask for more. If you are coloring with them, deliberately place the colors just a little out of their reach so they’ll have to ask you to hand them the crayons. These are just a few simple examples, but extend the concept as much as possible during the day. Through this simple technique you can create dozens of opportunities for your child to verbalize each day. Every single utterance adds up to extra practice. A child with apraxia needs as much practice as you can possible squeeze in.

    Do not take this to extremes. You are not trying to be mean, or to deliberately frustrate the child. You are simply intentionally creating opportunities for requests. You want the process to feel natural and not forced. If the child is not able to vocalize a request, respond to nonverbal requests (and signs) as well. You want to avoid increasing frustration. Think “create opportunities” rather than “force practice.”

Trying to write this as one continuous post was simply too long. Look for the continuation of this series the rest of the week. In the meantime, if you need more general information about Childhood Apraxia of Speech, the following posts may be useful:
  1. What is Childhood Apraxia of Speech and How Is It Diagnosed?
  2. What makes Childhood Apraxia of Speech different from other speech disorders?
  3. Childhood Apraxia of Speech Therapy Fundamentals: Part 1 - How Much and How Often?
  4. Childhood Apraxia of Speech Therapy Fundamentals: Part 2 - Types and Variability of Practice
  5. Childhood Apraxia of Speech Therapy Fundamentals: Part 3 - Methods and Content


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