Apraxia Therapy: Gestural Prompts

What are Gestural Prompts?

Gestural prompts (sometimes referred to as hand signals or visual cues) are hand signals made by the adult or child as cues to help the child try to make certain target sounds. Using these prompts or cues paired with specific speech sounds has been very successful at helping children with Childhood Apraxia of Speech learn and use the target sounds. Every professional book I have read about Childhood Apraxia of Speech has a section on this technique. Every Speech-Language Pathologist I know who works with children with Childhood Apraxia of Speech uses gestural prompts.

How do I use Gestural Prompts?

Using gestural prompts is a straightforward technique. Make sure your child is watching you (otherwise they will not see the prompt). Use the signal as you make the sound. If you are trying to cue a sound in a word, make the hand signal when you say the target sound. So if you are cueing a /p/ at the end of a word, make the /p/ prompt when you say the /p/ at the end of the word.

For example, let's say you're working on the /t/ sound. The gestural prompt for /t/ is tapping your index finger on your upper lip right under your nose. If your child says "ha" instead of "hat", ask him/her to look at you. Then repeat the word "hat" and make the /t/ gestural prompt as you emphasize the /t/ sound at the end of the word. You can also use the cue to emphasize a sound in the middle of a word. Let's say your child leaves the middle /p/ out of the word "puppy." You can pair the gestural prompt for /p/ (close your fist and then pop it open) paired with emphasizing the /p/ sound in the middle of the word "puppy".

Why do Gestural Prompts work?

Children with Childhood Apraxia of Speech respond well to being cued in multiple ways. Emphasizing the /t/ sound is an auditory cue. Using the /t/ gestural prompt is a visual cue. If they mimic the gestural prompt, it is also a movement or tactile cue as well. It grabs their attention and stimulates multiple pathways in the brain at the same time. This is what makes the technique so effective.

What are some common Gestural Prompts?

These are some commonly used gestures. You can use a different hand signal, it just needs to be consistent.

• T - tap the index finger on the upper lip right under the nose
• D - tap the index finger on the lower lip above the middle of the chin
• P - close your fist and pop it open (into a "5" position)
• B - use the ASL sign for /b/ and tap the hand gently against the side of your chin
• M - gently pretend to pinch both lips closed together with your index finger and thumb
• N - push index finger against one side of your nose as if you're trying to close one nostril
• SH - finger across your lips like you're shushing a child

There are more. You can find a hand signal (or make one up) for any sound you might be working on. Here is a link to a great video of a woman demonstrating a hand signal for almost every sound. Some of her signals are different from what I described above and that’s fine. You can use any signal you’re comfortable with as long as that symbol is consistent. Also, don't feel like you need to learn all of these at once. Pick one or two to start with and if that goes well you can always learn more. Be sure to choose a sound that your child is currently working on and check with your SLP. She or he may already be using a hand signal for that sound. You would want to use the same gestural prompt in order to be consistent.

Other than tapping, this is one of the techniques I find to be most effective.

Note: You may have found this web page searching for information on PROMPT (Prompts for Restructuring Oral Muscular Phonetic Targets) therapy. PROMPT is a formal therapy technique conducted by PROMPT certified Speech-Language Pathologists that uses tactile cues (the therapist places his/her hands on the child in specific ways to try to stimulate sound production). If you're looking for more information on PROMPT, start here.

You might also be interested in the following articles:

Apraxia Therapy: Communication Boards

Apraxia Therapy: Two-Word Combinations

Ava's Speech - What next?

Ava's speech continues to improve in subtle ways. She's talking all the time. Her sentences are often multi-word sentences. She's a full conversational partner in the household. She listens to the conversations around her and tries to participate. She initiates new conversations. She is trying to sing songs. Slowly she's starting to use consonants in the middle of words and put some on the ends of words. Her vowels are usually correct now. The consonants that are missing are still missing, but they are consonants you wouldn't necessarily expect a young two year old to be using like /f, v, k, g, r, l, ch, J, s/. She still has difficulty with more complex syllable structures like C1V1C2V2, but those would be difficult for many typically developing early two year old children too.

She looks so different from the child who less than four months ago had only three "words", very few sounds, couldn't imitate, and scored at the 4 month old level on the early intervention speech and language assessment. She had so many of the items on the checklist for early red flags for Childhood Apraxia of Speech.

Now her therapists are starting to hint that she's looking more and more age appropriate. They're starting to say that the remaining issues she has look more like articulation or phonological issues than apraxic issues. This is exactly why Speech-Language Pathologists are reluctant to diagnose Childhood Apraxia of Speech this early.

If Ava had/has Childhood Apraxia of Speech it is mild. Anyone with moderate or severe CAS would have improved much more slowly. She's in an odd place. She's outgrown many of those "early red flag" signs (although her history of those red flags will never change). She's not quite old enough for the classic signs of Childhood Apraxia of Speech to show up yet.

We're in an odd limbo place. She's made great strides that have brought her to a place that is almost age appropriate. You could argue that we could stop therapy or go to therapy fewer times a week. After all, I am a speech therapist and I'm working with her at home too. I'm also able to monitor her for signs of backsliding. However, it took therapy multiple times a week over several months (and possibly multiple kinds of supplements) to achieve those improvements. I don't want to stop too early. She wasn't making any improvements before the therapy (and supplements).

I'm just not sure what to do. Continue therapy for now? Reduce therapy and see if she's still improving or at least maintaining her skills? Stop therapy for a while and wait to see if she falls behind again?

What do you guys think?

Easter 2011

We had a wonderful Easter. I hope you had a great day too.

The morning began with the children discovering their Easter baskets. They enjoyed the candy and small toys included in their baskets. I had found some small pinwheels and included one in each basket. I didn't really think about it at the time, but they are a great oral motor activity. Ava had a lot of trouble getting her pinwheel to spin, but didn't give up. Of course there's always that one item that is more popular than all the rest. The kids loved the M&M filled gumball machines. They were the first things the children spotted and it was hard to get them to put the gumball machines down long enough to even look at the Easter baskets.

Mid-morning my parents arrived and the entire family participated in dyeing and decorating Easter eggs. Everyone had fun. We began by dyeing them and just as Michael was getting bored with the activity the first set were dry. He loved decorating them. We used the stickers in the egg dying kit and when those ran out I pulled out some art materials and glue and we used those too.

A couple eggs were cracked and therefore the children got to try hard-boiled eggs for the first time. I don't like hard-boiled eggs and never make them. So my kids had never tried them. My parents like them though and were able to set a good example. Michael refused to try a bite at first, but he'll do anything for his grandpa and eventually tried some. He eventually took a few bites of the white, but never tried the yolk. Ava finally decided she'd try a bite after feeling left out of all the attention Michael was getting. She spit the bite back out without even chewing it. I think she was startled that it was cold and didn't like the texture at all. I was pretty impressed she took a bite at all and praised her for trying it.

After lunch (breakfast for lunch - yummy) we were invited to a neighbor's house for an Easter egg hunt. The rain forced the hunt inside. This was the first year the children were old enough to really participate in an Easter egg hunt. Michael loved it. His bag was full at the end of the hunt and he thoroughly enjoyed discovering what was inside the eggs. Ava seemed a bit confused by it all, and entertained the adults by refusing to put any egg in her bag that wasn't pink. If she found a egg of any other color she'd toss it to the floor and practically run away. I slipped a purple one in her bag thinking it was close enough, but when she found it the purple one got tossed too. The other children were wonderful and began bringing all their pink finds to her for her bag.

It was a great family day and we all had a wonderful time.