Apraxia Therapy: Articulation Practice

What is Articulation Practice?

Articulation practice is practicing making specific sounds. Children with all types of speech sound disorders have to practice making sounds.

• Children with a simple articulation disorder only have trouble with one or two sounds and they practice those sounds first in isolation, then at the beginning, middle, and ends of words, then in phrases and sentences, and finally in conversation.
• Children with phonological disorders have trouble with groups of sounds or patterns of sounds and their speech therapist chooses words in those groups or words that have those patterns to practice.
• Children with Childhood Apraxia of Speech have trouble with the motor planning of speech movements. They need to practice all possible combinations of sounds in as many contexts as possible as often as possible to try to make that motor planning smooth and automatic.

How does Articulation Practice need to be different for children with Childhood Apraxia of Speech?

1. Children with Childhood Apraxia of Speech need many more repetitions than children with other types of speech disorders in order to show improvement. It takes a lot of practice to improve motor planning.
2. Children with Childhood Apraxia of Speech need to practice speech in a way that builds complexity much more gradually than children with other types of speech disorders. Instead of working with words as the smallest unit of complexity, they will look at specific types of syllables and work their way up from the simplest syllable shapes to more complex ones. For example, a Consonant-Vowel (CV) syllable shape such as the word "boo" is a very simple syllable shape. Another very simple syllable shape is Vowel-Consonant (VC) such as "at". A complex syllable shape is CCVCC such as "blast". Yes, boo and blast are both one-syllable words that start with B, but one is much simpler than the other.
3. Children with Childhood Apraxia of Speech need to practice consonant sounds paired with as many vowels as possible. For children who do not have difficulty with motor planning, it is enough to simply practice beginning, middle, and ending consonants without thinking about the vowels in between. Children with motor planning problems have to practice each consonant with each vowel because a consonant paired with one vowel requires different motor planning than that same consonant paired with a different vowel.
   
   Here is an example: Say "bee, bee, bee" and then pause before making the next /b/ sound. Your lips are pressed together. Now say "boo, boo, boo" and then pause before making the next /b/ sound. Your lips are pursed as if you're about to blow a kiss. The motor planning for a /b/ paired with the "ee" is different than the motor planning for a /b/ paired with the "oo".

What are some speech therapy materials that can be used to practice articulation in a way that is best for children with Childhood Apraxia of Speech?

• The only formal speech therapy materials that I know of that addresses syllable shapes is the Kaufman Kits (level one and level 2). The Kaufman Kit is designed to work systematically through the simplest syllable shapes in approximate order of difficulty. Alternately, you can simply take free word lists you find online and sort them by syllable shape and start with the simplest ones first gradually working your way up to harder syllable shapes.
• I am not aware of any articulation picture sets that make a deliberate effort to include all vowels. I am currently creating my own picture sets to try to address this issue. The sets are designed as much as possible to include words that are familiar to young children or that are easily taught. The sets will include only one-syllable words and will include at least one example of all possible vowel pairings. Eventually I would like to create multi-syllable words lists as well but that will not happen for quite some time. Look for the sets to begin to appear on this site shortly.

Key Points to Remember about Articulation Practice for Childhood Apraxia of Speech

1. Many, many repetitions.
2. Move from simple syllable shapes to more complicated syllable shapes.
3. Pair each consonant with as many different vowels as possible. Some pairings will be easier than others. Practice them until they become automatic.

Note: Remember that your child's production does not have to be perfect. For example, say you are practicing "spoon" because it has the "ooh" vowel paired with a final /n/. Your child says "soon". Great! They may have left out the /p/ in "spoon", but they correctly pronounced the vowel and final /n/ that you were looking for. Treat that as correct (for now - until you start working on the /sp/ blend) and heap on the praise.

You might also be interested in the following articles:

Apraxia Therapy: Communication Boards

Apraxia Therapy: Gestural Prompts

Apraxia Therapy: Two-Word Combinations

The Weekly Review: Week Thirteen

Favorite Blog Post of the Week - Men and their New Baby Toys

Amalah shares a story about getting a baby swing for her newborn Ike. My favorite quote from her post was about why her husband chose this particular swing, "It's like somebody attached a cradle seat to an iPad and taught it to fry bacon."

Sibling Moment of the Week:

Last week I taught the kids how to play a modified version of "Red Light, Green Light." We were each holding a hand bell and when I said, "Green Light" everyone shook their bells as fast as possible until I said, "Red Light" when everyone stopped. Then the kids would quiver in anticipation until I said "Green Light" again and the cacophony could resume. They loved it. Next we tried giving the red bell to Ava and the green one to Michael and the person with the red bell got to say "Red Light" while the person with the green bell was the "Green Light" person. They loved that too. We passed a fun and extremely loud half hour and played the game a couple more times over the course of the week.

A few days ago, I was in one room desperately searching a laundry basket for enough clothes to make up outfits to send the kids to school in. The children were crouched over something sitting on the kitchen floor. Two heads bent over a single object. I don't actually know what it was, because I was only half paying attention. All of a sudden I heard them playing "Red Light, Green Light". I have no idea what the game was exactly, but they were playing together and initiated the game entirely on their own while being ignored by their parents. It was a brilliant moment of sibling independent play.

Michael's Update of the Week:

Michael was moved up from one room to the next at his preschool. He was pretty happy in his old room. He always seemed excited to be dropped off and was reluctant to make his way over to me when I came back to pick him up. He liked his teacher and she loved him too.

His new room is more of a formal preschool room. Their routine is a lot more structured and their expectations are higher. He also moved in to a room with a group of rather rambunctious boys. In the two weeks since the move, I have noticed that he doesn't want to go into his room when I drop him off. He clings to my legs and is reluctant to let me leave. He's also practically waiting at the door when I come back to pick him up.

I'm not sure what to do about the problem. I spoke with his teacher and she said that many of the new children are having some trouble adjusting. She'll keep a closer eye on him, but suggested giving him some more time before deciding to be officially worried about the situation.

Does anyone have any ideas or suggestions?

Project of the Week:

This week I'm getting structured home therapy set up for Ava again. I made a speech bag, printed some articulation cards, and prepared a reward chart. We've had two 15-20 minute sessions so far and they are going fairly well.

I've been unhappy with the comprehensiveness of the articulation card sets I've been able to find online for free. Each set will have 20-25 cards, but I have to leave some of them out because they are too hard. In particular, I leave out the ones that are two syllables or include a /k/ or /g/. So we end up with only 10-15 words to practice.

I decided that I can do it better myself. I'm now working on making my own sets of picture articulation cards. My goal is that each set will have 40 one-syllable words that should be familiar to a young child. I am also trying to make sure that each set includes at least one word with each of the American English vowels and diphthongs. That way, the targeted consonant gets practiced with all the vowels. That's important for kids with Childhood Apraxia of Speech because the motor planning is different for each different vowel. You have to practice each different combination to make the motor planning automatic. So far I've made an initial /b/ set and a final /n/ set. I'm going to try to figure out how to share them soon and I'll make more sets as I have time. It takes me several hours per set, so it'll be a slow process, but I'm pleased with the results so far. If any of you have requests for specific sets, let me know and I'll move those sounds to the head of my list of ones to work on.

Speech-Language Pathology Topics: Vowels

What are vowels and why are they important to speech?

A vowel is a sound produced with a relatively open vocal tract. In contrast, consonant sounds are produced by constricting or interrupting the air flow at some point during production. You can maintain a vowel until you run out of breath. For example, take a deep breath and say "eeeeee" for as long as you can. You can keep making that sound until you get bored or until you run out of breath. However, when you make the "p" sound, you can't draw it out. You simply make the sound once and then have to move on. Vowels are essential to speech because they are the core of every syllable we make. Every word has at least one vowel. When vowels are produced incorrectly, that makes speech very difficult to understand.

What are the characteristics of vowels?

What makes an "e" different than an "o"? The vowel sounds are different from each other because you change the shape of your mouth when making each vowel. There are two main ways you change the shape of your mouth. Some vowels are made in the front of the mouth, some in the center, and some in the back. At the same time, some are made with the mouth relatively closed while some are made with the mouth relatively open. Speech-Language Pathologists use a vowel chart to keep track of the vowels and their characteristics.

If you say "beeeeeeee" and then say "baaaaaaaa" (as in "bat") you'll notice that you open your mouth more to make the "baaaaaa" sound. Next, say "beeeeeee" again and then "baaaaaaa" (as in "body"). This time you'll notice that the first sound is made in the front of the mouth while the second is made in the back.

What is the difference between a simple vowel and a diphthong?

A simple vowel is a sound made by keeping your mouth in a single position. When making a diphthong vowel, your mouth changes position. So, when making the /aI/ sound as in "bike" your mouth starts in a very open position and then closes for the second half of the diphthong. This second chart shows the five common diphthongs in American English and how they move in the mouth.

Why are vowel characteristics important to understand when planning therapy for Childhood Apraxia of Speech?

First of all, understanding the characteristics of vowels can help you understand why some vowels are harder than others for your child. Diphthongs are going to be harder than simple vowels because they require more complicated motor planning. If your child has an easier time with front sounds, they'll probably have an easier time with front vowels. If you are trying to help your child learn a back consonant (like /k/) it should be easier for them to make when paired with a back vowel because that makes the motor planning simpler.

Remember that Childhood Apraxia of Speech is fundamentally a problem with the motor planning of speech. The child has to form a motor plan to get from one sound to the next in a word including the consonants and the vowels. So if your child is working on /b/ words, the motor planning will be different if they are saying "bee" instead of "boo" because the vowels are produced in completely different ways. When you set up practice word lists, you want to pair /b/ with as many different vowels as possible to maximize generalization.

You might also be interested in the following articles:

Voicing Pairs

Random Example of the Complexity of Motor Planning