Don’t just teach the speech. The importance of co-articulation and prosody in the treatment of CAS
Those are two words you might have seen when researching apraxia. If you are treating a kid with apraxia or you have a child with apraxia and are not familiar with these terms, you NEED to familiarize yourself with them.
To have a diagnosis of apraxia, you need three main criteria:
- Inconsistent productions with sounds
- Difficulty with co-articulatory transitions
- Errors with prosody (stress, intonation, pitch, rate, volume)
Recently, I’ve noticed (maybe hoped) that information is getting out there, and SLP’s who are treating apraxia are at least using principles of motor learning and focusing on movement gestures (sound sequences) and NOT sounds or sound patterns. This is awesome because this step and this step alone will help take a child from nonverbal to verbal. Common approaches such as Kaufman and PROMPT teach SLP’s to do this step, and do it well. I can speak as an authority on this matter because I made it a point now to be trained in both.
Here’s the problem. I’m not seeing a lot of emphasis on co-articulatory transitions or prosody.
“It’s okay, I just want my kid to talk!” you might say, and YES. This is the most important thing. HOWEVER, our kids’ fate doesn’t have to be one of disordered prosody and odd sounding speech as they get older. Depending on the severity it may be, but it doesn’t HAVE to be, and that is where we come in.
I would like to see SLP’s who have a good understanding of motor planning now also focus on helping the child “sound” more natural in their speech.
Here’s the thing about apraxia. When kids with apraxia learn a certain motor plan, they learn it well and they say it the same way consistently. This is a good thing in terms of learning the appropriate sound sequences, but if we don’t also consider prosody and co-articulation, we are teaching them to sound robotic, staccato, or monotone; and they WILL learn this motor plan for these features as well, and not necessarily grow out of it.
Okay, so let’s focus on co-articulation and prosody. How do we incorporate it?
Prosody is actually one of my favorite activities to incorporate in therapy. You can choose to do it in both structured and unstructured tasks, which makes it dynamic and versatile in terms of weaving it into therapy. The most obvious way is to make sure, even when you are doing the very direct and structured work of making sure a child is articulating every sound in a word, you do so with varying your intonation. For example, let’s take the word “daddy.” This was my daughter’s favorite word. Ashlynn would frequently omit the medial /d/ and say “da-eee.” When we corrected her, we would make a point of stressing the medial /d/ sound, effectively causing a staccato type prosody. Think about it. We would make her say “daDEE.” We don’t say “daDee” in everyday speech. We say “DAdee.” If we don’t go back and try and get this natural stress pattern along with the correct articulation, we are teaching the child to say “daDEE” which sounds off. This is something we should be conscious of starting from the very early beginning of therapy.
Focused and direct work with prosody should also be targeted. Not to be self-serving, but I created a game I sell on teachers pay teachers just because I wanted something fun to specifically target this area. I called it, “say it like a costume character” and I have various characters and the child has to say the target word the way the “costume character”would say it. This provides not only practice for articulatory accuracy, but also variation at the supra segmental level. The kids LOVE it.
Other activities I’ve done include singing songs that vary the volume. Recently, I just had a child sing BINGO with me, and we shouted the first letter and then had to be quiet the remaining letters. Obviously, this child is more verbal and in a later stage of apraxia resolution; however, even in the early stages, the SLP could request a child say a target word loud vs soft.
As with everything else, I love using books. A recent one I read was “Going on a Bear Hunt” and the child had to say the repetitive phrase “I’M not scaaared” each time it came up in the book varying the stress and rate. Right now I’m moving into the “Old Lady” books. If you haven’t seen them, they seem to have one for every holiday, event, or season and you can have the child “sing” certain parts with you.
Kids with apraxia already have an extremely difficult time sequencing longer syllables or putting words together. You may notice, that when kids with apraxia do start combining words, they articulate every single sound. That’s what we want right?
Yes and no.
Let’s take the the phrase “come here.” A typical English speaker will say “com-ear” when beckoning someone. Say it out loud as though you are calling someone. I doubt you articulated the /h/ in “here.” If you did, you would end up having a slower rate and maybe sounding more robotic. Let’s do another one. Let’s take the phrase, “Put it on.” How many times do we say that to our kids? Now say it out loud. Did you articulate every single sound, or did it sound something like, “pudi-on.” My bet is on the latter.
Though our kids do need to know how to articulate all sounds correctly in various syllable shapes, they ALSO need practice sounding more natural and it’s up to us, SLP’s and parents, to help them.