Childhood Apraxia of Speech (CAS) in children with CVI

Aiden smiles for the camera with his hands by his mouth and elbows out wide. He's wearing a red sport's jersey.

Some children with CVI have Childhood Apraxia of Speech (CAS). The CVI visual behaviors must be considered at every turn when designing a total communication plan and intervention approach. Every child with CVI has their own unique needs, and therefore a whole-child, collaborative approach to assessment and intervention is critical.

What is Childhood Apraxia of Speech (CAS)?

The American Speech-Language and Hearing Association (ASHA) defines Childhood Apraxia of Speech as:

“A neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g. abnormal reflexes, abnormal tone). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known and unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.” (ASHA, 2007b, Definitions of CAS section, para. 1)

In other words, it’s a brain-based issue with motor planning, leading to what may be significant challenges with speech sound production, intonation and rate of speech (prosody).

It’s important to note that in this demographic, Childhood Apraxia of Speech may co-occur with delayed language development. It is absolutely critical for speech therapy to target language development in tandem with speech sound production. Without the underlying conceptual development of basic communication skills, the speech-sound development has nothing to “stick” to. That’s why therapy must target language development as well (if that is at all impacted and it often is). The treatments overlap in a helpful way!

Unique challenges for individuals with CVI and Childhood Apraxia of Speech

The CVI visual behaviors make treating Childhood Apraxia of Speech (CAS) uniquely difficult. CAS interventions often rely on visual modeling of articulators (movement of lips, tongue, teeth) to produce a sound.

Impact of motion. Some individuals with CVI have impaired motion perception (difficulties understanding the speed, distance or direction of motion of objects). Any treatment approach that expects the child to look at an adult modeling how to produce a sound will not be an ideal option for the child. They won’t be able to perceive the model, because speech sounds are produced by a series of quick movements.
Access to People. Some individuals with CVI might have difficulty looking at faces, difficulty with facial recognition, and interpreting facial expressions. Many CAS treatments expect individuals to visually attend to faces, then interpret the movements of the articulators (lips, tongue, teeth) appropriately in order to copy them and produce the associated sound. In other words, in order to follow a visual model, the student must be able to access faces and facial expressions. Many students with CVI struggle with this—and many don’t want to look at faces. This is another reason that visual modeling of speech sound production is uniquely challenging for this demographic.
Sensory integration. Individuals with CVI may have a lot of difficulty processing multiple sensory inputs at once—noise, visual clutter, distracting movement and light, internal sensory input, tactile information. Often vision is the first to go. Most CAS treatment approaches expect the student to be able to look and listen at the same time: to watch a visual model of a speech sound or word and listen to it being produced. Looking and listening at the same time can be quite difficult for many children with CVI.

Promising practices

Here are some ways to bring together the adaptable parts of the evidence-based CAS approaches to best serve the needs of children with CVI and Childhood Apraxia of Speech.

Model, model, model!

Encourage lots of auditory modeling in meaningful contexts to ease the demand and load of visual modeling that most likely leads to visual fatigue in children with CVI. Since the brain of a child with CAS struggles to form a motor plan for specific sounds, an immediate auditory model gives helpful support before the child tries to form the sound.
Model with AAC. This provides a consistent, immediate auditory model for the functional communication that children with CAS need. The use of an AAC device will help motivate the child to develop the speech sounds or words associated with items, activities or people that they are the most excited about—which is where good AAC systems start. This nicely dovetails with therapy addressing language development. Also, we don’t want the child to be discouraged with communication in general because speaking is so challenging. AAC provides a more efficient (and thus, enjoyable) method of communication.

Aiden and his sister on playing uno on their living room carpet. Aiden uses his AAC as he plays.

Practice, practice, practice!

Childhood Apraxia of Speech is challenging because the only way to grow is to practice, practice, practice. We all need repetition to learn a motor plan (imagine learning to throw a frisbee—you have to try several times, in order to even get it to fly flat!), and children with CAS need lots of repetition to learn the highly precise and delicate movements to produce speech sounds.

Accept approximations. The Kaufman Approach to CAS is uniquely helpful in encouraging clinicians to accept word approximations, and gradually shape them into more precise sounds. For example, if the child says “Wah-wah” for water, accept it and give them water when they ask for it. Expand on their utterance (“You want water!”) and reinforce it. The key here is accepting and encouraging ongoing production of the sounds—which leads to increased practice—and providing a more precise and accurate model when they use it.
Consider verbal placement cues. The Dynamic Tactile-Temporal Cueing approach (DTTC) to CAS is helpful in encouraging consistent use of verbal placement cues to guide motor planning. In other words, there is a consistent phrase to support the appropriate placement of specific speech sounds. For “th” you might say, “tongue between teeth!” DTTC in general places high visual demands on children, but a child with CVI can learn spatial words and concepts (behind, between, above, back, front, etc.), which will allow them to access the verbal placement cues approach.
Consider tactile and kinesthetic cues. The Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT) approach to CAS uses a series of tactile cues to help individuals find the correct placement and manner to make specific sounds. The general principle of touch as a method of cueing is helpful—if an individual is struggling with finding an appropriate placement for their articulators, then a light touch in the appropriate area may be helpful. If you do use tactile cues, be consistent—always use the same cue associated with the same sound. This is only an appropriate method if the individual feels comfortable with the clinician’s hand on and around their face, so always keep the unique needs and preferences of the child at the center of planning treatment.
Make it meaningful. Some treatment approaches advocate for drilling sounds in isolation. There’s little evidence that this will generalize to the child’s daily life. The easiest words to generalize across contexts are the most motivating and meaningful. Use predictable routines, motivating music, or exciting movement activities to make target words meaningful. For example, if the target word is “more!” then we’ll do whatever is most exciting for the student (swing? bubbles? bouncing on a ball?) and pause the activity to model “more!” and encourage the child to make a word approximation for “more” before we begin the activity again. “More” just became meaningful!
Make it FUN. Speech therapy is such hard work for students. Pull out all the stops, break out all the bubble fans, take them to the water park—whatever motivates them! CAS can be so challenging and tiring to work on that some students may become averse to trying. Pump up the fun and motivation!

Learn more about CVI and communication right here on CVINow.org!

Get an inside look into Aiden’s communication journey living with CVI and Childhood Apraxia of Speech.