This article will focus on intervention specific for older children, specifically around grade 4 through adolescence. As always, therapy goals and frequency will need to be adapted to the needs of a given individual, depending on the severity of the speech disorder and other supports they are receiving.

It is clear that work on “speech” with older children cannot be entirely disconnected from other parts of their development and lives. While not addressed in detail here, additional areas of concern may include the following:

• There is a high rate of co-occurrence of language needs among children with CAS. Fortunately, it is often possible to work on improving speech production while working at the same time on language-related goals.
• There is research that tells us that, without a doubt, there is increased risk for reading/academic challenges for any child with a history of speech sound disorder, including CAS.
• Researchers are identifying areas of additional challenges, such as motor differences and anxiety that need further study.
• There are social implications for participation in school, community, and family situations. Older children may benefit from assistance in developing self-advocacy skills to help navigate different types of social interaction.

To be prepared to offer the best intervention we can for older children, careful assessment is needed to understand current motor speech, phonological, and language skills. By this age, most children with a diagnosis of CAS have had some speech therapy. Understanding what has been worked on previously and how the individual has responded to treatment can provide helpful insights.

A full assessment for older children and adolescents may include:

• Analysis of speech across different tasks, looking at word- and sentence-level intelligibility. Are there error patterns, segmental errors (as reported in a recent study), prosody differences (i.e., stress errors or the melody of words or sentences is “off”), or other issues?
• Gathering information about the student’s perception of how they sound to others, and what their goals are for improving participation in desired activities.
• Careful assessment of language, given known co-occurrence of language issues. This includes the likelihood of a receptive-expressive gap (a difference between understanding and production) and of the persistence of word-form errors (such as not using plurals or past tense). Assessment of conversational speech can provide information about both speech characteristics and language use.

Some elements of intervention are important throughout the course of therapy, including for older children. First, there needs to be sufficient practice to help the student be able to automatically retrieve and use the motor plan for what they want to say. Occasional inconsistency may be noted, and it is important to provide the student with support to help them maintain their best speech.

Working on prosody (the melody of speech) should be a part of speech therapy from the beginning and continue as needed. This may be an area of particular challenge for children who have more severe or persistent motor difficulty. An approach that focuses on prosody can be important for older students for improving overall intelligibility.

The main goal for any child with CAS is to increase the effectiveness of their communication. This may include using supports such as gestures, pictures, spelling, etc. These kinds of supports should continue to be available to a student of any age who needs them.

An element of intervention important for older students to work on is their awareness of how listeners are reacting to their communication in different settings. They need to know how to adjust their communication depending on their listeners and where they are. This includes recognizing that they may need to slow down or speak more clearly when listeners ask them frequently to repeat what they said or to know when to use more formal or polite styles of communication (e.g., adults versus peers). This is what we call pragmatic use of language. SLPs can often address this aspect more explicitly with older students.

Parents, teachers, and other therapists may be asked to help the SLP working with their older student to identify specific activities or places (e.g., classroom presentations, extra-curricular activity, or job) where the student is motivated to use their “best speech”. A collaboration that includes the student and other important people in their world can mean reaching beyond the school doors.

A clinician working with older students may begin to introduce strategies or “rules” to help the student take responsibility for their speech clarity even after speech therapy has ended. Such strategies may include:

• Learning to break down long or challenging words into syllables and then re-assemble them with smooth articulation between the syllables. Using backward build-ups (starting at the end and moving syllable by syllable to the beginning of the word), with careful attention to stress patterns, is often helpful. For instance: -tion, -LAtion, -cuLAtion, -TIcuLAtion, arTIcuLAtion.
• Working on multisyllabic words in sets of words that share:
  • stress-related suffixes (i.e., suffixes with fixed stress that impact the stress pattern of the word, such as -ity and -ation)
  • stress-related spellings (spellings that give cues to likely stress; See Kelly et al., 1998 and McCabe et al., 2014, below)
  • Note: These patterns wouldn’t necessarily be taught explicitly – though they could be – but grouping targets by pattern will facilitate learning and generalization
• Recognizing patterns that can help with grammar and speech accuracy, such as:
  • the diphthong for present tense becomes lax (a “short vowel”) in past tense (hide/hid, slide/slid, feed/fed)
  • regular past tense (“ed”) becomes a voiced or voiceless cluster (blend) depending on the final consonant (walked “walkt”, bagged “bagd”)
  • As above, these patterns may not be taught explicitly, but grouping targets by pattern may be helpful.

In summary, while many elements of intervention for CAS may remain similar across ages, there are additional considerations for older, more verbal students. Collaboration that supports generalization is important at any age, but may become more of a factor as the student engages more widely in the world. It is up to all of us to help.

By Dr. Ruth Stoeckel and Dr. Shelley Velleman April, 2022

References:
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Cassar, C., McCabe, P., Cumming, S. (2022). “I still have issues with pronunciation of words”: A mixed methods investigation of the psychosocial and speech effects of Childhood Apraxia of Speech in adults. International Journal of Speech-Language Pathology, 1-13. Advance online publication. doi: 10.1080/17549507.2021.2018496.

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