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Chapter 18
Motor Speech Disorders in Children

Amy Skinder-Meredith and Andrea
MacLeod
Comprehensive Perspectives on Child Speech Development and Disorders 1

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What are Motor Speech Disorders?
• The term motor speech disorders is used to denote a

collection of communication disorders involving the
retrieval and activation of motor plans for speech,
OR the execution of movements for speech
production. The two major subcategories are apraxia
and dysarthria of speech.

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Dysarthria
• Dysarthria: impaired control of muscles used for
speech related to:
• weakness
• decreased range of motion
• decreased speed
• impaired coordination
• Caused by some impairment in the central or

peripheral nervous system (e.g., UMN, LMN,
cerebellar control circuit, or basal ganglia control
circuit)
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Causes of Dysarthria in Children
• Cerebral palsy
• Anoxia
• Tumors
• Head injury

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Table 17.1 Summary table of
different types of dysarthria
*Hypokinetic dysarthria is also due to an imbalance in the basal ganglia control circuit, but is
primarily only seen in adults with Parkinsonism, and is thus not listed in this table.

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18S1 Word productions of a boy, age 10, with dysarthria

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Language Considerations for Children
with Dysarthria
• Some children with developmental motor disorders
delayed language development due to the severity of
their speech disorder.
• These children may be able to only produce single
words, rather than sentences, and may omit
grammatical morphemes.
• In addition, these children may have language delays
linked to more general cognitive delays or to reduced
interaction with others and their environment.
• Lastly, some children may also have impaired language
comprehension

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Apraxia
• Apraxia of speech: a problem with the ability to

plan/program movement (praxis). This is usually
caused by some determined (acquired) or
undetermined (developmental) problem in the
central nervous system
• Like dysarthria, CAS can be either acquired or

developmental.
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CAS Definition (ASHA, 2007)
• Childhood apraxia of speech is 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
or 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.

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Motor Planning vs. Motor
Programming
• “Planning” vs. “programming”: These terms
are used inconsistently in the literature
• Most agree that speech production involves
the following elements and processes
– Stored lexicon with specified sound sequence
– Stored set of simultaneous/sequential motor
action commands
– Finely tuned motor control that specifies
recruitment of muscle fiber groups
• Supported by sensory feedback

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CAS Influence in Other Areas
• The presence of CAS influences the development

of phonology and other language processes.
• Thus, children with motor planning and
programming deficits may also exhibit phonologic
and perhaps other linguistic deficits
• Delays in speech development may occur because
of concomitant delays or deviancies in both
phonologic and motor processing
(Caruso & E. Strand, 1999).

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Theories about Underlying Deficits
• A motor programming/planning deficit is responsible
(Hall, Jordan & Robin, 1993; Rosenbek & Wertz, 1972).
• There is a breakdown in linguistic processes relating to a
subtype of CAS where prosodic errors are a diagnostic
marker (Shriberg, Aram, & Kwiatkowski, 1997)

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cont’d
• The linguistic integrity of underlying phonological structures
may be compromised
• Dissolution of the neural substrates representing the
phonologic framework of the child’s speech motor
programming performance (Marquardt, Sussman & Snow,
1998).
b? p?
t? k?

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Theories about
Underlying Deficits /t/?
What’s
cont’d that?
• “speech motor output would be
severely handicapped as the
phonological targets driving Move tongue tip to /t/.
articulation may be totally missing
or in various states of marginal
operational integrity” (Marion et al.,
1993).
Vocal tract image from:

http://www.dukemagazine.duke.edu/issues/050608/images
/050608-lg-figure1purves.jpg

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cont’d
• Impaired ability to generate and utilize frames, which would
otherwise provide the mechanisms for analyzing, organizing,
and utilizing information from their motor, sensory, and
linguistic systems for the production of spoken language
(Velleman & Strand, 1994).
C V C

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cont’d
• There is an interdependence of perception and
production Groenen, Maassen, Crul, and Thoonen
(1996; 2003).
• Speech errors are due to impaired sensorimotor

integration, due to missing rich sensory feedback and
rhythmic coordination during the babbling period if
the child is reported to have been a “quiet baby”.

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cont’d
• There is an impairment of sensory processing and in
particular proprioceptive input with an ensuing
failure to program, organize, and carry out
movements necessary for expressive speech.
(Nelson, 1983)

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Important to note:
• CAS may be (and often is) exhibited along with any
number of other deficits and strengths for any
particular child.
• Our goal: be as informed as possible regarding the
nature of the motor planning deficit (in relation to any
other deficits, such as cognitive, linguistic, and motor
execution)
– Be able to answer, “What is the relative contribution of the
disorder to the child's overall communicative
performance?” (E. Strand, 1996)
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Core Characteristics (ASHA, 2007)
1. Inconsistent errors on consonants and vowels

in repeated productions of syllables or words.
– E.g., ogi, tu-i, ku-i for “cookie”
2. Lengthened and disrupted coarticulatory
transitions between sounds and syllables. (see
next slide for example)
3. Inappropriate prosody, especially in the
realization of lexical or phrasal stress.

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Examples
May I play please? (produced normally)
May I play please? (produced

with CAS)
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CAS: Articulatory Characteristics
• Multiple speech sound errors

1. Omissions (most common)
2. Substitutions
3. Distortions (can be difficult to transcribe)
4. Additions- (e.g., balue for blue; mana for man)

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5. Voicing errors
6. Errors related to the complexity of articulatory adjustment.
a. Consonant hierarchy: clusters > fricatives > stops > nasals
b. Vowel hierarchy: diphthongs > monophthongs
7. Independent phonetic inventory is larger than relational
inventory
8. Presence of vowel errors

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• Difficulties with Sound Sequencing
– Evident in DDK tasks and multisyllabic words
• Disturbances in timing
– Longer word and sentence durations
– Shallower f2 slope (shallow vs. normal production of “bike”)

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18V1: 18-year-old woman with intellectual
impairment, phonologic awareness delays, and
CAS saying words of increasing length
18S2 Conversational sample and single-word

productions of a girl, age 5, with a diagnosis of
severe CAS
18S3 Conversational sample and multisyllabic

word imitations of a girl, age 10, with a history
of severe idiopathic CAS

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• Disturbance in temporal spatial relationship of the

articulators
– Imprecise, nonspecific speech gestures
– Palatometry data suggest that children with apraxia do not
develop the more finely tuned speech movements with any
specificity or precision. (Gibbons, 2002)

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• Contextual Changes in Articulatory Proficiency
– Errors increase with increasing length of word or utterance
– Target sounds are more easily produced in single word
production than in conversational speech
– Articulatory accuracy improves when rate is decreased
– Articulatory accuracy improves when given a simultaneous
visual and auditory model

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Language Implications
• Receptive language better than expressive
language
– HOWEVER performance may vary according to the
task (e.g., receptive one-word vocabulary may be age
appropriate while comprehension of complex
sentences is impaired.)
– Crary (1993) states AT LEAST three areas of
comprehension be assessed
1. semantic comprehension
2. syntactic comprehension
3. influence of increased length of input

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Language Implications cont’d
– Some children who appear to have normal language

skills early on may demonstrate difficulty in “higher
language processes such as categorizing, organizing
and abstracting in the 3rd or 4th grades (Air, Wood, and
Neils, 1989).
– Children with CAS were found to have impaired
language skills by school age in a follow-up study by
Lewis and colleagues (2004)

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Language Implications cont’d
• Expressive language
– Pronoun errors
– Syntactic errors
• Morphological omissions of plural, possessive,
third person singular, and past tense markers
– Word omissions
– (Ekelman & Aram, 1983; Lewis et al., 2004)

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Metalinguistic and Literacy Characteristics of
Children with CAS (ASHA Technical Report, 2007; Caspari, 2007)
• At risk for phonological awareness deficits (important

for literacy development)
• Deficits in:
– rhyming (producing rhymes)
– word attack, word identification, and spelling
– phonological perception
– phonological discrimination
– phonological memory

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Phonologic and Phonemic
Awareness Defined
• Children with CAS are at risk for difficulties with
phonologic and phonemic awareness.
– Phonologic awareness: the ability to reflect on
and manipulate the sound structure of a language
as distinct from its meaning. (Stackhouse, 1997;
Sweeney James, 2006)
– Phonemic awareness: the ability to hear, identify,
and manipulate individual sounds in spoken words
(Armbruster, Lehr, and Osborn, 2001)
– Some sources use these terms interchangeably
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Neurological Implications
• A high incidence of “subtle” or “soft” signs often (but
not always) appear as an associated characteristic of
CAS
These include:
1. fine and gross motor incoordination
2. difficulties with gait
3. difficulties with alternating repetitive
movement

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Neurological Implications cont’d
• Older studies failed to specifically delineate consistent
neurological findings with respect to localizing a neuro-
anatomical etiology for childhood apraxia of speech.
– A variety of studies report a wide pattern of neurological signs across
children diagnosed with CAS (Crary, 1984; Hall, Jordan & Robin, 1993; and
Yoss & Darley, 1974).

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Neurological Implications cont’d
• A recent study (F. Liégeois, Morgan, Connelly, Vargha-Khadem,
2011) found “repetition (in a non-word repetition task)
in the affected members was severely impaired, and
brain activation was significantly reduced in the
premotor, supplementary and primary motor cortices,
as well as in the cerebellum and basal ganglia.”

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Genetics
• KE family: a multigenerational family studied by Vargha-Khadem et
al. (1995; 2011) in England
– Mutation of the FOXP2 gene
– Syndromic involvement (speech, nonspeech oromotor, language, brain
structures)
• Galactosemia: an inherited metabolic disorder that sometimes
coincides with CAS
• Motor sequencing deficits in multigenerational families with CAS
(Peter & Raskind, 2011; Peter, Matsushita & Raskind, 2012)
– Discrepancy between monosyllabic DDK and multisyllabic DDK
– Discrepancy between repetitive and alternating finger tapping
• General difficulty with sequential processing (Peter et al., 2013;
Button et al. 2013)
– Phoneme sequences in real word and nonword imitations
– Reading nonwords
– Spelling

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Assessment and Diagnosis
Is CAS over-diagnosed?
The problem is that many CAS characteristics overlap with other disorders.
Case Example 1
A five-year-old boy was brought in for an assessment to
participate in a study on CAS. However, when the examiner
tried to test him, he showed no interest in the people in the
room. He walked in on his toes, waved his hands, and
darted from object to object in the room. When the mother
was asked if she had any concerns other than CAS, she
reported that this was the only diagnosis that the doctor
had mentioned to her.

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Table 17.2 Characteristics
differentiating CAS and
dysarthria from other
speech disorders
CR= Cluster Reduction

ICD=Initial Consonant Deletion
FCD=Final Consonant Deletion

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Framework for Using Assessment Data in
Treatment Planning
• Overview of the neuromuscular condition
• Structural-functional examination
• Examination of physiological parameters
• Motor speech examination
• Articulation testing and phonologic analysis of speech
errors
• Consistency analysis of errors
• Prosody
• Hearing screen
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Framework for Using Assessment Data in
Treatment Planning
• Keep in mind: These procedures are specifically

for motor speech disorders
• Most children have linguistic and cognitive
factors that contribute to the communication
disorder
• Language, phonologic awareness and cognitive
processes should also be assessed

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Examination of the Neuromuscular Condition
• Observation of the physical/neuromotor status

of the child will
– Lead you to hypotheses or predictions regarding the
status of the child's speech motor control system.
– Reflexes, or the condition of muscles in the extremities

may assist you in developing a clinical picture; helps
support or confirm a specific diagnosis.

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cont’d
• Examine Gait
– Is there evidence of spasticity? Ataxic involvement? Dyskinetic (extra)
movement?
• Muscle Examination
– Is there any atrophy or hypertrophy?
– Is there any spasticity or flaccidity?
• Examine Muscle Strength
– Response to resistance
• Little to no resistance vs. lead pipe resistance?

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cont’d
• Examine Muscle Tone

– Low tone points to LMN or cerebellar involvement
• High tone points to UMN involvement
• Examine Coordination
– Need to sort out cerebellar involvement where coordination is affected vs.
apraxic involvement, where the child can’t volitionally sequence the
movement
• Examine Reflexes
• Sensory Function Examination

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Structural-Functional Examination
• CN Exam
– Jaw- CN V
– Tongue- CN XII
– Lips- CN VII
– Velum- CN IX, X
• Structures at rest
– Note symmetry
– Atrophy
– Adventitious movement
– Tissue characteristics
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Structural-Functional Examination cont’d
• Function of each structure

– Range of motion
– Coordination
– Strength
– Ability to vary muscular tension
– Speed
– Limits of function

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Structural-Functional Examination cont’d
• Sensation
– Two point discrimination
– Stimulus localization
– Texture discrimination
– Superficial tactile
– Talk to parents regarding signs of sensory integration
dysfunction
• Hypersensitivity, hyposensitivity, mixed sensitivity
– Motion and position

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Examination of Physiologic Parameters
• Respiratory function
– Sustained phonation
– 5 cmH2O for 5 seconds rule
• Velopharyngeal function and Resonance
– Fogging the mirror
– Pinching and releasing nares during ‘pa’
– Listening tube
• Laryngeal function
– Cough
– Voice quality during sustained phonation
– Ability to vary pitch and loudness

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Motor Speech Evaluation
• Examine ability to sequence phonetic segments in various
contexts.
– V, CV; VC; CVC (using various vowels)
– Monosyllabic words with the same first and last
phoneme
– Monosyllabic words with different first and last
phonemes
– Words of increasing length, e.g.,
me zip ball
meat zipper baseball
meeting zippering basketball

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Motor Speech Evaluation cont’d
–multisyllabic word repetition
• Kindergarten
• Multiplication
• Refrigerator
– phrase repetition
– Sentences of increasing length, e.g.,
I eat I go
I eat lunch I go home
I eat lunch every day I go home with mom

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• For more advanced kids
– I play baseball
– I play baseball after school
– I play baseball after school and on Saturday
• Sentences of varying phonetic complexity,
– I want more to do.
– Mom and Dad sit on my bed.
– I like to eat ice cream after school.
– We ordered pepperoni and sausage pizza.
– Please put the groceries in the refrigerator.

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• Evaluating automatic vs. more controlled contexts
– Counting 1-10
– Naming particular numbers
– Familiar and unfamiliar phrases
• Connected Speech
– Conversation
– Picture Description
– Narrative
• Note: Of course, not all tasks are appropriate for
all kids.
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• Examine ability to produce particular phonetic

sequences while varying the temporal relationship
between stimulus and response
– Simultaneous
– Immediate Repetition
– Delayed Repetition
– Delayed Consecutive Repetition
Keep in mind that this is just a tool to help in diagnosis,
treatment planning, and treatment.

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• Diadochokinesis (besides comparing to norms)
– Was the child able to sequence the syllables?
– Was rhythm affected?
– Where there voicing errors?
– How was the coordination of respiration, phonation, and
articulation?
– Are there differences between repetitive monosyllables
and sequences of different syllables?
18S4 Eight-year-old boy with CAS and

galactosemia attempting the DDK task

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Articulation/Phonologic Analysis
• Standardized Articulation tests:

– Use a standardized articulation test, (e.g., Goldman
Fristoe Test of Articulation-2 with the Kahn-Lewis Phonologic Analysis-
2) to obtain:
• Phonetic inventory and phonologic analysis
• Percent consonants correct: compare single word
production to sentence

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Articulation/Phonologic Analysis
cont’d
• Syllable shape inventory at various word

lengths
Syllable Shapes One Syllable Two Syllable Three Syllable
Percent Correct Percent Correct Percent Correct
CV 94% 50% 0%
VC 55% 0% 0%
CVC 89% 31% 0%
VCC 12.5% 0% 0%
CVCC 33% 0% 0%
CCVC 0% 0% 0%

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Consistency of Errors
• Elicit five words six times each and then calculate
consistency of the most frequently used error type.
• Calculation: number of productions of the most frequently
used error type minus 1, divided by the number of erred
productions minus 1, multiplied by 100 to obtain the
percentage score.

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Consistency of Errors cont’d
• Betz and Stoel-Gammon (2005):
– Children are asked to name pictures of 25 words three times.
– An activity is inserted between trials
– Avoid using imitation, but you can use semantic cues or teach
the name of the item and then ask what it is called later.
• Dodd (1995):
– “Variable production of 10 or more words on two of the three
trials warrants classification as inconsistent disorder.”
– “Both consonants and vowels should be included. If not all
words can be spontaneously elicited then a percentage score
can be derived.”
– “A score of more than 40% would indicate a diagnosis of
inconsistent disorder.”

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Assessing Prosody
• Observe prosody in conversational speech, as
well as the ability to imitate prosodic contours of
phrases.
• Does the child stress the appropriate words and
syllables?
• Can the child use contrastive stress (e.g., “I want
to go home” vs. “I want to go home”)?
• Can the child imitate the prosodic contour of
sentences? (See Appendix B for sentence
imitation task)
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Tests on the Market
• Verbal Motor Production Assessment for

Children (VMPAC) (Hayden & Square, 1999)
• Screening test for Developmental apraxia of
Speech-2 (Blakely, 2000)
• The Apraxia Profile/Checklist (Hickman, 1997)
• The Kaufman Speech Praxis Test for Children
(1995)
• For a good review of these tests read: McCauley, R. & Strand, E., (2008). A
Review of Standardized Tests of Nonverbal Oral and Speech Motor
Performance in Children. AJSLP, vol. 17, 81-91
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VERY IMPORTANT
• A child is rarely ever JUST APRAXIC!

• Don’t let the diagnosis of apraxia be the only
diagnosis when there’s more going on!
• Don’t assume that because the child has
apraxia their other symptoms are part of the
CAS diagnosis.
• Be very clear with parents about ALL of the
factors contributing to the child’s
communication disorder.
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Motor learning and how it applies to
speech
If we think of speech as movement and a child can’t plan the
correct sequence of movements for speech, it makes sense to
incorporate principles of motor learning in our therapy.

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Principles of Motor Learning and Their
Application to treatment
First, appreciate the difficulty of sequencing movement you are not familiar with.
Would she please

slow down?!#*

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Precursors to Motor Learning
• Motivation
• Focused attention
• Pre-practice (preparing the child for what the
movement goal will be)
• If the child is difficult to motivate or has a
difficult time with focused attention, a
behavior plan may be warranted.
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Case Example 2
The role of motivation is extremely important. If a child has met a
lifetime of verbal communicative attempts with little success, he or she
may understandably want to give up. Annabel was a bright 6-year-old
girl with dysarthria and apraxia. She wanted to be a verbal
communicator, but this was very difficult for her motorically. It was
made clear to Annabel from the onset that she had three jobs in
speech therapy; to watch the therapist's mouth, listen to the therapist,
and try to say what the therapist asked her to say. If she did these
three things enough times in a session, she would earn a prize. During
one therapy session she was asked to work on her speech and she
turned her back to the therapist and signed, "no." She did not earn her
prize on this particular day, which made her very upset. However, she
came back to the next therapy session willing to work hard on her
speech again. Extrinsic reinforcement may be necessary initially.
However, the intrinsic reinforcement of successful verbal
communication should soon take over once the child has put the work
in to see the gains that can be made in speech therapy.

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Example of Behavior Plan
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
____ ____ ____ ____ ____ ____ ____ ___ ___ ___ ___ ___
(good listening)
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
(good watching)
_ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
(verbal attempt)
Fill in a space or have child fill in space for every time they do any of the
above. If they’ve filled in every space, they earn a reward.
Rewards can take many shapes (e.g., prizes, play time, etc.). Work with
the parents on deciding the most appropriate and motivating
reward for the child.

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Conditions of Practice
• There are many issues pertinent to conditions of
practice. These include
– motivation
– goal setting
– instructions
– Modeling (more effective than verbal instructions)
• Three issues especially relevant to treatment of motor
speech disorders are the use of repetitive practice, and
the concepts of mass vs. distributed practice and
random vs. blocked practice.

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Repetitive Motor Drill
• Need enough trials per session in order to
allow motor learning to occur and become
habituated toward more automatic processing.
– Choose time efficient reinforcements
– Develop activities that facilitate repeated
opportunities for production of target utterance
– Just producing the target 5 times in a therapy
session is not enough for the motor learning to
occur.

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Mass vs. Distributed Practice
Mass practice refers to working on the same skill
continuously without taking breaks versus practicing the
skill in shorter periods of time with breaks in between, as
in distributed practice.
Some may equate this with providing speech therapy to a
child in one long session per week instead of in several
shorter sessions per week (e.g., one 60 minute session
versus three 20 minute sessions per week).
Maas and colleagues (2008) describe mass practice as giving
a number of trials in a small period of time and distributed
as giving a number of trials over a longer period of time.
Mass practice yields quick development of the skill, but poor
generalization; distributed takes longer, but achieves
better motor learning.
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Blocked vs. Random Practice
• Blocked practice - all practice trials of a given stimulus

are practiced together before moving on to the next.
• Random practice - the order of presentation of the
stimuli are randomly mixed up throughout the session.
Blocked practice leads to better performance but random
practice seems to result in better retention, or motor
learning.

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Principles of Motor Learning
• Knowledge of results vs. knowledge of performance
– knowledge of results (KR) = general feedback, such
as correct vs. incorrect
– knowledge of performance (KP) = specific
feedback, such as “put your lips together”
• KP is more effective (Morehouse & Cornish, 2004)
• Specific feedback may be more appropriate initially
• KR is more time efficient and is good for maintenance
(Maas et al., 2009)

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Feedback Schedule
• Reduced amount of feedback has been found
to be more effective (Schmidt & Lee, 2005)
– High frequency feedback can be helpful in
acquiring the skill, but low frequency feedback is
more helpful for long-term retention.
• Increased pause time after the client's

response has also been found to more
effective in studies of AOS (Austermann Hula,
Robin, Maas, Ballard, & Schmidt, 2008)
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Influence of Rate
• There is a tradeoff between rate and accuracy; slowing

rate will increase accuracy (up to a point).
• Varying rate can be an effective tool to vary during
repetitive practice of targeted utterances, in order to
allow habituation of articulatory movement accuracy
while working toward natural rate and prosody.

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Treatment of Children with Dysarthria
• Treatment of developmental dysarthria is variable
and depends on the type of dysarthria the child has
(e.g., ataxic, spastic, flaccid, hyperkinetic, mixed), the
subsystems involved (e.g., articulatory, phonatory,
respiratory, and resonance), and if the condition is
static (e.g., cerebral palsy) or progressive (e.g.,
Friedreich's ataxia).

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• Treatment for dysarthria often consists of increasing
physiological drive and effort, increasing articulatory
precision, managing velopharyngeal dysfunction, and
developing compensatory strategies, such as using
an augmentative communications system when
necessary.
• Results from the assessment should guide the
therapist in their treatment goals, as it will alert
them as to which subsystems are most compromised
for speech. See Table 17.3 for treatment examples.

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Table 17.3 Examples of treatment
from a systems approach

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Alphabet and Semantic Topic Board
small talk food school health
schedule
family A B C D E F G yes
H I J K L M N
no
personal wait
O P Q R S T
Start over
trips U V W X Y Z Not done
Forget it
0 1 2 3 4 5 6 7 8 9 maybe Please stop
Will spell words
Don’t know
Will point to first letter
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Relevant Principles for Treatment of CAS
• Use of intensive paired auditory and visual

stimuli.
• Production of sound combinations versus
isolated phoneme training.
• Use of repetitive production and intensive
systematic drill.
• Careful construction of hierarchies of stimuli.

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• Use of decreased rate, with proprioceptive
monitoring.
• Use of carrier phrases.
• Use of pairing movement sequences with
suprasegmental facilitators such as stress,
intonation and rhythm.
• Establishment of a core vocabulary (especially
for the non verbal child).

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Examples of Different Treatment
Programs
• Kaufman apraxia kit

• Phonemic simplification and progressive approximation
• E.g., bottle: baba > bado > bottle
• Prompts for Restructuring Oral Muscular
Phonetic Targets (PROMPT) (Debora Hayden)
• Nuffield Dyspraxia Programme

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Dynamic Temporal and
Tactile Cueing (DTTC) (Strand, 2004)
• Adapted from Rosenbek, et al. (1973). This

technique
– allows high levels of success
– emphasizes extensive practice
– uses meaningful, useful utterances for motivation
and functional communication
– maximizes proprioceptive input

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DTTC (Strand, E., Stoeckel., R., & Baas, B. (2006 )
• Therapist says utterance while child watches
clinician’s face and child repeats
– if child is unsuccessful, move to simultaneous
production, adding tactile or gestural cues as
necessary
– maintain auditory and visual stimuli for repetitions
– continue until child can easily produce the
utterance with therapist
– fade cue by reducing volume, reducing
tactile/gestural cues

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• Immediate repetition
– therapist says target utterance
– child repeats (therapist mouths utterance if additional
support is needed, then fades)
• Addition of delay
– therapist says target utterance
– insert 1-3 second delay before prompting imitative
response
– after child is successful in 2-3 second delay, prompt to
repeat target several times without intervening stimuli

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• Elicit utterance spontaneously
– Work on prosody by asking questions that prompt different
lexical stress patterns.
• E.g., target phrase: “I have football on Fridays.”
• Clinician: Do you have ballet on Fridays?
• Client: No, I have football on Fridays.
• Clinician: Do you have football on Mondays?
• Client: No, I have football on Fridays.
The hierarchy is constantly changing as the therapist adds

or fades cues, depending on the child’s responses

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Examples of Tx Phrases
Beginning set Building on after 1st set is
accomplished
• No
• No more _____
• Hi Mom
• I want _____
• I do
• I do it
• My turn
• May I have ____?
• Open ____
• My turn please
• More ____ • _____on ____
• All done • I’m all done

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Phonologic Awareness
• Supplement motor speech therapy with phonemic
and phonologic awareness to:
– Improve the linguistic underpinnings that could help
improve motor speech skills
• Strengthen neural substrates of phonemes
• Compensate for spatial temporal awareness deficits
• Build a bridge from the motor conceptualization of
phonemes as represented by graphemes to sequence
of movements for speech.
– Improve literacy

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Adding Motor Speech to Phonological and
Phonemic Awareness
• Lindamood Phoneme Sequencing®

– for Phonemic Awareness, Reading and Spelling
(LiPS®)
http://www.lindamoodbell.com/programs/lips.html
– Use phoneme labels that describe the movement of
the sound. (next slide)

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LiPS
• Use mouth pictures to go with the labels.
• Overlie mouth pictures with letter tiles.
• Later, spell with mouth pictures and then letter tiles.
• Demonstrate how when letters change, sounds change, which
changes the word.
if it
18V2 Jackie learning the kinesthetic, auditory, visual, and graphemic

cue for /k/ and /g/ with LiPS®. Note how the client is paying
attention to all elements of this sound. This is the first time she has
been able to establish a grapheme phoneme relationship.
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LiPS
• Colored blocks can be used to track syllable changes and work on

demonstrating the following skills:
– omission (taking away a block when the sound went away, e.g., changing
‘vop’ to ‘op’)
– substituting (switching sounds, e.g., changing ‘vop’ to ‘vip’)
– addition (adding a sound, e.g., changing ‘vip’ to ‘vips’)
– shifting sounds (e.g., changing ‘ip’ to ‘pi’)
– and repeating sounds (e.g., change ‘sop’ to ‘sops’)

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Pros and Cons
• Pros
– A multi-modality approach
– Systematic
– Ability to build on this program with their other programs
(e.g., Seeing Stars)
– Guides the student as a collaborator and active problem
solver
– Peer reviewed journal articles have shown this program to
be effective
• Cons
– May be difficult for a child with attention issues
– Manipulatives may be distracting and too abstract

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Phonic Faces
• “PHONIC FACES is a unique alphabet that enables children
to SEE sounds!”
• “The letters in the mouth look like the lips or tongue
making the sound, a form of cued speech. “
• “Phonic Faces make learning articulation, letter-sound
correspondence, sounding out and spelling words, and
learning phonic principles easier than any other program.”
• http://www.elementory.com/index.html

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Using Phonic Faces
• Introduce one sound at a time.
– Each sound has a picture card, a story, and activities
• After a group of sounds has been introduced, you can
start blending them. For example:
– Introduce first group of sounds: p, b, k, and g, a, e, g, I
– Begin blending sounds into /cvc/: words big, pig, dig
– Implement rhyming activities
• Set of cards available with onsets and rhymes

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Using Phonic Faces
• After phonic faces has been used to teach
grapheme-phoneme relationships
– Fade out phonic face and just use traditional
letters
– Use print to facilitate speech as an additional cue
to tactile, visual and auditory.

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Activity Example
 Play dough
 Child uses these words
in a carrier phrase or on
their own:
◦ I need to ______.
◦ I can ________.
◦ Poke the dough.

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What about Perfect Spelling?
• Sometimes it is difficult to have graphemes
match correct spelling
– “do” vs. “go”
– “you” vs. “mouse”
– “row” vs. “how”
– “bread” vs. “treat”

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Pros and Cons
• Pros
– Fast and friendly way to teach grapheme-sound awareness
– Phonic faces gives a cue for articulatory placement
– Pictures and stories are engaging for children with attention
issues
– Other materials for later developing skills are available
– Materials in Spanish are available
• Cons
– Stories don’t always make sense
– Studies are showing positive results but have not been
published in peer reviewed articles yet.

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To Summarize
• Key points for when motor planning is the major

contributor to the speech disorder.
– Child will generally benefit the most from one on one
therapy.
– Multiple productions of the target phrases is crucial for
motor learning to occur.
– Mass blocked practice with frequent feedback may help
initially, but distributed random practice with lower
frequency of feedback will give better retention.

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– Need to work on appropriate prosody as well as correct
articulation.
– Build stimuli carefully as the child progresses (phonetic
complexity, syllable shape, # of syllables, length of
utterance).
– Carefully plan therapy time to address all needs
• May also need to address areas such as:
– Expressive language
– Receptive language
– Phonological awareness and literacy skills
– Pragmatic skills

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Connections
• Chapter 15 focuses on speech sound disorder
subtypes that are not motor-based
• Chapter 20 outlines general assessment
procedures
• Chapter 22 addresses treatment design and
implementation

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Concluding Remarks
• In children with motor speech disorders, a variety of areas
(dysarthria, apraxia, phonological delay, language delay,
intellectual impairment) may be affected, requiring a
careful diagnostic workup
• Children with motor speech disorders benefit from one-on-
one treatment
• Multiple productions of stimuli are important
• Mass blocked practice with frequent feedback is helpful
initially; distributed random practice is more effective later
on
• This chapter focused on motor speech and literacy skills.
However, expressive language, receptive language, and
pragmatic skills may also need to be addressed.

NOVA

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Chapter 18

Motor Speech Disorders in Children

Comprehensive Perspectives on Child Speech Development and Disorders 1

• The term motor speech disorders is used to denote a

Comprehensive Perspectives on Child Speech Development and Disorders 2

• Caused by some impairment in the central or

Comprehensive Perspectives on Child Speech Development and Disorders 4

Comprehensive Perspectives on Child Speech Development and Disorders 5

Comprehensive Perspectives on Child Speech Development and Disorders 6

Comprehensive Perspectives on Child Speech Development and Disorders 7

• Apraxia of speech: a problem with the ability to

• Like dysarthria, CAS can be either acquired or

Comprehensive Perspectives on Child Speech Development and Disorders 9

Comprehensive Perspectives on Child Speech Development and Disorders 10

• The presence of CAS influences the development

Comprehensive Perspectives on Child Speech Development and Disorders 11

Comprehensive Perspectives on Child Speech Development and Disorders 12

Comprehensive Perspectives on Child Speech Development and Disorders 13

Vocal tract image from:

Comprehensive Perspectives on Child Speech Development and Disorders 14

Comprehensive Perspectives on Child Speech Development and Disorders 15

• Speech errors are due to impaired sensorimotor

Comprehensive Perspectives on Child Speech Development and Disorders 16

Comprehensive Perspectives on Child Speech Development and Disorders 17

1. Inconsistent errors on consonants and vowels

Comprehensive Perspectives on Child Speech Development and Disorders 19

May I play please? (produced normally)

May I play please? (produced

• Multiple speech sound errors

Comprehensive Perspectives on Child Speech Development and Disorders 21

Comprehensive Perspectives on Child Speech Development and Disorders 22

Comprehensive Perspectives on Child Speech Development and Disorders 23

18S2 Conversational sample and single-word

18S3 Conversational sample and multisyllabic

Comprehensive Perspectives on Child Speech Development and Disorders 24

• Disturbance in temporal spatial relationship of the

Comprehensive Perspectives on Child Speech Development and Disorders 25

Comprehensive Perspectives on Child Speech Development and Disorders 26

Comprehensive Perspectives on Child Speech Development and Disorders 27

– Some children who appear to have normal language

Comprehensive Perspectives on Child Speech Development and Disorders 28

Comprehensive Perspectives on Child Speech Development and Disorders 29

• At risk for phonological awareness deficits (important

Comprehensive Perspectives on Child Speech Development and Disorders 30

Comprehensive Perspectives on Child Speech Development and Disorders 32

Comprehensive Perspectives on Child Speech Development and Disorders 33

Comprehensive Perspectives on Child Speech Development and Disorders 34

Comprehensive Perspectives on Child Speech Development and Disorders 35

Comprehensive Perspectives on Child Speech Development and Disorders 36

CR= Cluster Reduction

Comprehensive Perspectives on Child Speech Development and Disorders 37

• Keep in mind: These procedures are specifically

Comprehensive Perspectives on Child Speech Development and Disorders 39

• Observation of the physical/neuromotor status

– Reflexes, or the condition of muscles in the extremities

Comprehensive Perspectives on Child Speech Development and Disorders 40

Comprehensive Perspectives on Child Speech Development and Disorders 41

• Examine Muscle Tone

Comprehensive Perspectives on Child Speech Development and Disorders 42

• Function of each structure

Comprehensive Perspectives on Child Speech Development and Disorders 44

Comprehensive Perspectives on Child Speech Development and Disorders 45

Comprehensive Perspectives on Child Speech Development and Disorders 46