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Apraxia Case Study

Vol. 16 •Issue 12 • Page 13
Apraxia Case Study

Increasing speech intelligibility and phonemic awareness skills

Phonemic awareness activities can be incorporated into therapy for children with developmental apraxia or other moderate to severe articulation disorders or delays who may be at particular risk for reading difficulties.

Even if their receptive language skills are within normal limits, children with moderate or severe phonological disorder or delay are at risk for deficits in phonological awareness, some research has shown.1,2 Gail Gillon, PhD, developed a strong interest in phonological awareness intervention because she witnessed the written language difficulties that many children with speech and language impairment encounter.3 She frequently observed the struggle of many of them learning to read.

Like Dr. Gillon, we have noticed that children we treated for speech impairment at 4 or 5 years of age later reappear due to reading difficulty. Children with a history of speech-language impairment are four to five times more likely to have reading difficulty than children from the general population.4

We successfully used speech therapy that included a combination of therapy approaches with a preschool-age child diagnosed with developmental apraxia. The child previously had received services through early intervention, the public school system, and the Valdosta State University (VSU) Speech and Hearing Clinic in Valdosta, GA.

During the fall of 2003, a preschool teacher was considering recommending that the child be retained in preschool due to poor speech intelligibility and the impact the severe speech impairment might have on her ability to learn to read. In an effort to increase the child's speech intelligibility and prevent future difficulties with reading, a combination of a phonological approach, a traditional approach and phonemic awareness intervention was utilized.

The sequence of articulation treatment targets used was very similar to the one outlined in Easy Does It® for Apraxia-Preschool (LinguiSystems, 1994), by Robin Strode and Catherine Chamberlain. Therapy progressed from having the child be able to consistently produce vowels, vowel sequences and isolated consonants to syllables and words. Real words (rather than nonsense words) were utilized in therapy as much as possible.

A phonological approach was used to target multisyllabic words. Auditory bombardment lists containing the error sounds/patterns were sent home for the parents to read to the child on a daily basis. Phonemic awareness was targeted through the discrimination of rhyming words, letter identification tasks, labeling of letters, written words displayed when practicing articulation, and isolated phoneme practice accompanied by the graphemes.

Beginning in the fall of 2003, the child received 30 minutes of therapy four times weekly at VSU and two times through the public school. The VSU supervisor and graduate clinician met with the public school speech-language pathologist to coordinate services.

The Goldman Fristoe Test of Articulation (GFTA)-2, administered in March of 2004, resulted in 38 errors (third percentile) as compared with 59 errors (first percentile) when the test was administered in June of 2003. A comparison of the child's performance on the Kaufman Speech Praxis test for Children-Part 2 (simple phonemic/syllabic level), standard score (disordered), was 45 in 2003 and 91 in 2004.

In addition, the child's conversational speech was judged to be highly unintelligible (no formal measure) in June of 2003. By November of 2004, a speech intelligibility index calculated from a taped speech sample was judged to be 81 percent intelligible to an untrained listener.

The speech-language pathologist who worked with the child in the public schools was amazed with the progress. Immediate family members and relatives made comments regarding the dramatic improvement in her speech intelligibility.

The child entered kindergarten in the fall of 2004. In January of 2005, the Phonological Awareness Literacy Screening (PALS-K) was administered to evaluate her phonemic awareness skills. The results for Section 1 were nine of 10 for Group Rhyme Awareness (Part A) and 10 of 10 for Group Beginning Sound Awareness (Part B), Individual Rhyme Awareness (Part C), and Individual Beginning Sound Awareness (Part D). In Alphabet Knowledge under Section II, Lower Case Alphabet Recognition was 26/26.

The results for Section III, on Letter-Sound Knowledge, were 19/26 for Letter Sounds and 18/20 for Spelling. The scores for Section IV, the Concept of Word, were four for Pointing (benchmark two), six for Word ID (benchmark two), six for COW Word List (benchmark zero), and 16/22 for the COW total score. The child scored 11/20 in the optional Word Recognition in Isolation, identifying several words as class "word wall" words. The summed score was 89. (Note: The spring benchmark for summed score is 81; the client's summed score was above the benchmark!)

This child seemed to benefit greatly from the incorporation of the graphemes and words into articulation therapy, both in her phonological awareness skills and her articulation. Dr. Gillon found that the inclusion of phonological awareness activities into therapy sessions didn't detract from a child making gains in speech articulation. She suggested that phonological awareness and knowledge of how speech and print are related may help establish more fully specified underlying phonological representations and thus may facilitate accurate speech production.5

The effects of her study suggest that intervention for phonological awareness and speech production can result in improvement in the two skills concurrently. Dr. Gillon's data strongly supported the hypothesis that the inclusion of activities to facilitate phoneme awareness and letter knowledge for young children with speech impairment would result in successful early reading and spelling experiences.

Other children may benefit from the combination of therapy approaches used in this case study. Further controlled research studies need to be conducted to determine whether this combination is effective with large numbers of children.


1. Bird, J., Bishop, D.V.M., Freeman, N.H. (1995). Phonological awareness and literacy development in children with expressive phonological impairments. Journal of Speech and Hearing Research, 38: 446-62.

2. Rvachew, S., Ohberg, A., Grawburg, M., Heyding, J. (2003). Phonological awareness and phonemic perception in 4-year-old children with delayed expressive phonology skills. Language, Speech, and Hearing Services in Schools, 12: 463-71.

3. Gillon, G. (2000). The efficacy of phonological awareness intervention for children with spoken language impairment. Language, Speech, and Hearing Services in Schools, 31: 126-41.

4. Catts, H., Fey, M., Zhang, X., Tomblin, B. (2001). Estimating the risk of future reading difficulties in kindergarten children: A research-based model and its clinical implementation. Language, Speech, and Hearing Services in Schools, 32: 38-50.

5. Gillon, G. (2005). Facilitating phoneme awareness development in 3- and 4-year-old children with speech impairment. Language, Speech, and Hearing Services in Schools, 36: 308-22.

Lila Carson and Tanya Enloe are assistant professors and clinical supervisors in the Department of Special Education and Communication Disorders at Valdosta State University. Carson can be contacted at (229) 219-1306 or, and Enloe can be contacted at (229) 259-2595 or Cook and Cannon are graduates of the university. Cook now works at Upson Lee South Elementary School, in Thomaston, GA; and Cannon is on staff at Archbold Medical Center in Thomasville, GA. Lindsey Guobaitis and Andrea Boutwell are graduate students at VSU.


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