By Breanna Waldrup, MS, CCC-SLP
I am regularly asked to evaluate children who are in upper elementary or middle school who have been dismissed from speech therapy, but their parents still report concerns with their speech. Sometimes these are children who were diagnosed with childhood apraxia of speech (CAS) when they were younger and other times the families say that the speech-language pathologist (SLP) mentioned or suspected CAS but they were not formally diagnosed. In a couple of cases, the families have told me that one SLP had said their child had CAS, while another SLP said they did not. In other cases, families have reported that their child’s speech is intelligible, but they sound like they have “an accent” meaning that the child’s speech doesn’t completely fit with Standard American English or the American accent.
In these cases, a thorough motor speech evaluation is warranted, assessing for characteristics of CAS across a variety of speech tasks including multisyllabic words, token-to-token inconsistency, diadochokinesis, and a dynamic motor speech exam at a level appropriate for the individual’s age. During these evaluations, I feel like a detective, looking for tell-tale signs of difficulty motor planning and programming for speech, even though the child may no longer display enough characteristics of CAS to warrant the formal diagnosis. Over the course of my 14 years as an expert in apraxia, there are a few features in an individual’s speech that are not characteristics of apraxia per se, but are a result of disruptions to coarticulation and prosody, which are two of the major features of CAS (ASHA, 2007).
1. Omitting “ed” in Regular Past-Tense Verbs
One issue that I’ve seen regularly in these cases is an inconsistent or lack of using “ed” to mark regular past-tense, even though the individual understands regular past tense and will use irregular past-tense verbs. Often this comes down to difficulties with coarticulating multiple consonants, especially those that involve unreleased plosives. It’s important in these cases to make note of the sequencing patterns that the individual is or isn’t using, so making note of the verbs in which they do or do not mark past-tense to see if there is a pattern.
The way that we pronounce “ed” varies, depending on the final sound of the verb. If the final sound is a voiceless continuant consonant, then the “ed” is pronounced as a /t/, as in “kissed.” However, if the final voiceless sound is a stop, then the stop is unreleased as in “hopped.” Producing an unreleased stop may require altering the motor plan that the individual learned for /p/, if they always release it by opening their lips.
Sometimes I have seen that an individual can produce the coarticulation required for an unreleased bilabial stop, as in “hopped,” but not for an unreleased velar stop, such as “picked.” In the case of “picked,” the movement to produce the unreleased plosive is not as visible, and is motorically more difficult than an unreleased bilabial plosive, in my experience.
If the final sound in a verb is a voiced sound, we pronounce the “ed” as “d” as in “buzzed.” If the final voiced sound is a stop, then the stop is unreleased as in “rubbed” or “hugged.” Similar to the coarticulation mentioned above for the voiceless cognates, the motor plans for the stops have to be tweaked, which can be difficult for individuals with a history of apraxia. Moreover, avoiding the use of an intrusive schwa either between the two voiced stops (e.g. “rub-bed”) or after the /d/ (e.g. “rub-duh”) can also be challenging.
If the final sound in a verb is a /t/ or /d/, then the “ed” is pronounced as “id” as in “petted” or “shredded.” This is probably the easiest regular past-tense to coarticulate, since the sequence is CVCVC, rather than involving a CC cluster or sequence.
2. Difficulty with Subject-Verb Agreement for Third Person Singular
Similarly to using regular past-tense verbs, children with apraxia or a history of apraxia may understand the language concept for subject-verb agreement for third person singular in the present tense, but fail to demonstrate this skill in their spoken language. If we think about what is required for third person singular, it often involves adding an “s” on to the verb, which may be pronounced as /s/ or /z/, depending on the final phoneme in the verb. Due to coarticulation, if the final phoneme is a voiceless sound, the “s” is pronounced /s/; if it’s a voiced phoneme, the “s” is pronounced /z/. For example, in “she sits in the chair,” “s” is pronounced as /s/, but in “He goes there” or “She hugs it” the “s” is pronounced as a /z/. If the final consonant is a /s/ or /z/, then the vowel /ɪ/ will be added prior to the “s” as in “she kisses the baby” or “the flies buzzes around the food.” So, adding “s” to the verb for subject-verb agreement for third person singular actually requires a different motor plan, depending on the final phoneme in the verb.
In addition to learning multiple different motor plans depending on the final phoneme in the verb, for verbs that end in consonants, adding the “s” means producing a consonant-consonant cluster or sequence that may be motorically difficult. In particular, sequences that involve plosives mean that the plosive will probably be unreleased, requiring a change to the motor plan that the child may have learned for conjugations for personal pronouns.
3. Failing to Use an Alveolar Tap/Flap
This is a big one and probably the most-frequent tell-tale sign I have seen that a child has a history of difficulty motor planning and programming, if the child has been raised in an environment where they have primarily heard the American accent. In the American accent, /t/ that occurs in unstressed syllables between vowels, in both words and across word-boundaries, are frequently produced as an allophonic variation of /t/, the alveolar tap or flap /ɾ/. This is the sound that is often produced in words such as “water” and phrases like “put it on.” It is a faster movement and is voiced, as it is typically occurring between vowels.
Production of an alveolar tap/flap is often challenging for children with apraxia. If this coarticulatory pattern is not taught in therapy and rehearsed to automaticity, many children with apraxia or a history of apraxia will use /t/ instead. This can sometimes result in their speech sounding more formal or for people to question if they have a British accent, since in many British accents, the /t/ is not coarticulated as an alveolar tap/flap. Sometimes the use of /t/ emerges more as the child begins reading and is sounding out words. For many children with apraxia, their motor speech system is not flexible enough to switch between using the alveolar tap/flap in spoken speech then switching to /t/ when reading aloud and sounding out words.
4. Using Long Vowels in Articles
A major feature of vowel coarticulation in Standard American English is neutralization of vowels in unstressed syllables, particularly neutralization to the schwa. The articles ‘a, “an,” and “the” are typically not stressed in connected speech, and we neutralize the long vowels to a schwa to pronounce the articles as “uh,” “un” and “thuh,” respectively. When learning to read, children are often taught that vowels at the end of syllables (open syllables) say their long sound, so they are taught to read “a” as /e/ or /eɪ/ and “the” as /ði/. Most of us do not use the long vowels in articles in connected speech unless we are stressing the article for some reason. If we hear a child using long vowels in articles in connected speech, it may be an indicator of inefficiencies motor planning and programming, in which their motor speech system is not flexible enough to vary the motor plans between reading aloud and spontaneous speech.
5. Never Using a Glottal Stop
In Standard American English, young children use a /t/ when followed by a syllabic /n/, such as in “button.” However, many older children and adults transition to using a glottal stop /ʔ/, at least some of the time. A child with a history of apraxia may not make this change on their own, as they do not have the flexibility to learn a new movement gesture without direct instruction and practice.
Summary
The next time that you hear a child’s speech that isn’t quite right or sounds slightly accented, pay attention to what you are hearing that is different and look for patterns regarding the use of regular past-tense, third-person singular verb agreement, vowels in articles, and allophonic variations of /t/, including the alveolar tap/flap and glottal stop. It may be that the child has a history of apraxia and will need direct instruction and practice using the principles of motor learning in order to make these changes to their speech.
Stay tuned for next month’s blog in which I’ll discuss how to incorporate strategies for these speech differences when you are treating children with apraxia, so that they do not become residual issues!
