In a previous blog post on tell-tale signs of apraxia, I discussed residual signs of apraxia that I see in older children and teenagers who were never formally diagnosed with apraxia or who have graduated from speech therapy. These tell-tale signs are often due to difficulties with coarticulation and prosody and the interaction of motor speech skills with expressive language skills, especially morphosyntax. In this blog, I’ll discuss ways that you can address these skills, or if you are currently treating children with apraxia, how you can plan your goals so that the children will hopefully not display these residual signs as they get older.
Past Tense Verbs
When treating a young child with apraxia, it’s really important to do as much as we can to facilitate expressive language growth. This includes using augmentative and alternative communication (AAC) but it also includes thinking carefully about language goals and the interaction of motor speech and expressive language skills.
Typically, we see children begin to use past-tense as toddlers and preschoolers. According to Brown’s Morphemes, children begin using irregular past-tense between 31-34 months (about 2.5 years) and regular past-tense between 35-40 months (by about age 3). However, this language skill may be delayed in children with difficulties motor planning and programming speech. This could be due to a co-occurring language concern, but motor speech skills can also play a part.
Regular past-tense conjugations require some tricky coarticulation of consonants, often including unreleased plosives. In my experience working with hundreds of children with apraxia, many preschoolers with apraxia do not yet have the degree of motor speech control needed for this type of sequencing.
I still address irregular past tense, but I start with irregular verbs that typically only require a vowel change and still have a syllable shape or sequence that is within the child’s repertoire, usually a VC (e.g. eat/ate) or CVC (e.g. make/made). I try to select verbs that are highly relevant and functional in the child’s life, but that also have sounds and syllable shapes that are within the child’s repertoire. In this way, I can still address the language goal of using past-tense verbs, while also making the expression/execution of the skill in the child’s speech attainable.
Of course, if the child is using an AAC device, I will model both regular and irregular past-tense conjugations on their device.
If the child is older and/or has the motor speech skills required to produce consonant-consonant sequences, including those involving unreleased plosives, I will work on both regular and irregular past-tense verb conjugations, usually picking a couple of verbs at a time to address and practice, following the principles of motor learning.
Plural Nouns
According to Brown’s Morphemes, children begin using plurals between 27-30 months (by the time they are 2.5). Obviously any child at this age will be using a number of phonological patterns and sound substitutions or approximations. For children with apraxia, we may see the language/morphological skill delayed, at least in part to increased difficulty producing and sequencing sounds accurately in speech.
If we think about what is required to mark a noun as plural, we typically just think “add an “s””. However, if we think about the actual phoneme sequencing and motor plans involved, we realize it is a bit more complicated. Of course making a noun plural involves adding an “s” on to the noun, which may be pronounced as /s/ or /z/, depending on the final phoneme in the noun. 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, for “giraffe,” “s” is pronounced as /s/ in “giraffes.” However, for many words that end in /f/ we actually produce the voiced cognate /v/ and add /z/, as in “wolves.” If the final consonant is a continuant sound, such as /s,z, ʃ, tʃ, dʒ/, then the vowel /ɪ/ will be added prior to the “s” and is actually said as /z/, as in “buses” or “beaches” Making a plural of a noun that ends in a vowel means adding the /z/ sound, as in “cows.”
The motor skills needed becomes more challenging for nouns that end in plosives. For these words, the plosive will become unreleased, and whether or not /s/ or /z/ is produced will depend on whether the plosive is voiced or unvoiced. For example, “cups” and “cats” are produced with an unreleased plosive followed by /s/, while “crabs” and “dads” are produced with an unreleased plosive followed by /z/. The same is true for velar consonants, although these are arguably even more complex, since the unreleased plosives are less visible and also require posterior to anterior movement, as when saying “bugs” or “trucks.”
If the child is not yet able to produce consonant-consonant sequences, I typically start by picking nouns that end with vowels, such as cow-cows, to work on this language skill in a way that is achievable for the child. If the child is able to produce continuant sounds, I will also select nouns ending with those sounds as long as the child is also able to produce the CVCVC syllable shape that will be required for the plural. For example, “buses” or “beaches.” Of course, I also do my best to select words that are within the child’s expressive vocabulary and are functional in their everyday life, to maximize generalization.
Subject-Verb Agreement for Third Person Singular
According to Brown’s Morphemes, the use of third-person singular develops by 40 months, roughly between 3 and 3.5 years of age. Similar to using the plural form of nouns, the actual verb conjugation produced will depend on the final phoneme of the verb being conjugated.
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 most 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.
To start targeting the language skill of third person singular for a child who may not be able to produce the more involved consonant sequencing required for many verbs, I consider irregular verbs or verbs that end in vowels so that the syllable shape is a CVC instead of a CVCC. For example, have/has or go/goes. I also think carefully about what phonemes are within the child’s repertoire, and try to select sequences that the child can produce, if possible.
Summary
When we are treating children with childhood apraxia of speech or a history of apraxia, we have to consider the intersection and overlap of expressive language and speech skills. This means that when we are selecting language goals and targets, we must carefully consider the motor skill and sequencing/coarticulation skills required to express the language in speech. Overall, it's all about working on the expressive language skill, but in a way that is within the child's motoric ability. Consider the language goal, the sequencing required, and the vocabulary/word choice, to find goals and targets that are achievable for the child at that time.
