Q: I am working with an 8-year-old client with severe apraxia who only can produce vowels, M and B. I have tried all the strategies in beginning of your book called Apraxia Uncovered. But this has also not yielded much. Do you have any hints for how to physically prompt other consonants? This child has severe cognitive dysfunction, too.

The reason that the information in Apraxia Uncovered was not of much help to you is because although your client may be apraxic, that is not his big problem. Your client’s big problem is that he has good old-fashioned mental retardation.  I realize that this is a politically incorrect term, but I am going to use it anyway.

The big question in regard to this client is about how severely limited his cognitive skills actually are.  Determining his cognitive level will go a long way toward helping you understand what to expect from him.  We used to divide kids into cognitive levels.  Putting politically correctness aside, this is how we used to think––

• If the client is in the range we used to call “Profound,” he may never speak in his lifetime.  Teach him to say any words he can in any way he can.

• If “Severe,” he may speak only 1-10 words in his lifetime. Teach him to speak each word the best way he can in very simply phonological patterns.  For example, teach him to say “Buh” for “banana.”

• If “Trainable,” he may speak up a few hundred words, and he probably will use “pre-sentences” with significant syntactic errors.  Teach him to acquire as many of the distinctive features that he can, and teach him to make words in simple phonological patterns.  For example, teach him to say the word “please” as “pea” or “peash” or “peach” or “peath” or “bea” or whatever he can do.

• If “Educable” he will learn hundreds of words and be able to do 1st grade reading and math.  He could work in a classic cycles approach to phonology. All the methods listed below should help him.

In terms of rolling up your sleeves and teaching a client to produce specific phonemes, there are many ways to do this.  I have written an article that summarizes the main techniques SLPs have used throughout our history.  See: “Oral motor treatment vs. non-speech oral motor exercises” online at the Oral Motor Institute.  The methods described in that article include:

• Assist
• Associate
• Contrast
• Cue
• Describe
• Develop sensory awareness & discrimination
• Direct
• Dissociate
• Exaggerate
• Increase/decrease muscle tone
• Increase range of motion
• Inhibit
• Maintain positions
• Mark the target
• Model
• Normalize tactile sensitivity
• Practice
• Resist
• Speed up / Slow down
• Stabilize
• Stimulate reflexes
• Vivify