There is a question that arose in a seminar recently that I want to share.

I was teaching on apraxia, and using the 23 methods of jaw, lip, and tongue facilitation as the main focus of the class. The question was about a three-year-old boy who had no other consonants but /d/. He was speaking single words of 1-3 syllables, but his productions were limited to CV structure. Thus, telephone would be produced as “deh-duh-doh.” The question the therapist had was, “What should I do with him?” I have worked with many such children, so let me use this opportunity to give my answers.

First, the main point of this class was to demonstrate that there is no one way to facilitate new phonemes, that each therapist approaches this his or her own way, and that the historic articulation and motor speech literature points to at least 23 main ways. A child with a severe speech delay or disorder, including apraxia, needs to learn many phonemes. This child needs to learn almost all the consonants. Any one or all of the 23 ways could be used to teach him any number of consonant phonemes. Here are our 23 ways with notes about what you might do with this child:

• Assist – e.g., press his lips together to get him to say /b/ instead of /d/.
• Associate – e.g., use his /d/ to teach him to say /t/ by teaching him how to turn off his voice.
• Contrast – e.g., help him understand that he is sending sound out the mouth for /d/, and help him learn to send sound out the nose for /n/.
• Cue – e.g., use a cue to teach him another feature (say, stridency), and help him learn to produce stridency to say /s/ or /ʃ/ or /tʃ/.
• Describe – e.g., use descriptions he can understand to try new phonemes
• Develop Sensory Awareness &Amp; Discrimination – e.g., help him wake up his mouth to learn other sounds by sucking on ice cubes or by brushing his tongue or lips.
• Direct – e.g., point to the back of the tongue moving upward to help him learn to lift the back for /k/ or /g/.
• Dissociate – e.g., help him learn to move his tongue independently from his jaw so that it moves more independently for other phoneme productions.
• Exaggerate – e.g., super-exaggerate your production of /p/ to see if he can imitate it.
• Increase/Decrease Muscle Tone – e.g., perhaps that child has very few phonemes because his overall oral tone is too low. Help him increase it.
• Increase Range of Motion – e.g., perhaps this client had /d/ only because he doesn’t move the tongue or lips to their full range. Teach him gross oral movements.
• Inhibit – e.g., perhaps this child cannot move the back of the tongue for /k/ or /g/ because the tongue-tip does all the moving. Hold the tip down and see if that stimulates him to move the back.
• Maintain Positions – e.g., if he can press his lips together to blow through a straw, have him maintain lip closure on the straw to become aware of lip closure. Then use that movement to teach him /p/, /b/, /m/, or /w/.
• Mark the Target – e.g., have him put lipgloss on his lips to learn bi-labial contact for /p/, /b/, or /m/.
• Model – show him how to make other sounds. Use your mouth, hands, pictures, and other 3-D models.
• Normalize Tactile Sensitivity – maybe this child does not make any other sounds because it is uncomfortable for him to do so. Help him normalize his oral-tactile sensitivity so he can explore with more oral movement.
• Practice – have him practice any new sounds that happen to come along, whether taught or spontaneous. Drill them, rehearse them.
• Resist – use resistance to get the lips and tongue to move more for more phonemes. E.g., press downward on the lower lip to get it to elevate to the top lip for the bi-labials.
• Speed up / Slow Down – maybe this child cannot process your models. Slow your models so the client has more time to hear and see what you are producing.
• Stabilize – Maybe the jaw is unstable, and only /d/ is used as a result. Stabilize the jaw to force more variety of lip and tongue movement.
• Stimulate Reflexes – Consider using the oral reflexes to stimulate new movement. For example, stimulate the cough reflex to encourage back sounds /k/ and /g/.
• Vivify – The client may not produce many consonants because the oral mechanism simply has not learned to move enough in gross ways. Have the client move in any and all ways to cause new phonemes to emerge by chance. Van Riper said that any new movement was a step in the right direction.

Second, I would not limit my choice of phonemes to teach one at a time. Instead, I would target all consonants because we never know which ones a client will be stimulable for. I would stimulate him for all the glides, all the nasals, all the stops, and all the fricatives and affricates. I would use the 23 methods to determine which ones he was ready to produce, and I would put special stress on those that he seemed ready to assimilate. I would find at least one word to practice that contains each of the target phonemes. Thus I might use the following words:

• Stops – up, boo, eat, dada, cookie, go
• Glides – one, la-la, you, car
• Nasals – me, no, sing
• Fricatives/Affricates – thumb, that, off, vee, bus, zoo, sh!, ouch, jump, hot

Third, I would not expect phoneme perfection for a long time. I would expect the client to produce gross forms of each phoneme, and I would expect his pronunciation to get better and better over time.

Fourth, I would expect words to take a long time to perfect. So, for example, telephone might go from “deh-duh-doh” to “deh-wuh-boh” to “deh-weh-pone”, and so forth. I would help parents and teachers understand how these words are getting better even though they are not correct yet. In class we talked about basic ways to do this with charts and cards.

Fifth, children with apraxia do not change quickly because they do not imitate well. Even though they say some words and sounds, they do not know how to engage in what Piaget called “spontaneous imitation of new repertoire.” As a result, they do not know how to watch and listen to another person, and to abstract what they need to learn new phonemes. The child in question is not spontaneously imitating new repertoire sounds. We know this because when his therapist presents words with correct pronunciation for him to imitate, he cannot do it. He cannot adjust what he says to match what she says. He is wearing a sign that says, “I do not know how to imitate new sounds on demand in turn.” Therapy therefore should be directed toward teaching him how to imitate in the turn-taking process. We do this by spending considerable time imitating him (mutual imitation), and by getting him to say the words he can say. We reward him for saying his words just the way he says them. In this way, the client will begin to pay attention to the relationship between what he is saying and what you are saying. This is the beginning of true imitation, and true imitation will carry him forward to learn any and all phonemes.

Finally, in the long run we are not teaching phonemes, per se. Instead we are teaching the client HOW to learn new phonemes. We teach a client HOW to learn new phonemes when we use the 23 fundamental methods to teach new phonemes, and when we develop the child’s imitative skills.