Q: My client is 7;0 and is being denied SL services because he has cognitive impairment and apraxia. The insurance company is saying that there is no evidence to demonstrate that he will improve because of his cognitive problems. Will he improve? Is there supportive research on this? Have you seen these kids improve?

Children or adults with cognitive impairment bring unique challenges to the work of speech-language pathology. When reviewing the research in this area recently I found very little to support therapy and all of it was very old. (This was a popular area of interest in the 1970s but since then not so much.)

But we do have tons of research on normal development, and this info can serve as our guide. Children with cognitive impairment often are stuck with the phonological skills of a toddler. Therefore the more we understand the phonology of the child UNDER three years of age, the better we know how to design therapy for the client with significant cognitive impairment.

What is the purpose of therapy when a client cannot be totally fixed? The purpose of therapy is to help the client become as good as he can become. He will do that with therapy; he may not do it without therapy.

Treatment Suggestions

The following advice is from my next book, The Marshalla Guide. I hope it helps you think through this issue with your client.

1. Research demonstrates that first words emerge as “protowords.” Protowords are attempts at real words that do not have enough adult-like phonology to be assured that the child actually was trying to say the actual word. This suggests that SLPs should accept whatever production a client makes for a word at first. For example, reward him for saying “grandma” as “noo-noo.” Let him use this as his word for grandma as long as necessary for him.
2. Research reveals that typically developing children try to say first words as whole words rather than as parts. Therefore it may not help the client with cognitive impairment to learn words phoneme-by-phoneme or syllable-by-syllable as we do with apraxic and other children. It may be better to focus on saying the whole word better with the right number of syllables before trying to correct any of the consonants.
3. Research indicates that producing words with missing syllables is one way that very young children allow themselves to make holistic starts of new words. Allow clients to drop syllables if that encourages them to say new words.
4. Research reveals that the CV is the syllable shape that dominates first words in normal development. Therefore stop focusing so much on final consonants and focus more on CVs. It is more important that the child say “ma” than “mom.”
5. Research reveals that first words generally are made with correct vowels and incorrect consonants. Teaching vowels may be more important to improving intelligibility in children with cognitive impairment.
6. Research demonstrates that labial consonants dominate the CV syllables of early words. Research also demonstrates that big up-and-down jaw movements are what make these early consonants emerge. Focus getting the jaw to move up and down to stimulate early anterior consonants in CV syllables.
7. Research has shown that reduplication of syllables is one of the most common patterns noted in the early words productions of typical children. New words can be taught in reduplicated patterns in order to establish them, and they can be improved upon later. For example, butter can be taught as /buhbuh/ to start.
8. Research demonstrates that children acquire manner before place of articulation. A client who is still learning his first 50-100 words should be allowed and encouraged to make this same type of error.
9. Consonant deletion also is very common in early word acquisition in young children. Practicing words with deleted consonants is another strategy one can employ to help these clients produce words at their cognitive skill level but beyond their phonological capacity.
10. Tailor therapy toward the client’s existing phonological skill set. Work on generalizing the phonemes he already has acquired instead of perpetually trying to get him to produce new phonemes.
11. Throw out the developmental norms and use stimulability as your means of determining what to work on. The developmental norms are based on normal or typical development, and these clients do not fall within that category.
12. Keep expressive verbal performance alive through the years by making the client “Say it” and “Show it” when he is using an augmentative communication device. Do this no matter how poor his verbal productions are.
13. Teach phonemes through multisensory stimulation. It will not be enough to tell the client to “Say ” The client may need cues, tactile input, and other instruction methods.
14. Employ real words. Cognitive input may be more important than motor input for the client with cognitive dysfunction. Therefore the client may perform better if real words are used to teach phonemes instead of babbling sequences. Babbling is speech motor practice. Real words present concepts the client needs.