Intervention in apraxia

Child Language Teaching and Therapy
27(1) 9–20
© The Author(s) 2011
Reprints and permission: sagepub.
co.uk/journalsPermissions.nav
DOI: 10.1177/0265659010369985
clt.sagepub.com
Intervention for childhood apraxia
of speech: A single-case study
Anna-Leena Martikainen
University of Oulu, Finland
Pirjo Korpilahti
University of Turku, Finland
Abstract
The underlying nature and diagnosis of childhood apraxia of speech (CAS) still requires clarification.
However, the label ‘CAS’ or ‘suspected CAS’ continues to be assigned to a group of children with
speech problems, and speech and language therapists need to be aware of effective treatment for
these children. The aim of this study was to assess the effectiveness of the combination of two
motor intervention methods, Melodic Intonation Therapy (MIT) and the Touch-Cue Method (TCM),
on a child with CAS. SS, a girl aged 4 years and 7 months (4;7) whose speech characteristics fulfilled
the criteria of CAS received a 6-week treatment with MIT, and following a 6-week treatment-free
period, a 6-week treatment period with TCM. Speech sound errors decreased and sequencing
abilities increased significantly after the MIT period, and the positive progression continued during
the TCM period. SS made substantial gains in producing whole words correctly during the TCM
block. Improvement was maintained during the 12-week follow-up. Our findings suggest that the
combination of MIT and TCM was an effective way to address the child under study.
Keywords
childhood apraxia of speech, single-case study, intervention, melodic intonation therapy, speech
disorders, touch-cue method
I Introduction
The definition of childhood apraxia of speech (CAS) is controversial, because there are no diagnostic
markers that differentiate CAS from other speech acquisition disorders (Ozanne, 2005; ASHA,
2007). However, researchers and clinicians have generally agreed on the most typical behavioural
characteristics of CAS, including a large number of inconsistent phonemic speech errors, difficulties
Corresponding author
Anna-Leena Martikainen, Torikatu 9 A, 80100 Joensuu, Finland
Email: anna-leena.martikainen@puheterapeutti.fi

10 Child LanguageTeaching andTherapy 27(1)
in sequencing speech movements, an increase in errors when length or complexity of an utterance
increases, groping and suprasegmental differences (e.g. Davis et al., 1998; ASHA, 2007).
There has been a longstanding debate over the theoretical frameworks of CAS. It is proposed
to be a result of either an impaired representation of phonological constructs or access to such
representations (Marquardt et al., 2002), or impairment in perceptuomotor control and learning
(Maassen et al., 2003). Some investigators emphasize the multi-systemic nature of CAS (Crary,
1993: 59–61; Ozanne, 2005), while others have suggested it to be a disorder of hierarchical organization
(Velleman and Strand, 1994).
Furthermore, several models for CAS assume that the causal factor is found somewhere at the
level of motor planning and/or motor programming of speech movement sequences (e.g. Caruso
and Strand, 1999; ASHA, 2007). During motor planning, the spatial and temporal specifications of
articulatory movements needed for sound production are recalled from the sensorimotor memory
and adapted to the context of the planned unit. A formed phonetic plan is implemented at the motor
programming level where the muscle-specific ‘instructions’for speech movements are specified in
terms of muscle tone and rate, direction and range of movements (Caruso and Strand, 1999).
The hypothesis that the underlying deficit of CAS lies in an impairment of planning of speech
movement is supported by Bradford and Dodd (1996), who noticed that the children with CAS have
difficulties in learning to produce new words. The authors concluded that this indicates problems at
the level of motor planning, because the phonological representation of words was well defined and
articulatory skills for the needed phonemes were adequate. More recently, children with CAS have
been noted to have problems with varying systemic duration of segments when syllable structure is
manipulated without changing phoneme sequences (e.g. ice cream vs. I scream; Nijland et al. 2003b).
Nijland et al. (2003b) interpreted the results as evidence of a problem in the planning of syllables in
speech production.
The inferiority of motor programming is proposed to be supported by the observation that children
with CAS have a slow speaking rate and high variability in repeated productions (Maassen et al.,
2001; Nijland et al., 2003b). Nijland et al. (2003a) drew the same conclusion from a bite-block study
in which bite-block condition had significant effects on coarticulatory patterns and vowel quality in
the speech of children with CAS. The lexical stress deficit in CAS is suggested to be a result of speech
praxis deficit at either the motor planning or programming stage (Shriberg et al., 2003).
Treatment of CAS
There is a critical need for intervention studies in CAS, because no specific treatment has been found
to be superiorly effective (Morgan and Vogel, 2006; ASHA, 2007). On a broad level, the treatments
can be grouped into linguistic and motor-based therapies. The former ones include the Multifocal
Intervention Programme (Crary, 1993: 223–29) and Integration PhonologicalAwareness Intervention
(Moriarty and Gillon, 2006), both of which contain linguistic elements to improve awareness of the
phonological components of a word in addition to motor rehearsal. In motor-based approaches,
children with CAS are believed to benefit from producing combinations of sound, although an isolated
phoneme might also be needed to train sometimes. In addition, tactile-kinaesthetic, melodic and
rhythmic facilitation and gestural cueing are often mentioned as means to exploit in training. The
motor-based methods include, for example, Dynamic Temporal and Tactile Cueing treatment method
(DTTC; Strand et al., 2006), the Prompt System (Chumpelik, 1984), and the methods trialled in this
study, Melodic Intonation Therapy (MIT; Helfrich-Miller, 1984, 1994) and the Touch-Cue Method
(TCM; Bashir et al., 1984).

Martikainen and Korpilahti 11
Melodic Intonation Therapy (MIT) was developed at the beginning of the 1970s for adult aphasic
patients with at least fair language comprehension but markedly restricted output (Albert et al., 1973).
Ten years later Helfrich-Miller (1984) introduced an adapted MIT method for children with CAS.
The object of MIT is to sequence sounds and words taking advantage of the prosodic elements of
speech: melodic line, tempo, rhythm and stress. The verbal output is supported by intoning utterances;
in song-like speech the tempo of phrases is slower than in normal speech, the range of pitch variation
is reduced, and rhythm and stress are exaggerated.
Helfrich-Miller (1994) has reported three case studies of using MIT with children with CAS. The
participants (aged 2;9, 2;10 and 8;0 years) had multiple errors and omissions of consonants. Two of
them were reported to have problems in sequencing consonants, and the consonant repertoire of the
youngest one was so limited that determination of sequencing problems could not be made. Substantial
gains in articulation and sequencing abilities were found at the conclusion of MIT.
In the Touch-Cue Method (TCM), which was introduced in the early 1980s (Bashir et al., 1984),
the sequencing of speech sounds is supported by giving touch cues on the child’s face and neck.
TCM consists of three stages, each of which includes a series of hierarchically arranged steps. The
first stage focuses on drills of nonsense syllables. In the second stage, mono- and polysyllabic
nonsense sequences and real words are formulated from the previously learned articulatory move-
ments. The last stage incorporates the practice of the learned sequencing skills, first in multiword
utterances and then in spontaneous speech. As far as we know, there are no earlier research data on
the efficacy of TCM.
Because it is proposed that children with CAS have problems in planning syllables (Nijland et al.,
2003b) and/or programming speech movements (Nijland et al., 2003a), it can be speculated that effec-
tive treatment of CAS should be focused on these elements. The purpose of this study was to assess
the effectiveness of the combination of two motor therapy methods, MIT and TCM, for a child with
CAS. In particular, the study examined the effect of MIT and TCM on speech sound production and
sequencing abilities.
MIT was selected as the first therapy method because it is supposed to support articulation of both
consonants and vowels as well as their sequencing (Helfrich-Miller, 1994). It is currently not known
which aspects of MIT have facilitative effects on speech production. It can, however, be supposed that
the lengthening of speech gestures – i.e. using a slower rate of speech – may heighten sensory feedback
during articulation and also provide necessary time for motor planning and programming (Wambaugh
and Martinez, 2000). From a psychological point of view, MIT might also be an appropriate technique
to start with a child who has severe speech disorder and extreme difficulty and reluctance to practise
at segmental level. TCM was used after MIT to support sequencing skills of phonemes and increase
the child’s awareness of speech production. During TCM the rate of speech is slower than normal,
which may facilitate the processing of tactile, kinaesthetic and auditory feedback from speech produc-
tion. Moreover, touch cues provide additional cues about positioning and movements of articulators,
facilitating the production of speech elements and proceeding from one element to another.
Furthermore, as we assume that CAS involves motor processing impairment it can be supposed
that practice should comprise motor learning principles known to be effective in the acquisition of
motor skills (see Magill, 2004). First, training sessions should be carried out frequently enough to
enable repetitive practice. Second, to improve movement accuracy and to allow sufficient mass
practice (i.e. repetition of a small stimulus set) it is necessary that the same material is repeated several
times before moving on. On the other hand, an adequate number of stimuli are needed to improve
motor learning.Third, the temporal relationship between the therapist’s model and the child’s response
as well as number of cues should be varied.

II Method
1 Participant selection procedure
Initial selection of a participant was determined by clinical diagnosis of suspected CAS by the child’s
speech and language therapist. After that the child’s speech production and oral motor abilities were
evaluated further. For the diagnosis of CAS the child was required to fulfil at least 8 of the following
11 speech and non-speech characteristics (Thoonen et al., 1997; Davis et al., 1998):
1. limited consonant and vowel repertoire;
2. frequent omission errors;
3. high incidence of vowel errors;
4. inconsistent articulation errors;
5. altered suprasegmental errors;
6. increased errors in longer units of speech output;
7. significant difficulty imitating words and phrases;
8. predominant use of simple syllable shapes;
9. impaired volitional oral movements;
10. reduced expressive compared to receptive language skills; and
11. incorrectness in producing multisyllabic sequences.
Additional inclusion criteria were:
•• no structural problems in the speech organs;
•• no signs of dysarthric symptoms;
•• at least average nonverbal intelligence; and
•• no hearing problems.
For speech and oromotor assessment the following informal tasks were administered: spontaneous
speech during play, picture naming, repetitive imitation of words and short sentences, oral motor
and diadochokinetic task (Thoonen et al., 1997). Evaluation was performed by the first author.
2 Participant
At the beginning of the study, SS was 4;7 years old. She had a normal birth and medical history. She
produced her first words at the age of 12 months, but they disappeared for a period of 6 months.
Speech development speeded up at 36 months, when word-joining also appeared. Several of SS’s
family members and relatives had speech and/or language disorders, but none of them had the diag-
nosis of CAS. At age 3;5 years, SS was referred for assessment by a speech and language therapist.
The referral came from a child welfare clinic.At that age SS’s speech was difficult to analyse properly
due to her reluctance to produce sounds and words on request. On the whole, her speech was very
limited and unintelligible. The consonant inventory was notably restricted and many consonants were
substituted by glottal stops. All Finnish vowels were heard in her speech, but they were used incon-
sistently. Language comprehension was within normal limits. Speech and language therapy was given
by the first author, and it started 3 months after the assessment. Therapy was infrequently executed,
12 times in all (from 3;8 to 4;6 years of age), before SS was referred to the intervention study.
SS met 10 of the 11 inclusion criteria of CAS. Her phonetic repertoire of consonants did not
include the phonemes /d/, /l/ and /r/, but the vowel inventory was complete. In words, consonant

omissions and vowel errors, especially vowel substitutions and distortions, occurred frequently. In
addition, glottal stops were substituted for many consonants, for example lammas ‘a lamb’ was
produced as [], compared to []. The inconsistency of articulation was difficult to analyse
from spontaneous speech due to the unintelligibility, but variability was noted while SS repeated
single words. An auditory and visual model did not help SS produce words more precisely. There
were no clear signs of groping in spontaneous speech or in naming pictures, but when imitating
short sentences signs of groping and decelerating of speech tempo were obvious. When unsure of
producing target words, SS moved her lips only slightly, resulting in neutralization of vowels.
Nasalizing of vowels occurred occasionally in spontaneous speech. SS used predominantly simple
syllable shapes (V, VV, VC, CV, CVV, CVC) and reduced polysyllabic words, and omitted inflec-
tions. She was not able to produce rapid alternating speech movements in a diadochokinetic task
when repeating trisyllabic sequences /pataka/, whereas repetition of monosyllabic sequences /
papa…/, /tata…/ or /kaka…/ was correct and fast. There where no signs of structural problems or
dysarthric symptoms in an oral motor task, and only mild difficulty in protruding of lips and alternate
lip protrusion and retraction.
SS’s receptive language skills were within normal limits when tested with Reynell Developmental
Language Scales III (Edwards et al., 1997; Finnish version of RDLS III, Kortesmaa et al., 2001).
Naming ability was poor on the Finnish word-finding test (German, 1986a, 1986b; Finnish version
of Test of Word Finding, Tuovinen et al., 2005). Non-verbal intelligence assessed with the Wechsler
Preschool and Primary Scale of Intelligence Revised (WPPSI-R; Wechsler, 1995 – Finnish edition)
was normal. SS demonstrated normal hearing measured bilaterally and based on pure tone audiometric
screening at 125, 250, 500, 1000, 2000, 4000 and 8000 Hz.
SS’s auditory perception was not assessed at the beginning of the intervention because there is no
standardized test available in Finnish for children under 5 years old. Informal assessment with syllable
discrimination was not reliable due to lack of concentration ability. SS’s accuracy in auditory percep-
tion of consonants and vowels was tested at the end of the second treatment period (when SS was
5;0 years old) with the Same or Different Test (Korpilahti, 1991) consisting of judgements for mono-
and bisyllabic stimuli in Finnish. The discrimination of vowels was within normal limits, whereas
discrimination of consonants was one standard deviation under the mean of the test values.
3 Procedure
This single-case study was implemented with two motor intervention methods, Melodic Intonation
Therapy (MIT) and the Touch-Cue Method (TCM). The first treatment phase started after a baseline
period and was followed by a treatment-free period, a second treatment period and a follow-up period.
All periods lasted for 6 weeks except the follow-up, which lasted 12 weeks (see Figure 1). Both
6-week treatment periods included 18 therapy sessions, each of which was 30 minutes in length.
During the study, no home practice was required, and all speech and language therapy not linked
to the study was suspended.
a Melodic IntonationTherapy: The treatment comprised three sentence lists with 10 sentences each.
The sentence items were 2–3 words long and consisted of developmentally appropriate words
relevant to the participant’s life (e.g. Pepi haukkuu ‘Pepi [the name of SS’s dog] barks’). The words
were mainly bisyllabic and all but one consisted of phonemes included in the participant’s phonetic
repertoire at the first assessment. First the therapist intoned the target sentence twice, and then the
therapist and the child intoned it simultaneously.After hearing the model again the child was assisted
to intone it alone and then to answer a question posed by the therapist. Simultaneous Finnish signing

was used systemically at the beginning, but was faded out when the sentences became familiar. If
the child was not able to produce the words correctly a new sentence was introduced.
b Touch-Cue Method: The practice material consisted of sequences of syllables and meaningful
words that included the phonemes /p/, /k/, /s/ and /l/, as well as all Finnish vowels. The first phase
was divided into three steps, in which nonsense syllables were used. In stage 1, a syllable (e.g. /pa/
or /ka/) and repetition of the same syllable (/papa/, /kaka/) were practised. In stage 2, two syllables
with different consonants but the same vowel (/a/) were combined (e.g. /paka/, /kapa/), and in stage 3,
vowels were also changed (e.g. /paku/, /kopi/). At the second phase, meaningful bisyllabic words
were used. When practising target items the therapist said them out loud 2–3 times and applied the
touch cues of the consonants on the child’s face. After this the therapist and the child repeated the
target item together 5–10 times (dependent on the stage).After the second model auditory and visual
cues were faded out so that the child produced the target item 5 times by herself with touch cues.
At the first stage the same drill was continued until 100% of trials were correct in three successive
sessions, and at later stages each drill was practised until 90% of trials were correct in three suc-
cessive sessions.
The study plan was approved by the Ethics Committee of the North Karelia Central Hospital,
Joensuu, Finland. Written informed consent was obtained from the parents before starting the inter-
vention, and they were told that the intervention could be discontinued at any time at their request.
4 Outcome measurement
The effectiveness of the intervention was measured by assessing SS’s speech production on a picture-
naming task, modified from the Finnish articulation test (Remes and Ojanen, 1996). The child was
asked to name 46 picture cards 6 times during the study: at the beginning and at the end of baseline
(weeks 0 and 6), at the beginning and at the end of both treatment phases – weeks 6 (which is the
same as the second baseline assessment), 12, 18 and 24 – and 12 weeks after the last TCM session
(week 36). These untreated probe words were developmentally appropriate and included both nouns
and verbs, and they were chosen to include a representative variety of Finnish phonemes. Only
spontaneous productions were used in the analyses. The child’s speech was digitally audiotaped
and videotaped with a video camera recorder.
5 Data analysis
Because of the child’s fluctuating performance at the different stages of the study the number of probe
words in the assessments ranged from 42 to 46. Narrow phonetic transcription of words was carried
out by the first author using the International Phonetic Alphabet (IPA). The reliability was tested by
using another speech and language therapist who re-transcribed 15% of the data independently.
Point-to-point agreement between the transcriptions regarding both consonants and vowels was 89%
(disregarding differences involving diacritics and word-initial glottal stops). In case of disagreement
the transcription of the first author was used.
Both segmental and whole-word level productions were assessed.At the segmental level, the vowels
and consonants of the words were assessed and categorized as correct or incorrect. In deciding whether
a sound was correct or not, even minor differences between the child’s production and the expected
target (e.g. [] for //) were considered an error. The participant’s productions were analysed for the
Percentage of Vowels Correct (PVC) and the Percentage of Consonants Correct (PCC).

In the whole-word analysis whole-word complexity, correctness, and proximity were examined.
The child’s whole-word complexity was defined by the Phonological Mean Length of Utterance
(PMLU; Ingram, 2002), which reflects the length of the child’s words and the number of correct
phonemes. The PMLU of the child’s words was calculated by giving one point for each segment that
the child produced and one additional point for each correctly produced phoneme. In Ingram’s measure
the correctness point is only given for correctly produced consonants. In this study correct vowels
were scored as well (Saaristo-Helin et al., 2006), because Finnish is a language with a high propor-
tion of vowels (Iivonen, 1991). The phonemes were classified as correct or incorrect with the same
principles as mentioned above. The correctness point was, however, given only for segments realized
in the proper position in the word (Bónová et al., 2005). For example, the maximal PMLU for the
word reppu [repu] (‘a rucksack’) is 10 (i.e. one point each for five segments and one additional point
each for correct consonants and vowels). The child’s PMLU was determined by calculating the total
number of PMLU scores of the words produced by the child in one assessment, and that number was
then divided by the number of words. Thus, the child’s PMLU – and the PMLU of target words
(representing the maximal score a child is able to obtain for words she is attempting to say) as well –
represent a mean value of the entire sample. The accuracy of the child’s whole-word productions
was defined by the Proportion of Whole-Word Proximity (PWP). It was determined by dividing the
child’s PMLU by the PMLU of target words. The value of PWP ranges from zero to one. The closer
the value of PWP to one, the higher the degree of accuracy. Whole-word correctness was measured
by determining the proportion of correctly produced words from the entire sample to obtain the
Proportion of Whole-Word Correctness (PWC).
Generalized Cochran–Mantel–Haenszel statistics for repeated measures of PVC, PCC, PMLU
and PWC were used to analyse the difference between consecutive measuring points. A p value of
less than 0.05 was considered statistically significant.
III Results
1 Segmental level analysis
The percentage of correct vowels (PVC) improved over the investigation period (Figure 1). Before
the MIT period slightly over half of the vowels produced by SS were correct (week 0: 54.8%; week
6: 57.8%), and the percentage increased to 93.0% at the end of the study period (week 36). The
improvement was statistically significant after the MIT block (week 12, p = .033), after the treatment-
free period (week 18, p = .014) and after the follow-up (week 36, p = .019).
Adifferent pattern emerged for consonants. The percentage of correct consonants (PCC) increased
during the baseline period but decreased again over the MIT block (p = .046). There was a significant
improvement 6 weeks after the MIT block (week 18; PCC 49.1%, p < .000), and the progression
continued during the TCM block (week 24; PCC 65.7%, p = .003). Improvement was maintained
during the follow-up period, and at the end of the study period SS produced 73.1% of consonants
correctly (Figure 1).
2 Whole-word analysis
The target words (i.e. words the child was attempting to say) were almost the same at every assess-
ment: the PMLU scores for target words thus varied only little, from 9.29 to 9.74, during the study
period (Figure 2). The PMLU scores for SS’s productions ranged from 6.12 to 8.80. SS’s scores

0
10
20
30
40
50
60
70
80
90
100
0 6 12 18 24 36
Weeks
PVC
PCC
*
*
*
*
***
**
Percentagecorrect
Baseline MIT No treatment TCM Follow-up
Figure 1 PVC and PCC in SS’s productions
Notes: Asterisks indicate statistically significant difference compared to the previous measuring point.
*** p < .001, ** .001 ≤ p < .01, * .01 ≤ p < .05
0
2
4
6
8
10
12
0 6 12 18 24 36
Weeks
Target PMLU
SS's PMLU
TCM
***
*
*
Scores
Baseline MIT No treatment Follow-up
Figure 2 PMLU for the target words and SS’s word productions
Notes: Asterisks indicate statistically significant difference compared to the previous measuring point.
*** p < .001, * .01 ≤ p < .05
improved only slightly during the baseline period and during the MIT block. Six weeks after the MIT
treatment PMLU increased from 6.32 to 7.54, indicating significantly increased (p = .001) complexity
of the words produced by SS. At the end of the TCM treatment PMLU was 8.22 (p = .011) and at
the end of the follow-up it was at its highest, 8.80 (p = .023).

Because PMLU target scores varied only slightly, the improvement of PWP scores followed the
improvement of SS’s PMLU. The PWP scores ranged from 0.64 (week 0) to 0.91 (week 36) dur-
ing the study period (Table 1). SS’s accuracy improved only slightly during the baseline and the
MIT block. Proximity increased from week 12 to week 18, and the positive tendency continued in
weeks 24 and 36.
The PWC of SS ranged from 0.17 to 0.39 (Table 1). From week 0 to week 18 less than 20 per cent
of the words were produced correctly.At week 24, just after the TCM block, the PWC score was 0.33,
indicating that SS produced one third of the words correctly, i.e. the correctness of both vowels and
consonants increased significantly (p = .035).At the end of the investigation her PWC value was 0.39.
Qualitative analysis of SS’s way to produce words (i.e. koira ‘a dog’, etana ‘a slug’ and kala ‘a
fish’) revealed that at the beginning of the study almost all of the consonants of the words omitted
or substituted by glottal stops (Table 2).Also the vowels were often substituted or distorted. During
the investigation production of phonemes improved and sequencing abilities increased.
IV Discussion
The purpose of this study was to evaluate the effectiveness of MIT and TCM as intervention
approaches for a child with the diagnosis of CAS. The aim was to decrease speech-sound errors and
to increase sequencing abilities. Both vowel and consonant accuracy increased during the interven-
tion. Phoneme errors decreased significantly during a 6-weeks period after the MIT block, and the
progression, particularly with consonants, continued during the TCM period. The complexity and
the accuracy of SS’s words also improved significantly after the MIT block, but a more substantial
gain in producing whole words correctly occurred during the TCM block.
As there was only minimal progression in the speech of SS over the 6-week baseline period,
improvements in her speech production can cautiously be attributed to the intervention programmes.
The results of TCM should, however, be interpreted with caution due to possible cumulative effects
Table 1 PVC, PCC, PMLU, PWP and PWC during the investigation
Week 0 Week 6 Week 12 Week 18 Week 24 Week 36
PVC 54.8% 57.8% 63.2%* 77.9%* 80.2% 93.0%*
PCC 24.0% 31.2% 23.8%* 49.1%*** 65.7%** 73.1%
PMLU 6.12 6.36 6.32 7.54*** 8.22* 8.80*
PWP 0.64 0.68 0.67 0.79 0.84 0.91
PWC 0.17 0.19 0.18 0.17 0.33* 0.39
Notes: Asterisks indicate statistically significant difference compared to the previous measuring point for PVC, PCC, PMLU
and PWC. *** p < .001, ** .001 ≤ p < .01, * .01 ≤ p < .05
Table 2 Examples of changes of SS’s words during the investigation
Phonetic SS’s productions
Week 0 Week 6 Week 12 Week 18 Week 24 Week 36
koira       
kala       
etana       

of MIT. It is not known what the results of TCM would have been without the preceding MIT
treatment.
Changes in the speech production of SS were not constantly positive during the study. After the
MIT block the production of vowels improved, whereas the accuracy of words and the percentage
of correct consonants was the same or even slightly lower than prior to it. During the MIT block the
main target was in sequencing abilities, not in individual phones. The aim to reach longer and better-
constructed words might lead the participant’s attention away from consonant accuracy. Furthermore,
we suggest that the skills of motor planning and programming required more than 6 weeks being
consolidated, so the variable production of probe words was characteristic of CAS. It can be sup-
posed, however, that the skills had begun to develop and the process continued after the intervention.
This might explain the improvement during the non-intervention periods.
As is typical in CAS, SS presented with a high rate of consonant and vowel errors. At the begin-
ning of the study SS’s PCC was 24% and the PVC was 54,8%. Her PMLU was 6.12 when the PMLU
of the target words was approximately nine. The relatively high PMLU value, but low PCC and
PVC values result from the fact that SS produced several phonemes in each word, but many of them
were incorrect. When PCC and PVC began to improve after MIT, PMLU and PWP also increased;
this is understandable. In this study, PMLU value represents the ability to sequence phonemes
because correctness points were only given for segments realized in the proper position of the word.
It seems that MIT decreased the number of both sound and sequencing errors without particular
instructions or cues on their production, which has also been proven by the previous findings of
Helfrich-Miller (1994).
The improvement in producing phonemes continued during and after TCM, but more inconsist-
ently than after MIT: the improvement of vowel accuracy evened out, but the improvement of
consonant accuracy continued almost as strongly as after MIT. The hypothesis that TCM facilitates
the sequencing of phonemes was supported because the number of correctly sequenced words what
were related to the entire sample increased particularly after TCM. SS’s ability to produce phonemes
in the correct position developed significantly.
At the end of the study, the PWP of SS was improved from 0.64 to 0.91 when the maximum value
is one. According to Ingram (2002: 718), ‘PWP can be seen as at least an indirect measure of the
child’s intelligibility.’Thus SS’s speech can be considered fairly intelligible after the follow-up period.
Children with CAS have, however, typically more errors in phrase than in single word production,
which is why the intelligibility of conversational speech must be estimated cautiously while based
on single word production.
One factor that may have also contributed to SS’s progress might be that treatment comprised
several motor learning principles known to be effective in the acquisition of motor skills as Strand
and colleges (Strand and Debertine, 2000; Strand et al., 2006) have also proposed in their studies of
children with CAS. In addition, while selecting interventions the therapist has to take into account
the individual’s needs and readiness to accept intensive training programmes. However, in this study
it is not able to exclude the possibility that the improvement was due to intensive practice rather than
the types of interventions selected.
In summary, the results of this study suggest that a combination of two motor-based treatments
– MIT and TCM – was appropriate for this child with CAS. Increased accuracy of speech produc-
tion is proposed to reflect more precise motor planning and programming. Thus, even though the
current findings do not exclude other possibilities of etiological origin of CAS, the view of CAS
involving motoric components is supported. As the study was non-controlled and concerned only
a single participant, more research is still needed. Future experiments should focus on the examina-
tion of MIT and TCM separately and together with alternating treatment design and other interven-
tions, as well.

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