Copyright @ 2014, Abergel, A.
Critical Review:
Evaluating the Effectiveness of an Integrated Phonological Awareness Intervention Model for Childhood Apraxia of
Speech
Ashley Abergel
M.Cl.Sc (SLP) Candidate
University of Western Ontario: School of Communication Sciences and Disorders
This critical review evaluates the effectiveness of an integrated phonological awareness (IPA) intervention model in
simultaneously improving speech production, phonological awareness and literacy skills in children with childhood
apraxia of speech (CAS). Overall, the research suggests that the use of an IPA approach is both appropriate and
effective in improving the phonological awareness deficits, speech sound production, and literacy skills of children
with CAS.
Introduction average range on letter knowledge and word decoding
measures than the comparison groups.
What is Childhood Apraxia of Speech (CAS)?
Children with CAS demonstrate difficulties with the The diverse nature of CAS symptoms creates a
accuracy and consistency of speech sound production in challenge for clinicians to provide efficient and
the absence of neuromuscular deficits (American
effective intervention. The majority of interventions for
Speech–Language–Hearing Association [ASHA], 2007; CAS focus on remediating speech deficits (Dale &
Dale & Hayden, 2013). CAS is considered to be a Hayden, 2013). The development of written language
multi-level impairment, as it contains both motor must also be fostered in intervention as phonological
(phonetic production and sequencing of sounds, awareness deficits at phoneme, rhyme and syllable level
syllables and words) and linguistic deficits appear to underlie the written deficits of children with
(phonological representation and awareness of CAS.
phonemes) (Gillon & Moriarty, 2007; Moriarty &
Gillon, 2006). The motor deficits associated with CAS One longitudinal study focusing on language
include inconsistent speech errors on vowels and impairment and written language abilities among
consonants, sound sequencing difficulties, articulatory children with CAS, children with isolated speech
groping, and inappropriate prosody (ASHA, 2007). disorders (S), and children with combined speech and
Linguistic deficits include expressive and receptive language impairment (SL) found that children with
language impairment, phonological awareness deficits, CAS were more likely to experience receptive and
and reading and spelling difficulties (Lewis, Freebairn, expressive language deficits in addition to their speech
Hansen, Iyengar et al., 2004). difficulties than the two comparison groups (Lewis et
al., 2004). This study provides valuable information
Delays in speech production associated with CAS are regarding the severity of language impairment in
typically correlated with an expressive language delay children with CAS.
that may evolve into a more global language processing
delay. This puts children with CAS at risk for language This multi-level impairment limits the ability of
and academic problems (i.e., spelling, reading, and traditional approaches to improve these children’s
writing) (Lewis et al., 2004). linguistic deficits or reduce their risk for later language
and academic problems (Gillon & Moriarty, 2007).
Preliminary findings indicate that children with CAS
are more likely than children with similar surface One intervention that may be a promising method of
disorders to experience written language difficulties simultaneously targeting speech and language deficits is
(Lewis, et al., 2004). McNeill, Gillon, and Dodd an integrated phonological awareness (IPA)
(2009c) compared phonological awareness, word intervention model. This approach incorporates targeted
decoding, and letter knowledge ability between children speech practice into phonological awareness activities
with CAS, children with inconsistent speech disorder and uses letters and phonological cues to prompt speech
(ISD) and children with typical speech-language production (McNeill et al., 2009b).
development (TD). The researchers found that the CAS
group exhibited inferior phonological awareness skills What is an IPA intervention model?
and had more participants performing below the
Copyright @ 2014, Abergel, A.
IPA is an intervention model designed to
simultaneously target speech, phonological awareness, Results
reading, and spelling deficits in children with CAS
(McNeill et al., 2009b, c). This approach is consistent McNeill, Gillon, and Dodd (2009b) evaluated the
with theoretical descriptions of CAS that emphasize effectiveness of an IPA intervention model for 12
disordered phonological representation systems, and children with CAS with no history of sensory, cognitive
unstable motor programming for speech production or neurological deficits using a multiple single subject
(McNeill et al., 2009b). The IPA intervention model design and an AB (baseline-intervention) format for
provides children with a more stable motor program for each treatment goal and speech probe. The children
speech production by focusing on improving underlying were aged 4-7 years (3 females). Participants
phonological representations of targeted speech words completed two 6-week blocks of intervention (24
(McNeill et al., 2009b). This approach simultaneously sessions in total) targeting speech errors, phonological
improves speech and phonological awareness. awareness, letter-sound knowledge, word decoding, and
spelling. Appropriate assessment measures were
Objectives administered to each child to establish a baseline phase
and to evaluate intervention effects. Appropriate
The primary objective of this paper is to critically statistical analysis including a two standard deviation
evaluate the existing literature on the effectiveness of (2SD) band method, and paired t-tests revealed
an IPA intervention model at improving phonological significant improvements for the majority of the
awareness, literacy skills, and speech production in participants (67%-83%) on trained and untrained
children with CAS. The secondary objective is to speech probes, phonological awareness, and literacy
propose recommendations for future practice and measures (except real-word decoding), with transfer to
research on integrated intervention programs for spontaneous speech contexts.
children with CAS.
Methods Due to the small number of children aged 6 years and
older, it was difficult for the researchers to detect
Search Strategy statistically significant results on the reading tasks
The following computerized databases were searched: (real-word decoding).
CINAHL, PubMed, PsychInfo and the University of
Western Ontario’s library search engine. The effects of intervention on each child’s speech,
The following search terms were used: reading, and spelling ability were appropriately
“childhood apraxia of speech” OR “CAS” OR monitored using assessment measures commonly
“developmental apraxia of speech” OR “DAS” AND employed in similar research. Multiple measures were
“integrated phonological awareness program”. taken for each child throughout the study (every second
intervention session and three times post intervention).
Reference lists of the articles selected were also
searched for further relevant articles. Additionally, in order to ensure treatment fidelity, the
content and materials used in intervention were
Selection Criteria standardized and administered by trained Speech-
Studies selected for inclusion in this review were Language Pathologists (SLPs). Inter-rater reliability on
required to examine the phonological or literacy deficits the non-word reading and spelling measures ranged
of children with CAS and the effectiveness of an IPA from 88-100% agreement, demonstrating high
approach in treating children with CAS. Studies treatment adherence. Both trained and untrained speech
examining the effectiveness of an IPA program for probes were used to measure improvements in speech
children and/or adults with speech impairments alone or error patterns ensuring a transfer of knowledge rather
spoken language impairments were excluded as they than a teaching to the test. Finally, intervention was
did not meet the criteria of CAS. provided over an extended period of time which
allowed the researchers to determine if these
Data Collection participants were able to maintain their improvements
Results of the literature search yielded the following post-intervention.
study types: two multiple single-subject designs with
repeated measures, and one multiple single-subject Results from this study offer compelling evidence that
baseline analysis. an integrated approach improves phonological
awareness, letter knowledge, and the development of
reading and spelling in children with CAS.
Copyright @ 2014, Abergel, A.
Moriarty and Gillon (2006) investigated the at the ages of 4;5, 4;9, 5;3, and 5;9 (pre-intervention,
effectiveness of an IPA intervention model for three post-intervention, six months and one year following
children with CAS aged 7;3, 6;3 and 6;10 (two males, completion of the intervention program). Appropriate
one female). They used a multiple single-subject assessment measures were used to establish a baseline
design with repeated measures (pre- and post- and determine the effects of intervention. The results of
intervention) to determine the effects of intervention. the study showed that improvements were noted in
Each participant acted as their own controls. consonant and vowel production within single words as
Participants completed three sessions per week for three well as consistency in speech production throughout the
weeks targeting speech error patterns, phonological study. Improvements were made on phoneme
awareness, and word decoding. Appropriate statistical awareness, phonological representation, and reading
analysis including the celeration line and the 2SD band and spelling measures, as both participants performed
method revealed significant improvements in all trained near ceiling levels.
speech production and phoneme awareness skills, as
well as transfer of grapheme to phoneme knowledge to The results of this study should be interpreted with
non-word reading tasks. The phoneme awareness skills caution as it lacked any statistical analysis. The
acquired also led to an improved performance on researchers completed a visual inspection of the data to
untrained items. Two of the three children improved measure improvements. It is uncertain whether
performance to near-ceiling levels post-intervention. improvements in speech, phonological awareness, and
literacy skills were statistically significant.
It should be noted that one of the participants’ non-
verbal cognition may have inhibited his ability to This study revealed the long term positive effects of an
progress as quickly as the other two participants. IPA intervention model for children with CAS. A
follow-up period of 1 year allows for an appropriate
These results should be interpreted with caution as it is evaluation of the long term effects of an IPA model,
unknown if the children maintained or improved skills and provides clinicians the ability to understand the
post- intervention due to the lack of long term follow- evolving shape of the disorder over time. Additionally,
up of the participants’ speech production and the use of identical twins in a study allows for a better
phonological awareness skills. This is concerning understanding of the etiology of the disorder and the
because children with CAS are renowned for the role of genetics.
persistent nature of their impairments even with
extended periods of intervention (McNeill et al., Overall, this study suggests that an IPA intervention
2009b). The varied linguistic profiles of each child did may be effective in treating CAS; however, its
not permit for comparisons across participants. A lack effectiveness cannot be concluded due to the omission
of repeated measures throughout the study made it of statistical analyses. Therefore, this study offers a
difficult to assess the effects of intervention. suggestive level of evidence with high clinical
importance.
Despite the participants’ severe speech impairments,
and relatively short treatment period, improvements Discussion
were noted on phonological awareness skills to many
untrained tasks. Point-by-point analysis showed 90% The studies reviewed in this paper found that an IPA
and 92% inter-rater agreement for baseline and post intervention model has a positive impact on the
intervention repeated measures, respectively. This study development of speech, language, and literacy skills in
employed an appropriate and commonly used method children with CAS.
for CAS diagnosis (Ozanne’s method) to decrease
problems arising from non-standard inclusionary The McNeill et al., (2009b), and Moriarty and Gillon
criteria. (2006) studies targeted speech production by focusing
on speech error patterns rather than employing drill
Overall, results from this study provide compelling exercises. This approach may be more likely to create a
evidence that speech production and phoneme widespread change in a child’s phonological system as
awareness skills in children with CAS can be improved it corrects patterns of errors rather than specific words
within an IPA intervention model. or phrases. Additionally, these intervention models
employed a visual–verbal learning style that facilitated
McNeil, Gillon, and Dodd (2009a) evaluated the long the development of letter–sound knowledge by using
term effectiveness of an IPA intervention model for letters to prompt speech production and phoneme
identical twin boys with CAS, using a multiple baseline awareness. The visual-verbal learning is strongly
analysis. The two boys were assessed on four occasions correlated to reading ability and is better at achieving
Copyright @ 2014, Abergel, A.
this skill than verbal-verbal or visual-visual learning model at improving both linguistic (phonological
approaches (McNeill et al., 2009b). Furthermore, the awareness, literacy skills) and motor (speech sound
Moriarty and Gillon (2006) study targeted sound production and articulation) abilities in children with
structures in words through the use of explicit phoneme CAS.
awareness. As a result, children with CAS were able to
develop strong and specific underlying phonological Recommendations
representations of the phonemes, which in turn
provided them with the ability to manipulate language For future research, the following factors need to be
(i.e., rhyme, identify phonemes) and develop a addressed:
foundation for literacy (i.e., reading and spelling). i) A follow-up on participants in the Moriarty
and Gillon (2006), and McNeill, Gillon and
All three studies demonstrated the efficiency of an IPA Dodd (2009b) studies
model at simultaneously targeting speech production, ii) More longitudinal studies that evaluate the
phonological awareness, letter knowledge, and reading long term effectiveness of this approach on
and spelling skills in children with CAS. speech, language, and literacy
iii) More studies that use multiple baseline
It is important to note that the following limitations measures to measure effectiveness of the
should be considered when summarizing the results of intervention
these studies: iv) Comparing IPA intervention to traditional
(1) Single subject designs were employed in all three of therapy for children with CAS in order to
the studies. Although this was an appropriate design evaluate the added value phonological
method for a rare population such as CAS, single awareness and literacy training provides to
subject designs often lack external validity, making it these children
difficult to generalize results.
(2) Two of the three studies reviewed had a small Clinical Implications
sample size of three or less. Although this is an on-
going issue when conducting research with rare Currently there is no designated treatment that is known
populations, it is still a limitation to the evidence. to be most effective for CAS. Various interventions are
(3) All participants included had been diagnosed with being employed by Speech-Language Pathologists,
CAS. Currently there is a lack of consensus regarding however further research is needed in order to
diagnostic criteria and there is no designated protocol determine an effective course of therapy for treating
for diagnosis of this disorder. Despite the varying children with CAS. This critical review has examined
diagnostic criteria and definition of the impairment, the current literature concerning the effectiveness of
based on the information provided, it appears as though employing an IPA approach with this population and
all the authors had selected participants with a diagnosis has revealed that there is compelling evidence for the
of CAS to the best standard available. Although one of validity and clinical importance of such an intervention
the studies included a participant with an underlying design. This approach improves speech sound
cognitive impairment, improvements post-intervention production in children with CAS and targets
were still noted. phonological awareness and literacy skills including
word decoding, spelling, and reading. Overall, it
Regardless of these inherent differences among appears that an integrated model is an ideal approach
participants, each study demonstrated positive results for Speech-Language Pathologists to consider when
for all participants with CAS as well as compelling working with children with CAS as it simultaneously
evidence for the clinical importance of an IPA targets multiple levels of the impairment.
intervention model.
References
Conclusion
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This comprehensive literature review provides support (2007). Childhood apraxia of speech [Technical
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of the disorder. In addition, the two studies by Moriarty with Tactual Input: The PROMPT Approach.
& Gillon (2006), and McNeil et al., (2009b) provided American Journal of Speech-Language
compelling evidence for the effectiveness of an IPA
Copyright @ 2014, Abergel, A.
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