PROMPT- Useful for Childhood Apraxia of Speech (CAS)

What is PROMPT?

PROMPT is an acronym for:

Prompts for Restructuring Oral Muscular Phonetic Targets.  This is a dynamic, hands-on program for children with apraxia of speech in which the trained clinician shapes the movement of a child’s jaw, tongue, and lips using our hands in support of sound production.  Although the use of touch and movement is an integral component, PROMPT is more than just executing tactile support.  It is a program that incorporates all aspects of a child’s processing, understanding, and interaction.

These areas of development, or domains, are known individually as: The Cognitive-Linguistic, (ability & language), Social-Emotional (socialization), and Physical-Sensory (muscle tone & senses) Domains.  Together, these domains function in unison and influence each other to the extent that challenges in one area directly impact progress in another.  This video for families on the PROMPT website visually explains the domains and PROMPT’s multifaceted treatment approach.  Some children that may benefit from PROMPT include those diagnosed with motor speech disorders like apraxia and dysarthria, cerebral palsy, and autism.  To determine if PROMPT is appropriate for your child, your clinician will begin with an observation and comprehensive evaluation.

Evaluation:

PROMPT is rooted in a Dynamic Systems Theory, meaning that clinicians must factor in cognitive, social, behavioral, sensory-motor, and physical influences on communication.  Let us break these down into some specific questions that we as clinicians ask ourselves during a comprehensive assessment process:

• Cognitive: What is the child’s ability to process sensory information and comprehend language?  Does the child need visual schedules and/or other modifications and cues to learn new information?  How should clinicians and parents’ scaffold, cue, and elicit language with the child?
• Social: Do we need to work on establishing trust before diving into PROMPT?  How does the child express his wants and needs (i.e., pointing, gestures, sounds?)  How is the child’s non-verbal communication?  What communicative intents does the child relay (i.e., greeting, requesting, commenting, responding to questions?)  Is the child interested in engaging in communication and interactions with others?
• Physical: What is the child’s skeletal system and muscle tone like?  Do we need to provide additional supports in the environment to support skeletal and/or musculature issues?  Does the child have difficulty with vision, hearing, tactile/touch?

System Analysis Observation (SAO) and Motor Speech Hierarchy (MSH):

In addition to collecting information from a parent interview, a PROMPT evaluation also includes analyzing the movements necessary for speech. These yes/no questions are based on typical speech development. Next, the clinician transfers the results to a visual representation to rate the severity of the speech disorder.  The System Analysis Observation (SAO) and Motor Speech Hierarchy (MSH) provide us with practical information to develop a treatment plan.

Well-Built House

Marcus Neal, a PROMPT instructor, describes the Motor Speech Hierarchy as a well-built house with a strong foundation (jaw) necessary for sustaining the other structures (lips, tongue.)  The jaw is the first articulator to develop, so we need to make sure that this foundation is ready to support sophisticated lip and tongue movements.  Jaw stability and the ability to open our mouths in four graded levels (minimal to wide) helps us sequence movements for speech.  In PROMPT, we incorporate vowels into a child’s practice because vowels shape jaw movements.

After completing a SAO, clinicians calculate percentages for each of these areas:  tone, phonatory, mandibular (jaw), labial-facial (lips-face), lingual (tongue), sequenced movements, and prosody (inflections/intonation.)  Next, we shade in the boxes for each of these areas on the MSH to help identify points of intervention.  Given the fluid interaction between these Stages, we need to address three areas to work on immediately.  While we cannot change a child’s tone, it is important to note limitations and consult with OTs and PTs for suggestions on improving posture.

After selecting three areas to prioritize, we develop goals and vocabulary lists to practice words/ phrases during functional activities.  This list will include a variety of vowels, consonants, and blends with emphasis on core vocabulary.  From the start, we blend words into phrases to work on prosody (intonation).  So, we model and support with PROMPTs, “ma more!” or “go ma?”  The reason for working on prosody early on is to help make speech movements fluid and vary communication intentions.

Service Delivery:

Typically, young children with apraxia of speech benefit from at least two, 30-minute sessions.  Depending on the degree of severity, services may range anywhere from a few months to several years.  Other contributing factors that can impact longevity of services are medical conditions, cognition, social/pragmatic skills, sensory/tactile defensiveness, and comprehension delays.

Typical PROMPT Therapy Session:

If a child with apraxia of speech has limited verbal skills, then sessions will initially focus on using vowel sounds.  As vocalizations increase, then PROMPT support shifts to productions of consonant sounds/words/phrases/sentences.

A typical 30-40 minute PROMPT session for apraxia of speech would proceed as follows:

1. Greeting and set up (5-10 minutes)
2. Motor phoneme warm-up reviewing the targeted words embedded in the session’s activities with 3-5 PROMPT supported repetitions per target. (5-10 minutes)
3. Most sessions have 2-3 activities, each lasting 5-10 minutes.  These activities incorporate pertinent aspects from the Domains reviewed above factoring in picture supports, timers, movement breaks, supported seating, and any other cues the child may need for success.  Speech sound movements are worked on during play to help the child attach meaning and strengthen memory.
4. Review home practice plan (5-10 minutes)

Here are some examples of activities that I have used for children with varying cognitive abilities during my PROMPT sessions:

• early childhood: Toy Vet Play Set with word targets to address needs in tongue control and jaw movements (go, goes, take, push, home, help)
• preschool: Play-Doh Kitchen Oven with words to help work on lips-face control with movements that require rounding lips (no, two, dough, do, “mo” for more)
• elementary school-aged: Pop the Pirate Game practicing words that support improving jaw control, lip contact (pop, Bob, up, “hep” for help)
• middle school-aged: Knock, knock jokes to address improving prosody (intonation) and tongue control (Who’s there? cat, kitten, bike, show)

PROMPT Supports:

There are four levels of PROMPT (Parameter, Surface, Complex, Syllable) with clinicians using at least 2-3 of these in one session.  Here is a breakdown on each level and the type of support it provides a child:

Parameter: provides the most support you can offer through stabilizing/ moving the jaw and lips.  There are 13 sounds supported at this level some of which include: h, p, b, m, sh, and vowels in words like “cat”, “father”, and “eat”.

Syllable: only used for consonant-vowel (CV) productions such as “go”.

Complex: helps the child contract and/or tighten his tongue to produce consonants such as (r), blends (sh), and vowels.

Surface: these supports specifically help a child with placing articulators accurately, timing movements using rhythm and prosody, and transitioning from one sound movement to another to create words.

PROMPT and Teletherapy:

In 2020, PROMPT training for speech pathologists shifted from in person to virtual because of global shelter-in-place restrictions.  The PROMPT Institute also developed specific training for clinicians using PROMPT via teletherapy. Parameter PROMPT offers the most support for a child and can be easily administered by a caregiver following a trained speech pathologist demonstration.  Some surface PROMPTs can also be used in teletherapy with the clinician showing this support on herself, a doll, or willing assistant.

My hope in writing this post was to provide a thorough explanation of the dynamic intervention of PROMPT.  This program is unlike any other that I have been trained in over the last two decades in the field of speech pathology, as I have witnessed tremendous success when applying this methodology with clients who have motor speech disorders.  Both caregiver carryover and early intervention are crucial to these achievements, so please continue advocating for your child and seeking resources like the PROMPT website to further your knowledge and education.

If you want to find a speech pathologist in your area trained in PROMPT, then you can visit this link and conduct a search.