Cueing in Childhood Apraxia of Speech: How to Fade Support Without Losing Accuracy
The child can say the word when you say it together. But the moment you stop helping, their accuracy falls apart.
Sound familiar?
How do you know when to fade a cue? And what do you do when reducing support results in an inaccurate production?
These are questions I consider throughout every therapy session.
Should I say the word with the child? Slow it down? Add a gesture? Use a tactile cue? Mouth the word silently? Or see whether they can produce it independently?
After more than 20 years as a paediatric speech pathologist, including over 15 years specialising in childhood apraxia of speech (CAS), I’ve developed an approach influenced by hands-on mentoring with David Hammer, Edythe Strand’s Dynamic Temporal and Tactile Cueing (DTTC), Kaufman Speech to Language Protocol (K-SLP) principles and my own clinical experience.
My philosophy is simple:
Provide enough support for a successful speech movement, then fade that support as soon as the child is ready.
The goal isn’t simply accurate words during therapy. It’s speech children can use independently.
Why Cueing Matters
Children with CAS have difficulty planning and programming the movements required for speech.
Simply asking a child to repeat a word doesn’t necessarily provide the information they need to improve their production.
Depending on the child and target, I might use auditory models, visual information, verbal descriptions, gestures or tactile prompts.
But I don’t automatically use every cue.
The best cue isn’t necessarily the most intensive one. It’s the one that helps the child succeed without unnecessary assistance.
Hammer and Ebert (2018), in The SLP’s Guide to Treating Childhood Apraxia of Speech, describe how multisensory cues can support articulatory placement, transitions between sounds and syllables, and aspects of speech production such as voicing.
Importantly, these cues can be selected and combined according to the child’s individual needs.
What I Learned Through One-to-One Mentoring With David Hammer
In 2010, I had the opportunity to spend a week receiving intensive, one-to-one, hands-on mentoring from David Hammer during real therapy sessions with children with CAS.
David spent 35 years at Children’s Hospital of Pittsburgh before becoming Director of Professional Development and Speech Services at the Childhood Apraxia of Speech Association of North America (CASANA), now known as Apraxia Kids. He later served as Vice President of Programs.
He also had a close connection to the organisation’s beginnings, having provided therapy to the child of one of its founders.
His multisensory approach has had a lasting influence on my clinical practice.
In his 2007 Brisbane presentation, Hammer described using signs, visual prompts, tactile cues and other supports, with an emphasis on gradually fading cues as children become more capable.
He also discussed increasing support when a child struggled.
This principle is reinforced in Hammer and Ebert’s (2018) discussion of multisensory cueing.
Cueing isn’t necessarily a one-way progression
If a child succeeds, I try reducing support. If accuracy breaks down, I provide additional information and try again.
These principles have helped shape the simplified cueing hierarchy I use in my own clinical practice.
My Four-Level Cueing Hierarchy: From Most Support to Least Support
Over the years, I’ve developed a simplified cueing hierarchy that I share in my CAS Therapy Handbook and as a free resource on my website.
It’s informed by Hammer’s teaching, DTTC and K-SLP principles, but isn’t intended to reproduce any one treatment protocol.
My hierarchy is deliberately arranged from the highest level of support (tactile cueing) to the lowest level (independent production).
The aim is to help children produce target words with progressively less assistance until they can say them independently when presented with a picture, sign or natural communication opportunity.
However, this doesn’t mean every child starts at Level 1 or needs to progress through every level.
I begin with the least support that enables a successful production and adjust according to the child’s response.
Level 1: Tactile Cueing — Most Support
When necessary, I may use appropriate tactile prompts to facilitate a movement the child is struggling to achieve.
This may be combined with simultaneous production and visual or verbal cues.
Although tactile cueing represents the highest level of support in my framework, I don’t automatically begin here.
Level 2: Simultaneous Production With Visual Cueing
The child and I produce the word together while they watch my mouth and hear the movement sequence.
I may slow the production, emphasise articulatory movements or introduce a hand gesture.
I also use descriptive sound names such as poppy sound for /p/ and /b/, tippy sound for /t/ and /d/, and hummy sound for /m/.
Level 3: Silent Visual Modelling
I reduce support further by silently mouthing the target rather than saying it aloud.
The child can still see my articulatory movements without relying on an auditory model.
Sometimes I’ll silently model only the beginning and allow the child to finish independently.
Level 4: Independent Production — Least Support
The child produces the target without my verbal model, silent mouth movements, gestures or tactile assistance.
I might present a picture, use a familiar sign or create a natural opportunity for the child to say the word.
For example, I show a picture of a puppy and the child says puppy without needing me to model it.
The picture or sign elicits the word rather than showing the child how to produce its speech movements.
The hierarchy shows the order of support available, not a compulsory sequence of steps.
A Word on Tactile Cueing
I don’t automatically introduce tactile cues unless the child needs them.
If a child can achieve an accurate production through a verbal model, simultaneous production or visual cue, there’s no reason to add tactile assistance.
When tactile support is necessary, I aim to fade it as quickly as possible while maintaining successful movement.
If accuracy breaks down, I can briefly reintroduce it.
Tactile cueing should be appropriate, consent-based and within the clinician’s training and competence.
The goal isn’t to work through a hierarchy. It’s to help the child become independent of that hierarchy.
Timing of Cues: Providing the Right Information at the Right Moment
Effective cueing isn’t just about which cue we use. It’s also about when we provide it.
This is particularly important with tactile cues.
If I’m helping a child achieve lip closure for /p/, the tactile information needs to coincide with the movement I’m facilitating.
There’s little value in applying a cue to the child’s mouth when they aren’t even attempting the word.
The same principle applies to other cues.
Simultaneous production needs to be coordinated with the child’s attempt. Gestures should coincide with the relevant sound or movement. Silent modelling should provide useful visual information at the appropriate moment.
Sometimes the most helpful thing I can do is stop cueing and allow the child time to attempt the word independently.
Effective cueing means providing the right information at the right moment.
Dynamic Cueing: Just the Right Amount of Support for Each Trial
For me, one of the most important clinical skills in CAS therapy is knowing how much support to provide for each production and adjusting it from one trial to the next.
Too much support can be as unhelpful as too little.
If a child can already produce a word independently, there’s little benefit in continuing to provide a full verbal model, gesture or tactile cue every time.
We don’t want unnecessary cue dependence or missed opportunities for independence and generalisation.
But the opposite is equally important.
We can’t simply ask a child to repeat a word over and over when they’re consistently producing it incorrectly.
Repeatedly practising an incorrect production risks reinforcing the very motor pattern we’re trying to change. This is sometimes referred to as negative practice — and it’s certainly not the kind of practice we want in CAS therapy!
Instead, I might slow the production, provide a simultaneous model, introduce a gesture or tactile cue, or simplify the target.
In my clinic room a child might produce a word independently on one trial, need a visual reminder on the next, and return to independent production immediately afterwards.
I’m constantly assessing, adjusting, fading and reintroducing cues according to what happens on each trial.
The balance is important:
Too much support: Unnecessary cue dependence and missed opportunities for independence.
Too little support: Repeated unsuccessful attempts without the information needed to improve.
Just enough support: Successful movements with increasing independence.
Striking this balance moment by moment is, in my experience, one of the most important components of effective CAS therapy.
The goal isn’t to provide the most cues or the fewest cues. It’s to provide the support needed for that particular attempt — and no more.
Fading One Cue Doesn’t Mean Removing Every Cue
An important consideration when using multisensory cues is that individual supports can be faded independently.
Hammer and Ebert (2018) describe this flexibility in their discussion of cue fading.
For example, if a child initially needs both a gesture and an auditory model, I may remove the auditory model while retaining the gesture, or remove the gesture while continuing to provide an auditory model.
I don’t necessarily need to withdraw every cue simultaneously or follow a rigid sequence.
I can also reintroduce a particular cue if the child begins to struggle.
This is particularly important when combining auditory, visual, verbal and tactile information.
The aim is to reduce the support the child no longer needs while retaining whatever is still helping them succeed.
How Does My Approach Relate to DTTC?
My approach also draws on principles from Edythe Strand’s Dynamic Temporal and Tactile Cueing (DTTC).
DTTC uses a structured temporal hierarchy in which the timing of the clinician’s model changes as the child progresses towards independent production. Additional auditory, visual and tactile cues can be introduced, adjusted and faded according to the child’s performance (Strand, 2020).
My four-level hierarchy has a different focus.
Rather than describing the timing relationship between the clinician’s model and the child’s response, it provides a simplified framework for considering the amount and type of support a child needs to produce a target successfully.
It is not intended to replace or reproduce the complete DTTC protocol.
Both approaches recognise the importance of adjusting support dynamically rather than providing the same cues for every production.
Fading Cues Doesn’t Mean Reducing Practice
Imagine I’m teaching a child to say mummy.
Initially, they might need simultaneous production. After a few successful attempts, I may silently mouth the word.
If they're successful, I might ask them to imitate the word after me, perhaps providing a gestural cue for a sound they're likely to omit or produce incorrectly. If they succeed, I might then say, “Say it again,” to see if they can produce the word without another verbal model.
If accuracy breaks down, I provide additional support.
Either way, I’ve learned something about what the child needs.
But just because a child can produce a word successfully with support during a therapy session doesn't mean they'll be able to say it independently and consistently when they get home.
This is why repetition matters.
One of the practical principles I took from my mentorship with David Hammer is what he calls the rule of three. As a general rule of thumb, I aim for three successful productions in a row, unless the child is able and willing to do more.
The goal isn't simply to achieve one correct production and move on. It's to provide repeated opportunities to practise the movement sequence successfully, while gradually reducing the support needed.
Helping Children Develop Their Own Cues
Another important aspect of cueing is helping children become increasingly aware of their own speech movements.
Hammer and Ebert (2018) discuss encouraging children to recognise when they need assistance and begin developing self-cueing skills.
In my sessions, I often use familiar, simple reminders rather than immediately providing another model. For example:
"You forgot your poppy sound at the end!"
"Can you feel your teeth when you make your windy-bitey sound?"
"Remember to put your /s/ at the end."
Over time, something interesting can happen. Children begin using these cues themselves!
I've seen even very young children spontaneously use the same hand gestures or mouth-position reminders I've been providing during therapy. They recognise that a particular cue helps them produce a word and begin using it without waiting for me to prompt them.
Not every child will develop these self-cueing skills at the same time, and many will continue to need direct modelling and support.
But when children begin recognising what helps them and start using those strategies independently, they're taking an important step towards becoming less reliant on my cues during speech production.
Successive Approximations and Achievable Targets
Sometimes a child cannot produce the complete target accurately, regardless of how much support we provide. In these situations, I may accept an appropriate successive approximation and gradually shape it towards the intended word.
For example, when establishing /s/, I might temporarily accept an approximation containing some frication rather than an unrelated substitution.
Another example came up in two of my CAS therapy sessions today. Both children were working on the word the, not because I expected them to have mastered the voiced /ð/ sound at their age, but because they were producing less helpful substitutions, such as "nah", "gah" or "mah" instead.
When modelling the, I slowed my speech rate and provided a gestural cue for /ð/ (voiced 'th'). With additional effort and concentration, the children were often able to produce a closer, developmentally appropriate approximation, such as "va" or "da".
If a child can produce the adult target accurately, wonderful! But if they aren't motorically ready, I don't insist on it. Instead, I accept an achievable approximation that moves them closer to the intended word.
And if the child still cannot produce an appropriate approximation despite cueing, I may explicitly explain:
"The word is the, but you can say da for now."
Or va, depending on which movement sequence is more accessible to that child.
This is why I place so much emphasis on syllable shapes, achievable movement sequences and successive approximations in CAS therapy.
Sometimes the solution isn't another cue. It's choosing a movement sequence the child can successfully produce and build upon.
Cues Should Support Learning, Not Become Permanent Prompts
I don’t want a child to need me sitting opposite them, modelling every word or providing gestures just to achieve accurate productions.
Those supports may initially be necessary, but their purpose is to help children develop speech movements they can eventually access independently.
Hammer and Ebert (2018) similarly encourage clinicians to move beyond relying primarily on verbal imitation and to gradually shift responsibility for speech production towards the child.
This doesn’t mean imitation is unhelpful. In fact, it can be an essential part of motor-based treatment.
The concern is when we continue providing support that the child no longer needs, rather than creating opportunities for more independent production.
A child might produce a word beautifully during therapy, but what happens when I’m not there?
Can they say it after a delay? Tomorrow? In a sentence or conversation?
Can they apply what they’ve learned to other words with similar syllable shapes or movement sequences?
Successful cued production doesn’t automatically demonstrate retention or generalisation.
We need to monitor those outcomes separately.
And while parents, teachers and other communication partners may initially use familiar cues to support practice and communication outside therapy, the longer-term goal is to reduce unnecessary prompting as the child’s speech skills develop.
It’s to help children develop speech movements and syllable shapes they can access, retain and use independently in everyday communication.
The purpose of cueing isn’t to make a child better at following our prompts. It’s to help them develop a stronger speech motor system so they can eventually communicate clearly and independently, without relying on our support.
Just today, I was reflecting on how much one of my early school age clients' speech motor skills have developed over the past two years.
When we first started working together, her connected speech was largely unintelligible. I could understand perhaps 5–10% of what she said and frequently needed to ask her mum to interpret.
Fast forward two years, and her speech motor system is now so much more established that I can provide feedback on almost any word, even within connected speech, and she can adjust her production in the moment. We can also work on sentence structure and pronouns during natural conversation, and she happily takes these corrections on board because she can experience her own success.
Something else struck me during today's session. I commented to her mum on how beautifully clear her /s/ sounds have become.
For a long time, her /s/ productions were distorted. But we didn't specifically target those distortions. Instead, we focused on establishing early consonants and syllable shapes, gradually introducing more complex speech movements as her skills developed.
Over time, her /s/ productions became accurate too, without us having directly targeted them.
Of course, this doesn't mean that distorted sounds will always resolve without direct intervention. But this isn't the first time I've seen this happen in my clinical practice. It's one of the reasons I often accept developmentally appropriate approximations for more challenging sounds while focusing on building the child's overall speech motor skills through early sounds, syllable shapes and increasingly complex movement sequences.
As those foundations become more established, I sometimes see improvements in sounds we haven't specifically targeted.
Ultimately, effective cueing isn't about getting a child to produce a word correctly while we're there to help them.
It's about providing the right support at the right time, giving children enough successful practice, and gradually helping them develop the speech motor skills they need to produce words independently.
Because the real measure of our cueing isn't what a child can say with us. It's what they eventually learn to say without us.
Want to feel more confident treating CAS?
I created the OKAT CAS Academy to give speech pathologists the kind of learning opportunities that shaped my own clinical practice — hands-on mentorship, observing specialist CAS clinicians working with real children, and learning the practical tips and strategies that aren't always found in textbooks.
I've tried to recreate that experience by bringing together everything I've learned over more than 20 years of working with children with CAS and co-occurring conditions.
More than just another course, the Academy is a six-month learning and mentorship experience featuring:
Seven in-depth learning modules covering CAS assessment and diagnosis, treatment approaches, neuroaffirming CAS therapy, motivation and engagement, monitoring progress, and clinical report writing.
Over 10 additional hours of long-form, real-life CAS assessment and therapy footage, with guided teaching so you can see not just what I do, but how and why I make clinical decisions.
But perhaps even more valuable than the knowledge and demonstrations is the opportunity to have me walking alongside you, helping you apply what you're learning to the real children on your caseload.
And the best part? You can access this learning and mentorship from the comfort of your own home, wherever you are in the world.
Join the waitlist for our February 2027 intake!
References and Further Reading
Hammer, D. W. (2007). Childhood Apraxia of Speech: Evaluation and Therapy Challenges. Presentation, Brisbane, Australia, 15 June 2007.
Hammer, D. W., & Ebert, C. (2018). The SLP’s Guide to Treating Childhood Apraxia of Speech. Speech Corner. Chapter 7, Using Multisensory Cues in Therapy, pp. 71–80.
Hammer, D. W. Multi-Sensory Approach to Achieving Speech Outcomes: An Interview with Dave Hammer.OPPEN CAS. https://oppencas.ca/multi-sensory-approach-dave-hammer/
Komadina, O. CAS Therapy Handbook. Cueing Hierarchy and Motor Speech Cues, pp. 20–24. https://www.olgakomadinapraxiatherapy.com.au/product-page/the-apraxia-cas-therapy-handbook-live-examples-detailed-strategies-1
Marshalla, P. Hammer’s Cues for Apraxia. https://pammarshalla.com/hammers-cues-for-apraxia/
Strand, E. A. (2020). Dynamic Temporal and Tactile Cueing: A Treatment Strategy for Childhood Apraxia of Speech. American Journal of Speech-Language Pathology, 29(1), 30–48. https://doi.org/10.1044/2019_AJSLP-19-0005
Comments