When “Simon Says” Doesn’t Work:Alternatives to Imitation for FacilitatingEarly Speech Development

Laura S. DeThorneCynthia J. JohnsonUniversity of Illinois at Urbana-Champaign

Louise WalderPrivate Practice, Mahomet, IL

Jamie Mahurin-SmithUniversity of Illinois at Urbana-Champaign

Purpose: To provide clinicians with evidence-based strategies to facilitate early speech devel-opment in young children who are not readilyimitating sounds. Relevant populations mayinclude, but are not limited to, children with autismspectrum disorders, childhood apraxia of speech,and late-talking toddlers.Method: Throughmultifaceted search procedures,we found experimental support for 6 treatmentstrategies that have been used to facilitate speechdevelopment in young childrenwith developmentaldisabilities. Each strategy is highlighted withinthis article through a summary of the underlyingrationale(s), empirical support, and specific exam-ples of how it could be applied within intervention.

Conclusions: Given the relatively sparseexperimental data focused on facilitating speechin children who do not readily imitate, theoreticalsupport emerges as particularly key and under-scores the need for clinicians to consider whythey are doing what they are doing. In addition,this review emphasizes the need for the researchcommunity to bridge the gap between pressingclinical needs and the limited evidence base thatis currently available.

Key Words: speech treatment, toddlers,preschool children, apraxia

Aspeech-language pathologist sits on the floor acrossfrom Micah, a 2-year-old boy with few intelligiblewords and a limited repertoire of speech sounds.

Despite Micah’s speech-language difficulties, there is no di-rect evidence of any neuromuscular difficulties.

In the clinician’s attempt to engageMicah, she pulls two ofhis favorite toys out of her bag—little plastic animals. Sheholds up a dog in one hand and a cat in the other.

“Which one do youwant, Micah?”He reaches for the dog.“You want the dog?” she inquires, stressing the name

of the desired object. Micah silently reaches again for thedesired toy.

The clinician pulls it just out of his reach and instructs,“Say dog.” Micah is silent.

The clinician prompts him again, this time with a sim-plified version of the word, “Watch my mouth. Say da,” butbefore she is able to finish, Micah has wandered off. The

clinician is frustrated. Although Micah has a small repertoireof speech sounds, including /d/, which he uses in spontaneousjargon, he will not imitate any of them. How is she supposedto help him talk intelligibly?

Children like Micah, who are not readily imitating soundsdespite typical strength and structure of oral neuromuscula-ture, are not uncommon on the caseloads of practicing speech-language pathologists, particularly those in early intervention.Relevant populations may include children with apraxia ofspeech, autism spectrum disorders (ASD), or those referred todescriptively as “late-talking toddlers.” Although goals forlanguage development are primary in many of these children,speech sound development may also be key. Recent researchin the treatment of speech sound disorders has focused pri-marily on how to select target speech sounds (e.g., Kamhi,2006) and relied heavily on traditional practices of speechsound elicitation that build on imitation abilities. For example,

Clinical Focus

American Journal of Speech-Language Pathology • Vol. 18 • 133–145 • May 2009 • A American Speech-Language-Hearing Association1058-0360/09/1802-0133

133

Van Riper’s hierarchy of production training begins by at-tempting to elicit imitation of isolated speech sounds (VanRiper & Erickson, 1996). Similarly, Strand and Skinder (1999)note that integral stimulation, one of the most common ap-proaches to treating childhood speech disorders, requireschildren to imitate models by the clinician. This void betweenthe literature that emphasizes imitation as a basic strategy forfacilitating speech sound production and the skills of youngchildren who do not readily imitate leaves clinicians strug-gling to determine best practice through a process of trial anderror. From this rich experience base, a few clinicians havetaken the initiative to share their strategies through books,videos, Web sites, and conference presentations (e.g., Boshart,2004; Hammer, 2006; Marshalla, 2003). In addition, themarketplace for practicing clinicians has been flooded withmaterials, such as whistles and chewy tubes, that are adver-tised as products to facilitate early speech production. Despitethe wealth of good ideas embedded in many of these re-sources, they are rarely grounded within a solid theoreticalframework or linked to the small repository of empiricalresearch on treatment efficacy that is available. Consequently,clinicians are left to filter through such products and ad-vice without much guidance in regard to evidence-basedpractice (EBP).

EBP has been defined as a framework for clinical decisionmaking that integrates scientific evidence with clinical ex-pertise and client values (American Speech-Language-HearingAssociation [ASHA], 2004; Dollaghan, 2007; Johnson, 2006).The importance of EBP has recently been emphasized inmultiple ASHA publications (e.g., ASHA, 2004, 2005;Mullen, 2007). Although the “gold standard” for evidenceof treatment efficacy is empirical data from randomizedexperimental designs emerging from a variety of indepen-dent investigators (ASHA, 2004; Johnson, 2006; Mullen,2007; Odom et al., 2005), few treatment approaches in speech-language pathology have accumulated this form of support.How then do clinicians answer pressing questions regardingthe treatment of children on their caseloads? Fortunately, EBPencompasses varied forms of evidence, including theoreticalgrounding and clinical expertise, and does not preclude use ofexperimental interventions. However, EBP dictates that webe aware of what evidence does or does not exist for our prac-tices and that we give thought to why certain strategies andtechniques might be successful. Without an understandingof why something works, there is always the danger that itwill be misapplied, and we will be left unable to build on thestrategy to form new and potentially better ideas.

The purpose of the present article is to highlight strategiesfor facilitating early speech sound development based on thecurrent evidence base. Although the strategies may applymore broadly, the focus is on young children who are notreadily imitating early speech sounds despite typicalstrength and structure of peripheral oral musculature. Theclinical goal is to facilitate speech development througheliciting relevant child vocalizations, whether imitative orspontaneous.

We began the process by generating a list of strategieswith an established theoretical framework that were beingpromoted by prominent clinical authorities in the treatmentof speech in children with developmental disabilities (e.g.,

Hammer, 2006; Manolson, 1992; Marshalla, 2003; Square,1999; Strand, 1995). We then used multifaceted search pro-cedures to identify relevant intervention studies, includingelectronic keyword searches of relevant databases (e.g.,PsycInfo, ERIC, PubMed) and ancestral searches of refer-ences in identified sources. Based on this review, we iden-tified six strategies with Level II empirical support (see ASHA,2004; Johnson, 2006; Justice & Fey, 2004, for a review ofevidence levels). Specifically, we selected strategies that weresupported by at least one experimental or quasi-experimentalstudy on a relevant population. Consistent with criteria outlinedin Dollaghan (2007) in regard to the evaluation of treatmentstudies, we considered a study as experimental if it activelymanipulated treatment in order to examine its effect on mean-ingful speech outcomes in a relevant pediatric populationusing either a comparison group or condition. Due to therelatively sparse literature, we have included semiexperi-mental studies that lack the random group assignment ornaBve evaluation usually associated with the gold standardin experimental design. To be considered a relevant popu-lation, the treatment study had to include children with sub-stantial speech impairment associated with developmentaldisability. Table 1 lists the six treatment strategies that metour criteria of evidential support. The remaining documentserves to summarize the theoretical and empirical supportfor each of these strategies as well as to underscore im-portant areas for future intervention research.

Before proceeding, we want to emphasize our focus oneliciting speech-like vocalizations in young children who arenot readily imitating speech sounds. If and when speechimitation skills emerge, additional strategies for shapingspeech productions are likely to apply. In addition, thepresent strategies do not explicitly address important goalsrelated to vocabulary and pragmatic development that willalso be key in many of these children. In sum, this articleis not intended as a “cookbook” for how to provide inter-vention. On the contrary, the focus on theoretical frame-works and the empirical research related to each strategy isintended to encourage clinicians to think independently andcritically about how each strategy may or may not applyto an individual case.

Evidence-Based Strategies for ElicitingSpeech-Like Vocalizations

1. Provide Access to Augmentative and AlternativeCommunication (AAC)Rationale. AAC encompasses the use of manual signs,

communication boards/books, high-tech electronic devices,and other forms of unaided and aided communication (Binger& Light, 2006, p. 200). We highlight the use of AAC asthe first strategy because of its relatively strong empiricalsupport and its underappreciated role in natural speech de-velopment. Although AAC can serve as a compensatorymeans of facilitating social interactions for children withsubstantial speech-language difficulties (e.g., Charlop-Christy,Carpenter, Le, LeBlanc, & Kellet, 2002; Cumley & Swanson,1999), we want to stress its utility in facilitating naturalspeech development. Although counterintuitive to many, AACcan serve as a critical tool in facilitating speech development

134 American Journal of Speech-Language Pathology • Vol. 18 • 133–145 • May 2009

TABLE1.

Summaryofsixstrategiesforfacilitatingsp

eech

soundsdev

elopmen

tin

child

renwhoarenotread

ilyim

itating.

Strateg

yPrim

aryratio

nale

Exa

mple

Key

empiric

alev

iden

ce

1.Provide

acce

ssto

AAC

Suc

cessfulc

ommun

icationen

hanc

esthe

deve

lopm

ento

frelev

ants

eman

tican

dsy

ntac

ticne

tworks

(i.e.,itprov

ides

amea

ning

fulframew

orkforprod

uctio

nof

new

words

,syllables

,and

soun

ds),

andin

theca

seof

voiceou

tput

device

s,prov

ides

atim

elyau

ditory

mod

el.

Provide

ach

ildwith

a“corevo

cabu

lary

book

”:a

smalla

lbum

that

includ

esph

otos

ofmea

ning

ful

objects,

peop

le,a

ndplac

es.

Millar

etal.(20

06)

2.Minim

izepres

sure

tosp

eak

Anx

iety

andstress

canha

veane

gative

impa

cton

motor

performan

ce.

Utilizepu

ppet

play

tomod

eltarget

soun

dsor

mov

emen

ts.

Bas

kett(199

6),K

ouri(200

5)

3.Im

itate

thech

ildIm

itatio

nmay

serveas

amod

elfor

eliciting

imita

tionitself.

Ifthech

ildba

bbles“bab

a,”repe

atthis

back

and

useitto

begintheso

ng“Baa

Baa

Black

She

ep.”

Field

etal.(20

01),Sno

w(198

9),

Tam

is-LeM

onda

etal.(20

01)

4.Utilizeex

agge

ratedintona

tion

andslow

edtempo

Neu

ralm

echa

nism

sde

votedto

melod

icprod

uctio

nca

nbe

used

to“boo

tstrap

”sp

eech

prod

uctio

n.

Produ

cemea

ning

fulw

ords

andph

rase

swith

exag

geratedpros

ody,

such

asan

elon

gated

risingintona

tionforthewordmorewhe

nus

edas

arequ

est.

Kou

ri&Winn(200

6),W

ade(199

6)

5.Aug

men

taud

itory,v

isua

l,tactile,a

ndprop

rioce

ptive

feed

back

Childrenwith

spee

chso

unddiso

rders

may

beless

able

toca

pitalizeon

the

sens

oryfeed

back

typica

llyav

ailable.

Enh

ance

visu

al/ta

ctile

feed

back

byprov

idingalight

tapon

your

ownor

thech

ild’s

lipswhile

mod

eling

prod

uctio

nof

a/b/s

ound

.

Berna

rd-O

pitz

etal.(19

99),

Hailpernet

al.(20

08)

6.Avo

idem

phas

ison

nons

peec

h-likearticulator

mov

emen

ts:foc

uson

func

tion

Sen

sory

motor

controlfor

spee

chis

somew

hatd

istin

ctfrom

nons

peec

horom

otor

beha

viors.

Ifalve

olar

spee

chso

unds

arebe

ingtargeted

,inco

rporatingtong

ueclicks

into

mea

ning

fulp

lay

wou

ldbe

moreap

prop

riate

than

tong

uewag

ging

orprotrusion

.

Braislin

&Cas

cella

(200

5)

DeThorne et al.: Alternatives to Imitation 135

by enhancing children’s ability to build relevant semanticand syntactic networks, and in the case of voice outputdevices, by providing a consistent acoustic model of targetsounds and words that children can select as needed (seeMillar, Light, & Schlosser, 2006).

Evidence. A review of evidence regarding the impact ofAAC on speech-language development in individuals withdisabilities is provided by Millar et al. (2006). Of the six stud-ies identified by the authors as demonstrating experimentalcontrol, 89% of the individual cases demonstrated increasesin speech production with the introduction of AAC, andthe remaining 11% of the cases showed no change. None ofthe 27 cases demonstrated a deleterious effect on speechproduction; however, a study by Yoder and Layton (1988)highlighted the potential importance of providing verbalmodels in conjunction with sign if the ultimate goal is tofacilitate speech production. On a related note, a single-subject design by Iacono and Duncum (1995) found that theuse of sign in conjunction with a speech output device wasmore effective in elicitingword productions from a 2-year-oldchild with Down syndrome than use of sign alone. In sum,the literature suggests rather convincingly that AAC not onlyprovides a compensatory mechanism for speech difficultiesbut can also serve as a powerful tool in facilitating naturalspeech development.

Examples. The many issues involved in successfully se-lecting and implementing AAC are beyond the scope of thisarticle, and readers are referred to the variety of more com-prehensive resources (e.g., Beukelman & Mirenda, 2005;Light, Beukelman, & Reichle, 2003; Reichle, Beukelman, &Light, 2002). However, we offer a few examples of low- andmid-tech options that have been successfully implementedwith young children. For example, meaningful signs can bemodeled directly by the examiner or through hand-over-handfacilitation of the child’s hands, if he or she is receptive tothis. Blacklin and Crais (1998) stress the importance of be-ginning with “survival words” that are likely to be motivatingand powerful, such as words that facilitate requesting andprotesting (see also Bondy & Frost, 1994). Considerationsfor selecting signs, especially for children with cognitiveor motor coordination constraints, include the iconic andmotoric complexity of the signs, with symmetrical contactgestures with high iconicity being easiest. Specific examplesinclude modeling the sign for “more”when a child is reachingfor another cookie or “open” when a child is struggling toopen a container of interest.

Given the possibility that children with substantial articu-lation difficulties may also experience difficulties coordi-nating manual communication, AAC devices that utilizepicture symbols and voice output provide another potentiallyhelpful modality. Hammer (2006) suggests a “core vocab-ulary book” that could include photos or symbols of favoredobjects, people, and activities. A child who is searching fora favorite toy or wondering where Mom is could point tothe relevant item or person in his or her book. As another ex-ample, options for snacks and mealtime could be pictoriallyrepresented on the refrigerator door, so that a child couldpoint to what he or she wanted to eat either as an initiationor at the prompt of a caregiver. Bondy and Frost (1994) pro-vide a concrete hierarchy of steps that can be implemented

to help children discover the power of using pictures tocommunicate.

Voice output devices might also be appropriate for somechildren. Examples are varied and range from “talking keychains” that offer up to 10 s of voice recording to dynamicdisplays with word prediction and synthetic speech output.Examples for how to incorporate the simpler devices includeencouraging a child’s use of a speech output device to takehis or her turn in “reading” reoccurring words or phrasesfrom a repetitive book. A one-button speech output devicewith a belt clip could be worn throughout the day and used toparticipate in a common social routine, such as saying hello,or in making a frequent request, such as going to the bath-room. In addition to the texts cited earlier, the following Websites are useful in understanding the options and issues sur-rounding AAC: http://aac.unl.edu/, where the Universityof Nebraska at Lincoln provides a collection of resources andlinks related to AAC; www.wati.org/, where the WisconsinAssistive Technology Initiative sponsors a loaning library,training events, and related resources; and www.attainment-company.com/xcart/home.php, the Web site for the Attain-ment Company, which is known for its variety of relativelylow-cost AAC systems.

2. Minimize Pressure to SpeakRationale. In addition to building children’s linguistic

networks, AAC may actually facilitate speech in part by re-ducing pressure to “speak” in the traditional sense. The gen-eral strategy of reducing communicative pressure is basedon the premise that high-pressure situations can have a nega-tive impact on motor performance in both adults and childrenacross a variety of tasks, including speaking (e.g., Beuter&Duda, 1985; I.M. Blood,Wertz, Blood, Bennett, & Simpson,1997; Caruso, Chodzko-Zajko, Bidinger, & Sommers, 1994;Hardy, Mullen, & Martin, 2001; Milne, 1970; Tolkmitt &Scherer, 1986). Consider the difference between conversingwith a friend versus delivering a public speech, or singingin the shower versus performing a solo. The precise mecha-nism through which anxiety affects motor performance iscomplex, although the general response to stress involves ac-tivation of the sympathetic nervous system paired with inhi-bition of the parasympathetic system (G. W. Blood, Blood,Bennett, Simpson, & Susman, 1994; Robertson, 2004;Weber& Smith, 1990). Relevant effects on speech may include dis-ruption of respiratory function, increased muscular tremor,and altered sensitivity of sensory receptors within articulatoryregions (Weber & Smith, 1990).

Evidence. Experimental evidence in support of decreasingcommunicative pressure comes from studies that have com-pared children’s communicative behavior across conditionsin two different populations: children with autism and chil-dren late to talk. Specifically, a group design byBaskett (1996)directly compared the amount of vocalizations in 8 childrenwith autism, age 4–6 years, during two conditions: one inwhich the child and examiner were in the same room together,and one in which the examiner was in a separate room butcould be viewed live by the child through a video monitor.Both conditions included a scripted pseudoconversationintended to elicit interaction. The video condition was ex-pected to increase communicative behaviors by decreasingthe stress associated with direct interpersonal interaction. In

136 American Journal of Speech-Language Pathology • Vol. 18 • 133–145 • May 2009

support of this prediction, the children’s mean vocal behaviorpaired with eye gaze toward the examiner was higher in thevideo condition than in person. The study also providedpreliminary support for the idea that using a puppet as aconversational partner might decrease communicative pres-sure in some children, as evidenced by increased eye gaze andvocal behaviors (see also Bishop, Hartley, & Weir, 1994).

Additional support for the use of lower-pressure tech-niques comes from a recent study by Kouri (2005), a groupdesign comparing the effect of two treatment approaches,mand-elicited imitation and modeling with auditory bom-bardment, on word production in 29 late-talking preschool-ers. Although the mand-elicitation condition, which utilizedmands (e.g., “What do you want?”) and prompted imitations(e.g., “Tell me bubble”) of lexical items, elicited more tar-get words within the treatment setting, the number or per-centage of target words generalized to the home setting didnot differ between conditions. The study suggests that higher-pressure techniques, such as direct requests for imitation,do not enhance word learning outside the treatment settingto any greater extent than lower-pressure strategies, such asmodeling (see also Camarata, Nelson, & Camarata, 1994, fora similar study focused on grammatical targets).

Examples. Attempts to reduce communicative pressurecan take a variety of forms, depending in large part on whatcircumstances an individual child finds stressful. Examplesmight include avoiding direct requests for imitation, min-imizing time pressure, avoiding “test questions,” followingthe child’s lead, and utilizing familiar interactions and natu-ralistic settings (e.g., Girolametto, 1988). Additional clini-cal strategies include simultaneous vocalization (Velleman,2006) or “vocal contagion” (Marshalla, 2003) in which chil-dren vocalize in conjunction with others, thereby creatingless focus on their own voice.

We also recommend the use of puppets as interactive part-ners. Puppet play reduces the potential power differentialassociated with adult–child interactions and minimizes thepressure of certain social conventions such as eye contactand conversational turn-taking. Children can either interactdirectly with the puppet or simply observe interactions be-tween the puppet and clinician. Such interactions can be usedto model target sounds (e.g., using a bumblebee puppet tomodel syllable-initial /b/: “Bumblebee, you had better noteat my banana. Beware bumblebee, if you bite my banana I’llbop you with my bean bag!”), elicit imitations of relevantoral motor movements (e.g., encouraging a reticent puppetto open its mouth and say “ah” while pretending to playdoctor), or provide a comfortable context in which to useunfinished carrier phrases (“Let’s tell the bee when to start—ready, set I go!” to encourage spontaneous production of/go/).

3. Imitate the ChildRationale. In addition to being a low-pressure strategy,

the primary rationale for imitating the child is that it serves asa means to model the skill of imitation itself. In short, beingimitated may teach a child to imitate, and imitation is a use-ful strategy in learning to use spoken language (see Masur &Eichorst, 2002; Schwartz & Leonard, 1985; Snow, 1989).Recent evidence of mirror neurons is also consistent withthe importance of developing imitation skills (Nishitani,

Avikainen, & Hari, 2004; Rizzolatti & Craighero, 2004).Mirror neurons fire when an observer sees someone per-form a familiar action, and their firing activates relevantmotor neurons. A clinician’s imitation of a child’s speechmay trigger mirror neuron firing (Oberman&Ramachandran,2007), thereby serving as a form of involuntary rehearsalon the child’s part. Of interest, neural imaging studies in-dicate that the mirror neuron system is impaired in childrenwith ASD (Iacoboni & Dapretto, 2006); in fact, Daprettoet al. (2006) found an inverse relationship between symp-tom severity and mirror neuron activity in their func-tional magnetic resonance imaging study of 9 boys withASD.

Whether or not the adult’s example of imitation leadsto imitation by the child in the short term, focusing on thechild’s spontaneous activity within his or her natural envi-ronment is likely to be more engaging for the child (e.g.,Lewy & Dawson, 1992), facilitate generalization of any elic-ited speech sounds (Koegel, Camarata, Koegel, Ben-Tall,& Smith, 1998), and simplify the speaking task by using afamiliar form to elicit the unfamiliar function of imitation(Velleman, 2006).

Evidence. Imitating the child is incorporated as a singlethread in several multifaceted therapy programs (e.g., TheHanen Program for Parents or Greenspan’s Floortime ap-proach). The Hanen Program, for instance, stresses the im-portance of imitation, specifying “one of the best ways toconnect with very young children who are just beginningto communicate is to imitate their sounds, actions, facialexpressions and words” (Manolson, 1992, p. 18). Despiterelatively widespread use of this strategy in conjunctionwith other techniques, we focus here on evidence to supportits use in isolation. For example, Field, Field, Sanders, andNadel (2001) examined the effect of adult imitation of childbehavior in a sample of 20 nonverbal children with autism,age 4–6 years. Specifically the investigators compared chil-dren’s behavior across two conditions: one in which the adultimitated a child’s behaviors, including vocalizations, andthe other in which the adult was simply asked to play with thechild. The children exposed to the imitation condition dem-onstrated a significant increase in vocalizations across ses-sions, whereas the children in the play condition did not.

In addition, work by Snow (1989) including 100 childrenage 14–20 months demonstrated associations between thefrequency with which mothers imitated their children andthe frequency with which the children used imitation. Asmaternal imitation increased, spontaneous imitative behaviorincreased in their children’s speech as well. Although cor-relation designs do not specify causal influence, Snow usedsuch data to make the point that imitation is a skill that canbe learned, rather than a less mutable personality trait. Simi-larly, a prospective longitudinal study of 40 mother–childdyads by Tamis-LeMonda, Bornstein, and Baumwell (2001)found the extent to which mothers imitated their 13-month-old children predicted the timing of the children’s later childlanguage milestones even after controlling for child languagedifferences at 13 months. For instance, a mother might re-spond “Ball!” to a child’s vocalization of “ba”; such a re-sponse was found to predict the timing of developmentsincluding the child’s acquisition of his or her first 50 words,

DeThorne et al.: Alternatives to Imitation 137

the use of combinatorial speech, and first references to thepast.

Finally, a study by L. B. Leonard et al. (1982) supported theidea of selecting targets from the child’s current productions,which is a key element of imitation (see also Stoel-Gammon,1998). Leonard et al. found that young children (age 2;8 [years;months] to 3;1) were significantly more likely to producenewwords with phonological characteristics they had alreadyacquired than to produce phonologically challenging words.The authors introduced 16 unfamiliar words to 28 children,14 with normal language development and 14 with specific lan-guage impairment. Half of the items were “out-of-phonology”words containing initial consonants or clusters not yet ac-quired by the child, and half were “in-phonology” words.Both groups showed a clear preference for the in-phonologywords. The intervention strategy employed in this study, inwhich the in-phonology targets presented to the child weredetermined by the child’s prior productions, could be viewedas a form of delayed imitation of the child, which in turn fa-cilitated the child’s word production.

Examples.A clinician’s imitation of the child might includeverbal or nonverbal actions. In regard to the latter, imitating achild’s nonverbal actions, especially oral motor movements,could provide a useful springboard for facilitating verbal in-teraction. For example, if the child yawns, the clinician mightpretend to yawn (with an exaggerated vowel-like sound)and wait to see how the child responds. Similarly, if a childwere to make a lip-spreading movement (e.g., to smile for aphoto or to “show off ” something he or she did), the clini-cian might imitate the action and pair with a relevant speechsound, like a prolonged /i / for “See!”

Clinicians can also imitate a child’s spontaneous verbali-zations; for example, if the child says “baba,” the adult con-versational partner might imitate “baba” and then use it asa start for the song “Baa Baa Black Sheep.” As mentioned byMarshalla (2003), this strategy also allows a clinician to as-sign meaning to vocalizations that are already in a child’srepertoire. For example, the child may regularly vocalize“dih-uh” in his spontaneous jargon. If he happens to say itwhile pointing to a desired object, the clinician might imitateand assign meaning (which may or may not be there alreadyin the child’s mind) by saying, “Dih-uh. Oh, this one. Youwant this one,” and then pausing to give the child a chance torespond verbally or otherwise. Once a child is producing rec-ognizable words, incorrect pronunciations need not be imi-tated. Instead, imitation could serve as an opportunity tomodel the adult form of the word in conjunction with addi-tional strategies for facilitating language development, suchas expansion, which fall outside the scope of this article(see McCauley & Fey, 2006).

4. Utilize Exaggerated Intonation and Slowed TempoRationale. Whether imitating the child or initiating inter-

action, exaggerated intonation is a commonly employedtechnique (e.g., J. S. Leonard, 1992; Macaluso-Haynes,1985). Although the slower tempo that often characterizesphrases with exaggerated intonation may be facilitatory inits own right, we suggest that the primary rationale for thisstrategy is that neural mechanisms involved in singing can beused to “bootstrap” speech production due to partially dis-tinct but also overlapping neural networks. In a 2003 article,

Patel hypothesized that “linguistic and musical syntax sharecertain syntactic processes (instantiated in overlapping fron-tal brain areas) that apply over different domain-specificsyntactic representations in posterior brain regions” (p. 679).Similarly, research into the neural bases of pitch processingindicates that both right and left cerebral hemispheres, aswell as some subcortical structures, are involved in evalu-ating pitch changes in both speech and music (Baum & Pell,1999). However, some imaging studies have described dis-tinct patterns of brain activity for speech and singing. Jeffries,Fritz, and Braun (2003) concluded that speech involved rela-tively greater neural activation in left-hemisphere structures,while singing the same text resulted in a relative increase inright-hemisphere activity. For children in the target popula-tions, a focus on tasks that emphasize right-hemisphere activa-tion could prove to be a valuable compensatory mechanism.

In addition to the idea of neurological bootstrapping, asecondary rationale for modeling exaggerated prosody is thatprosodic features may be key in facilitating speech intelli-gibility. Even children without clear speech sound produc-tion may be able to increase their communicative success byutilizing familiar intonational patterns, such as a rising into-nation to mark a question versus a falling intonation tomark a comment (see Hargrove, Roetzel, & Hoodin, 1989).In other words, even if exaggerated intonation does nothelp with the accuracy or fluency of speech production, itmay highlight important features of the speech signal forintelligibility.

Evidence.While the neural pathways involved have yet tobe labeled conclusively, the use of music in speech therapyhas a long history. Clinicians have used singing in therapyfor patients with acquired apraxia (Wambaugh & Doyle,1994), and the fluency-inducing effects of singing are welldocumented in the stuttering literature (Alm, 2004). In fact,Melodic Intonation Therapy, developed by Albert, Sparks,and Helm (1973) for adults with aphasia, has been frequentlyapplied to young children with speech and language diffi-culties. The approach focuses on (a) the addition of a melodicline, (b) slowed tempo, and (c) exaggerated rhythm and stress(Wade, 1996).

Although exaggerated prosody has been used in the treat-ment of adult communication disorders (Hyland & McNeil,1987), we focus here on its use to facilitate speech produc-tion in young children. Wade (1996) conducted a single-subject alternating-treatment design to compare the effectsof Melodic Intonation Therapy versus oral motor treatmenton the initial consonant production of a 3-year-old girl withapraxia of speech. When the study began, she had been intreatment for a year and evidencedmore than a 1-year delay inthe areas of expressive language and phonology. A 2-monththerapy program targeted phonemes at varying levels of dif-ficulty, classed as “easy,” “intermediate,” or “hard.” Whenresults were compared for Melodic Intonation Therapy andoral motor therapy, the former was found to be significantlymore effective for phonemes at all three difficulty levels (seealso Helfrich-Miller, 1984). Additional studies with weakerexperimental designs have also noted gains in verbal imi-tation (Krauss & Galloway, 1982) and general intelligibility(Grube, Spiegel, Buchhop, & Lloyd, 1986) as a function ofexaggerating intonational patterns.

138 American Journal of Speech-Language Pathology • Vol. 18 • 133–145 • May 2009

In the realm of child language, a recent study by Kouriand Winn (2006) compared the use of sung versus spokenstories to facilitate learning of nonsense words by 16 preschool-age children with language difficulties. Although the sungcondition did not differentially facilitate word comprehen-sion, it was associated with more unsolicited attempts atimitation of the target forms during the second of the twoexperimental sessions. In sum, converging evidence supportsthe use of melody and exaggerated prosody to facilitate chil-dren’s attempts and accuracy at speech production.

Examples. Exaggerated prosody can be overlaid onto anymeaningful word or phrase. For example, the word hi couldbe produced with an elongated falling intonation, or the wordmore could be modeled with a rising intonation to denote arequest. Frequent two-syllable phrases could be presentedwith exaggerated two-tone patterns (e.g., high-low) and laterused as an unfinished carrier phrase (e.g., “AllllllI done” or“Light I on”). Phrases might be practiced with or withoutmusical “accompaniment,” such as striking two keys on akeyboard. Similarly, pauses could be inserted into familiarsongs to tempt children into completing the anticipated piece(e.g., “Like a diamond in theI” or “Row row row yourI”).

5. Augment Auditory, Visual, Tactile,and Proprioceptive FeedbackRationale. Though established speech production is usu-

ally highly automatic and accomplished without attentionto sensory feedback (Lof, 2007; see also Todorov, 2004),the latter likely plays an important role in establishing newspeech behaviors (Clark, Robin, McCullagh, & Schmidt,2001). Consequently, when imitation of a new speech move-ment is challenging under natural circumstances, we recom-mend enhancing sensory feedback to guide the newmovement.The rationale is that childrenwith speech difficultiesmay be lessable to capitalize on sensory feedback due to one or moreof the following reasons: (a) the need to focus the bulk of theirattention on the movement itself, (b) a lack of sensory recep-tors or good sensory function in certain feedback domains,such as audition, or (c) the tendency to experience more“sensory” or “motor noise” (Todorov, 2004, pp. 910–911)than typically developing children. In any case, augmentedsensory data may then be needed to develop internal modelsfor speech sound production. Internal models refer to theneural mechanisms that associate motoric plans with theirsensory consequences (Brass &Heyes, 2005; Iacoboni, 2005;Iacoboni & Wilson, 2006; Kawato, 1999).

Evidence. The small literature on the benefits of enhanc-ing sensory input or feedback focuses largely on manipulationof four domains: auditory, visual, tactile, and proprioceptive.In the auditory domain, the Fast ForWord Program (ScientificLearning Corporation, 1997) was developed to provide chil-dren with exposure to acoustically modified speech that in-volves slowed consonant-vowel transitions; we do not reviewthis literature here due to its focus on language outcomes inschool-age children who are likely to have already acquiredspeech imitation skills (Gillam, Loeb, & Friel-Patti, 2001;Gillam et al., 2008; Merzenich et al., 1996; Tallal et al., 1996,1997). In addition, there is a small literature regarding theuse of visual feedback to facilitate speech sound productionusing real-time spectrographic displays, ultrasound, and elec-tromagnetic articulography in older children and adults

(Adler-Bock, Bernhardt, Gick, & Bacsfalvi, 2007; Barry,1989; Carter & Edwards, 2004; Katz, Bharadwaj, &Carstens,1999; Katz et al., 2007; Meredith, 2007; Shuster, Ruscello, &Smith, 1992).

We focus here on two treatment studies that have utilizedmixed forms of augmented feedback to facilitate speech dev-elopment in young children with significant developmentalspeech disabilities. First, a study by Hailpern, Karahalios,Halle, DeThorne, and Coletto (2008) examined the role ofcomputerized contingent auditory and visual feedback onthe vocalizations of 2 nonverbal children with autism, age 5and 7 years, using an adapted within-subject experimentaldesign. Visual feedback included colorful circles, fireworks,or jagged lines that appeared on a computer screen in re-sponse to the loudness, pitch, and duration of the child’svoice. Auditory feedback included pitch-shifted replay ofthe child’s vocalizations, reverberation, or segments offamiliar musical tunes. Results found that computerizedfeedback increased vocalizations significantly in one childand demonstrated a promising trend toward increasingspeech-like vocalizations in the other (see also Bernard-Opitz, Sriram, & Sapuan, 1999). Despite its promise, resultsfrom this line of research are extremely preliminary. Theextent to which results will generalize across children andacross contexts is an area for further investigation.

In the tactile and proprioceptive realms, another moreestablished means of providing augmented feedback to fa-cilitate speech is a cuing system referred to as PROMPT,which stands for Prompts for Restructuring Oral MuscularPhonetic Targets (Chumpelik, 1984; Square, 1999). Thissystem uses a different tactile prompt for each English pho-neme according to its place, manner, and voicing in con-junctionwith providing auditory and visualmodels (Chumpelik,1984). Most cited research using PROMPTwith children hasbeen disseminated outside of peer-reviewed venues and comesfrom a single set of investigators (www.promptinstitute.com/;see Smit, 2004, as a potential exception). We will draw at-tention here to a study by Square, Bose, Goshulak, andHayden(n.d.) that was accessible online. This pilot study utilized asingle-subject design to target production accuracy of trainedlexical items in 6 boys, all age 4, with substantial language andphonological disabilities. The authors noted gains in targetproduction accuracy as well as in overall communication andsocial interaction (see also Rogers et al., 2006).

Examples. Enhanced feedback has been advocated formany years by prominent clinical authorities (e.g., Boshart,2004;Marshalla, 2005, 2007), with techniques such as speak-ing more loudly and facing the child to accentuate the audi-tory and visual characteristics of target sounds (Ertmer et al.,2002, p. 193). Focusing first on the auditory realm, targetwords and sounds can be delivered with slight amplificationthrough headphones (e.g., Hodson& Paden, 1991). Low-techoptions, such as talking into an echo microphone, a sec-tion of PVC pipe, a mailbox, or any chamber that creates anecho, can be used to attract the child’s interest to the targets.Enhanced visual feedback can be promoted by face-to-faceinteraction, mirror work, and gestures. Similarly, a puppetwith a movable mouth can provide visual input for speechin a way that may be less threatening to children than beingasked to attend directly to an adult (see Strategy 2). Currently

DeThorne et al.: Alternatives to Imitation 139

available computer programs that provide real-time visualfeedback in response to vocalization are limited to specializedinstruments, such as the Visi-Pitch IV by KayPentax, whichincludes voice games designed for children. In the tactileand proprioceptive domains, touch-pressure cues, such as alight tap on the clinician’s or child’s lips while modelingbilabial plosives, have been utilized (Bleile, 2004). Simi-larly, brushes (e.g., a toothbrush or cotton swab) and snackfoods (e.g., frosting or a lollipop on the alveolar ridge) haveall been used to draw attention to key articulator locations.

6. Avoid Emphasis on Nonspeech-Like ArticulatorMovements: Focus on FunctionRationale. One current controversy in the area of speech

motor control involves the relative task-specificity of speechproduction (see Ballard, Granier, & Robin, 2000; G. Weismer,2006; Ziegler, 2003). One view, referred to as the task-independent view or the hypothesis of “body part coding,”postulates a general sensory motor mechanism that under-lies movement regardless of function, thereby suggestingthat the neural basis of imitation is body part-specific (e.g.,Goldenberg & Karnath, 2006). Lof (2006) reports that someof the most commonly used oral motor activities includeblowing, tongue wagging, and smiling, in which a body partsuch as the lips or tongue is the focus, yet the direct relation tospeech sound production is unclear.

Despite the prevalence of such techniques, convergingevidence supports a more task-dependent model, in whichthe sensorymotor control of speech is somewhat distinct fromnonspeech oral motor behaviors, such as emotional expres-sion and vegetative functions (see G.Weismer, 2006; Ziegler,2003). Although the same muscles may be employed forspeech and nonspeech oral motor tasks, different musclefibers may be recruited and in markedly different waysdepending on the goal of the action (Iacoboni, 2005; Iacoboni& Wilson, 2006; Moore & Ruark, 1996; Ruark & Moore,1997). In sum, the task-dependent view stresses the impor-tance of helping individuals form an internal model of thetarget in regard to motor plans and sensory consequences, andemphasizes the goal or purpose of the motor task as criticalto its generalization.

Evidence. In regard to experimental evidence, studiesrelated to the effectiveness of nonspeech activities have gen-erally not supported their use for facilitating speech in chil-dren without gross neurological deficits (see reviews byForrest, 2002; Lof, 2006); however, few studies have beenpublished in peer-reviewed journals. As a notable excep-tion, Braislin and Cascella (2005) published a brief researchreport on the effect of oral motor treatment on the articu-lation errors of 4 first-grade students. Treatment includedgross motor activities, body positioning, and various artic-ulator movements and resistance exercises. The outcomevariable, scores on a standardized articulation test, did notimprove substantially after 7 weeks of intervention, which in-cluded a total of 15 half-hour sessions (see also Gommerman& Hodge, 1995). Although to date most studies of oral mo-tor activities have focused on older children who are alreadyattempting speech sound imitation, we recommend utilizingnonspeech activities judiciously and only when a child isnot yet imitating speech sounds. In addition, the nonspeechactivity should mimic the position, movement, and function

of the target speech sound(s) as closely as possible. One finalnote: It is important to distinguish between the use of non-speech oral motor activities, such as blowing bubbles orlicking a lollipop, for therapeutic versus motivational pur-poses. Such activitiesmay serve asmotivatingmaterials throughwhich to implement the strategies we discuss, but may notin and of themselves facilitate speech sound production.

Examples. Examples of incorporating relevant and func-tional nonspeech activities into therapy vary based on thetarget. For example, if alveolar sounds are being targeted,modeling tongue clicks would be more suitable than tongueprotrusion or tongue wagging, particularly if it could bepaired with a meaningful activity, such as a sound effect for aclock or knocking on “doors” in a lift-the-flap book. Sim-ilarly, if a clinician wanted to target fricatives, attempting toelicit airflow paired with constriction in the vocal tract islikely to be more facilitative than blowing exercises. For ex-ample, one might produce bilabial raspberries during vehicleplay to simulate a motor noise. Similarly, velars could betargeted through coughing sounds (e.g., make a kangaroopuppet “cough” and then ask it, “Kangaroo, do you have acold? Let me get you a Kleenex. Here’s a Kleenex, Kangaroo.Can you cough in the Kleenex? Ready, setI oh no, Kangaroois keeping his cough inside. Let’s help him cough”). As afinal example, attempts to elicit /m/ may be better facilitatedthrough use of a kazoo than a whistle because use of a kazooinvolves bilabial closure and the initiation of voicing (seeMarshalla, 2003).

Strategies for Future ResearchAlthough all of the strategies we have reviewed are in

need of additional investigation, this section focuses on fourpromising strategies that have not received direct examina-tion within a treatment study of childhood speech outcomes.We highlight each of these strategies in conjunction with itstheoretical rationale in hopes that it will elicit additionalexperimental investigation. First, a common strategy in thetreatment of children with motor speech disorders is utilizingcarrier phrases (Macaluso-Haynes, 1985; Strand, 1995;Yoss & Darley, 1974). The rationale is that carrier phrasesprovide a rich linguistic context for priming relevant seman-tic (e.g., Ferrand&New, 2004), structural (e.g., Kemp, Lieven,& Tomasello, 2005; Miller & Deevy, 2006; Savage, Lieven,Theakston, & Tomasello, 2003), and prosodic (e.g., Church &Schacter, 1994; Niedenthal, Krauth-Gruber, & Ric, 2004)networks. As an example, the repetitive phrase “Brown bear,brown bear, what do you ____ ?” (Martin & Carle, 1967)offers a syntactic frame that may prime the target word see viaits grammatical properties (i.e., the phrase requires a verb).In addition, it offers a context that activates semantic proper-ties (e.g., the concept of a bear elicits properties of animacy),and the prosodic pattern elicits the opportunity to close theintonational phrase or “melody.” Indeed, theories on the roleof prosody in language development and disorders proposethat a prosodic hierarchy of feet, prosodic words, and phonol-ogical phrases determines young children’s abilities to producestrong and weak syllables (Gerken & McGregor, 1998).

Despite widespread use, the effect of using carrier phraseson speech production has not been isolated within a treatment

140 American Journal of Speech-Language Pathology • Vol. 18 • 133–145 • May 2009

study, though their use in language treatment has beendocumented. For example, Bradshaw, Hoffman, and Norris(1998) found that the cloze procedure paired with expansionsfacilitated children’s language use more than a combinedparadigm of direct questions and direct modeling during bookreading in two 4-year-old children with language delay (seealso Girolametto, Pearce, & Weitzman, 1996, 1997). Futureresearch needs to evaluate the independent effects of carrierphrases on speech production in children from a variety ofrelevant populations.

A second strategy worthy of study is pairing vocalizationswith “analogous” cross-modality movements. For example,Hammer (2006) suggests modeling fricative sounds, such as/s/, by pulling one’s fingers along a string or pairing specificvowel sounds with gross arm movements that mimic lip po-sitioning, such as spreading armswide for /i/ or putting arms ina circle for /o/. Key to this strategy is utilizing movements thatare relatively automatic and analogous to the target vocali-zation so as not to compete with the attempted speech pro-duction for motoric or cognitive resources. We propose thatcoordinating or synchronizing movements may simplifymotor control for the nervous system (see Beheshti, 1993;Chang & Hammond, 1987; Getchell, 2006; Peters, 1977). Toour knowledge, this strategy has not been directly examinedin regard to facilitating children’s speech development. How-ever, there is a long tradition in vocal music pedagogy ofanalogous cross-modality movement as a teaching tool (e.g.,Gruhn, 2002; Wis, 1998).

A third strategy for consideration is encouraging vocal play,particularly play that involves articulator movement relevantto speech sound production (see Strategy 6 above), such asturning on and off voicing with a vowel-like production orexploring variations in pitch. The rationale for encouragingvocal play is based on the hypothesized importance of ex-perience and sensory feedback in forming internal models forspeech sound production (Max, Guenther, Gracco, Ghosh,& Wallace, 2004; Mussa-Ivaldi, 1999). Once children learnto associate specific motor commands with their sensory con-sequences, “motor control can be executed in a pure feed-forward manner” (Kawato, 1999, p. 718; see also Kent, 1998).Although not evaluated within an experimental treatment study,support for this strategy comes from links between infants’vocal play and their early speech development (Oller, 1980;Stark, 1980; Stoel-Gammon, 1998). In addition, a numberof studies have documented early speech difficulties in chil-dren whose vocal exploration was limited by tracheostomy(Hill & Singer, 1990; Kamen & Watson, 1991; Locke &Pearson, 1990; Ross, 1982).

Finally, for children with early metacognitive abilities, in-corporating metaphoric devices to solidify emergent speechsound knowledge should receive investigation. By meta-phoric devices, we refer to the pairing of specific speechsounds with meaningful environmental sounds, objects, orevents (e.g., referring to /s/ as “the snake sound”). As chil-dren try to acquire new speech sounds, they are essentiallyattempting to store, recall, and consistently produce a newform that for the moment carries little meaning. Motor learn-ing theorists speculate that imagery analogies or metaphorsmight help to relieve the load on abstract working memoryduring complex motor tasks by allowing individuals to use

visual processing skills or episodic memory and limiting re-liance on phonological processing (Baddeley & Hitch, 1974;Liao & Masters, 2001; Poolton, Masters, & Maxwell, 2006).This strategy may be particularly powerful for children withlimited verbal working memory capacity (S. E. Weismer,Evans, & Hesketh, 1999) or slowed learning ability (Windsor& Hwang, 1999). Additional examples of such “metaphors”for new target sounds include referring to /m/ as the “yummyfood” sound, /p/ as the “popcorn” sound, or /u/ as the “monkey”sound (cf. Bleile, 2004; Ertmer et al., 2002; Lindamood &Lindamood, 2003; Mawhinney & McTeague, 2004; Sindrey,1997).

Concluding RemarksIn sum, many children who do not readily attempt sound

imitation pose a significant clinical challenge in regard totargeting speech development. When experimental support isnot readily available, clinicians need to give conscious con-sideration to the rationale for their techniques, and the re-search community needs to take seriously the charge to fillcurrent gaps in the clinical knowledge base. Due to the pau-city of explicit and comprehensive resources on facilitatingspeech sound development in young children who do notreadily imitate, we considered theoretical frameworks andempirical research findings to emphasize six strategies to guideintervention. With this in mind, the following text “rewrites”the opening vignette using some of the evidence-basedstrategies outlined in this article.

In the clinician’s attempt to engage Micah, she pulls twoof his favorite toys out of her bag—little plastic animals. Sheholds up a dog in one hand and a cat in the other.

“Which one do you want Micah?”He reaches for the dog.“You want the dog?” she inquires, stressing the name

of the desired object with exaggerated intonation (Strategy 4).Micah silently reaches again for the desired toy.

“You want the dog,” she says as she touches the picture ofthe dog on Micah’s voice output device (Strategy 1). Theclinician hands him the dog and says the word one moretime, this time with a light touch to Micah’s upper lip as shepronounces the /d/ and a light touch to the underside of hischin as she pronounces the /g/ (Strategy 5).

With the dog in hand, Micah begins to walk it across thefloor while vocalizing “gogogogo.” The clinician imitatesMicah (Strategy 3) by saying, “Go go go. Go dog go.”WhenMicah abandons his dog in search of more toys, the clini-cian uses exaggerated falling intonation followed by a pause(Strategy 4) to say, “AllI done. We’re allI done. Bye-byedog.”

“Buh-buh,” adds Micah.

AcknowledgmentsThis project was supported in part by the U.S. Department

of Education, Project FOCAL (Grant H325D070061). Thanks toAmie King and Julie Hengst for sharing their expertise in AAC,Ashley Sharer and Lauren Mueller for their frequent trips to thelibrary (online and in person), and Bonnie Johnson, Pamela Hadley,and Pamela Marshalla for their feedback on earlier drafts of themanuscript. Finally, thanks to Z for inspiration.

DeThorne et al.: Alternatives to Imitation 141

ReferencesAdler-Bock, M., Bernhardt, B. M., Gick, B., & Bacsfalvi, P.

(2007). The use of ultrasound in remediation of North Amer-ican English /r/ in 2 adolescents. American Journal of Speech-Language Pathology, 16, 128–139.

Albert, M. L., Sparks, R. W., & Helm, N. A. (1973). Melodicintonation therapy for aphasia.Archives of Neurology, 29, 130–131.

Alm, P. A. (2004). Stuttering and the basal ganglia circuits: Acritical review of possible relations. Journal of CommunicationDisorders, 37, 325–369.

American Speech-Language-Hearing Association. (2004).Evidence-based practice in communication disorders: An intro-duction [Technical report]. Available from www.asha.org/policy.

American Speech-Language-Hearing Association. (2005).Evidence-based practice in communication disorders [Positionstatement]. Available from www.asha.org/policy.

Baddeley, A., & Hitch, G. (1974). Working memory. In C. H. Bower(Ed.), The psychology of learning and motivation (pp. 47–89).New York: Academic Press.

Ballard, K., Granier, J., & Robin, D. (2000). Understanding thenature of apraxia of speech: Theory, analysis, and treatment.Aphasiology, 14, 969–995.

Barry, R. M. (1989). EPG from square one: An overview of elec-tropalatography as an aid to therapy. Clinical Linguistics andPhonetics, 3, 81–91.

Baskett, C. (1996). The effect of live interactive video on the com-municative behavior in children with autism. Unpublishedmaster’s thesis, University of North Carolina, Chapel Hill.

Baum, S. R., & Pell, M. D. (1999). The neural bases of prosody:Insights from lesion studies and neuroimaging. Aphasiology,13, 581–608.

Beheshti, Z. (1993). Effect of imposed auditory rhythms on humaninterlimb coordination. Australian Physiotherapy, 39, 135–144.

Bernard-Opitz, V., Sriram, N., & Sapuan, S. (1999). Enhanc-ing vocal imitations in children with autism using the IBMSpeechViewer. Autism, 3, 131–147.

Beukelman, D. R., & Mirenda, P. (2005). Augmentative and al-ternative communication: Supporting children and adults withcomplex communication needs (3rd ed.). Baltimore: Brookes.

Beuter, A., & Duda, J. L. (1985). Analysis of the arousal /motorperformance relationship in children using movement kinemat-ics. Journal of Sport Psychology, 7, 229–243.

Binger, C., & Light, J. (2006). Demographics of preschoolers whorequire AAC. Language, Speech, and Hearing Services inSchools, 37, 200–208.

Bishop, D., Hartley, J., &Weir, F. (1994). Why and when do somelanguage-impaired children seem talkative? A study of initiationin conversations of children with semantic-pragmatic disorder.Journal of Autism and Developmental Disorders, 24, 177–197.

Blacklin, J., & Crais, E. (1998, November). Severe expressiveoutput disorders: A treatment protocol for young children. Paperpresented at the Annual Convention of the American Speech-Language-Hearing Association, San Antonio, TX.

Bleile, K. (2004). Manual of articulation and phonological dis-orders: Infancy through adulthood (2nd ed.). Clifton Park, NY:Delmar Cengage Learning.

Blood, G. W., Blood, I. M., Bennett, S., Simpson, K. C., &Susman, E. J. (1994). Subjective anxiety measurements andcortisol responses in adults who stutter. Journal of Speech andHearing Research, 37, 760–768.

Blood, I. M., Wertz, H., Blood, G. W., Bennett, S., & Simpson,K. C. (1997). The effects of life stressors and daily stressors onstuttering. Journal of Speech, Language, and Hearing Research,40, 134–143.

Bondy, A. S., & Frost, L. A. (1994). The Picture Exchange Com-munication System. Focus on Autistic Behavior, 9, 1–19.

Boshart, C. (2004, October). Oral-motor analysis and remedia-tion techniques. Presented at the One-Day Inservice, SpeechDynamics, Champaign, IL.

Bradshaw, M. L., Hoffman, P. R., & Norris, J. A. (1998).Efficacy of expansions and cloze procedures in the developmentof interpretations by preschool children exhibiting delayed lan-guage development. Language, Speech, and Hearing Servicesin Schools, 29, 85–95.

Braislin, M. A. G., & Cascella, P. W. (2005). A preliminary in-vestigation of the efficacy of oral motor exercises for childrenwith mild articulation disorders. International Journal of Reha-bilitation Research, 28, 263–266.

Brass, M., & Heyes, C. (2005). Imitation: Is cognitive neuro-science solving the correspondence problem? Trends in CognitiveSciences, 9, 489–495.

Camarata, S. M., Nelson, K. E., & Camarata, M. N. (1994).Comparison of conversational-recasting and imitative proce-dures for training grammatical structures in children with spe-cific language impairment. Journal of Speech and HearingResearch, 37, 1414–1423.

Carter, P., & Edwards, S. (2004). EPG therapy for children withlong-standing speech disorders: Predictions and outcomes.Clinical Linguistics and Phonetics, 18, 359–372.

Caruso, A. J., Chodzko-Zajko, W. J., Bidinger, D. A., &Sommers, R. K. (1994). Adults who stutter: Responses tocognitive stress. Journal of Speech and Hearing Research, 37,746–754.

Chang, P., & Hammond, G. R. (1987). Mutual interactions be-tween speech and finger movements. Journal of Motor Behavior,19, 265–274.

Charlop-Christy, M. H., Carpenter, M., Le, L., LeBlanc, L. A., &Kellet, K. (2002). Using the Picture Exchange Communi-cation System (PECS) with children with autism: Assessmentof PECS acquisition, speech, social-communicative behavior,and problem behavior. Journal of Applied Behavior Analysis,35, 213–231.

Chumpelik, D. (1984). The PROMPT system of therapy: The-oretical framework and applications for developmentalapraxia of speech. Seminars in Speech and Language, 5(2),139–156.

Church, B. A., & Schacter, D. L. (1994). Perceptual specificity ofauditory priming: Implicit memory for voice intonation andfundamental frequency. Journal of Experimental Psychology,20, 521–533.

Clark, H. M., Robin, D. A., McCullagh, G., & Schmidt, R. A.(2001). Motor control in children and adults during a non-speechoral task. Journal of Speech, Language, and Hearing Research,44, 1015–1025.

Cumley, G. D., & Swanson, S. (1999). Augmentative and alterna-tive communication options for children with developmentalapraxia of speech: Three case studies. Augmentative and Alter-native Communication, 15, 110–125.

Dapretto, M., Davies, M. S., Pfeifer, J. H., Scott, A. A., Sigman,M., Bookheimer, S. Y., & Iacoboni, M. (2006). Understandingemotions in others: Mirror neuron dysfunction in children withautistic spectrum disorders. Nature Neuroscience, 9, 28–30.

Dollaghan, C. A. (2007). The handbook for evidence-based prac-tice in communication disorders. Baltimore: Brookes.

Ertmer, D. J., Young, N., Grohne, K., Mellon, J. A., Johnson, C.,Corbett, K., & Saindon, K. (2002). Vocal development inyoung children with cochlear implants: Profiles and implicationsfor intervention. Language, Speech, and Hearing Services inSchools, 33, 184–195.

142 American Journal of Speech-Language Pathology • Vol. 18 • 133–145 • May 2009

Ferrand, L., & New, B. (2004). Semantic and associative primingin the mental lexicon. In P. Bonin (Ed.), Mental lexicon: Somewords to talk about words (pp. 25–43). New York: Nova Science.

Field, T., Field, T., Sanders, C., & Nadel, J. (2001). Children withautism display more social behaviors after repeated imitationsessions. Autism, 5, 317–323.

Forrest, K. (2002). Are oral-motor exercises useful in the treatmentof phonological /articulatory disorders? Seminars in Speech andLanguage, 23, 15–25.

Gerken, L. A., & McGregor, K. (1998). An overview of prosodyand its role in normal and disordered child language. AmericanJournal of Speech-Language Pathology, 7, 38–48.

Getchell, N. (2006). Age and task-related differences in timing sta-bility, consistency, and natural frequency of children’s rhythmic,motor coordination. Developmental Psychobiology, 48, 675–685.

Gillam, R. B., Loeb, D., & Friel-Patti, S. (2001). Looking back: Asummary of five exploratory studies of Fast ForWord. Amer-ican Journal of Speech-Language Pathology, 10, 269–273.

Gillam, R. B., Loeb, D. F., Hoffman, L. M., Bohman, T.,Champlin, C. A., Thibodeau, L., et al. (2008). The efficacy ofFast ForWord language intervention in school-age children withlanguage impairment: A randomized controlled trial. Jour-nal of Speech, Language, and Hearing Research, 51, 97–119.

Girolametto, L. E. (1988). Improving the social-conversationalskills of developmentally delayed children: An interventionstudy. Journal of Speech and Hearing Disorders, 53, 156–167.

Girolametto, L., Pearce, P. S., & Weitzman, E. (1996). Inter-active focused stimulation for toddlers with expressive vocab-ulary delays. Journal of Speech and Hearing Research, 39,1274–1283.

Girolametto, L., Pearce, P. S., & Weitzman, E. (1997). Effects oflexical intervention on the phonology of late talkers. Journal ofSpeech and Hearing Research, 40, 338–348.

Goldenberg, G., & Karnath, H. (2006). The neural basis of imi-tation is body part specific. The Journal of Neuroscience, 26,6282–6287.

Gommerman, S. L., & Hodge, M. M. (1995). Effects of oralmyofunctional therapy on swallowing and sibilant production[Abstract]. International Journal of Orofacial Myology, 21,9–22.

Grube, M. M., Spiegel, B. B., Buchhop, N. A., & Lloyd, K. L.(1986). Intonational training as a facilitator of intelligibility.Human Communication Canada, 10, 17–24.

Gruhn, W. (2002). Phases and stages in early music learning: Alongitudinal study on the development of young children’smusical potential. Music Education Research, 4, 51–71.

Hailpern, J., Karahalios, K., Halle, J., DeThorne, L., & Coletto,M. (2008, April). Visualization: Speech, language & autisticspectrum disorder. Work in Progress poster presented at theComputer Human Interaction 2008 Conference, Florence, Italy.Retrieved April 17, 2008, from www.chi2008.org/works_in_progress.html.

Hammer, D.W. (2006). Treatment strategies for childhood apraxiaof speech [DVD]. Pittsburgh, PA: CASANA.

Hardy, L., Mullen, R., & Martin, N. (2001). Effect of task-relevant cues and state anxiety on motor performance. Percep-tual and Motor Skills, 92, 943–946.

Hargrove, P. M., Roetzel, K., & Hoodin, R. B. (1989). Mod-ifying the prosody of a language-impaired child. Language,Speech, and Hearing Services in Schools, 20, 245–258.

Helfrich-Miller, K. R. (1984). Melodic intonation therapy withdevelopmentally apraxic children. Seminars in Speech and Lan-guage, 5, 119–125.

Hill, B. P., & Singer, L. T. (1990). Speech and language develop-ment after infant tracheostomy. Journal of Speech and HearingDisorders, 55, 15–20.

Hodson, B. W., & Paden, E. P. (1991). Targeting intelligiblespeech (2nd ed.). Austin, TX: Pro-Ed.

Hyland, J., & McNeil, M. R. (1987). The effects of intoningtherapy and the speech of a developmentally apraxic adult. InR. Brookshire (Ed.), Clinical aphasiology (pp. 288–299).Minneapolis, MN: BRK.

Iacoboni, M. (2005). Neural mechanisms of imitation. CurrentOpinion in Neurobiology, 15, 632–637.

Iacoboni, M., & Dapretto, M. (2006). The mirror neuron systemand the consequences of its dysfunction. Nature, 7, 942–951.

Iacoboni, M., & Wilson, S. M. (2006). Beyond a single area:Motor control and language within a neural architecture encom-passing Broca’s area. Cortex, 42, 503–506.

Iacono, T. A., & Duncum, J. E. (1995). Comparison of sign aloneand in combination with an electronic communication devicein early language intervention: Case study. Augmentative andAlternative Communication, 11, 249–259.

Jeffries, K. J., Fritz, J. B., & Braun, A. R. (2003). Words inmelody: An H2

15O PET study of brain activation during singingand speaking. Neuroreport, 14, 749–754.

Johnson, C. J. (2006). Getting started in evidence-based practicefor childhood speech-language disorders. American Journal ofSpeech-Language Pathology, 15, 20–35.

Justice, L. M., & Fey, L. (2004, September 21). Evidence-basedpractice in schools: Integrating craft and theory with science anddata. The ASHA Leader, 9, pp. 4–5, 30–32.

Kamen, R. S., & Watson, B. C. (1991). Effects of long-termtracheostomy on spectral characteristics of vowel production.Journal of Speech and Hearing Research, 34, 1057–1065.

Kamhi, A. G. (2006). Treatment decisions for children with speech-sound disorders. Language, Speech, and Hearing Services inSchools, 37, 271–279.

Katz, W. F., Bharadwaj, S. V., & Carstens, B. (1999). Electro-magnetic articulography treatment for an adult with Broca’saphasia and apraxia of speech. Journal of Speech, Language,and Hearing Research, 42, 1355–1366.

Katz, W. F., Garst, D. M., Carter, G. S., McNeil, M. R., Fossett, T.R., Doyle, P. J., & Szuminsky, N. J. (2007). Treatment ofan individual with aphasia and apraxia of speech using EMAvisually-augmented feedback. Brain and Language, 103,213–214.

Kawato, M. (1999). Internal models for motor control and trajec-tory planning. Current Opinion in Neurobiology, 9, 718–727.

Kemp, N., Lieven, E., & Tomasello, M. (2005). Young children’sknowledge of the “determiner” and “adjective” categories. Jour-nal of Speech, Language, and Hearing Research, 48, 592–609.

Kent, R. D. (1998). Normal aspects of articulation. In J. E. Bernthal& N. W. Bankson (Eds.), Articulation and phonological dis-orders (pp. 1–62). Boston: Allyn & Bacon.

Koegel, R. L., Camarata, S., Koegel, L. K., Ben-Tall, A., &Smith, A. E. (1998). Increasing speech intelligibility in chil-dren with autism. Journal of Autism and Developmental Dis-orders, 28(3), 241–251.

Kouri, T. A. (2005). Lexical training through modeling and elici-tation procedures with late talkers who have specific languageimpairment and developmental delays. Journal of Speech, Lan-guage, and Hearing Research, 48, 157–171.

Kouri, T. A., & Winn, J. (2006). Lexical learning in sung andspoken story script contexts. Child Language Teaching andTherapy, 22, 293–313.

Krauss, T., & Galloway, H. (1982). Melodic intonation therapywith language delayed apraxic children. Journal of Music Ther-apy, 19, 102–113.

Leonard, J. S. (1992). Intervention with young children at risk forspecific communication disorders. Seminars in Speech and Lan-guage, 13, 223–236.

DeThorne et al.: Alternatives to Imitation 143

Leonard, L. B., Schwartz, R. G., Chapman, K., Rowan, L. E.,Prelock, P. A., Terrell, B., et al. (1982). Early lexical acqui-sition in children with specific language impairment. Journalof Speech and Hearing Research, 25, 554–564.

Lewy, A. L., & Dawson, G. (1992). Social stimulation and jointattention in young autistic children. Journal of Abnormal ChildPsychology, 20, 555–566.

Liao, C., &Masters, R. S. W. (2001). Analogy learning: Ameans toimplicit motor learning. Journal of Sports Sciences, 19, 307–319.

Light, J. C., Beukelman, D. R., & Reichle, J. (2003). Com-municative competence for individuals who use AAC: Fromresearch to effective practice. Baltimore: Brookes.

Lindamood, P., & Lindamood, P. (2003). Lindamood phonemesequencing program for reading, spelling and speech (LiPS)(3rd ed.). Bloomington, MN: Pearson Education.

Locke, J. L., & Pearson, D. M. (1990). Linguistic significance ofbabbling: Evidence from a tracheostomized infant. Journal ofChild Language, 17, 1–16.

Lof, G. L. (2006, November). Logic, theory and evidence againstthe use of non-speech oral motor exercises to change speechsound productions. Paper presented at the Annual Convention ofthe American Speech-Language-Hearing Association, Miami, FL.

Lof, G. L. (2007, November). Reasons why non-speech oral motorexercises should not be used for speech sound disorders. Semi-nar presented at the Annual Convention of the American Speech-Language-Hearing Association, Boston.

Macaluso-Haynes, S. (1985). Developmental apraxia of speech:Symptoms and treatment. In D. Johns (Ed.), Clinical manage-ment of neurogenic communication disorders (pp. 259–266).Boston: Little, Brown.

Manolson, A. (1992). It takes two to talk: A parent’s guide to help-ing children communicate. Toronto, Ontario, Canada: The HanenCentre.

Marshalla, P. (2003). Becoming verbal with childhood apraxia:New insights on Piaget for today’s therapy. Kirkland, WA:Marshalla Speech and Language.

Marshalla, P. (2005). Successful r therapy. Kirkland, WA: MarshallaSpeech and Language.

Marshalla, P. (2007, March). Practical therapy techniques forapraxia and dysarthria: Innovative strategies for developingmore intelligible speech (Grades PreK-6). Workshop conductedby the Bureau of Education and Research, Champaign, IL.

Martin, B., & Carle, E. (1967). Brown bear, brown bear, what doyou see? New York: Holt.

Masur, E. F., & Eichorst, D. L. (2002). Infants’ spontaneousimitation of novel versus familiar words: Relations to observa-tional and maternal report measures of their lexicons. Merrill-Palmer Quarterly, 48, 405–426.

Mawhinney, L., & McTeague, M. S. (2004). Early languagedevelopment: Handouts and activities with bonus CD-ROM.Greenville, SC: Super Duper.

Max, L., Guenther, F. H., Gracco, V. L., Ghosh, S. S., &Wallace,M. E. (2004). Unstable or insufficiently activated internal mod-els and feedback-biased motor control as sources of dysfluency:A theoretical model of stuttering. Contemporary Issues in Com-munication Science and Disorders, 31, 105–112.

McCauley, R. J., & Fey, M. E. (2006). Treatment of languagedisorders in children. Baltimore: Brookes.

Meredith, A. (2007, June). Implementing electropalatography inthe treatment of a child with a persistent speech sound disorder.Paper presented at the 2007 International Child PhonologyConference, Seattle, WA.

Merzenich, M. M., Jenkins, W. M., Johnston, P., Schreiner, C.,Miller, S. L., & Tallal, P. (1996). Temporal processing deficitsof language-learning impaired children ameliorated by training.Science, 271, 77–81.

Millar, D. C., Light, J. C., & Schlosser, R. W. (2006). The im-pact of augmentative and alternative communication interven-tion on the speech production of individuals with developmentaldisabilities: A research review. Journal of Speech, Language,and Hearing Research, 49, 248–264.

Miller, C. A., & Deevy, P. (2006). Structural priming in childrenwith and without specific language impairment. Clinical Lin-guistics and Phonetics, 20, 387–399.

Milne, D. C. (1970). The relation between anxiety and motor per-formance in young children. Unpublished doctoral dissertation,Michigan State University, East Lansing.

Moore, C. A., & Ruark, J. L. (1996). Does speech emerge fromearlier appearing oral motor behaviors? Journal of Speech andHearing Research, 39, 1034–1047.

Mullen, R. (2007, March 6). The state of the evidence: ASHAdevelops levels of evidence for communication sciences anddisorders. The ASHA Leader, 12(3), pp. 8–9, 24–25.

Mussa-Ivaldi, F. A. (1999). Modular features of motor control andlearning. Current Opinion in Neurobiology, 9, 713–717.

Niedenthal, P. M., Krauth-Gruber, S., & Ric, F. (2004). A rolefor emotion in lexical access. In P. Bonin (Ed.), Mental lexicon:Some words to talk about words (pp. 147–166). New York:Nova Science.

Nishitani, N., Avikainen, S., & Hari, R. (2004). Abnormalimitation-related cortical activation sequences in Asperger’ssyndrome. Annals of Neurology, 55, 558–562.

Oberman, L. M., & Ramachandran, V. S. (2007). The simulat-ing social mind: The role of the mirror neuron system andsimulation in the social and communicative deficits of autismspectrum disorders. Psychological Bulletin, 133, 310–327.

Odom, S. L., Brantlinger, E., Gersten, R., Horner, R. H.,Thompson, B., & Harris, K. R. (2005). Research in specialeducation: Scientific methods and evidence-based practices.Exceptional Children, 71(2), 137–148.

Oller, D. K. (1980). The emergence of the sounds of speech ininfancy. In G. H. Yeni-Komshian, J. F. Kavanagh, & C. A.Ferguson (Eds.), Child phonology (pp. 93–112). New York:Academic Press.

Patel, A. D. (2003). Language, music, syntax and the brain. NatureNeuroscience, 6, 674–681.

Peters, M. (1977). Simultaneous performance of two motoractivities: The factor of timing. Neuropsychologia, 15,461–465.

Poolton, J. M., Masters, R. S. W., & Maxwell, J. P. (2006). Theinfluence of analogy learning on decision-making in table ten-nis: Evidence from behavioural data. Psychology of Sport andExercise, 7, 677–688.

Reichle, J., Beukelman, D. R., & Light, J. C. (2002). Exemplarypractices for beginning communicators. Baltimore: Brookes.

Rizzolatti, G., & Craighero, L. (2004). The mirror-neuron sys-tem. Annual Review of Neuroscience, 27, 169–192.

Robertson, D. (2004). Primer on the autonomic nervous system(2nd ed.). New York: Elsevier.

Rogers, S. J., Hayden, D., Hepburn, S., Charlifue-Smith, R.,Hall, T., & Hayes, A. (2006). Teaching young nonverbal chil-dren with autism useful speech: A pilot study of the DenverModel and PROMPT interventions. Journal of Autism andDevelopmental Disorders, 36, 1007–1024.

Ross, G. S. (1982). Language functioning and speech developmentof six children receiving tracheotomy in infancy. Journal ofCommunication Disorders, 15, 95–111.

Ruark, J. L., & Moore, C. A. (1997). Coordination of lip muscleactivity by 2-year-old children during speech and nonspeechtasks. Journal of Speech, Language, and Hearing Research, 40,1373–1385.

144 American Journal of Speech-Language Pathology • Vol. 18 • 133–145 • May 2009

Savage, C., Lieven, E., Theakston, A., & Tomasello, M. (2003).Testing the abstractness of children’s linguistic representations:Lexical and structural priming of syntactic constructions inyoung children. Developmental Science, 6, 557–567.

Schwartz, R. G., & Leonard, L. B. (1985). Lexical imitation andacquisition in language-impaired children. Journal of Speechand Hearing Disorders, 50, 141–149.

Scientific Learning Corporation. (1997). Fast ForWord [Computersoftware]. Oakland, CA: Author.

Shuster, L. I., Ruscello, D. M., & Smith, K. D. (1992). Evoking /r/using visual feedback. American Journal of Speech-LanguagePathology, 4(2), 37–44.

Sindrey, D. (1997). Listening games for littles. London, Ontario,Canada: Wordplay.

Smit, A. B. (2004). Articulation and phonology resource guidefor school-age children and adults. Clifton Park, NY: DelmarCengage Learning.

Snow, C. E. (1989). Imitativeness: A trait or a skill? In G. E. Speidel& K. E. Nelson (Eds.), The many faces of imitation in languagelearning (pp. 73–90). New York: Springer-Verlag.

Square, P. A. (1999). Treatment of developmental apraxia of speech.In A. Caruso & E. Strand (Eds.), Clinical management of motorspeech disorders in children (pp. 149–185). New York: Thieme.

Square, P. A., Bose, A., Goshulak, D., & Hayden, D. (n.d.).Effects of articulatory subsystem treatment for developmentalneuromotor speech disorders: A pilot study. Retrieved April 17,2008, from http://promptinstitute.com/.

Stark, R. E. (1980). Stages of speech development in the firstyear of life. In G. H. Yeni-Komshian, J. F. Kavanagh, & C. A.Ferguson (Eds.), Child phonology (pp. 73–92). New York:Academic Press.

Stoel-Gammon, C. (1998). Role of babbling and phonology inearly linguistic development. In A. M. Wetherby, S. F. Warren,& J. Reichle (Eds.), Transitions in prelinguistic communication(pp. 87–110). Baltimore: Brookes.

Strand, E. A. (1995). Treatment of motor speech disorders in chil-dren. Seminars in Speech and Language, 16, 126–139.

Strand, E. A., & Skinder, A. (1999). Treatment of developmentalapraxia of speech: Integral stimulation methods. In A. J. Caruso& E. A. Strand (Eds.), Clinical management of motor speechdisorders in children (pp. 109–148). New York: Thieme.

Tallal, P., Miller, S. L., Bedi, G., Byma, G., Wang, X., Nagarajan,S. S., et al. (1996). Language comprehension in language-learning impaired children improved with acoustically modifiedspeech. Science, 271, 81–84.

Tallal, P., Saunders, G., Miller, S., Jenkins, W. M., Protopapas,A., & Merzenich, M. M. (1997, October). Rapid training-driven improvement in language ability in autistic and otherPDD children. Paper presented at the annual meeting of theSociety for Neuroscience, New Orleans, LA.

Tamis-LeMonda, C. S., Bornstein, M. H., & Baumwell, L.(2001). Maternal responsiveness and children’s achievement oflanguage milestones. Child Development, 72, 748–767.

Todorov, E. (2004). Optimality principles in sensorimotor control.Nature Neuroscience, 7, 907–915.

Tolkmitt, F. J., & Scherer, K. R. (1986). Effect of experimentallyinduced stress on vocal parameters. Journal of ExperimentalPsychology: Human Perception and Performance, 12, 302–313.

Van Riper, C., & Erickson, R. (1996). Speech correction: Anintroduction to speech pathology and audiology (9th ed.).Englewood Cliffs, NJ: Prentice-Hall.

Velleman, S. (2006, November). Childhood apraxia of speech:Assessment/treatment for the school-aged child. Paper presentedat the Annual Convention of the American Speech-Language-Hearing Association, Miami, FL.

Wade, C. A. (1996). A case study: The effects of Melodic Intona-tion Therapy and oral-motor treatment on initial consonantproduction by a child with developmental verbal dyspraxia. Un-published master’s thesis, Kansas State University, Manhattan.

Wambaugh, J. L., & Doyle, J. R. (1994). Treatment for acquiredapraxia of speech: A review of efficacy reports. ClinicalAphasiology, 22, 231–243.

Weber, C. M., & Smith, A. (1990). Autonomic correlates of stut-tering and speech assessed in a range of experimental tasks.Journal of Speech and Hearing Research, 33, 690–706.

Weismer, G. (2006). Philosophy of research in motor speech dis-orders. Clinical Linguistics & Phonetics, 20, 315–349.

Weismer, S. E., Evans, J., & Hesketh, L. J. (1999). An exami-nation of verbal working memory capacity in children with spe-cific language impairment. Journal of Speech, Language, andHearing Research, 42, 1249–1260.

Windsor, J., & Hwang, M. (1999). Testing the generalized slow-ing hypothesis in specific language impairment. Journal ofSpeech, Language, and Hearing Research, 42, 1205–1218.

Wis, R. M. (1998). Invite, instruct, inspire. Teaching Music, 5(6),38–40.

Yoder, P. J., & Layton, T. L. (1988). Speech following sign lan-guage training in autistic children with minimal verbal language.Journal of Autism and Developmental Disorders, 18, 217–229.

Yoss, K. A., & Darley, F. L. (1974). Therapy in developmentalapraxia of speech. Language, Speech, and Hearing Services inSchools, 5, 23–31.

Ziegler, W. (2003). Speech motor control is task-specific: Evidencefrom dysarthria and apraxia of speech. Aphasiology, 17, 3–36.

Received December 11, 2007Revision received May 28, 2008Accepted September 19, 2008DOI: 10.1044/1058-0360(2008/07-0090)

Contact author: Laura S. DeThorne, University of Illinois–Speech& Hearing Science, 901 South Sixth Street, Champaign,IL 61820. E-mail: lauras@illinois.edu.

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