Motor Speech Treatment Hierarchy
Motor Speech Treatment Hierarchy
Motor Speech Treatment Hierarchy
Dynamic Temporal and Tactile Cueing (DTTC) for speech motor learning is a method that
incorporates principles of motor learning and is used with children who struggle and are
unsuccessful with articulatory imitation. DTTC allows for continuous shaping of the movement
gestures, with the goal of improving motor planning (Bowen, 2011). According to Strand (2020),
the overall goal of the DTTC is to improve the patient’s efficiency of neural processing for the
development and refinement of sensorimotor planning and programming. DTTC is based on
integral stimulation (“look at me, listen to me, say what I say”) and involves intensive drill on a
core vocabulary (Maas & Farinella, 2012). This integrated stimulation involves the manipulation
of imitation, cues, speech rate, and the timing of models and imitation (Skelton & Hagopian,
2014). The steps in DTTC are as follows:
1. Imitation – In its implementation, DTTC begins with direct, immediate imitation of
natural speech.
2. Simultaneous production of prolonged vowels (most clinician support) – If the child
cannot imitate, the therapist makes the task easier and more ‘supported’ by introducing
simultaneous production. The clinician says the utterance at normal volume with child,
very slowly with touch or gesture cues as required. The utterance is slowed by sustaining
the vowel and not by undue emphasis on the onset consonant. This usually helps the child
to imitate while allowing the clinician to run a ‘visual check’ of jaw and lip postures.
3. Reduction of vowel length – The rate of stimuli production is increased (vowel length
is reduced) to sound more natural.
4. Gradual increase of rate to normal – Practice continues at this level to the point where
the child synchronizes effortlessly with the therapist at normal rate, with normal
movement gestures, and without silent posturing.
5. Reduction of therapist’s vocal loudness, eventually miming – Using delicate timing,
the therapist is then in a position to reduce volume eventually reaching a point where the
therapist is producing a mime (mouthing the utterance) as the child actually says it aloud.
Because of the intellectual closeness within the dyad this can be a tricky point in therapy,
and some children will dutifully follow exactly what the adult is doing so that the two are
miming at each other! This is obviously not the goal, and children may need explicit
instruction to keep their voice ‘turned on’ even though the adult’s is ‘off’. The gesture
and touch cues may still be needed at this point, and will be necessary in the next step, the
integral stimulation method proper.
6. Direct Imitation – The clinician ensures that the child is comfortable with moving to
this harder level in which the child watches the adult’s face while an auditory model is
provided. The child attempts to repeat the model and if successful does so many times. If
unsuccessful, the therapist may backtrack to the simultaneous level or silent
mouthing/miming level described above. Eventually all miming is faded completely, and
the child directly imitates and ‘repeats’ targets numerous times before the final step is
introduced.
7. Introduction of a one or two second S-R delay (least support) – Once the child is
directly imitating the therapist’s model with normal rate, prosody he or she can vary, and
appropriate articulatory gestures, the therapist inserts a new requirement: a one to two
second delay before the child imitates, so that the child produces a very slightly delayed
response (1- to 2- seconds delay). To facilitate this for the children who find the delay
difficult and want to ‘jump in’, miming while the child produces the delayed response is
often helpful.
8. Spontaneous production – Finally, the therapist elicits the spontaneous utterances,
for example, by asking the child questions (‘What is this called?’), using cloze tasks
(‘Twinkle, twinkle ___ ___’), sentence completion (‘Mother elephant is big, her baby is
____’) (Bowen, 2011).
