Intervention of Speech Sound Disorders in Preschool and School-Age Children

Question 1

Characteristics of phonologically disordered
children

Answer 1

• Restricted range and frequency of sound segments
• Restricted range and frequency of segmental combinations
• Syllable structure form limited: CVCV
• Restricted range of features, especially affecting PLACE
• Limited range of FRICATIVES

Likelihood of voiced/voiceless confusion
* Limited production of consonant clusters
* Use of glottal stop as a substitute form
* Late developing sounds are more affected than earlier
developing sounds

Question 2

Treatment program
Comprehensive Treatment Program Components: 8

Answer 2

1. Identifying information (report)
2. Target behaviors selected for training (goals)
3. Establish pretreatment baseline
4. Select a specific treatment approach (articulation disorders vs. phonological disorder)
5. Identify sequence of training and behavioral procedures - progression from sounds to
   connected speech, reinforces, corrective feedback.
6. Generalization and Maintenance procedures (carry over, family training about prompting and
   reinforcing the target responses outside of clinic)
7. Dismissal criterion (90% accuracy or more)
8. Follow-up and booster treatment (e.g. 3 months following treatment, 6 months…)
   It is applicable to all clinical settings, across all children, for articulation or phonological disorders

Question 3

SELECT TARGET BEHAVIORS
Long term vs short term

Answer 3

Target behavior – treatment goals and objectives that aim to teach the child any skill or action

• Short-term objectives – steps towards support and achievement of long-term goals. Skills are
  taught within a short period of time (2 weeks to 3 months)
• Long-term goals - target overall communication behaviors (e.g. improve age-appropriate
  articulation/phonological skills; intelligibility; maintenance over time and in different contexts).
  Skills are taught over a longer period of time (6 months to 1 year)

Question 4

Establish baselines

Answer 4

Baselines – measured rates of treatment in the absence of treatment (Hedge,
1998). Baseline trials provide an opportunity to produce specific sounds in
different word positions in different words ( assessment results may not be as
accurate by the time of treatment, spontaneous improvement may occur).

1. Specify treatment targets (e.g. production of /s/ in initial-word position at the
   word level)
2. Prepare the stimulus items (select words to be taught and pictures to represent
   those words, modeling may be sufficient to evoke production)
3. Prepare a recording sheet
4. Administer discrete baseline trials – structured opportunity to produce a target
   sound in words/phr./sent. (can be evoked or modeled trials). If production
   does not improve with modeling – use other procedures (phonetic placement
   ….).
   * Evoked trials for /f/ - Show a picture with the target sound (fish); show four fingers (to evoke
   “four”); ask q-ns (what do you see).
   * Modeled trials are similar – with added modeling of correct production

Question 5

Select initial level and sequence of training

Answer 5

• Identify the level of response complexity – appropriate starting point
  for therapy (e.g. sound/syllable/word/phrase/sentence level,
  consider information from the baseline in terms of modeled and
  evoked trials)
• Use high frequency words for treatment and generalization (familiar
  and meaningful)
• Use facilitative phonetic contexts
• Higher level of response complexity increases treatment efficiency,
  progress is more rapid

Question 6

Development of measurable objectives

Answer 6

Define the target behaviors (short-term objectives and long term goals) in
measurable/operational terms
* Measurable objective/goal should consist of the following:
* Response topography or actual skills targeted ( e.g. will produce /s/..)
* Quantification of response (e.g. with 90% accuracy)
* Response mode (e.g. discrimination versus production training)
* Response level (e.g. in words/sentences)
* Response setting (e.g. in the clinic, in child’s home)
* # of sessions in which the target behavior productions are to be documented (e.g. across three
sessions)
* Only observable activities should be measured and documented.
* Observable activities and verbs are: point, repeat, match, name, tell, ask, count,
write, say….. (vs. think, feel, remember, understand, know..)

Question 7

Writing goals

Answer 7

SMART – popular systems of writing goals
* Specific – clearly defined
* Measurable – observable and written in measurable terms
* Attainable – consider underlying skills important for attainment
* Relevant – realistic, outcome focused
* Time bound – provide a clear time frame for achievement
* Treatment objectives for individual sounds:
* Jonny will produce /s/ and /z/ consonants in initial position in words, with 80 % accuracy, without cueing
* Treatment objectives for phonological error patterns:
* Jonny will demonstrate reduction of final consonant deletion by producing /p, t, k, m/ consonants in the word-final
position, using minimal pairs, with 90 % accuracy

Question 8

Behavioral Treatment Procedures 7
Shaping

Answer 8

Treatment is accomplished through the use of behavioral treatment
procedures to establish correct production of speech sounds and to
promote generalization/maintenance of correct production

• Shaping – production training that incorporates various behavioral procedures to help
  establish sounds in isolation and progress to more complex levels (for children with
  difficulty imitating target sounds correctly).
• Behavioral procedures:
  1. Phonetic placement
  2. Successive approximation
  3. Modeling
  4. Verbal instructions and Prompts
  5. Paired stimuli
  6. Positive reinforcement
  7. Corrective feedback

Question 9

Phonetic placement

Answer 9

1. Phonetic placement – teaching correct articulatory positioning by description and
   demonstration.
   * Use mirror for placement
   * Use tongue depressor for manipulation of articulators
   * Visual feedback – spectrographic displays
   * Diagrams and pictures of articulatory positions
   * Feeling laryngeal vibration
   * Manual guidance – physical manipulation of articulators, using tactile-kinesthetic stimulation or
   cueing (e.g. shaping child’s or clinician’s lips with fingers, for production of /b/; touching alveolar
   ridge with a tongue depressor to indicate place of articulation for /l/).

Question 10

Successive Approximation

Answer 10

2. Successive Approximation (sound shaping) – using sound that a child can already
   produce to help him learn a new sound.
   * First target a related sound that later can be related to the final target sound (shaping /r/ from /l/).

Question 11

Modeling

Answer 11

3. Modeling – demonstration of the target response . Child’s
   response
   to modeling is called imitation. Modeling is used in phonetic
   placement and successive approximation.

Question 12

. Verbal instructions and prompts

Answer 12

4. Verbal instructions and prompts
   * Instructions – verbal stimuli to facilitate actions
   * Prompts – cues that help elicit responses.
   * Verbal prompts: a). use of vocal emphasis such as increased vocal intensity or duration; b).
   Serve to facilitate production of the target sound (e.g. don’t forget the sound at the end of
   words)
   * Nonverbal/physical prompts (visual cues or stimulation): using signs and gestures to
   facilitate visualization of correct production of the target sound (e.g. gesturing tongue –tip
   contact against alveolar ridge, articulatory placement for /l/, using hands).

Question 13

Paired stimuli

Answer 13

5. Paired stimuli – pairing of picture stimuli to facilitate correct
   production of a target sound in words .
   * Identify key words (words in which incorrect sound is produced correctly )
   * Select 10 training words to pair with the key word , and create a picture
   board with the key word in the center and training words around the key
   word (fan-five, fan-fist, fan-fox…)
   * Reinforcement is given for correct production and corrective feedback is
   given for an incorrect production
   * Programmed sentence level follows (e.g. does the fan have five blades? Yes,
   the fan has five blades).

Question 14

Positive reinforcement
and
Corrective feedback

Answer 14

6. Positive reinforcement – primary reinforcers (e.g. food and drink)
   and social, secondary, reinforcers (e.g. verbal praise, tokens,
   stickers). Move from continuous to intermittent reinforcement.
7. Corrective feedback – verbal and mechanical

Question 15

Use specific treatment activities

Answer 15

Use specific treatment activities
* Use fun activities to engage children
* Find out child’s interests and find relevant games, materials
* Therapy activities should provide opportunities to practice target
speech sounds.
* Well selected materials increase motivation, cooperation, and
progress.

Question 16

Generalization

Answer 16

Generalization
* Assess generalization to untrained stimulus items
(production of trained speech sounds in untrained
stimuli (words, phrases..)
* Assess generalization across word positions
* Assess generalization within sound classes (e.g.
manner, place, voice features)and across sound classes
(teaching /s/ resulted in correct production of /l/).
* Assess generalization across situations – e.g. new
conversational partners or a different situation at
home.

Question 17

Maintenance considerations

Answer 17

Maintenance considerations
* Clinician should select functional speech sounds with a potential for
generalization, from the child’s environment
* Select common everyday words, phrases, questions
* Use naturally occurring reinforcers
* Delay reinforcement, with intermittent schedule
* Invite different people as part of treatment sessions, move treatment out of
treatment room
* Teach self-monitoring skills
* Teach contingency priming – children prime other to pay attention and
reinforce (e.g. mom, did you notice how I said /s/ in that word?)
* Work with family to carry over, do homework, use reinforcement for correct
production, to promote maintenance.

Question 18

Final steps in treatment program

Answer 18

Final steps in treatment program
* Dismissal (not always planned)
* Follow-up
* Booster therapy

Question 19

Frequently Asked Questions

Answer 19

Will the child get better without therapy?
* Maturation is possible, it is difficult to change patterns that persist for long
periods of time
* How long will therapy take?
* Each child is different
* Kids learn at a different pace
* Learning some phonemes can aid the acquisition of others
* Must reassess throughout therapy

Question 20

Selecting Intervention Targets
* Choosing Processes:

Answer 20

Choosing Processes: (Edwards, 1983)
* Choose processes that result in early success (stimulability)
* Choose processes that are “crucial” for an individual child
* Choose “early “ processes

Question 21

Selecting Intervention Targets cont.
Choosing Target Sounds:

Answer 21

Choosing Target Sounds: (Edwards, 1983)
* Choose sounds which are in the child’s phonetic repertoire
* Choose sounds for which the child is stimulable
* Choose sounds that should improve overall intelligibility
* Choose frequently occurring sounds

Question 22

Traditional articulation therapy:

Answer 22

Traditional articulation therapy:
* Approach that addresses improvement of speech production at
the level of production
* The main goal of therapy is to improve articulation by teaching
the motor skill of target sound production
* Generalization is achieved through practice of the target skill
* Sound by sound analysis treatment

Question 23

Phonological therapy

Answer 23

Phonological therapy:
* Addresses the child’s cognitive system as the basis of therapy.
* Main goal is to teach to conceptualize or understand the rules that
govern a language
* Intervention focuses on development of the phonological system
* Activities emphasize the communicative function of speech
* Limited use of drill work
* Procedures emphasize rule discovery
* Focus on more than one sound, focus on an entire class of sounds at
the same time

Question 24

Phonological therapy cont:
Goals of remediation

Answer 24

1. Facilitate the reorganization of the child’s sound system so that it
   matches the adult system.
2. Eliminate processes
3. Establish phonemic contrasts
4. Generalization

Question 25

A list of treatment approaches:
5

Answer 25

1 Van Riper traditional approach (Artic. disorder)
2. Phonological contrast approaches (Phon. disorder)
3. Cycles approach (Phon. Disorder)
4. Naturalistic speech intervention approach (primary focus:
overall speech intelligibility – for children with developmental
disabilities)
5. Metaphon therapy (Phon. Awareness treatment)

Question 26

Traditional approach
5 phases

Answer 26

• Motor based approach (Van Riper)
• Behavioral treatment procedures used during production training
• 5 major phases:
  1. Auditory discrimination training:
   Identification
   Isolation
   Stimulation
   Discrimination
  2. Production training: sound establishment
  3. Production training: sound stabilization
  4. Transfer and carry-over training
  5. Maintenance

Question 27

2. Phonological Contrast approaches

Answer 27

Main objective: to establish phonological contrasts.
* Theoretically based on linguistic phoneme feature analysis
* All approaches use minimal pair word sets that differ by only one
phoneme
* Child learns that change in phonemes will change the meaning.
* This approach teaches to self-monitor the correctness of
utterances, and it aids in generalization to connected speech

Question 28

Phonological Contrast approaches continue
SLP uses pairs of words that differ by either

Answer 28

• SLP uses pairs of words that differ by either:
• One feature : Minimal contrast (minimal opposition)
  – examples: tea-key (place)
  toe – so (manner)
  pig – big (voicing)
• Multiple features: Maximal contrast (maximal opposition)
  examples: chop – mop;
  can – lane;
  gear – shear

Question 29

Phonological Contrast approaches continue:
Steps:

Answer 29

• Identify a consistent substitution/pattern
• Identify minimal pair words that are distinguished by one
  phoneme
• Familiarize the client with the minimal pair words
• Display examples of each member of the pair (preferably
  in pictures) and ask child to identify (…show me “tea vs.
  key”)
• Reverse roles and have client name each word
• If child produces substitution, clinician would point to
  word that was said.

Question 30

Phonological Contrast approaches continue:
1. Perception
2. Production

Answer 30

Example: teach a CVC syllable structure for a child who only
produces CV utterances (FCD).

1. Perception – ability to discriminate between minimal pairs (bow-
   boat; pie-pipe)
   * Teaches the child to hear the contrast. SLP asks questions about
   the words to show meaning, or SLP labels the words and asks
   the child to point to the words being labeled.
2. Production – ability to produce the target word and another
   word, while pointing to corresponding picture
   * Here the child is instructed to tell SLP which pictures to pick up.
   Child can become highly frustrated.

Question 31

Phonological Contrast approaches continue:
* how does the SLP teach the child to produce the target sound ?

Answer 31

• Clinician teaches the child to produce the target response by either
  heightening the contrast or underlining the meaning differences
  between the words.
• Ultimately, a child learns that final consonant makes a difference in
  word meaning.
• When child has difficulty discriminating using minimal contrast pairs
  – then use maximal pairs (maximal phonological contrast).
• Maximal pairs/oppositions:
• Minimal pair words whose segments differ along several
  features (can/man, sat/mat, key/me)

Question 32

3. Cycles approach

Answer 32

• attempts to approximate the way phonological development normally occurs, (i.e., gradually,
  with a variety of sounds emerging before becoming productive)
• Designed for severely unintelligible children with phonological processes (intelligibility of less
  than 20%)
• Work in cycles, regardless of achievement
• Don’t aim for mastery, aim for progress
• No success for a certain time  move to another sound and then come back (recycling)

Question 33

Cycles approach continues:
Identification and selection of patterns and phonemes
How does the SLP identify error pattern what to work
On ?

Answer 33

Identification and selection of patterns and phonemes:
1. SLP identifies the error patterns based on standardized testing
and conversational samples.
2. Then SLP selects error patterns and specific phonemes for
treatment. Primary target patterns or phonemes:
* Early develop. phonological patterns and phonemes
* Most stimulable patterns and sounds

Question 34

Cycles approach continues:
General guidelines
What’s errors pattern based on ?

Answer 34

• Error patterns are targeted for treatment based on stimulability,
  intelligibility, and percentage of occurrence (40% or greater)
• Error patterns are not drilled to a criterion of mastery (e.g. 90%
  accuracy) – it’s a gradual process
• SLP works on error patterns for a period of time, and returns to
  them at a later date.

Question 35

Cycles approach continues:
* A cycle runs
How many cycles are needed ?
How
Many hours a week and for how long a cycle runs?
How many errors are worked on per sessions ?
When is a cycle completed ?

Answer 35

A cycle runs 5-16 weeks, all error patterns are targeted during a cycle.
* Each child needs 3-6 cycles (20-40 hours at 40-60 min per week) in total
treatment.
* Each sound in an error pattern receives 1 hour of treatment per cycle before
SLP works on the next sound in the pattern
* Only one error pattern is treated in each therapy session
* A cycle is complete when all target phonological patterns have been worked
on.
* Patterns are recycled as needed until they are corrected

Question 36

Cycles approach continues:
Treatment session components
1,2,3

Answer 36

1 Review of the previous session’s target words (practice word cards)

2 Auditory bombardment:
listening to 12 target words for 2 min, with amplification (via headphones)
Contrast correct and incorrect production of the target using minimal or maximal pairs in pictures (first SLP points to target and says it, then encourage the client to point to the target as you say it)

3 Target word cards - (drawing, coloring… pictures of 3 to 5 target words on index cards)

Question 37

Cycles approach (treatment session components
continues)
4,5,6,7

Answer 37

4. Production practice – repetition of target words using structured play
   activities (multisensory stimulation at the word level)
   * Use minimal pair words (with minimal or maximal contrast)
   * Ask the client to produce the target, give only the picture that
   corresponds with the word produced, even if it’s different from the
   target (e.g. if client says “ give me bow” instead of “boat”, then you will
   give a picture of a “bow”)
   * Then focus on play activities
5. Stimulability probing for the next session.
6. Repeating auditory bombardment
7. Home practice

Question 38

Cycles approach continues:
Selection of production practice words:

Answer 38

Selection of production practice words:
* Select words vs nonsense syllables
* Begin with simple monosyllabic words (CVC) , with facilitative
phonetic contexts
* Select words that can be represented by actual objects (especially
for younger children)
* Select words appropriate for child’s vocabulary level

Question 39

Naturalistic Speech Intervention Approach

Answer 39

Naturalistic Speech Intervention Approach (Camarata, 1993)
* for severe speech sound disorders, with profoundly compromised speech
intelligibility
* This program is for preschool children who are unable to comply with traditional
service delivery model, involving sitting, listening and producing on demand
* For children with developmental disabilities (DS, autism)
* Intelligibility is defined as “degree to which the listener understands the
speaker”
* Speech accuracy is defined as the accuracy/correctness with which individual
sounds are produced

Question 40

Naturalistic Speech Intervention continues:
Two-tiered program

Answer 40

1. Improve overall speech intelligibility
2. Focus on improving the accuracy of
   individual speech sound errors.

• For some children typical sound production may never be achieved, therefore speech
  intelligibility is the primary goal (by use of compensatory speech productions and target
  approximations), in order to achieve functional communication.
• Therapy is child-led
• Select toys and activities of high interest, therapy may take place in the clinic, home,
  school environment, playground, cafeteria.
• Service delivery is 2-3 times per week, 30-60 min sessions

Question 41

Naturalistic speech intervention continues:
First phase
Second phase:

Answer 41

First phase:
goal – to increase child’s functional speech intelligibility by establishing sound and word
approximations, so that the listener could understand
Naturalistic activities: watching videos, playing games, picture stimuli cards, reading books,
playing with objects, spont. Conversation
Provide natural feedback via natural recasts : corrective feedback given in a naturalistic fashion,
without requiring the child to imitate upon adult model.
* It follows immediately after child’s production, it is an exact or reduced imitation of
the child’s production, with correct adult production (child: “this a wion”. Clinician:
“yes, a lion”.)

Second phase:
Goal: to increase speech accuracy of selected sounds
Use more traditional articulation or phonological approach when the child is ready and mature

Question 42

Metathon Therapy

Answer 42

Phonological awareness
treatment:
* Phonological awareness – refers to explicit awareness and
attention to the internal structure of words (Owens, 2004).
* Phonological awareness - subcategory of metalinguistic
awareness (ability to manipulate and think about the structure of
a language).
* There is a link between phonological awareness deficits and later
problems in reading, spelling, and writing.
* Metaphonology – ability to attend to and reflect on phonological
structure of language.

Question 43

Metaphon Therapy: Designed to

Answer 43

Metaphon Therapy: Designed to enhance metaphonological skills
 Assumption that speech sound production difficulties stem from limited acquisition of the
rules of the phonological system
 Metaphonological activities are incorporated in therapy for highly unintelligible children
(because they have phonological awareness deficits).
 Metaphonological activities focus on rhyming, syllable segmentation and blending skills.
 Focus is on feature differences between sounds
 Helps develop awareness of sound based on place (front-back), duration (long-short) etc.
 Systematic training of phonological awareness, awareness of the properties of sound

Question 44

Metaphon therapy continues
Therapy play activities

Answer 44

Therapy play activities:
* Match long and short ribbons (for long vs short sounds)
* Place blocks at the front or back of a dollhouse (front/back sounds)
* Describing sounds in general (noisy vs. quiet sounds)
* Train game with an engine, middle car, and caboose (beginning, middle, and end sounds in
words).
* Playing with blocks where each block represents a syllable in a word.
* Children are provided with corrective feedback for incorrect production ( e.g. child said
“ca…” for “cat” and clinician replied: “ I heard the engine and the middle train car, but the
caboose was left out. Can you say the word again with caboose too?”