Evidence-based approaches to intervention with children with speech sound disorders (SSD) that have been covered elsewhere in this book are mentioned briefly in this chapter, along with more detailed accounts of those that have not. The reader is referred to Mirla Raz (A4) for information about an adaptation of traditional articulation therapy (Van Riper, 1978) she employs; to Barbara Hodson (A5) who describes the Cycles Phonological Patterns Approach (CPPA); and Karen Golding-Kushner (A17) and Dennis Ruscello (A48), both of whom share their expertise in managing resonance and speech difficulties, and compensatory errors in children with craniofacial anomalies, including clefts; Nicole Watts Pappas (A30) for a discussion of family-centred practice; and B. May Bernhardt and Angela Ullrich (A37) for an account of constraints-based non-linear phonology approaches. In Chapter 3, Karen Pollock (A18) clarifies the intervention needs of internationally adopted children, and Brian Goldstein (A19) advises on working with multilingual children who have SSD; information that is augmented by Krisztina Zajdó (A20) writing about speech acquisition in languages other than English. In Chapter 7, where treatment approaches and techniques for childhood apraxia of speech (CAS) are presented, Edythe Strand (A45) explains Dynamic Assessment using the DEMSS and its relationship to Integral Stimulation, and, Dynamic Temporal and Tactile Cueing for Motor Speech Learning (DTTC); Pam Williams and Hilary Stephens (A46) describe the Nuffield Centre Dyspraxia Programme; and Patricia McCabe and Kirrie Ballard (A47) present the Rapid Syllable Transition Training (ReST) intervention for school-aged children with CAS. Each account contains enough information for clinicians to implement the methodologies and/or to locate relevant literature.
In this chapter, there is Stimulability Therapy (Miccio, A23); an account of Auditory Input Therapy by Gwen Lancaster (A24); Perceptually-based Interventions by Susan Rvachew (A25); a minimal pair approach, Multiple Oppositions intervention, presented by A. Lynn Williams (A26); the Stackhouse, Wells and colleagues’ Psycholinguistic framework covered by Hilary Gardner (A27); Phoneme Awareness Therapy by Anne Hesketh (A28); and finally Vowel Therapy by Fiona Gibbon (A29). What a line-up!
Also in this chapter, are summaries of the phonetic, Grunwell and Metaphon approaches; three further minimal pair approaches: Weiner’s Conventional Minimal Pairs, Gierut’s Maximal Oppositions and Gierut’s Empty Set; Klein’s Imagery Therapy; the Whole Language Approach of Hoffman and Norris; and Dodd and co-workers’ Core Vocabulary Approach. As noted above, interventions for CAS are in Chapter 7 along with Velleman’s Phonotactic Therapy, which can be applicable to both phonological disorder and CAS. Parents and Children Together (PACT) which I developed, and ultimately evaluated under the supervision of Dr. Linda Cupples, for my doctoral research is detailed in Chapter 9.
Phonetic approaches focus on discrimination and production of articulatory targets. Motor-skills learning techniques (Schmidt & Lee, 2011) are used to teach individual error phones to preset criteria. Therapy that targets the phonetic level has its roots in traditional articulation therapy, and as Van Riper (1978, p. 179) wrote, ‘The hallmark of traditional therapy lies in its sequence of activities for: (1) identifying the standard sound, (2) discriminating it from its error through scanning and comparing, (3) varying and correcting the various productions until it is produced correctly, and finally, (4) strengthening and stabilizing it in all contexts and speaking situations.’
A phonetic approach or ‘articulation therapy’ is often used appropriately by SLPs/SLTs as a stand-alone intervention to address one or a few sound substitutions, omissions, distortions or additions in cases of functional articulation disorder, or persisting residual errors, where the client’s difficulty with speech production is at the perceptual and/or phonetic level. That is, the client has a functional difficulty with producing the phone involved in terms of their ability to perceive the target, and articulate it with accurate place, manner and voicing features. Furthermore, it can be the intervention of choice for children and youth whose articulation errors can be attributed to hearing impairment (e.g., those fitted with hearing aids or cochlear implants) or structural/anatomic differences (e.g., those with dental malocclusion or clefts). A sound-by-sound phonetic or articulatory approach is sometimes misapplied, however, by SLPs/SLTs when they use it as a stand-alone treatment for children with phonologically based difficulties, and in treating children with CAS.
Phonetic placement techniques are routinely incorporated into the treatment of children with SSD, whether they have a primary diagnosis of articulation disorder, or phonological disorder, or CAS, or structurally based speech impairment – or some permutation of these, with or without an auditory perceptual component. Target selection for children with articulation disorder is usually grounded in the eight traditional criteria displayed in Table 8.1, of (1) proceeding in typical developmental sequence, (2) favouring targets that are socially ‘important’ to the child or family, (3) prioritising phonemes that are readily stimulable in isolation, (4) using minimal feature contrasts, (5) selecting unfamiliar words as therapy targets, (6) giving preference to inconsistently erred sounds as treatment targets, (7) opting for sounds that have the most destructive effect on intelligibility and (8) addressing errors that are uncommon in typical development.
It was indicated in the explanation for parents in Box 2.1 that the types, or levels, of difficulty that children with SSD have with their speech can co-occur in the same child. For example, a child with a clear diagnosis of CAS may have a motoric explanation for the majority of his or her speech production problems (hence the diagnosis), but the same child might also have, for example, a difficulty at the perceptual level in distinguishing /ʃ/ from /s/, as well as a phonemic level difficulty with phonological organisation, replacing /k, ɡ/ with /t, d/, despite being able to produce the velar stops in CVs, VCs and CVCs. Similarly, a child with an unambiguous diagnosis of phonological disorder might have an articulatory (phonetic level) difficulty in producing the affricates /tʃ, dʒ/ and a perceptual level difficulty with distinguishing /.ɹ/ from /w/. What this means is that children with SSD may have a predominant ‘underlying cause’ or explanation for their speech problems coupled with some combination of perceptual, phonetic (articulatory), phonological (phonemic) and motoric (as in CAS or one of the dysarthrias that can present in children) explanations.
In principle, separating phonetic approaches from phonemic approaches helps us think clearly about the level at which we are working. In practice, ‘phonemic/phonological therapy’, ‘phonetic/articulation therapy’, ‘auditory discrimination training’ (perceptual intervention) and ‘Stimulability Therapy’ are not always completely distinct. This means that in the intervention process the clinician sometimes has to stop and think, ‘which level(s) am I addressing right now, and why?’ For example, Stimulability Therapy, with its aim of phonetic inventory expansion, is rooted at the phonetic level and can be thought of as a form of pre-practice (see below). But in addressing a child’s treatment goals, the clinician may combine it with auditory discrimination (perceptual) activities and group the child’s targets systemically into sound classes and phonemic contrasts so that the stimulability intervention affects a phonological flavour.
The aim of stimulability assessment is to discover whether the production of an error sound or missing sound is enhanced or made possible when elicitation conditions are modified or simplified. Traditionally, in child speech assessment, a child was said to be stimulable for a sound if he or she could produce it in isolation when given auditory and visual models, encouragement and support while ensuring that distractions and linguistic demands on the child were minimal. Also traditionally, developers of treatment approaches for child speech disorders have had no difficulty in persuading clinicians to focus on early developing and stimulable (in isolation) sounds first, on the basis that these sounds are easier for children to learn, and easier for the clinician to teach. As this made logical good sense, these rationales for treatment target selection remained unchallenged for decades; but eventually, dissenting voices were heard (Miccio, Elbert & Forrest, 1999; Powell & Miccio, 1996; Rvachew, Rafaat & Martin, 1999). The profession is now in a position to appreciate that stimulability data are of most interest in young children with severely restricted phonetic inventories, and of most use when they are collected for sounds absent from a child’s inventory. What is the current understanding of the term ‘stimulable’? In more recent speech assessment literature, ‘stimulability’ and ‘true stimulability’ have been used to mean that a child is stimulable for a consonant in at least two syllable positions, rather than simply being able to produce it imitatively in isolation. So, for example, a child would be considered stimulable for /k/ if able to produce it in isolation, and in the pre-vocalic and post-vocalic syllable positions (/k/, /ki/, /ak/); or in isolation, and in the pre-vocalic and inter-vocalic syllable positions (/k/, /ki/, /eɪki/). The child would not need to produce /k/ in a variety of vowel contexts (e.g., /ki/, /ku/, /kɔ/, /ka/; /ɪk/, /ɒk/, /ʌk/ and /æk/) in order to demonstrate ‘true stimulability’; two syllable positions suffice.
Schmidt and Lee (2011) define motor learning, discussed in more detail in Chapter 7, as ‘a set of processes associated with practice or experience leading to relatively permanent changes in the capability for movement.’ The precursors to motor learning are: (1) motivation, (2) focused attention and (3) pre-practice. In speech motor learning, pre-practice involves phonetic placement training prior to entering the practice phase; so, for many clients, it is inextricably bound up with stimulability training. Irrespective of speech diagnosis, for those clinicians who see their clients infrequently (e.g., on a sporadic consultative basis, or for brief therapy blocks of say, six consultations over six weeks), and for those who have virtually unlimited access to their clients, the modern notion of true stimulability for consonants has major implications.
Unfortunately – due to lack of personnel, funding and resources – in many clinical settings worldwide SLPs/SLTs see their clients with speech disorders infrequently. There are at least three common service delivery scenarios. First, some SLPs/SLTs working in consultative models may only see a given client once or twice a school term, and then only briefly. Second, other SLPs/SLTs see children for between 6 and 10 assessment/treatment sessions and then hand over the entire business of intervention to a parent in the form of a home program, or to a teacher, aide, assistant or other non-SLP/SLT as a school program, perhaps reviewing the child’s progress at intervals, but possibly not. And third, and literally quite close to home for the me, children attending publicly funded (government) agencies are allocated, by legislation, a maximum of 10 SLP/SLT appointments. Not 10 per school term or 10 per year: 10 full stop! Against this background, we know that SLPs/SLTs are uniquely qualified to make non-stimulable sounds stimulable, whereas most non-SLPs/SLTs probably have to rely on luck to achieve success in this area!
Dr. Adele Miccio (1952–2009) explored the role of stimulability in the treatment of children with SSD in A23. When she wrote her essay, Dr. Miccio was Associate Professor of Communication Sciences and Disorders and Applied Linguistics and Co-Director of the Center for Language Science at Pennsylvania State University, where she taught courses in phonetics and phonology and conducted research on typical and atypical phonological acquisition, the relationship between bilingual phonological development and later literacy abilities, bilingual phonological assessment, and treatment efficacy. Formerly a clinical SLP in Colorado, she received her PhD in Speech and Hearing Sciences from Indiana University–Bloomington. She was an Associate Editor of the American Journal of Speech-Language Pathology and on the editorial board of Clinical Linguistics & Phonetics. Her contribution to scholarship in our field was immeasurable and she is sorely missed. Her contribution is included in the second edition of this book with the kind cooperation and permission of her children, Anthony and Claire Miccio.
Several intervention approaches include the delivery of auditory input as key components. The rationale is the same for each, but the manner in which input is provided to children differs somewhat. The approaches are: CPPA with amplified auditory stimulation and focused auditory stimulation; PACT with listening lists and alliterative input delivered without amplification; Auditory Input Therapy described by Gwen Lancaster in A24; and Naturalistic Intervention (Camarata, 2010) in which multiple exemplars of target words are delivered as ‘broad target recasts’ to facilitate both increased sentence length and speech intelligibility.
Hodson and Paden (1983) incorporated amplified auditory stimulation, sometimes called ‘amplified auditory input’ at the beginning and ending of intervention sessions as a component of Cycles Therapy, also called the Cycles Phonological Remediation Approach (Prezas & Hodson, 2010). ‘Cycles’ has more recently come to be known as the Cycles Phonological Patterns Approach (CPPA) (Hodson, A5). Children listen to the clinician read 20 words with the week’s target pattern. The words are amplified slightly. In the session described in Hodson and Paden (1991, pp. 107–109) Amplified auditory stimulation is but one important component, and it is stressed that most of the time in each intervention session is devoted to production-practice motivational activities (Hodson, personal correspondence, 2013). The child must produce the target pattern appropriately in order to ‘take a turn’.
The small auditory input component involves children listening, through headphones for <30 seconds to 15–20 words, spoken by an adult, at the beginning and end of each session and once daily at home without amplification. Professor Hodson now prefers the terms ‘amplified auditory stimulation’ and ‘focused auditory input’ (‘focused auditory stimulation’) rather than ‘auditory bombardment (AB)’ because of concerns expressed by some caregivers and audiologists about possible negative connotations of the word bombardment, in the sense that ‘bombardment’ suggests the procedure is damaging to the ears (it is not!). The terms ‘focused auditory input’ (‘focused auditory stimulation’) relate to a technique used in working with toddlers, described in the next section.
Hodson and Paden (1983) proposed that auditory stimulation helped develop ‘auditory images’, allowing the child to learn to monitor incorrect productions, while production practice helped children develop accurate kinaesthetic images, which also assisted in error monitoring. Commenting on this proposal, Ingram (1989), citing Pye, Ingram and List (1987) posited that a promising explanation for the apparent usefulness of AB might lie in preliminary data from cross-linguistic phonetic acquisition studies of phonological acquisition. The 1987 study by Pye et al. suggested that the acquisition of first sounds is influenced more by their linguistic prominence than by their assumed articulatory difficulty. For instance, /v/ is acquired early by monolingual French-speaking and late by monolingual English-speaking children. The incidence of /v/ in French is higher than in English. Accordingly, Ingram (1989) suggested that AB might facilitate phonological change by increasing the frequency of some targets.
Professor Hodson describes a second procedure called focused auditory input (also known as focused auditory stimulation). It is intended for very young children who are unwilling or unable to participate in regular production practice activities when SLPs/SLTs first see them. In this case no production is requested. The clinician designs the environment to provide for lots of opportunities for the child to hear the target sound or pattern (Hodson, A5). The clinician essentially does language stimulation activities (following child’s lead, talking about what the child is doing, and so on) and in the process the child is exposed to many examples of the target. Focused auditory input is only used for one ‘cycle’.
In PACT intervention (Bowen & Cupples, 1999a), described in detail in Chapter 9, a variation of Hodson and Paden’s (1983) ‘original’ AB appears as a constituent of the Multiple Exemplar Training component. Hodson and Paden used headphones and amplified AB, but in PACT neither is employed. Auditory input, or AB, without amplification, is used in PACT on the basis that phonological progress is sensitive to phonological input (Ingram, 1989). In practice there is overlap between the AB and the minimal pair games listed in Chapter 9. AB in the context of PACT sees the child:
listening to words with common phonetic features (e.g., all starting with /ʃ/); or
listening to minimally, or near-minimally contrasted words (‘rhyming pairs’) exemplifying a phonological process (e.g., the minimal pairs ship–sip, shell–sell, shy–sigh, etc., for palatal fronting; or the near minimal pairs two–toot, tie–tight, toe–tote, etc., for final consonant deletion; or the near minimal pairs nip–snip, nail–snail, no–snow, etc., for cluster reduction);
hearing alliterative input in the context of games and stories (Bowen & Rippon, 2013); and
Not to be confused with auditory integration training (also abbreviated AIT) (ASHA, 2004), Auditory Input Therapy (Lancaster & Pope, 1989; Flynn & Lancaster, 1996) has the advantage of being suitable for younger children and children with cognitive challenges, and it encourages the active participation of their caregivers (Lancaster, 1991). Camarata (2010) and co-workers use the term ‘Naturalistic Intervention’ to refer to similar ‘whole word’ procedures to improve the overall intelligibility and sentence length of children with severe SSD, including children with Down syndrome, children with autism and children who stutter. The essence of both AIT and naturalistic intervention involves setting up interesting and attractive games and tasks, called ‘thematic play’ in some literature, during which the client is exposed to multiple ‘repetitions’ of particular sound or word targets, spoken by the adult, with no requirement for them to practice saying sounds or words. AIT incorporates Conventional Minimal Pair therapy and metalinguistic activities.
Mrs. Gwen Lancaster is a British SLT working for the London Borough of Merton. She was a lecturer at City University in London for 10 years, where she taught in the area of child speech at Master’s level. Mrs. Lancaster is the surviving co-author of Working with Children’s Phonology (Lancaster & Pope, 1989) and Children’s Phonology Sourcebook (Flynn & Lancaster, 1996), and author of Phoneme Factory: Developing Speech and Language Skills (Lancaster, 2007), the companion book for the Phoneme Factory and Phoneme Factory Sound Sorter software (Roulstone, A8). She is involved in professional development teaching to SLT colleagues in the South West region of England, mentoring and providing second opinions. In A24 she talks about Auditory Input Therapy.
Dr. Susan Rvachew is a Professor in the School of Communication Sciences and Disorders at McGill University, Montreal, Canada. Her research interests are focused on phonological development and disorders with specific research topics, including the role of speech perception development in sound production learning, speech development in infancy, efficacy of interventions for phonological disorders and digital media applications in the treatment of phonological disorders. Current projects include an investigation of alternative approaches to the treatment of CAS, the generalisation of perceptually based interventions from the English to the French context and the impact of digital media on shared reading interactions. In A25, she discusses the role of speech perception development in sound production learning and the use of the Speech Assessment and Interactive Learning System (SAILS) software and other therapy tools in the remediation of categorical misperception (Rvachew, 2005a).
Selecting targets for phonemic (phonological) intervention begins with describing the child’s error patterns, and this can be done in at least two ways: by identifying phonological processes (phonological patterns) or by identifying phoneme collapses. Working from a natural processes perspective, the therapy targets are the correct productions; meaning that the correct adult form (the target) is contrasted with the sound the child usually produces (the error). For example, in working on velar fronting, with a child who replaces /ŋ/ with /n/, the therapist might choose fan, run, pin, gone and thin to contrast with fang, rung, ping, gong and thing, respectively. On the other hand, when working from the perspective of phoneme collapses, there are two steps. The first is to look for lost contrast, for example, funny → /tʌni/ shell → /tæw/ cup → /tʌp/ cheese → /tid/, where four phonemes have been collapsed into one: /t/. The second step is to decide how to present the minimal contrast in intervention: will the therapist choose a Minimal Opposition (as is usual but not binding in Conventional Minimal Pairs), Multiple Oppositions, a Maximal Opposition or an Empty Set (Unknown Set)? No matter how targets are selected, in minimal pair therapy, activities are designed to demonstrate to the child how changing sounds in words (e.g., from back to bag, or from car to tar), or how changing the structure of syllables (e.g., from so to soap, or from tap to trap), results in changes in word meaning, and that this affects communication. And, no matter which approach is chosen, feature contrasts are central to the child’s learning.
Phonemes are not ‘contrastive’ but their features are. Featural distinctions serve to create ‘opposition’ between phonemes (see Table 2.5). The non-major class distinctions are in place: differentiating labial, coronal and dorsal consonants; manner: differentiating stops, fricatives, affricates, nasals, liquids, glides; and voice: differentiating the voiced–voiceless cognate pairs, /p b, t d, k ɡ, f v, s z, ʃ ʒ, tʃ dʒ, θ ð/. Major class features distinguish between the main groupings of sounds in a language, namely, consonants versus vowels, glides versus consonants and obstruents (stops, fricatives, affricates) versus sonorants (nasals, liquids, glides, vowels). For example, bake–make illustrates a major class distinction between obstruents and sonorants; make–wake illustrates the major class distinction between consonants and glides. In the minimal pair silly versus Billy, the contrast is not quite maximal, but it is ‘maximal enough’ to be highly salient for a child receiving intervention. In silly versus Billy is labial /b/ versus coronal /s/, stop /b/ versus fricative /s/ and voiced /b/ versus voiceless /s/. It cuts across many featural dimensions, but as /s/ and /b/ are both obstruents there is no obstruent versus sonorant opposition (i.e., no major class feature distinction).
Recall that phonological (phonemic) approaches focus on teaching children the function of sounds, and all rest on the principle that, once it is introduced to a child’s system, a featural contrast will show generalisation to other relevant phonemic pairs. Four stand-alone minimal pair therapies – Conventional Minimal Pairs, Multiple Oppositions, Maximal Oppositions and Empty Set (Unknown Set) – are described below. Other phonological approaches incorporate minimal pair therapy, and these include Grunwell’s approach, Metaphon, Imagery Therapy, Auditory Input Therapy, CPPA, the Psycholinguistic Model and PACT, whereas minimal pair treatments are used in tandem with perceptually based interventions, such as SAILS (Rvachew, A25).
Employing Stampe’s natural phonology theory and identifying phonological processes in assessment (Grunwell, 1975, 1985a), British Linguist Pamela Grunwell proposed a treatment that was based around the principle that homophony motivates phonemic change, challenging the clinician to, ‘Expose the child systematically to the dimensions of the target system absent from his or her speech in a way in which both their form and communicative functions are made evident’ (Grunwell, 1989). Grunwell saw four main types of phonological change that could become the clinician’s focus for target selection and intervention:
Stabilisation: the resolution of a variable pronunciation pattern into a stable pattern.
Destabilisation: the disruption of a stable pattern, resulting in variability.
Innovation: the introduction of a new pattern.
Generalisation: the transfer of a pronunciation pattern across four possible contexts: phonological, lexical, syntactic and socio-environmental.
In selecting targets, Grunwell advised therapists to work in developmental sequence where possible, giving priority to patterns most deviant from normal phonology and/or to those most destructive of communicative adequacy. Systemic feature contrasts were minimal (e.g., fan vs. van; comb vs. cone) and structural contrasts near minimal (e.g., top vs. stop; Ben vs. bend) on the basis that, with small feature difference between the target and the error, there was nothing else to get in the way. There was no attempt to increase the saliency of contrasts, and clinicians tended to accept, unquestioningly, the notion that something might ‘get in the way’ if there were more feature differences within a word pair. I am still thinking about that idea.
Only gold members can continue reading. Log In or Register to continue
