Phonological and Articulation Treatment: Current Best Practices

Submitted by
Jennifer Taps – jen.taps@gmail.com
Kathy Jillson - Manager - kathy.jillson@csesc.org

I. Introduction

Speech-language pathology has undergone a sea change in the last twenty-five years. In the early days of the profession, speech-language pathologists (SLPs) primarily worked with children who demonstrated speech sound disorders. School-based SLP caseloads now include children who have language-learning disabilities, students requiring literacy support, children with autism spectrum disorders as well as students with voice, fluency or dysphagia needs. Professional development opportunities abound to increase knowledge in these areas.

Despite these other developments, it is critical to stay current in the treatment of phonological and articulation disorders. According to the 2006 ASHA Schools Survey, 91% of school-based SLPs treat children with such needs. Private and hospital-based SLPs report similar trends.

The historical practice of teaching one sound at a time in developmental sequence to children with unintelligible speech has been turned on its head. Current research suggests that teaching complex, nonstimulable and later-developing sounds yields more change in a child's sound system. For children with one or two sounds in error, motor learning strategies lead to increased intelligibility and generalization of treated sounds. Such paradigm shifts require the careful study and application of SLPs. This effort leads to reduced treatment time and a more expedient return to classroom instruction.

This document features resources to help SLPs utilize the most current thinking and approaches to treat children with mild articulation errors and those with significant phonological disorders. These resources include assessment tools, treatment ideas, homework suggestions, research summaries and links to other online resources.

II. Theoretical Basis: What does the latest research say?

a. Four Goals of Treatment

This document will summarize current research on phonological and articulation treatment with several key principles underscoring its content. The treatment methodology suggestions follow the astute advice of Dr. A. Lynn Williams. In 2005, she wrote:

“Any phonological intervention program should be structured to include the following goals:
1. Provide opportunities for the child to discover the rule(s) that are being trained
2. Provide focused practice on the new target(s) in order for them to become automatic
3. Provide the child with linguistic/communicative feedback with regard to the semantic meaning of the child’s production
4. Provide opportunities to practice the new target(s) in naturalistic play activities”

These goals apply to both students with phonological and articulation needs. Furthermore, Dr. Williams emphasized the importance of attending to all aspects of a speech sound disorder:

“Regardless of the placement on the phonetic-phonemic continuum, children with speech disorders require aspects of each in remediating their sound disorders. The focus on either the phonetic or phonemic aspects of sound production will vary depending upon the child’s learning needs. I believe that intervention that focuses on one aspect to the exclusion of the other will be limited in terms of longer intervention periods and/or in failure to generalize.”

That is, Dr. Williams noted that all speech sound treatment must focus on both the linguistic aspects and physical production of targeted sounds. Children must know that sounds signal a change in meaning and how to say those sounds in various levels of difficulty (isolation to conversation). For the purposes of this document, however, phonemic (linguistic) strategies are shared in the phonological section while phonetic (motoric) strategies are shared in the articulation section. Researchers have started to study the interaction of these principles. To date, there is substantial evidence that each set of principles works. For now, clinicians can include aspects of both, as suggested by Dr. Williams, to ensure that each child masters his or her target sounds.

b. Evidence-based practice3 (E3BP)

In selecting the research for this, Dollaghan’s evidence-based practice3 (E3BP) paradigm (2007) was applied. During the last ten years, conversations have highlighted the importance of evidence-based practice (EBP). Clinicians engage in critical analysis of existing research to identify the most effective methodologies for treating communication disorders. Dollaghan clearly delineated and specified the three aspects of E3BP as taking into account: 1) the best available external evidence (relying on evidence from systematic research), 2) the best available evidence internal to clinical practice (relying on clinical expertise and training) and 3) the best available evidence concerning client preferences (looking at client characteristics). The author suggested that successful application of E3BP is marked by the following: an open mind about various theoretical perspectives, professional integrity and clinically ethical behavior. In particular, Dollaghan cautioned “Seeking evidence not in an effort to reduce honest uncertainty but rather in an effort to prove what one already believes is contrary to the fundamental thrust of E3BP.” With these principles in mind, clinicians must consider the best available external evidence to date.

c. Summary of five major theoretical perspectives (Kamhi, 2006)

In 2006, Kamhi summarized the five major theoretical perspectives in treating phonological disorders, including normative, bottom-up/discrete skill, language-based, broad-based and complexity-based. He described the normative approach as the treatment of sounds in typical developmental sequence, but questioned this practice when applying these principles to children with disorders. The bottom-up, discrete skill approach is marked by teaching the discrete skills of nonspeech movements and traditional motor teaching (one sound at a time from syllables to words to sentences, etc.); however, this approach lacks empirical support and other researchers (Lof, 2006; Green et al, 2000) have argued that “while differentiated movement is necessary for speech production, speed and strength of oral movements have little impact on speech sound production.” Kahmi characterized the language-based perspective as targeting language and communication directly and speech sound production indirectly. Other studies (Tyler & Sandoval, 1994) suggest that direct sound treatment is necessary to elicit change. The broad-based perspective was summarized as an eclectic approach that features different goal attack strategies depending on the individual child’s needs. Kamhi included Hodson and Paden’s cycles approach in this category. He cautioned that most of the current evidence supporting this worthwhile approach is presented in case studies rather than experimental studies. Systematic research of this methodology is required to demonstrate its efficacy. Lastly, Kamhi described complexity-based treatment as treating later-developing, phonetically-complex targets, the goal of which is treatment efficiency and maximum change. As of 2006, he reported that there was almost more research supporting the efficacy of this approach than the other four theoretical perspectives combined (Weston & Bain, 2003).

III. Phonological assessment: What assessment information drives efficient treatment?

a. Typical assessment procedures

i. Standardized Tests

A complete assessment allows the examiner to identify what sounds are in the child’s repertoire and what sounds are not. Frequently, standardized tests, such as the Goldman-Fristoe Test of Articulation-2 (GFTA-2) (Goldman & Fristoe, 2000) and the Assessment of Phonological Processes-Revised (APP-R) (Hodson, 1986), are employed for this purpose. Such instruments provide a quick “snapshot” of a child’s system as compared to their same age peers and yield standard scores and percentiles.

However, these tests usually sample sounds once in each word position. It may be the case that a child has partially acquired a sound in his or her system, but that he or she did not use it in that particular target. For example, a child might substitute /j/ for /l/ (as in [jaIt]) even though he or she produces /l/ with 60% accuracy in words. A clinician may recommend that /l/ be targeted even though this sound does not warrant treatment. Consequently, this task does not yield a full representation of the phonological system.

In 2005, Kollia and Eisenberg compared the performance of children on five standardized tests, including the GFTA-2, the Photo Articulation Test-Third Edition (PAT-3) (Lippke, Dickey, Selmar & Soder, 1997), Bankson-Bernthal Test of Phonology (BBTOP) (Bankson & Bernthal, 1990), the Clinical Assessment of Articulation and Phonology (CAAP) (Secord & Donohue, 2002) and Smit-Hand Articulation and Phonology Evaluation (SHAPE) (Smit & Hand, 1997). They wanted to determine if these tests accurately identify articulation or phonological disorders. Their preliminary findings suggested that the CAAP was the most stringent while SHAPE, GFTA-2 and PAT-3 were the most lenient (regarding error scores). Overall, they concluded that the content from these tests identified disorders, but they provided insufficient information to determine appropriate goals because they focused on relational analyses. That is, each test compared the child’s productions to adult-like productions rather than determining what sounds are present or absent in the inventory (independent of adult targets). To accomplish this goal, Kollia and Eisenberg recommended using independent probes to fully describe a child’s sound system.

ii. Oral mechanism examination

A phonological assessment protocol typically includes an oral mechanism examination. The purpose of this task is to note any structural or organic issues that may impact sound production. A child may present with a high palate or poor coordination of the jaw and lips. It is critical to note, however, that other children may possess these characteristics and yet produce sounds accurately.

The purpose is not to identify areas of need for oral-motor exercises. These practices lack empirical support (Lof, 2006). Moreover, Lof and Green et al (2000) have argued that “while differentiated movement is necessary for speech production, speed and strength of oral movements have little impact on speech sound production.” SLPs may access an oral motor examination resource (Addington, n.d.) here: http://www.speechfriends.com/BAoral_mechanism.pdf

During these tasks, SLPs may discover nonspeech apraxia, which may accompany childhood apraxia of speech. Other motor speech disorders may also be evident. SLPs are directed to this current summary of motor speech disorder assessment and treatment (Kent, 2000): LINK

iii. Conversation samples vs. single-word samples

Clinicians may also elicit a brief conversation sample during the assessment process. Masterson, Bernhardt and Hofheinz (2005) addressed the results generated by conversation samples as opposed to the information provided by single word samples. They established that conversation samples took three times as long to elicit and transcribe as compared to single-word tasks. Fortunately, the good news is that Masterson et al concluded that single-word tasks yielded the same information and fully represented a child’s system. Both tasks resulted in comparable Percentage Consonant Correct (PCC) scores. Moreover, word-level samples can be transcribed during administration and they provide the “big picture” of the phonological system. However, Masterson and her colleagues still suggested that conversation samples be collected to assess a child’s prosody, overall intelligibility, syntax, morphology, etc. Such tasks enable clinicians to rule in or out the possibility of childhood apraxia of speech (CAS) or other disorders. McCauley and Velleman (2008) reviewed the ASHA CAS technical documents. Based on existing evidence, the panel concluded that there are three hallmarks of CAS: 1) inconsistent error patterns, 2) disordered vowel productions and 3) prosodic difficulties. Children with CAS demonstrate one or more of these characteristics. For more information, readers may visit: LINK

b. Advanced descriptive assessment procedures

A thorough assessment will allow clinicians to fully describe a child’s sound system. Given the time constraints of a busy caseload and schedule, this creates a significant challenging for practicing SLPs. However, the initial investment of time spent in assessment and analysis will yield more efficient treatment results in the long run. The tasks below may initially take more time than the standard protocol of a standardized test, criterion-referenced test, oral mechanism examination and conversation sample. These tasks still provide valuable information that can corroborate more descriptive tasks. Once clinicians have had practice utilizing the performance-based tasks below, it should take no more than three hours to complete a full assessment, identify ideal treatment targets and to write a report. Anecdotal evidence from San Diego Unified School District SLPs suggests that many SLPs do not have an assessment report template. The creation of one will save significant time as well, thus allowing the SLP to focus on characterizing the child’s system rather than paperwork.

i. Strength-based assessment and child characteristics

A descriptive assessment includes performance-based tasks that identify the child’s strengths, needs and personal characteristics. Oftentimes, parents comment that reports are esoteric and focus on what their children cannot do; consequently, clinicians should strive to objectively characterize the child’s sound system in parent-friendly, yet positive terms. In particular, the clinician may highlight the fact that a child is stimulable for many sounds, demonstrated willingness to take risks or that he or she showed interest in various activities. SLPs may wish to write reports that feature parent-friendly sections in bullet points that identify strengths, describe the family or teacher concerns, characterize the sound system and offer facilitative strategies to support the child as he or she acquires sounds.
The next few sections focus on the characterization of the child’s sound system and the predicted results of targeting sounds for treatment. This resource also offers two case studies that illustrate the phases of the assessment process.

ii. Independent probes of singletons and clusters

Independent probes sample sound production in various positions and contexts (next to different vowels and consonants), allow clinicians to assess the level of knowledge for each sound (from “least” to “most”) and ultimately enable the identification of sounds out of inventory that may be targeted to create maximal change in the sound system. Of course, the elicitation of a large sample and subsequent analysis require more time to complete. Masterson and Apel (2006) argued that this time in analysis leads to more effective treatment approaches. Similarly, Dyson and Robinson (1987) stated that “Despite differences, the most appropriate treatment for a given child emerges directly from the results of the diagnostic assessment of the phonological disorder.”

Ideally, independent probes sample singleton sounds across word positions at least five times each. The sounds should also be elicited in clusters to determine which clusters are represented in the child’s repertoire. Due to the limited number of picturable clusters, it may be most feasible to sample each cluster two to three times (instead of five as mentioned for singletons). Elbert and Gierut (1986) suggested that an effective independent probe should be easy to administer, easy to analyze and that it should measure sound production in the context of treatment (i.e., at the word level). They also emphasized that these words should remain untreated so that the probe measures change throughout the treatment process. The same probe should be readministered frequently to monitor the effectiveness of treatment and/or treatment target selections. Moreover, these samples reveal generalization not just for target sound(s), but also within-class and across-class generalization. For example, a child might present with a sound system that includes all sounds, except for /s/, /z/, /ʃ/, /ʧ/, /ʤ/, /θ/, /ð/, /l/ and /r/ and most clusters. Based on the results of the assessment, the SLP may recommend targeting /sl/ and /θr/ words. During the treatment process, changes in the entire sound system should be monitored (not just the treatment sounds) to determine progress and whether or not the predictions for change came to fruition. The SLP may have predicted that some of the missing fricatives and affricates would emerge and that other clusters would be added to the system.

The contents of Gierut’s Phonological Knowledge Protocol (independent probe) are available in Dinnsen and Gierut’s book, Optimality Theory, Phonological Acquisition and Disorders (Advances in Optimality Theory) (2008). In addition, McLeod and Hand created an independent clusters probe accessible at: http://athene.riv.csu.edu.au/~smcleod/Consonantclustertest.pdf.

iii. Stimulability tasks

Research suggests that children will likely acquire stimulable sounds without intervention (Powell, Dinnsen & Elbert, 1991; Gierut, 2007). Consequently, to complete a full assessment, clinicians must determine the stimulability of sounds missing from the phonological system. For years, the most common method of determining stimulability consisted of asking the child to produce the sound in isolation given a model. In the last few years, researchers have used more in-depth tasks to determine the modifiability of a child’s production given various contexts, articulatory cues and modeling. Glaspey and Stoel-Gammon (2005) developed a task that samples target sounds across word positions and in the context of various vowels. The article abstract describing this dynamic assessment process is accessible here LINK For example, if a child does not produce /l/ during the independent probes, the examiner determines if the child can produce /l/ given various levels of support. Given cues and modeling, the SLP asks the child to produce /l/ in isolation, with the /a/ vowel (as in /la/, /ala/ and /al/), with the /i/ vowel (as in /li/, /ili/ and /il/) and with the /u/ vowel (as in /lu/, /ulu/ and /ul/). This provides the child with ten opportunities to produce the target sound rather than the one opportunity described above. Barlow, Storkel and Taps (2007) stipulated that any sound produced with 30% accuracy or greater be deemed stimulable and anything below this accuracy nonstimulable. Like sampling sounds more thoroughly in the independent probes, this provides the clinician with a more complete picture of what a child can do.

c. Analysis of the independent probe data

i. Phonetic inventory

As stated earlier, an independent analysis reveals the essence of a child’s phonological system rather than just comparing the child’s productions to those of adults. Once an in-depth independent probe has been administered, the results yield information about a child’s phonetic and phonemic inventories (Elbert & Gierut, 1986). The phonetic inventory consists of phones that occur at least two times in the probe sample (Stoel-Gammon, 1990) and encompasses all sounds that a child produced regardless of whether these sounds are correct or incorrect relative to the target. (For instance, a child may produce [θ] as a substitute for /s/ targets ([θʌn] for /sʌn/), but not for /θ/ targets. If the /θ/ sound occurs twice in the sample, it is considered to be part of the child’s phonetic inventory because there is evidence of sound production. Alternatively, relational analysis would not represent knowledge of this sound because it is a substitution rather than a “correct” target.) Sounds in the phonetic inventory are those which the child can physically produce. This implies at least some knowledge of the target sound.

ii. Phonemic inventory

A more complete assessment also provides data regarding the child’s phonemic inventory. Phonemes in the child’s phonemic inventory show a contrast in meaning. Such a contrast may be shown in initial (“hat” vs. “bat”), medial (“beg“ vs. “bag“) or final (“flag” vs. “flap”) positions. In these examples, /h/ and /b/ would be part of the child’s phonemic inventory as would /ɛ/, /æ/, /g/ and /p/. SLPs identify minimal pairs from the results of the independent probes. A smaller sample (like most standardized tests) would not yield enough opportunities for a child to demonstrate this kind of knowledge. Inclusion in the phonemic inventory implies greater knowledge of a sound because there is evidence that the child has both the motoric ability to produce the sound and the linguistic knowledge that its purpose is to denote a different meaning.

IV. Phonological Treatment (Emphasis on phonemic): What are the best targets?

a. Treatment targets: Which sounds?

i. Early-developing vs. later-developing sounds

Teaching phonetically-complex, later-developing sounds constitutes a significant paradigm shift in addressing speech sound disorders. In the past, conventional wisdom has suggested that treatment should mimic typical development in that sounds are presented in developmental sequence. However, children with phonological disorders require different input because of their limited sound repertoires. Gierut (2007) stipulated that children with such needs must be provided with “positive evidence” or “input that illustrates for the child the full range of advanced constructions, categories and structures that are permissible (“legal”) in the language.” In contrast, she argued that “It has been shown that simpler input actually makes language learning more difficult because the child is provided with only partial information about linguistic structures.” Teaching earlier sounds provides children with partial information about the sound system. In early intervention, time is of the essence. As stated earlier, Gierut (1998) noted the possible academic ramifications of arriving in kindergarten with unintelligible speech.

ii. Maximal vs. minimal pairs

Historically, SLPs have taught children rules about their linguistic systems through minimal pair contrasts. Frequently, these contrasts have targeted place (e.g., /t/ vs. /k/), voice (e.g., /s/ vs. /z/) or manner (e.g., /s/ vs. /t/). Gierut (2001) and Barlow and Gierut (2002) investigated the effectiveness of teaching various sound contrasts. They looked at four conditions: 1) Unknown vs. known sounds (nonmajor class distinction), 2) Unknown vs. known sounds (major class distinction) and 3) Unknown vs. unknown sounds (two new sounds, nonmajor class distinction) and 4) Unknown vs. unknown sounds (two new sounds, major class distinction). Major class distinctions exist for obstruents (stops, fricatives and affricates) when contrasted with sonorants (liquids, glides and nasals). When obstruents are contrasted with obstruents (and sonorants with sonorants), this constitutes a nonmajor class distinction because both share the same major class.

In all, Barlow and Gierut ranked these four conditions from most to least effective. They determined that the most effective pairing was teaching two unknown sounds that differ by major class distinction. These sounds differed by a major class distinction (sonorants vs. obstruents) and were maximally different from one another. As a result, the children learned multiple sound feature differences. Significant across-class and within-class generalization occurred. That is, children acquired target sounds and sounds in other classes, thus maximizing treatment efficiency. These powerful contrasts are also known as maximal pairs. Next on the list were two conditions, both equally effective. Children made gains when taught two unknown sounds with a nonmajor class distinction and one unknown sound vs. known sound with major class distinction. The least effective method was targeting one unknown sound vs. known sound with a nonmajor class distinction. These sounds (such as /s/ vs. /t/) differ minimally (same place, both obstruents). From this pairing, they discovered that children learn other fricative-stop distinctions and little else. This strategy did not yield significant changes in the whole phonological system.

As stated in the introduction, one of the four goals of phonological intervention is to give children opportunities to learn the rule(s) that are being trained. By providing them with these maximal contrasts (two maximally-opposed, unknown sounds), children benefit by learning both taught and untaught sounds and sound features. It should be noted that such contrasts can include two clusters (/θr/ vs. /sl/). Consequently, children add clusters and singletons to their phonological repertoires.

b. Stimulable sounds vs. nonstimulable sounds

Experts have aligned with different schools of thought in teaching stimulable vs. nonstimulable sounds. Some researchers (e.g., Rvachew & Nowak, 2001) and clinicians advocate teaching stimulable sounds because they are earlier-developing, make sense to families and may be more accessible to children. Conversely, other researchers (e.g., Gierut, 2007) and clinicians advocate teaching nonstimulable sounds because they create greater change in phonological systems. Moreover, Powell, Elbert and Dinnsen (1991) suggested that nonstimulable sounds require treatment to change while stimulable sounds will likely be acquired without intervention. Teaching nonstimulable sounds creates change in the whole system while stimulable sounds spontaneously improve without direct treatment. Powell and his colleagues emphasized the fact that teaching stimulable sound(s) only creates change for treated sound(s). Consequently, based on the available evidence, it is advisable to teach nonstimulable sounds whenever possible because of the widespread changes that occur. Each SLP must decide what his or her internal evidence (clinical expertise) indicates regarding the issue of teaching stimulable or nonstimulable sounds. To teach nonstimulable sounds, SLPs must possess knowledge and resources regarding phonetic placement strategies. Please refer to page 33 for more information about these critical skills.

Proponents of E3BP consider client preferences as the third tenet of practice. Children present with different personalities, activity interests and levels of confidence. Therefore, some children will demonstrate willingness to learn harder sounds while others will lack the confidence to do so. When children are unwilling to attempt nonstimulable sounds, there are a few ways that an SLP may approach this challenge. One method may be to teach one complex sound (stimulable) in tandem with another complex sound (nonstimulable). The child may feel a sense of success from the stimulable sound and respond to the more challenging sound with greater resilience and effort.

c. Language universals

Language universals (also called language laws or co-occurrences) constitute universal, implicational relationships that apply across all languages. Moreover, they allow clinicians to identify ideal intervention sounds because language laws can be utilized to predict what changes would occur in a system if particular sounds were targeted. Language universals have been identified to explain the relationships between sound classes (phonemic laws), word positions (distributional laws) and clusters (syllable structure laws). In each law, there is a marked structure (more complex) that implies the presence or co-occurrence of the unmarked structure (less complex). The language laws will be summarized below. For a more complete description, the reader is directed to the Gierut (2007) article. She provided a comprehensive chart of all language laws and the English sounds corresponding with each universal.

i. Phonemic laws

Phonemic language laws demonstrate the implicational relationships between various sound classes.
For example, Stoel-Gammon (1996) identified this universal: velars imply coronals. Velars are essentially back sounds while coronals (palatals, alveolars and interdentals) are sounds produced in the middle of the mouth. In terms of development, every clinician has observed children who produce coronals (such as /t/ or /d/), but not velars (such as /k/ or /g/). Universals follow the typical developmental sequence. Velars imply the presence of coronals, but the child may incorporate coronals (without velars) in his or her system. If a child is missing both velars and coronals, researchers have advocated teaching the more marked structure, velars in this case. After teaching velars, the prediction is that the child would add both sound classes to satisfy this relationship. Thus, this is more efficient and effective than only teaching a coronal, the unmarked structure.

Other language laws have identified that affricates imply fricatives (Gierut, 1990), fricatives imply stops (Dinnsen & Elbert, 1984) and liquids imply nasals (Tyler & Figurski, 1994). McReynolds and Jetzke (1986) noted that voiced obstruents (stops, fricatives and affricates) imply the presence of voiceless obstruents. This reverses the long-standing recommendation to start with the voiceless sound. However, if both voiced and voiceless sounds are missing, the strategy advocates teaching a voiced obstruent to expand the repertoire. In each of these cases, the complexity approach recommends teaching the marked structures to create more widespread change.

ii. Distributional laws

The markedness, or complexity, of word position has also been identified for two sound classes. It has been demonstrated that stops are more marked in final position than in initial position (Rockman, 1983). If stops are taught as singletons, this tells practitioners that stops should be taught in final position and change would be predicted for initial position. Conversely, fricatives were observed to be more marked in initial position, implying fricatives in final position (Smith, 1973). To date, no marked positions have been stipulated for other sound classes, such as affricates or liquids.

iii. Syllable structure laws (Clusters)

Language laws also dictate the relationship between clusters and singletons and the relationship amongst clusters. In 1975, Gallagher and Shriner recognized that clusters imply the presence of singletons. There are many languages (e.g., Lao, Cantonese) that contain singletons, but no clusters. (The same holds true for children with disordered phonologies. Their repertoires often include singletons, but lack clusters.) If a child demonstrates difficulties with both clusters and singletons, this law suggests that clusters would be the ideal target to create maximal change.

Gierut and O’Connor (2002) designated another universal that clusters imply affricates. During training, SLPs learned that affricates are two sounds functioning as one, not quite clusters. Consequently, it follows that actual clusters are more complex and thus yield more change in a system if targeted. It should be noted that language universals are also cascading. Clusters imply affricates while affricates imply fricatives and fricatives imply stops. (Clusters à Affricates à Fricatives à Stops) This cascading relationship further accentuates the power of teaching clusters because learning extends well beyond clusters to impact these other sound classes.

Research (Baertsch, 2002; Fikkert, 1994) has also uncovered that liquid-onset clusters imply liquids in coda position (at the end of words). For example, if /l/ is not produced in singletons or clusters, this law advocates the liquid (/l/ or /r/) teaching it in a liquid-onset cluster (e.g., /spl-/, /gl-/, etc.). Generalization is predicted for the /l/ sound in final word position (as in “will”). Again, this is more efficient than starting with /l/ in the easier context (singleton in word final) and then later targeting /l/ in complex clusters.

In particular, one language law has the potential to create the most change possible. In 2001, Gierut and Champion found that three-element clusters (e.g., /spl-/, /str-/) imply the presence of two-element /s/ and non /s/ clusters (e.g., /sl-/, /gr-/). This translates into the practice of teaching three-element clusters, which are the latest developing structures in phonological systems. Their research consisted of teaching these complex sound structures to children as young as three. This practice coincides with the principle that Gierut outlined regarding the provision of the most complex input possible. However, Gierut and Champion offered a caveat in this practice. They emphasized that three-element clusters impact both cluster types and promote system-wide change; however, the results were significant only if the second consonant and third consonant already existed in the child’s phonetic inventory. That is, if /skr/ is the identified target, there should be evidence that /k/ and /r/ are already present in his or her inventory. (Readers should note that the presence in the phonetic inventory does not mean that the child has adult-like knowledge (full acquisition) of the target sounds. It merely means the child produced these sounds at least twice during phonological probes.) Therefore, the ideal target for many children with phonological disorders would be three-element clusters. Often, /skw-/ and /spl-/ represent feasible targets because children’s systems often include the second and third consonants (/k/ and /w/ or /p/ and /l/).

Gierut (1999) identified a hierarchy amongst two-element clusters. Such information is especially valuable and applicable when a child presents with a phonetic inventory too limited to teach three-element clusters. Gierut designated this hierarchy as the Sonority Sequencing Principle for Clusters (SSPC). Sonority is basically described as the inherent loudness of target sounds. Consequently, the mouth is more widely open when producing more sonorous sounds. Vowels are the most sonorous sounds while voiceless stops are the least sonorous. Steriade (1990) assigned values for the sonority of these consonant sound classes. (If included, the value of vowels would be 0.) That is, the most sonorous have the lowest value while the least sonorous have the highest value. The values were assigned as such:

Gierut applied these sonority values to characterize the hierarchy amongst two-element clusters. The SSPC represents the difference in sonority within a given cluster. For example, the cluster /tw-/ includes a voiceless stop (/t/ = value of 7) and a glide (/w/ = value of 1). The sonority difference of this cluster is 6 (7 -1). Conversely, /sl-/ features a difference of 3 (voiceless fricative (value of 5) – liquid (value of 2) = 3). Gierut demonstrated that clusters with a small sonority difference implied clusters with a large sonority difference. A summary of the various two-element clusters and their sonority differences is provided below and at http://slpath.com/sonoritysequencing.html.

C. Clusters

A hierarchical relationship exists between these levels. If a child’s system includes a cluster with a sonority difference of 2 (e.g., /sm-/), that implies the presence of a cluster at each of the levels below, 3, 4, 5 and 6. By teaching to the higher levels, children “fill in” the lower levels to satisfy this relationship. This hierarchy is also underscored by one final language universal. Elbert, Dinnsen and Powell (1984) demonstrated that fricative plus liquid clusters (e.g., /sl-/) imply the presence of stop plus liquid clusters (e.g., /br-/). It should be noted that the more complex clusters (fricative plus liquid clusters) are marked by a small sonority difference (3) while the less complex clusters (stop plus liquid clusters) are marked by a larger sonority difference (4 or 5). If a child is missing multiple clusters, it is recommended that SLPs target the clusters with small sonority differences.

Readers may have noted the absence of /sp-/, /sk-/ and /st-/ on the chart. Gierut offered the caveat to avoid teaching /sp-/, /sk-/ and /st-/ because they violate the Sonority Sequencing Principle, resulting in a difference of –2 (voiceless fricative (value of 5) – voiceless stop (value of 7) = -2). Furthermore, Gierut and her colleagues have found that teaching these three fricative + stop clusters inhibited generalization to other clusters. Targeting these clusters often results in a child adding /s/ at the beginning of words where it does not belong (e.g., [s] + [baIk] for the target “bike”). Linguists do not consider /sp-/, /sk-/ and /st-/ to be true clusters, labeling them adjunct clusters.

Different schools of thought exist for the clusters /sm-/ and /sn-/. Some linguists consider these adjunct clusters and suggest avoiding the treatment of these (even though they do not violate the SSPC per se) (Morrisette, Farris & Gierut, 2006). Children may group /sn-/ and /sm-/ with true clusters or with adjunct clusters. If they group these sequences with adjunct clusters, they are best avoided in treatment because of the potential for inhibiting generalization.

d. Treatment targets: Which words?

i. High-frequency word list/balanced density

The work of Morrisette & Gierut (2002), Morrisette (1999) and Storkel & Morrisette (2002) identified two lexical properties, frequency and density, that interact with phonology. First, treating high-frequency words created more change in a child's system than low-frequency words. Second, these studies identified the target of word density, or the number of words that differ from a target word by one sound through substitution, addition or deletion. For example, the word “sound” has ten neighbors that differ by one sound, such as “found,” “send” and “sounds.” These studies categorized words with ten or fewer neighbors as low-density and those with eleven or higher as high-density. Different treatment effects were observed for each category. Low density tended to impact the treated sound(s) while high density impacted untreated sounds or contexts. In order to apply these principles, SLPs can download a document entitled High Frequency Word List at: http://slpath.com/highfrequencywordlist.html. This resource was created based on the database of Dr. Larry Sommers at Washington University in St. Louis (http://128.252.27.56/neighborhood/Home.asp)(n.d.) and is organized by sounds (and often word position). Two numbers follow each target word. For instance, the first word is “race” following by the numbers 103 and 29. 103 indicates that “race” is a high frequency word. (According to the database, any word that occurs 100 or more times out of one million is deemed high-frequency. All words in the resource fall into this category.) 29 refers to the number of neighbors or counterparts “race” has, making it a high-density word.

For children with phonological disorders, SLPs strive to create maximal change in the system. Therefore, Storkel (personal communication, November 30, 2007) recommended that treatment offer words balanced in density. If there are ten target words, this means that five would be high-density and the other five low-density. (A different recommendation is given for children with mild articulation needs. Please refer to the articulation treatment section.) In all, these complexity principles have led to more efficient generalization for students.

e. Phonological Assessment and Treatment Targets (Taps, 2004)

A resource for phonological assessment and identifying powerful treatment targets is accessible at: http://slpath.com/phonologicalassessment.html. This document features the steps discussed above for clinicians to fully describe each child’s phonological system. SLPs can note the child’s phonetic inventory, phonemic inventory, clusters, stimulable and nonstimulable sounds out of the system. Given this data, SLPs can identify treatment targets based on the maximum change possible. Rationales for target selection include increasing the phonetic inventory level, application of language laws, treating nonstimulable sounds and teaching a rule or contrast that will inform the child about sound features and distinctions.

V. Progress Monitoring for Phonological Treatment

As stated earlier, it is critical to frequently monitor progress to ensure that the proper sound target(s) were selected and that generalization is occurring for treated and untreated sounds. This can be accomplished through sound probe administration and other methods that will be described below.

a. Frequent probes consisting of untreated words
This document described the independent probes of singletons and clusters that should be administered frequently before, during and after treatment. Generally, it is recommended that probes be readministered every 3-4 months (Elbert & Gierut, 1986). Such an interval ensures that enough time has elapsed to note progress and that administration is not so frequent that oversampling occurs. Baseline data on written goals should include the percentage of accuracy for all treated and untreated sounds missing from the child’s phonological system. The results of the readministered probe provide an updated comparison so that families are aware of systemic changes.

b. Short conversation and practice samples
Clinicians may also collect data each week to ensure that the target sounds are appropriate for each child. This could be accomplished through short conversation samples, tallying +/- for target sounds. The sample could be elicited by asking the child to make up a short (often nonsensical) story using his or her target words (Taps, 2008). Many children will require modeling for such a task to get started. For example, if a child’s target sounds include a contrast between /sl/ and /θr/, a modeled story (or the child’s story) might go like this: “One day, Bob decided that he wanted to ride on his sled. He got dressed, but his sweater had a large hole. So Bob found some thread and sewed for three minutes. After he was ready, Bob jumped on the sled and it went slowly down the hill. Then his friend started to throw snowballs at him. They had fun, but then Bob was tired. He went home and went to sleep. The end.” SLPs could take data as the child tells the story with a simple +/- system. Similar data could be collected during any task that the child produces target sounds. Data may reflect performance during syllable-level, word-level, phrase-level or sentence-level tasks or perhaps a combination of levels. Data is critical for monitoring progress; however, the collection of data should not prevent SLPs from providing the proper scaffolds in the moment so that children produce sounds successfully.

c. Family report
Of course, family members generally spend the most time with the child. SLPs should frequently communicate with families so that all parties are aware of progress in the child’s sound system and to ensure that the same facilitative techniques are being employed across environments. Parents may notice that a child suddenly changes his production of “sleep” from [wip] to [slip]. A parent may comment that the child was able to talk clearly with a family member. Or the child may respond positively to a shared hand signal that reminds him or her to use the target sounds. Any success, whether large or small, should be celebrated by those surrounding the child.

d. Teacher report
Educators also spend significant time with their students. They may observe that certain words are now produced correctly or that he or she uses target sounds during guided reading. Teachers may note that the child volunteers more frequently in class or that he or she appears more willing to take risks.

e. Student report
Later in this document, there will be a discussion of the importance of promoting ownership of sounds for students in speech therapy. Ultimately, they retain the responsibility of using their best sound production so that others can understand their message. Consequently, SLPs should ask students what they are noticing about their speech sounds, the reaction of others and how they might help conversational partners understand their message.

VI. Phonological Case Studies

a. “Harriet”

i. Background

Harriet (age 6;1) enrolled in 1st grade at a school in San Diego Unified and demonstrated a significant phonological disorder. Her strengths included openness to trying new tasks, strong social communication, interest in interacting with other children and a supportive teacher. She had no history of ear infections and she was a monolingual English speaker. Family history was unremarkable for speech and language disorders. Harriet had received one year of treatment in her prior school district. She also presented with a moderate language disorder, which impacted her expression of ideas in the classroom and text comprehension. Her phonetic inventory was nearly complete; however, cluster reduction and substitutions still impacted overall intelligibility. Upon initiation, Harriet’s intelligibility was approximately 50% in known contexts and 40% in unknown contexts. When not understood, Harriet often withdrew from communication and relied on other children in the classroom. A sample from her independent probe results can be accessed here: http://slpath.com/casestudies.html

ii. Assessment data (Prior to treatment)

In October 2006, Harriet’s phonetic inventory included the following sounds:

In October 2006, Harriet’s phonemic inventory included the following sounds:

iii. Treatment decisions

The following questions were considered based on this data:

1. What sounds are out of her inventory (“least knowledge”)?
/θ/ (only occurred once in the sample), /ð/ and most clusters

2. What sounds in error are stimulable? What sounds in error are nonstimulable?
Stimulable for: none
Nonstimulable for: /θ/, /ð/

3. What clusters are in her repertoire?
In October 2006, Harriet’s phonological repertoire consisted of /kw-/ (sonority difference = 6), /pw-/ (6), /gw-/ (5), /tr-/(5), /bw-/ (5), /fw-/ (4), /dr-/(4), /θw-/ (4), /fr-/(3) and /sr-/ (3). It should be noted that the clusters /pw-/ (as in [pweI] for “play”), /gw-/, /bw-/, /fw-/, /θw-/ and /sr-/ do not occur in English. However, in Harriet’s system, these combinations function as clusters.

4. What language laws could be applied to create significant change in her phonological system?

a. Three-element clusters à Two-element clusters (Gierut & Champion, 2001) could be applied in this situation. Harriet’s phonetic inventory is mostly complete and includes the second and third consonants for all three element clusters, including /skw-/, /spl-/, /str-/, /skr-/ and /spr-/. These constitute the most complex target possible for treatment.

b. Clusters with a small sonority difference à Clusters with a large sonority difference could be applied due to Harriet’s limited cluster repertoire. However, three-element clusters may have a broader impact. If these targets prove too challenging (based on her frustration level), complex two-element clusters (those with a small sonority difference) provide other possible treatment targets.

5. What later-developing sounds could be targeted?
Earlier-developing sounds (to be monitored): none
Later-developing sounds: /θ/, /ð/, most clusters

6. What are Harriet’s strengths and characteristics?
Her strengths included openness to new tasks, strong social communication and a supportive teacher. Harriet also reported that she enjoyed talking with others, especially children. However, she experienced significant frustration when conversational partners did not understand her message, occasionally withdrawing from interactions.

iv. Selected treatment targets

Given Harriet’s nearly complete phonetic inventory, many options for treatment were available. As discussed in this document, the most complex targets possible are three-element clusters. Harriet’s primary errors occur on later-developing sounds, including clusters; however, these substitutions and reductions significantly compromised her intelligibility. She was also at-risk for academic issues so expedient treatment was warranted. Consequently, the complex targets /skw-/ (as in “squeeze”) and /spl-/ (as in “splat”) were selected. Unfortunately, no high-frequency words include these cluster sequences. Therefore, the examiner applied the principle of selecting commonly known words for children. Based on these targets, predictions were made that Harriet would learn these clusters, two-element clusters and perhaps the fricatives (θ/, /ð/) missing from her repertoire.

v. Progress monitoring results (Part 1)

In December 2006, Harriet’s phonetic inventory included the following sounds:

vi. Progress monitoring results (Part 2)

In April 2007, Harriet’s phonetic inventory included the following sounds:

In April 2007, Harriet’s phonological repertoire consisted of /kw-/ (sonority difference = 6), /kl-/ (5), /fw-/ (4), /dr-/ (4), /gl-/ (4), /bl-/ (4), /sw-/ (4), /sl-/ (3), /θr-/ (3), /sn-/ (2), /sm-/ (2), /sp-/ (-2), /str-/, /sk-/ (-2), /spw-/, /spl-/ and /skw-/. It should be noted that the clusters /spw-/ (as in [spwIt] for “split”), and /fw-/ do not occur in English. However, in Harriet’s system, these combinations function as clusters. She added seven clusters (two treated and five untreated) to her system. Moreover, Harriet’s productions were more consistent with the clusters represented in English.

Below are examples of untreated words from independent probes that illustrate the change of production over a short period of time.

vii. Post-treatment summary

Harriet’s phonological system underwent significant changes in the six-month period. She added the two sounds missing from her inventory and seven clusters. Her overall intelligibility increased from approximately 40% to 80%. Most importantly, Harriet demonstrated more willingness to talk with familiar and unfamiliar conversation partners. Her teacher reported that she demonstrated more confidence in her speech in the classroom and at home. Phonological treatment continued after this initial treatment phase to target the remaining sounds. In particular, the /r/ sound was targeted with strategies discussed later in this document. Shortly thereafter, Harriet demonstrated age-appropriate sound production. However, given her language disorder, she required continued support from the SLP and education specialist. Harriet experienced the academic impact of arriving in kindergarten with unintelligible speech.

b. “Thom”

i. Background

Thom (age 4;11) enrolled in kindergarten at a school in San Diego Unified and demonstrated a significant phonological disorder. His strengths included social communication, language skills and hearing within normal limits and strong family support. History of ear infections was significant and English was his only language. Family history was remarkable for speech and language disorders. Thom had received one year of treatment in preschool. Upon initiation, Thom’s intelligibility was approximately 40% in known contexts and 25% in unknown contexts. Thom frequently withdrew from communication when others did not understand his speech. Two samples (singletons and clusters) from his independent probe results can be accessed here: http://slpath.com/casestudies.html

ii. Assessment data (Prior to treatment)

In September 2008, Thom’s phonetic inventory included the following sounds:

In September 2008, Thom’s phonemic inventory included the following sounds:

iii. Treatment decisions

The following questions were considered based on this data:

1. What sounds are out of his inventory (“least knowledge”)?
/v/, /θ/, /ð/, /l/, /r/, /ʃ/, /ʒ/, /tʃ/, /dʒ/

2. What sounds in error are stimulable? What sounds in error are nonstimulable?
Stimulable for: /v/, /θ/
Nonstimulable for: /l/, /ð/, /r/, /ʃ/, /ʒ/, /tʃ/, /dʒ/

3. What clusters are in his repertoire?
In September 2008, Thom had /bw-/ and /fw-/ in his system. /bw-/ and /fw-/ are not English clusters; however, these sounds functioned as clusters for Thom. He was missing all other clusters.

4. What language laws could be applied to create significant change in his phonological system?
a. Affricates à Fricatives (Gierut, 1990) could be applied because fricatives are limited and no affricates are present.

b. Voiced obstruents àVoiceless obstruents (McReynolds & Jetzke, 1986) could be applied by teaching a voiced obstruent.

c. Clusters à Affricates (Gierut & O’Connor, 2002) could be applied to create maximum change for clusters and affricates. Because language laws are cascading, the prediction would be that fricatives and stops would also be impacted.

d. Liquid-onset Clusters à Liquids in Coda Position (Baertsch, 2002; Fikkert, 1994) could be applied because liquids are not present in clusters or singletons. A liquid-onset cluster (e.g., /sl-/) constitutes a more complex target than /l/ in final position (e.g., “will”).

This law was also considered for treatment, but would not be ideal for Thom’s profile:

Three-element clusters à Two-element clusters (Gierut & Champion, 2001) would not be ideal for this situation. Thom’s phonetic inventory is limited and does not include the second and third consonants for /skw-/ (/k/ is emerging), /spl-/ (/l/ is absent), /str-/ (/r/ is absent), /skr-/ (/r/ is absent) or /spr-/ (/r/ is absent).

5. What later-developing sounds could be targeted?
Earlier-developing sounds (to be monitored): /v/
Later-developing sounds: /θ/, /ð/, /l/, /r/, /ʃ/, /ʒ/, /tʃ/, /dʒ/

6. What are Thom’s strengths and characteristics?
His strengths included social communication, language skills and hearing within normal limits and strong family support. Thom frequently withdrew from communication because others could not understand his speech. His shy demeanor needed to be taken into account.

iv. Selected treatment targets

Thom’s intelligibility was compromised by his limited phonetic inventory (missing nine sounds overall) and the presence of only two clusters in his system. Three-element clusters were the first choice for treatment. However, because his system did not feature the second and third consonant in each three-element cluster (e.g., /r/ was absent so /str-/ could not be targeted), these complex targets were not feasible. Instead, complex two-element clusters (/sl-/ and /θr-/) were taught in contrasting maximal pairs (“throw” vs. “slow”). Both of these clusters feature a small sonority difference of three. Thus, it was predicted that Thom would add other two-element clusters to his repertoire with larger sonority differences. In addition, the language universals informed the predictions that Thom would add an affricate (clusters imply affricates) and a fricative (clusters imply affricates which imply fricatives).

v. Progress monitoring results (Part 1)

In January 2009, Thom’s phonetic inventory included the following sounds:

vi. Progress monitoring results (Part 2)

In May 2009, Thom’s phonetic inventory included the following sounds:

Clusters in Thom’s system as of May 2009: /sn-/, /sw-/, /sm-/, /tw-/, /kw-/, /bl-/, /θr-/, /kl-/, /sk-/, /sl-/, /st-/, /pl-/, /fr-/, /fw-/, /dw-/, /gw-/, /pw-/, /bw-/. It should be noted that /bw-/, /pw-/, /dw-/, /fw-/ and /gw-/ are not English clusters; however, these sounds functioned as clusters for Thom.

Below are examples of untreated words from independent probes that illustrate the change of production over a short period of time.

vii. Post-treatment summary

Thom’s phonological system underwent significant changes in the eight-month period. He added 8/9 sounds missing from his inventory and is stimulable for the remaining sound (/ð/). His overall intelligibility increased from approximately 40% to 80%. Most importantly, Thom’s family reported that he talked more at home and that grandparents understood his speech on the phone. His teacher also shared that he volunteered his thinking in the classroom more frequently.

Treatment will continue in the fall of 2009. The goal shared by Thom’s family and educators is that he will complete treatment by the spring of 2010. Currently, Thom’s academic performance is nearly at grade level. The impact of his arrival in kindergarten with unintelligible speech will remain to be seen in his academic endeavors.

VII. Articulation Assessment (Emphasis on phonetic)

a. Typical assessment protocol

i. Standardized tests

A complete assessment allows the examiner to identify what sounds are in the child’s repertoire and what sounds are not. Frequently, standardized tests, such as the Goldman-Fristoe Test of Articulation-2 (GFTA-2) (Goldman & Fristoe, 2000) and the Assessment of Phonological Processes-Revised (APP-R) (Hodson, 1986), are employed for this purpose. Such instruments provide a quick “snapshot” of a child’s system as compared to their same age peers and yield standard scores and percentiles. However, these tests usually sample sounds once in each word position. It may be the case that a child has partially acquired a sound in his or her system, but that he or she did not use it in that particular target. For example, a child might substitute /j/ for /l/ (as in [jaIt]) even though he or she produces /l/ with 60% accuracy in words. A clinician may recommend that /l/ be targeted even though this sound does not warrant treatment. Consequently, SLPs cannot use this information to fully represent the phonological system.

In 2005, Kollia and Eisenberg compared the performance of children on five standardized tests, including the GFTA-2, the Photo Articulation Test-Third Edition (PAT-3) (Lippke, Dickey, Selmar & Soder, 1997), Bankson-Bernthal Test of Phonology (BBTOP) (Bankson & Bernthal, 1990), the Clinical Assessment of Articulation and Phonology (CAAP) (Secord & Donohue, 2002) and Smit-Hand Articulation and Phonology Evaluation (SHAPE) (Smit & Hand, 1997). They wanted to determine if these tests accurately identify articulation or phonological disorders. Their preliminary findings suggested that the CAAP was the most stringent while SHAPE, GFTA-2 and PAT-3 were the most lenient (regarding error scores). Overall, they concluded that the content from these tests identified disorders, but they provided insufficient information to determine appropriate goals because they focused on relational analyses. That is, each test compared the child’s productions to adult-like productions rather than determining what sounds are present or absent in the inventory (independent of adult targets). To accomplish this goal, Kollia and Eisenberg recommended using independent probes to fully describe a child’s phonological system.

For children with mild articulation disorders, assessment should focus on in-depth probes of the sounds in error. A short conversation sample will likely reveal the sounds that require attention. However, SLPs may wish to administer a standardized test and in-depth probes to fully describe the child’s skills.

ii. Oral mechanism examination

An articulation assessment protocol typically includes a thorough oral mechanism examination. The purpose of this task is to note any structural or organic issues that may impact sound production. A child may present with a high palate or poor coordination of the jaw and lips. It is critical to note, however, that other children may possess these characteristics and yet produce sounds accurately.

The purpose is not to identify areas of need for oral-motor exercises. These practices lack empirical support (Lof, 2006). Moreover, Lof (2006) and Green et al (2000) have argued that “while differentiated movement is necessary for speech production, speed and strength of oral movements have little impact on speech sound production.” SLPs may access an oral motor examination resource (Addington, n.d.) here: http://www.speechfriends.com/BAoral_mechanism.pdf

During these tasks, SLPs may discover nonspeech apraxia, which may accompany childhood apraxia of speech. Other motor speech disorders may also be evident. SLPs are directed to this current summary of motor speech disorder assessment and treatment: LINK

iii. Conversation samples

Conversation samples should be collected before, during and after treatment. SLPs can take data as the child tells a story or engages in conversation with a simple +/- system. These samples demonstrate change over time and serve as progress updates for families and teachers.

b. Advanced descriptive assessment procedures

i. Strength-based assessment and child characteristics

A thorough assessment is required to fully describe and characterize a child’s sound system. This includes performance-based tasks that identify the child’s strengths, needs and personal characteristics. Oftentimes, parents comment that reports are esoteric and focus on what their children cannot do; consequently, clinicians should strive to objectively describe the child’s sound system in parent-friendly, yet positive terms. In particular, the clinician may highlight the fact that a child is stimulable for many sounds, demonstrated willingness to take risks or that he or she showed interest in various activities. SLPs may wish to write reports that feature parent-friendly sections in bullet points that identify strengths, describe the family or teacher concerns, characterize the sound system and offer facilitative strategies to support the child as he or she acquires sounds.

ii. In-depth probes

For the purposes of assessing mild articulation disorders, word-level tasks may not provide the full-picture of the child’s production of the target sound(s). Often, children produce sounds at the sentence-level due to coarticulation. In-depth probes uncover these facilitative contexts, targeting sounds in words, phrases, sentences and connected speech. Like the lengthy independent probes (suggested for assessing phonological disorders), these probes allow the SLP to fully characterize the child’s sound system. In addition, these instruments can be utilized during treatment to monitor progress and ensure that appropriate targets are selected.

Two commercially-available tools may be utilized to characterize a child’s system:

1. S-CAT Secord Contextual Articulation Tests (Secord & Shine, 2003):
http://www.superduperinc.com/products/view.aspx?pid=TM90

2. Entire World of R Screening (Ristuccia, 2004): http://www.sayitright.org/advancedscreening.html

iii. Speech Improvement Sound Inventories (SISI)

San Diego Unified offers general education services (Speech Improvement Class) to children with mild articulation disorders who do not meet criteria for an IEP. These inventories are used before, during and after the Speech Improvement Class for progress monitoring. Each probe includes the protocol, an attendance form, clip art pictures, words (typed out) and sentences. It should be noted that the pages featuring clip art and sentences (that the student utilizes) do not denote the target sound. The most natural production should be elicited during this task. The inventories target the following later-developing sounds: /k/, /g/, /s/, /z,/ /r/, /ʃ/,/tʃ/, /ʤ/, /l/, /θ/, /ð/ and can be accessed from this site: http://slpath.com/soundinventories.html.

iv. Stimulability tasks (Miccio & Glaspey, 2002)

Research suggests that children who are stimulable for target sounds will likely acquire them without intervention (Powell, Dinnsen & Elbert, 1991; Gierut, 2007). Consequently, to complete a full assessment, clinicians must determine the stimulability for sounds that are missing from the system. For years, the most common method of determining stimulability consisted of asking the child to produce the sound in isolation given a model. In the last few years, researchers have used more in-depth tasks to determine the modifiability of a child’s production given various contexts, articulatory cues and modeling. Glaspey and Stoel-Gammon (2005) developed a task that samples target sounds across word positions and in the context of various vowels. The article abstract describing this dynamic assessment process is accessible here: LINK For example, if a child does not produce /l/ during the independent probes, the examiner determines if the child can produce /l/ given various levels of support. Given cues and modeling, the child would be asked to produce /l/ in isolation, with the /a/ vowel (as in /la/, /ala/ and /al/), with the /i/ vowel (as in /li/, /ili/ and /il/) and with the /u/ vowel (as in /lu/, /ulu/ and /ul/). This provides the child with ten opportunities to produce the target sound rather than the one opportunity described above. Barlow, Storkel and Taps (2007) stipulated that any sound produced with 30% accuracy or greater be deemed stimulable and anything below this accuracy nonstimulable. Like sampling sounds more thoroughly in the independent probes, this provides the clinician with a more complete picture of what a child can do.

VIII. Articulation Treatment

a. Phonetic placement strategies

SLPs must employ as many “tricks in their bags” as possible to establish placement of sounds. Often, what works for one student may not work for the next. Mastery of these sounds in isolation and syllables smoothes the way for full and efficient acquisition of sounds later at higher levels, including conversation. Many newly-trained SLPs have reported that they feel unprepared to teach nonstimulable or later-developing sounds (Taps, 2009). Consequently, employers and mentors should provide needed training and hands-on practice for acquiring these critical skills.

Readers are directed to four excellent texts to support their practice in this area. No clinical office should be complete without these indispensable resources. Dr. Secord (2007) provides exhaustive strategies in the second edition of his book, Eliciting Sounds. These strategies target all sounds in English and special chapters address the challenges of treating the /r/ sound and remediating lisp patterns. Dr. Bleile (2005) offers comprehensive lists and techniques to elicit the latest-developing sounds in his book, The Late Eight. Moreover, his book is accompanied by a CD with all of the featured information for ease of use. Dr. Bauman-Waengler (2007) authored the text, Articulatory and Phonological Impairments: A Clinical Focus. In particular, she presents a chapter on phonetic placement strategies. Lastly, sound placement brochures were created by attendees of the Fort Hays State University Summer Workshop in Hays, Kansas in June 2008. Each brochure stipulates placement strategies to teach later-developing sounds. These brochures supplement the practice of teaching phonetically-complex, later-developing sounds as advocated by the complexity approach (Gierut, 2007). Links to the books and the brochures are provided at: http://slpath.com/soundplacementbrochures.html.

b. Lisp remediation

i. Lateral vs. frontal lisp patterns

As stated earlier, lateral lisps are atypical patterns in development (Smit, 1993a). Treatment is warranted as soon as this pattern is identified, even for preschool-aged children, so that such a production does not become ingrained. Conversely, Smit noted that a frontal lisp pattern is typical and that many children outgrow this tendency in the natural course of development. If this does not occur, it has been suggested that an ideal treatment age is around seven.

A complete description of techniques to remediate these patterns is beyond the scope of this document. A common strategy is to establish placement of the /s/ and /z/ (or other affected sounds) by teaching them in the final cluster of /ts/ or /dz/. /t/ and /d/ are also alveolar sounds, which can support proper placement for the /s/ and /z/. Readers are directed to three excellent resources. First, as mentioned earlier, Dr. Secord’s Eliciting Sounds (2007) includes a chapter on remediating lisp patterns. A link for this book is accessible here: http://slpath.com/soundplacementbrochures.html. A second resource is available on Caroline Bowen’s Web site. A step-by-step description of her “butterfly procedure” can be accessed at: http://www.speech-language-therapy.com/fsd-butterfly-procedure.htm. Lastly, Christine Ristuccia’s The Entire World of S and Z Instructional Workbook (2004) provides facilitative techniques and worksheets to support each step of the process. Interested parties can visit: LINK

c. Summary of /r/ studies

i. Paucity of research

A recent literature review revealed a paucity of /r/ treatment research despite the fact that it is one of the most treated sounds. (Several studies examined the assessment or acoustic characteristics of /r/. This short summary does not include those studies.) ASHA (2004) stipulated levels of evidence in systematic research. The table below summarizes the various levels.

ASHA (2004) Levels of Evidence

Baker and McLeod (2008) reported that most studies fall into the quasi-experimental category (IIb). Research from categories Ia and Ib provide the highest level of evidence. Professional fields, including speech-language pathology, benefit from such careful review and systematic research. Moreover, a body of evidence enables researchers to complete meta-analyses (Level Ia) that demonstrate trends and findings across experiments. At this point in time, the paucity of /r/ research does not facilitate this high level of review. The ASHA Web site and other scientific search engines provided seven experimental studies that targeted the treatment of the /r/ sound in the past 50 years. ASHA’s Levels of Evidence were applied to these seven studies, resulting in the following (tentative) determinations of levels:

The Web site called Speech Bite (accessible at: http://www.speechbite.com/) concurred on the assigned levels of evidence for the Clark et al study and Adler-Bock et al study.

ii. Possible strategies to remediate /r/

Despite the paucity of /r/ research, clinicians require effective techniques to treat this sound. Many clinicians have reported that /r/ is particularly challenging because of the difficulty of describing how and where to produce the sound. A short summary of an effective strategy will be discussed below. However, for a complete version of this approach, readers are directed to Christine Ristuccia’s resources, The Entire World of R Book of Elicitation Techniques (http://www.sayitright.org/ET.html) and The Entire World of R Instructional Workbook (http://www.sayitright.org/EWR_Instructional_Workbook.html). Ristuccia collaborated with San Diego Unified School District in 2005 to complete an efficacy study on this approach. These findings are summarized in her book on elicitation techniques. Overall, significant generalization occurred for all 31 students, many of whom completed treatment because of their expedient progress.

Researchers have primarily regarded /r/ as a consonant. Vocalic /r/ has often been overlooked as a result. According to Ristuccia (2000), /r/ can be divided into 32 categories: prevocalic /r/ (1), 18 vocalic /r/ types (/ear/, /ire/, /or/, /air/, /ar/ and /er/ across initial, medial and final positions), /rl/ (1) and 12 clusters. Each /r/ is produced slightly differently depending on the type of /r/ and sounds in nearby contexts. By saying aloud “star” and “right,” it is evident each /r/ is produced almost in the same way, but not quite. This small difference leads to errors for many children. In addition, children may utilize retroflexed or retracted /r/ productions (or both).

The traditional approach to treating /r/ generally lumps all kinds of /r/ into the same categories of initial, medial and final position. For example, a clinician might target final /r/ by teaching “star,” “here”, “more”, “ladder” and “dare.” These five words contain five different types of /r/. It may be the case that a child has one or some of these types in his or her system. If all /r/ types are all taught in tandem, this does not give the child the opportunity to consistently practice the motor skill necessary for one type of /r/ at a time.

The 2005 collaboration followed the Ristuccia’s approach of targeting one type of /r/ at a given time. She described the importance of using phonetically-consistent probe lists so that all targets share the same type of /r/. To identify the type of /r/, Ristuccia advocates a thorough assessment of /r/ across types in words, phrases and sentences. After San Diego Unified SLPs completed the evaluation, Ristuccia determined the type of /r/ for treatment. Typically, she selected a /r/ type that was between 50 and 80% accurate. This /r/ was targeted until it was produced with 80% accuracy at the sentence level across five sessions. SLPs helped children to identify which type of /r/ production they use naturally (retroflexed or retracted). Following this level of mastery, the /r/ assessment was readministered and a new target was selected. In many cases, children acquired the targeted /r/ sounds and also generalized to untreated /r/ types, thus making treatment more efficient. This methodology requires more empirical study, but the preliminary findings were quite promising.

To date, research has not addressed /r/ from the perspective of complexity for children who only have difficulties with this one sound. If complexity theory were applied to teaching /r/, SLPs might teach the /r/ types for which the child demonstrates “least knowledge.” Consequently, SLPs would administer an in-depth /r/ probe and then target the types not present in the system. (This is a different perspective that Ristuccia’s selection of targets between 50 and 80% accurate.) Anecdotally, this approach has been successful for several students at Chesterton Elementary in San Diego Unified School District. Of course, experimental research and analysis are necessary to investigate the true efficacy of this approach.

d. Motor learning strategies

i. Three phases of motor learning

According to motor learning theory, there are three phases of acquisition: 1) pre-practice/placement (when the child learns how to produce the sound in isolation and syllables until 80% accuracy), 2) practice (when the child practices at different levels of difficulty - sounds, syllables, words, phrases, sentences and conversation - in varied activities), and 3) generalization (Skelton, 2004). Randomized practice has been shown to facilitate retention and generalization of sounds (Skelton, 2005). Furthermore, this approach advocates that practice should consist of connected, meaningful speech because that is how we actually communicate. Hoffman and Norris (2005) suggested that intervention that is independent of communication (i.e. drill only) often results in the child defaulting to the old motor pattern of speech during actual communication. This would, of course, inhibit generalization and extend treatment time.

ii. Traditional treatment vs. motor learning

The traditional approach for how to treat sounds typically consists of incrementally increasing the level of difficulty. Treatment frequently proceeds from 80% at the sound level to 80% at the syllable level to 80% at the word level and so on. This practice is represented by the ladder below.

The motor learning approach advocates a different sequence. After establishing a sound in isolation and syllables (80% accuracy), children then produce sounds at different levels on given turns. Such a strategy enables students to develop greater flexibility in their sound usage rather than at a fixed level. The motor learning approach is represented below as a gumball machine. One never knows what color will emerge after turning the knob. The same thing goes for sound production practice. On one turn, a child might draw a card saying “sentence” and practice at that level. The next turn may yield a card denoting “syllable” while the following turn may indicate “conversation.” The key is to keep things unpredictable because this aligns with how real life communication works. Sometimes, people communicate by saying single words, telling stories or perhaps offering a sentence or two. Through randomized tasks, students learn to adjust to different contexts and self-monitor as they would in contexts outside of the speech/language room.

iii. Randomization

Randomization can be accomplished by:
· switching levels (isolation, syllables, words, phrases, sentences, conversation)
· switching the order of target words
· switching number of repetitions
· changing body position - standing, sitting, etc.
· changing stress, prosody, intonation, emotional context, rate of speech

For examples of these contexts, please refer to this link: http://slpath.com/randomizedcardideas.html. It includes ideas brainstormed by students at Chesterton Elementary in San Diego Unified School District.

iv. Massed practice

Dr. Williams suggested that speech therapy “provide focused practice on the new target(s) in order for them to become automatic.” Consequently, children require significant opportunities to utilize their new sounds each session. Taps (2005) recommended that SLPs strive for 150 trials per student per session. It may not be feasible for this to occur each time because most of the practice should be meaningful, but the goal for a high production rate remains.

Here are some suggestions and activities for eliciting massed responses per session:

• Require students to subvocalize (say it with their “voices turned off”) during other students’ turns to increase the motor practice, number of repetitions and maximize engagement. (SLPs may need to monitor this initially, but they should become independent in their subvocalization.)
  
• Ask students to make cards with different levels to ensure that they are getting mixed practice within a given session – sounds, syllables, words, phrases, sentences, conversation/stories. (They would draw a card for every turn.) SLPs can further randomize this by specifying different word positions on each card and/or clusters. For instance, cards might say, “medial sound in sentence,” “final sound in phrase,” “initial cluster in single word,” etc.
  
• The students can practice saying sounds, words, sentences, etc. while being given directions by other students (provided they can do so without interrupting the feedback loop too much). For instance, while saying a sentence with the target sound, one student could walk around the classroom and do whatever the other children suggest. This could include walking around the table, touching a picture, doing jumping jacks, closing their eyes, etc. SLPs may need to model this for a session, but children will likely want to take over giving directions quickly. Each turn lasts a random amount of time and each student should have several turns in a given 30-minute session.
  
• To emphasize the feedback loop, ask the students to cover their ears and close their eyes. They will practice a given target (random words and levels) while doing so. This blocks out all other stimuli and helps them concentrate on the motoric requirements for the target sounds and the resulting accuracy of production.
  
• A range of manipulatives can be used for random activities, especially for kinesthetic learners. For example, younger students may enjoy using counting bears of varying colors and numbers (perhaps 25 total, including 8 green, 4 blue, 7 yellow, etc.). (To access these materials, please visit: http://slpath.com/motorlearningresources.html) On a given turn, the child might put all of the yellow ones into a cup while saying the practice items. During the next turn, he or she might put all of the blue ones into the cup and so on. This ensures randomized practice each turn. Children might also enjoy creating patterns with the colors or arranging the manipulatives into shapes (all of the bears into a circle, etc.).
  
• Have the students draw a number from an envelope to determine the random number of items to say. It is recommended that the numbers in the envelope fall between one and ten so that higher numbers do not result in a drill-like activity, thus distracting from self-monitoring.

  
  v. Meaningful communication

Articulation therapy aligns with fluency treatment in that practice should occur in multiple, meaningful environments. That is, opportunities for practice abound in these contexts outside of the speech/language room: classroom, playground, the media center, making phone calls, the front office and during field trips. This underscores the critical need for daily practice at home as well.

e. Language universals

A complete review of the language universals is provided on pages 15-16. For children with mild articulation disorders, SLPs may consider applying the following language laws to expedite treatment.

Affricates à Fricatives (Gierut, 1990)
Voiced obstruents à Voiceless obstruents (McReynolds & Jetzke, 1986)
Fricatives in initial position à fricatives in final position (Smith, 1973)
Fricative + Liquid Clusters à Stop + Liquid Clusters (Elbert et al, 1984)
Liquid-onset Clusters à Liquids in Coda Position (Baertsch, 2002; Fikkert, 1994)
Three- element clusters à Two-element /s/ and non /s/ clusters (Gierut & Champion, 2001)

f. Clusters and Sonority Sequencing Principle for Clusters

Readers are directed to the Sonority Sequencing Principle for Clusters (Gierut, 1999) section of this document. This principle will primarily be applicable for children with significant sound disorders. However, some children present with cluster reduction after the age of 5;6 (atypical after this age according to Smit, 1993). In those cases, it is advisable for SLPs to target three-element clusters (if the phonetic inventory permits) or two-element clusters as identified on the SSPC hierarchy. Teaching these more complex clusters leads to untreated acquisition of less complex clusters, thereby increasing the efficiency of treatment. Please refer to the above section for more detailed information.

g. High-frequency word list/low-density

The work of Morrisette & Gierut (2002), Morrisette (1999) and Storkel & Morrisette (2002) identified two lexical properties, frequency and density, that interact with phonology. First, treating high-frequency words created more change in a child's system than low-frequency words. Second, these studies identified the target of word density, or the number of words that differ from a target word by one sound through substitution, addition or deletion. For example, the word “sound” has ten neighbors that differ by one sound, such as “found,” “send” and “sounds.” These studies categorized words with ten or fewer neighbors as low-density and those with eleven or higher as high-density. Different treatment effects were observed for each category. Low density tended to impact the treated sound(s) while high density impacted untreated sounds or contexts. In order to apply these principles, SLPs can download a document entitled High Frequency Word List at: http://slpath.com/highfrequencywordlist.html. This resource was created based on the database of Dr. Larry Sommers at Washington University in St. Louis (http://128.252.27.56/neighborhood/Home.asp)(n.d.) and is organized by sounds (and often word position). Two numbers follow each target word. For instance, the first word is “race” following by the numbers 103 and 29. 103 indicates that “race” is a high frequency word. (According to the database, any word that occurs 100 or more times out of one million is deemed high-frequency. All words in the resource fall into this category.) 29 refers to the number of neighbors or counterparts “race” has, making it a high-density word.

For many students with mild articulation needs, only one or two sounds may be in error. Therefore, Barlow, Storkel & Taps (2007) recommended that treatment focus primarily on low-density words for these children because these lexical features impact treated sounds (and there is no need for widespread change for children with only one or two sounds in error). (A different recommendation is given for children with phonological disorders.) In all, these complexity principles have led to more efficient generalization for students.

h. Home practice

The results of the ASHA National Outcome Measurement System should come as no surprise to SLPs (ASHA, n.d.). They found that children who practice sound production at home were significantly more likely to generalize sounds than children who did not. Consequently, San Diego Unified School District requires home practice for all Speech Improvement students and strongly encourages all children with IEPs to practice at home. The goal of homework is to provide meaningful practice and support in as many contexts as possible.

i. Practice to create automaticity

Research suggests that homework has several important functions, including strengthening the automaticity of skills (Fisher, 2009). It is important not to send home tasks that the child cannot yet do independently. This may reinforce old patterns or result in mislearning. Therefore, this principle can be applied to sound production homework.

One way to apply this would be to use the principles of motor learning. As stated earlier, there are three phases of motor learning (1) pre-practice/placement during which a child produces sounds and syllables until they are 80% accurate; 2) practice (sounds, syllables, words, phrases, sentences and conversation in a given session); 3) generalization (conversation in authentic situations and about meaningful topics)). If a child is working on a sound in mixed practice (the second phase), SLPs can send home practice on the sounds in isolation and/or syllables (the first phase). This will build up the fluency of something that is already solid.

Another way to apply this would be to ask the child to practice past sounds while working on current sounds. For instance, if an SLP utilizes the phonetic approach to /r/ by teaching one kind of /r/ at a given time, this practice may be feasible. A child may have just mastered /ear/ in final position and may have recently begun working on prevocalic /r/. Home practice would focus on /ear/ final to further strength the automaticity and fluency of this skill.

ii. Daily practice

Daily practice expedites a child’s progress in treatment. The rationale for home practice is that speech articulation is a habit, an automatic behavior. When learning a new skill, it benefits children to move slowly and deliberately. This is true for many skills, such as eating, riding a bicycle and swimming. Through regular practice, students rehearse these habits until the movements become automatic and they can engage in the skill without thinking. This applies to articulation as well. For speech and other skills, practice makes perfect.

iii. Peer support

If students’ families cannot support home practice, there is another option. In those cases, students may practice with a peer in class for five minutes a day, something comparable to what would have been completed at home (Hazel, 1990). It may be the case that a “speech graduate” is in the same class as a student who would benefit from this supplementary rehearsal.

IX. Articulation Case Study

a. “Michael”

i. Background

Michael moved to San Diego Unified School District at the end of third grade. His speech/language skills were assessed in the spring of 2004. Michael presented with a significant lateral lisp, but did not qualify for special education services because his academic performance was above grade level. He reported feeling self-conscious about his lisp pattern and confided that he often played the role of the “class clown” to divert attention from his speech production. Consequently, the SLP met with his grandmother twice to establish a home program for the summer vacation.

Over the summer, the district established a policy for offering general education speech services to children who did not qualify for IEP services. (This is allowed under the reauthorization of IDEA. For more information on the Speech Improvement Class model, please visit: http://slpath.com/innovations.html.)

ii. Treatment decisions

When the class was first offered in the fall of 2004, he was the first student enrolled. The Speech Improvement Class Sound Inventories for /s/ and /z/ were administered at baseline. (A conversation sample revealed that all other sounds were produced with 100% accuracy.) Prior to treatment, Michael produced /s/ and /z/ singletons in words and sentences with 0% accuracy while /s/ clusters were produced with 75% accuracy. (As readers are aware, lisp patterns frequently do not impact clusters as much as singletons because the surrounding consonants allow the child to achieve the correct placement for /s/.)

As stated earlier, the language universals can be applied to select treatment targets for both children with phonological and articulation disorders. In this case, two laws were utilized to identify the most complex contexts possible. First, the SLP selected /z/ as the primary sound because voiced obstruents imply voiceless obstruents. Secondly, /z/ was taught in initial position because fricatives are more marked in initial position, which implies the presence of fricatives in final position. (Clusters were not directly targeted because they were largely intact.) Treatment also included massed practice, meaningful contexts, frequent self-monitoring and self-evaluation, home practice and the three phases of motor learning.

X. Progress Monitoring for Articulation Treatment

As stated earlier, it is critical to frequently monitor progress to ensure that the proper sound target(s) were selected and that generalization is occurring for treated and untreated sounds. This can be accomplished through sound probe administration and other methods described below.

a. Frequent probes consisting of untreated words

This document describes the in-depth probes that should be administered frequently before, during and after treatment. Generally, it is recommended that probes be readministered every 2 months or so. Such an interval ensures that enough time has elapsed for progress to be evident and that administration is not so frequent that oversampling occurs. Baseline data on written goals should include the percentage of accuracy for all treated and untreated contexts. The results of the readministered probe provide an updated comparison so that families are aware of systemic changes.

b. Short conversation and practice samples

Clinicians may also collect data each week to ensure that the target sounds are appropriate for each child. This could be accomplished through short conversation samples, tallying +/- for target sounds. The sample could be elicited by asking the child to make up a short (often nonsensical) story using his or her target words (Taps, 2008). Many children will require modeling for such a task to get started. For example, if a child’s target sounds include a contrast between /sl/ and /θr/, a modeled story (or the child’s story) might go like this: “One day, Bob decided that he wanted to ride on his sled. He got dressed, but his sweater had a large hole. So Bob found some thread and sewed for three minutes. After he was ready, Bob jumped on the sled and it went slowly down the hill. Then his friend started to throw snowballs at him. They had fun, but then Bob was tired. He went home and went to sleep. The end.” SLPs could take data as the child tells the story with a simple +/- system. Similar data could be collected during any task that the child produces target sounds. Data may reflect performance during syllable-level, word-level, phrase-level or sentence-level tasks or perhaps a combination of levels. Data is critical for monitoring progress; however, the collection of data should not prevent SLPs from providing the proper scaffolds in the moment so that children produce sounds successfully.

c. Family report

Of course, family members generally spend the most time with the child. SLPs should frequently communicate with families so that all parties are aware of progress in the child’s sound system and to ensure that the same facilitative techniques are being employed across environments. Parents may notice that a child suddenly changes his production of “read” from [wid] to [rid]. A parent may comment that the child was able to talk clearly with a family member. Or the child may respond positively to a shared hand signal that reminds him or her to use the target sounds. Any success, whether large or small, should be celebrated by those surrounding the child.

d. Teacher report

Educators also spend significant time with their students. They may observe that certain words are now produced correctly or that he or she uses target sounds during guided reading. Teachers may note that the child volunteers more frequently in class or that he or she appears more willing to take risks.

e. Student report

Students should be encouraged to take ownership of their sounds and progress in speech therapy. Ultimately, they retain the responsibility of using their best sound production so that others can understand their message. Consequently, SLPs should frequently ask students what they are noticing about their speech sounds, the reaction of others and how they might help conversational partners understand their message.

XI. Bilingual Considerations

a. Literature review

Goldstein (2007) reported that few studies have examined phonological assessment and treatment of bilingual children. As of that date, only four studies had been completed. Moreover, the four included only case studies, which provide the lowest level of evidence. In each study, a child received treatment in English while the other languages were monitored utilizing less than systematic methods. A recent review of the Web site Speech Bite (accessible at: http://www.speechbite.com/) and ASHA yielded no other current studies. Fortunately, Goldstein and his colleagues received a substantial grant to dedicate their time and systematic research to this important issue.

For now, readers are directed to Goldstein and Fabiano’s overview of bilingual assessment and intervention for children with phonological disorders. They summarized what research has suggested so far on these critical issues. To access this article, please visit: LINK

b. Assessment

Goldstein and Fabiano (2007) suggested that a thorough evaluation should consist of the five critical steps, which will be summarized below. For the full explanation of the process, please access the above-mentioned article.

Step 1: Perform a detailed case history: Consider the amount languages are spoken and purposes.
Step 2: Obtain speech samples: If possible, collect samples in each language.
Step 3: Perform an independent analysis: Consider what sounds the child produces in each language (independent of whether or not they are correct).
Step 4: Perform a relational analysis: Consider the accuracy of the sounds and patterns in each language because they may differ depending upon the language.
Step 5: Perform an error analysis: Consider whether there are true errors or influences from the other language (cross-linguistic), which would indicate a difference rather than a disorder.

These and other factors warrant careful consideration during the assessment process. In particular, they cautioned:

“Knowledge of phonological representation in bilinguals is helpful because it allows speech-language pathologists to distinguish a phonological difference from a disorder. Evidence-based assessment of phonological disorders in bilingual children should consider recent theories of bilingual phonological representation. By assessing the languages and determining how they interact, clinicians can make a valid diagnosis, determine the child's strengths and weaknesses, and plan for intervention.”

c. Treatment

In general, Goldstein and Fabiano suggested that ideal treatment consists of targeting structures that would impact both or all languages, even if that means providing treatment in each language. Given the challenges of providing school-based services, this would require creative service delivery and possible collaboration with native speakers. Whatever the case, Goldstein and Fabiano recommended monitoring progress in both languages. For a more detailed discussion, please refer to the full article.

d. Cross-linguistic influences and relevant resources

When assessing a child’s speech, SLPs must consider whether the patterns may be due to language acquisition (cross-linguistic influence). For example, Vietnamese does not include /θ/ or /ð/ in its phonological repertoire. Therefore, someone whose primary language is Vietnamese may not produce /θ/ or /ð/while speaking English. Like dialect, this pattern should be respected and does not occur due to a disorder. However, Vietnamese and English both include the /l/ sound. If a child has difficulty producing this sound in both languages, this sound may warrant treatment. It is critical that clinicians are aware of the phonological systems of languages spoken by their students. Andrea Schindler (2009) created a resource that highlights the 15 most commonly spoken languages other than English in San Diego Unified School District. In addition, readers are directed to an excellent resource by Dr. Sharynne McLeod, The International Guide to Speech Acquisition (2007). Dr. McLeod summarizes the research and phonological characteristics of 12-English speaking dialects and 24 languages other than English. (Links are available at http://slpath.com/languagechart.html for Schindler’s resource and Dr. McLeod’s book.) ASHA also features many useful resources at: http://www.asha.org/practice/multicultural/biphono.htm.

XII. Promoting Ownership of Sound Production

a. Mediated Constructivism

Ertmer and Ertmer (1998) discussed sound production through the prism of mediated constructivism. According to this tutorial, they advocated encouraging children to employ metacognitive strategies. Children should be viewed as “leaders” in authentic situations to practice speech production. Student reflection should emphasized during all aspects of the process.

b. Self-Monitoring

i. Charts and data collection

One way to encourage self-monitoring is for children to take data regarding their performance in given sessions or at home. A data sheet can be placed on the refrigerator at home so children can indicate each time they hear themselves use good sounds at home. Hence, this log that encourages children to take ownership is called the “fridge log.” It can be accessed at: http://slpath.com/fridgelog.html. The log comes with a key for students to personalize. For example, one student might draw a happy face for "Just right," a neutral face for "Okay" and a frown for "Can do better."

ii. Daily generalization plan

Research has suggesting that self-monitoring is critical for generalization (Koegel, Koegel, Van Voy & Ingham, 1988). Therefore, SLPs need to provide frequent opportunities for self-reflection (Ertmer & Ertmer, 1998). This document requires students to rate their conversational use of sounds throughout the day to foster generalization: http://slpath.com/dailygeneralizationplan.html.

iii. Rubrics

The same principles apply to this document as described for the Daily Generalization Plan. Students can utilize these rubrics to rate their skills in three specific areas: sound production, self-monitoring and rate of speech: http://slpath.com/studentrubric.html.

iv. Tally counters

Tally counters can also be used to foster ownership for students in their own sound production. Students may click for each practice item or they may click only when they think they used their best production possible. Links for purchasing affordable tally counters are available here: http://slpath.com/motorlearningresources.html

c. Feedback

i. Delayed and specific

Dr. Williams offered this as one of the four goals for phonological treatment: “Provide the child with linguistic/communicative feedback with regard to the semantic meaning of the child’s production.” SLPs have posed the question for years of how and when to offer feedback. Strand and Kent (2005) suggested that delayed feedback (waiting at least 5 seconds) produces better results. Yorkston, Beukelman, Strand, and Bell (1999) advocated this practice because the delay provides the child with an opportunity to assemble and retrieve motor plans. Furthermore, these studies advised that more feedback be given during the pre-practice stage than during the practice phase. They also stipulated this principle: the more specific to the process feedback is, the better. For example, if a child successfully produces /s/ in a target word, the SLP may say “I like the way you pushed the air through the middle and placed your tongue behind your teeth.” This is more specific than “Good job.”

ii. Kind of praise

Psychological and educational research also informs the practice of SLPs regarding the kind of praise or feedback provided in treatment. Studies have shown that praise that is nonspecific (“Good job,” “Excellent”) may be viewed as insincere. Furthermore, Donahue and Foster (2004) found that too much praise can undermine a child’s self-monitoring and self-correction skills. In other studies, some children became so dependent on praise that they lost their ability to evaluate own performance and failed to take pleasure in their own success (Burnett, 1994; Good, 1987).

XIII. Naturalistic Play Activities That Yield Maximum Practice

a. Overview

Dr. Williams suggested that one of the four tenets of treatment should include the provision of “opportunities to practice the new target(s) in naturalistic play activities.” Similarly, Hoffman and Norris (2005) suggested that children “produce words in a range of simple to complex contexts.” As motor learning stipulates, children need to practice sound production during connected interactions because these are the contexts in which they will use their new skills. Such practice should mirror that of fluency treatment in that children use sounds in multiple, meaningful contexts. This section will describe activities that yield such opportunities for practice.

b. Centers

Classroom instruction frequently gives children opportunities throughout the day to participate in various centers (e.g., writing centers, math centers). Based on this observation, Taps (2005) developed the idea of “speech centers.” During a given session, students are given the chance to partake in different activities while practicing sounds. Centers change from session to session to keep treatment interesting. Each center features an activity and a treatment target. At one center, one student may assemble a puzzle while practicing a different sentence each turn. Simultaneously, another student may tell a story (featuring his or her sounds) into a tape recorder as another child says words while drawing pictures on the board. ”Switch” is called at random intervals allowing children to get practice at different levels in a given session. This arrangement requires them to be independent and allows them to get well beyond the recommended 150 correct productions of the target sound per session. During this process, the SLP circulates to ensure that children are maintaining their best productions, sometimes providing subtle reminders to modify sounds. Moreover, the clinician may ask the child to talk about his or her activity. This requires the child to switch to a different mode of communication while continuing to utilize his or her best sounds.

c. Sample activities

Below are sample naturalistic play activities that offer multiple opportunities for practicing sound production (Taps, 2005).

i. Shopping for items with target sounds

Children enjoy playing with a toy cash register or money for this activity. One child acts as the “store owner” while the others shop at the store. The store owner owns the cards (with target words) of the other children. He or she sets the price for each card, about which the other children inquire. The child (looking to purchase) one of his cards may say “How much does ‘sled’ cost?” To that, the cashier may reply “Sled costs two dollars.” Given this basic scenario, children adopt these roles and practice their sounds frequently during a short time span. The fact that both children produce the target words works one of two ways. It may be the case that both children are working on the same sounds. This provides more chances to practice the targets. Or the child playing cashier may be working on different sounds. In this instance, he or she provides a good model of the target sounds for the child learning the sounds represented on the cards.

ii. Hide and seek with cards

Children love to play hide and seek or to partake in scavenger hunts. One quick way to generate fun, meaningful practice is to play hide and seek with the child’s cards. For the last five minutes of the session, one child is selected and his or her cards are hidden by the other students while he or she does not look. As he or she looks, the other children know the location of the cards and say “You’re getting close to ‘thread’” or “You’re far away from ‘street’.” When the child locates the card, he or she says “I found ‘thread’” or “’Street’ was under the desk!”

iii. Guessing targets

For this activity, one student displays all of his or her cards for a partner to also see. The partner mentally notes one card without revealing its contents. The child guesses until he or she identifies the card in question. For instance, a child may practice prevocalic /r/ with the cards, “read,” “writing,” “running,” and “ready.” The guessing child may say, “Are you thinking of ‘read?’” to which the other child may reply “No, I’m not thinking of ‘read.’” This process is continued until the proper card is selected. During a short amount of time, both students practice the sound in several meaningful trials. Moreover, it may be the case that both children are working on the same target, thus requiring both to self-monitor their productions during this enjoyable task. Conversely, it may be the case that the assisting child is not working on the same sound. In that case, he or she provides an excellent model for the guessing child. Either way, this simple task offers multiple opportunities to practice sounds.

iv. Retelling stories

Whenever possible, therapy should link to classroom content and curriculum. Classroom text offers an excellent opportunity to accomplish this goal while practicing sound production at a higher level. Students self-monitor while reading aloud text or while retelling familiar stories. Both complex tasks require careful attention to maintain optimal sound production. Reading text or retelling stories also provide excellent opportunities for home practice.

v. Role playing

Role playing provides more opportunities to practice classroom content at a higher level. Children may act out historical events or other subjects of study in the classroom. Again, during all of these activities, students are responsible for self-monitoring their sound production.

vi. Puppet shows

Puppet shows provide more opportunities to practice classroom content at a higher level. Children may act out stories from the classroom. Again, during all of these activities, students are responsible for self-monitoring their sound production.

vii. Fishing pond

Many SLPs are familiar with magnetic fishing ponds. Discovery Toys sells one with letters on each fish: http://slpath.com/abseas.html. This set can be utilized for a randomized activity. After a child catches a fish, he/she looks at the chart (below and at http://slpath.com/abseas.html) to determine which level to practice. For example, if a child catches "A," he or she says two sentences with the target sound. For "D," the child tells a story including the target. This encourages active participation from students and creates opportunities for massed practice.

XIV. Intervention Issues and Family and Teacher Education

Speech-language pathologists frequently provide family and teacher education regarding speech sound disorders. It is critical that SLPs also share information about sound acquisition, sound differences and facilitative strategies for all children.

a. Sound Acquisition

i. Developmental norms

For years, practitioners have shared developmental norms with families and teachers. This information is valuable because it provides general information about when sounds are acquired and whether patterns are typical or atypical. However, despite the power of this information, there are caveats. First, normative data is highly dependent on the sample population involved. The two biggest studies of recent collected data from children in Iowa and Nebraska (Smit, 1990; Smit et al, 1993). Of course, this data represents trends in those demographic areas. However, the samples do not represent the diversity of other states or regions. Second, the fact that a child has not acquired a particular sound by a particular age does not necessarily indicate a concern. Even Smit (1990) cautioned against using norms as a strict guide as when to treat sounds. Third, normative studies have reported a vast range of ages for when sounds are acquired. For example, Lof (2004) noted that /s/ is reportedly acquired between the ages of 3;6 and 8;0 according to the studies completed by Sander (1972), Prather, Hedrick and Kern (1975), Templin (1957), Smit et al (1990) and Goldman-Fristoe Test of Articulation (2000).

ii. Speech normalization boundary

Speech acquisition constitutes a social-interactive process that, for many children, is not complete until approximately age 8 years, 5 months. Shriberg, Gruber & Kwiatkowski (1994) dubbed this approximate age of 8;5 the “speech normalization boundary.” In essence, they theorized that a child’s speech normalizes during this critical age range. This means that it is difficult (though not impossible) to remediate sounds after this age.

One advantage of using this as a metric (as opposed to developmental norms) is that it acknowledges the unique timetable of every child’s sound acquisition. It is not that every child first acquires /p/, then /b/ and /m/ and so on. Rather, high variability occurs even in typically developing sound systems. Clinicians keep this in mind when deciding to pursue treatment. Some children need more time to mature and will eventually add sounds to their repertoires. In particular, Powell, Elbert and Dinnsen (1991) suggested that children who are stimulable for target sounds will likely acquire them without intervention.

Another advantage of this metric is that it informs SLP practice by suggesting a “window of opportunity” for treating mild articulation disorders. San Diego Unified has followed a general method of when to treat sounds for students with mild needs (Taps, 2008). The ideal treatment time falls between the ages of 7;0 and 8;5. This ensures that a child has had adequate time to develop, but sufficient time remains to intervene before the speech normalization boundary sets in.

SLPs make two notable exceptions to waiting until age 7;0. Smit et al (1993a) identified typical and atypical error patterns in development. The first exception is a lateral lisp pattern. This phenomenon constitutes an atypical pattern in development. Research suggests that children are highly unlikely to outgrow such a pattern without intervention. Therefore, treatment is warranted as soon as a lateral lisp is identified, even for preschool-aged children. The sooner this atypical pattern is interrupted, the better. Conversely, a frontal lisp pattern is considered to be a typical aspect of development. Many children outgrow this production in due time. Consequently, San Diego Unified SLPs watch and monitor younger students who demonstrate this pattern. If a child has not outgrown a frontal lisp by age 7;0, he or she is enrolled in treatment (possibly in a Speech Improvement Class, a general education offering). In many cases, intervention is completed within a few weeks, resulting in the child’s expedient return to classroom instruction.

The second exception is made for cluster reduction after the age of 5;6 (Smit, 1993b). Prior to this age, cluster reduction represents a typical aspect of development. However, after 5;6, this pattern becomes atypical. Many children demonstrate only this phonological process (while other sound productions are age-appropriate). Treatment is warranted if a child continues to reduce clusters after this age. Later, this document will cover the ideal treatment targets for these students. Gierut (2007) and her colleagues have identified a hierarchy amongst clusters that leads to more efficient change. These clusters can be targeted for children who demonstrate only cluster reduction or for children with significant phonological disorders. Clusters have been taught to children as young as 3;0 despite the fact that these sounds are later-developing. Relevant intervention strategies will be described in detail in the phonological treatment section.

b. Speech Differences vs. Speech Disorders

SLPs also frequently offer information that differentiates a speech difference from a speech disorder. A speech difference exists for people whose sound production does not match the Standard American English version. Speech differences include dialects, patterns resulting from second language acquisition and developmental patterns. These patterns do not require treatment, but need to be respected as differences. ASHA (1983) developed a position paper regarding social dialects and stated the following:

“It is the position of the American Speech-Language-Hearing Association (ASHA) that no dialectal variety of English is a disorder or a pathological form of speech or language. Each social dialect is adequate as a functional and effective variety of English. Each serves a communication function as well as a social solidarity function. It maintains the communication network and the social construct of the community of speakers who use it.”

Importantly, ASHA stressed that clinicians cannot assume that a person speaks with a particular dialect based on ethnicity or background. Rather, through careful interview, a clinician should work with the family to determine if a dialectal pattern is present. Educators may be unaware that such dialectal productions do not warrant treatment and that such differences should be respected because they align with the community standards.

Similarly, patterns may be due to second language acquisition. For example, Vietnamese does not include /θ/ or /ð/ in its phonological repertoire. Therefore, someone whose primary language is Vietnamese may not produce /θ/ or /ð/while speaking English. Like dialect, this pattern should be respected and does not occur due to a disorder. However, Vietnamese and English both include the /l/ sound. If a child has difficulty producing this sound in both languages, this sound may warrant treatment. It is critical that clinicians are aware of the phonological systems of languages spoken by their students. Andrea Schindler (2009) created a resource that highlights the 15 most commonly spoken languages other than English in San Diego Unified School District. In addition, readers are directed to an excellent resource by Dr. Sharynne McLeod, The International Guide to Speech Acquisition (2007). Dr. McLeod summarizes the research and phonological characteristics of 12-English speaking dialects and 24 languages other than English. (Links are available at http://slpath.com/languagechart.html for Schindler’s resource and Dr. McLeod’s book.)

c. Ramifications of waiting to treat phonological disorders or CAS

For students with suspected phonological disorders or childhood apraxia of speech (CAS), early intervention (ages 3-5) is strongly warranted. Gierut (1998) reported that children starting kindergarten with unintelligible speech are significantly more likely to experience academic difficulties than those who received appropriate services.

d. Facilitating strategy: conversational recasts

Research has demonstrated that conversational recasts are powerful scaffolds that facilitate sound acquisition (Camarata, 1993). This powerful and natural strategy should be shared with educators and families. This technique benefits children with phonological disorders, children acquiring sounds in the course of development or children with mild articulation needs.

During conversation, a child might make a substitution for a target sound, such as “wake” for “rake.” In layman’s terms, a conversational recast is saying the word again for the child, modeling a good sound production. This is not a correction, but rather an extra model that keeps the conversation going. It is not necessary to emphasize the word or sound. It would go something like this:

Parent: Did you do what I asked?
Child: I put away the wake.
Parent: Thank you for putting the rake away. You did a lot to help us in the yard.

Researchers have found conversational recasts to be effective in teaching new sounds, grammar and sentence structures. When a child is provided with these cues over several weeks (10 – 20 weeks), he or she may start using the correct sound or structure naturally in conversation. Such meaningful interactions and patient modeling (not corrections) provide natural contexts for learning new skills.

e. Importance of home practice

The ASHA NOMS Project (ASHA, n.d.) reinforced the notion that many SLPs share: students who practice at home are more likely to generalize target sounds. A parent-friendly letter is available for download at http://slpath.com/homepracticeletter.html. SLPs are invited to insert their names on the letter and distribute this to families. It underscores the concept that speech is a motor skill that requires daily practice.

f. Social-emotional ramifications

Historically, SLPs have recognized the social impact a communication disorder can have for an individual, including both mild and significant sound disorders. These ramifications were initially acknowledged by Van Riper in the early 1900s (as cited in Duchan, 2006). Research conducted by Crowe-Hall (1991) provided evidence to support the belief of speech-language pathologists that services should be available for children with sound disorders. She evaluated the perception of children with single-sound errors by peers. The results suggested that 4th and 6th grade children who present with single sound errors were viewed negatively compared to peers with typical speech patterns. Crowe-Hall encouraged districts to intervene because of the possible social and emotional impact of such a speech difference. ASHA (2008c) also recognized this impact when it included prevention in the role of the school-based speech-language pathologist.

g. PowerPoint presentation for educators

San Diego Unified School District has created a short PowerPoint presentation (Dunaway & Taps, 2004) to educate teachers and families about sound acquisition, facilitative strategies and the general education offering, the Speech Improvement Class. Readers are welcome to access this resource at: http://slpath.com/tieri.html or to create a similar resource. Families and educators may also benefit from this brief resource from ASHA: LINK

XV. Summary: Best Practices in Phonological Assessment and Treatment

A summary of evidence-based practices for phonological assessment and treatment is accessible here: http://slpath.com/bestpractices.html. This document includes research findings and how to employ this information in practice. Research citations are included for each so that interested parties can review the original sources.

XVI. Summary: Best Practices in Articulation Assessment and Treatment

A summary of evidence-based practices for articulation assessment and treatment is accessible here: http://slpath.com/bestpractices.html. This document includes research findings and how to employ this information in practice. Research citations are included for each so that interested parties can review the original sources.

XVII. References

a. Online resources and links

There are numerous resources available online to support both phonological and articulation treatment. The resources cited in this document are available at http://slpath.com. This site features randomized homework sheets, randomized activity cards, complexity research resources, information about motor learning, presentation materials (from ASHA, CSHA and other conferences) as well as procedural forms created for San Diego Unified School District’s Speech Improvement Class, a general education option.

Readers are also directed to these informative sites:

http://www.speech-language-therapy.com: Caroline Bowen’s wonderful site that provides a wealth of assessment and intervention resources. Dr. Bowen also facilitates the phonological therapy listserv. Please visit her Web site for more information.

http://www.speechandlanguage.com/ebp/index.asp: EBP briefs are available on this site to enable SLPs to access the systematic research that provides external evidence.

http://www.iub.edu/~sndlrng/: This Indiana University Web site offers information and links about the Learnability Lab. A substantial portion of the research on the complexity approach has been conducted by the dedicated researchers in this facility.

http://www2.ku.edu/~wrdlrng/: Dr. Holly Storkel has investigated the efficacy of the complexity approach and numerous other areas of interest at the University of Kansas. Many of her project presentations are available for download on this site.

http://slhs.sdsu.edu/pdlmain.php: Dr. Jessica Barlow has investigated the efficacy of the complexity approach and numerous other areas of interest at San Diego State University. This site includes a list of her publications that readers may access through www.asha.org.

http://www.speechbite.com/: This Web site offers analyses and links about existing research, which enable SLPs to make informed decisions when selecting treatment methodologies.

http://www.mnsu.edu/comdis/kuster2/sptherapy.html: Dr. Judith Kuster’s excellent Web site that features countless links to online resources in the fields of speech-language pathology and education. Phonological and articulation resources appear scrolling down to about 1/3 of the home page.

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