Treatment of Speech Sound Disorders

Considerations

Many approaches for treating SPEECH SOUND DISORDERS

Treatment of speech sound production is similar whether it is ARTICULATORY or PHONOLOGICAL

BEST PRACTICE: take elements from well-researched approaches to develop an individualized, comprehensive treatment plan for each client

Target Selection

Any skill or action that is taught to a client

AKA: Treatment “goals” and “objectives”

Long Term Goal

Broad communication behaviors

Age-appropriate articulation, phonological skills, intelligibility, etc.

Short Term Goal

Skills that can be taught in a relatively short period of time

Steps to achieve the LTG

Production of specific sounds or elimination of error patterns

2-weeks, 1-month, 3-month

Target Selection: DEVELOPMENTAL NORMS

Age-appropriate sounds are easier to teach

“Makes sense” to teach sounds in the normal sequence

For Example: 5-year old would work on sounds typically mastered by children 5 years old or younger

Criticism: Not challenged as an approach; Current research suggests teaching AHEAD of developmental norms might be beneficial

Target Selection: “EASY TO TEACH”

Ideal Targets: Sounds in the child’s current repertoire; Phonological processes that are unstable/inconsistent

Criteria for SOUNDS (ARTICULATION): 20-40% accuracy – IDEAL TARGET Sounds the child is stimulable for visible sounds (e.g., /p, b, f/)

Criteria for PHONOLOGICAL PROCESSES: Error with a percentage of occurrence less than 100% (but more than 40%)

Target Selection: “HARD TO TEACH”

Ideal Targets:

Complex phonological patterns (e.g., cluster reduction, gliding, stopping)

Sounds that are consistently omitted by the child

Sounds nonexistent in child’s sound repertoire

Sounds the child is NOT stimulable for

Research Support:

Acquisition of “easier sounds and patterns” achieved with no therapy

Higher rate of generalization to settings outside of therapy

Target Selection: IMPACT ON INTELLIGIBILTY

Ideal Targets: Phonological/sound errors that: occur frequently, affect large numbers of sounds, and idiosyncratic

Other Considerations: Address multiple sounds if needed and sounds that occur frequently in child’s speech (high frequency words)

Target Selection: HOW MANY TARGETS TO SELECT?

Traditional: No more than 2 targets at time; targeting more sounds can cause confusion

Current: Work on multiple targets (2+ sounds) at one time; Targeting multiple sounds/errors yields faster progress

Target Selection:

ESTABLISHING BASELINE

BASELINE: Measured rate of behavior in the absence of treatment

MAIN Purpose: Measure the child’s performance of a skill prior to beginning treatment; Help with identifying a “starting point” for therapy.

Other Purposes: Evaluate child’s progress over time; Establish clinician accountability; Modify treatment as needed

Target Selection: ESTABLISHING BASELINE (Examples)

Evoked: Ask child to name pictures with target sound in all positions. No model provided; Develop a list of questions or “fill in the blank” sentences in which answers are words that contain target sound. (e.g., A pig and a cow live on a ______.”)

Modeled: Ask child to name pictures with target sound in all positions given a model; Develop list of words and ask child to say following a model.

LTG (Broad)

Articulation, Phonological Skills, Intelligibility, Age-appropriate speech production, Etc.

Client will improve articulation skills to an age-appropriate level as measured by an intelligibility rating of > 90% in settings outside of the clinic.

STO (Specific)

Phonemes & Phonological Processes

In 3-months of therapy, the client will correctly produce /r, l/ phonemes in words with 80% accuracy given minimal cues.

Short-Term Objectives

Help track treatment progress

allow third-party payers to verify results of therapy

Measureable Behaviors

• Point

• Repeat

• Match

• Name

• Tell

• Ask

• Count

• Write

• Say

NOT Measurable Behaviors

• Think

• Believe

• Discover

• Feel

• Appreciate

• Remember

• Understand

• Know

General Treatment Strategies - Approach

GENERAL philosophies or ways of thinking

Guides your ENTIRE course of treatment (selecting targets, number of targets, use of strategies, types of activities, etc.)

General Treatment Strategies - Strategy

Specific actions implemented to facilitate execution of a desired behavior

Also know as: Techniques

Phonetic Placement

Teaching the articulatory placement of sounds

Model the position

Show pictures of correct postition

Manual Guidance (hands, tongue depressor)

Successive Approximation: Sound Shaping

Use of sound the child can ALREADY make to learn a new sound

Sounds can be a phoneme or any type of sound

Break down a “difficult” phoneme into easier steps

Modeling

Clinician models (produces) the target response

Child watches clinician produce target and encourage to imitate

Vocal Emphasis

Verbal Instruction

Verbal stimuli that help facilitate a client’s actions

Given before a model

e.g., For /k, g/: “See the back of my tongue, I’m going to make it go up really high to touch the top of my mouth in the back.”

Prompt

Hints or cues that help facilitate an expected response

Verbal Prompt: vocal emphasis (“Say [zzzzu]“)

Non-Verbal Prompt: physical signs and gestures to help child produce sound

Positive Preinforcement

Event following a response that increases respone’s frequency

Primary: food and drink

Secondary: verbal praise, postive attention, tokens, etc

Fading: consistent reinforcement and fade as accuracy increases

Guidelines: reinforce promptly, clear statements, positivity, various use of phrases

Corrective Feedback

Feedback that informs the child when an error has been made

Provide feedback for ALL incorrect productions

Withdraw positive reinforcement

positive reinforcemet EXCEEDS corrective feedback

*for every 1 corrective feedback you should have at least 5 positive sayings

Children in the Early Stage of Phonological Development

Fewer than 50 words in vocabulary

Reduced inventory of sounds in PHONETIC INVENTORY when compared to others of the same age

Reduced inventory of SYLLABLE STRUCTURES when compared to others of the same age

Typically children 3 and under

Combined Approach - Consideration 1

Child’s Current Phonetic Inventory

Select specific word targets that contain sounds the child can already produce

Combined Approach - Consideration 2

Child’s Current Syllable Structure

Select specific word targets that contain syllable structures the child can already produce AND basic, novel syllable structures the child cannot produce

Combined Approach - Consideration 3

Developmental Sequence of Sound Acquistion

Select word targets that contain age-appropriate sounds that are not in child’s inventory

Combined Approach - Consideration 4

Words Important to the Child

e.g., family names, favorite toys, food, or activities, functional words, routines

Combined Approach - Consideration 5

Word Classes

e.g., nouns, verbs, prepositions, etc.

Sample Activites - Strategies

Model, model, model, and model again

Wait time

Sabotage (i.e., give them a reason to communicate)

Sample Activites - Activities

Pretend Play (e.g., cars, house, farm, etc.)

Books

Songs and Finger Plays

Gross Motor Play (e.g., ball, swing, giant blocks)

Sensory Play (e.g., play dough, snack, bubbles)

Articulation Therapy

aka phonetic approach, motor approach

Best for: children with ARTICULATION and/or motor based errors

Main Objective: treat substitutions, omissions, and distortions of isolated error phonemes

Sequence/Progession: treatment progresses in a specifed sequence (isolation, words, sentences); client does not progress to next level until mastery

Sensory Perceptual Training (Ear Training)

Purpose: teach auditory discrimination between correct vs incorrect forms, build awareness

Sample Activites: asked to determine if a sound is a target sound or

a different sound; produce words with target sounds — child is asked

to detect if target sound is produced correct or incorrect

Stage 1: Isolation

Purpose: elicit correct production of sound alone; not in combination with others

Sample Activities: client receives sticker for every correct production; games using numbers (e.g. Chutes & Ladders)

Stage 2: Nonsense Syllables

Purpose: elicit correct productions of sound when in varying vowel contexts.

Sample Activities: “articulation cards“ with nonsense syllables; require 5 nonsense syllables from cards

Stage 3: Words

Purpose: maintain production accuracy of target sounds in words

• Word Length - fewer syllables = easier production of word

• Sound Position - initial position = easier production of target sound

• Syllable Structure - open syllable structures = easier than closed syllables

• Syllable Stress - stressed syllable = easier production of target sound

Sample Activities: card games, gross motor, board games, token activity

Stage 4: Phrases

Purpose: maintain production accuracy of target sound in structured 2-4 word phrases

Sample Activities: can answer basic questions that elicit use of phrases with target sound (e.g. where does a cow live? In a farm); requre child to use same carrier phrase when naming pictures

Stage 5: Sentences

Purpose & Considerations: maintain production accuracy of target sound in sentences of various lengths and complexities

Sample Strategies & Activities: slow motion speech vs shadowing; correcting the clinician

Stage 6: Spontaneous Speech

Purpose: maintain production accuracy of target sounds in spontaneous convo; first addressed it therapy but then carried over into outside settings; structured convo to naturalistic convo

Sample Activities: tell story using pictures with target sounds; games (table topics, would you rather)

Treatment for Phonological Disorders

Best for PHONOLOGICAL-BASED error patterns

Principles: intervention begin at WORD level - sounds have value in meaning (e.g. fin vs chin, sad vs sat); error patterns are considered when selecting targets; may address multiple targets and/or entire sound classes

Minimal Pair

Word pair only differs from one phoneme

Targe/Correct Word (e.g., cop)

Comparison/Incorrect Production (e.g., top)

Phonological Contrast Therapy: Minimal Contrasts/Opposition

Phoneme Contrast: 2 sounds that are as similiar as possible; differ by only 1-2 production features (P, M, V)

Best for: children with mild-moderate phonological impairment, <6 error patterns; error substitutions consistent

Targets: 5-10 word pairs (mirror typical errors)

(e.g., velar fronting, stopping, FCD)

Phonological Contrast Therapy: Maximal Contrasts

Phoneme Contrast: 2 sounds that are as different as possible; differ by all production features (P, M, V)

Best for: children with moderate-severe phonological impairment, +6 error patterns

Targets: 5-10 word pairs (DOES NOT mirror typical errors); sounds in both word pairs are not in sound inventory

(e.g., stopping, velar fronting)

Phonological Contrast Therapy - Step 1: Discussion of Words

Clinician teaches concepts within words

Procedure: clinician asks the child questions about each picture; child is required to point to correct picture

Can the child understand the difference between the 2 concepts

Phonological Contrast Therapy - Step 2: Discrimination Testing and Training

Clinician test child’s ability to discriminate between two targets

Procedure: clinician produces word pairs in random order while patient points to picture named; criteria is 7 consecutive responses

Phonological Contrast Therapy - Step 3: Production Training

Clinician prompts child to produce minimal word pairs

Sound teaching strategies are used as needed to teach target sounds

Activity: Child acts as the “teacher“ prompting clinician to point to picture they say (“hide the penny“)

Phonological Contrast Therapy - Step 4: Carryover Training

Clinician prompts child to produce minimal word pairs in phrases/sentences of increasing length

Progression:

“a” + word — a pig, a fig

“the” + word — the pig, the fig

“Touch the” + word — Touch the pig, touch the fig

“Point to the “ + word — Point to the pig, point to the fig

Longer expression + word — That is a big pig vs. fig

Maintenance vs Generalization

Generalization

• Production of a learned response in a new context

• Production of an untrained response

Maintenance

• Ability to continue producing sounds correctly over time and across situations

Promoting Maintenance and Generalization

Select targets that have functional impact on child

Select treatment stimuli from child’s environment

Continue treatment until mastery is achieved in conversation

Use natural reinforcers (secondary reinforcers)

Fade reinforcement

Invite various people into therapy

Move treatment outside of the therapy room

Teach self-monitoring

Work closely with families