CHILDREN with HIGHLY UNINTELLIGIBLE SPEECH-SOME CONCERNS

1. INTERVENTION STRATEGIES & ACTIVITIES for PRESCHOOLERS with SPEECH SOUND DISORDERSNancy Creaghead & Barbara HodsonASHA Annual Convention—November 16, 2006 PART 1--INTERVENTION for PRESCHOOLERS with HIGHLY UNINTELLIGIBLE SPEECHBarbara W. Hodson, PhD, CCC-SLPbarbara.hodson@wichita.edu

2. CHILDREN with HIGHLY UNINTELLIGIBLE SPEECH-SOME CONCERNS • “Critical Age” Hypothesis [5:6][Bishop & Adams] • “Matthew Effects” [Stanovich] • Later Years--Some Common Difficulties • Reading[Comprehension & Fluency] • Spelling & Writing • “Multisyllabicity” • Imprecise Speech & Subtle Errors • Word Finding

3. _________________________ **Profound EXTENSIVE Omissions Many Substitutions Extremely Limited Repertoires ______________________________ ~Moderate Some Omissions Some Substitutions ________________________________ _______________________ *Severe Many Omissions EXTENSIVE Substitutions Limited Repertoires ___________________________ Mild Omissions Rare Few Substitutions SEVERITY CONTINUUMNote: Distortions & Assimilations may occur at all levels, but Distortions more common for Mild/Moderate Unexpected Assimilations Common for Severe/Profound ______________________________

4. 3-5Years Syllable “Structures” Omissions Rare[by age 4 yrs] [e.g., Final Consonants (by age 2); /s/ Clusters (by age 3, but /s/ may be distorted)] Few “Simplifications” [Most (e.g., Fronting)Eliminated] Intelligibility > 90% “Adult-like” Speech 5-7Years Phonemic Inventory Completed Liquids [4-6 years] “th” [by age 7] Phonetic Distortions [e.g., Lisps- Eliminated by age 7] “Multisyllabicity” “Adult-standard” TYPICAL PERFORMANCE3-7 Years

5. MAJOR OPTIONS for TREATMENT • Emphasis on Phonemes • “Traditional” [Van Riper] • Least Phonological “Knowledge” [Elbert & Gierut] • Maximal Oppositions [Gierut] • Multiple Oppositions [Williams] • Oral Motor Exercises [e.g.,Marshalla] • Whole Language[Hoffman, Norris, & Monjure] • Phonological Awareness [Gillon] • Phonological PATTERNS[Including Minimal Pairs (Fairbanks) that Contrast child’s actual deviations]

6. POTENTIAL OPTIMAL “PRIMARY” PHONOLOGICAL TARGET PATTERNS*for BEGINNING CYCLES *Target only those that are CONSISTENTdeviations. Targets must be STIMULABLE, however [otherwise would reinforce inaccurate kinesthetic image] • Word/Syllable Structures [OMITTED Phoneme Segments] • “Syllableness”[i.e., number of vowels/diphthongs] • Compound Words[e.g., cowboy, baseball] • 3-syllable/word combinations[e.g., cowboy hat, baseball bat] • Singleton Consonants[Syllable/Word Structure] • CV [word-initial /p,b,m,w/ if lacking] • VC[voiceless final Stops /p, t, k/; final /m,n/ if lacking] • VCV[e.g., apple] • /s/ Clusters[for omissions, not substitutions/distortions] • Word-initial[e.g., /sp/, /st/, /sm/, /sn/] • Word-final[e.g., /ts/, /ps/] Incorporate phrase: “It’s a [/s/ cluster word]” after child demonstrates facility producing /s/ clusters in production-practice words [typically by 3rd cycle]

7. PRIMARY TARGETS-2[for BEGINNING CYCLES] • Anterior/Posterior Contrasts[when stimulable] • Velars [if “Fronter”] • Word-final /k/ • Word-initial /k,g/ [occasionally /h/] • Alveolars/Labials [if “Backer”] • Facilitation of Liquids[even if not stimulable] • Word-Initial /l/ [preceded by week of tongue-tip clicking] • Word-Initial /r/[suppress gliding initially] • Exaggerate vowel • Do not blend initially Incorporate /kr/, /gr/ [when child has velars--typically 3rd cycle]

8. GENERAL COMMENTSRegarding Targets • Approximately 60 mn per PHONEMEtarget • At least 2 phonemes per target PATTERN • Reassess phonology between cycles • Recycle PrimaryPatterns as needed [until begintoemerge in conversation] • Proceed to Secondary Patterns after • Early developing patterns established • /s/ clusters emerging in conversation • Contrastiveuse of Velars & Alveolars • Practice words for Liquids-produced without Glide

9. POTENTIAL “SECONDARY” TARGETS Target Any of the Following that are still Consistently Lacking/Deficient • Palatals • Singleton Stridents • Other Consonant Sequences • Vowel Contrasts • Voicing Contrasts • Assimilations • Any Remaining Idiosyncratic Patterns Minimal Pair Words especially useful for these

10. INAPPROPRIATE TARGETS for PRESCHOOLERS Don’t target aspects that phonologically “normal” peers don’t actually produce • Word-final Voiced Obstruents[e.g., /b,d,g,z/] • Unstressed[weak]Syllables[e.g., refrigerator] • “th” [e.g., mouth] • “ng” [e.g., going] • Vocalic /l/ [e.g., ball] Note: Sibilants are appropriate targets for preschoolers only if stridency is lacking [e.g., /t/ for /s/; /s/ cluster reduction], but NOT for LISPS [which maintain stridency and do not have a particularly adverse effect on intelligibility].

11. TREATMENT SESSION-BASIC STRUCTURE • Review last session’s practice words • Listening activity[approximately 30 seconds] • 15-20 words containing target[NOT carefully selected] • Child must not repeat these words • Slightamplification • Production-practice words[5-6 carefully selected] • Activities for elicitingproductions • use cues/assists/models as needed [Goal is 100%] • child “takes turn” after saying “target” correctly in production-practice word [change activities every 7 or 8 minutes] • Metaphonological Activity[e.g., rhyming] • Probe for next session’s target • Repeatlistening activity[with slight amplification] • Home practice[2 minutes per day]

12. CLIENT EXAMPLEAge 3:5:15[years:months:days] HISTORY • Upper SES home • One younger sibling[toddler] • Health/Physical History Unremarkable [except for congestion & upper respiratory infections] • Receptive Language-Superior *Adenoidectomy & PE tubes [age 3:9]

13. CLIENT’s PHONOLOGICAL ASSESSMENTPRETREATMENT SCORES* OMISSIONS Phonological DeviationsOccurrence Percentages Syllables 0 Consonant Clusters/Sequences 118 Consonant Singletons Prevocalic 0 Intervocalic 7 Postvocalic 100 *Hodson Assessment of Phonological Patterns (HAPP-3; 2004)

14. PRETREATMENT SCORES-2CONSONANT CATEGORY DEFICIENCIES Phonological DeviationsOccurrence Percentages Sonorants Liquids 100 Nasals 76 Glides 60 Obstruents Stridents 100 Velars 100 Other [Anterior Nonstridents/Backing] 33 TotalOccurrences of Major Phonological Deviations [TOMPD] = 195 Pretreatment Severity Interval Rating = High Profound [HAPP-3 TOMPD Severity Intervals: 1-50 = Mild; 51-100 = Moderate; 101-150 = Severe; >150 = Profound (Top 10 pts-High; Bottom 10-Low)]

15. PRETREATMENT SCORES-3STRATEGIES: SUBSTITUTIONS/ASSIMILATIONS Occurrences • Vowel Deviations 31 • Stopping 16 • Fronting 12 • Gliding 12 • Reduplication 10 • Labial Assimilation 7

16. PHONETIC & PHONOTACTIC INVENTORIES & PCC • Consonants • /p/, /b/ • /t/, /d/ • /m/, /n/ • /w/, /j/ • Syllable Structures CV and Reduplications of CVs • No Final Consonants • No Consonant Clusters Percentage of Consonants Correct [Shriberg & Kwiatkowski] PCC = 10%

17. STIMULABILITY CONSIDERATIONS& GOAL STATEMENT • Stimulable[with assists (i.e., models, tactile cues, & amplification)] at time of initial assessment [Age 3:6] for • Final C[/p/ & /t/] • /s/ Clusters[word-initial /sp/, /st/, /sm/, /sn/] • Not Stimulable initially for • Velars • Liquids Goal Statement [for Beginning Cycles] Enhance the following phonological patterns [to expedite intelligibility gains] (a) Final Consonants (b) /s/ Clusters [Stridents & Consonant Clusters] (c) Velars [when stimulable] (d) Liquids

18. CLIENT’S PHONOLOGICAL TARGETS for CYCLE-ONE • Word-Final C: /p/; /t/; [1 hour each per semicolon] • /s/ Clusters: • Word-Initial /sp/; /st/; • Word-Final /ts/; /ps/; • Velars: Word-Final /k/;[7 sessions/hours] [Summer Break--May to Sept—No Phonology Clinic Available] • Word-Initial /k/; /g/; • /s/ Clusters: /sn/; /sm/; /sk/; &recycled/sp/; /st/; • Liquids: /l/; /r/; /kr/;[10 sessions] [Also facilitated/stimulated /h/ without actually targeting it] [Cycle-One Total Sessions/Contact Hours = 17]

19. CYCLE-TWO TARGETS • /s/ Clusters:/sp/ & /st/; /sm/ & /sn/; /sk/; • Liquids: /l/; /r/; /kr/; /gr/; • Recycled all /s/ clusters Added “It’s a ____” phrase[2 sessions] • Other CCs[Secondary Patterns] • /kw/; /kj/; [e.g., queen, Q] • Medial /st/; [e.g., toaster] • Final /st/; [e.g., nest] [Cycle-Two Total Sessions/Hours = 13]

20. CLIENT’S ADDITIONAL TARGETS forCYCLES THREE & FOUR • Liquids • Palatal Sibilants • Consonant Clusters/Sequences • Medial & Final /s/ Clusters [e.g., basket, desk] • Glide Clusters [e.g., cube, queen] • /r/ Clusters [e.g., /kr, gr, tr, dr/] • CCC [3-Consonant Clusters, e.g., /skr/] [Cycle Three-13 sessions; Cycle Four-9 sessions] Total for Cycles Three & Four = 22 Sessions/Hours

21. PRE-, INTERIM, & POST-TREATMENT DATA*/OUTCOMES 3:64:75:7 Cons. Seq. 118% 62% 18% Post. Sing. 100% 0 0 Stridents 100% 10% 5% Velars 100% 50% 5% Liquids 100% 100% 95% TOMPD 195 65 30 Severity Hi-Profound Moderate Mild Intelligibility 5% 65% 90% - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - [30 hrs] + [22hrs] = 52Contact Hrs [across 25 months] *Hodson Computerized Analysis of Phonological Patterns (2003)

22. PRODUCTIONS/TRANSCRIPTIONS OVER TIME Chronological Age Stimulus3:64:24:75:7 basket bApc bQjI bQsIt bQskIt cowboy hat tAtcA taUbehQt kaUbehQt kaUb]IhQt glasses dAtU dQjI dQtIs gwQsIz hanger jojc heNgU heNU heNU ice cubes Apu aItup aItups aIskjubz music box mowIbA mudibAk musIbAks mjusIkbAks smoke po moUk smoUk smoUk soap po toUp soUp soUp square pE pIo sEc skwEU television jLjLjojo tEjc IdZcn tEwcsIscn tEwcbIScn

23. Total Occurrences of Major Phonological Deviations [TOMPD]Ages 3:6 to 5:7

24. MAJOR RECOMMENDATIONSExpressive Phonology • Identify Consistent Broad Deviations • Determine Priorities[Clients, Time, Individual/Group] • Select Optimal Targets[Patterns, Phonemes, Words] • Increase Complexity Gradually • Facilitate Development of Awareness [Auditory, Kinesthetic, Semantic] • Incorporate • Slight Amplification[a few minutes & as needed] • Tactile Cues[as needed] • Models[particularly for new target] • Enhance Metaphonological Skills Develop Precise Phonological Representations [see Mody; Stackhouse]

25. GENERAL RECOMMENDATIONS for CHILDREN with HIGHLY UNINTELLIGIBLE SPEECH • Early Intervention-Critical • Individualize Treatment • Evidence-based Practices/Documentation • Enhancement of PATTERNS

26. ENHANCE PATTERNS PHONOLOGICAL & METAPHONOLOGICAL

27. Appendix ASELECTING OPTIMAL PRODUCTION-PRACTICE WORDS [forBEGINNINGCYCLES] • Monosyllabic Words [Real] • Facilitative Phonetic Environment (Kent) • Words in Child’s Lexicon • Avoid selecting words with consonant at sameplace of articulation as substitute • [e.g., NOT cat, coat, can, kiss, corn, candy, gas, goat, gate, gun, sock, tack, dog (if substituting /t/ for /k/; /d/ for /g/)] • [e.g., NOT rope, robe, row, room, roof, rabbit; leaf, lamb, lamp, lip, loop, laugh (if substituting /w/ for /l/, /r/)]

28. Appendix BSOME SUGGESTIONS for ELICITING SOUNDS • Final C[e.g.,final /p/-pop lips & puff of air] • /s/ Clusters[Draw finger along arm for /s/ and tap for the 2nd consonant for initial /s/ clusters] • Velars [Tap throat for /k/ to indicate “backness”; sometimes use “dum dum” sucker to stimulate back of tongue; occasionally model velar fricative /x/] • Liquids • /l/ [tongue tip clicking independent of jaw--1 week before] • /r/-open mouth as wide as possible & emphasize/prolong vowel; do not blend during initial cycles [Eliminate /w/ first] • Palatal Sibilants[/s/ plus /j/ for “sh” (e.g., missyou) /t/ + /s/ + /j/ for “ch”; /d/ + /z/ + /j/ for “j”] [Reminder: Amplification often helps child]

29. SOME SELECTED REFERENCES-Books/Special Issues ASHA Monograph (1994).Children’s phonology disorders: Pathways and patterns. Bernthal, J., & Bankson, N. (2004).Articulation and phonological disorders. Bleile, K. (2004). Manual of articulation and phonological disorders. Gillon, G. (2004).Phonological awareness: From research to practice. Hodson, B. (Ed.) (1994). From phonology to metaphonology: Issues, assessment, and intervention. Topics in Language Disorders. Hodson, B. (2007). Evaluating and enhancing children’s phonological systems: From research and theory to practice. Hodson, B., & Edwards, M. (Eds.) (1997).Perspectives in applied phonology. Hodson, B., & Paden, E. (1983, 1991).Targeting intelligible speech: A phonological approach to remediation. Kent, R. (Ed.) (2004).The MIT encyclopedia of communication disorders. Stackhouse, J., & Wells, B. (1997, 2001, 2006).Children’s speech and literacy difficulties (I, II, & III).

30. SOME SELECTED REFERENCES-Articles/Chapters Forrest, K. (2002). Are oral-motor exercises useful in the treatment of phonological/articulatory disorders? Seminars in Speech and Language. Gordon-Brannan & Hodson (2000). Intelligibility/severity measurements of prekindergarten children’s speech. AJSLP. Hodson, B. (1994). Helping children become intelligible, literate, and articulate: The role of phonology. Topics in Language Disorders Hodson, B. (1997). Disordered phonologies: What have we learned about assessment and treatment? Perspectives in applied phonology. Hodson, Scherz, & Strattman (2002). Evaluating communicative abilities of a highly unintelligible preschooler. AJSLP. Hodson & Strattman (2004). Phonological awareness intervention for children with expressive phonological impairments. The MIT Encyclopedia of Communication Disorders. Nathan, Stackhouse, Goulandris, & Snowling (2004). The development of early literacy skills among children with speech difficulties. JSLHR. Porter & Hodson (2001). Collaborating to obtain phonological acquisition data for local schools. LSHSS.

31. Intervention Strategies and Activities for Preschoolers with Speech Sound DisordersClassroom Intervention Nancy CreagheadUniversity of Cincinnati

32. Questions to Consider • Can/should we work on phonology in the preschool classroom? • Can/should work on phonology and language be combined? • Does the child’s severity level affect these decisions? • What is the evidence?

33. Relationship between Language and Phonology • It has been found that: • Children with phonological disorders are more likely to have language disorders. • Children with language disorders are more likely to have phonological disorders • There is an obvious synergistic relationship between the two – phonology is an aspect of language! • Current theories of language and phonologic acquisition support this relationship.

34. Assumptions about Intervention • Does work on phonology help language skills? • Does work on language skills help phonology? • Where is it best to target phonology? • In individual phonological therapy? • Concurrently with language therapy? • In naturalistic environments – e.g. the classroom?

35. Treatment Strategies • Phonology treatment only • Language treatment only • Sequential phonology and language treatment • Simultaneous language and phonology treatment - non integrated • Integrated phonology and language treatment

36. Implications for Treatment • The possibilities to consider are: • There is generalization across phonology and other language domains • There is no generalization across domains • There is generalization only in one direction, i.e. from phonology to other language domain only or from other language domains to phonology only.

37. Generalization from language-based intervention to phonologic domain • Hoffman et al.(1990) • 2 children treated by: • Minimal pairs for phonology OR • Story retell for language • Both children made gains in phonology. Child with phonology treatment made slightly greater gains • Child with language treatment made language gains, but child with phonology treatment did not make significant language gains • Tyler et al. (2002) • 20 children treated for morphosyntax and phonology in different consecutive orders • Children who received morphosyntax first performed as well as those who had phonology first. • Suggests consideration of treatment of morphosyntax first • Hoffman (1996)

38. Little generalization from language to phonology • Tyler and Sandoval (1994) • Six preschoolers with both language and speech sounds disorders • received intervention on language (focused stimulation of narratives), phonology (modified cycles: elicited imitation and minimal pairs) or both • Some generalization from phonology to language • Negligible generalization for language to phonology • Children who received combined approach made greatest gains in both. • Tyler & Waterson ( 1991)

39. Little generalization from language to phonology • Fey et al. (1994) • 26 children in moderate to profound range for speech sound disorders • Treated grammar, e.g. • Focus on “will” for future time • Focus on “are” as aux and copula • Focus on “is” as aux and copula • Focus on combining sentences with “and”, “but” • No direct effects on phonology

40. Evidence to date is not conclusive.Possible Explanations for Discrepancies among Studies • Differences in: • Research methodology • Duration of treatment programs • *Treatment methods • *Severity of impairments across studies • Importance of child’s ability to make the sound

41. Phonological Awareness and Reading Problems • Research indicates that • Children with reading problems often have difficulty with segmentation. • Sound segmentation ability in kindergarten is a strong predictor of later reading ability. • Sound segmentation may be a necessary prerequisite for reading. • Ability to read may improve sound segmentation.

42. Relationship between Phonological Awareness and Speech Sound Disorders • Webster and Plante (1992) k-2 • Children with normal phonology scored higher than children with speech sounds disorders on 3 of 4 phonological awareness tasks • Performance was correlated with intelligibility • Cowan and Moran (1997) k-2 • Children with mild speech sound disorders scored lower than typical children on the 3 tests. • Performance was not related to specific sound errors • Children with accompanying language problems did not perform more poorly than children without. • BUT some children with speech sounds errors performed better than the typical children. • Severity may be an important factor

43. Implications regarding Phonological Awareness • Improvement of phonological production? • Improvement of phonological awareness? • Combination of intervention/instruction?

44. Treatment Approaches for Speech Sound Disorders • Contrast training • Minimal pair opposition • Maximal pair opposition • Selected word practice • “Seizing the moment” • Using books • Using the curriculum • Intervening during play

45. We have to consider the treatment issues when we plan Phonologic Treatment in Naturalistic Settings – for example: • Patterns/process selection • Sound/word target selection • Stimulability • Facilitating contexts • Intelligibility • Frequency of occurrence of the sound • Developmental appropriateness • Phonological knowledge

46. PRINCIPLES OF LANGUAGE LEARNING • Children learn language by learning at least four sets of rules: pragmatic, semantic, syntactic,phonologic/graphic. • The language learning process is self-regulated by each child. The child must be cognitively ready for the language function, meaning and structure. • Children learn language in appropriate contexts which are experientially based and meaningful for them. • Children learn language when they have a reason to communicate.

47. PRINCIPLES FOR LANGUAGE "TEACHING" • The content for language teaching must be meaningful and relevant to the child and sequentially based on normal development. • Pacing must be at the child's own speed. • Sequencing of skills should consider typical development. • Careful observation of each child will allow the child to help us choose meaningful goals. • The best motivator is natural reinforcement for successful communication.

48. PRINCIPLES FOR LANGUAGE "TEACHING" • The context for language teaching should: • be based on the child's level of cognitive development; • draw from the child's natural environment; • involve interpersonal interaction; • involve active participation on the part of the child; • be larger than life.

49. Remediation Based on Normal Development • The acquisition of phonemes and phonological rules is not an all-or-non process. accuracy comes gradually and not for one sound at a time. • All exemplars of a phoneme do not have to be practiced for acquisition to occur • Treatment of multiple error patterns in preschool children presents different issues than treatment of older children who have errors on only /r/ or /s/. • There are advantages to working with children in groups. • Like other language rules, phonological rules are learned through the process of communication in natural and meaningful contexts.

50. Implications for Serving Preschool Children • The preschool classroom provides a natural and meaningful context where communication is required. • Every child does not have to work on only one sound that is chosen as his target. Modeling and practice of a variety of sounds can occur and is in keeping with normal acquisition. • Naturally occurring words can be used for practice words. • Modeling, exposure and the opportunity for practice can be provided. • Children can learn from each other and can be encouraged to try when other children participate.