Treatment section of the Speech Sound Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
The broad term "speech sound disorder(s)" is used in this Portal page to refer to functional speech sound disorders, including those related to the motor production of speech sounds (articulation) and those related to the linguistic aspects of speech production (phonological).
It is often difficult to cleanly differentiate between articulation and phonological errors or to differentially diagnose these two separate disorders. Nevertheless, we often talk about articulation error types and phonological error types within the broad diagnostic category of speech sound disorder(s). A single child might show both error types, and those specific errors might need different treatment approaches.
Historically, treatments that focus on motor production of speech sounds are called articulation approaches; treatments that focus on the linguistic aspects of speech production are called phonological/language-based approaches.
Articulation approaches target each sound deviation and are often selected by the clinician when the child's errors are assumed to be motor based; the aim is correct production of the target sound(s).
Phonological/language-based approaches target a group of sounds with similar error patterns, although the actual treatment of exemplars of the error pattern may target individual sounds. Phonological approaches are often selected in an effort to help the child internalize phonological rules and generalize these rules to other sounds within the pattern (e.g., final consonant deletion, cluster reduction).
Articulation and phonological/language-based approaches might both be used in therapy with the same individual at different times or for different reasons.
Both approaches for the treatment of speech sound disorders typically involve the following sequence of steps:
- Establishment—eliciting target sounds and stabilizing production on a voluntary level.
- Generalization—facilitating carry-over of sound productions at increasingly challenging levels (e.g., syllables, words, phrases/sentences, conversational speaking).
- Maintenance—stabilizing target sound production and making it more automatic; encouraging self-monitoring of speech and self-correction of errors.
Approaches for selecting initial therapy targets for children with articulation and/or phonological disorders include the following:
- Developmental—target sounds are selected on the basis of order of acquisition in typically developing children.
- Non-developmental/theoretically motivated, including the following:
- Complexity—focuses on more complex, linguistically marked phonological elements not in the child’s phonological system to encourage cascading, generalized learning of sounds (Gierut, 2007; Storkel, 2018).
- Dynamic systems—focuses on teaching and stabilizing simple target phonemes that do not introduce new feature contrasts in the child’s phonological system to assist in the acquisition of target sounds and more complex targets and features (Rvachew & Bernhardt, 2010).
- Systemic—focuses on the function of the sound in the child’s phonological organization to achieve maximum phonological reorganization with the least amount of intervention. Target selection is based on a distance metric. Targets can be maximally distinct from the child’s error in terms of place, voice, and manner and can also be maximally different in terms of manner, place of production, and voicing (Williams, 2003b). See Place, Manner and Voicing Chart for English Consonants (Roth & Worthington, 2015).
- Client-specific—selects targets based on factors such as relevance to the child and his or her family (e.g., sound is in child's name), stimulability, and/or visibility when produced (e.g., /f/ vs. /k/).
- Degree of deviance and impact on intelligibility—selects targets on the basis of errors (e.g., errors of omission; error patterns such as initial consonant deletion) that most effect intelligibility.
See ASHA's Person-Centered Focus on Function: Speech Sound Disorder [PDF] for an example of goal setting consistent with ICF.
In addition to selecting appropriate targets for therapy, SLPs select treatment strategies based on the number of intervention goals to be addressed in each session and the manner in which these goals are implemented. A particular strategy may not be appropriate for all children, and strategies may change throughout the course of intervention as the child's needs change.
"Target attack" strategies include the following:
- Vertical—intense practice on one or two targets until the child reaches a specific criterion level (usually conversational level) before proceeding to the next target or targets (see, e.g., Fey, 1986).
- Horizontal—less intense practice on a few targets; multiple targets are addressed individually or interactively in the same session, thus providing exposure to more aspects of the sounds system (see, e.g., Fey, 1986).
- Cyclical—incorporating elements of both horizontal and vertical structures; the child is provided with practice on a given target or targets for some predetermined period of time before moving on to another target or targets for a predetermined period of time. Practice
then cycles through all targets again (see, e.g., Hodson, 2010).
The following are brief descriptions of both general and specific treatments for children with speech sound disorders. These approaches can be used to treat speech sound problems in a variety of populations. See
Speech Characteristics: Selected Populations [PDF] for a brief summary of selected populations and characteristic speech problems.
Treatment selection will depend on a number of factors, including the child's age, the type of speech sound errors, the severity of the disorder, and the degree to which the disorder affects overall intelligibility (Williams, McLeod, & McCauley, 2010). This list is not exhaustive, and inclusion does not imply an endorsement from ASHA.
Contextual Utilization Approaches
Contextual utilization approaches recognize that speech sounds are produced in syllable-based contexts in connected speech and that some (phonemic/phonetic) contexts can facilitate correct production of a particular sound.
Contextual utilization approaches may be helpful for children who use a sound inconsistently and need a method to facilitate consistent production of that sound in other contexts. Instruction for a particular sound is initiated in the syllable context(s) where the sound can be produced correctly (McDonald, 1974). The syllable is used as the building block for practice at more complex levels.
For example, production of a "t" may be facilitated in the context of a high front vowel, as in "tea" (Bernthal et al., 2017). Facilitative contexts or "likely best bets" for production can be identified for voiced, velar, alveolar, and nasal consonants. For example, a "best bet" for nasal consonants is before a low vowel, as in "mad" (Bleile, 2002).
Phonological Contrast Approaches
Phonological contrast approaches are frequently used to address phonological error patterns. They focus on improving phonemic contrasts in the child's speech by emphasizing sound contrasts necessary to differentiate one word from another. Contrast approaches use contrasting word pairs as targets instead of individual sounds.
There are four different contrastive approaches—minimal oppositions, maximal oppositions, treatment of the empty set, and multiple oppositions.
- Minimal Oppositions (also known as "minimal pairs" therapy)—uses pairs of words that differ by only one phoneme or single feature signaling a change in meaning. Minimal pairs are used to help establish contrasts not present in the child's phonological system (e.g., "door" vs. "sore," "pot" vs. "spot," "key" vs. "tea"; Blache, Parsons, & Humphreys, 1981; Weiner, 1981).
- Maximal Oppositions—uses pairs of words containing a contrastive sound that is maximally distinct and varies on multiple dimensions (e.g., voice, place, and manner) to teach an unknown sound. For example, "mall" and "call" are maximal pairs because /m/ and /k/ vary on more than one dimension—/m/ is a bilabial voiced nasal, whereas /k/ is a velar voiceless stop (Gierut, 1989, 1990, 1992). See
Place, Manner and Voicing Chart for English Consonants (Roth & Worthington, 2018) [PB3] .
- Treatment of the Empty Set—similar to the maximal oppositions approach but uses pairs of words containing two maximally opposing sounds (e.g., /r/ and /d/) that are unknown to the child (e.g., "row" vs. "doe" or "ray" vs. "day"; Gierut, 1992).
- Multiple Oppositions—a variation of the minimal oppositions approach but uses pairs of words contrasting a child's error sound with three or four strategically selected sounds that reflect both maximal classification and maximal distinction (e.g., "door," "four," "chore," and "store," to reduce backing of /d/ to /g/; Williams, 2000a, 2000b).
The complexity approach is a speech production approach based on data supporting the view that the use of more complex linguistic stimuli helps promote generalization to untreated but related targets.
The complexity approach grew primarily from the maximal oppositions approach. However, it differs from the maximal oppositions approach in a number of ways. Rather than selecting targets on the basis of features such as voice, place, and manner, the complexity of targets is determined in other ways. These include hierarchies of complexity (e.g., clusters, fricatives, and affricates are more complex than other sound classes) and stimulability (i.e., sounds with the lowest levels of stimulability are most complex). In addition, although the maximal oppositions approach trains targets in contrasting word pairs, the complexity approach does not. See Baker and Williams (2010) and Peña-Brooks and Hegde (2015) for detailed descriptions of the complexity approach.
Core Vocabulary Approach
A core vocabulary approach focuses on whole-word production and is used for children with inconsistent speech sound production who may be resistant to more traditional therapy approaches.
Words selected for practice are those used frequently in the child's functional communication. A list of frequently used words is developed (e.g., based on observation, parent report, and/or teacher report), and a number of words from this list are selected each week for treatment. The child is taught his or her "best" word production, and the words are practiced until consistently produced (Dodd, Holm, Crosbie, & McIntosh, 2006).
The cycles approach targets phonological pattern errors and is designed for children with highly unintelligible speech who have extensive omissions, some substitutions, and a restricted use of consonants.
Treatment is scheduled in cycles ranging from 5 to 16 weeks. During each cycle, one or more phonological patterns are targeted. After each cycle has been completed, another cycle begins, targeting one or more different phonological patterns. Recycling of phonological patterns continues until the targeted patterns are present in the child's spontaneous speech (Hodson, 2010; Prezas & Hodson, 2010).
The goal is to approximate the gradual typical phonological development process. There is no predetermined level of mastery of phonemes or phoneme patterns within each cycle; cycles are used to stimulate the emergence of a specific sound or pattern—not to produce mastery of it.
Distinctive Feature Therapy
Distinctive feature therapy focuses on elements of phonemes that are lacking in a child's repertoire (e.g., frication, nasality, voicing, and place of articulation) and is typically used for children who primarily substitute one sound for another. See
Place, Manner and Voicing Chart for English Consonants (Roth & Worthington, 2018) [PB4] .
Distinctive feature therapy uses targets (e.g., minimal pairs) that compare the phonetic elements/features of the target sound with those of its substitution or some other sound contrast. Patterns of features can be identified and targeted; producing one target sound often generalizes to other sounds that share the targeted feature (Blache & Parsons, 1980; Blache et al., 1981; Elbert & McReynolds, 1978; McReynolds & Bennett, 1972; Ruder & Bunce, 1981).
Metaphon therapy is designed to teach metaphonological awareness—that is, the awareness of the phonological structure of language. This approach assumes that children with phonological disorders have failed to acquire the rules of the phonological system.
The focus is on sound properties that need to be contrasted. For example, for problems with voicing, the concept of "noisy" (voiced) versus "quiet" (voiceless) is taught. Targets typically include processes that affect intelligibility, can be imitated, or are not seen in typically developing children of the same age (Dean, Howell, Waters, & Reid, 1995; Howell & Dean, 1994).
Naturalistic Speech Intelligibility Intervention
Naturalist speech intelligibility intervention addresses the targeted sound in naturalistic activities that provide the child with frequent opportunities for the sound to occur. For example, using a McDonald's menu, signs at the grocery store, or favorite books, the child can be asked questions about words that contain the targeted sound(s). The child's error productions are recast without the use of imitative prompts or direct motor training. This approach is used with children who are able to use the recasts effectively (Camarata, 2010).
Nonspeech Oral–Motor Therapy
Nonspeech oral–motor therapy involves the use of oral-motor training prior to teaching sounds or as a supplement to speech sound instruction. The rationale behind this approach is that (a) immature or deficient oral-motor control or strength may be causing poor articulation and (b) it is necessary to teach control of the articulators before working on correct production of sounds. Consult systematic reviews of this treatment to help guide clinical decision making (see, e.g., Lee
& Gibbon, 2015 [PDF]; McCauley,
Strand, Lof, Schooling, & Frymark, 2009). See also the Treatment section of the Speech Sound Disorders Evidence Map filtered for
Speech Sound Perception Training
Speech sound perception training is used to help a child acquire a stable perceptual representation for the target phoneme or phonological structure. The goal is to ensure that the child is attending to the appropriate acoustic cues and weighting them according to a language-specific strategy (i.e., one that ensures reliable perception of the target in a variety of listening contexts).
Recommended procedures include (a) auditory bombardment in which many and varied target exemplars are presented to the child, sometimes in a meaningful context such as a story and often with amplification, and (b) identification tasks in which the child identifies correct and incorrect versions of the target (e.g., "rat" is a correct exemplar of the word corresponding to a rodent, whereas "wat" is not).
Tasks typically progress from the child judging speech produced by others to the child judging the accuracy of his or her own speech. Speech sound perception training is often used before and/or in conjunction with speech production training approaches. See Rvachew, 1994; Rvachew et al., 2004; Rvachew, Rafaat, & Martin, 1999; Wolfe, Presley, & Mesaris, 2003.
Traditionally, the speech stimuli used in these tasks are presented via live voice by the SLP. More recently, computer technology has been used—an advantage of this approach is that it allows for the presentation of more varied stimuli representing, for example, multiple voices and a range of error types.
Techniques used in therapy to increase awareness of the target sound and/or provide feedback about placement and movement of the articulators include the following:
- Using a mirror for visual feedback of place and movement of articulators
- Using gestural cueing for place or manner of production (e.g., using a long, sweeping hand gesture for fricatives vs. a short, "chopping" gesture for stops)
- Using ultrasound imaging (placement of an ultrasound transducer under the chin) as a biofeedback technique to visualize tongue position and configuration (Adler-Bock, Bernhardt, Gick, & Bacsfalvi, 2007; Lee, Wrench, & Sancibrian, 2015; Preston, Brick, & Landi, 2013; Preston et al., 2014)
- Using palatography (various coloring agents or a palatal device with electrodes) to record and visualize contact of the tongue on the palate while the child makes different speech sounds (Dagenais, 1995; Gibbon, Stewart, Hardcastle, & Crampin, 1999; Hitchcock, McAllister Byun, Swartz, & Lazarus, 2017)
- Amplifying target sounds to improve attention, reduce distractibility, and increase sound awareness and discrimination—for example, auditory bombardment with low-level amplification is used with the cycles approach at the beginning and end of each session to help children perceive differences between errors and target sounds (Hodson, 2010)
- Providing spectral biofeedback through a visual representation of the acoustic signal of speech (McAllister Byun & Hitchcock, 2012)
- Providing tactile biofeedback using tools, devices, or substances placed within the mouth (e.g., tongue depressors, peanut butter) to provide feedback on correct tongue placement and coordination (Altshuler, 1961; Leonti, Blakeley, & Louis, 1975; Shriberg, 1980)
When treating a bilingual or multilingual individual with a speech sound disorder, the clinician is working with two or more different sound systems. Although there may be some overlap in the phonemic inventories of each language, there will be some sounds unique to each language and different phonemic rules for each language.
One linguistic sound system may influence production of the other sound system. It is the role of the SLP to determine whether any observed differences are due to a true communication disorder or whether these differences represent variations of speech associated with another language that a child speaks.
Strategies used when designing a treatment protocol include
- determining whether to use a bilingual or cross-linguistic approach (see ASHA's Practice Portal page on
Bilingual Service Delivery);
- determining the language in which to provide services, on the basis of factors such as language history, language use, and communicative needs;
- identifying alternative means of providing accurate models for target phonemes that are unique to the child's language, when the clinician is unable to do so; and
- noting if success generalizes across languages throughout the treatment process (Goldstein & Fabiano, 2007).
Criteria for determining eligibility for services in a school setting are detailed in the Individuals with Disabilities Education Improvement Act of 2004 (IDEA). In accordance with these criteria, the SLP needs to determine
- if the child has a speech sound disorder;
- if there is an adverse effect on educational performance resulting from the disability; and
- if specially designed instruction and/or related services and supports are needed to help the student make progress in the general education curriculum.
Examples of the adverse effect on educational performance include the following:
- The speech sound disorder affects the child's ability or willingness to communicate in the classroom (e.g., when responding to teachers' questions; during classroom discussions or oral presentations) and in social settings with peers (e.g., interactions during lunch, recess, physical education, and extracurricular activities).
- The speech sound disorder signals problems with phonological skills that affect spelling, reading, and writing. For example, the way a child spells a word reflects the errors made when the word is spoken. See ASHA's resource
language in brief and ASHA's Practice Portal pages on
Spoken Language Disorders and
Written Language Disorders for more information about the relationship between spoken and written language
Eligibility for speech-language pathology services is documented in the child's individualized education program, and the child's goals and the dismissal process are explained to parents and teachers. For more information about eligibility for services in the schools, see ASHA's resources on
eligibility and dismissal in schools,
IDEA Part B Issue Brief: Individualized Education Programs and Eligibility for Services, and
2011 IDEA Part C Final Regulations.
If a child is not eligible for services under IDEA, they may still be eligible to receive services under the
Rehabilitation Act of 1973, Section 504. 29 U.S.C. § 701 (1973). See ASHA's Practice Portal page on
Documentation in Schools for more information about Section 504 of the Rehabilitation Act of 1973.
Dismissal from speech-language pathology services occurs once eligibility criteria are no longer met—that is, when the child's communication problem no longer adversely affects academic achievement and functional performance.
Speech difficulties sometimes persist throughout the school years and into adulthood. Pascoe et al. (2006) define persisting speech difficulties as "difficulties in the normal development of speech that do not resolve as the child matures or even after they receive specific help for these problems" (p. 2). The population of children with persistent speech difficulties is heterogeneous, varying in etiology, severity, and nature of speech difficulties (Dodd, 2005; Shriberg et al., 2010; Stackhouse, 2006; Wren, Roulstone, & Miller, 2012).
A child with persisting speech difficulties (functional speech sound disorders) may be at risk for
- difficulty communicating effectively when speaking;
- difficulty acquiring reading and writing skills; and
- psychosocial problems (e.g., low self-esteem, increased risk of bullying; see, e.g., McCormack, McAllister, McLeod, & Harrison, 2012).
Intervention approaches vary and may depend on the child's area(s) of difficulty (e.g., spoken language, written language, and/or psychosocial issues).
In designing an effective treatment protocol, the SLP considers
- teaching and encouraging the use of self-monitoring strategies to facilitate consistent use of learned skills;
- collaborating with teachers and other school personnel to support the child and to facilitate his or her access to the academic curriculum; and
- managing psychosocial factors, including self-esteem issues and bullying (Pascoe et al., 2006).
Children with persisting speech difficulties may continue to have problems with oral communication, reading and writing, and social aspects of life as they transition to post-secondary education and vocational settings (see, e.g., Carrigg, Baker, Parry, & Ballard, 2015). The potential impact of persisting speech difficulties highlights the need for continued support to facilitate a successful transition to young adulthood. These supports include the following:
- Transition Planning—the development of a formal transition plan in middle or high school that includes discussion of the need for continued therapy, if appropriate, and supports that might be needed in postsecondary educational and/or vocational settings (IDEA, 2004).
- Disability Support Services—individualized support for postsecondary students that may include extended time for tests, accommodations for oral speaking assignments, the use of assistive technology (e.g., to help with reading and writing tasks), and the use of methods and devices to augment oral communication, if necessary.
The Americans with Disabilities Act of 1990 (ADA) and Section 504 of the Rehabilitation Act of 1973 provide protections for students with disabilities who are transitioning to postsecondary education. The protections provided by these acts (a) ensure that programs are accessible to these students and (b) provide aids and services necessary for effective communication (U.S. Department of Education, Office for Civil Rights, 2011).
For more information about transition planning, see ASHA's resource on
Service Delivery section of the Speech Sound Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
In addition to determining the type of speech and language treatment that is optimal for children with speech sound disorders, SLPs consider the following other service delivery variables that may have an impact on treatment outcomes:
- Dosage—the frequency, intensity, and duration of service
- Format—whether a person is seen for treatment one-on-one (i.e., individual) or as part of a group
- Provider—the person administering the treatment (e.g., SLP, trained volunteer, caregiver)
- Setting—the location of treatment (e.g. home, community-based, school [pull-out or within the classroom])
- Timing—when intervention occurs relative to the diagnosis.
Technology can be incorporated into the delivery of services for speech sound disorders, including the use of telepractice as a format for delivering face-to-face services remotely. See ASHA's Practice Portal page on
The combination of service delivery factors is important to consider so that children receive optimal intervention intensity to ensure that efficient, effective change occurs (Baker, 2012; Williams, 2012).