Treatment section of the Speech Sound Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Historically, the treatment of speech sound errors involved teaching the motor skills needed for the articulation of speech sounds. Since the 1970s, speech sound disorders have also been viewed from a linguistic or phonological perspective.
Some treatment approaches have traditionally focused on articulation production and others have been more phonological/language-based. 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 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). Both approaches might be used in therapy with the same individual at different times or for different reasons.
The sequence of most treatment approaches for speech sound disorders are reflected in the following phases of therapy:
Establishment—eliciting target behaviors 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 behaviors and making production more automatic; encouraging self-monitoring of speech and self-correction of errors.
Approaches used for selecting initial therapy targets for children with articulation and/or phonological disorders include
- developmental approaches in which target sounds are selected based on order of acquisition in typically developing children;
- non-developmental/theoretically motivated approaches, including
- complexity approach—targets more complex, linguistically marked phonological elements not in the child's phonological system to induce cascading generalization learning of sounds (Gierut, 2007);
- dynamic systems approach—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 approach—bases treatment 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 classes, places of production, and voicing (Williams, 2003b).
Other approaches, including
- selecting client-specific targets based on factors, such as relevance to the child and his family (e.g., sound is in child's name), stimulability, and/or visibility when produced (e.g., /f/ vs. /k/);
- selecting targets based on degree of deviance and impact on intelligibility (e.g., errors of omission and error patterns, such as initial consonant deletion, that contribute most to intelligibility).
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.
Fey (1986) identified the following (goal attack) strategies:
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;
Horizontal—less intense practice on fewer targets; multiple targets are addressed individually or interactively in the same session, thus providing exposure to more aspects of the sounds system;
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 (e.g., Hodson, 2010)
The following are brief descriptions of both general and specific treatments for children with speech sound disorders. These approaches, listed alphabetically, can be utilized to treat speech sound problems in a variety of populations, including children with apraxia of speech, structurally based disorders, syndrome-based disorders, and hearing impairment. 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). Note that this list is not exhaustive, and inclusion does not imply an endorsement from ASHA.
Contextual utilization approaches are based on the recognition that speech sounds are produced in syllable-based contexts in connected speech and that some contexts can facilitate correct production of a particular sound. Instruction for that sound is initiated in the context(s) where the sound can be produced correctly (McDonald, 1964). The syllable is used as the building block for practice at more complex levels. These approaches may be helpful for children who use a sound inconsistently and need a method to facilitate consistent production in other contexts. For example, production of a "t" may be facilitated in the context of a high front vowel (Bernthal et al., 2013). Facilitative contexts or "likely best bets" for production can be identified for voicing, velar, alveolar, and nasal consonants. For example, a "best bet" for nasal consonants is before a low vowel, as in "mad" (Bleile, 2002).
Contrast therapy focuses on production using contrasting word pairs instead of individual sounds. This approach emphasizes sound contrasts necessary to differentiate one word from another and includes four different contrastive approaches—minimal opposition contrasts (minimal pairs), maximal opposition contrasts, 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, in an effort to establish contrasts not present in the child's phonological system (e.g., door vs. sore, pot vs. spot, key vs. tea; Baker, 2010; Blache, Parsons, & Humphreys, 1981; Weiner, 1981).
Maximal Oppositions—uses pairs of words in which one speech sound known and produced by the child is contrasted with a maximally opposing sound not known or produced by the child (e.g., manner of production and place of production, such as /m/ vs. /s/; Gierut, 1989, 1990, 1992).
Treatment Of The Empty Set—similar to maximal opposition contrasts, but uses pairs of words containing two maximally opposing sounds that are unknown to the child—ideally, an obstruent with a sonorant (e.g., /l/ vs. /s/; Gierut, 1992).
Multiple Oppositions—a variation of the minimal opposition contrast approach that 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 (Williams, 2000a, 2000b).
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 that are 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 "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 highly unintelligible children who have extensive omissions, some substitutions, and a restricted use of consonants. The goal is to increase intelligibility within a short period of time, and 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 normal 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 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. This approach uses tasks (e.g., minimal pair contrasts) 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 contrast often generalizes to other sounds that share the targeted feature (Blache & Parsons, 1980; Blache et al., 1981).
Metaphon therapy is designed to teach metaphonological awareness, 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, and the focus is on the sound properties that need to be contrasted. For example, for problems with voicing, the concept of "noisy" (voiced) versus "quiet" (voiceless) are taught. Targets typically include processes that impact intelligibility, can be imitated, or are not seen in typically developing children of the same age (Howell & Dean, 1994).
Naturalistic Speech Intelligibility Intervention
Naturalist speech intelligibility intervention directs treatment of 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, the child can be asked questions about items 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 intelligible enough to be able to use the recasts effectively (Camarata, 2010).
Non-Speech Oral-Motor Therapy
Non-speech 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 immature or deficient oral-motor control or strength may be causing poor articulation and that it is necessary to teach control of the articulators before working on correct production of sounds.
Speech Sound Perception Training
Speech perception training is a procedure used to help the 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 (1) auditory bombardment in which many and varied exemplars of the target are presented to the child, sometimes in a meaningful context such as a story and often with amplification, and (2) 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). Traditionally the speech stimuli used in these tasks are presented live-voice by the speech-language therapist but more recently computer technology has been used which has the advantage of allowing for the presentation of more varied stimuli representing, for example, multiple voices and a range of error types. Typically the tasks progress from a focus on child judgments of speech produced by other talkers to child judgments of the accuracy of self-produced speech. Speech sound perception training is often utilized prior to and/or in conjunction with speech production training approaches. (See Rvachew, Rafaat, & Martin, 1999; Wolfe, Presley, & Mesaris, 2003.)
Treatment Techniques and Technologies
There are a number of techniques used in therapy to increase awareness of the target sound and/or to provide feedback about placement and movement of the articulators. These include
- use of a mirror for visual feedback of place and movement of articulators;
- use of 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);
- ultrasound imaging (placing an ultrasound transducer under the chin) used as a biofeedback technique to visualize articulatory positioning and movement for vowel production (Adler-Bock, Bernhardt, Gick, & Bacsfalvi, 2007; Preston, Brick, & Landi, 2013);
- palatography (using 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);
- amplification of 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);
- spectral biofeedback through a visual representation of the acoustic signal of speech (Byun, & Hitchcock, 2012);
- 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; Shriberg, 1980).
When treating a bilingual individual with a speech sound disorder, the clinician is working with two 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 represent variations of speech associated with another language a child speaks.
Strategies used when designing a treatment protocol include
- determining whether to use a bilingual or cross-linguistic approach (see
bilingual service delivery);
- determining the language in which to provide services, based on factors such as language history, language use, and communicative needs;
- identifying alternative means to provide appropriate models for speech sound productions when targeting phonemes unique to the child's language, if the clinician is unable to accurately and appropriately do so;
- 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 Act (IDEA; 2004). 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,
- if specially designed instruction and/or related services and supports are needed to help the student make progress in the general education curriculum.
Eligibility for speech-language pathology services is documented in the child's individualized education program (IEP), and the child's goals and the dismissal process are explained to parents and teachers.
Dismissal from speech-language pathology services occurs once the criteria for eligibility are no longer met—that is, when the child's communication problem no longer adversely affects academic achievement and functional performance.
For more information about eligibility for services in the schools, see
eligibility and dismissal in schools,
IDEA Part B Issue Brief: Individualized Education Programs and Eligibility for Services, and
2011 IDEA Part C Final Regulations.
For some children, speech difficulties persist throughout their school years and into adulthood. Pascoe, Stackhouse, and Wells (2006) define persisting speech difficulties (PSD) 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 PSD is heterogeneous, varying in etiology, severity, and the nature of their difficulties (Dodd, 2005; Stackhouse, 1996) and includes children with
- speech sound disorders of unknown etiology (i.e., typical articulation and phonological disorders),
- motor-based speech disorders (e.g., childhood apraxia of speech, dysarthria),
- medical conditions and sensory-based problems (e.g., chronic otitis media, hearing loss),
- structure-based speech disorders (e.g., cleft lip/palate, other craniofacial anomalies).
A child with PSD may be at risk for
- difficulty communicating effectively when speaking,
- difficulty acquiring literacy skills,
- psychosocial problems (e.g., low self-esteem, at increased risk of bullying).
Intervention approaches will vary and may depend on the child's diagnosis (e.g., structural vs. condition-related) and his/her area(s) of difficulty (e.g., speaking, literacy, and/or psychosocial issues). In designing an effective treatment protocol, the SLP considers
- a psycholinguistic approach to identify the level at which speech processing is disrupted, including
- input/perception (auditory discrimination of sounds and words),
- storage (underlying lexical representation),
- speech output (planning and production of sounds needed for speech);
- phonological (linguistic) approaches to treat the level or levels of identified disruption, using specific interventions and stimuli (e.g., minimal pairs, maximal pairs, metaphon approaches);
- medical and surgical intervention (e.g., for children with cleft lip/palate or other physical conditions);
- collaboration with teachers and other school personnel to support the child and to facilitate his/her access to academic curriculum;
- management of 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, literacy, and social aspects of life as they transition to post-secondary education and vocational settings. The potential impact of persisting speech difficulties highlights the need for continued support to facilitate a successful transition to young adulthood. These supports include
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 accommodations, such as extended time for tests, the use of assistive technology (e.g., to help with reading and writing tasks), accommodations for oral speaking assignments, and methods/devices to augment oral communication, if necessary.
The Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act provide protections for students with disabilities transitioning to postsecondary education to ensure that programs are accessible to these students and to provide aids and services necessary for effective communication (U.S. Department of Education, Office of Civil Rights, 2011).
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 other service delivery variables that may have an impact on treatment outcomes, such as
- 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 providing the treatment (e.g., SLP, trained volunteer, caregiver)
- Setting: the location of treatment (e.g. home, community-based, school)
- Timing: the timing of intervention relative to the diagnosis.
The combination of service delivery factors is important to consider, so that children receive optimal intervention intensity to ensure that efficient and effective change occurs (Baker, 2012; Williams, 2012).