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Enhancing Ph Children Witt \

by Barbara Williams Hodson

Major Early Contributions

Intelligibility Considerations
Bishop and Adams (1990) posited in their critical age hypothesis that children need to be intelligible by 5'/2 years of age or they are likely to have difficulty with decoding and spelling. Children with severe/ profound speech-sound difficulties frequently demonstrate poorer phonological awareness skills than their typically developing peers, which, in turn, negatively affect literacy acquisition (Gillon, 2004). There is some urgency, therefore, for children to be intelligible before entering school. The method generally recommended for assessing intelligibility is to obtain a connected-speech sample of more than 100 words and have at least one unfamiliar listener write down words that can be understood, placing a dash for words that cannot be identified. The number of words understood is divided by the total number of words in the sample to obtain an intelligibility percentage. A guideline for expected intelligibility (originally proposed by Caplan and Gleason, 1988) can be calculated by dividing the child's age in years by four and converting that number into a percentage: 2-year-old: 50% 3-year-old: 75% 4-year-old: 100% Thus a 4-year-old who is 50% intelligible is considered to be "delayed" by two years. Intelligibility is a much more meaningful measure for young children

oung clients with speechsound deviations comprise the largest group of children receiving speechlanguage services (see Table A online; ASHA, 2010). Practicing speech-language pathologists often use the term "articulation" to refer to mild or moderate speech-sound disorders and either "phonology" or "apraxia" to refer to severe or profound issues. The umbrella term preferred by ASHA, however, is "speech-sound disorders" (Bernthal, Bankson, & Flipsen, 2009).

The earliest published comprehensive method for working with children with speech-sound disorders was developed by Charles Van Riper (1939). Although there have been many adaptations (e.g., behaviorism overlay) from his original work more than 70 years ago, it has survived the test of time and is still the foundation for the practice of most SLPs. This phoneme-oriented approach is considered adequate for children with mild speech-sound disorders (e.g., lisp), but has been found to require an incredible amount of time for children with highly unintelligible speech as they "perfect" one sound (or cognate pair) at a time. SLPs have reported that phoneme-oriented methods work well for a child who has two or three sounds in error, but a child who has a dozen or so missing sounds may take five or six years for each sound to reach a criterion (e.g., 90%) in each position of words, in phrases, in sentences, and in conversation. The landmark book. Phonological Disability in Children, by David Ingram (1976), provided a bridge between linguistic phonology and speech-sound disorders. His work helped SLPs look beyond individual phonemes to patterns of deviations, referred to as phonological "processes," and paved the way for new phonologically based remediation principles and procedures as well as phonological assessment instruments.

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Dnologcal Patterns of Young Highly Unintelligible Speech

Every time children continued making the error in their production-practice words, they were reinforcing the inaccurate kinesthetic image.
Table 1. Potential Optimal Primary Target Patterns
Target only those patterns that are consistent deviations. Targets must be "stimulable." Otherwise, practicing error would reinforce inaccurate kinesthetic image (Exception: "facilitate" liquids at end of each cycle even if not stimuiable in order to lay a foundation). Stimulate nonstimulable patterns/sounds (e.g.. M) for a few minutes during regular sessions until they become stimulable (i.e., teaching stimulability) and then these can be targeted during treatment sessions. "Syllableness" (i.e., for utterances restricted to monosyllables). 2-syllable compound words (e.g., cowboy, baseball). 3-syllable/word combinations (e.g., cowboy hat, baseball bat). Singleton consonants (syllable/word structures) CV (word-initial /p, b, m, w/ if lacking). VC [voiceless final stops /p/, /t/, and/or /k/ (depending on whether child produced world-ijitiai /p/ or /b/, IM or lui, lYJ or /g/), possibly final /m, n/ if lacking]. /s/ Clusters [for omissions, not substitutions/distortions (e.g., lisps)] Word-initial (e.g., /sp/, /st/, /sk/). Note: Add /s/ to consonant child already produces (i.e., if child produces /b/ or /p/ can target /sp/; if child produces /k/ or /g/ can target /sk/: as child's repertoire increases can target all /s/ clusters). Word-final (e.g., /ts/, /ps). Incorporate phrase: "It's a (/s/ cluster word)" after child demonstrates facility producing /s/ clusters in productionpractice words (typically by third cycle). Anterior/posterior contrasts (after stimulability evidenced) Velars (if "fronter"): word-final /k/ (before prevocalic velars: never final /g/) and word-initial /k, g/ (occasionally the glottal /h/). Alveolars (if "backer"): occasionally labials. Facilitation of liquids (even if not stimulable) Word-Initial / I / (preceded by week of tongue-tip clicking independent of jaw). Word-Initial /r/ (suppress gliding initially: exaggerate vowel: do not blend at this time]. Incorporate /kr/, /gr/ when child already has velars, typically third cycle). Reassess and recycle primary patterns as needed. Must meet criteria in Table 2 (see p. 18) before progressing to secondary target patterns.

than are phoneme acquisition normative data, which vary greatly from study to study (see Smit, 1986, for a review of some of the issues related to phoneme acquisition norms). Because different school districts in the United States use different sets of norms, a child may qualify for speech-language services in one school district but may not qualify in another.

Expediting Intelligibility Gains

In 1975, we (graduate students and author) began an experimental phonology clinic at the University of Illinois (see Hodson, 2010) that accepted only children with highly unintelligible speech (intelligibility generally between 0% and 15% in spontaneous speech samples at the onset of treatment). In the first three years, as hypotheses were formulated and tested, we made drastic changes. For example, it soon became apparent that targeting word-initial singleton lit or /s/ first was a mistake for children who substituted stops for stridents and also reduced As/ clusters. As we experimented with targeting /s/ clusters before singleton stridents for these children, they achieved major

gains in intelligibility. Moreover, most of the children generalized to singleton stridents, eliminating the need to target them. During this period, we explored the concept of focusing on phonological patterns (e.g., final consonants, /s/ clusters), with phonemes serving as a means to an end rather than the end goal (e.g., 90% mastery of phonemes, one at a time). We also found that the emphasis on "counting and charting errors" was counterproductive for these young clients with highly unintelligible speech. Instead, our goal was for the child to produce the specified target pattern 100% correctly in carefully selected production-practice words, incorporating "assists" (e.g., tactile cues, amplification) as needed, and phasing out the assists as the child gained facility in producing the target. Every time children continued making the error in their production-practice words, they were reinforcing the inaccurate kinesthetic image. Thus, it is critical that the child be "stimulable" and capable of producing the target sound (usually with assistance at first) in order to develop the new accurate kinesthetic image. We would, of course.

Word structures (omitted segments)

See Phonology page 18

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Phonology from page 7 Table 2. Potentiai Secondary Target Patterns

Proceed to secondary patterns after the following criteria have been met: Early developing patterns (e.g., final "consonantness" established) /s/ clusters emerging in conversation Contrastive use of velars and alveolars Practice words for liquids produced without insertion of intrusive consonant (e.g., glide) Target any of the following secondary patterns that are still consistently lacking/deficient. Many of these will no longer need to be targeted. (Note: It is important to incorporate minimal pairs for production practice for secondary patterns when possible.) Palatals Glide / j / if lacking. Palatal sibilants (e.g., "sh," "ch"). (Mote; Model /sj/ and /tsj/to help child develop kinesthetic image; this will coalesce into the palatal sibilants as when adults say "miss you" quickly.) Other M clusters and word-medial (intervocalic /r/). Vocalic (r) (unless dialectal). Other singleton stridents (e.g., /f/, /s/) (Note; To eliminate an intrusive consonant, exaggerate vowel rather than the strident.) Word-medial CC (e.g., toaster, basket). Word-final CC (e.g., toast, desk). CC with glides (e.g., /kj/, /kw). CCC (e.g., /skw/, /skr/, /spl/). Vowel and dipthong contrasts (nondialectal) Voicing contrasts (prevocalic only) Assimilations (if any remain problematic) Any remaining idiosyncratic deviations (e.g., fo7for town)

"stimulate" nonstimulable sounds (e.g., /k/) for a few minutes during each session (i.e., teach stimulability) and then target these as soon as the child could actually produce them. We also explored targeting phonological patterns via cycles (time periods varying from five to 16 hours, depending on the number of patterns that needed to be targeted and also stimulability). Typically a phoneme (or consonant cluster) is targeted one hour per week (i.e., one 60-minute session, two 30-minute sessions, or three 20-minute sessions), with each pattern typically being targeted from two to five hours per cycle. We also realized that phonological patterns needed to be divided into primary (those targeted first and then recycled as needed until they began emerging in conversational speech) and secondary patterns (see Tables 1 and 2). It is important to note that complexity is increased gradually so that the client is optimally challenged but successful from the beginning of treatment. Most young children in our phonology clinics (Wichita State University, San Diego State University, University of Illinois) were judged to be essentially intelligible within three to four cycles (i.e., approximately 30 to 40 contact hours) and simultaneously demonstrated vastly improved phonological systems.

Other consonant sequences

(e.g., sue for zoo) (e.g., faffor caff

(e.g., an individual sound preference used inappropriately)

Underlying Concepts, Theoretical Underpinnings

The approach that has emerged from this researchthe cycles approach to phonological remediationis based on developmental phonology theories and cognitive psychology principles as well as on ongoing clinical phonology research. The cycles approach most closely aligns with the gestural phonology theory (Browman & Goldstein, 1986). A basic tenet of gestural phonology is that phonological representation is based on speech perception as well as on "speech production physical constraints." Seven underlying concepts serve as the basis for the cycles approach (Hodson, 2007; Hodson & Paden, 1991). Phonological acquisition is a gradual process (Ingram, 1976). Children typically do not learn each sound to a 90% criterion and then learn the next sound to a criterion. There is considerable vacillation and experimentation on the part of typically developing young children (Dyson, 1988). This principle is the major reason for the cycles approach, which enhances phonological patterns in a sequential manner, and then recycles patterns as needed until the patterns begin carrying over into conversation. Children with normal hearing typically acquire the adult sound system primarily hy listening (Van Riper, 1939). Most parents do not tell children where to place their tongues. Children need optimal hearing and adequate perceptual skills during their early speech-learning years (Shiller, Rvachew, & Brosseau-Lapre, 2010). Children associate kinesthetic and auditory sensations as they acquire new phonological patterns, enabling later self-monitoring (Fairbanks, 1954). We incorporate production practice to help children learn new accurate kinesthetic images. When we imitate children's error productions, they usually tell us that we are wrongbut then repeat their error productions because they rely on inaccurate kinesthetic images and fail to perceive their own errors. We also incorporate slight amplification during a listening activity at the beginning and end of each session to help children learn to perceive differences between errors and desired productions. Phonetic environment can facilitate (or inhibit) correct sound productions (Kent, 1982). Production-practice words must be chosen with extreme care during beginning cycles. Words with phonemes at the same place of articulation as the error should be avoided until later cycles (e.g.. "cat" is inappropriate at first for a child who demonstrates velar fronting because of alveolar assimilation effects). Children tend to generalize new speech production skills to other targets (McReynolds & Bennett, 1972). We know that children generalize (and sometimes overgeneralize). The key is to target optimal patterns to facilitate generalization and increase intelligibility and then proceed on to other patterns, with a period of rest for a pattern before recycling it. An optimal match facilitates a child's learning (Hunt, 1961). Phonological analysis determines the child's match (e.g., Hodson, 2003, 2004) so that treatment can begin one "step" above the child's current functioning level, resulting in the child being optimally challenged but also successful from the beginning of treatment. Children are actively involved in their phonological acquisition. This principle is important for children with speech-sound disorders as well as for typically developing children. Young children need to be actively engaged participants rather than passive imitators.

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A great need exists for a large, well-designed controlled experimental study comparing outcomes of various interventions for children with highly unintelligible speech.
Phonological Remediation
The structure described below has been used successfully in schools, hospitals, clinics, and private practice. The child reviews production-practice picture cards from the previous session. These cards are then set aside (and may be used again along with new, more complex words during a later cycle, depending on whether the phonological pattern needs to be recycled). The SLP then reads a list of approximately 20 words that contain the new target pattern for the week. The child is to listen attentively, but must not repeat these words. Slight amplification is provided during this 30-second listening activity. The child participates in experiential-play production-practice motivational activities (e.g., bowling, flashlight game), naming pictures and objects of four or five carefully selected target words with the week's pattern before taking a tum in the activity. The SLP changes activities every eight to 10 minutes. Many of these activities are repeated during ensuing weeks. A metaphonology activity is incorporated (e.g., rhyming, segmentation) to enhance the child's phonological awareness skills. The SLP probes for the optimal phoneme target for the next week (within the phonological pattern designated from phonological assessment results). For example, if the current pattern is hi clusters, the clinician models words with various /s/ clusters (e.g., spot, store, snow). The cluster that the child produces most successfully becomes the target for the ensuing week. The listening list from the beginning of the session is read to the child again with slight amplification. Parents receive the listening list and the productionpractice picture cards and are asked to provide two minutes of home practice every day.

participate in a cycle (typically a semester) of focused auditory input/stimulation for the primary patterns. The SLP fills the room with objects and activities for a primary pattern phoneme. For example, objects and tasks for final /p/ (e.g., mop, top. tape, rope, hop, up, cup, nap, pup, peep) are incorporated to stimulate awareness of final consonants. The child participates in the play activities but is not asked to name words during this cycle. The parents receive a list of words (with the week's target pattern) to read to the child each night, but they do not ask the child to say words at this time. These adaptations provide a great foundation and the child readily moves to production practice during the next cycle.

Barbara Williams Hodson, PhD, CCC-SLP, is a professor in the Department of Communication Sciences and Disorders at Wichita State University. Her research interests include clinical phonology and metaphonology, Spanish phonology, and early literacy. Contact her at barbara.hodson@ wichita.edu.

Evidence Considerations and Research Needs

There is consensus among SLPs that treatments for speech-sound disorders are successful. Baker and McLeod (2010) used the levels-of-evidence system selected by ASHA (adapted from the Scottish Intercollegiate Guideline Network) to review 134 studies. One of their observations was that comparative studies are generally lacking. A great need exists for a large, well-designed controlled experimental study comparing outcomes of various interventions for children with highly unintelligible speech. The number of participants in each treatment group needs to be large because of the heterogeneity of clients with speech-sound disorders (e.g., Harbers, Paden, & Halle, 1999). Ideally, this study should be conducted by investigators independent of the individuals who created these approaches to minimize actual bias or even the appearance of bias. It is critical, however, that the approach creators be consultants for purposes of fidelity. There also is a need for more advocacy so that treatment protocols that optimize outcomesrather than top-down factors such as scheduling issues determine intervention approaches, ij^

Selected References
Baker, E., Carrigg, B., & Linich, A. (2007). What's the evidence for. ..? The cycles approach to phonological intervention? Acquiring Knowledge in Speech, Language, and Hearing, 9, 29-31. Bernthal, J., Bankson, N., & Flipsen, P. (2009). Articulation and phonological disorders: Speech sound disorders in children (6th ed.). Boston: Pearson. Gillon, G. (2004). Phonological awareness: From research to practice. New York: Guilford. Hodson, B. (2007). Evaluating and enhancing children's phonological systems: Research and theory to practice. Wichita, KS: Phonocomp Publishers.

Additional references for this article can be found at The Leader Online- Searcti on the title
ot the article www.asha.org/ieader.aspx.

Adaptations for Toddlers

Most of the 2-year-olds referred to our clinic are not willing to participate in regular production-practice activities. Some are nonverbal; others are unwilling to name pictures or imitate words. These children

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