Phonological Process Treatments

Within the Pediatric Population

Samantha Bensavage Samantha Jansson, Amanda Pavalko, Janelle Strickler
9/26/2011
 T ABLE OF CONTENTS
Introduction 3

Phonological Processes 4

Baseline Measures 5

Stimulability Approach 6

Probes 6

Phonological Approaches 10

Phonological Process Target 10

Cycles 10

Metaphon 10

Minimal Pairs 11

Backwards Chaining Procedures 12

Facilitative Vowel Contexts 12

Computer Applications 12

Combination 12

Research Conclusions 13

Intervention Activities 32

Future Areas of Study 41

Glossary: Phonological Processes 42

Appendix A: Critical Reviews 44

References 84

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INTRODUCTION
The topic of this manual is phonological process treatments, with a focus on treatment
approaches, rather than different processes. It provides a framework for clinicians to utilize in
their clinical practice. First, however, a phonological disorder must be defined, because without
this, the treatment approaches would be unwarranted. Therefore, a phonological disorder, used
interchangeably with speech sound disorder, affects   the   speaker’s   production and/or mental
representation of speech sounds of the target language. A phonological disorder is also
characterized by the use of phonological processes. These  processes  are  defined  as  “systematic  
sound changes that operate across a class of sounds or across sound sequences so that multiple
members  of  the  class  are  affected  similarly”  (Ingham  (1988).  A phonological disorder may also
reflect an inability to articulate speech sounds, with the communication difficulty involving a
motoric component (Gierut, 1998). Since both phonological processes and misarticulations have
the  ability  to  characterize  and  individual’s  speech  as  unintelligible,  it  is  imperative  that  a  speech-
language pathologist be able to distinguish a phonological error from that of an articulation
error.

In phonological disorders the error is viewed on a more linguistic level, where as an articulation
error is simply a physical or motoric malfunction. Phonological process therapy focus on
treating the rules of a language while articulation treatments work on a more simplified level
which includes oral-motor movements and imitation. In order to identify a distinction between
these two errors, a speech-language pathologist should complete a language sample for the
child. When analyzing this sample it is important to examine the phonemic inventory the child
displays. This information will demonstrate whether a child can use phonemes in the initial,
medial or final position or if the child cannot produce the phoneme at all. For an example, if a
child cannot produce the phoneme /t/ in the final position of several words in the sample but
they have consistently produced a /t/ in the initial or medial positions, then the child is
considered to have a phonological process disorder. It would be considered an articulation
disorders if the child cannot produce /t/ anywhere in the sample. Further, the pediatric
population suffers from various disorders. The phonological approaches illustrated throughout
this manual, provide clinicians and practicing speech pathologists with systematic and efficient
methods for eliminating error patterns (Hutton, 2008).

Interestingly enough, the cause of many speech sound disorders is unknown. When children are
learning speech sounds, they can learn to produce the sounds incorrectly and may have
difficulty in learning the speech sounds or the rules of speech sounds on their own (Association,
2007-2011). This does not mean, however, that physical problems cannot be the cause of some
speech sound disorders. Keep in mind that physical problems tend to signal an articulation error
rather than a phonological error.

Risk is prevalent in children with neurological disorders (e.g., cerebral palsy), developmental
disorders (e.g., autism), genetic syndrome (e.g., Down syndrome), and various illnesses.
Hearing loss and those children that experience frequent ear infections at a young age are also at
risk for problems in speech sound development. In fact, several research studies done by
various   U.S.   federal   agencies   which   concluded   “five   percent   of   the   school   age   population   may  
have  communication  impairment,  with  10  to  15  percent  occurring  in  the  preschool  population”  

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(Bernthal, Bankson, & Flipsen, 2009). As speech language pathologists, this illustrates the
clinical importance of intervention and assessment of phonological disorders, when developing
individualized therapy plans for children. Also, it is imperative to note, there   are   “subsets   of  
children who may exhibit phonological difficulties that are associated with their multicultural
origins,”   including   bilingualism,   dialectal   differences   or   native   language   differences.   Further,  
children with these variations in their speech sounds do not have a phonological disorder
(Gierut, 1998).

PHONOLOGICAL PROCESSES
As children are maturing, their speech and language skills are being shaped by many elements of
their environment. Their parents and other adult figures are two of the major contributors that
guide the development of these skills. In an attempt to imitate the speech of an adult, a young
child may simplify the patterns that are being used. This simplification is known as phonological
processes. As children continue to progress through their speech and language development, it
is assumed that their speech would become more intelligible as they grow. However not all
children will be as consistent in acquiring these skills. The children who demonstrate a
difficulty in incorporating these adult-like patterns into their speech and language skills tend to
utilize more phonological processes.

The use of these processes affect sound properties which in turn affects the message the speaker
is attempting to convey. Researchers have developed three different categories of phonological
processes. As explained by the authors of our text, Articulation and Phonological Disorders:
Speech Sound Disorders in Children, the process of assimilation occurs  when  “a  sound  changes  
to  assimilate,  or  become  similar,  to  another  sound”  in  the  word  (Bernthal,  Bankson,  &  Flipsen,    
2009). Assimilation can also be contiguous or noncontiguous and progressive or regressive
(Owens, 2008). If two constituents occur next to each other then the assimilation is considered
contiguous. On the other hand, noncontiguous assimilation occurs if the constituents are apart.
In the text Language Development: An Introduction,   the   author   explains   that   “progressive  
assimilation occurs when the affected element follows the element that influences it; regressive
assimilation,   when   the   affected   element   precedes”   (2008). The process of assimilation occurs
across the distinctive feature qualities of phonemes. Author Robert Lowe notes “that   in   a  
phonetic context (e.g., a word) where assimilation occurs, there is a sound that changes and a
sound that influences (causes) the change (2010). Assimilation affecting the place feature of a
phoneme includes sounds produced as labial, alveolar, velar and/or nasal. For an example of
labial  assimilation  we  will  use  the  word  “rob.”    Here  the  phoneme  /r/  would  be  replaced  with  the  
phoneme /w/. This occurs because the bilabial feature of the final phoneme /b/ is assimilated to
the initial phoneme /r/. Assimilation processes also affect voicing qualities of phonemes.
Prevocalic voicing and postvocalic devoicing take into account the voice quality of other
phonemes found in individual words. To model prevocalic voicing a voiceless phoneme, for
instance /p/, will become voiced, such as /d/. Finally the assimilation of the manner feature
occurs in metathesis and coalescence.

Substitutions are the second type of phonological processes that will be discussed. According to
Bernthal, Bankson and Flipsen (2009), substitution occurs “when one sound is substituted by
another   sound   in   a   systematic   fashion.”   There are a significant number of substitution

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processes, the majority of which modify the place of articulation. In the phonological process
known   as   stopping,   the   qualities   of   place   are   altered   when   “fricatives   and/or   affricates   are  
realized  as  stops”  (Bernthal,  et  al.,  2009). To illustrate this process, the phoneme /s/ in the word
“sun”   would   be   substituted   with   the   phoneme   /t/,   forming   the   word   “tun.” Other substitution
processes include fronting, backing, gliding, labialization, depalatalization, palatalization,
alveolarization, deaffrication, and affrication. A definition, as well as an example of each of these
processes, can be found in the glossary. Before moving on to the third category of phonological
processes,   it   is   important   to   “keep   in   mind   that   the   simple   substitution   of   one   segment   for  
another   does   not   define   a   phonological   process”   (Lowe,   2010).   In order for this error to be
considered a process, a pattern must be present in the speech sample of the client.

The final category of phonological processes that needs to be discussed are those that affect the
syllable structure of a word. Processes including final consonant deletion, initial consonant
deletion, week syllable deletion, cluster simplification, cluster substitution, reduplication, and
epenthesis all change the composition of syllables in words. The concept of final consonant
deletion can be explained  when  considering  the  word  “dog.”  If  a  child  is  exhibiting  this  process,  
the   word   “dog”   would   be   produced   as   “do.”     The absence of the final consonant /g/ from this
word presents a challenge to the listener who is communicating with this speaker because their
speech would be considered unintelligible. As with substitution processes discussed, a list of
syllable structure processes, their definitions and an example of each can be found in the
glossary of this manual.

As with any speech and/or language disorder, it is important to take cultural differences and
dialects into consideration when considering phonological processes to be the root of your
client’s  speech  sound  disorder.  This  is  important  factor  is  explained  by  the  phonological  process  
affecting syllable structure known as metathesis. According to Lowe (2010), this process is
characterized by the reversal of the position of two sounds in a word. This process can be found
in African American English (AAE) where the  word  “aks”  represents  “ask.”    The  reversal  of  the  
phonemes /s/ and /k/ in this word serve as a perfect example of metathesis. Despite the
confusion this reversal may cause to a foreign listener, this production is not incorrect in the
AAE dialect.

BASELINE MEASURES
Once   a   child   is   referred   to   a   speech   language   pathologist,   it   is   essential   to   assess   the   child’s  
competences in speech sound production, patterns of speech, etc., to establish baseline
measures   that   are   used   as   a   basis   to   plot   the   child’s   progress   in   therapy. Baseline measures
warrant adequate documentation of data and ensure efficacy of the treatment. Additionally, they
are used to ascertain pretreatment status of the targets and the treatment procedures are then
implemented for one of them. Once the child successfully reaches the goals for the trained
targets, the same process is then completed for the untrained targets. If the untrained baseline
scores do not show a significant difference or change when compared to original baseline
measures, the clinician   can   be   confident   that   the   treatment   was   responsible   for   the   client’s  
success in reaching trained therapy targets (Roth & Worthington, 2010).

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STIMULABILITY
According to extensive research done by Powell and Micco (1996), stimulability is positively
related to phonological treatment approaches and learning (Rvachew, Rafaat, & Martin, 1999).
Those children with phonological disorders, who are stimulable to a target phoneme, though not
assured, are more likely to acquire that sound, even without treatment. Consequently, those
children who are unstimulable for a particular sound, most likely will not acquire the sound
unless treatment is provided (Rvachew, Rafaat, & Martin, 1999). Stimulability training
employed into practice is said to work better for those children who have a minute amount of
phoneme sounds in their repertoire and show little stimulability for learning sounds (Owens,
Metz, & Haas, 2003).

PROBES
A probe is something that measures or tests an   individual’s   ability   or   knowledge   base.  
Specifically in speech and language pathology probes serve as a key feature of assessment.
Probes help an SLP to establish a baseline for what to target within and across therapy sessions,
and also to  aids  in  selecting  the  appropriate  treatment  for  the  child’s  needs.

ACTIVITY 1
 Phonological Strategy for Remediation

o Hierarchy – Minimal Pairs (Backing)

 Isolation

 All phonemes produced in the front of the oral cavity

 Syllable

 All syllables

 Words

 tan, fin, bun, zoo, mat, sun

 Carrier Phrase

 “I  found  a…”

 “I  see  a…”

 Phrases

 “the  yellow  sun”

 “the  round  bun”

 Sentences

 “The  sun is yellow.”

 “The  bun is stale.”

 Conversation

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  “Tell  me  about  the  zoo!”

 Generalization to Release

ACTIVITY 2
 Phonological Strategy for Remediation

o Hierarchy – The Cycling Approach (Backing, Stopping, Gliding)

 Isolation

 All phonemes produced in the front of the oral cavity, continuants and
liquids

 Syllable

 All syllables

 Words

 fun, tan, pin, van, bee

 fan, sand, shoe, nose, zoo

 laugh, red, roll, light, log

 Carrier Phrase

 “I  found  a…”

 “I  see  a…”

 Phrases

 “a  big  bee”

 “a  good  laugh”

 Sentences

 “The  sun is fun.”

 “Sit  on  the  log.”

 Conversation

 “Tell  me  about  the  sand!”

 Generalization to Release

ACTIVITY 3
 Phonological Strategy for Remediation

o Hierarchy – Metaphon Final Consonant Deletion

 Isolation

 All phonemes

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  Syllable

 All syllables

 Words

 tide, kite, peep, team, plane, height

 Carrier Phrase

 “I  found  a…”

 “I  see  a…”

 Phrases

 “a  big  plane”

 “the  good  team”

 Sentences

 “The  team is good.”

 “The  cat is black.”

 Conversation

 “Tell  me  about  the  team!”

 Generalization to Release

ACTIVITY 4
 Phonological Strategy for Remediation

o Hierarchy – Backwards Chaining Procedure (Cluster Reduction)

 Isolation

 All two-phoneme consonant clusters

 Syllable

 All syllables

 Words

 plum, grape, prune, broccoli, spinach

 Carrier Phrase

 “I  found  a…”

 “I  see  a…”

 Phrases

 “a  sweet  plum”

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  “the  green  broccoli”

 Sentences

 “The  broccoli is good.”

 “The  grape is purple.”

 Conversation

 “Tell  me  about  the  fruits!”

 Generalization to Release

ACTIVITY 5
 Phonological Strategy for Remediation

o Hierarchy – Minimal Contrast Pairs (Stopping)

 Isolation

 All continuant phonemes

 Syllable

 All syllables

 Words

 shoe, food, van, mom, noon, sun

 Carrier Phrase

 “I  found  a…”

 “I  see  a…”

 Phrases

 “a  stinky  shoe”

 “the  red  van”

 Sentences

 “The  food is good.”

 “The  van is fast.”

 Conversation

 “Tell  me  about  your  mom!”

 Generalization to Release

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PHONOLOGICAL APPROACHES
A variety of evidenced-based approaches exist for treating children with phonological process
disorders. These methods potentially reduce the time children spend in therapy correcting
unintelligible speech. Gierut’s  research study on treatment efficacy proposed several questions
that must be addressed concerning the implementation of therapy and the functional outcomes
of phonological treatments. The questions focused on the efficiency, reliability, and validity of
the treatment and if one treatment, in fact, worked better than another. Additionally, identifying
the type and extent of the sound change induced in the treatment was another area of interest
(Gierut, 1998). “The  available treatment methods are oftentimes based on different theoretical
frameworks,   emphasize   different   treatment   goals,   and   rely   on   different   teaching   strategies”
(Gierut, 1998). The one implemented in practice, however, is chosen after receiving and
assessing the child’s   diagnostic results of the phonological disorder, ensuring the appropriate
treatment is individualized for that child.

PHONOLOGICAL PROCESS TARGETS

Children with unintelligible speech characterized by multiple incorrect phonological patterns
may benefit from phonologically based treatments. These treatments focus on remediating rule
based error patterns. Two of these approaches, cycles and metaphon, are discussed in further
detail below.

C YCLES
Cycles is a linguistic approach intended for children with multiple sound errors. This approach
recognizes poor phonological patterns and identifies targets to integrate into therapy, which will
move along in a sequential manner. Cycles does not work on eliminating inappropriate speech
production, but rather, works on helping children acquire appropriate phonological patterns.
The procedure for the cycles approach, according to Hodson and Paden (1991) include (1)
auditory stimulation of a target, (2) production practice in order for the child to develop new
kinesthetic images, and (3) participation in experiential play activities, such as picture and
object naming tasks that incorporate target patterns into word production. A cycle is complete
when all the phonological patterns have been worked with during various therapy sessions.
Treatment cycles can range from 5-16 weeks. This depends on the client’s errors and the
amount of stimulable phonemes within each pattern. The next cycle focusing on a new target
will begin even if mastery of the first target is not reached. In order to become intelligible,
Hodson (1989) recommends three to six cycles of remediation, consisting of 40 to 60 minutes of
treatment per week. The cycles approach has been found to work with children having recurrent
otitis media and hearing impairments (Gordon-Brannan, Hodson, and Wynee, 1992), as well as
with children with cleft palate (Hodson, Chin, Redmond, and Simpson, 1983).

M ETAPHON
The   child’s   active   cognitive   participation   is   a   crucial   element   in   the   metaphon   approach.     In  
order for this approach to be effective, the client has to be actively involved in the remediation
process. This means that he/she must be aware of their incorrect production of a phoneme,
want to modify it, understand the relevant targets, and have the neuromotor capability of
accurately producing each target in a variety of phonemic contexts (Owens et al., p. 304).

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Metaphon therapy is divided into two phases. Phonological awareness is the focus of phase one
in which the clinician teaches the client the difference between correct and incorrect
productions. Phase two works on transferring the knowledge from phase one to communicative
situations. The concept of minimal pairs helps solidify the scheme that is covered in this
therapy approach.

MINIMAL PAIRS
A minimal pair consists of two words that differ in pronunciation by one phoneme target or
feature that ultimately changes the meaning of the word (Hutton, 2008). A phoneme, each with
distinctive features, is the smallest linguistic unit of each sound that can signal a difference in
meaning when modified. Typically, a child, through minimal pair contrast treatment, will
distinguish through discrimination, imitation and/or spontaneous production of the pairs of
syllables or words that are unique along a single feature or dimension (Gierut, 1989). Clinicians
have implemented this approach into practice and further, have adopted intervention and
assessment frameworks on the basis of this distinctive feature method. Studies done by Gierut,
reflected in her article “Maximal   Opposition Approach to Phonological Treatment,” revealed
that this treatment approach has been successful in facilitating the acquisition of specific and
trained minimal pairs, as well as enhancing the generalization of word pairs with similar
features (Gierut, 1989). Once an analysis has been completed and incorrect phonological
patterns are noticeable, the minimal pairs approach can be applied (Crosbie, 2005).

E RROR /T ARGET P HONEME

This approach is a subset of the minimal pair approach; however, it focuses on one phoneme
target. The clinician uses the error/target production of the client and contrasts it with the
correct production. If  the  client  were  to  say  “tea”  for  “team,” he/she is exhibiting final consonant
deletion. Pictures can be supplemental in this activity and the speech pathologist can ask the
child to point to the pictures represented for each member of the pair. An additional exercise
can be completed where the clinician can embed each word in a sentence, e.g.  “the  boy  played on
the tea”  or  “the  boy  played on the team,” asking if one or the other makes more sense (Owens,
Metz, & Haas, 2003).

M INIMAL C ONTRAST
Another subheading to minimal pairs approach is minimal contrast. This treatment involves
pairs of words that can be differentiated by a single distinctive feature. Particularly, focusing on
the process of deaffrication in which the phonemes differ by manner. In this process, for
example, the affricate, /dʒ/, is simplified to /j/.

M AXIMAL O PPOSITIONS /C ONTRAST

A final subset of the minimal pairs approach is known as maximal oppositions. This concept still
involves pairs of words, though the pairs differ by multiple elements amongst targets (Hutton,
2008). Whereas, minimal pair treatment involves distinctions that contrast along narrow,
binary dimensions, maximal contrastive sounds are distinct among several feature dimensions,
i.e. including the place, manner and voice. Maximal oppositions, sometimes termed maximal
contrasts, are oftentimes used earlier in intervention considering the contrasts are easier for the
client to distinguish between. Furthermore, implementing this approach into practice may

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possibly lead to modification of error phonemes beyond what is targeted immediately (Owens,
Metz, & Haas, 2003).

BACKWARD CHAINING PROCEDURES

During this procedure, the final part of the target word is taught before the whole word is
taught. After success is observed with the final part of the word, it is then incorporated into the
rest of the word so that the entire word can be trained. For example, if a clinican were teaching
a child to appropriately produce initial clusters, he/she might use the target word “train.”     In  
using the backwards chaining procedure, first the final portion of the cluster would be taught
(“rain”).    When  the  client  is able to produce this portion of the word it is incorporated into the
rest  of  the  word.    The  child  is  then  taught  to  say  the  whole  word  “train.”    This  breaks  down  the  
word, and may assist the child in producing both consonants sounds in the cluster (Young,
1987).

Rebuses may be used during this treatment. A rebus is a picture or symbol that carries meaning.
It may be used during backward chaining procedures to represent a part of a word rather than
the whole word. For example, if we are working on the  word  “monkey,”  we  may  use  a  picture  of  
a  key  to  help  the  child  remember  that  the  last  part  of  the  word  sounds  like  “key”  (Young,  1987).  

FACILITATIVE VOWEL CONTEXTS

Facilitative Vowel Contexts use vowels in combination with a target consonant sound to aid in
the production of the target sound. This treatment approach uses a continuum of vowel-
consonant (#_VC) and consonant- vowel (CV_#) combinations. An example of this would be
the fronting of the target phoneme /k/ replaced by the phoneme /t/. The child  may  use  “coat”  
for  “tote”  to  illustrate  this  example.  After determining the target process, the target /k/ must be
paired with a vowel with the same place characteristics. Since the /k/ is made in the back of the
mouth, the clinician would choose a back vowel. Considering this, the vowels /a/ and /o/ can be
paired with the /k/, e.g., /ak/ and /ko/. As treatment continues, the tasks become increasingly
more difficult as they involve less facilitative vowel contexts. This way, clients are able to learn
correct placement for the target consonants and also use self-monitoring for correct production
(Griffiths, Stokes, 2010).

COMPUTER APPLICATIONS
Computer applications can be supplemental to various approaches and treatment interventions
described above. These programs provide the client with exercises to work on target phoneme
productions, thus allowing the client to gain independent practice with the phonemes (Owens,
Metz, & Haas, 2003). In Treatment Efficacy for Phonological Disorders, Gierut concluded,
“computer  assisted  instruction  has  been  reported  to  be  highly  effective  because  it  is  structured,  
supplemental, entertaining and can be completed   independently   by   the   child.”   Computer
applications are helpful in providing immediate feedback, allowing clinician to efficiently
monitor the progress and success of their clients. The client, too, receives visual and auditory
feedback about the accuracy of responding in a computer game format (Gierut, 1998).

COMBINATION
A combination of approaches can be organized to fit the needs of a client.

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RESEARCH CONCLUSIONS
The following research articles, focusing on the topic of phonological processes, were examined and a
critical review was completed for each for the purpose of completing this manual (See Appendix B). This
research was completed to identify the phonological approaches used to treat phonological processing
disorders and determine the validity and reliability of these approaches.

SUMMARY 1
Research Article 1 — The effects of treatment on consonant cluster and weak syllable reduction
processes in misarticulating children

Citation: Young, E. (1987). The effects of treatment on consonant cluster and weak syllable
reduction processes in misarticulating children. Language, Speech, and Hearing Services in
Schools, 18, 23-33.

 Purpose
o Backwards chaining procedure as an effective treatment for phonological
processes (cluster reduction and weak syllable reduction)
 Subjects
o Two female children, age four with persisting phonological processes
 Levels of Evidence: Level II– Before and After
 Method
o Four steps of treatment for both cluster reduction and weak syllable reduction
o Control process of final consonant deletion
o Probes taken at three points
 Results
o Probes taken for correct production of clusters and weak syllables
 Subject 1 baseline probe= 0%
 Subject 1 Follow up probe= 80-100%
 Subject 2 baseline probe= 0-20%
 Subject 2 Follow up probe= 60-100%
 Control process= no improvement
 Conclusion
o Backwards chaining procedures appeared to be an effective treatment method for
two phonological processes

Summary: An article by Edna Carter Young (1987) entitled The Effects of Treatment on
Consonant Cluster and Weak Syllable Reduction Processes in Misarticulating Children discusses
a study on the effects of backward chaining procedures as treatment for phonological processes.
Backward training procedures involve teaching only the final part of a word first, and then
incorporating it into the whole word. This treatment was used in a study of two 4-year-old
children who each demonstrated at least three phonological processes. Both subjects received
treatment for the processes of weak syllable reduction and cluster reduction while final
consonant deletion acted as a control process that was not treated. The results for both subjects
showed an improvement in both weak syllable reduction and cluster reduction. There was no

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improvement in final consonant deletion (the control process), which suggested that backward
training procedures are an effective treatment method for phonological processes.

SUMMARY 2
Research Article 2 —The use of facilitative vowel contexts in the treatment of post-alveolar
fronting: A case study

Citation: Griffiths, R. Stokes, S. (2010). The Use of Facilitative Vowel Contexts in the Treatment
of Post-Alveolar Fronting: A Case Study. International Journal of Language and
Communication Disorders, 45(3), 368-380.

 Purpose
o To determine effectiveness of facilitative vowel contexts in one subject with
persistent post-alveolar fronting
 Subjects
o One boy, age 7 with persisting post-alveolar fronting
 Levels of Evidence: Level III– Case Study
 Method
o Nine therapy sessions from 45-55 mins.
o Target  sound  [∫]
o Probes taken at five points
o Generalization, target, and control measured
 Results
o Probes taken for correct production of post-alveolar fricatives
 Baseline= <10%
 Follow up=100% Statistical significance (p<0.001)
 Control Process = No statistical significance
 Conclusion
o Facilitative Vowel Contexts appear to reduce the phonological process of post-
alveolar fronting

Summary: A case study was conducted by Griffiths and Stokes (2010) in an article entitled The
Use of Facilitative Vowel Contexts in the Treatment of Post-Alveolar Fronting: A Case Study.
This study examined the use of facilitative vowel contexts in the treatment of phonological
processes. Facilitative vowel contexts use a continuum of vowel-consonant and consonant-
vowel combinations to aid the child in the correct production of each sound. The child involved
in the study exhibited post-alveolar fronting. He was seven years of age at the time of the study.
The child received three therapy sessions per week for three weeks. The sessions typically lasted
for 45-55 minutes. The results of the case study indicated that after receiving treatment, the
child’s   scores   were   significantly   higher   than   when   they   began   treatment.     This   suggests   that  
facilitative vowel contexts are an effective treatment for post-alveolar fronting. More studies
could be conducted to determine effectiveness of this treatment for other phonological processes
as well.

14
SUMMARY 3
Research Article 3 — Clinical application of two phonologically based treatment procedures

Citation: Edwards, M. Saxman, J. Tyler, A. (1987, November). Clinical Application of Two

Phonologically Based Treatment Procedures. Journal of Speech and Hearing Disorders, 52,
393-409.

 Purpose
o Determine effectiveness of minimal pair contrasting and a modified cycles
procedure as treatment for phonological processes
 Subjects
o Four children, ages 3-5, exhibiting moderate to severe phonological processes
 Levels of Evidence: Level II- Before and After
 Method
o Subjects split into two groups
 Group 1
 Minimal pairs- Clients presented with pairs of words that contrast
by one aspect
 Group 2
 Modified Cycles- Processes targeted in cycles
 Measurements of target and control words taken during
pretreatment, treatment, and follow-up
 Results
o Group 1
 Probes taken for occurrence of treated processes and untreated processes
 Baseline= 90-97% occurrence of processes
 Follow-up= 0% occurrence of processes
 Control= No or little change
o Group 2
 Probes taken for occurrence of treated processes and untreated processes
 Baseline= 70-100% occurrence of processes
 Follow-up= 0-40% occurrence of processes
 Control= No change
 Conclusion
o Minimal pair contrasts and a modified cycles procedure appear to be effective
treatments for phonological processes

Summary: An article by Edwards, Saxman, and Tyler (1987) entitled Clinical Application of Two
Phonologically Based Treatment Procedures included a study on the effectiveness of two
different treatments for phonological processes. One treatment, minimal pair contrasting,
involves presenting the client with a pair of words that contrast by one aspect. One word will
contain the phonological process and the other word will be the correct production. The other
treatment that was implemented in the study was a modified cycles procedure. For this
procedure, treatment would occur in cycles. For example, in this particular study, a cycle was 3
weeks long. During each week of the cycle, a different process was targeted. There were four

15
subjects involved in the study ranging in age from 3-5. The subjects exhibited moderate to
severe phonological processes. The subjects were separated into two groups. One group
received minimal pair contrasting treatment and the other group received the treatment for a
modified cycles procedure. The results of this study showed that both treatments demonstrated
effectiveness in reducing the targeted phonological processes. All four subjects of the study
showed improvement in a short amount of time.

SUMMARY 4
Research Article 4—Remediation of common phonological processes: Four case studies

Citation: Monahan, D. (1986,July). Remediation of Common Phonological Processes: Four

Case Studies. Language, Speech, and Hearing Services in Schools, 17, 199-206.

 Purpose
o Determine effectiveness of minimal-word-contrast pairs as treatment for
phonological processes
 Subjects
o Four children, age five, demonstrating at least five phonological processes at a
moderate to severe level
 Levels of Evidence: Level III- Case Studies
 Method
o Children split into two groups
o Groups received therapy together
o Therapy occurred two times a week for 30 minutes
o Measurements taken at pretreatment and post-treatment
 Results
o Subject A
 Baseline= 10-88% occurrence of processes
 Post-treatment= 0-53% occurrence of processes
o Subject B
 Baseline= 0-82% occurrence of processes
 Post-treatment= 0-61% occurrence of processes
o Subject C
 Baseline= 0-76% occurrence of processes
 Post-treatment= 0-48% occurrence of processes
o Subject D
 Baseline= 0-92 % occurrence of processes
 Follow-up= 0-73% occurrence of processes
 Conclusions
o Studies show that minimal pairs contrasting may be an effective treatment for
phonological processes; however, future study is recommended

Summary: Another study, conducted by Dana Monahan (1986), was included in an article
entitled Remediation of Common Phonological Processes: Four Case Studies. The purpose of
the study was to determine the effectiveness of minimal-word-contrast pairs as a treatment for

16
phonological processes. Minimal-word-contrast pairs are a pair of words given to the client that
contrast by one aspect. One word contains a phonological process and the other word contains
the correct production. The study involved four five-year-old children who demonstrated at
least five phonological processes at a moderate to severe level. The children were separated into
two groups and each group received therapy together two times a week in 30 minute sessions.
The results of the study demonstrated a decrease in the targeted phonological processes for all
subjects. This suggests that minimal-word-contrast pairs are an effective treatment for
phonological processes.

SUMMARY 5
Research Article 5 —Stimulability, speech perception skills, and the treatment of phonological
disorders

Citation: Martin, M., Rafaat, S., Rvachew, S. (1999). Stimulability, speech perception skills, and
the treatment of phonological disorders. American Journal of Speech-Language Pathology. 8,
33-43.

 Purpose
o “Discusses two descriptive studies that examine the relationship between
stimulability, speech perception, and phonological learning.”
o Both – “Describe  the  relationship  between  pretreatment  stimulability  and  speech  
perception  ability  and  progress  toward  the  acquisition  of  target  sounds”
 Study 1 – focused on group treatment
 Study 2 – modified study 1 – individual session followed by group
treatment
 Design
o Demonstrate   measureable   &   satisfactory   progress   in   small   groups   on   “block”  
basis.
o Received no more than one 3-month block of weekly treatment in 6 month pd
o Mod-severe phonological delays achieve intelligible speech within 18 months
with cycles approach.
o Cycle= 3 targets/3 cycles/3 sessions – 9 weeks = 9 targets
o Study 1 – Cycles approach: 1 – pretreatment session, 9 – 45-60 min group
sessions, 1 – post-treatment session (1 session/wk)
o Study 2 – Cycles approach modified each child received:1 – pretreatment session,
3 – 20 min individual sessions (stimulability & speech perception training), 6 –
45-60 min group sessions, 1 – post-treatment session over 9 weeks (1
session/wk).
 Level of Evidence: Level III – Case control study/retrospective study
 Sample
o Probes test for sound production accuracy, stimulability, and speech perception
ability.
o Only contained 23 subjects all about the same age – small sample size

17
 o Study 1 – 10 children, 4;6, mod-severe phonological delay into 4 groups (2-4
kids/group), Groups formed by scheduling constraints, age, similar error
patterns)
o Study 2 – 13 children, 4;7, mod-severe phonological delay into 4 groups (same
process)
 Results
o Each study used a pre & post-assessment tools to measure results.
o Study 1 – Goldman-Fristoe Test of Articulation
 All but 1 child was ranked below the 10th percentile (moderate or severe
phonological delays).
 Post-assessment mean differences were used to determine change
between the pre-mean and post-mean
o Study 2 – Same standardized test & results. Also used mean to measure change
 Speech Assessment and Interactive Learning System (SAILS) used in each
session to target stimulability
o Study 1 – Mean pre-treatment probe score was 1.19, all 10 production probes
were misarticulated on 13 (62%) of targets. After post-treatment, mean difference
was 2.62. Difference examined level of stimulability. Good perceptive ability
average gain 4.55 points/Difficulty with perceptive skills gain 0.5 points.
o Study 2 – Mean pre-treatment probe score was 1.19, all 10 production probes
were misarticulated on 15 (58%) of targets. Mean difference was 4.56 for sounds
that were stimulable. Ave change for unstimulable before treatment was 3.00.
Good stimulability and speech perception presented by SAILS was < 70%
accurate judgments.
 Conclusion
o Relationship between pre-treatment stimulability and speech perception ability
was examined. Study 1 – showed much variability in the outcome. Variability
was attributed to pretreatment levels of stimulability and speech perception
ability. Coincided with previous beliefs that pre-treatment stimulability predicts
treatment success. Study 2 – allowed for more gains in multiple areas (including
unstimulable targets and poor perception abilities) because there was more focus
on individual needs. All children demonstrated stimulability for their target
sounds after a brief period of direct, one-to-one stimulability training. Both
studies used the cycles approach to sound disorders

Summary: In the article Stimulability, Speech Perception Skills, and the Treatment of
Phonological Disorders, Martin, Rafaat, and Rvachew (1999) examined the relationship between
three important elements of speech. The authors conducted two separate studies when testing
stimulability, speech perception and production of speech sounds. In the first study 10 children
were placed into groups and received nine group sessions of therapy. The findings of this study
were inadequate because there no improvement of the speech sounds production, stimulability
or perception were evident. Since the results of the first study were non-existent, a second study
was conducted. The second study followed the same guidelines of the first study however with a
different procedure. Instead of organizing a group of subjects, the researchers performed three
individual sessions with each of the 13 children prior to group formation. The individual

18
sessions focused on stimulability and speech perception training. This allowed the researchers
to become familiar with the children which, in turn, gave them a better means of grouping their
subjects. The results of the second study showed that this technique was more effective.
Modification of the procedure allowed for greater gains as evidence by the results. The second
study great improvements in production of speech sounds as well as triggered previously
unstimulable sounds and poor speech perception. This article demonstrated the importance of
focusing  on  each  individual  client’s  needs  before  planning  treatment.      As  stated  in  a  previous  
study conducted   by   Judith   A.   Gierut,   “children   with   phonological   disorders   are   not   a  
homogenous group and that individual differences in learning are one hallmark of this
population”  (Gierut,  1998,  p  S93).

SUMMARY 6
Research Article 6 —Treatment efficacy: Functional phonological disorders in children

Citation: Gierut, J. A. (1998). Treatment efficacy: Functional phonological disorders in children.

Journal of Speech, Language, and Hearing Research, 41, S85-S100.

 Purpose:
o “Report  addresses  the  efficacy  of  treatment  for  functional phonological disorders
in children. Impact of this disorder on children and the role of the SLP in
treatment. Evidence of positive outcome of phonological treatment (effective)
improving  intelligibility.”
o “Clinical  case  intended  to  illustrate  the nature of a disordered sound system and
treatment  methods  that  may  facilitate  such  change.”
o Report outlines terms, incidence/prevalence, treatment methods & evidence of
positive change. Case study demonstrates phonological treatment provides both
narrow and broad changes in a sound system that enhances overall intelligibility
and communication functioning.
 Design
o Report provides information on both group and single subject studies. From
these studies information has been compiled about treatment methods and the
effectiveness of their application.
o Case study focused on one boy, 4;7 who displayed the omission of all word-initial
consonants except for [m b w y]. His speech was highly unintelligible and had a
surgically repaired secondary cleft. He was normally developing except for sound
production.
 Level of Evidence: Level I – Review of Research/Case Study
 Sample
o Report –covered results found from many studies
o Case study
o Focused on 1 boy who exhibited the error pattern of word-initial consonant
deletion
o SLP used minimal pair treatment pairing known and unknown sounds

19
  Results
o Case study – pretesting was needed to determine the phonological disorder &
treatment. Client was dismissed from therapy after gaining 13 sounds in initial
position. Post-test taken 1 week later, 100% accuracy. No subsequent
phonological treatment was needed and intelligibility was greatly improved.
o Report coincided with results found in case study. Results are important because
they provide proof that treatment works.
o Plays into EBP; if the treatment is found to be effective in research, then it is used
in the therapy room and will provide the best results possible.
 Conclusion
o Report   recognizes   that   “children   with   phonological   disorders   are   not   a  
homogenous group and that individual differences in learning are one hallmark
of  this  population.”
o Traditional approach, sensory-motor method, cycles approach, minimal pair
treatment, and metaphon method provide a variety of techniques that can be
effective in therapy.
o Important to individualize treatment because each client will have different needs
and interests.

Summary: Author Judith A. Gierut utilized a case study in conjunction with a significant amount
of research when examining the efficacy of treatment for phonological disorders in children. In
the article Treatment Efficacy: Functional Phonological Disorders in Children, Gierut (1998)
discussed the many different studies, which included both single and group subjects, of children
with multiple phonological disorders. This research allowed Gierut to provide an abundant
amount of information regarding a description of the disorder including incidence, prevalence
and the different types of methods used in treatment. Most importantly Gierut discussed the
benefits of the different types of treatment and followed up with a case study to make the
findings more concrete. The results of the case study supported the findings that phonological
treatment is effective. This treatment not only corrects a flawed sound system but provides
many long-term benefits across communication, learning and social settings.

SUMMARY 7
Research Article 7 – Maximal opposition approach to phonological treatment

Citation: Gierut, J .A. (1989). Maximal opposition approach to phonological treatment. Journal
of Speech and Hearing Disorders, 54, 9-19.

 Purpose
o To evaluate a phonological treatment program of maximal rather than minimal
feature contrasts by charting the course of learning in a child displaying a
systematic error pattern involving a nonoccurrence of word-initial consonants.
 Design
o Pre-Post Test
o Single-subject multiple baseline design across 21 sounds that J used in word-
initial position

20
 o Sixteen phonemes were not used in word-initial position and/r/, served as a
control sound
o Production evaluated using a generalization probe measure
o Probe items were randomized and elicited in a spontaneous picture-naming task
both pre and post treatment, as well as at various points throughout treatment.
o Treatment = twice weekly for 30 minutes each session.
o One maximal opposition contrast was then selected for treatment based on the
multiple distinctions of voice, place and manner.
o Actual treatment involved contrasting five "picturable" word pairs
o Treatment continued in each phase until J produced word-initial consonants in
treatment pairs with 90% accuracy over each of two consecutive 30-min sessions.
o A second maximal opposition was selected for treatment based on the nature of
J's generalization learning.
o Treatment and generalization probes continued until the child mastered all 16
word-initial sounds.
o A final generalization probe measure and spontaneous connected speech sample
were obtained 1 week following the completion of treatment.
 Level of Evidence: Level III – Case Study
 Sample
o N=1
o Age= 4 years, 7 months
o Displayed numerous sound errors in conversational speech as well as
performance on the Foldman-Fristoe Test of Articulation
 Results
o J generalized accurate word-initial production to novel words with the treated
phoneme as well as to other words with untreated phonemes—100% accuracy
o J generalized to the word-initial consonants—g generalization was not 100%
accurate in all cases.
o J generalized accurate word-initial productions to /p,f,v/; generalization was not
100% accurate in all cases.
o Post treatment generalization probe indicated /k,g/were used in word-initial
position with 100% accuracy
o 11/16 of the initial sounds targeted were used with 100% accuracy following
o J made substantial improvements in the nature of his phonological system.
 Conclusions
o These generalization data demonstrated that, for J, a treatment approach based
on maximal oppositions was effective in changing and improving the
phonological system. The apparent success of this treatment approach may have
been associated with J's specific pattern of production involving extensive
omission.

Summary: Gierut’s   purpose   in   the   research   article,   Maximal   Oppostition   Approach   to   the  
Phonological Treatment, was to evaluate a phonological treatement program of maximal rather
than minimal feature contrasts by charting the course of learning in a child displaying a
systematic error pattern involving nonoccurance of word-initial consonants. Regarding this

21
approach, phonemic distinctions that vary along extremes of broad and multiple dementions of
place, manner and voice, providing the child the opportunity to learn about the target phonology
in his or her own unique way by filling gaps along these extremes of multiple feature
dimentions. The results of the study showed reports of accurate production of 21 word-initial
sounds on repeated administartions of the probe sounds. Also, expansions in the range of
sounds used in the word-iniital position, decreases in the range of sounds omitted from the
word-initial poisitons and the overgenralizations of certain word initial consonants for the
subject. The study concluded that maximal oppostions treatment encouraged the subjects
acquisiton of word-initial consonsants through conceptualization but also suggested that the
subject learned larger phonological and organizational categories.

SUMMARY 8
Research Article 8 — Phonological/Traditional approaches to articulation therapy: A
retrospective group comparison

Citation: Klein, E. S. (1996). Phonological/traditional approaches to articulation therapy: A

retrospective group comparison. Language, Speech, and Hearing Services in Schools, 27, 314-
323.

 Purpose
o “Compare children with multiple articulation disorders who received traditional
programs of therapy with similar children who received phonologically based
intervention.”
 Design
o Children with unintelligible speech and severe rating on standardized testing
o Must receive at least 50 hours of therapy or dismissed with essentially normal
speech
o Must receive either a traditional or phonological program of intervention – Not
both
 Level of Evidence: Level III – Retrospective Comparative Study
 Sample
o 19 Children (5 girls/14 boys) – Traditional Therapy
o 17 Children (5 girls/12 boys) – Phonological Therapy
o Standardized tests uses before and after:
o Arizona Articulation Proficiency Scale (AAPS)
o The Goldman-Fristoe Test of Articulation
o Received 2-3 50 min sessions/week
 Results
o 17 of 19 children who received traditional therapy had essentially normal speech
after an average of 22 months
o All 17 children who received phonological therapy had essentially normal speech
after an average of 13 months
 Conclusion
o Phonological vs. Traditional Treatment

22
 o Phonological – allows client to learn difference between good and bad
productions of target sounds
o No instruction/imitation for how to produce sound
o Rule was taught in context of its contrast
o Minimal Pairs technique used in this study
o Tradition – focus on oral movement
o Imitative and motor oriented – articulation
o Comparison study that examined which approach would result in dismissal from
therapy, with essentially normal speech, in a shorter time period.
o Both approaches were successful however phonological approaches were more
efficient.

Summary: Edward Klein completed the first group study comparing the traditional approach
and the phonological approaches to intervention of a phonological disorder. The subjects if this
study were children with phonological disorders who were placed in two groups for the study.
One group received a phonological approach to therapy while the other group was treated with a
traditional approach. All children were involved in pre and post standardized testing which
utilized the Arizona Articulation Proficiency Scale (AAPS) or the Goldman-Fristoe Test of
Articulation to determine the severity of their disorder. Each client also received two to three 50
minute therapy sessions per week. The focus of this study was to determine which method of
treatment would provide the client with essentially normal speech in the shortest amount of
time. At the beginning of this study, no significant difference existed between the clients
meaning that the two groups essentially had equivalent articulation disorders. Once treatment
concluded the findings showed a significant difference in improvement between the groups. The
traditional approach was successful however the phonological treatment allowed for more
efficient results. The group that received phonological treatment was able to identify errors that
they produced as well as utilize methods of self-correction. Results of this first comparison
study were valid and able to be used in therapy. Since there are a variety of phonological
disorders, it is important to have multiple methods of intervention in order to find the best
treatment that fits any specific client.

SUMMARY 9
Research Article 9 — Minimal pair approaches to phonological remediation

Citation: Barlow, J. A., Gierut, J. A. (2002). Minimal pair approaches to phonological

remediation. Seminars in Speech and Language, 23, 57-67.

 Purpose:
o “Considers   linguistic   approaches   to   phonological   treatment   that   emphasize   the  
role  of  the  phoneme  in  language.”    
o Structure/function of a phoneme, determining contrast pairs, application to a
case study and effectiveness of treatment are discussed.
 Design:
o More informative than applicable – information based off extensive research
o Basic elements of the minimal pairs approach were broken down and explained
adequately

23
 o Definition given for a phoneme
o Explanation for concept of contrast pairs
o Assessment process and intervention planning
 Level of Evidence: Level I – Review of Research
 Sample:
o Research based
 Results:
o Assessment – initial language sample taken by an SLP
o Focus of sample – evaluate   client’s   phonemic   inventory and determine what
phonemes are missing
o Results of research on all elements of minimal pairs approach – vital to success in
the therapy room
 Conclusion:
o How to assess initial phonemic repertoire & choose next correct phoneme
o Variety of ways to approach the minimal pairs technique:
o Simple pairings focus on difference of one aspect of language
o Place, Manner, or Voice
o Complex pairings cover all three areas of language
o Allows greater generalization across phonemes – broader improvements

Summary: The article entitled Minimal Pair Approaches to Phonological Remediation, by

Barlow and Gierut (2002), offers an overview of all aspects of the minimal pairs approach. The
authors begin by explaining the process of assessment and finish with a detailed description of
three  variations  of  this  technique.    Assessing  the  child’s  phonemic  repertoire  before  treatment  
beings allows the clinician to choose phonemes that are most needed, and will then begin
intervention. There are a variety of approaches that can be used when considering the method
of minimal pairs in treatment. The clinician can choose to use minimal pairs which will focus on
only a few differences between two phonemes or maximal opposition which will incorporate
many different distinctive features of a pair of phonemes. Maximal opposition allows for greater
generalization which can lead to broader improvements across the sound system. The
conclusive   findings   in   this   study   states   that   “minimal   pair   treatment   models,   no   matter   their  
form, maintain a common goal that derives from constructs of linguistic theory; that is, to teach
the  phonemic  distinctions  of  a  language.”    

SUMMARY 10
Research Article 10— A minimal word-pair model for teaching the linguistic significance of
distinctive feature properties

Citation: Blanche, S. E., Parsons, C. L., & Humphreys, J. M. (1981). A minimal-word-pair model
for teaching the linguistic significance of distinctive feature properties. Journal of Speech and
Hearing Disorders, 291-296.

 Purpose
o The   purpose   of   this   study   was   to   answer   the   question,   “Does   the   receptive   and  
productive training of word contrasts in one sound pair context aid in the

24
 reduction of errors in the same feature category in other lexical sound pair
contexts?”
 Design
o One sound pair was randomly selected for each subject from the feature category
with the greatest number of errors
o Two subjects were trained on tense/lax, two on continued/interrupted
o One subject on grave acute, strident/mellow and compact/diffuse
o Four of the features were trained in the initial position and 3 in the final
o Each subject was shown representations of the minimal pair pictures and was
trained on auditory discrimination until 90% performance level was attained in
pass/fail trial blocks of 20 attempts
o Also the client was asked to indicate their knowledge of difference between the 2
words to the clinician until 90% performance criteria was met
 Level of Evidence—Level I
o Testing of previously developed diagnostic criteria on consecutive patients
 Sample
o N=7 children
o Age range: 4 months to 6 years 7 months, with a mean age of 5 years 9 months
 Results
o Within feature showed a consistent reduction after minimal word pair training
o 73.3% reduction in feature error could be noted (excluding original sound pair
from pre and post tests) implying significant transfer of learning from the sound
pairs used in training to the other sound pairs within the therapeutic feature class
o 82.2% of the within class feature errors were improved in the tense/lax,
grave/acute/strident mellow, and compact/diffuse categories
o 53.8% of the continued interrupted errors were changed
o Reduction of the within feature class of all 7 subjects—that is the exact probability
of this occurring is .007—which is great enough to reject the null hypothesis of no
feature generalization
o 30% of untreated features were improved—while this figure is 50% less
improvement then that of the treated, the overall improvement in general
articulation, even if modest, is of therapeutic utility.
o A t-test for related measures indicated significant advantage in improvement in
treated features (t=4.7808; p<.01)
o Of the 23 untrained feature possibilities, 3 showed greater number of errors in
post tests, seven remained the same, while 13 improved—results proved
significant at the confidence interval level implying that generalization occurred
in the untreated feature class
 Conclusions
o It does appear that distinctive feature generalization, measured in binary mode,
does occur following receptive/productive training with minimal pairs.
o This study does not purport to draw conclusions outside the context of
experimental design. Inferences cannot be drawn as to such phenomenon as

25
 decay rate and the stability of the feature improvement – which are important
questions of the future.

Summary: In the article, A Minimal Word-Pair Model for Teaching the Linguistic Significance of
Distinctive Feature Properties, tested a word level behavioral routine for the remediation of
distinctive feature errors, developed to resolve current theoretical criticisms of the minimal pair
theory. Seven children participated in the study and were taught to correctly discriminate and
produce sounds in word utilizing lexical contrast. Pre and post therapeutic performance levels
were measured to establish that the number and severity of the sound substitutions decreased
with training. Four of the seven subjects were tested using the Fisher-Lugermann Test of
Articulation Competence and three of the seven were tested using Photo-Articulation Test. In
the post therapeutic testing, the tests were alternated to reduce learning effects. It does appear
that distinctive feature generalization, measured in binary mode, does occur following
receptive/productive training with minimal pairs. Additionally, the attending behavior of the
child and psychological practices, in which the child learns produce and integrate muscular
movements, are necessary, both from general operational fields of learning irrespective of the
feature pattern to be successful. The research concluded the minimal pair technique is a clinical
and research perspective offered not as a final answer, but the initial formulation of a type of
question.

SUMMARY 11
Research Article 11 – Phonological reorganization: A qualitative measure of phonological
improvement

Citation: Williams, A.L. (1991). Generalization patterns associated with training least
phonological knowledge. Journal of Speech and Hearing Research, 34, 722-733.

 Purpose
o The purpose of this study was to identify a procedure for documenting
phonological improvement following a treatment.
o The procedure was intended to be a different way of treating a patient and for
obtaining information.
o The procedure used was a qualitative measure rather than a quantitative one.
o The author argues that qualitative  reorganization  of  a  child’s  phonological  skills  
can be as equally valid when compared to quantitative measure.
 Design
o A minimal pair treatment approach was utilized with this client.
o Three sounds were selected for use during treatment.
o The sounds were selected by the following:
 Representativeness of the error pattern and when they were contrasted
with a target that was different in place, manner, and voicing.
 The targets selected for treatment included: /s/~/w/ word initially,
/t∫/~/k/  word  initially,  and  /∫/~/θ/  word  finally.    All  three  error  patterns  
were trained within each treatment session.
o Training consisted of two phases.

26
  The first phase, the words were produced after imitating the clinician. In
the second phase, Michael generated the pairs when the clinician showed
him pictures. This was done without a verbal model.
 The criterion to move from the first stage to the second stage was 90%
accuracy across two consecutive training sets.
 The training set was comprised of 20 responses.
o Each session involved 5 training sets, or 100 trials. There were thirteen sessions,
each lasting 45 minutes.
 Level of Evidence: Level III–Case Studies
 Sample
o Michael: 6 years 11 months at the time of the study.
o Michael had a congenital cleft lip on the right side. It was surgically repaired at 3
months of age.
o Michael received treatment in a university clinic for 6 semesters. He also
received treatment at his public school.
o His goal during sessions was suppression of stridency deletion on the targets /f, s,
z,  t∫,∫/  word  initially  and  word  finally.    
o Michael exhibited a cleft on the lip only. He did not exhibit articulatory patterns
that are associated with cleft palate speech.
o Michael exhibits average intelligence and is from a monolingual English-speaking
family (Williams, 1993).
 Results
o In order to move from the first phase to the second, Michael needed to achieve
90% accuracy in the production of sounds across two consecutive training sets.

Summary: Throughout this study, the author argued the fact that qualitative measures can have
important   implications   as   well   as   quantitative   measures.     After   assessing   the   child’s  
phonological system, the clinician started treatment by using a contrastive minimal pairs
approach. Here, three sounds were selected for use during treatment. The author went on to
explain the treatment measures in regards to the use of minimal pairs. In order to move from
phase to phase, the client needed to say/ work with the minimal pairs at 90% accuracy in
production. The author argues that allow there may not be concrete/ quantitative data showing
the positive effects of using minimal pairs, when reviewing the relational analysis, we can see a
qualitative change in the form of phonological reorganization (Williams, 1993). The author
went through to describe how the use of minimal pairs can not only be seen through quantitative
measures, but through qualitative as well. By using minimal pairs, the client was able to focus
on various sounds. By using qualitative measures to observe the clients progress and the
effectiveness of the use of minimal pairs, the researchers were able to see a uniquely organized
phonological system in place. (The system observed and compared to that of the adult systems.

SUMMARY 12
Research Article 12 – Treatment of phonological disability using the method of meaningful
minimal contrast: Two case studies

27
Citation: Weiner, F. (1981). Treatment of phonological disability using the method of
meaningful minimal contrast: Two case studies. Journal of Speech and Hearing Disorders, 46,
97-103.

 Purpose
o To examine the effects of a minimal contrast treatment method in teaching
phonological oppositions to children with unintelligible speech (Weiner, 1981).
 Is a minimal contrast treatment method an effective means of reducing
the frequency of phonological processes in children with phonological
disability?
 Will there be a generalization of any treatment effect to words not
included in the treatment task?
 Design
o A multi-response baseline was used as the treatment design.
o Treatment items consisted of five repetitions each of the four target words within
each minimal pair.
o Two baseline measures were used before the beginning of treatment.
o Sessions were Monday, Wednesday, and Friday for 1 hour
 Level of Evidence: Level III–Case Studies
 Sample
o 2 Children (both boys)
o Subject A- 4 years 10 months
o Subject B- 4 years 4 months
o Each subject had to have:
 normal hearing
 the ability to attend to speech tasks for a 60 minute therapy session
 Results
o Subject A-
 Began using final consonants and produced some correctly
 Production of final sounds of target words improved 60%
 Correct production of initial fricatives in target words improved 70%
 Correct production of initial /k/ and /g/ improved 80%
o Subject B-
 Production of final sounds of target words improved 50%
 Correct production of initial fricatives in target words improved 65%
 Correct production of initial /k/ and /g/ improved 30%

Summary: The purpose of this study was to examine the effects of minimal contrast treatment
when teaching phonological opposition to children with unintelligible speech (Weiner, 1981).
Frederick Weiner researched the use of minimal contrast with two 4 year old children that
demonstrated various incorrect phonological processes, including final consonant deletion,
stopping of fricatives, and fronting of velars. These processes were focused on during treatment.
After using minimal contrast with the two preschool subjects, Weiner found that it was
successful in reducing the frequency of the processes previously mentioned. While working with
the subjects, Weiner (1981) would confront them with the fact that their productions of the

28
second word was exactly like the first word. Weiner wanted the subjects to see how their
misarticulations were leading to miscommunications. The minimal contrast therapy allows for
the suppression of phonological processes (Weiner, 1981). While working with the subjects, a
correct response was not based on whether sounds were produced correctly, but based on the
presence of the phonological processes in which they working with. Weiner discussed the
difficulty some clinicians might have in doing this. He explained how we should not expect
speakers who have difficulty to acquire sounds all at one (Weiner, 1981). The study also
evaluates the results of the study. He compares the findings of both boys. By looking at the
evidence gathered throughout this study, it is evident that minimal contrast therapy works.

SUMMARY 13
Research Article 13—Remediation of phonological disorders in preschool age children: evidence
for the cycles approach

Citation: Hassink, J. M. & Wendt, O. (2010). Remediation of phonological disorders in

preschool age children: evidence for the cycles approach. EBP Briefs 5(2), 1-7.

 Purpose
o To analyze and appraise the available literature on the cycles approach and to
answer the following questions:
 Does the cycles approach effectively reduce the frequency of occurrence of
phonological processes?
 Does the cycles approach efficiently remediate phonological disorders?
 Design:
o Three of the studies were descriptive in nature and were nonexperimental
because control groups were not used
o The remaining three were experimental group designs.
o One of these was a randomized control trial
o Other two were pre- and post-test group designs
 Level of Evidence—Level II, Comparative study and development of diagnostic criteria
on consecutive patients
 Sample
o Number of Included Studies– 6
o Number of Participants– Total n for all 6 studies = 90
o Age range– 2:9 to 5:7
o All exhibited moderate to profound phonological disorders
 Results:
o Treated children demonstrated improved consonant production in
conversational contexts
o Treated children with less severe phonological and language impairments
improved both domains
o Earlier intervention resulted in great outcome of improvement
 Conclusions:
o Evidence found that the systematic review for the effectiveness and efficacy of the
cycles approach is limited.

29
 o The best evidence available suggests that this approach is effective with children
who exhibit severe phonological disorders both in isolation and in combination
with other language disorders.
o Clinicians must be aware of individual study limitations and refer to their own
clinical expertise as well as client preferences when considering implementation
of the cycles approach

Summary: In this EBP Brief, Hassink and Wendt , discuss phonological disorders, focusing on
the     cycles   approach   treatment,   which   is   described   here   as   addressing   a   child’s   use   of  
phonological processes by cyclically targeting affected classes. The purpose of this Brief was to
analyze and appraise the available literature on the cycles approach and to answer the two
questions stated above. The methodology of the cycles approach targets a different process every
1 to 2 weeks, whether or not the sound has been mastered or not. The authors incorporated 6
studies within this Brief, each fulfilling certain requirements. The requirements are as follows:
1) an experimental, quasi-experimental or descriptive/nonexperimental group design must be
used (i.e., no case studies), 2) target population must include preschool age children (2.5 to 6.0
years) diagnosed with phonological disorders and 3) the cycles or modified cycles approach
must be used as the intervention. All six studies used small sample populations (n<30
individuals). Research design, interrater reliability and treatment integrity were used to
appraise the studies. Additionally, the quality of the studies varied widely according to the
authors of the Brief. Further, Hassink and Wendt categorized two of the studies as suggestive,
proposing  that  the  cycles  approach  “might”  be  an  effective  form  of  intervention.    The  remaining  
four studies, considering their week design, were ranked as inconclusive, and thus the results
regarding the effectiveness of the cycles approach should be reviewed with caution.

SUMMARY 14
Research Article 14 – Intervention for children with severe speech disorder: A comparison of
two approaches

Citation: Crosbie, S. Holm, A., & Dodd, B. (2005). Intervention for children with severe speech
disorder: A comparison of two approaches. International Journal of Language &
Communication Disorders, 40(4), 467-491.

 Purpose
o “Evaluate/investigate   the   relative   effects   of two different types of
therapy/treatment approaches on the consistency of word production and speech
accuracy  of  children  with  consistent  or  inconsistent  speech  disorder.”
 Design
o Intervention program comparing phonological contrast and core vocabulary
therapy.
o All the increased consonant accuracy during intervention
o Core vocabulary therapy resulted in greater change in children with inconsistent
speech disorder
o Phonological contrast therapy resulted in greater change in children with
consistent speech disorder

30
 o Resulted in suppression of error patterns, not just remediation of targeted lexical
items
o Resulted in wider changes
o Gave specific feedback regarding one aspect of this planning: the consonant–
vowel structure of words.
 Level of Evidence: Level II–Comparison Study
 Sample
o 18 Children – allocated to one of the two therapies by order of referral.
o Treatment 1 – after the baseline period followed by a 4-week withdrawal period,
followed by treatment 2.
o Phonological contrast therapy (targeting error patterns):
o Error pattern:
 Identified from phonological assessment data
o Selected for intervention according to the following criteria:
 Targeting non-developmental patterns before developmental
 Consistency and frequency of the use of the error pattern
 Effect on intelligibility of successful remediation
 Stimulability of the speech sounds required
 Targeted structural error patterns:
o 4 Stages:
 Auditory Discrimination
 Production in single words
 Production in phrases
 Production in sentences within conversation
o Minimal Pair (multiple opposition)
 Pairs of words targeted a range of sounds affected by error pattern
 Results
o Evidence – treatment   targeting   speech   processing   deficit   underlying   the   child’s  
speech disorder will result in generalization
o All of the children increased their consonant accuracy during intervention. Core
vocabulary therapy resulted in greater change in children with inconsistent
speech disorder and phonological contrast therapy resulted in greater change in
children with consistent speech disorder.

Summary: The  article  “Intervention  for  children  with  severe  speech  disorder:  A  comparison  of  
two   approaches”   looks   at   comparing   phonological   contrast   treatment   with   core   vocabulary  
therapy. Crosbie found that both approaches were effective in remediation however
phonological contrast treatment resulted in greater change for a child with a consistent speech
sound disorder. The study conducted in this article does not compare two phonological
approaches however it is relevant to our study because it found that the phonological approach
was successful. This evidence, along with other information found in the research literature of
this article, provided us with information that was useful to our research for this manual.

31
Intervention Activities
ACTIVITY 1—MINIMAL PAIRS (BACKING)
Title: The Fishing Game

Objectives (The bolded objective is the focus of this activity):

The client will increase speech intelligibility by correctly producing phonemes made in
the front of the oral cavity.

1. The client will correctly produce target phonemes in the front of the oral
cavity in the initial position of single words with assistance from the
clinician with 80% accuracy across 5 consecutive sessions.
2. The client will correctly produce target phonemes in the front of the oral cavity in the
final position of single words with assistance from the clinician with 80% accuracy across
5 consecutive sessions.
3. The client will correctly produce target phonemes in the front of the oral cavity in the
medial position of single words with assistance from the clinician with 80% accuracy
across 5 consecutive sessions.
4. The client will correctly produce target phonemes in the front of the oral cavity in
connected speech with the clinician achieving 80% accuracy across 5 consecutive
sessions.

Materials:
 The Fishing Game
 Fishing pole
 Fish
 Worms
 List of Target Phonemes

Target Phonemes
/t/
/f/
/p/
/m/
/d/
/v/
/b/
/s/
/z/
/n/

Introduction:
Have the client work on producing target phonemes in the initial position. By choosing a
worm to go fishing, he/she chooses a syllable. When a fish is caught, the client combines
the syllable from the worm with the target phoneme from the fish. Once the target and
syllable are combined, the client will produce the word containing the target sound.

32
Activity:
1. Spread  the  fish  out  in  the  “pond,”  give  the  client  the  fishing  pole.    Lay  the  worms  in  front  
of the client.
2. Pick a worm containing a syllable and start fishing!
3. After catching a fish, correctly produce the target found on the back. Then join the target
on the back of the fish with the syllable on the worm.
4. Remove the used fish from the pond and continue fishing until all of the fish have been
caught.
5. Put all the fish back in the pond and pick a new worm.
6. Repeat.

Closure:
After completing the activity and combining the target phonemes and the syllables,
review the combination of the target and syllable. Complete this same practice with the
second target phoneme. Review all words containing both target phonemes.

*This activity may demonstrate articulation related treatment; however, the child is
exhibiting the phonological process of backing. The targets for this activity are
phonemes produced in the front of the mouth.

33
ACTIVITY 2—THE CYCLING APPROACH (BACKING, STOPPING, GLIDING)
Title: Good Apples/ Bad Apples

Objectives (The bolded objective is the focus of this activity):

The client will increase speech intelligibility by correctly producing phonemes made in
the front of the oral cavity, continuants, and liquids.

1. The client will correctly produce target phonemes in the front of the oral cavity in the
initial position of single words with assistance from the clinician with 80% accuracy
across 5 consecutive sessions.
2. The client will correctly produce continuant phonemes in the initial position of single
words with assistance from the clinician with 80% accuracy across 5 consecutive
sessions.
3. The client will correctly produce liquid phonemes in the initial position of single words
with assistance from the clinician with 80% accuracy across 5 consecutive sessions.
4. The client will correctly produce phonemes made in the front of the oral
cavity, continuants, and liquids in the initial position of single words with
assistance from the clinician with 80% accuracy across 5 consecutive
sessions.

Materials:
 The Good Apples/ Bad Apples file folder game
 15 paper apples containing words with the target phonemes
 List of Target Words

Backing Stopping Gliding

Fun Fan Laugh
Tan Sand Red
Pin Shoe Roll
Van Nose Light
Bee Zoo Log
Introduction:
Concentrate on the three target processes. Using the Cycles Approach, work on each
target for one week. Once all of the targets have been covered, cycle back through all
words targeted in the past three weeks. To incorporate the Good Apples/ Bad Apples file
folder game, make a list of 15 words that focus on each process to use during the review
week of cycling. After the client produces each word, allow them to determine if it was a
“good  apple”  or  a  “bad  apple.”    This  will  help  identify any incorrect productions to focus
on.

Activity:
1. Review the word list comprised of 15 words containing the target sound in the initial
position of the word.
2. Attach words to apples and give it to the client.
3. If the word is produced correctly, place  the  apple  in  the  “Good  Apples”  basket.    If  the  
word  is  produced  incorrectly,  place  the  apple  in  the  “Bad  Apples”  basket.
4. After all 15 words are sorted, review the bad apples and keep these words to continue
for further work.
5. End with reviewing the good apples.

34
Closure:
Once the game is completed and all of the apples have been sorted, it is important to
review the words that were produced incorrectly. This helps the client focus on their
errors. End with a review of the apples he/she said correctly. Recycle any incorrect
productions.

35
ACTIVITY 3 – METAPHON (FINAL CONSONANT DELETION)
Title:  “Go  Fish”

Objectives (The bolded objective is the focus of this activity):

The client will increase speech intelligibility by correctly producing the final consonant of
words.

1. The client will correctly produce the final consonant at word level with
picture cues given by the clinician with 80% accuracy across 5 consecutive
sessions.
2. The client will correctly produce the final consonant of words in phrases with picture
cues given by the clinician with 80% accuracy across 5 consecutive sessions.
3. The client will correctly produce the final consonant of words in phrases without picture
cues with 80% accuracy across 5 consecutive sessions.
4. The client will correctly produce the final consonant of words in sentences without
picture cues with 80% accuracy across 5 consecutive sessions.

Materials:
 “Go  Fish”  Cards  – containing target sounds and images
o In this case, cards focusing on adding the final consonant of words.
 List of target words

Final Consonant
Play Plane
Pea Peep
Tray Train
Tea Team
Tie Tide

Introduction:
The focus of this session is to correct the phonological process of final-consonant
deletion. The clinician will begin by discriminating between words that contain a final
consonant and words that have the final consonant attached. This will demonstrate for
the client that meaning is changed when the final consonant is attached as well as when
it is missing. Next, the clinician will divide the playing cards between all players. The
client   will   begin   by   asking   “Do   you   have   a   ___?”     Here   the   clinician   can   individualize  
each  move.    If  the  client  says,  “Do  you  have  a  /ple/?”    The  clinician  may  say,  “Yes,  I have
a  card  where  kids  play.”    This  will  cause  the  client  to  focus  on  adding  the  final  consonant  
of  the  word  and  ask  for  “a  /plen/.”

Activity:

1. Clinician will deal cards to all players.

2. Each player begins to ask other players if they have a card similar to one in their
hand.
3. Focus is to ensure correct production and the client is receiving the card that is
requested.

Closure:
The activity will end when one player has all of the cards in the deck. The clinician will
then go back through cards and focus on errors made while playing.

36
ACTIVITY 4 – BACKWARDS CHAINING PROCEDURE (CLUSTER REDUCTION)
Title: Clusters of Fruits and Veggies

Objectives (The bolded objective is the focus of this activity):

The client will increase speech intelligibility by correctly producing clusters in all word
positions.

1. The client will correctly produce consonant clusters in the initial position
of words with picture cues given by the clinician with 80% accuracy across
5 consecutive sessions.
2. The client will correctly produce consonant clusters in the final position of words with
picture cues given by the clinician with 80% accuracy across 5 consecutive sessions.
3. The client will correctly produce consonant clusters in the medial position of words
with picture cues given by the clinician with 80% accuracy across 5 consecutive
sessions.

Materials:
 Game board
 Dice
 Background for craft
 Scene stickers
 List of Target Words

Target List—Fruits and Vegetables

Plum
Blueberry
Grape
Prune
Cranberry
Grapefruit
Broccoli
Green Beans
Brussels Sprouts
Spinach

Introduction:
Concentrate on the consonant clusters in the initial position of words. The client will roll
the dice and move that many places on the game board. In order to obtain the sticker,
the client must correctly produce the syllables in that word. After the game board is
completed, review the pieces the client did not acquire because the target sound was not
produced correctly. During the review, syllables will be taught using the backwards
chaining procedure. The final part of the word will be said first (breaking up the cluster)
and then the entire word will be said in order to incorporate both sounds in the cluster.
For   example,   if   the   target   word   is   “prune,”   the   client   will   first   say   “rune”   and   then  
“prune.”    End  the  reviewing  with  the  correct  production  of  the  word.

Activity:

1. Give client a white or black canvas and one food sticker as their game piece.
2. Roll die and move game piece that number of spaces.

37
 3. Client must correctly produce the consonant cluster in the word to receive that sticker.
4. Finish game board while building his/her picture with the pieces the client earns.
5. Review the words the client struggled with to ensure the correct production and
reward him/her with that game piece.

Closure:
Once the client has reached the end of the game board, review the words that were
produced incorrectly using the backwards chaining procedure. After the word is
produced correctly, give the child all of the pieces to complete his/her picture. Review all
words from the game.

38
ACTIVITY 5—MINIMAL CONTRAST PAIRS (STOPPING)
Title: Bowling

Objectives (The bolded objective is the focus of this activity):

The client will increase speech intelligibility by correctly producing continuant
phonemes in all word positions.

1. The client will correctly produce continuant phonemes in the initial word
position with verbal cues from the clinician with 80% accuracy across 5
consecutive sessions.
2. The client will correctly produce continuant phonemes in the final word position with
verbal cues from the clinician with 80% accuracy across 5 consecutive sessions.
3. The client will correctly produce continuant phonemes in the medial word position
with verbal cues from the clinician with 80% accuracy across 5 consecutive sessions.
4. The client will correctly produce continuant phonemes in the all word positions
without verbal cues in connected speech with 80% accuracy across 5 consecutive
sessions.

Materials:

 Bowling pins containing the syllable(s)

 Bowling Ball(s) containing the continuant phoneme(s)
 Target List of Phonemes

Continuant Target Phonemes

/s/
/f/
/v/
/z/
/θ/
/ð/
/m/
/r/
/n/
/ʃ/

Introduction:

The focus of this activity is to use the minimal pair technique to work on the initial
position of continuant phonemes. The client will choose a bowling ball with the target
phoneme that will be combined with a syllable from the pins that he/she knocks over.
The pins will contain syllables that need an initial consonant. The client will continue to
bowl until all pins are knocked over.

39
Activity:

1. Choose the bowling ball containing the continuant target sound.

2. The client will bowl, knocking over bowling pins containing syllables.
3. The client will pick up the knocked over pins and combine the continuant target phoneme
with the syllable(s) on the bowling pins.
4. The client will bowl again and knock over the remaining pins.
5. Repeat step 3.

Closure:

Once the activity is completed the clinician will review all possible combinations with the client.
After the client correctly produces each word, he/she can complete this same activity with the
other target phoneme.

40
Future Areas of Study
Unfortunately, few published studies exist that delineate what treatment methods result in the most
success. Considering this, it is suggested by many researchers and speech language pathologists that
evaluations continue on the efficacy of relative treatment. In conjunction with this, the direct comparison
of treatment methods and the time it takes to successfully complete different treatment programs is a
future topic of interest. Moreover, research that systematically examines the etiology, course, and
remediation of phonological disorders, will ultimately bring us closer to prevention, diagnosis and
treatment of these disorders that affect many   of   the   world’s   children. Therefore, an emphasis on the
development of novel and improved teaching methods is crucial for future phonological treatment
approaches.

Prospectively, greater attention should be focused on the production of vowels, non-segmental errors
involving stress and intonation, and multifaceted speech errors, as in disorders of phonology combined
with disfluency. It is a known fact most studies exclusively focus on the consonantal system and less
attention is given to errors in the production of vowels. This is because of several reasons including: 1)
vowels are the earliest acquired; 2) the accurate rate production of consonants has been thought to
influence intelligibility to a greater degree than vowels; and 3) variations in the productions of vowels are
often linked to differences between dialects. Recent findings outline that errors in the production and
reduced inventories of vowels have been described for children with phonological disorders. Further, the
diagnosis of vowel errors may motivate future treatment programs, aimed at expanding vowel repertoire.

It is important for both clinicians and researchers to be aware of individual differences as well as
understanding variability in learning across children. Furthermore, individual differences exist among
children in terms of nature and the extent of generalization observed with treatment. An example of this
would be two children with similar phonological systems being taught the same target sound might
evidence different degrees of change. Considering this, the identification of the sources of individual
differences in phonological learning can help establish the minimal and defining conditions of
phonological change for all children. Additionally, with a potential precedence of relationships among the
contributing factors, the conditions could be applied systematically in phonological treatment to
potentially guarantee specific improvements in sound production and generalization of sounds.

The relationship between speech perception ability and speech sound acquisition also deserves more
attention. Many studies focused on this topic reveal perception ability has not been shown to predict
phonological learning. One study found no existing relationship between speech discrimination skills and
spontaneous improvements in articulation ability in school aged children; however appropriate
techniques for the assessment of speech were not employed. Obviously, when appropriate methods are
used, speech perception training facilitated sound production learning. This too corresponds with finding
the best methods for facilitating stimulability among children. This topic remains ambiguous, thus future
research is necessary.

Finally, other concerns regarding future areas of study give attention to those children who are bilingual,
dialectal and English as second language learners. These are not to be confused with actual phonological
disorders, rather the source of target sound production errors may be traceable to phonological
differences   between   a   child’s   native   language   or   dialect   and   the   target   language   being   learned   (Gierut,
1998).

41
GLOSSARY: PHONOLOGICAL PROCESSES
Assimilation Processes – One sound becomes similar to another sound in the word
 Contiguous – consonants next to each other in word
 Noncontiguous – consonants apart
 Progressive – affected element follows the element that influences it
o i.e. doddie/doggie
 Regressive – affected element precedes the element that influences it
o i.e. goggie/doggie
1. Assimilation Types:
a. Labial – Consonant becomes a labial due to influence of another labial
consonant, i.e. w-ob/rob
b. Alveolar – Consonant becomes alveolar due to influence of another alveolar
consonant, i.e. d-oat/goat
c. Velar – i.e. g-og/dog
d. Nasal – i.e. n-an/van
2. Prevocalic Voicing – Voiceless obstruent preceding vowels become voiced
a. i.e. d-ea/pea
3. Postvocalic Devoicing – Voiced obstruent in word-final position becomes voiceless
a. i.e. ra-k/rag

Substitution Processes - One sound is substituted by another in a systematic fashion

4. Stopping – Fricatives and/or affricates are turned into stops
a. i.e. tun/sun
5. Fronting – velars sounds produced further forward in oral cavity (typically replaced by
alveolars)
a. i.e. tar/car
6. Depalatization – Palatal sounds produced further forward in oral cavity (typically
replaced by alveolars)
a. i.e. fis/fish
7. Palatalization – Addition of a palatal component to non-palatal target
a. i.e. sho/sew
8. Affrication – Replacing of a fricative consonant with an affricate
a. i.e. ch-oap/soap
9. Deaffrication – Affricates replaced by fricatives

42
 a. i.e. shursh/church
10. Backing – Front consonants are replaced with back consonants (velars/glottal)
a. i.e. k-oe/shoe
11. Alveolarization – Replacing of consonants made with the lips or teeth with consonants
made on the alveolar ridge
a. i.e. s-ood/food
12. Labialization – Labial sounds replacing interdental or alveolar obstruents
a. i.e. f-un/sun
13. Gliding – Liquids /l, r/ are replaced by glides /w, j/
a. i.e. wabbit/rabbit

Syllable Structure Processes – phonological processes that affect the syllable structure
14. Final Consonant Deletion – Deletion of final consonant in a word
a. i.e. do/dog
15. Initial Consonant Deletion – Deletion of consonant in initial position of a word
a. i.e. eam/team
16. Cluster Simplification/Reduction – Deletion of one element of the cluster
a. i.e. pane/plane
17. Cluster Substitution – 1 member of a cluster is replaced with another consonant
a. i.e. bwue/blue
18. Weak Syllable Deletion – Deletion of the unstressed syllable
a. i.e. nana/banana
19. Reduplication – “Doubling”  – Partial or total reduplication of a syllable of a word
a. i.e. bay-bay/baby
20. Epenthesis – Inserting a sound (typically a vowel) between 2 consonants
a. i.e. b-uh-lue/blue

Multicultural Factors
21. Metathesis – reversal of the position of two sounds
a. i.e. aks/ask

All information found in:

Lowe, R. J. (2010). Workbook for the identification of phonological processes and distinctive
features (4th ed.). Austin, TX: PRO-ED, Inc.

43
APPENDIX A: CRITICAL REVIEWS (NUMBERS CORRESPOND TO SUMMARIES)
CRITICAL REVIEW 1
Citation: Young, E. (1987). The effects of treatment on consonant cluster and weak syllable
reduction processes in misarticulating children. Language, Speech, and Hearing Services in
Schools, 18, 23-33.

STUDY PURPOSE: Key purpose of the study. How does the study apply to Speech sound
Was the purpose stated clearly? treatment and/or your treatment group focus?
o Yes The purpose of this study was to determine the effects of Backward
o No Chaining Procedures when used as treatment for phonological
processes displayed by two children with developmental speech
disorders.
This study applies to speech sound treatment and our group focus by
examining a specific method of treatment for phonological processes.

DESIGN: Level
o Randomized (RCT) Blinding of clients, clinicians, data analyzers?
o Cohort Yes No
o Single case design Brief Description of study design.
o Before and after  Baseline:
o Case-control -Imitate  “This  is  a  ____.”  for  25  pictured  words
o Cross-sectional -Baseline determined for cluster reduction and weak syllable
o Case study deletion (targeted processes)
-Baseline determined for final consonant deletion (control
process not targeted)
 Treatment:
-Backwards training procedures
-Cues gradually faded
-First process targeted until 80% accuracy was reached, then
treatment began for second process
-Control process not treated
 Maintenance/ Followup:
-Data collected for target processes and control process
-Data for targeted processes compared to data for control
process to determine effectiveness of treatment

SAMPLE: N = 2 Sampling (who; how selected; inclusion/exclusion

Clearly described, recognizable criteria)
clients? Subjects: Females, both age 4
o Yes Consistent deletion of weak syllables, all initial clusters reduced, final
o No consonant deletion for multiple phonemes
Was the sample size justified? Inclusion: Preschool language Scale- normal language comprehension
o Yes skills, Normal hearing, delayed phonological development and poor
o No intelligibility according to the Arizona Articulation Proficiency Scale
and Phonological Process Analysis
Exclusion: Language comprehension skills inappropriate, impaired
hearing, normal phonological development and intelligibility

If more than one group, what difference existed?

The study did not include more than one group

Describe ethics procedures. Was informed consent obtained?

Ethics procedures were not addressed.

44
OUTCOMES: Specify the frequency of performance and/or outcome measurement
Were the measures reliable? (i.e. pre, post, follow-up)
o Yes Performance/Outcomes Areas/Instruments
o No List specific measures used
o Not addressed 3 phases of testing- baseline, treatment, and maintenance
Were the measures valid? Materials included black and white drawings of nouns and verbs
o Yes (rebus); trained words included 5 disyllabic words, five words
o No containing initial consonant clusters, and five control words assessing
o Not Addressed final consonant deletion; additional words were used to assess
generalization. Scoring was based on correct production of clusters,
weak syllables and final consonants in order to determine accuracy for
each process before, during, and after treatment.
Scoring procedures were identical for both baseline and treatment
procedures.
A follow up probe was given 6 weeks after treatment concluded,
following the same scoring procedures as baseline and treatment
Control over nuisance variables?
o Yes
o No

RESULTS: What were the results?

Statistically significant differences? Subject 1: Baseline of weak syllable reduction,
o Yes cluster reduction, and final consonant deletion was
o No 0-20% accuracy. Follow up scores indicated that the
o Not addressed targeted processes of weak syllable reduction and
cluster reduction improved to 80-100% accuracy,
Practical significance: size and importance of while the control process of final consonant deletion
treatment effects? remained at about 20% accuracy.
o Yes Subject 2: Baseline of weak syllable reduction,
o No cluster reduction, and final consonant deletion was
o Not addressed 0-20% accuracy. Follow up scores indicated that the
target processes of weak syllable reduction and
Precision of treatment effect? cluster reduction improved to 60-100% accuracy,
o Yes while the control process of final consonant deletion
o No remained at 20% accuracy.

Outcomes for all clients who entered? Were they statistically significant (i.e., p<0.05)? Not
o Yes addressed
o No
What was the clinical importance of the results?
The results showed three different phonological
processes and the effectiveness of one specific
treatment on two of these processes. The results of
the third process (control process) were used to
determine if treatment was responsible for any
improvement.

Were differences between groups clinically

meaningful?(if applicable) N/A

45
CONCLUSIONS AND CLINICAL What did the study conclude? What are the implications of
IMPLICATIONS: these results for speech sound disorders?
Conclusions were appropriate given study Due to the results of the study, it can be determined that
methods Backwards Chaining Procedures were responsible for
and results improvement in the targeted phonological processes. The
o Yes control process that was untreated remained at baseline level
o No while the treated processes improved for both subjects. This
suggests that Backwards Chaining Procedures are effective in
Feasibility in community and practice? treating phonological processes.
o Yes These results could then be applied to treatment of speech
o No sound disorders as a determiner of treatment procedures.

Cost-benefit?
o Yes
o No
APPLICATION: How does the study apply to clinical services provided to
Applies to clinical services to children children with speech sound disorders?
with speech It is important that clinicians become familiar with various
sound disorders types of treatments and their effectiveness. This study can be
o Yes used when determining a specific treatment method for a
o No child that may demonstrate the same characteristics of the
subjects in the study.

How will you use the evidence?

Each child is different and some treatments may not work for
every child or every disorder. This needs to be remembered
when considering the evidence from a study on the
effectiveness of different treatments. The evidence from this
particular treatment may be used to design or research future
studies using the same treatment.

46
CRITICAL REVIEW 2
Citation: Griffiths, R. Stokes, S. (2010). The use of facilitative vowel contexts in the treatment
of post-alveolar fronting: A case study. International journal of language and communication
disorders, 45(3), 368-380.

STUDY PURPOSE: Key purpose of the study. How does the study apply to Speech sound
Was the purpose stated clearly? treatment and/or your treatment group focus?
o Yes The purpose of this study was to determine the effectiveness of
o No Facilitative Vowel Contexts as a treatment for phonological processes,
specifically post-alveolar fronting demonstrated by one subject. This
study applies to speech sound treatment and our group focus by
examining a specific method of treatment for phonological processes.

DESIGN: Level
o Randomized (RCT) Blinding of clients, clinicians, data analyzers?
o Cohort Yes No
o Single case design Brief Description of study design.
o Before and after The subject of this study received nine individual therapy sessions for
o Case-control 45-55 minutes. During the sessions, facilitative vowel contexts were
o Cross-sectional used as treatment for post-alveolar   fronting.     This   treatment   uses   “a  
o Case study continuum of maximum to minimal vowel-consonant (#_VC) and
consonant-vowel  (CV_#)  coarticulation”  (Griffiths,  et  al.,  370).    This  is  
done in the hope that the place and manner of vowels can be used for
correct production of the following segment. Assessments were given
before and after treatment to measure improvements in post-alveolar
fronting.
Thirty picture probes were presented to test the [∫] phoneme in the
initial position of words. A control cluster was used in a similar
naming task. Probes were given five times within the study to
determine effectiveness of the treatment.

SAMPLE: N = 1 Sampling (who; how selected; inclusion/exclusion

Clearly described, recognizable criteria)
clients? Subject: Male, age 7
o Yes Received special education services in a mainstream school, speech
o No and language assessments indicated developmental verbal dyspraxia
Was the sample size justified? and language delay, normal hearing, post-alveolar fronting, received
o Yes therapy focused on post-alveolar fronting and articulation therapy-
o No Nuffield dyspraxia programme

How selected; inclusion/exclusion: Determination of eligibility for the

study was not addressed. Inclusion/exclusion criteria were not
addressed.

If more than one group, what difference existed?

The study did not include more than one group

Describe ethics procedures. Was informed consent obtained?

Informed  consent  was  obtained  from  the  subject’s  mother

47
OUTCOMES: Specify the frequency of performance and/or outcome measurement
Were the measures reliable? (i.e. pre, post, follow-up)
o Yes Performance/Outcomes Areas/Instruments
o No List specific measures used
o Not addressed Prior to study: Information was collected from questionnaires given
Were the measures valid? to   the   child’s   teacher   and   Language Support Assistant (LSA). A case
o Yes history was obtained from the parents. Observations were taken in
o No various settings and a 2-minute sample of spontaneous speech was
o Not Addressed also  taken  from  the  child.    In  order  to  evaluate  the  subject’s  expressive  
and receptive language abilities, he was given the British Picture
Vocabulary Scales, Test for Reception of Grammar, and the Renfrew
Word Finding Vocabulary Test. Screening tests were also used to
determine expressive language ability. His non-verbal cognition was
evaluated using the Test of Non-Verbal Intelligence-3 and his
articulation and phonology was testing using the Diagnostic
Evaluation of Articulation and Phonology.
During the study: Word list probes were given at pre-therapy, after
three therapy sessions, after six therapy sessions, at post-therapy, and
at a follow-up/maintenance session.
Control over nuisance variables?
o Yes
o No

RESULTS: What were the results?

Statistically significant differences? The data shows that percentage correct for each of
o Yes the probes improved as the study progressed.
o No Treatment scores for the pretest were less than 10%
o Not addressed accuracy; however, this improved to 100% accuracy
at the follow-up/maintenance stage. This showed a
Practical significance: size and importance of greater than 90% improvement in post-alveolar
treatment effects? fronting when treated with facilitative vowel
o Yes contexts. There was no significant improvement in
o No the control set.
o Not addressed
Were they statistically significant (i.e., p<0.05)?
Precision of treatment effect? Treatment scores were significantly higher at post-
o Yes therapy than they were at the point of pre-therapy
o No (p<0.001)

Outcomes for all clients who entered? What was the clinical importance of the results?
o Yes These results compare a treatment set to a control
o No set. This way a clinician is able to determine if the
improvement in post-alveolar fronting is due to the
treatment. A clinician may use this information to
determine whether or not facilitative vowel contexts
are an appropriate method of treatment.

Were differences between groups clinically

meaningful?(if applicable) N/A

48
CONCLUSIONS AND CLINICAL What did the study conclude? What are the implications of
IMPLICATIONS: these results for speech sound disorders?
Conclusions were appropriate given study The study concluded that facilitative vowel contexts were an
methods effective treatment for post-alveolar fronting in the case
and results study. There was a significant improvement in this process
o Yes over the course of the study.
o No Implications: Because there was an improvement of post-
alveolar fronting for the targeted phoneme and not for the
Feasibility in community and practice? control phoneme, we may infer that facilitative vowel
o Yes contexts were effective as a treatment.
o No

Cost-benefit?
o Yes
o No
APPLICATION: How does the study apply to clinical services provided to
Applies to clinical services to children children with speech sound disorders?
with speech It is important that clinicians become familiar with various
sound disorders types of treatments and their effectiveness. This study can be
o Yes used when determining a specific treatment method for a
o No child that may demonstrate the same characteristics of the
subject in the study.

How will you use the evidence?

Each child is different and some treatments may not work for
every child or every disorder. This needs to be remembered
when considering the evidence from a study on the
effectiveness of different treatments. The evidence from this
particular treatment may be used to design or research future
studies using the same treatment.

49
CRITICAL REVIEW 3
Citation: Edwards, M. Saxman, J. Tyler, A. (1987). Clinical application of two phonologically
based treatment procedures. Journal of Speech and Hearing Disorders, 52, 393-409.

STUDY PURPOSE: Key purpose of the study. How does the study apply to Speech sound
Was the purpose stated clearly? treatment and/or your treatment group focus?
o Yes The purpose of this study was to determine the effectiveness of two
o No different treatments for phonological processes. These treatments are
minimal pairs contrasting and a modified cycles procedure. This study
applies to speech sound treatment and our group focus by examining a
specific method of treatment for phonological processes.

DESIGN: Level
o Randomized (RCT) Blinding of clients, clinicians, data analyzers?
o Cohort Yes No
o Single case design Brief Description of study design.
o Before and after Subjects were given two 1 hour therapy sessions per week. The
o Case-control subjects were split into two groups based on a phonological process
o Cross-sectional analysis. One group received minimal pairs contrasting therapy and
o Case study the other group received the modified cycles therapy. The remediation
was conducted in three phases. These phases were pretreatment,
treatment, and follow-up. Probes were given throughout all phases of
the study. This way, progress could be measured throughout
treatment.

SAMPLE: N = 4 Sampling (who; how selected; inclusion/exclusion

Clearly described, recognizable criteria)
clients? Subjects: 4 children (3 girls and 1 boy) from 3-5 years of age
o Yes Each child was referred to the clinic after a diagnostic evaluation
o No
Was the sample size justified? Inclusion: Moderate to severe phonological disorders, poor speech
o Yes intelligibility, normal functioning in language comprehension and
o No production, normal hearing, oral mechanism was normal in structure
and function, no prior speech or language therapy
Exclusion: Less than moderate phonological disorder, adequate
speech intelligibility, poor language comprehension and production,
hearing impairment, structural or functional problems with the oral
mechanism, prior speech or language therapy

If more than one group, what difference existed?

The study split the children into two groups to receive two different
types of therapy. The type of therapy was chosen based on the
phonological processes used by the children. The first two subjects
were chosen for minimal pairs therapy because, although they
displayed nine phonological processes each, they have one prominent
process that caused unintelligibility and occurred the most frequently.
The modified cycles procedure was chosen for the third and fourth
participant because it targeted three processes.

Describe ethics procedures. Was informed consent obtained?

Ethics procedures were not addressed.

50
OUTCOMES: Specify the frequency of performance and/or outcome measurement
Were the measures reliable? (i.e. pre, post, follow-up)
o Yes Performance/Outcomes Areas/Instruments
o No List specific measures used
o Not addressed 3 phases were used in remediation and scoring: pretreatment,
Were the measures valid? treatment, and follow-up
o Yes Generalization probes used tasks to elicit single words, 6 probe words
o No were chosen for each process, these words were represented by objects
o Not Addressed or pictures

Control over nuisance variables?

o Yes
o No

RESULTS: What were the results?

Statistically significant differences? Subject 1: Gliding of fricatives initially occurred 90%
o Yes of the time. At the end of treatment, gliding of
o No fricatives was reduced to 0% occurrence. The control
o Not addressed process of depalatalization continued at 100%
occurrence until treatment began for the control.
Practical significance: size and importance of Subject 2: Stopping of fricatives initially occurred
treatment effects? 97% of the time. At the follow-up probe, stopping of
o Yes fricatives was reduced to 0% occurrence. Velar
o No fronting was chosen as the untreated control process.
o Not addressed It originally occurred 100% of the time and only
reduced to 92% accuracy at the post-treatment
Precision of treatment effect? period.
o Yes Subject 3: Velar fronting occurred about 70% of the
o No time before treatment. After treatment, it occurred
less than 10% of the time. /s/ cluster reduction
Outcomes for all clients who entered? originally occurred about 98% of the time.
o Yes Treatment reduced occurrence to about 40%. Liquid
o No cluster reduction initially occurred 100% of the time
and was reduced to less than 10%. The untreated
control process was depalatalization. At
pretreatment this occurred at 100% and at follow-up
this occurred at about 100%.
Subject 4: Backing at pretreatment occurred 100% of
the time. At follow-up backing occurred 0% of the
time. Final consonant deletion was at about 97%
occurrence at pretreatment and reduced to 0%
occurrence at follow-up. Velar fronting occurred at
100% at pretreatment and reduced to about 20% at
follow-up. The untreated control process of
prevocalic voicing occurred at about 70% at the
pretreatment stage. The probe at the follow-up stage
yielded results of 100% occurrence for the control
process.

Were they statistically significant (i.e., p<0.05)? Not

addressed

51
 What was the clinical importance of the results?
These results display a variety of phonological
processes and the effects that two different
treatments had on different processes. Clinicians are
able to apply these results to similar clients who may
display one of the treated phonological processes.

Were differences between groups clinically

meaningful?(if applicable) Although the groups
utilized different treatments, results for both groups
yielded about the same results.
CONCLUSIONS AND CLINICAL What did the study conclude? What are the
IMPLICATIONS: implications of these results for speech sound
Conclusions were appropriate given study disorders?
methods The study concluded that both treatment methods
and results were effective in treating the targeted phonological
o Yes processes. Results also showed that treatment
o No reduced the occurrence of processes in a short
amount of time, making both treatments efficient as
Feasibility in community and practice? well as effective.
o Yes Implications were made based on rapid
o No improvement of phonological processes that were
targeted during treatment and lack of improvement
Cost-benefit? in the untreated control process for each child.
o Yes These results imply that both treatments are effective
o No and fast methods of treatment for phonological
processes.
APPLICATION: How does the study apply to clinical services
Applies to clinical services to children with speech provided to children with speech sound disorders?
sound disorders It is important that clinicians become familiar with
o Yes various types of treatments and their effectiveness.
o No This study can be used when determining a specific
treatment method for a child that may demonstrate
the same characteristics of the subjects in the study.
It is convenient to have a study that uses various
phonological processes in order to be able to
determine treatment effects for different processes.
The study gives the clinician the ability to observe
effectiveness of two different treatments.

How will you use the evidence?

Each child is different and some treatments may not
work for every child or every disorder. This needs to
be remembered when considering the evidence from
a study on the effectiveness of different treatments.
The evidence from this particular study can be used
in choosing treatments for clients.

52
CRITICAL REVIEW 4
Citation: Monahan, D. (1986). Remediation of common phonological processes: Four case
studies. Language, Speech, and Hearing Services in Schools, 17, 199-206.

STUDY PURPOSE: Key purpose of the study. How does the study apply to Speech sound
Was the purpose stated clearly? treatment and/or your treatment group focus?
o Yes The purpose of this study was to examine the effectiveness of minimal-
o No word-pair contrasts in treating common phonological processes at the
word and sentence level. This study applies to speech sound treatment
and our group focus by examining a specific method of treatment for
phonological processes.

DESIGN: Level
o Randomized (RCT) Blinding of clients, clinicians, data analyzers?
o Cohort Yes No
o Single case design Brief Description of study design.
o Before and after This study contained four case studies. The treatment utilized a
o Case-control program entitled Remediation of Common Phonological Processes.
o Cross-sectional This treatment incorporated a perceptual sorting task, a lexical
o Case study production procedure, auditory bombardment, and a phonemic
contrasting task for semantic differences. Probes were given to each
subject at a pretreatment and post-treatment period to observe any
improvement.

SAMPLE: N = 4 Sampling (who; how selected; inclusion/exclusion

Clearly described, recognizable criteria)
clients? Subjects: 4 kindergarten children, age 5
o Yes
o No Inclusion: Enrolled in public school, multiple misarticulations, no
Was the sample size justified? prior speech therapy, adequate oral structure and function- Dworkin-
o Yes Culatta Oral Mechanism Examination, normal hearing
o No Exclusion: Not enrolled in school, few misarticulations, prior speech
therapy, inadequate oral structure or function, impaired hearing

If more than one group, what difference existed?

The study included four separate individuals. There were no groups
established during the study.

Describe ethics procedures. Was informed consent obtained?

Ethics procedures were not addressed.

OUTCOMES: Specify the frequency of performance and/or outcome measurement

Were the measures reliable? (i.e. pre, post, follow-up)
o Yes Performance/Outcomes Areas/Instruments
o No List specific measures used
o Not addressed Measurements were taken at two different points. These points were
Were the measures valid? pre and post treatment. The Assessment of Phonological Processes
o Yes from Hodson (1989) was administered. This was given to determine
o No the phonological processes used by each child. The same assessment
o Not Addressed was given at the post-treatment stage to determine results of the study.

53
Control over nuisance variables?
o Yes
o No

RESULTS: What were the results?

Statistically significant differences? Subject 1: Consonant clusters were produced with
o Yes 3% accuracy in the pretreatment stage and 44%
o No accuracy at the post-treatment stage. Final
o Not addressed consonants were produced at 24% accuracy at the
pretreatment stage. These improved to 77% accuracy
Practical significance: size and importance of at the post-treatment stage. The final target of
treatment effects? stridency occurred at 15% at the pretreatment level
o Yes and increased to 75% accuracy at pos-treatment.
o No Subject 2: Consonant clusters were produced with
o Not addressed 20% accuracy at pretreatment and 79% accuracy at
post-treatment. Velars were produced with 46%
Precision of treatment effect? accuracy at the pretreatment stage and improved to
o Yes 91% at the post-treatment stage. Stridency was the
o No last target. Accuracy for stridency was at 56% at
pretreatment and 97% accuracy for post-treatment.
Outcomes for all clients who entered? Subject 3: Stridency was the only treated process for
o Yes this subject. Stridency was produced with 19%
o No accuracy at pretreatment and increased to 65%
accuracy at post-treatment.
Subject 4: Consonant clusters were targeted for this
subject. Consonant clusters were produced with 13%
accuracy at pretreatment and increased to 57%
accuracy at post-treatment.

Were they statistically significant (i.e., p<0.05)? Not

addressed

What was the clinical importance of the results?

The results displayed improvement levels for four
different children who were involved in four separate
case studies involving the same treatment. This may
be used by clinicians to observe treatment effects of
minimal-word-pair contrasts in different children
and for various phonological processes.

Were differences between groups clinically

meaningful?(if applicable) N/A

54
CONCLUSIONS AND CLINICAL What did the study conclude? What are the implications of
IMPLICATIONS: these results for speech sound disorders?
Conclusions were appropriate given study The study concluded that minimal-contrast treatment is
methods responsible for the improvement of various phonological
and results processes in four case studies.
o Yes The improvement in the children included in this study
o No implies that minimal-contrast treatment is an effective
method of treatment for children who use phonological
Feasibility in community and practice? processes. These results could then be applied to treatment
o Yes of speech sound disorders as a determiner of treatment
o No procedures.

Cost-benefit?
o Yes
o No
APPLICATION: How does the study apply to clinical services provided to
Applies to clinical services to children children with speech sound disorders?
with speech It is important that clinicians become familiar with various
sound disorders types of treatments and their effectiveness. This study can be
o Yes used when determining a specific treatment method for a
o No child that may demonstrate the same characteristics of the
subjects in the study. This study used various phonological
processes, so clinicians are able to see results for different
processes.

How will you use the evidence?

Each child is different and some treatments may not work for
every child or every disorder. This needs to be remembered
when considering the evidence from a study on the
effectiveness of different treatments. The evidence from this
particular treatment may be used to design or research future
studies using the same treatment.

55
CRITICAL REVIEW 5
Citation: Martin, M., Rafaat, S., Rvachew, S. (1999). Stimulability, speech perception skills, and the
treatment of phonological disorders. American Journal of Speech-Language Pathology, 8, 33-43.

STUDY PURPOSE: Key purpose of the study. How does the study apply to Speech sound
Was the purpose stated clearly? treatment and/or your treatment group focus?
o Yes Article – discusses two descriptive studies that examine the
o No relationship between stimulability, speech perception, and
phonological learning
Both – “Describe  the   relationship   between   pretreatment   stimulability
and speech perception ability and progress toward the acquisition of
target  sounds”
Study 1 – focused on group treatment
Study 2 – modified study 1 – individual session followed by group
treatment
DESIGN: Level
o Randomized (RCT) Blinding of clients, clinicians, data analyzers?
o Cohort Yes No
o Single case design Brief Description of study design.
o Before and after Demonstrate measureable & satisfactory progress in small groups on
o Case-control “block”   basis.     (Received   no   more   than   one   3-month block of weekly
o Cross-sectional treatment in 6 month pd) Mod-severe phonological delays achieve
o Case study intelligible speech within 18 months with cycles approach.
Cycle = 3 targets/3 cycles/3 sessions – 9 weeks = 9 targets
Study 1 – Cycles approach: 1 – pretreatment session, 9 – 45-60 min
group sessions, 1 – post-treatment session (1 session/wk)
Study 2 – Cycles approach modified each child received:1 –
pretreatment session, 3 – 20 min individual sessions (stimulability &
speech perception training), 6 – 45-60 min group sessions, 1 – post-
treatment session over 9 weeks (1 session/wk).
SAMPLE: N= 23 Sampling (who; how selected; inclusion/exclusion criteria)
Clearly described, recognizable If more than one group, what difference existed? Describe ethics
clients? procedures. Was informed consent obtained?
o Yes Probes test for sound production accuracy, stimulability, and speech
o No perception ability. (p35) Targets – pre-assessment took inventory of
Was the sample size justified? phoneme errors which lead to phonological processes. Processes
o Yes chosen as focus then targets to correct were chosen from there.
o No Sample size is not justified because it only contains 23 children who
are all about the same age. Speech sound disorders are common ergo
23   is   not   a   large   enough   sample.     Doesn’t   include   children   slightly  
older/younger. Also lacks gender specifications.
Study 1 – 10 children, 4;6, mod-severe phonological delay into 4
groups (2-4 kids/group), Groups formed by scheduling constraints,
age, similar error patterns)
Study 2 – 13 children, 4;7, mod-severe phonological delay into 4
groups (same process)

56
OUTCOMES: Specify the frequency of performance and/or outcome measurement
Were the measures reliable? (i.e. pre, post, follow-up)
o Yes Performance/Outcomes Areas/Instruments
o No List specific measures used
o Not addressed Each study used a pre & post-assessment tools to measure results.
Were the measures valid? Study 1 used the Goldman-Fristoe Test of Articulation. All but 1 child
o Yes were ranked below the 10th percentile (moderate or severe
o No phonological delays). In the post-assessment mean differences were
o Not Addressed used to determine change between the pre-mean and post-mean.
Study 2 used the same standardized test and obtained the same
results. The Speech Assessment and Interactive Learning System
(SAILS) was used in each session to target stimulability. Study 2 also
used differences in the mean as a way to measure change.
Control over nuisance variables? Efficiency – needs to be assessed using random assign-experiment
o Yes
o No

RESULTS: What were the results?

Statistically significant differences? Study 1 – Mean pre-treatment probe score was 1.19,
o Yes all 10 production probes were misarticulated on 13
o No (62%) of targets. After post-treatment, mean
o Not addressed difference   was   2.62.   Difference   examined   child’s  
level of stimulability. Good perceptive ability average
Practical significance: size and importance of gain 4.55 points/Difficulty with perceptive skills gain
treatment effects? 0.5 points. Some gain in production was likely to
o Yes occur if the child showed stimulability and good
o No perception. Study 2 – Mean pre-treatment probe
o Not addressed score was 1.19, all 10 production probes were
misarticulated on 15 (58%) of targets. Mean
Precision of treatment effect? difference was 4.56 for sounds that were stimulable.
o Yes Ave change for unstimulable before treatment was
o No 3.00. Good stimulability and speech perception
presented by SAILS was < 70% accurate judgments.
Outcomes for all clients who entered?
o Yes Were they statistically significant (i.e., p<0.05)? Not
o No addressed

What was the clinical importance of the results?

Study 2 was more effective due to the use of
individual sessions that focused on stimulability and
speech perception training. The use of the SAILS
also helped with recognition.

Were differences between groups clinically

meaningful?(if applicable) N/A
CONCLUSIONS AND CLINICAL What did the study conclude? What are the
IMPLICATIONS: implications of these results for speech sound
Conclusions were appropriate given study disorders?
methods The relationship between pre-treatment stimulability
and results and speech perception ability was examined. Study 1
o Yes – showed much variability in the outcome.
o No Variability was attributed to pretreatment levels of
stimulability and speech perception ability.
Feasibility in community and practice? Coincided with previous beliefs that pre-treatment
o Yes stimulability predicts treatment success. Study 2 –
o No allowed for more gains in multiple areas (including

57
 unstimulable targets and poor perception abilities)
Cost-benefit? because there was more focus on individual needs.
o Yes All children demonstrated stimulability for their
o No target sounds after a brief period of direct, one-to-
one stimulability training. Both studies used the
cycles approach to sound disorders
APPLICATION: How does the study apply to clinical services
Applies to clinical services to children with speech provided to children with speech sound disorders?
sound disorders This research proves that stimulability and speech
o Yes perception are important elements to consider when
o No planning   treatment.     “Speech   perception   training
may facilitate the acquisition of stimulabilty if both
production and perception treatment are provided
concurrently.”    In  comparing  the  studies,  study  2  was  
more effective because of the direct, one-to-one
attention  that  was  given  to  the  child’s  needs.

How will you use the evidence?

It is important to consider individual needs before
working with students in groups. It is also important
to consider stimulability of the targets being used as
well  as  the  child’s  perception  of  these  targets  in  order
to achieve the most success in therapy.

58
CRITICAL REVIEW 6
Citation: Gierut, J. A. (1998). Treatment efficacy: Functional phonological disorders in children. Journal
of Speech, Language, and Hearing Research, 41, S85-S100.

STUDY PURPOSE: Key purpose of the study. How does the study apply to Speech sound
Was the purpose stated clearly? treatment and/or your treatment group focus?
o Yes
o No “Report  addresses  the  efficacy  of  treatment  for  functional  phonological  
disorders in children. Impact of this disorder on children and the role
of the SLP in treatment. Evidence of positive outcome of phonological
treatment  (effective)  improving  intelligibility.”
“Clinical   case   intended   to   illustrate   the   nature   of   a   disordered   sound  
system and treatment methods that  may  facilitate  such  change.”
**Manual outlines terms, incidence/prevalence, treatment methods &
evidence of positive change. Case study demonstrates phonological
treatment provides both narrow and broad changes in a sound system
that enhances overall intelligibility and communication functioning.
DESIGN: Level
o Randomized (RCT) Blinding of clients, clinicians, data analyzers?
o Cohort Yes No
o Single case design Brief Description of study design.
o Before and after
o Case-control Manual provides information on both group and single subject studies.
o Cross-sectional From these studies information has been compiled about treatment
o Case study methods and the effectiveness of their application.
Case study focused on one boy, 4;7 who displayed the omission of all
word-initial consonants except for [m b w y]. His speech was highly
unintelligible and had a surgically repaired secondary cleft. He was
normally developing except for sound production.

SAMPLE: N= 1 Sampling (who; how selected; inclusion/exclusion criteria)

Clearly described, recognizable If more than one group, what difference existed? Describe ethics
clients? procedures. Was informed consent obtained?
o Yes
o No Manual included many studies but only covered the results found.
Was the sample size justified? The case study focused on one boy who exhibited the error pattern of
o Yes word-initial consonant deletion. The SLP used minimal pair treatment
o No pairing known and unknown sounds. I believe consent was obtained
because the child received therapy for 3 months which included 23
direct treatment sessions.
OUTCOMES: Specify the frequency of performance and/or outcome measurement
Were the measures reliable? (i.e. pre, post, follow-up)
o Yes Performance/Outcomes Areas/Instruments
o No List specific measures used
o Not addressed
Were the measures valid? Case study – pretesting was needed to determine the phonological
o Yes disorder and plan treatment. J was dismissed from therapy after
o No successfully gaining 13 sounds in the initial position. J was then
o Not Addressed brought back a week after for post-testing and passed with 100%
accuracy. No subsequent phonological treatment was needed and
intelligibility was greatly improved.

59
Control over nuisance variables?
o Yes
o No
o Not addressed
RESULTS: What were the results? Were they statistically
Statistically significant differences? significant (i.e., p<0.05)?
o Yes Not addressed
o No
o Not addressed What was the clinical importance of the results?
Results in this manual coincided with the results
Practical significance: size and importance of found in the case study. These results are important
treatment effects? because they provide proof that the treatment works.
o Yes This plays into the EBP which speech pathology is
o No based on. If the treatment is found to be effective in
o Not addressed research then it is used in the therapy room and will
Precision of treatment effect? provide the best results possible.
o Yes
o No Were differences between groups clinically
meaningful? (if applicable) N/A
Outcomes for all clients who entered?
o Yes
o No
CONCLUSIONS AND CLINICAL What did the study conclude? What are the
IMPLICATIONS: implications of these results for speech sound
Conclusions were appropriate given study disorders?
methods The   manual   recognizes   that   “children   with  
and results phonological disorders are not a homogenous group
o Yes and that individual differences in learning are one
o No hallmark of this population.”    A  traditional  approach,  
sensory-motor method, cycles approach, minimal
Feasibility in community and practice? pair treatment, and metaphon method provide many
o Yes different techniques that can be effectively used
o No during therapy. It is important to individualize
treatment because each client will have different
Cost-benefit? needs and interests.
o Yes
o No
APPLICATION: How does the study apply to clinical services
Applies to clinical services to children with speech provided to children with speech sound disorders?
sound disorders The research presented here demonstrates the
o Yes importance of considering the client when planning
o No treatment. All methods have been found to be
successful however it is ultimately up to the clinician
to determine what method will work best for each
client.

How will you use the evidence?

This evidence discussed the importance of
phonological treatment because it will improve
intelligibility which allows for long-term benefits in
communication areas, educational and social
settings.

60
CRITICAL REVIEW 7
Citation: Gierut, J. A. (1989). Maximal opposition approach to phonological treatment. Journal of
Speech and Hearing Disorders , 9-19.

STUDY PURPOSE: Key purpose of the study. How does the study apply to Speech sound
Was the purpose stated clearly? treatment and/or your treatment group focus?
o Yes
o No The purpose of this paper is to describe and evaluate such a treatment
approach of maximal opposition. The effectiveness of this program will be
evaluated by tracing patterns of phonological generalization and
overgeneralization in a child displaying a systematic sound pattern involving
the nonoccurrence of consonants word initially.
DESIGN: Level
o Randomized (RCT) Blinding of clients, clinicians, data analyzers?
o Cohort Yes No
o Single case design Brief Description of study design.
o Before and after
o Case-control Pre-Post Test—
o Cross-sectional In this study, the maximal opposition approach to treatment was implemented
o Case study within the framework of a single-subject multiple baseline design across 21
sounds. The 21 charted sounds included: /m,b,w,j/ (the 4 phonemes J used in
word-initial position);/n,p,t,d,k,g,f,v,0,s,
z,/,tS,d3,h,l/ (the 16 phonemes not used in word-initial position); and/r/,
which served as a control sound. Production of these 21 sounds was evaluated
using a generalization probe measure consisting of a total of 178 words (89
nonprefixed words plus the same 89 words with the prefix "re-" added). Each
of the 21 sounds was sampled a minimum of six times. Probe items were
randomized and elicited in a spontaneous picture-naming task both pre and
post treatment, as well as at various points throughout treatment.
Treatment sessions were held twice weekly for 30 minutes each session.
Initially, a pretreatment baseline of all 21. One maximal opposition contrast
was then selected for treatment based on the multiple distinctions of voice,
place and manner.
Actual treatment involved contrasting five "picturable" word pairs (e.g., sad-
mad, sat-mat, see-bee, suit-boot, and sail-whale) in first an imitative and then
a spontaneous phase of production. During the imitative phase, picture pairs
were presented, and J was required to name the items following the clinician's
verbal model. During the spontaneous phase, the same picture pairs were
presented,
And J named each item without a model.
Treatment continued in each phase until J produced word-initial consonants
in treatment pairs with 90% accuracy over each of two consecutive 30-min
sessions. Upon reaching criterion in both imitative and spontaneous phases,
the generalization probe of all 21 sounds was re-administered. A second
maximal opposition was selected for treatment based on the nature of J's
generalization learning. Five new picturable word pairs were then chosen for
treatment in both imitative and spontaneous phases of production. Treatment
and generalization probes continued in this manner until the child mastered
all 16 word-initial sounds. A final generalization probe measure and
spontaneous connected speech sample were obtained 1 week following the
completion of treatment.
SAMPLE: N= Sampling (who; how selected; inclusion/exclusion
Clearly described, recognizable criteria) If more than one group, what difference existed? Describe
clients? ethics procedures. Was informed consent obtained?
o Yes N= 1

61
 o No The subject of this study was a boy, J, age 4 years, 7 months. He was referred
Was the sample size justified? to the Speech and Hearing Center at Indiana University for a diagnostic
o Yes evaluation at age 4 years, 1 month by his mother due to the unintelligibility of
o No his speech. J displayed numerous sound errors in conversational speech as
well as in performance on the Goldman-Fristoe Test of Articulation
(Goldman & Fristoe, 1969). Errors were characterized primarily by the
nonoccurrence of word-initial consonants. Results of the diagnostic intake
indicated that J had normal hearing bilaterally with no history of middle ear
infections. Also, J's performance on the Preschool Language Scale was age
appropriate both receptively (point score = 33; age equivalency= 5 years) and
expressively (point score = 27; age equivalency = 4 years, 4.5 months).
Parental report indicated that J had no apparent gross or fine motor, cognitive,
social, or emotional dysfunctions. J's history, however, revealed a secondary
cleft of the hard and soft palates that was surgically repaired 2 years prior.
OUTCOMES: Specify the frequency of performance and/or outcome measurement
Were the measures reliable? (i.e. pre, post, follow-up)
o Yes Performance/Outcomes Areas/Instruments
o No List specific measures used
o Not addressed The investigator and two trained listeners (SC, KH) with experience in
Were the measures valid? narrow phonetic transcription served as reliability judges. The investigator
o Yes and one of the listeners (SC) independently transcribed a portion (20%) of J's
o No pretreatment spontaneous speech sample. Consonant transcriptions were
o Not Addressed compared point to point. Mean transcription reliability was 80% agreement
(N = 222 segments). The investigator and the second listener (KH)
independently transcribed all of J's responses on repeated administrations of
the generalization probe measure. Consonant transcriptions were compared
point to point. Mean transcription reliability was 96% agreement (N = 1,988
segments; range: 92%-100% agreement).
Control over nuisance variables?
o Yes
o No
o Not addressed
RESULTS: What were the results? Were they statistically
Statistically significant differences? significant (i.e., p<0.05)?
o Yes What was the clinical importance of the results?
o No Were differences between groups clinically
o Not addressed meaningful? (if applicable)
Following maximal opposition treatment over eight
Practical significance: size and importance of sessions, J generalized accurate word-initial
treatment effects? production to novel words with the treated phoneme,/s/, as
o Yes well as to other words with untreated phonemes/n,hL
o No Generalization to all three phonemes was with 100%
o Not addressed accuracy. From this initial generalization learning, we
Precision of treatment effect? predicted that J would continue to expand the range of
o Yes phonemes used in word-initial position along any one (or
o No all) of the features.
Outcomes for all clients who entered?
o Yes Following treatment of this maximal opposition over five
o No sessions, J generalized to the word-initial
consonants/t,d,z,S,t$,d3,1/; however, generalization was not
complete (100% accurate)
in all cases. This generalization pattern relative to the
treated phoneme ~t f~ suggested that J identified a new
feature dimension, stridency, as a significant aspect of
contrast, as evidenced by his use of word-initial/f,tf,d3/.

62
 Following treatment of/f/ over four sessions, J generalized
accurate word-initial productions to/p,f,v,O/; generalization
was not 100% accurate in all cases. Continued gains were
noted, however, in the accuracy of other sounds J
previously introduced in word-initial position. From this
pattern of generalization relative to the treated phoneme/f/,
J apparently attended to only those previously treated
relevant dimensions

A generalization probe administered 1 week post treatment

indicated that/k,g/were used in word-initial position with
100% accuracy Also, further improvements were observed
in production of other word-initial sounds. Of the 16
charted word-initial sounds, 11 were used with 100%
accuracy following treatment of only three sets of contrasts.
Moreover, 4 other sounds were used in word-initial position
with greater than 65% accuracy. One sound,/~/, was used
word initially with less than 50% accuracy following
treatment.

Over a relatively short period of intervention involving

direct treatment of only three sets of maximally opposed
contrasts, J made substantial improvements in the nature of
his phonological system. It should also be noted that,
throughout treatment, production of the control
phoneme/r/did not improve, nor were changes observed in
word-initial production of previously known
phonemes/m,b,w,j/.
CONCLUSIONS AND CLINICAL What did the study conclude? What are the
IMPLICATIONS: implications of these results for speech sound
Conclusions were appropriate given study disorders?
methods These generalization data demonstrated that, for J, a treatment
and results approach based on maximal oppositions was
o Yes effective in changing and improving the phonological system.
o No The apparent success of this treatment approach
may have been associated with J's specific pattern of
Feasibility in community and practice? production involving extensive omissions
o Yes
o No It will be important to evaluate further the efficacy of this
treatment approach relative to other patterns of production and
Cost-benefit? relative to other methods of contrast treatment.
o Yes
The generalization data also suggested that J's approach to
o No
phonological learning involved building on what was
o N/A
previously learned in treatment.

Gradual improvements in the accurate production of sounds

were observed over the course of intervention. J continued to
refine his production of word-initial consonants, even after
direct treatment of those (or related) sounds. In addition, J
apparently assigned some priority to those oppositions that
were treated first The child seemed to rely on a set or core of
features (e.g., [+coronal], [+anterior],[-voice], [+continuant])
in expanding his word-initial repertoire. This observation
suggests that, perhaps, first treated oppositions drive or govern
the course of later phonological acquisition and learning.

63
APPLICATION: How does the study apply to clinical services provided to
Applies to clinical services to children children with speech sound disorders?
with speech How will you use the evidence?
sound disorders
o Yes The overall goal of contrast treatment remains the same: to present a
o No conceptual approach to the acquisition of phonemic distinctions in
order to reduce the occurrence of homonymyin a child's phonological
system.

In a maximal opposition approach distinctions are more global along

the broader, multiple dimensions of voice, place, and manner. Within
this approach, however, as more oppositions are learned by a child,
distinctions become further differentiated eventually leading to
minimal contrasts.

64
CRITICAL REVIEW 8
Citation: Klein, E. S. (1996). Phonological/traditional approaches to articulation therapy: A retrospective
group comparison. Language, Speech, and Hearing Services in Schools, 27, 314-323.

STUDY PURPOSE: Key purpose of the study. How does the study apply to speech sound
Was the purpose stated clearly? treatment and/or your treatment group focus?
o Yes “Compare   children   with   multiple   articulation   disorders   who   received  
o No traditional programs of therapy with similar children who received
phonologically  based  intervention.”    This articled helps to differentiate
between a phonological and a traditional approach. Phonological
approaches focuses on allowing the client to learn the difference
between a good and bad production through the use of language. The
traditional approach focuses on imitation and oral movements.
DESIGN: Level
o Randomized (RCT) Blinding of clients, clinicians, data analyzers?
o Cohort Yes No
o Single case design Brief Description of study design.
o Before and after 19 children received traditional therapy and 17 children received
o Case-control phonological therapy and compared efficiency of each treatment. The
o Cross-sectional goal was to determine if phonological treatment would require a
o Case study significant shorter period of time to dismiss the client from therapy
with normal speech. After therapy and standardized testing the
children were compared on 5 variables: rating before intervention,
after final session, number of hours in therapy, number of months in
therapy,  and  child’s  age  at  first session.
SAMPLE: N = 36 Sampling (who; how selected; inclusion/exclusion criteria)
Clearly described, recognizable If more than one group, what difference existed? Describe ethics
clients? procedures. Was informed consent obtained?
o Yes All students came in with phonological errors which caused
o No unintelligible speech. This study was ethical because all children
Was the sample size justified? received therapy and were not released until their speech was
o Yes “normal.”    The  purpose  of the study was not to release all clients when
o No one group had normal speech, but to compare the number of months it
took to reach normal speech. Groups were formed only by when they
were seen for therapy.
OUTCOMES: Specify the frequency of performance and/or outcome measurement
Were the measures reliable? (i.e. pre, post, follow-up)
o Yes Performance/Outcomes Areas/Instruments
o No List specific measures used
o Not addressed For the pre and post-assessments the Arizona Articulation Proficiency
Were the measures valid? Scale (AAPS) and the Goldman-Fristoe Test of Articulation were used
o Yes to determine the severity of each client in the case study. The students
o No received 2-3 50 minute sessions per week. One group focused on the
o Not Addressed phonological approach while the other worked on the traditional
approach.

Control over nuisance variables?

o Yes
o No
o Not addressed

65
RESULTS: What were the results? Were they statistically significant
Statistically significant differences? (i.e., p<0.05)? At the beginning of intervention there was no
o Yes significant difference between the two groups and they
o No essentially had the same articulation disorders. At the end
o Not addressed the traditional group had a mean severity score of 12.84 (SD
5.40) and the phonological group had a mean severity score
Practical significance: size and of 1.53 (SD 1.90). Phonological group showed greater
importance of treatment effects? improvement. No significant difference between then
o Yes number of sessions
o No What was the clinical importance of the results?
o Not addressed Both treatments had the same results however the
Precision of treatment effect? phonological treatment was much more efficient.
o Yes Were differences between groups clinically meaningful?(if
o No applicable)
This study brought evidence that the phonological treatment
Outcomes for all clients who entered? was a better way to approach therapy and provided more
o Yes efficient treatment in less amount of time.
o No
CONCLUSIONS AND CLINICAL What did the study conclude? What are the implications of
IMPLICATIONS: these results for speech sound disorders?
Conclusions were appropriate given study 17 of the 19 children who had traditional therapy had
methods essentially normal speech after an average of 22 months
and results compared to all 17 children who received phonological
o Yes therapy were dismissed with normal speech after an average
o No of 13 months. Both of these approaches are effective however
in this study the phonological treatment was more efficient.
Feasibility in community and practice?
o Yes
o No

Cost-benefit?
o Yes
o No
APPLICATION: How does the study apply to clinical services provided to
Applies to clinical services to children children with speech sound disorders?
with speech This study confirms that both methods of therapy are
sound disorders effective. The final decision is made by the clinician as to
o Yes which type of therapy will be most successful.
o No How will you use the evidence?
After reading this evidence I find both methods to be good
sources  of  therapy.    It’s  important  to  consider  each  client  and  
choose the best therapy for that client whether it is
traditional or phonological.

66
CRITICAL REVIEW 9
Citation: Barlow, J. A., Gierut, J. A. (2002). Minimal pair approaches to phonological
remediation. Seminars in Speech and Language. 23, 57-67.

STUDY PURPOSE: Key purpose of the study. How does the study apply to Speech
Was the purpose stated sound treatment and/or your treatment group focus?
clearly? “Considers  linguistic approaches to phonological treatment that
o Yes emphasize   the   role   of   the   phoneme   in   language.”    
o No Structure/function of a phoneme, determining contrast pairs,
application to a case study and effectiveness of treatment are
discussed.
DESIGN: Level
o Randomized (RCT) Blinding of clients, clinicians, data analyzers? Yes No
o Cohort Brief Description of study design.
o Single case design This article was more informative than applicable. The basic
o Before and after elements of the minimal pairs approach were broken down and
o Case-control explained adequately. A definition was given for a phoneme
o Cross-sectional and the concept of contrast pairs was explained. The
o Case study assessment process and intervention planning were also
discussed. The information given was based off extensive
research.
SAMPLE: N= Sampling (who; how selected; inclusion/exclusion
Clearly described, criteria) If more than one group, what difference existed?
recognizable clients? Describe ethics procedures. Was informed consent obtained?
o Yes This article covered research and explained how it could be
o No added to a case study.
Was the sample size justified?
o Yes
o No
OUTCOMES: Specify the frequency of performance and/or outcome
Were the measures reliable? measurement (i.e. pre, post, follow-up)
o Yes Performance/Outcomes Areas/Instruments
o No List specific measures used
o Not Addressed The only assessment discussed was an initial language sample
Were the measures valid? taken by an SLP or a linguist. The focus of the sample was to
o Yes evaluate   the   client’s   phonemic   inventory   and   determine   what  
o No phonemes  are  missing  from  the  client’s  repertoire.    
o Not Addressed
Control over nuisance variables?
o Yes
o No
o Not Addressed
RESULTS: What were the results? Were they statistically
Statistically significant differences? significant (p<0.05)? N/A
o Yes What was the clinical importance of the results?
o No The results of the research gathered here are
o Not Addressed vital   to   success   in   the   therapy   room.     It’s  
important for the clinician to understand all
Practical significance: size and importance of elements of the minimal pairs approach in
treatment effects? order to apply it most successfully in therapy.

67
 o Yes Were differences between groups clinically
o No meaningful? (if applicable) N/A
o Not addressed
Precision of treatment effect?
o Yes
o No

Outcomes for all clients who entered?

o Yes
o No
CONCLUSIONS AND CLINICAL What did the study conclude? What are the
IMPLICATIONS: implications of these results for speech sound
Conclusions were appropriate given study disorders?
methods and results This study set up a variety of ways to approach
o Yes the minimal pairs technique. It discusses how
o No to   assess   a   child’s   initial   phonemic repertoire
and how to choose the correct phonemes to
Feasibility in community and practice? choose next. The minimal pairs approach offers
o Yes several different ways of pairing phonemes.
o No Simple pairings allow the client to learn the
different of one aspect of language (voice,
Cost-benefit? placement or manner) while other pairings that
o Yes cover all three areas of language. The latter
o No pairing has been shown to cause greater
generalization across phonemes.
APPLICATION: How does the study apply to clinical services
Applies to clinical services to children with provided to children with speech sound
speech sound disorders disorders?
o Yes This article clarifies all aspects of the minimal
o No pair approach. It accounts for different
techniques that will reach the variety of clients
that are seen for speech sound disorders.
How will you use the evidence?
The understanding I have gained from this
article allows me to implement the minimal
pairs technique in a way that will provide the
most success. Assessing the child and choosing
pairs that will be most beneficial for each client
will allow the greatest success.

68
CRITICAL REVIEW 10
Citation: Blanche, S. E., Parsons, C. L., & Humphreys, J. M. (1981). A minimal-word-pair model for
teaching the linguistic significance of distinctive feature properties. Journal of Speech and Hearing
Disorders , 291-296.

STUDY PURPOSE Outline the purpose of the study. How does the study apply to your
research question?
Was the purpose Does the and productive training of word contrasts in one sound pair aid in
stated clearly? the reduction of errors in the same feature category in other lexical sound pair
Yes contexts?
No
DESIGN Describe the study design. Was the design appropriate for the study question?
(e.g., for knowledge level about this issue, outcomes, ethical issues, etc.):
Randomized (RCT) One sound pair was randomly selected for each subject from the feature
cohort category with the greatest number of errors\two subjects were trained on
single case design tense/lax, two on continued/interrupted, and one on grave acute,
before and after strident/mellow and compact/diffuse—four of the features were trained in the
case-control initial position and 3 in the final
cross-sectional
case study Each subject was shown representations of the minimal pair pictures and was
trained on auditory discrimination until 90% performance level was attained
in pass/fail trial blocks of 20 attempts—also asked to indicate their knowledge
of difference between the 2 words to the clinician until 90% performance
criteria was met
SAMPLE Sampling (who; characteristics; how many; how was sampling
done?) If more than one group, was there similarity between the
N=7 groups?:
Was the sample 31 identified as having multiple articulation errors—tested to meet the
described in detail? experimental criteria for inclusion. The children were included if:
Yes
No 1. Demonstrated at least 4 sounds in errors on the developmental
test of articulation
2. Were free of structural and or motoric deficiencies as determined
Was sample size by extensive oral-peripheral examination
justified? 3. Passed a bilateral pure tone audiometric screening—any child
Yes who failed any frequency in either ear was rejected
No 4. Demonstrated a receptive vocabulary age no more than 2 months
N/A behind their chronological age
22 children (71%) of original sample were not included because they
didn’t  meet  the  criteria  –and 2 were removed due to lack of parental
consent
7 remained , ranging in age 5 years 4 months to 6 years 7 months with
a mean age of 5 years 9 months
OUTCOMES Specify the frequency of outcome measurement (i.e., pre, post, follow-
Were the outcome up):
measures reliable?
Yes Pre-Post Therapeutic performance levels measured
No Similar procedures were used before and after the minimal word pairs therapy
Not addressed to assess the transfer of learning
4 /7 subjects were tested using the fisher-lugermann test of articulation
Were the outcome competence and 3/7 were tested using photo-articulation test
measures valid? In the post therapeutic tests the tests were alternated to reduce learning
Yes effects
No
Not addressed

69
Control over nuisance What were the results? Were they statistically significant (i.e., p <
variables? 0.05)? If not statistically significant, was study big enough to show
Yes an important difference if it should occur? If there were multiple
No outcomes, was that taken into account for the statistical analysis?
Not addressed
*see below
RESULTS What did the study conclude? What are the implications of these
results for speech sound disorders?
Results were reported in
terms of statistical  Within feature showed a consistent reduction after minimal
significance? word pair training
Yes  73.3% reduction in feature error could be noted (excluding
No original sound pair from pre and post tests) implying
N/A significant transfer of learning from the sound pairs used in
Not addressed training to the other sound pairs within the therapeutic
feature class
Practical significance:  **specific features are too sparse to draw definite conclusions
size and importance of but the continuant feature showed most resistance to
treatment effects? spontaneous transfer
Yes  Where as 82.2% of the within class feature errors were
No improved in the tense/lax, grave/acute/strident mellow, and
Not addressed compact/diffuse categories, only 53.8% of the continued
interrupted errors were changed
Precision of treatment
 Reduction of the within feature class of all 7 subjects—that is
effect?
the exact probability of this occurring is .007—which is great
Yes
enough to reject the null hypothesis of no feature
No
generalization
 30% of untreated features were improved—while this figure
Outcomes for all clients
is 50% less improvement then that of the treated, the overall
who entered?
improvement in general articulation, even if modest, is of
Yes
therapeutic utility.
No
 A t-test for related measures indicated significant advantage
in improvement in treated features (t=4.7808; p<.01)
 Of the 23 untrained feature possibilities, 3 shoed greater
number of errors in post tests, seven remained the same,
while 13 improved—results proved significant at the
confidence interval level implying that generalization
occurred in the untreated feature class

CONCLUSIONS AND How does the study apply to clinical services provided to children
IMPLICATIONS with speech sound disorders? How will you use this evidence?
Conclusions were It does appear that distinctive feature generalization, measured in binary
appropriate given the mode, does occur following receptive/productive training with minimal pairs.
study methods and Attending behavior of the child and psychological practices, in which the
results? child learns produce and integrate muscular movements, both from general
Yes operational fields of learning irrespective of the feature pattern.
No This study does not purport to draw conclusions outside the context of
Not addressed experimental design. Inferences cannot be drawn as to such phenomenon as
Cost benefit? decay rate and the stability of the feature improvement – which are important
Yes questions of the future.
No
APPLICATION The minimal pair technique is a clinical and research perspective offered not
Applies to clinical services as a final answer, but the initial formulation of a type of question.
to children with speech
sound disorders
Yes
No

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CRITICAL REVIEW 11
Citation: Williams, A. L. (1993). Phonological reorganization: A qualitative measure of
phonological improvement. American Journal of Speech Language Pathology, 2, 44-51.

STUDY PURPOSE: Key purpose of the study. How does the study apply to Speech
Was the purpose stated sound treatment and/or your treatment group focus?
clearly? The purpose of this study was identify a procedure for
o Yes documenting phonological improvement following a treatment.
o No The procedure was intended to be a different way of treating a
patient and for obtaining information. The procedure used was
a qualitative measure rather than a quantitative one. The
author   argues   that   qualitative   reorganization   of   a   child’s  
phonological skills can be as equally valid when compared to
quantitative measure.

DESIGN:
o Randomized (RCT)
o Cohort
o Single case design
o Before and after
o Case-control
o Cross-sectional
o Case study
Level
Blinding of clients, clinicians, data analyzers?
Yes No
Brief Description of study design.
A minimal pair treatment approach was utilized with this
client. Three sounds were selected for use during treatment.
The sounds were selected by the following: representativeness of
the error pattern and when they were contrasted with a target
that was different in place, manner, and voicing. The approach
used was very similar to the maximal opposition approach. A
difference from the maximal approach was that the target sound
was   contrasted   with   Michael’s   error   production   for   the   target.    
The targets selected for treatment included: /s/~/w/ word
initially,   /t∫/~/k/   word   initially,   and   /∫/~/θ/   word   finally.     All  
three error patterns were trained within each treatment session.

Training consisted of two phases. The first phase, the words

were produced after imitating the clinician. In the second
phase, Michael generated the pairs when the clinician showed
him pictures. This was done without a verbal model.
The criterion to move from the first stage to the second stage
was 90% accuracy across two consecutive training sets. The
training set was comprised of 20 responses. Each session
involved 5 training sets, or 100 trials. There were thirteen
sessions, each lasting 45 minutes.
SAMPLE: N= 1 Sampling (who; how selected; inclusion/exclusion
Clearly described, criteria) If more than one group, what difference existed?
recognizable clients? Describe ethics procedures. Was informed consent obtained?
o Yes
o No The subject used during this study was a boy named Michael.
Was the sample size He was 6 years 11 months at the time of the study. Michael had
justified? a congenital cleft lip on the right side. It was surgically repaired
o Yes at 3 months of age. Michael received treatment in a university
o No clinic for 6 semesters. He also received treatment at his public
school. His goal during sessions was suppression of stridency

71
 deletion   on   the   targets   /f,   s,   z,   t∫,∫/   word   initially   and   word  
finally. Michael exhibited a cleft on the lip only. He did not
exhibit articulatory patterns that are associated with cleft palate
speech. An oral peripheral examination showed that his hard
and soft palates were intact. There was no evidence of a
submucous cleft. Michael has a history of recurrent ear
infections. However, at the time of testing, his fearing was
within normal limits. Michael exhibits average intelligence and
is from a monolingual English-speaking family (Williams, 1993).

The issue of consent was not mentioned in this article.

Ethics was not addressed.
OUTCOMES: Specify the frequency of performance and/or outcome
Were the measures reliable? measurement (i.e. pre, post, follow-up)
o Yes Performance/Outcomes Areas/Instruments
o No List specific measures used
o Not addressed An independent analysis and a relational analysis were used
to   assess   Michael’s   phonological   system   before   treatment.    
Were the measures valid? These   analyses   provide   a   complete   description   of   the   child’s  
o Yes phonological skills. An independent analysis describes the
o No child’s   phonological   system   as   a   unique   and   self   contained  
o Not Addressed system (Williams, 1993). Relational analysis compares the
child’s  system  to  the  adult  system.    

Independent Analysis- This analysis was completed with

Michael using a 245 item single word test. It sampled all
English sounds at least five times in each word position. The
analysis proved Michael with opportunities to discover
contrastive function of sounds using minimal pairs. The stimuli
were black and white line drawings that were shown to Michael.
Michael’s   system   was   described   in   terms   of   its   phonological  
system and phonological structure. By using this analysis, the
researcher determined that Michael showed a phonotactic
inventory constraint for affricates, liquids, and strident
fricatives. He produced bilabial, alveolar, velar and glottal
stops. His use of alveolar stops was limited to postvocalic
positions. Consonant clusters were not generated.

Relational Analysis- This analysis was completed in two steps.

The first step   was   to   taking   and   mapping   Michael’s   system   of  
contrasts onto the adult standard English system. By doing this,
it helped the researcher compare the relationship between they
systems  of  children  with  phonological  disorders  and  the  adults’  
systems. The second step was creating a diagram that showed
the collapses of adult contrasts that mapped the two sound
systems.

Michael’s  patters  were  systematic  and  patterned.    Word  initially,  

Michael organized his system into two primary patterns. Target
glides, liquids, and voiceless fricatives were collapsed to the
glide /w/. Target affricates and some stops were collapsed to

72
 the velar stop /k/. Word finally, the voicless fricatives and
affricates  were  collapsed  to  the  fricative  /θ/  (Williams,  1993).

A second phonological analysis was given at the end of training-

both independent and relational. The analysis used the same
245 item single word sample that was used for the first
phonological analysis.

In order to move from the first phase to the second, Michael

needed to achieve 90% accuracy in the production of sounds
across two consecutive training sets.
Control over nuisance variables?
o Yes
o No
o Not addressed
RESULTS: What were the results? Were they statistically
Statistically significant significant (i.e., p<0.05)?
differences? This research was a qualitative measure. Therefore, there was
o Yes no quantitative data to find out if it was statistically significant.
o No
o Not addressed What was the clinical importance of the results?
By doing this study, the researchers have discovered clinical
Practical significance: size implications to the use of qualitative measures. According to
and importance of treatment Williams (1993), phonological change should not be limited to
effects? quantitative measures of accuracy of production. Although
o Yes quantitative measures are considerably reliable, they can miss
o No the qualitative changes. They may also miss the organizational
o Not addressed principles   that   operate   in   the   child’s   system.     Procedures   that  
examine the organizational processes of children provide a way
Precision of treatment effect? to examine the  child’s  integration  of  phonological  information.    
o Yes
o No The results from this study have implications for the
description  of  a  child’s  phonological  systems  (Williams,  1993).    
Outcomes for all clients who The use of a predetermined set of phonological processes would
entered? have missed Michaels’   own   unique   phonological   system   in  
o Yes relation to the adult system. By performing qualitative
o No research,   we   were   able   to   get   a   better   picture   of   Michael’s  
phonological systems at work.

Were differences between groups clinically

meaningful? (if applicable)
N/A
CONCLUSIONS AND What did the study conclude? What are the implications of
CLINICAL these results for speech sound disorders?
IMPLICATIONS: Qualitative measurements can be a valuable asset to
Conclusions were appropriate researchers and clinicians. According to Williams (1993), these
given study methods and measurements can provide clinicians and researchers with
results information   about   the   child’s   phonologic   learning, their active
o Yes and creative hypothesis formulation, and the organizing
o No principles on which they structure their phonological system.
The combination of independent and relational analysis can

73
Feasibility in community and provide  us  with  a  more  thorough  measure  of  the  child’s  systems
practice? than either analysis by itself would. They also show us what the
o Yes child produces in relation to the target.
o No
By using a qualitative measure to look at the speech of children,
Cost-benefit? we are able to get a better sense of their phonological processes.
o Yes This doesn’t   mean   that   we   need   to   be   doing   qualitative  
o No measures instead of quantitative, but by using a combination of
both   we   would   get   better   insight   into   a   child’s   uniquely  
organized (or unorganized) phonological systems compared to
that of adults.
APPLICATION: How does the study apply to clinical services provided to
Applies to clinical services to children with speech sound disorders?
children with speech This study shows researchers and clinicians that quantitative
sound disorders measures can be enhanced when using qualitative measures.
o Yes The use of qualitative measures allows clinicians to see aspects
o No of   a   child’s   phonological   system   that   would   be   missed   when  
using quantitative measures alone. Qualitative measures show
us   a   child’s   uniquely   organized phonological systems, where
quantitative   gives   us   exact   numbers   of   the   child’s   success   (or  
lack  of).    By  using  both,  we  get  a  complete  picture  of  the  child’s  
phonological system.

How will you use the evidence?

This study utilized minimal pairs while doing qualitative
research. I have read many articles on the use of minimal pairs
with quantitative measures. However, this is the first article I
have read in regards to minimal pairs and qualitative measures.
It was an interesting read considering I never felt that I would
use qualitative measures. However, I can see the benefits.

For example, if I were working on minimal pairs with a child,

getting  quantitative  measures  would  allow  me  to  see  “number”  
wise where the child is in relation to others and how he/she is
doing   in   relation   to   themselves.     I   don’t   know   if   I   would   use  
qualitative research all the time, but I do believe that in using it
I  would  get  a  better  picture  of  the  child.    I  would  “see”  different  
changes that I might not see when only doing quantitative
measures. I would definitely keep this research in mind when
determining   how   I   want   to   measure   a   child’s   phonological  
systems, especially when it comes to the use of minimal pairs.
From this research, we have an example of how qualitative
measures can be successful when using minimal pairs.

74
CRITICAL REVIEW 12
Citation: Weiner, F. (1981). Treatment of phonological disability using the method of
meaningful minimal contrast: Two case studies. Journal of Speech and Hearing Disorders, 46
97-103.
STUDY PURPOSE: Key purpose of the study. How does the study apply to Speech
Was the purpose stated sound treatment and/or your treatment group focus?
clearly? The purpose of this study was to examine the effects of
o Yes minimal contrast treatment. The treatment was used to teach
o No phonological opposition to children who displayed unintelligible
speech. This study was intended to show whether minimal
contrast therapy is an effective means in reducing the frequency
of phonological processes with children who have a
phonological disability.
This study applies to speech sound treatment in that minimal
contrast therapy focuses on the phonological processes, or
sounds, that may appear in the initial, medial, or final position
of the word.
The focus of our treatment group was to find ways in which
clinicians can work with children on phonological process
treatments. The minimal contrast approach does just that-
treatment is geared to working on phonological (speech)
processes.
DESIGN: Level
o Randomized (RCT) Blinding of clients, clinicians, data analyzers?
o Cohort Yes No
o Single case design Brief Description of study design.
o Before and after This was a case study that focused on two boys with
o Case-control phonological process disorders. The processes chosen were
o Cross-sectional ones in which the boys had trouble and also ones that many 4
o Case study years with normal speech can correctly produce. The processes
include: final consonant deletion, stopping, and word-initial
fronting. A minimal pairs approach was chosen. Treatment
sessions were scheduled for Mondays, Wednesdays, and Fridays
each week. Each session was one hour long. The number of
trials differed. This depended on the speed at which the child
could work.
SAMPLE: N= 2 Sampling (who; how selected; inclusion/exclusion
Clearly described, criteria) If more than one group, what difference existed?
recognizable clients? Describe ethics procedures. Was informed consent obtained?
o Yes This particular study focused on two boys, ages 4 years 10
o No months and 4 years 4 months. Both children were referred to
Was the sample size the Child Speech Program at The Pennsylvania State University.
justified? The complaint was that each boy had unintelligible speech.
o Yes They each had to demonstrate at least 6 phonological processes
o No described by Weiner. Also, the boys also had to have normal
hearing and the ability to work on speech tasks during a 60-
minute therapy session. Both children were from monolingual
homes and had normal screening at 15 dB.

The first child demonstrated deletion of final consonants 95% of

the time during baseline. He demonstrated stopping 95% of the

75
 time and demonstrated fronting in 100% of his responses.
During   the   final   session,   there   weren’t   any   instances   of   final  
consonant deletion, stopping, or fronting.

The second child had baseline measures of 100% for fronting,

final consonant deletion, and stopping. During the final session,
stopping was measured at 60%, final consonant deletion at 50%,
and fronting was at 30%.

It did not mention whether consent was obtained, but the

parents obviously had to bring them to these sessions. Consent
to participate is inferred.

Ethics was not addressed.

OUTCOMES: Specify the frequency of performance and/or outcome
Were the measures reliable? measurement (i.e. pre, post, follow-up)
o Yes Performance/Outcomes Areas/Instruments
o No List specific measures used
o Not addressed Each session with the clients was tape recorded. An
independent observer was used in judging the speech recorded
Were the measures valid? from each subject. The observer listened to the responses to
o Yes target words and scored them for the presence or absence of the
o No appropriate use of phonological processes. The agreement
o Not Addressed between the observer and the experimenter was calculated. For
Subject A, the two were in agreement 96% of the time. For
Subject B, they were in agreement 94% of the time. The lowest
percentage of agreement for individual sessions for Subject A
was 90%. The lowest percentage agreement for individual
sessions for Subject B was 92%.

Control over nuisance variables?

o Yes
o No
o Not addressed
RESULTS: What were the results? Were they statistically
Statistically significant differences? significant (i.e., p<0.05)?
o Yes The results for the first child indicated that
o No production of sounds during final consonant
o Not addressed deletion improved 60%, correct production of
initial fricatives during responses to ST target
Practical significance: size and importance of words improved 70%, and correct production of
treatment effects? initial /k/ and /g/ improved 80%. During the
o Yes final session, final consonant deletion was
o No produced 60% of the time, stopping was 75%,
o Not addressed and fronting 80%

Precision of treatment effect? The results for the second child indicated that
o Yes the production of sounds during final consonant
o No deletion improved 50%, production of initial
fricatives improved 65%, and the correct
Outcomes for all clients who entered? production of the initial /k/ and /g/ improved

76
 o Yes 30%. During the final session, final consonant
o No deletion was produced 50% of the time,
stopping was 60%, and fronting was 30%

What was the clinical importance of the

results?
The results of the study are clinically important.
They demonstrated that this treatment works in
a clinical setting. The effectiveness of the
treatment in the study indicates that this is one
that would be effective in a clinic. This study is
a good example of EBP.

Were differences between groups clinically

meaningful? (if applicable)
Although this case study was performed with 2
individuals, their abilities before and after
treatment were quite significant. The study
proved to us that minimal contrast therapy can
be useful in a clinical setting.
CONCLUSIONS AND CLINICAL What did the study conclude? What are the
IMPLICATIONS: implications of these results for speech sound
Conclusions were appropriate given study disorders?
methods and results This study found the use of minimal contrast
o Yes treatment is an important approach one can use
o No when working with children who have
phonological disorders. This treatment is
Feasibility in community and practice? effective in reducing the frequency of
o Yes phonological processes. With the increase of
o No communication during this treatment, it is a
practical procedure to use when working with
Cost-benefit? the unintelligible speech of children. With the
o Yes use of minimal contrast therapy as a treatment,
o No it is safe to say that children would greatly
increase their speech intelligibility.
APPLICATION: How does the study apply to clinical services
Applies to clinical services to children with provided to children with speech sound
speech disorders?
sound disorders Phonological process treatments are ways in
o Yes which a clinician works with children to correct
o No their speech. The research presented indicated
a way in which clinicians can work with children
using the minimal contrast approach. The
study proved that the use of minimal contrast
works and can be used during clinical services.

How will you use the evidence?

I will use this evidence when I get a child on my
caseload who has difficult with phonological
processes. I have concrete evidence that this
approach works. Since the study has proven

77
that minimal contrasts work, I will definitely
keep it in mind if remediation in phonological
processes is needed.

78
CRITICAL REVIEW 14
Citation: Crosbie, S. Holm, A., & Dodd, B. (2005). Intervention for children with severe speech disorder:
A comparison of two approaches. International Journal of Language & Communication Disorders,
40(4), 467-491.

STUDY PURPOSE: Key purpose of the study. How does the study apply to Speech
Was the purpose stated sound treatment and/or your treatment group focus?
clearly? “Evaluate/investigate   the   relative   effects   of   two different types of
o Yes therapy/treatment approaches on the consistency of word production and
o No speech  accuracy  of  children  with  consistent  or  inconsistent  speech  disorder.”
DESIGN: Level II
o Randomized Blinding of clients, clinicians, data analyzers?
(RCT) Yes No
o Cohort Brief Description of study design.
o Single case  Intervention program comparing phonological contrast and core
design vocabulary therapy.
o Before and  All the increased consonant accuracy during intervention
after o Core vocabulary therapy resulted in greater change in children
o Case-control with inconsistent speech disorder
o Cross-sectional o Phonological contrast therapy resulted in greater change in
o Case study children with consistent speech disorder
 Resulted in suppression of error patterns, not just
remediation of targeted lexical items
 Resulted in wider changes
 Gave specific feedback regarding one aspect of this
planning: the consonant–vowel structure of words.
 Baseline Data – pg. 12
o “The  initial  speech  assessment  was  repeated with a 3- week
interval. A paired samples t-test compared the measures and
revealed no significant change (t50.11, d.f. 17, p50.92). The
Pearson correlation coefficient, r50.82 (p,0.001), confirms the
high inter agreement between the two measures. The children’s  
phonological systems were considered to be stable before
intervention.”
SAMPLE: N = 18 Sampling (who; how selected; inclusion/exclusion
Clearly described, criteria) If more than one group, what difference existed?
recognizable clients? Describe ethics procedures. Was informed consent obtained?
o Yes  Children were allocated to one of the two therapies by order of referral.
o No o Treatment 1 – after the baseline period followed by a 4-week
Was the sample size withdrawal period, followed by treatment 2.
justified? 1. Phonological contrast therapy (targeting error patterns):
o Yes  Error pattern:
o No o Identified from phonological assessment
data
o Selected for intervention according to the
following criteria:
 Targeting non-developmental
patterns before developmental
 Consistency and frequency of the
use of the error pattern
 Effect on intelligibility of
successful remediation
 Stimulability of the speech
sounds required
o Targeted structural error patterns:

79
  Final Consonant deletion,
Cluster Reduction, etc.
o 4 Stages:
 Auditory Discrimination
 Production in single words
 Production in phrases
 Production in sentences within
conversation
2. Minimal Pair (multiple opposition)
 Pairs of words targeted a range of sounds affected
by error pattern
OUTCOMES: Specify the frequency of performance and/or outcome
Were the measures measurement (i.e. pre, post, follow-up)
reliable? Performance/Outcomes Areas/Instruments
o Yes List specific measures used
o No  Pre/Post Testing:
o Not addressed o A multiple baseline design with alternating treatments was used.
Were the measures o Observations & Standardized Testing
valid?  Each child participated in 16 (30-minute) individual therapy sessions in
o Yes each 8–9-week treatment block.
o No  All received two 8-week blocks of intervention
o Not Addressed

Control over nuisance variables?

o Yes
o No
o Not addressed
RESULTS: What were the results? Were they statistically significant (i.e.,
Statistically significant p<0.05)?
differences? What was the clinical importance of the results?
o Yes Were differences between groups clinically meaningful? (if
o No applicable)
o Not addressed  Evidence – treatment targeting speech processing deficit underlying
the  child’s  speech  disorder  will  result  in  generalization
Practical significance: size  All of the children increased their consonant accuracy during
and importance of intervention. Core vocabulary therapy resulted in greater change in
treatment effects? children with inconsistent speech disorder and phonological contrast
o Yes therapy resulted in greater change in children with consistent speech
o No disorder.
o Not addressed

Precision of treatment
effect?
o Yes
o No

Outcomes for all clients

who entered?
o Yes
o No

80
CONCLUSIONS AND CLINICAL What did the study conclude? What are the
IMPLICATIONS: implications of these results for speech sound
Conclusions were appropriate given disorders?
study methods  The results provide evidence that treatment targeting
and results the speech processing deficit underlying  a  child’s  
o Yes speech disorder will result in efficient system-wide
o No change. Differential response to intervention across
subgroups provides evidence supporting theoretical
Feasibility in community and practice? perspectives regarding the nature of speech disorders:
o Yes it reinforces the concept of different underlying
o No deficits resulting in different types of speech disorder
 Different parts of speech-processing chain respond
Cost-benefit? differently to therapy targeting different processing
o Yes skills
o No  A cognitive–linguistic deficit responds best to a
phonological contrast approach.
APPLICATION: How does the study apply to clinical services
Applies to clinical services to children provided to children with speech sound disorders?
with speech How will you use the evidence?
sound disorders  This study focused on the use of phonological target
o Yes treatment in comparison to core vocabulary. The
o No findings for phonological treatments were relevant to
our  study  however  core  vocabulary  wasn’t  need.    This  
article is used as more of a reference point.

81
CRITICAL REVIEW 15
Citation: Hassink, J. M. & Wendt, O. (2010). Remediation of phonological disorders in
preschool age children: Evidence for the cycles approach. EBP Briefs 5(2), 1-7
STUDY PURPOSE Key purpose of the study. How does the study apply to Speech sound
Was the purpose stated treatment and/or your treatment group focus?
clearly? To analyze and appraise the available literature on the cycles approach
o Yes and to answer the following questions:
o No Does the cycles approach effectively reduce the frequency of
occurrence of phonological processes?
Does the cycles approach efficiently remediate phonological
disorders?

DESIGN Level _______

o Randomized Blinding of clients, clinicians, data analyzers? _______
(RCT) Yes ____ No _____
o Cohort Brief description of study design.
o Single case design Level of Evidence
o Before and after Level II
o Case-control Comparative study
o Cross-sectional Development of diagnostic criteria on consecutive
o Case study patients
Design
Six prior studies accessed for this study

SAMPLE N=______ Sampling (who; how selected; inclusion/exclusion criteria)

Clearly described, If more than one group, what differences existed? Describe ethics
recognizable clients? procedures. Was informed consent obtained?
o Yes Number of Participants– Total n for all 6 studies = 90
o No Age range– 2:9 to 5:7
All exhibited moderate to profound phonological disorders
Was the sample size
justified?
o Yes
o No
OUTCOMES Specify the frequency of performance and/or outcome measurement
Were the measures (i.e. pre, post, follow-up). Performance/Outcomes. Areas/Instruments.
reliable? List specific measures used
o Yes
o No Pre/ Post test scores
o Not addressed Percentage Consonant Correct Measure
Mean Length Utterance
Were the measures valid? Effect Size Measure
o Yes
o No *Numbers seen in table contained in link below:
o Not addressed http://www.speechandlanguage.com/ebp/pdfs/EBP_V5_Article2.pdf
Control over nuisance variables?
Yes
No
Not addressed
RESULTS What were the results? Were they statistically significant (i.e., p<0.05)?
Statistically significant What was the clinical importance of the results? Were differences
differences? between groups clinically meaningful? (if applicable)
o Yes
o No Statistical Significance was not addressed, however, effect size was.
o Not addressed Numbers are included in the link above.

82
Practical significance: size Treated children demonstrated improved consonant production
and importance of in conversational contexts
treatment effects? Treated children with less severe phonological and language
o Yes impairments improved both domains
o No Earlier intervention resulted in great outcome of improvement
o Not addressed

Precision of treatment
effect?
o Yes
o No

Outcomes for all clients

who entered?
o Yes
o No
CONCLUSIONS AND What did the study conclude? What are the implications of these results
CLINICAL for speech sound disorders?
IMPLICATIONS The best evidence available suggests that this approach is effective with
Conclusions were children who exhibit severe phonological disorders both in isolation and
appropriate given study in combination with other language disorders.
methods and results Clinicians must be aware of individual study limitations and refer to
o Yes their own clinical expertise as well as client preferences when
o No considering implementation of the cycles approach
Feasibility in community
and practice?
o Yes
o No
Cost-benefit?
o Yes
o No
APPLICATION How does the study apply to clinical services provided to children with
Applies to clinical services speech sound disorders? How will you use the evidence?
to children with speech
sound disorders The research indicated that the participants in the treatment across the six
o Yes studies showed improvements after cycles approach intervention. Results
o No must be implemented with caution regarding the inflation of effect sizes.
The higher effect sizes could be a result of the small sample populations
within the individual studies. Additionally the results must recognize the
lack of randomization when considering implementation of the cycles
approach into practice.

83
 References

Association, A. S.-L.-H. (2007-2011). Speech sound disorders: Articulation and phonological

processes. Retrieved August 2011, from American Speech-Language-Hearing
Association: http://www.asha.org/public/speech/disorders/SSDcauses.htm

Barlow, J. A., Gierut, J. A. (2002). Minimal pair approaches to phonological remediation.

Seminars in Speech and Language, 23, 57-67.

Bernthal, J. E., Bankson, N. W., & Flipsen, P. (2009). Articulation and phonological disorders
(Sixth ed.). Boston, MA: Pearson Education, Inc.

Blanche, S. E., Parsons, C. L., & Humphreys, J. M. (1981). A minimal-word-pair model for
Teaching the linguistic significance of distinctive feature properties. Journal of Speech
and Hearing Disorders, 291-296.

Crosbie, S. Holm, A., & Dodd, B. (2005). Intervention for children with severe speech disorder:
A comparison of two approaches. International Journal of Language & Communication
Disorders, 40(4), 467-491.

Edwards, M. Saxman, J. Tyler, A. (1987). Clinical application of two phonologically based

treatment procedures. Journal of Speech and Hearing Disorders, 52, 393-409.

Gierut, J. A. (1998). Treatment efficacy: Functional phonological disorders in

children. Journal of Speech, Language, and Hearing Research, 41, S85-S100.

Gierut, J .A. (1989). Maximal opposition approach to phonological treatment. Journal of Speech
and Hearing Disorders, 54, 9-19.

Griffiths, R. Stokes, S. (2010). The use of facilitative vowel contexts in the treatment of post-
alveolar fronting: A case study. International Journal of Language and
Communication Disorders, 45(3), 368-380.

Hassink, J. M. & Wendt, O. (2010). Remediation of phonological disorders in preschool age

children: evidence for the cycles approach. EBP Briefs 5(2), 1-7

Hodson, B. W., & Paden, E. P. (1991) Targeting intelligible speech: A phonological approach to
remediation (2nd ed). Austin, TX: Pro-Ed, 1991.

Hodson, B. (1989). Phonological remediation: A cycles approach. Assessment and remediation

of articulatory and phonological disorders. Columbus OH: Merrill.

Hodson, B. (1989). Phonological remediation: A cycles approach. Assessment and remediation

of articulatory and phonological disorders. Columbus OH: Merrill.

Ingram, J. C. (1988). The state of the art in phonology. In S. E. Gerber & G. T. Mencher (Eds.),
International perspectives on communication disorders (pp. 127-137). Washington, DC:
Gallaudet University Press.

Klein, E. S. (1996). Phonological/traditional approaches to articulation therapy: A retrospective

group comparison. Language, Speech, and Hearing Services in Schools, 27, 314-323.

84
Lowe, R. J. (2010). Workbook for the identification of phonological processes and distinctive
features (4th ed.). Austin, TX: PRO-ED, Inc.

Martin, M., Rafaat, S., Rvachew, S. (1999). Stimulability, speech perception skills, and
the treatment of phonological disorders. American Journal of Speech-Language
Pathology, 8, 33-43.

Monahan, D. (1986). Remediation of common phonological processes: Four case studies.

Language, Speech, and Hearing Services in Schools, 17, 199-206.

Owens, R. (2008). Language development: An introduction (7th ed). Boston: Pearson

Education Inc. (Original work published 1996)

Owens, R. E., Metz, D. E., & Haas, A. (2007). Introduction to communication

disorders: A lifespan approach (3rd ed., pp. 302-307). Boston: Pearson Education Inc.
(Original work published 2000)

Roth, F. P., & Worthington, C. K. (2010). Treatment Resource Manual for Speech Language
Pathology. Cengage Learning.

Weiner, F. (1981). Treatment of phonological disability using the method of meaningful minimal
contrast: Two case studies. Journal of Speech and Hearing Disorders, 46, 97-103.

Williams, A.L. (1991) Generalization patterns associated with training least phonological
knowledge. Journal of Speech and Hearing Research, 34, 722-733.

Young, E. (1987). The effects of treatment on consonant cluster and weak syllable reduction
processes in misarticulating children. Language, Speech, and Hearing Services in
Schools, 18, 23-33.

85