A. Lynn Williams, Ph.D., CCC-SLPCollege of Clinical and Rehabilitative Health SciencesEast Tennessee State University

Clinical Management of Speech Sound Disorders in Children

Sound Evidence:

Disclosure statements• Financial disclosure

– Employed at East Tennessee State University– Receive royalties from Brookes Publishing

(Interventions for Speech Sound Disorders in Children)

– Receive royalties from EBS (SCIP app)– Travel funded by UNI

• Non-Financial disclosure

The Goal of Today’s WorkshopMake it ACAP!• Assessment

– Learn about 2 different analyses Morning

• Target Selection – Learn about 3 different approaches to target selection

• Intervention Approaches – Learn about 8 Different Interventions (match tx to dx)– Intervention Resources Afternoon– Case Examples

• Reflection

Did you know …• Nearly 1 in 12 children 3-17 years old

have a communication disorder?– Speech sound disorders (SSD) are the

most prevalent communicative disorder– Highest among children 3-6 years– This means there are 2-3 students in every

classroom who have a communication disorder

NIH (2012)

Did you know …• Preschool children with SSD do not perform as

well as their peers in literacy and learning during the early school years?– This continues until at least 9 years of age– Negatively impacts various aspects of children’s lives,

such as their verbal communication skills, interpersonal interactions, ability to handle stress, and participation in daily life activities with long term consequences on their educational experiences and employment outcomes

• So SSD are not confined solely to speech or to early childhood!

McCormack, McLeod, Harrison & McAllister, 2010

Did you know …• There is a critical age hypothesis for

remediating unintelligible speech?– Unintelligible speech must be resolved by age 5;6 in

order to significantly reduce academic problems associated with speech disorders

– Given that many children do not come to SLP for treatment until age 4, there is a significant need for efficient and effective therapies to remediate the speech disorder within a short time period (e.g., 18 months!)

Bishop & Adams, 1990

DIVERSITY AND DEFINITION OF SSD

What is the population of children with SSD?

Defining Speech Sound Disorders• Speech Sound Disorders (SSD) in children is a

complex neurodevelopmental disorder that is quite diverse and ranges in both severity and type of disorder (Shriberg, 2010). – SSD include articulatory, phonological, and motor speech

disorders and have been identified as one of the most prevalent types of communication impairment among children.

– Further, SSD can co-occur with other impairments of communication, such as language impairment, literacy difficulties, or fluency.

Distinction between articulation and phonology

Articulation PhonologyOrigin Errors only involve production Errors involve production + language

(linguistics)Problems are peripheral Problems are peripheral + central

Acquisition Children learn speech sounds Children learn a phonology (sound system of a language)

Symptoms DistortionsVariabilityImprecise productionsNo loss of contrasts

SubstitutionsOmissionsCollapse of contrasts

Assessment Focus on sounds Focus on phonemes Assess SODA (substitutions, omissions, distortions, additions)

Assess phonological rules

Intervention Goal is to improve speech production accuracy

Goal is to increase accuracy + “facilitate cognitive reorganization of the system and strategies” (Fey, 1992)

Focus on:PlacementsCueingPractice

Focus on:ContrastsProblem-solvingPerceptual contrastsMultiple sound errors

Williams (in press)

Interaction of Phonetic and Phonemic Factors

SSD: A Spectrum Approach

Articulation(Phonetic) Phonological

(Phonemic)

Ingram, Williams, & Scherer (2018)

Question 1

• SSD are:a. Phonologicalb. Articulatoryc. Both

Classification of SSDLinguistic Profile Characteristics Prevalence

Phonological Delay Phonological rules or processes are evident andare characteristic of younger TD children

47%

Consistent DeviantPhonological Disorder

Presence of both unusual errors and typical errors, which signal the child has impaired understanding of the ambient phonological system

30%

Inconsistent Deviant Phonological Disorder

Exhibit delayed and non-developmental error types and variability of production of single word tokens (> 40%)

12%

Articulation Disorder Unable to produce particular perceptually acceptable phones

11%

Childhood Apraxia of Speech (CAS)

Deviant surface speech production patterns that may sound similar to Incon Dev Phono Dis, but difference is the proposed level of breakdown and symptomatology

<1%

Time: Traditional Approaches vs Phonological Approaches

Assessment and Analysis: Review

Characteristics of a Phonological Disability

• Child’s system is smallerthan the adult system

• One-to-manycorrespondencebetweenchild:adult systems

One To Many Correspondence

sʃkʧ

t

Characteristics of a Phonological Disability

• Child’s system is smaller than the adult system

• One-to-many correspondencebetween child:adult systems

• Relationshipbetween thephonetic propertiesof adult target and child’s production

Phonetic Resemblance between Targets and Child’s Production

sʃkʧ

tvoiceless

1:4 phoneme collapse

s ʃkʧ

Phonetic Resemblance Between Targets and Child’s Production

t

fricatives

stopaffricate

voiceless obstruents

Question 2

• Which one does not fit in describing phonological impairments?a. Logicalb. Randomc. Amazing

GFTA-2Data Set(Adam, 4;6)

Adam’s GFTA

p/bl

Question 3

• What is the predominant error pattern in Adam’s speech?

a. Backing + Stopping + Cluster Reductionb. Cluster Reduction and Stoppingc. Glottal Replacement and Gliding

Question 4

• A PVM Analysis would be appropriate to complete on:

a. Child with several common errorsb. Child with distortionsc. Child with multiple and uncommon errors

Phoneme Collapse

s fricativesʃk stopʧ affricate

voiceless obstruents

t

SPACS: WI Phoneme Collapse

SPACS: WF Phoneme Collapse

Adam (4;6)

Question 5

• What is the organizing principles for the [g] and [w] WI phoneme collapses?a. Fricativesb. Mannerc. Front

What is the organizing principle?

• Manner (+ sonorant)

Mirror Rules

SONORANT

Obstruent[-sonorant]

Sonorant[+sonorant]

Obstruents and stop clusters [g] Sonorants and continuant clusters [w]

Adam: Comparison of PVM to SPACS

1. 1:18 phoneme collapse of obstruents and stop clusters to [g]2. 1:7 phoneme collapse of sonorants and continuant clusters to

[w]

Systemic ApproachIndependent + Relational Analysis

Phonological Processes ApproachRelational “Error” Analysis

2 complementary phoneme collapses•1:18 phoneme collapse of obstruents and stop clusters to [g]•1:7 phoneme collapse of sonorants and continuant clusters to [w]

7 unrelated phonological processes•Backing•Stopping•Voicing•Deaffrication•Cluster reduction•gliding•Idiosyncratic g/b; w/j

• Holistic • Fragmented • Systemic • Sound-based• Descriptive analysis • Error analysis• Child-based • Adult-based• Explanatory + Descriptive • Descriptive only

Question 6

• A SPACS analysis would be appropriate to complete on all the following EXCEPT:a. Child with several common errorsb. Child with distortionsc. Child with multiple and uncommon errorsd. OGK

Time: Traditional Approaches vs Phonological Approaches

TargetSelection

Goals are the driving force

behind intervention.

2Selecting Targets for Intervention• Target selection is the between

assessment and intervention• Is an important variable in treatment efficacy• The therapy goal, rather than the exact

treatment approach employed in the therapy session, may be the instrument of change (Gierut, 2005; Kamhi, 2006)(Gierut 2005; Kamhi 2006)(Gierut, 2005; Kamhi, 2006))))))))))

link

Traditional vs PhonologicalApproaches to Target Selection

Traditional Phonological• Based on nn phonemicBased onn honemph

(superordinate)micnem

)) factors– phonological complexity– distance metric (will

discuss as third option)• Assumptions

– learnability is enhanced with the greatest amount of change occurring in the least amount of time

• Based on n phonetic Based onn honph(subordinate)

netic hon)) factors

– developmental norms– stimulability– consistency of error

•y

Assumptions– motoric basis of sound

learning– ease of acquisition– sequential order of

acquisition

A Third Optionfor Target Selection

• The distance metric represents a different perspective to target selection that doesn’t rely on the dichotomous characterization of targets as early ~ late; stimulable ~ non-stimulable; known ~ unknown, etc.

A Third Optionfor Target Selection

• Rather, it is based on the function a particular sound has within a given child’s system– Using phoneme collapses that represent

compensatory strategies developed by the child to accommodate a limited phonetic inventory, we can use a distance metric to select those targets that will result in the greatest amount of change in the least amount of time

Distance MetricWilliams (2003, 2005)

• Select up to 4 different target sounds from one rule set based on two parameters:– Maximal Distinction:

select targets that are maximally different from child’s error in termsof PVM

– Maximal Classification:select targets from each of the following:

(a) different manner classes (b) different places of production (c) different voicing(d) different linguistic units

Target Selection Using Distance Metric

dkʧfsʃstsktrkrkl

1:11 phoneme collapse

d

Maximal Distinction

clusters

fricatives

affricate

stopsMaxi

malClass

ifi

cation

t

Practice Selecting Treatment Targetsw glidel liquidf

h s fricativesʃsw clusterssl

Question 7

• What targets did you select?

a. A glide, a liquid, a fricative and a clusterb. A glide OR a liquid, a fricative, and a

clusterc. A glide, a liquid, a fricative, NO cluster

Practice Selecting Treatment Targetsb d stopsg

Ø ð v fricativeszʤ affricate

Question 8

• Which targets did you select?

a. b, v, ʤb. d, z, ʤc. g, ð, ʤ

With the distance metric,targets are the salient

“corner puzzle pieces”that help the child

put together the big pictureof the adult sound system

Target Selection:The BIG Picture