MSHA Annual Conference

Winnipeg, Canada
April 26, 2012

An Evidence-Based
Speech Sound
Disorders Update

Presented by

Gregory L. Lof, Ph.D. CCC-SLP

Chair/Professor
Department of Communication Sciences and Disorders

Boston, MA

glof@mghihp.edu
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www.mghihp.edu

Introduction
o
o
o

Among the most prevalent communication disability in preschoolers and school age children; affects
approximately 10% of this population.
For 80% of these children, the disorder is sufficiently severe to require treatment.
Prevalence of speech delay in 6-year old children and co morbidity with language impairment
(Shriberg, Tomblin, & McSweeny, 1999)
Speech delay was approximately 1.5 times more prevalent in boys (4.5%) than girls (3.1%)
Cross-tabulations by sex, residential strata, and racial/cultural backgrounds yielded More than half
of the children diagnosed with speech sound problems will have later academic difficulties in
language, reading, and spelling.
Prevalence of speech delay in 4 to 5 -year old children from Australia (McLeod & Harrison, 2009)
4,983 children in Australia, data obtained in 2 ways (Questionnaires from parents and from teachers)
25.2% of parents indicated they had concerns about how their child talks and makes speech
sounds; 22.3% of teachers reported similar levels of concern

School SLPs Work with Speech-Sound Disorders

Percentage of Students
K3
4-6
7-12
Speech-sound production
58.5
51.7
22.4
Intelligibility
19.8
5.7
9.0
Spoken Language Production
37.7
40.6
37.3
Spoken Language Comp.
28.2
34.7
52.2
Fluency
5.3
7.2
13.4
Pragmatics
3.0
3.6
1.5
Voice
<1.0
1.2
1.5
Mullen, R., & Schooling, T. (2010). The national outcomes measurement system of pediatric
speech-language pathology. Language, Speech and Hearing Services in the Schools, 41, 44-60.
Effects on Daily Life
o Long term consequences; Difficulty processing linguistic information; Fewer years of formal
education; Hold jobs as unskilled laborers; Difficulties in reading/writing; May have children with
speech sound problems
o Canadian 25 year follow up on children with and without speech-language impairments (Johnson,
Beitchman, & Brownlie, 2010): Different results from prior data, probably because other studies
combined speech/language problems. Co morbid language problems is a key predictor of language
and academic problems in children with speech sound disorders.
Societal Attitudes
o Children with minor /w/ for /r/ substitution are considered to be: Less talkative; Dysfluent; Unpleasant
to listen to; Soft; Boring; Nervous; More tense; Afraid; Isolated; Uncomfortable; Less confident; Dull
(Silverman & Paulus, 1989)
o Social acceptance of an actor with a mild speech-sound impairment was less positive than the same
actor demonstrating a physical disability. (Anderson & Antonak, 1992)
o People with speech impairment were found to be less extroverted and socialized with fewer people
than people with typical speech productions. (Felsenfel et al., 1992)
o Ontario Association For Families of Children With Communication Disorders
http://www.oafccd.com/factshee/fact74.htm
nd
o Examined 2 grade teachers perception of the academic, social, and behavioral competence of
students with moderate speech sound disorders. Compared to children with no speech sound
disorders
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Will have social difficulty; Peers will make fun; Possible behavior problems; Shy because of
speech; Seems young; Hard to understand; School extremely hard; Reading affected; Spelling
delay; Writing a challenge; Felt sorry for child (Overby, M., Carrell, T., & Bernthal, J. ,2007).
Terms: A History Lesson of Terms
o 1920-1970: Articulation
o 1970-1980: Articulation/Phonology
o 1980- 2000: Phonology
o Current Term: Speech Sound Disorders
Genetic Bases of Speech Sound Disorders (Lewis, B., Shriberg, L. et al., 2006)
A Model of Input and Output (See chart toward back of handout)

DEVELOPMENTAL NORMS
Assumptions about Developmental Norms
o Universal order; Developmental prerequisites; Methodological issues in gathering norms
A Sequence of Development (Shriberg, 1993):
o Order of speech-sound acquisition divided into three categories
Order
Continuous Speech
Articulation Test
M b y n w d p h
M b n w d p h g
Early 8
T a k g f v . j
T a k f v . j y
Middle 8
C ; s z l r x
C ; s z l r
Late 8
Shriberg, L. (1993). Four new speech and prosody-voice mesures for genetics research and other stidies in
development phonological disorders. Journal of Speech and Hearing Research, 36, 105-140.

Norms for Treatment Eligibility

o Problem 1: Which set of norms can you believe?
o Problem 2: Holding children with disorders to a HIGHER standard.
Norms for Target Selection
o Issue 1: Universal Order
Is there a universal order? Data from other languages. Children with disorders follow normal?
o Issue 2 : Developmental Prerequisites
Is mastery of earlier developing sounds necessary before production of later developing sounds?
o Issue 3: Early vs. Late

PHONOLOGICAL PROCESSES
Phonological Processes: Historical Origins (Stampes Natural Phonology Theory)
o Assumptions; Full Perception Hypothesis; Underlying representation assumption
Suppression instead of development; Explanation vs. Description
Reasons NOT to Use Phonological Processes
o Philosophical reasons
o Clinical reasons
o Terminology reasons (processes vs. processing)
The ability to use phonological codes to encode, store and retrieve information.
Practice with a sound or syllable shape should not continue until 80%; some success should lead
to attempts at greater sound combinations in longer stings of utterances, require more complex
motor planning.
Look for the pattern
Do not write negative goals
Things to Look for to Help Identify Patterns Finding Non-Obvious Patterns
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o Phonetic Context; Word Position; Intra-class Variability; Syllable Structure; Morphological Ending;
Syllable Stress; Syllable Boundary; Situational Context

CAS: CHILDHOOD APRAXIA OF SPEECH

Also known as
Developmental Apraxia of Speech: DAS
Developmental Verbal Dyspraxia:
DVD
Developmental Verbal Apraxia:
DVA
Defining CAS (Ad Hoc Committee on Childhood Apraxia of Speech,2007)
Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder
in which the precision and consistency of movements underlying speech are impaired in the
absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). CAS may occur as a
result of known neurological impairment, in association with complex neurobehavioral disorders
of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core
impairment in planning and/or programming spatiotemporal parameters of movement sequences
results in errors in speech sound production and prosody.
Lets Dissect this Definition (Flipsen, 2008)
Childhood apraxia of speech (CAS) is a neurological disorder
o Like adult acquired apraxia of speech, CAS is considered to a motor speech disorder.
Childhood apraxia of speech (CAS) is a speech sound disorder
o CAS is a problem with the production of speech sounds
Childhood apraxia of speech...in which the precision and consistency of movements underlying
speech are impaired
o The movements of speech lack precision
o There is a problem hitting the exact targets
Childhood apraxia of speech (CAS) exists in the absence of neuromuscular deficits (e.g., abnormal
reflexes, abnormal tone).
o CAS is not dysarthria
o It is not about the nerve-to-muscle connection
o It is not spasticity or muscle weakness
o CAS and dysarthria may occasionally co-exist, but not frequently
CAS may occur as a result of known neurological impairment, in association with complex
neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech
sound disorder
o Where does CAS come from?
o Probably several ways for CAS to occur; there could be several ways for damage or some
problem to occur in the nervous system.
CAS may occur as a result of known neurological impairment, in association with complex
neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech
sound disorder
o It is possible that is can co-occur with autism, Fragile X, etc. (this what is meant by
complex neurobehavioral disorder)
o Idiopathic: means unique to the individual, or it can mean we just dont know and we
may never know.
The core impairment in planning and/or programming spatiotemporal parameters of movement
sequences
o Core impairment
o Like acquired apraxia, it is a problem of planning or programming of the movements of
speech
o Spatiotemporal parameters refers to the details, in time and space, for carrying out the
movements for speech.
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o Movement sequences: problem getting the order and timing of the movements right.
o Praxis: our mental ability to control and coordinate motor activity.
results in errors in speech sound production and prosody
o The core impairment leads to errors on speech sounds
o Also problems with prosody and the suprasegmental aspects of speech
o Prosodic problems, particularly problems with applying stress to syllables and words, may
be an important factor in CAS (more on this later)
The Bottom Line is
CAS is a neurological problem in children and the core impairment is difficulty with planning and
programming the movements for speech. In other words, it is a motor speech disorder. And like
other such disorders it can arise in several different ways.
A subtype of severe speech sound system disorder in children:
o Due to unidentified neurological differences with possible genetic bases.
o With abnormalities arising at the linguistic or early motor processing levels of production.
o Frequently characterized by vowel errors, prosodic disturbances, and/or inconsistency as well
as increased risk for persisting problems in language and literacy.
o Inconsistency of productions
o Problems with prosody (stress to syllables)
o Problems with transitions between syllables and sounds
o Limited phonetic inventory (vowels and consonants)
Model of Speech Output Processing (Flipsen, 2008)
Idea to Convey
o Using context, you decide you have something to say.
o Includes conversational partner, location, role in interaction, what was said before, etc.
Language Formation
o Figure out the way to express the idea
o Type of utterance (question, statement, etc.)
o Phrases that make up the utterance
o The particular words to use
o The syllable shapes
o The phonemes/allophones that make up the words
o The rate, stress, intonation
Speech Motor Planning and Programming
o Translate the language message into a series of instructions for muscle movements
o Arrangement of those instructions into a specific order relative to timeframes for each movement.
o Creating and assembling a motor plan
Speech Motor Execution
o The motor plan is sent to the oral musculature
o This plan is sent via the nerves and the instructions are carried out by the articulators
Output
o The articulators create an acoustic signal
Feedback
o As we speak, we receive tactile (touch) feedback when one articulator contacts another.
o We receive kinesthetic (motion) and proprioceptive (relative position in space) feedback
o We hear our own output as auditory feedback
Differential Diagnosis of CAS: Vowel Accuracy
o In-depth analysis requires attention to regional, social dialectal variation in vowels.
o Measures in which information about vowels is encouraged: HAPP-3; ALPHA-R
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o Complete list of American English monophthongs and diphthongs for SAE, see Walton &
Pollock, 1993
o Information on vowel development in typically developing children, see Pollock & Berni, 2003
Differential Diagnosis of CAS: Consistency of Errors
o Obtain 2 spontaneous (picture naming) and 2 imitated tokens of selected words (particularly
multisyllabic words) on a standard articulation test, consecutively.
o Children without CAS will usually improve across trials and with a model.
o Children with CAS are more likely to show degraded performance across trials.
o Examples of inconsistencies considered typical of CAS:
o kangaroo: /tqaqwu/,/tqaqku/, /tqnqwuk/
o elephant: /2nz2nt/,/2l1;8nk/,/2l3s8nk/
o dinosaur: /d0]n1s9/,/h2lq1s9/,/d0]n1s9/
o teeth: /tif/,/tis/,/tit/,/t2t/,tqf/
o umbrella: /1mb2;1/,/1nb2l1/,/1mbq;q/
Differential Diagnosis of CAS: Prosody
o Best observed in connected speech samples
o Formal measures are available, but time consuming
o Profiling Elements of Prosodic Systems, Children, American Version (Peppe & Wells,
forthcoming)
o Prosody Functions:
o Chunking: Using intonation and pauses to differentiate individual nouns from noun
phrases.
o Affect: Use of intonation to indicate like or dislike or neutral emotion
o Interaction: Use of intonation to indicate agreement or understanding vs. confusion
o Focus: Use of intonation for emphasis in a sentence
o Evaluate conversational speech
o Look for inappropriate use of stress on multisyllabic words
o Listen for inappropriate use of pitch and intonation
o Observe any inconsistent rate or loudness
o Any inconsistent nasality?
o Probably need at least 25-30 utterance to get a valid sample
o Problems with transitions
o DDK-focus on consistency and accuracy (not speed)
o May not have difficulty with same place of articulation (e.g., t4t4t4)
o More likely to have problems when place of articulation changes (e.g., p4t4p4)
o Problems with both may be a sign of dysarthria
o Problems with transitions
o Occurs on multisyllabic words, and/or as words get progressively longer.
hamhammerhammering
hopehopefulhopefully
handhandlehandily
widewidenwidening
o Probably only useful for children over 6 years
o Case History
o Any neurological events that might suggest neurological damageusually not there.
o Look for a family history of nay speech or language impairmentsmy not be there.
o Look for (past and current) problems with feeding, chewing, swallowing and/or drooling
(may suggest possible co-existing oral apraxia)
o Conversational speech for
o Overall intelligibility (% of words understood)
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o Syllable shape inventory (ignore accuracy; any consonant counts as C, and vowel counts as
V)
o Phonetic inventory (any sound that occurs counts regardless of whether it matches the
target)
Need for Accurate Diagnosis of CAS (Love, 1992, p. 98)
One significant value in correctly diagnosing a child with DAS is that the diagnosis often
radically changes the direction of the therapeutic management and opens the door to a variety of
techniques not usually employed with the typical child with developmental phonological
disability
Considerations for Target Selection
o Increasing phonetic inventory
o Establish new consonants, vowels, and/or word shapes
o Expand place, manner, or both
o Small steps
Sounds they have, use in more complex word shapes
Add a new word shape using sounds they have
o Decreasing errors
o Consonants, vowels and word shapes
o Improving suprasegmentals
Remediation Strategies Used with Children with CAS
o Motor Programming Approaches: Multisensory and Tactile Cueing; Touch cue, Sensory motor,
PROMPT, Cued speech
o Rhythmic and Prosodic Methods: MIT
o Articulation/Phonological Approaches
General Treatment Framework
o Use articulatory approach.
o Guide treatment based on entry-level skills.
o Choose highly functional words and phrases.
o Involve child and parents in decisions.
o Build complexityTake what they have and use it in a new way:
New sounds in familiar word shapes
New word shape with familiar sounds
o Focusing on speech product, increasing accuracy and use of articulators
Increase motor planning for speech by practicing speech
Hierarchical approach: simpler to more complex motor planning tasks
Greater emphasis on movement sequences and syllabic integrity than individual sounds
Remediation Strategies: Integral Stimulation (Gildersleeve-Neuman C. 2007)
o Some basic concepts:
o Requires knowledge of motor learning theory
o Speech is a serial motor task
o Must teach a speech routine
o Must target longer speech routines, rather tan mastery of simple repetitive movements
o Speech movement is unlike other motor tasks
o Speech is a cognitive motor task
o Must have a great deal of practice
o Must involve a variety of speech tasks in a variety of settings
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o
o
o

o Goal is to not perfect a particular series of movements, Rather, use of the movement is
transferred to running speech
Based on principles of cognitive motor learning
o Watch me, listen, do as I do
o Uses multimodal cues to teach
o Multi-step hierarchy
o Aids in determining levels of support
o Support is faded as success is achieved
4 Principles of Motor Learning
o Precursors to Motor Learning (things to consider to optimize therapy)
Motivation, family support, attitude toward therapy
Developmental delay, attention deficit
Help child to focus, work on attention, show reasons why therapy is helpful,
provide early success
o Conditions of practice
Mass practice vs. distributed practice
Block format vs. random format
Blockbetter short-term performance and useful when first targeting a new goal
Random motor learning is better achieve with random because it requires more
motor planning and cognitive involvement
In-session performance or mastery of a specific movement is enhanced by mass and
block treatment
Learning is enhanced by distributed and random treatment
o Feedback
Clinicians must move from extrinsic feedback (clinician-provided) to intrinsic
(client self-awareness)
Extrinsic
Knowledge of performance results in greater learning
This helps with self-awareness and self-monitoring
o Effects of Rate
Slowing down is important
Slowing down provide additional time for the child to plan the motor program
Clinician needs to slow down to be a good model
This approach teaches how to make speech movements, rather than absolute success on individual
sounds or isolated syllables.
Clinician must constantly increase the complexity of the motor planning task so there is success at
lower levels with complexity added.
Practice with a sound or syllable shape should not continue until 80%; some success should lead
to attempts at greater sound combinations in longer stings of utterances, require more complex
motor planning.

Excellent Article on CAS: Gillon, G., & Moriarty, B. (2007). Childhood apraxia of speech: Children
at risk for persistent reading and spelling disorder. Seminars in Speech and Language, 28(1), 48-57.
o Intervention of Children with CAS: Treatment usually emphasizes motor learning using drill, focusing
on automating speech motor plans for words, syllables, or phonemes.
o While helpful for speech, these treatments may not facilitate underlying phonological skills necessary
for reading/spelling.
o Phonological awareness also needs to be part of the intervention
CAS is RARE
o 5% of the preschool children have phonological disorders of unknown origin. Estimates suggest that
DVD has a prevalence rate of 1 to 2% of 1,000 live births, which places it in the category of a low
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incidence disorder. When compared to children with uncomplicated phonological speech delay, the
frequency of DVD in the population is quite small.
o The average clinician should have 1-2 cases of CAS for every 100 children with speech sound
disorders on their caseload
o There is probably an 80% false positive diagnosis of CAS. This means that approximately 80% of
the children labeled as apraxic are actually misclassified!!
Important Resources
o ASHA Ad Hoc Committee on Childhood Apraxia of Speech: Position Statement and Technical
Report from American Speech-Language-Hearing Association www.asha.org/docs/html/PS200700277.html
o Hall, P.K (2000). Clinical exchange: Letters to the parent(s) of a child with developmental apraxia of
speech. Language, Speech, & Hearing Services in the Schools, 31, 169-181.
o Flipsen, P. (2008). Understanding childhood apraxia of speech for SLPs. Available at: SLPinfo.org
o Caspari, S (2007). Working guidelines for the assessment and treatment of childhood apraxia of
speech: A review of ASHAs 2007 position statement and technical report. Available at:
www.speechpathlogy.com

NONSPEECH ORAL MOTOR EXERCISES

See supplemental handout toward the end of this document

SOME THOUGHTS ON ASSESSMENT OF SPEECH-SOUNDS

Procedures that should be accomplished
o Articulation test (52% of SLPs use Goldman-Fristoe Test of Articulation)
o Continuous speech analysis (citing vs. talking; Morrison & Shriberg, 1992)
o Hearing screening
o Stimulability assessment
Stimulable for a sound
Stimulability as a Dynamic Assessment
Teaching Stimulability: Enhancing stimulability to increase the phonetic inventory (Miccio &
Elbert, 1996; Miccio, 2005), using a multi-sensory approach: Concept, Movement, Icon
Use with young children with a very limited phonetic inventory.
Pair consonant sounds with alliterative characters and motions.
http://www.speech-language-therapy.com/awm.pdf
Seven Components of Treatment to Enhance Stimulability
1. Determine Stimulability
2. Directly Target Nonstimulable Sounds
3. Make Targets the Focus of Joint Attention (more likely to produce a sound when they are
attending to and interested in its corresponding referent. Speech sounds may be easier to
learn when they are associated with interesting objects that have been verbally labeled for
them.)
4. Associate Speech Sounds with Hand/Body Motions (multi-modal input increases
childrens ability to retain newly learned speech sounds. Hand motions serve as retrieval
cues for remembering).
5. Associate Speech Sounds with Alliterative Characters of Interest to the Child. (interesting
characters increase interest in the activity and encourage full participation. Enhances the
opportunity for a child to develop conscious awareness of the newly learned sound
segments. For example:
P Putt-putt pig
b Baby bear
t Talkie turkey
d Dirty dog
k Coughing cow
g Goofy goat
f Fussy fish
v Viney violet
Thinking thumb
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o
o

o
o

s Silly snake
z Zippy zebra
c Shy sheepy
6. Encourage Vocal Practice (do not use drill; instead, encourage vocal practice by including
sound elicitation activities that involve turn-taking and requesting).
7. Ensure Early Success (teach stimulable and nonstimulable sounds concurrently so they can
have success but also receive remediation for nonstimulable sounds).
Summary of Stimulability
Production of a sound during stimulability testing attests to the childs ability to perceive, to
recognize as different, and to produce the sound in question.
If the child is not stimulable for a sound, then one might question the childs: Motoric abilities,
Perceptual abilities, Linguistic abilities, Attention (focus), Non-compliance.
If a child is stimulable for a sound, then that sound is likely to be added to the childs phonetic
inventory, even without direct treatment on that sound.
If a child is NOT stimulable for a sound, then the likelihood of short term gains is poor;
normalization without therapy is much poorer than normalization for sounds that the child is
stimulable for.
Training on stimulable sounds is likely to improve regardless of what is taught.
Sounds that are NOT stimulable are unlikely to change without direct treatment.
In therapy, we need to encourage exploratory sound productions and provide phonetic
placement or other types of cues to effect stimulability skills.
Once stimulability has been achieved, generalization is more likely to occur.
To avoid frustration in training nonstimulable sounds, use less directive sound play activities
(e.g., those suggested by Miccio & Elbert, 1996) to provide a nurturing and supportive therapy
environment.
Perception/discrimination assessment
Is it still relevant? What assessment tools should be used?
Locke (1980) Speech Production/Perception Test (SPPT)
Oral-peripheral screening
o Is it still relevant? Why? Why not? (Lof, 2002)
Case historySome potential question to ask parents:
Describe your childs current speech performance; How often can your childs speech be understood
by parents, siblings, playmates, other relatives, strangers? How often does your child try to selfcorrect the speech errors? How willing is your child to repeat words after you, to try to say them
correctly? How is your childs speech in imitation compared to when s/he says the words by
him/herself? How would you describe your childs willingness to repeat his/her idea if it is not
understood? How would you describe your childs willingness to talk? What is your estimation of
severity of your childs speech problem? Did your child ever have ear infections or uninfected fluid in
the ears? Would you consider your childs physical development as typical? Please comment.
PCC: Percent of Consonants Correct
An objective severity metric; The examiner makes correct/incorrect judgments of individuals
sounds produced.
Number of Correct Consonants
PCC =
X 100
Number of Correct + Incorrect Consonants
Measuring Severity using PCC imitative sentences:
Intelligibility:
How good are we at understanding what is said? Caregiver glosses more accurate?
Rich interpretation?
Intelligibility Estimations (Ertmer, 2011)
o Ertmer, D.J (2011). Assessing speech intelligibility in children with hearing loss: Toward
revitalizing a valuable clinical tool. Language, Speech and Hearing Services in the Schools,
42, 52-58.
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o Speech assessments that rely mainly on clinician impressions and word-based articulation
tests appear to be inadequate for monitoring the development of intelligible connected
speech.
o Recent research has shown that word-based articulation tests are not dependable estimates
of connected speech intelligibility.
o Words from the G-F Articulation Test had higher percentage of words identified than words in
short sentences (86.7% vs. 54.5%).
o Children may correctly articulation a variety of consonants and vowels in single words but
still not have readily intelligible connected speech.
o Intelligibility Assessment
Scaling Procedures
Asking listeners to rate intelligibility along a continuum, usually 10-point equal
appearing interval scale
Use descriptors: not at all, seldom, sometimes most of the time, always
Quick and relatively easy to complete
Scaling ProceduresDisadvantages
Listeners have different internal criteria (pretty good for one may be not very good to
another)
Numerical numbers do not have clear meaning
Scaling is insensitive to the middle range of intelligibility (ratings may not well
distinguish between 30% and 60% intelligibility)
Scaling ProceduresModification
Use clear descriptors instead of numbers
No words were understood; a few words were understood; approximately half of the
words were understood; most of the words were understood; almost all of the words
were understood.
Item Identification Procedures
Open set where listener writes down the words understood
Audio recordings of unfamiliar sentences, listeners write words understood, place an X
for words not understood
Scored as a percentage of the number of times there was a match
Ertmer (2011) has a list of speech intelligibility sentences: One for preschool and early
elementary school children; One for students who can read
Preschool and early elementary (4 lists, 10 sentences each)
The baby falls
Mommy walks
The duck swims
The boy sits
Grandma sleeps
That is a little bed
The boy walked to the table
My car is blue
He is brushing his teeth
She is taking a bath
Presentation:
1. Clinicians says each sentence while using objects to act it out
2. Children watch and then imitate the sentence
3. Presented 2x for listener to write down all words
4. Percentage of words correctly written
For children who can read
This house is white.
My dog is mean.
Can he make any?
Did you find some?
You got a nice haircut.
Can he stop them?
We made a nice birdhouse.
Did she bring it?
My grandmother is beautiful.
That elephant was dangerous.
Presentation:
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1. Clinicians shows the card and says the sentence

2. Card is turned over and child is asked to say the sentences
3. Presented 2x for listener to write down all words
4. Percentage of words correctly written
o Phonetic/Phonemic Inventory (see forms toward back of handout)

Phonemic Inventory: A listing of the speech sounds produced in comparison to the target sound.
This is a Relational Analysis

Phonetic Inventory: A listing of speech sounds that are produced regardless of the target. This is
an Independent Analysis
o Cluster Analysis (see forms toward back of handout)
o Procedures that are always used in assessment (Skahan, Watson, & Lof, 2007)
76% Case History
51% Phonological Processes
75% Intelligibility
36% Connected Speech Sample
74% Single Word Test
36% Phonological Inventory
71% Hearing Screening
31% Classroom Observation
68% Stimulability
13% Perception/Discrimination
61% Parent Interview
13% Phonological Awareness
58% Oral Motor-Non Speech
11% Contextual Testing
54% Oral Motor-Speech
11% Syllable/Word Shapes
Some questions to ask
o How are word/syllable structures affected by error patterns?
Frequency of different syllable structures; Match between target & structure productions;
Determine affected syllable structures
o Which sound classes are proportionally more affected by error patterns?
Fricatives? Stops? Liquids? Etc.; Place/Manner/Voicing analysis is helpful
o Are there positional constraints?
Do the errors occur in all positions? Is it an inventory constraint or positional constraint?
o What sounds are present/absent in the phonetic inventory?
Use the phonetic inventory forms; Do you expand the inventory or do you make the inventory
more useful?
o What is the stimulability status of the sounds in error?
Do you select stimulable or nonstimulable sounds?
10 Factors to Consider for Selecting Targets (Adapted from Powell, 1991)
1. Age of Child/Age Appropriateness of Error(s): Use norms and other developmental information
2. Effect on Intelligibility--Error type: Deletions Substitutions all others
3. Effect on Intelligibility--Deviancy: Unusual, deviant, idiosyncratic
4. Frequency of Sound Occurrence (Shriberg & Kent, 2003)
1. n
7. ;
13. p
19. a
2. t
8. k
14. v
20.
3. s
9. m
15. f
21. j
4. r
10. w
16. h
22. c
5. l
11. z
17. g
23. .
6. d
12. b
18. y
24. x
5. Homonymy: The production of one phonetic form for several adult target forms (e.g., [bat] for
bad, bark, bent, bite; [bi] for beach, beat, beak, bike)
6. Markedness (a part of complexity models): The aspects that have more features are considered
marked and more complex. Working on the most marked aspects can be more effective in therapy
(e.g., fricatives are more marked than stops; affricates are more marked than fricatives; clusters are
more marked than singletons; voiced is more marked than voiceless).
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7. Morphological Status: Evaluate the tense markers and language structures that mark agreement.
Those complex final clusters should then be targeted (especially if client has speech AND
language problems):
Morphone
Example
Present Progressive ing
barking
Regular Plural -s
dogs
Possessive s
babys
Regular Past -ed
jumped
Regular Third Person -s
she eats
Contractable copula
Hes the baby
Contractable auxiliary
Shes going slow
8. Phonetic Inventory: Determine completeness of the phonetic inventory, the repertoire of speech
sounds produced independent of the adult model.
9. Relevance to Child: Select sounds/patterns important to the client.
10. Stimulability: Reasons to and not to select nonstimulable sounds.

SOME THOUGHTS ON TREATMENT OF SPEECH-SOUNDS

UNPROVEN Therapy Technique: Nonspeech Oral Motor Exercises (Lof & Watson, 2008, 2010;
Watson & Lof, 2008)
Minimal Pairs (a.k.a.: Minimal Opposition Contrast Therapy)
Use pairs of words that differ by one phoneme only; for example: bow/boat
Used to establish contrasts not present in the phonological system
Usually words are selected with one word as the target, the other the replacement
Child should be stimulable for correct sound
Have child say both words in the pair
Show a communicative confusion if both words are said the same
Maximal Pairs (a.k.a.: Maximal Oppositions Therapy)
Word pairs have multiple feature contrasts (maximal oppositions)
Features can differ on place, manner, and voicing
The oppositions contrasts only two sounds
A sound the child correctly produces is compared to a maximally different one
An example: chop/mop
o Suppose a child produces t/c
o Maximal Pairs: /t/ is contrasted with maximally opposed sound from /c/ (perhaps /m/); For
example: me/she; Mack/shack, my/shy
Follow the procedures for minimal pairs
Who is best to use Maximal Pairs?
o Best used for moderate/severe children
o Meant to change the childs entire phonological system because research shows it promotes
generalization
Multiple Oppositions
Much like minimal pairs, but pairs all or most errors simultaneously
Good approach if child substitutes a single sound for multiple sounds
Child confronts the rule from multiple contrasts
For example: /t/ for /s,k,.,tr/
Page 13

s
k
.
tr

tip

sip
kip
chip
trip

two

Sue
coo
chew
true

Metaphonological
A subcategory of metalinguistics.
Involves childs conscious awareness of sounds within the language.
Phonological awareness is the awareness of sound/phonological structure of spoken words in contrast
to written words.
Intervention to enhance early phoneme awareness and letter knowledge, combined with intervention
to improve speech intelligibility, may ensure that children with speech impairment approach literacy
instruction with age-appropriate phonological awareness development and will help with speech
sound productions.
This combined approach has shown to work for both speech sound training and for literacy
development.
Work on intelligibility, phoneme awareness, and letter-name/letter-sound knowledge.
o Phoneme blending (adult says: bal, child says ball).
o Phoneme segmentation (adult says: ball, child says bal).
o Phoneme manipulation: Say boat without the t; What word would you make if you put o
before pen?
Cycles Approach
First developed by Hodson & Paden (1983).
Patterns are trained successively (in cycles).
No predetermined level of mastery for movement to next cycle.
Several sounds in a pattern are worked on in each cycle.
Primarily used for highly unintelligible children (remediates intelligibility).
Modified Cycles Approach
o A cycle is 3 weeks; 1 pattern per week
o 2 training sounds per pattern
o Emphasis is eliciting numerous correct productions in 5-10 carefully selected words.
Language-Based Intervention
Many children with speech sound disorders also have difficulties with other aspects of language.
There is an intricate web of inter-dependencies between various aspects of language.
Some studies have shown that moderately severe children may improve in phonology and other
language domains with a combined phonological/language approach.
Children who are more severe may need focused attention directly on both domains.
Cycles approach to language and phonological therapy has been shown to be effective.
Work on language for one cycle, phonology for the next cycle.
Work on morphology can also help with phonology (plural, possessives, past tense, etc.)
Other Approaches:
PACT (Parents & Children Together); Psycholinguistic (using reading methods); Nonlinear
Phonology; Core Vocabulary
Principles of Phonological Therapy

Treatment is based on a thorough phonological assessment

Treatment is based on regularities in production pattern

Treatment is aimed at communicative reorganization

Page 14

Treatment tries to build up a system of contrasts

Treatment uses natural class of contrastive phones and structures

General Comments and Suggestions for Phonological Therapy

Remediating a pattern, not individual sounds (successive approximation; not trained to 90%)

Communication is the goal of training (successful communication is its own best reward;
misarticulation is miscommunication; internal rewards, not external rewards)

Use child-led interactive activities (play-like therapy; meaningful linguistic contexts

Phonological acquisition is gradual

Work on phonetic problems along with phonological ones

Carefully select words and sounds for therapy

Children generalize new skills to other targets

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Page 16

Evaluating Nonspeech Oral Motor

Exercises for Speech Sound Disorders
Gregory L. Lof, Ph.D., CCC-SLP
Department Chair/Professor
Department of Communication Sciences & Disorders
Boston, MA 02129-4557
glof@mghihp.edu
http://www.mghihp.edu

Introduction to the Controversy

Reported benefits (in rank order): Tongue
elevation; Awareness of articulators; Tongue
strength; Lip strength; Lateral tongue
movements; Jaw stabilization; Lip/tongue
protrusion; Drooling control; VP competence;
Sucking ability.
These exercises are used for children with
(in rank order): Dysarthria; Apraxia of speech
(CAS); Structural anomalies; Down syndrome;
Enrollment in early intervention; Late talker
diagnosis; Phonological impairment; Hearing
impairment; Functional misarticulations.

Nonspeech Oral Motor Exercises Defined

Any technique that does not require the child
to produce a speech sound but is used to
influence the development of speaking abilities
(Lof & Watson, 2008).
A collection of nonspeech methods and
procedures that claim to influence tongue, lip,
and jaw resting postures, increase strength,
improve muscle tone, facilitate range of
motion, and develop muscle control (Ruscello,
2008).
Oral-motor exercises (OMEs) are nonspeech
activities that involve sensory stimulation to or
actions of the lips, jaw, tongue, soft palate,
larynx, and respiratory muscles which are
intended to influence the physiologic underpinnings of the oropharyngeal mechanism and
thus improve its functions. They include active
muscle exercise, muscle stretching, passive
exercise, and sensory stimulation (McCauley,
Strand, Lof, et al., 2009).

Evidence-Based Practice
Defined: The conscientious, explicit, and
unbiased use of current best research results in
making decisions about the care of individual
clients (Sackett et al., 1996). Treatment
decisions should be administered in practice
only when there is a justified (evidence-based)
expectation of benefit.
Dollaghan (2004; 2007) reminds clinicians
that when using the EBP paradigm, valid and
reliable evidence needs to be given more
credence than intuition, anecdote and expert
authority. Evidence must come from works
that are independent and peer-reviewed.
Instead of Clinicians Experience, we
need practice-based evidence. That is, using
clinical data that have been reliably and
validly gathered using scientifically sound
methodologies (Lof, 2010).
See Muttiah, Georges, & Brackenbury
(2011) for more information about clinician
and researchers beliefs about NSOME and
EBP.

Do SLPs use NSOME? What Kind?

85% of SLPs in the USA use NSOME to
change speech sound productions (Lof &
Watson, 2008); 85% of Canadian SLPs use
NSOME (Hodge et al. 2005); 71.5% of SLPs
in the UK use them (Joffe & Pring, 2008);
79% of Kentucky SLPs use NSOME (Cima
et al., 2009).
Most frequently used exercises (in rank
order): Blowing; Tongue push-ups; Puckersmile; Tongue wags; Big smile; Tongue-tonose-to-chin; Cheek puffing; Blowing kisses;
Tongue curling.

See Page 11 for information on

Skepticism.
Page 17

Logical Reasons to Question Using NSOME

Clinical experience cautions: Finn, Bothe,
and Bramlett (2005) provided criteria for
distinguishing science from pseudoscience: It
is a pseudoscience when: Disconfirming
evidence is ignored and practice continues
even though the evidence is clear; The only
evidence is anecdotal, supported with
statements
from
personal
experience;
Inadequate evidence is accepted; Printed
materials are not peer reviewed; Grandiose

outcomes are proclaimed.

Many claims are made about NSOME
effectiveness in catalogs selling therapy
materials, non-peer reviewed publications,
CEU events, etc. But evidence of effectiveness
is not provided.
Some claims of effectiveness are outrageous
and are actually illogical when carefully
examined.

Theoretical Reasons to Question Using NSOME

document weakness of articulators and
objectively document supposed increases in
strength after NSOME? Do children with
speech
sound
disorders
have
weak
articulators?

Part-Whole Training and Transfer

Basic questions: Does training on a smaller

portion of the articulatory gesture transfer over
to the whole gesture? Is it more efficient and
better for learning by first training just part of
the movement and not the whole movement?
Tasks that comprise highly organized or
integrated movements (such as speaking) will
not be enhanced by learning the constituent
parts of the movement alone; training on just
the parts of these well-organized behaviors can
actually diminish learning. Highly organized
tasks require learning the information
processing demands, as well as learning timesharing and other inter-component skills
(Kleim & Jones, 2008; Wightman & Lintern,
1985).
Fractionating a behavior that is composed of
interrelated parts is not likely to provide
relevant information for the appropriate
development of neural substrates (Forrest,
2002).

Articulatory strength needs are VERY low

for speech and the speaking strength needs do
not come anywhere close to maximum
strength abilities of the articulators. For
example, lip muscle force for speaking is only
about 10-20% of the maximal capabilities for
lip force, and the jaw uses only about 11-15%
of the available amount of force that can be
produced (see also Bunton & Weismer, 1994).

only a fraction of maximum tongue force is

used in speech production, and such strength
tasks are not representative of the tongue's
role during typical speaking. As a result,
caution should be taken when directly
associating tongue strength to speech
(Wenke, Goozee, Murdoch, & LaPointe,
2006).

Agility

Some clinician-researchers believe that it can

and fine articulatory movements,

rather than strong articulators, are required for
the ballistic movements of speaking. NSOME
encourage gross and exaggerated ranges of
motion, not small, coordinated movements that
are required for talking.

be more effective to Train the Whole

(Ingram & Ingram, 2001) and to use WholeWord Phonology and Templates (Velleman
& Vihman, 2002) rather than breaking up the
gesture into small parts.

NSOME

may not actually increase

articulator strength. To strengthen muscle,
the exercise must be done with multiple
repetitions,
against
resistance,
until
failureand then done again and again. Most
NSOME do not follow this basic strength

Strengthening the Articulatory Structures

Basic questions: Is strength necessary for

speaking? If so, how much? Are the
articulators actually strengthened by using
NSOME? How do SLPs objectively

Page 18

training paradigm so there are probably no

actual strength gains occurring due to these
exercises.

coordinated activity needed during speech

(Hodge & Wellman, 1999).

For

sensory motor stimulation to improve

articulation, the stimulation must be done
with relevant behaviors, with a defined end
goal, using integration of skills.
The
PURPOSE of a motor behavior has a
profound influence on the manner in which the
relevant neural topography is marshaled and
controlled (Weismer, 2006).

Articulators

can be strengthened (e.g., the

tongue for oral phase of swallowing or the VP
complex) but these strengthened articulators
will not help with the production of speech.
Clark et al. (2009) and Robbins et al. (2005)
have demonstrated ways to increase oral
strength.

Measurements

Most

of strength are usually

highly subjective (e.g., feeling the force of the
tongue pushing against a tongue depressor or
against the cheek or just observing
weakness), so clinicians cannot initially verify
that strength is actually diminished and then
they cannot report increased strength
following NSOME.

NSOME dis-integrate the highly

integrated task of speaking (e.g., practicing
tongue elevation to the alveolar ridge with the
desire that this isolated task will improve
production of the lingual-alveolar sound /s/).
For example, a motor task (e.g., shooting a
free throw using a basketball) must be learned
in the context of the actual performance goal.
By analogy, no one would teach a ballplayer to
pretend to hold a ball and then pretend to
throw it toward a non-existent hoop with the
eventual hope of improving free throwing
ability. Breaking down basketball shooting or
the speaking task into smaller, unrelated
chunks that are irrelevant to the actual
performance is not effective.

Only

objective measures (e.g., tongue force

transducers, Iowa Oral Performance Instrument [IOPI]) can corroborate statements of
strength needs and improvement. Without
such objective measurements, testimonials of
articulator strength gains must be considered
suspect.

To

assess tongue strength, clinicians

commonly hold a tongue depressor beyond the
lips and the patient pushes the tongue against
the depressor. Strength is rated perceptually,
often with a 3-5 point equal-appearing
interval scale or with binary judgments of
normal or weak (Solomon & Monson,
2004).

Another

non-speaking example would be the

illogical finger pounding on a tabletop to
simulate playing on a piano. Learning and
improving piano playing must be practiced on
a piano, not on a tabletop. Likewise, learning
and improving speaking ability must be
practiced in the context of speaking. To
improve speaking, children must practice
speaking, rather than using tasks that only
superficially appear to be like speaking.

Preschool

children with speech sound

disorders may actually have STRONGER
tongues than their typically developing peers
(Sudbery et al., 2006).

Because

isolated movements of the tongue,

lips and other articulators are not the actual
gestures used for the production of any sounds
in English, their value for improving
production of speech sounds is doubtful. That
is, no speech sound requires the tongue tip to
be elevated toward the nose; no sound is
produced by puffing out the cheeks; no sound
is produced in the same way as blowing is
produced. Oral movements that are irrelevant
to speech movements will not be effective as
speech therapy techniques.

Relevancy of NSOME to Speech

Relevancy is the only way to get changes in

the neural system; the context in which a skill
is learned is crucial. In order to obtain transfer
from one skill to another, the learned skills
must be relevant to the other skills.

muscle

fibers are selectively recruited to

perform specific tasks, so static non-speech
tasks do not account for the precise and

Page 19

excellent examples and concepts dealing with

the importance of task specificity.

Task Specificity

The same structures used for speaking and

other mouth tasks (e.g., feeding, swallowing, sucking, breathing, etc.) function in
different ways depending on the task and each
task is mediated by different parts of the brain.
The organization of movements within the
nervous system is not the same for speech and
nonspeech gestures. Although identical
structures are used, these structures function
differently for speech and for nonspeech
activities.

Warm-Up/Awareness/Metamouth
Warm-up has a physiological purpose
during muscle exercise: to increase blood
circulation so muscle viscosity drops, thus
allowing for smoother and more elastic muscle
contractions (Safran, Seaber, & Garrett, 1989).
Warm-up of muscles may be appropriate
(Pollock et al., 1998) when a person is about to
initiate an exercise regimen that will
maximally tax the system (e.g., distance
running or weight training). However, muscle
warm-up is not required for tasks that are
below the maximum (e.g., walking or lifting a
spoon-to-mouth). Because speaking does not
require anywhere near the oral muscular
maximum, warm-up is not necessary.
If clinicians are not using the term warm-up to
identify a physiological task to wake up the
mouth, then perhaps they believe that they
are providing some form of metamouth
knowledge about the articulators movement
and placement.
Awareness and its role in therapy is always
questioned. It is well known that young
children have difficulty with various
metaphonological awareness tasks (Kamhi &
Catts, 2005). For articulation awareness,
Klein, Lederer and Cortese (1991) reported
that children age 5 and 6 years had very little
consciousness of how speech sounds were
made; 7 year olds were not very proficient
with this either. According to Koegel, Koegel,
and Ingham (1986), some children older than 7
years were successful during a metalinguistic
speech intervention program, but only when
they have the cognitive maturity required
to understand the concept of a sound
It appears that young children cannot take
advantage of the non-speech mouth cues
provided during NSOME that can be
transferred to speaking tasks. More research is
needed to determine the minimum cognitive,
linguistic, and motor abilities of children that
are necessary for such meta skills.

Weismer

(2006): The control of motor

behavior is task (speaking) specific, not
effector (muscle or organ) specific. There is
strong evidence against the shared control
for speech and nonspeech. Motor control
processes are tied to the unique goals, sources
of information (e.g., feedback), and
characteristics of varying motor acts, even
when those share the same effectors and some
neural tissue.

Some examples of task specificity: Babbling

and early nonspeech oral behaviors are not
related (e.g., Moore & Ruark, 1996); Patients
can have dysphagia with and without speech
problems (i.e., double dissociations; Ziegler,
2003); It is well documented that the VP
mechanism can be strengthened, however,
reduction of speech nasality does not occur
(e.g., Kuehn & Moon, 1994); Breathing for
speech is different than breathing at rest or
during other activities (e.g., Moore, Caulfield,
& Green, 2001). See Weismer (2006) for
summary of 11 studies that show that speech
and nonspeech are different for a wide variety
of structures, including facial muscles, jaw
motion, jaw operating space, jaw coordination,
lingual movement, lip motions, levator veli
palatini, and mandibular control.

Research

has shown that non-speech

movements activate different parts of the brain
than does speech movements (Bonilha et al.,
2006; Ludlow et al., 2008; Schulz et al., 1999;
Yee et al., 2007). This shows that the neural
basis of motor control is different for speech
and non-speech oral movements.

Bunton

(2008)
Yunusova, and

and Wilson,
Moore (2008)

Green,
provide

Page 20

Disorders that SLPs Often Use NSOME

procedures simply do not work and the
premises and rationales behind them are
scientifically unsound. (Golding-Kushner,
2001).
Ruscello (2008) evaluates the use of NSOME
and craniofacial anomalies in his article.

Childhood Apraxia of Speech (CAS)

Children

with CAS have adequate oral

structure movements for nonspeech
activities but not for volitional speech (Caruso
& Strand, 1999), so this would preclude the
use of NSOME because non-speech is not the
problem.

NSOME for Non-Motor Speech Disorders

Some may believe that motor exercises can
help children with motor production speech
problems, such as functional misarticulators
(phonetic/ articulatory problems) or children
with structural problems; however the
evidence does not support this.
It makes no sense that motor exercises could
help improve the speech of children who have
non-motor problems such as language/
phonemic/phonological problems like children
in Early Intervention diagnosed as late talkers.
It is puzzling why clinicians would use a
motor approach for non-motor speech
disorders; therapy must target the system that
is impacting the speech problem.

There

is no muscle weakness for children

with CAS, so there is no need to do
strengthening exercises. If there is weakness,
then the correct diagnosis is dysarthria, not
apraxia.

The

focus of intervention for the child

diagnosed with CAS is on improving the
planning, sequencing, and coordination of
muscle movements for speech. Isolated
exercises designed to "strengthen" the oral
muscles will not help. CAS is a disorder of
speech coordination, not strength. (ASHA
Technical Report on Childhood Apraxia of
Speech, 2007).

Cleft Lip/Palate

NSOME for Children with Dysarthria

The VP mechanism can be strengthened

through exercise (many studies have
demonstrated this since the 1960s), but added
strength will not improve speech productions.
Blowing exercises, sucking, swallowing,
gagging, and cheek puffing have been
suggested as useful in improving or
strengthening velopharyngeal closure and
speech. However, multiview videofluoroscopy
has shown that velopharyngeal movements of
these nonspeech functions differ from
velopharyngeal movements for speech in the
same speaker.
Improving velopharyngeal
motion for these tasks do not result in
improved resonance or speech. These

NSOME are frequently used for acquired

dysarthria, but their use is influenced by
folklore and not by evidence of
effectiveness (Mackenzie, Muir, & Allen,
2010).
Following guidance from adults with acquired
dysarthria, strengthening exercises are
probably only appropriate for a small number
of patients (Duffy, 2005).
weakness is not directly related to
intelligibility... for patients with ALS
(Duffy, 2005).
Based on the adult acquired dysarthria
literature, it appears that NSOME are not
recommended as a technique that can improve
speech productions.

Evidence Against the Use of NSOME

NSOME. Only 8 peer-reviewed articles met
rigorous criteria for inclusion. Insufficient
evidence to support or refute the used of OMEs
to produce effects on speech was found

Evidence-Based Systematic Review: Effects of

Nonspeech Oral Motor Exercises on Speech
(McCauley et al., 2009). Purpose was to
conduct evidence-based systematic review on

Page 21

There are a few studies evaluating the

effectiveness of NSOME that are not in peerreviewed journals; most of these studies were
reported at ASHA Conventions. Of the 11
studies available, 10 showed that NSOME were
NOT effective as a treatment approach. See
Lass and Pannbacker (2008) and Ruscello
(2008) for a review of these and other studies.

There

is much evidence that the NSOME

portion of combined treatments is irrelevant to
speech improvements.

NSOME probably do not harm the child when

used in combination with traditional
approaches (however, Hayes [2006] found that
some children may be negatively affected by a
combination approach).

Combining Treatment Approaches

It seems reasonable that if there is no speech

Most

improvement using combined approaches,

then clinicians should eliminate the approach
that is not effective (i.e., NSOME) so as to not
waste valuable therapy time with an
ineffectual technique.

SLPs use a combination of treatment

approaches so it is difficult to tease apart
which approach is providing therapeutic
benefit. Additionally, whenever intervention
approaches are combined, it is unknown if and
how they actually work in conjunction with
each other to enhance performance.

In Conclusion
Potential reasons why NSOME continue to
be used (Lof, 2009): The procedures can be
followed in a step-by-step cookbook
fashion; The exercises are tangible with the
appearance that something therapeutic is being
done; There is a lack of understanding the
theoretical literature addressing the dissimilarities of speech-nonspeech movements;
The techniques can be easily written out to
produce; There are a wide variety of
techniques and tools available for purchase
that are attractively packaged; Many
practicing clinicians do not read peer-reviewed
articles but instead rely on unscientific
writings; SLPs attend non-peer reviewed
activities that encourage their use; Parents
and therapists on multidisciplinary teams
encourage using NSOME; Frequently, other
clinicians persuade their colleagues to use
these techniques.
If clinicians want speech to improve, they
must work on speech, and not on things that
LOOK like they are working on speech.

Phonetic placement cues that have been used

in traditional speech therapy are NOT the
same as NSOME.
NSOME is a procedure not a goal. The goal
of speech therapy is NOT to produce a tongue
wag, to have strong articulators, to puff out the
cheeks, etc. Rather, the goal is to produce
intelligible speech.
We have been burned before. In the 1990s
many SLPs inappropriately embraced Facilitated Communication (FC) as a treatment
approach because they thought they observed
that it worked. Once it was tested using
scientific methodology, it was found to not
work. Pseudoscientific methodologies can
persuade clinicians to provide the wrong
treatment.
Following the guidelines of Evidence-Based
Practice, evidence needs to guide treatment
decisions. Parents need to be informed that
NSOME have not been shown to be effective
and their use must be considered experimental.

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2011 Gregory L. Lof

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Skepticism

Our best way to defend against quackery, pseudoscience, and questionable practices.
A skeptic is a person who has a questioning attitude or has some degree of doubt regarding claims that are
elsewhere taken for granted.
The word skepticism can characterize a position on a single claim, but more frequently describes a mind-set.
Skepticism is an approach to accepting, rejecting, or suspending judgment on new information that requires
the new information to be well supported by evidence.
A skeptics balancing act: An openness to new ideas, no matter how bizarre or counterintuitive VS. a
ruthlessly skeptical scrutiny of all ideas, old and new.
Ideally, skeptics do not go into an investigation closed to the possibility that a phenomenon might be real
or that a claim might be true. When we say we are skeptical, we mean that we must see compelling
evidence before we believe. (Shermer, 2010)
Tools for Skeptical Thinking: These ideas can help you remain appropriately skeptical when encountering
therapeutic techniques so you can analyze the purported findings.
Independent Confirmation: Can other clinician/researchers come up with the same findings?
Encourage Debate on the Evidence: There must be open and free dialogue in order for the science of new
techniques to be evaluated; this debate is NOT personal, it is about data.
Believe Data not Experts: It is important to look at the data, not just the words from authorities.
Be Skeptical of Anecdotes and Testimonials: Dont let testimonials and non-scientific findings sway you;
these may be interesting and may lead us to ask important questions, but without proper data all claims are
meaningless.
A Case Study is NOT Experimental: A case study cannot and never has been a methodology for
explaining cause-effect relationships.
Follow the Scientific Methodology: Including peer review.
Spin More than One Hypothesis: If you observe something working, try to determine WHY it works.
Perhaps why something works has nothing to do with the treatment itself.
Every Link in the Argument Chain Must Work: When following the logic of the argument ALL of the
pieces must fit together, not just some. We must always look at all aspects, and if there is one weak or
broken link, then the entire theory may not be supported.
Count the Hits and Misses: Look at all the evidence, not just some. We cannot overlook the misses and
only concentrate on the hits and we cannot overlook the hits and ignore the misses.
If it Sounds too Good to be True, It Probably is Not True: One therapeutic technique cannot possibly
work for all different types of disorders. There is no such thing as a cure-all.
Be Careful of the Popular Press: Just because something is in the popular press does not mean that it has
been scientifically tested. Only information from peer-reviewed reputable journals can be believed, and then
appropriate skepticism must still be applied. Be careful of the internet, promotional websites, self-published
books, and news stories on TV.
Nonstandard Treatments Rarely Look Outlandish: Promoters will often use scientific sounding terms
and quotes or they may misquote from scientific references. Be wary of pseudoscientific jargon.
Dont Let Desperation Cloud Our Judgment: Many times therapists, clients, and parents are desperate for
changes.
Evoking the Past: Just because something has been done for a long time does not make it legitimate; just
because someone has been doing it for a long time does not make it effective; just because Van Riper said
it does not automatically make it justifiable.

Good References:
Law, S. (2011). Believing bullshit: How not to get sucker into the intellectual black hole. Amherst, NY:
Prometheus Books.
Lof, G.L. (2011). Science-based practice and the speech-language pathologist. International Journal of SpeechLanguage Pathology, 13(3), 189-196.
Pigliucci, M. (2010). Nonsense on stilts: How to tell science from bunk. Chicago: University of Chicago Press.
Sagan, C (1996). The demon haunted world: Science as a candle in the dark. New York: Random House.
Shermer, M. (2011). The believing brain: From ghosts to gods to politics and conspiracies. New York: Times
Books.
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PROCESSING MODEL: COMPREHENSION AND PRODUCTION OF SPEECH

Mental Dictionary
Stored form for understanding/producing words.
Each word has its own entry

Linguistic Perception

Linguistic Encoding

Identifying the words in Input message

Choosing the words and sounds for

Output message

Phonetic Decoding

Motor Planning

Discriminating the speech sounds in

Input message

Planning oral movements to produce

desired words

Auditory Sensitivity

Articulation

Sounds received by auditory system

The sounds are actually produced

Input
Message transmitted
by another speaker

Feedback
Speaker hears speech;
feels articulators move

Output
Message is
produced

WHEN ARE SPEECH SOUNDS LEARNED?

Age range of normal
consonant development.
Average age estimates and
upper age limits of
customary consonant
production. The solid bar
corresponding to each sound
starts at the median age of
customary articulation; it
stops at the age level at
which 90% of all children
are customarily producing
the sound.

Sander, E. (1972). When are

speech sounds learned?
Journal of Speech and
Hearing Disorders, 37,
55-63.
Page 28

SCHEMATIC OF MODIFIED CYCLES APPROACH

PATTERN 1
Target Sound 1

WEEK 1

Target Sound 2
PATTERN 2
Target Sound 1
Target Sound 2

WEEK 2

PATTERN 3
Target Sound 1
Target Sound 2

Page 29

WEEK 3

Phonetic Inventory
Place-Manner-Voicing
Place a 9 in the box if the sound is ever produced in the sample.
Place a { in the box if the sound did not have an opportunity to be produced in the sample.

Place of Articulation
Manner
Voicing

Bilabial

-V

+V

Labialdental

Interdental

-V

-V

+V

+V

Alveolar

-V

+V

Palatal

-V

+V

Velar

Glottal

-V

+V

-V

Stop

Fricative

Affricate

Nasal

Liquid

Glide

Page 30

Page 31

17

16

56

62

61

63

57

52

51

55

41

40

38

19

36

26

18

35

39

11

10

25

64

58

53

42

37

27

20

12

43

21

13

54

22

14

44

23

45

15

24

59

46

28

60

47

29

48

49

15

Clinicians Name:

Date:

50

30

pr

31

tr

32

kr

33

pl

34

kw

Powell, T.W. (1995). A clinical screening procedure for assessing consonant cluster production. American Journal of Speech-Language Pathology, 4, 59-65.

[+ nasal] + C

/r/+ C

/l/ + C

C + /s,z/

/s/ + C

Word Final

/s/+ C

C + /r/

C + /l/

C + /y/

C + /w/

Word Initial

Singleton C:

Segments:

Consonant Cluster
Pattern Analysis
Clients Name:

Words for Assessing Consonant Cluster Production

1.

twin

tw

33.

splash

spl

2.

queen

kw

34.

squirrel

skw

3.

sweep

sw

35.

wasp

sp

4.

pew

py

36.

west

st

5.

beauty

by

37.

ask

sk

6.

cue

ky

38.

caps

ps

7.

few

fy

39.

cabs

bz

8.

view

vy

40.

cats

ts

9.

music

my

41.

kids

dz

10.

play

pl

42.

box

ks

11.

blue

bl

43.

dogs

gz

12.

clay

kl

44.

caves

vz

13.

glue

gl

45.

bathes

;z

14.

fly

fl

46.

combs

mz

15.

sleep

sl

47.

cans

nz

16.

pray

pr

48.

kings

az

17.

bread

br

49.

calls

lz

18.

tree

tr

50.

cars

rz

19.

drum

dr

51.

belt

lt

20.

cry

kr

52.

cold

ld

21.

grow

gr

53.

milk

lk

22.

fry

fr

54.

wolf

lf

23.

three

55.

sharp

rp

24.

shrub

cr

56.

cart

rt

25.

spy

sp

57.

card

rd

26.

stay

st

58.

work

rk

27.

sky

sk

59.

warm

rm

28.

smell

sm

60.

barn

rn

29.

snw

sn

61.

camp

mp

30.

spray

spr

62.

tent

nt

31.

stray

str

63.

hand

nd

32.

screw

skr

64.

ink

ak

LOF:Consonant ClusterAssessment Matrix

Page 32

Helpful Books Related to Speech-Sound Disorders

Velleman, S. (2003). Childhood apraxia of

speech resource guide. Thomson Delmar
Learning.

Hall, P., Jordan, L., & Robin, D. (2007).

Developmental apraxia of speech: Theory
and clinical practice (2nd ed.). Pro-Ed.

Hodson, B.W. (2007). Evaluating and

enhancing Childrens phonological systems:
Research and theory to practice. Thinking
Publications.

Williams, A. L. (2003). Speech disorders

resource guide for preschool children.
Thomson Delmar Learning.

Smit, A.B. (2004). Speech sound disorders:

Resource guide for school-age children and
adults. Thomson Delmar Learning.

Secord, W., Boyce, S., Donohue, J., Fox,

R., & Shine, R. (2007). Eliciting sounds:
Techniques and strategies for clinicians.
Thomson Delmar Learning.

Bliele, K. (2007). The late eight. Plural

Publishing.

Paul, R., & Flipsen, P. (2010). Speech

sound disorders in children. Plural
Publishing.

Kamhi, A. G., & Pollock, K. E. (2005).

Phonological disorders in children: Clinical
decision making in assessment and
intervention. Brooks.

Ruscello, D. (2008). Treating articulation

and phonological disorders in children.
Mosby Elsevier.

McLeod, S. (2007). The international guide

to speech acquisition. Thomson Delmar
Learning.

Bowen, C. (2009). Childrens speech sound

disorders. Wiley-Blackwell

Peterson-Falzone, S., Trost-Cardamone,

J., Karnell, M., & Hardin-Jones, M. (2006).
The clinicians guide to treating cleft palate
speech. Mosby Elsevier.

Williams, A.L., McLeod, S., & McCauley, R.

(2010). Interventions for speech sound
disorders in children. Brooks Publishing.

Caruso, A., & Strand, E. (1999). Clinical

management of motor speech disorders in
children. Theime

Page 33