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Chapter 9; The Basics of Remediations: A Framework for Conducting Therapy: 1. treatment targets (the things that the clinician is trying to change) 2. treatment mechanisms (how the treatment is expected to work) 3. treatment ingredients ( what the clinician does to affect the change) Treatment Tar...

Chapter 9; The Basics of Remediations: A Framework for Conducting Therapy: 1. treatment targets (the things that the clinician is trying to change) 2. treatment mechanisms (how the treatment is expected to work) 3. treatment ingredients ( what the clinician does to affect the change) Treatment Targets: usually, clinicians target one or more of the following: production accuracy of individual speech sounds reduction in the use of phonological patterns overall message intelligibility functional communication choosing a target behavior by itself is NOT sufficient as a treatment goal. treatment goals need to also include a specific time frame to achieve the goal and a criterion for success. time frames used may be short-term, intermediate-term, or long-term; these time frames may mean different things in different settings. In a public school setting, a short-term time frame frequently is a semester. Intermediate-term time frames may refer to an academic year, Long-term time frames typically refer to the point at which the client is eligible to be discharged from the caseload. the ultimate long-term goal for most speech sound therapy is adult-like accuracy of all the speech sounds of the language, as well as 100% intelligibility, unless there is a physical disability limiting motor functions the influence of word choice in speech therapy: (read pg 473) Word frequency: High-frequency words promote better generalization than low-frequency words Neighborhood density: Words with many phonologically similar neighbors yield better generalization than low-density words. Age of acquisition: Later-acquired words lead to greater speech sound generalization than earlier- acquired words, regardless of frequency. Lexicality: Non-words may promote faster speech sound learning & generalization compared to real words Treatment Mechanisms: Motor-based approaches generally assume that the underlying problem is either perceptual or motor learning. Linguistically based approaches assume that the child has failed to sort out some or all of the rules of the speech sound system. Treatment Ingredients: intervention style: the structure of treatment activities ranges from drill (highly structured therapy) to play (little structured) Drill: the clinician presents some form of antecedent instructional events followed by client responses. the client has little control over the rate and presentation of training stimuli. Drill-play: this type of therapy is distinguished from drill by the inclusion of an antecedent motivational event (e.g., activity involving a spinner, roll of dice, card games). Structured play: This type of instruction is structurally similar to drill-play, however, training stimuli are presented as play activities. In this mode, the clinician moves from formal instruction to playlike activities, especially when the child becomes unresponsive to more formal instruction. Play: The child perceives what they are doing as play; however, the clinician arranges activities so that target responses occur as a natural component of the activity. Clinicians may also use modeling, self-talk, and other techniques to elicit responses from a child. Stimulus Presentations and Feedback: Antecedent events: stimulus events presented prior to a responses (e.g., auditory/visual modeling or pictures presented by the clinician, followed by a request for the client to imitate or name a picture) Responses: production of a target behavior (e.g., a particular sound in isolation or imitating the word) Consequent events: reinforcement or feedback that follows the response (e.g., the clinician says "good" if a response is accurate or may say "try again" if inaccurate; tokens to reinforce correct responses) Goal Attack Strategies: vertical approach (training deep): focuses on one or two goals until he improves then move to another horizontal approach (training broad): adresses multiple goals in each session cyclical approach: a goal is addressed for a period of time, and then regardless of the progress another goal is selected Treatment Intensity: Dose: the number of teaching opportunities during anintervention session (50 trials / 30-min session) Dose form: the activity within which the teaching episodes are delivered aka intervention style (drill-play using single-word stimuli) Dose frequency: the number of times a dose of intervention is provided per day and per week ( one 30-min session twice per week ) Total intervention duration: the time period over which a specified intervention is presented ( 9 months or one year ) Cumulative intervention intensity: the product of dose × dose frequency x total intervention duration Dose form can also be specified. Using the previous examples: 50 trials × 2x per week × 40 weeks = 4,000 total single word trials using drill-play. Additional Service Delivery Considerations: scheduling of instruction: depends on factors such as age, attention span, and severity of the disorder and practical realities such as financial resources, availability of instructional services, size of the clinician’s caseload, and treatment models employed by the school system (pull-out vs classroom based) pull-out vs classroom based instruction: pull-out model: the client is instructed in a treatment room inclusion model: the client is instructed in a classroom setting individual vs group instruction: group therapy is more common in schools while group sessions can be effective, they may reduce individual practice time, so a combination of both approaches is often ideal Summary of Service Delivery Treatment goals, including specific targets and the stimuli to be used Style of intervention: drill, drill-play, structured play, play, or some combination Whether tabletop or digital materials will be used Goal attach strategy: vertical, horizontal, or cyclical Intensity of treatment: session length, sessions per week, dose per session Treatment schedule Pull-out or classroom-based instruction Individual or group instruction Tracking Progress in Intervention: it is the clinician’s responsibility to collect relevant data to ensure that: change is happening change is happening due to treatment and not extraneous factors relevant generalization is taking place using a norm-referenced test to measure progress is NOT a good idea, because; they are not sensitive enough to to behavioral changes everyday communication involves production of connected speech rather than single words. regression to the mean: poor performance on a norm-referenced test during an assessment may have been the result of the child having a very bad day (e.g., they didn't get enough sleep, they had a fight) Statistically, the odds of all those negative things happening again when the test is readministered are very low. any improvement in their performance may simply reflect them having a better day and not as a result of the intervention the child may remember the words of the test and he may have practiced these words Treatment data are performance data on the stimuli presented during the intervention session. As stimuli are presented, the clinician makes a note of whether or not the child responded correctly. At the end of the treatment session, if the child attempted to produce the target sound in 50 single words and produced 20 of them correctly, a value of 40% correct can be entered into a log, Generalization data are collected every few weeks or perhaps once a month. For example, if 20 stimulus words containing /S/ in word-initial position are being practiced in therapy, a check for generalization to other words containing /s/ in word-initial position might be conducted. These words can be presented to the child and, again, the percentage correct can be recorded. Control data involves presenting stimuli containing the predetermined control sound. These would be for a sound the child does not produce correctly, which is not being worked on in therapy, and where generalization is not expected. For example, when working on /k/, a very different sound like /V/ might serve as a control sound, or if the target is / sh/, a sound like /r/ could be the control sound. stimuli are presented every few weeks (or once a month) and percentage correct values are recorded Facilitating Generalization: phases of therapy: establishment: which involves the client mastering the skills being taught generalization: the extension of the skills being taught across a variety of contexts and situations maintenance or the development of automatic or permanent skill generalization: the occurrence of relevant behavior under different non-training conditions (i.e., across subjects, settings, people, behavior, and/or time) without the scheduling of the same events in those conditions as had been scheduled in the training conditions. generalization does not occur automatically, and people vary in their generalization abilities stimulus generalization: when a learned response to a particular stimulus is evoked by similar stimuli. A client who utilizes the process (pattern) of velar fronting (/t/ for /k/ substitution) has been taught to produce /k/ correctly at the word level in response to the auditory stimulus, "Say key." The client is later shown a picture of a key and asked to name it, but no model is provided. If the client says key with /k/ produced correctly in response to the picture (i.e., the model is no longer necessary for a correct production), stimulus generalization has occurred. response generalization: relevant to speech sound remediation, it is the process in which responses that have been taught transfer to other behaviors that are not taught. An example of response generalization is as follows: A client with /s/ and /z/ errors is taught to say [s] in response to an auditory model of [S]. She is then presented an auditory model [Z] and asked to imitate it. If the client emits a correct [Z], response generalization has occurred. 1) across-position generalization 2) across-context generalization 3) across-linguistic unit generalization 4) across-sound and feature generalization 5) across-situation generalization Across-Word Position/ Contextual Generalization: (read page 494 & 495) across-word position: this term refers to generalization from a word position that is taught (initial, medial, or final) to a word position that is not taught. By teaching a sound in a particular position (e.g., initial position), generalization may occur to a second position (e.g., final position). the word position in which a target is trained is NOT a factor in position generalization it is recommended that the clinician train the word position that the client finds easiest to produce, check for generalization to other positions, and then proceed to train the other word positions it generalization has not already occurred position generalization may be viewed as a type of contextual generalization. contextual generalization also refers to phonetic context transfer; for example, generalization from /s/ in ask to /s/ in biscuit or to /s/ in fist. This type of generalization, in which a production transfers to other words without treatment, is an example of response generalization Across Linguistic Unit Generalization: (read page 496) shifting correct sound productions from a level of linguistic complexity to another (from syllables to words) Instruction typically begins at the highest level of linguistic complexity at which a client can produce a target behavior on demand. Instruction progresses from that point to the next level of complexity. it is recommended that sounds be taught in nonsense syllables or nonsense words before they are practiced in meaningful words some clients generalize from one linguistic unit to another without specific training; others require specific instructional activities for transfer from one linguistic unit to another. Across-Sound and Across-Feature Generalization: (read page 497) when correct production of a target sound generalizes from one sound to another most often occurs within sound classes and sounds that are phonetically similar (e.g., /k/ to /g/, /s/ to /z/) expected when remediation targets are selected for linguistically based treatment approaches based on pattern analysis. A client can learn a feature and transfer the feature to other sounds without necessarily correcting a sound. For example, a client who substitutes stops for fricatives may learn to produce /f/ and overgeneralize its use to several fricative sounds. Although the client no longer substitutes stops for fricatives, they now substitute /f/ for other fricatives (e.g., [sun] - [fun] / [shoe] - [foo]) Although the same number of phonemes is in error, the fact that the client has incorporated a new sound class into their repertoire represents progress because it involves enhancement of the child's phonological system the establishment of feature contrasts is part of the effort to reduce and eliminate pattern usage and homonymy (when one sound is substituted for several sounds in the language). Across-Situations Generalization: (read page 499) transfer of behavior taught in the clinical setting to other situations & locations (school, home, etc) also known as carryover Parental Assistance with Generalization: (read pages 502 - 503) Involving parents, teachers, or peers in speech therapy can help with generalization by extending clinical activities into the client’s daily environment.  Studies indicate that trained parents can be as effective as SLPs in facilitating speech sound improvements. Engaging skilled and motivated parents can reduce therapy time and improve outcomes. To effectively use parents, clinicians should: Ensure parents can model and reinforce correct sound productions. Provide training and written instructions for activities. Design short, manageable programs for parents’ limited time. Recognize that parents function better as monitors than as primary teachers. Generalization Guidelines: for the most rapid context and situational generalization, begin instruction with target sounds that are stimulable or in the client's repertoire. For children with multiple errors, there are data to support each of the following as ways to facilitate generalization: Nonstimulable sounds should be treated before stimulable sounds for systemwide change. Sounds that show the least knowledge should be treated before those that show more knowledge to promote system-wide change. Because word productions form the basis of generalization, productions at the word level should be incorporated into the instructional sequence as soon as possible. When teaching a sound, words and syllable shapes within the child's lexicon should be used. The more features that sounds have in common, the more likely that generalization will occur from one to another. There aren’t enough data to support a particular order for teaching sounds in various word positions to facilitate generalization. Beginning with the word position that is easiest for the client is often used as a starting point. When selecting sounds to target phonologic patterns, choose target sounds from across different sound classes in which the pattern occurs to increase the likelihood of generalization across the sound system (e.g., for final consonant deletion, one might select /d/, /f/, and /m/). Nonsense syllables may facilitate production of sounds in syllable or nonword contexts during establishment of sound production because nonsense syllables pose less interference with previously learned behaviors than do words. Activities to facilitate situational generalization are advised as soon as the client can say a sound in words. In the case of preschool children, generalization frequently takes place without formal instruction to facilitate situational generalization. Parents, teachers, and others in the child's environment can be used effectively to facilitate phonologic change in children. Dismissal from Instruction and Maintenance: the final phase of therapy is known as maintenance, or automatization, because it is the automatic usage of standard articulation patterns in spontaneous speech. The term automatization implies that phonologic productions can be viewed as motor behavior that develops into an automatic response. Retention: refers to the continued and persistent use of responses learned during instruction. Once an individual learns a new pattern or response, they must continue to use (retain) the response. Intersession retention: the ability to produce recently taught responses correctly from one session to the next. Habitual retention: the persistent and continued use of the response after instruction has been terminated. factors that affect retention; the meaningfulness of the materials used, the degree or extent to which something has been learned, the frequency of instruction or distribution of the practice, motivation  Dismissal Criteria: mainly based on two questions: Has the maximum change in this individual's speech behavior been attained? Can this individual maintain this level of speech behavior and continue to improve without additional speech instruction? Maintenance and Dismissal Guidelines The reinforcement schedule should continue to be intermittent during maintenance, as during the latter stages of generalization. During the maintenance phase, clients should assume increased responsibility for self-monitoring their productions and maintaining accurate productions. Dismissal criteria may vary depending on the nature of the client's problem and the client's age. It has been suggested that clinicians may tend to keep many clients enrolled for remediation longer than necessary. Treatment Considerations for Very Young Children: Acclimate to the therapy process and environment : Allow toddlers to explore the therapy room, familiarizing themselves with the space, materials, and the clinician. Early treatment goals: Focus on overall communication rather than specific speech details. Encourage turn-taking, especially for children with unintelligible speech who may struggle with communication. Respond to all communicative signals (e.g., sounds, facial expressions, gestures) to motivate interaction. Imitate the child’s speech attempts with more correct examples. Intervention style: Begin with play-based therapy, progressing to structured play, drill-play, and possibly drill. Gradually increase the time spent on any one activity as the child becomes accustomed to therapy. Treatment intensity: Opt for shorter, more frequent sessions to match the child’s attention span. Incorporate a variety of brief activities within each session to increase the number of responses and trials. As the child adjusts, lengthen sessions and increase intensity. Working with Older Children: Motivation for Therapy: consult parents/caregivers for rewards respecting their choices, allowing them to have input into day-to-day decisions about activities used allowing them to invite a peer or two to attend therapy Treatment Decision Making As children grow, they desire more control over decisions affecting them, known as the right to exercise autonomy. It’s important to consider client preferences and values when possible, as discussed in EBP Children should be involved in the decision-making process. The Mechanics of Intervention: Older children tolerate drill-based therapy but may get bored; engagement through therapeutic alliance helps. They understand the need for frequent sessions to speed up progress. We could use reading stimulus rather than pictures Older children can complete homework, track progress, and practice with peers. Chapter 8; Using Evidence Based Practice in Treatment Evidence Based Practice (EBP): a system that provides scientific perspective for application of any treatment approach the goal of speech language therapy is to (facilitate change in client communication) how do we do so? we assess baseline skills, apply intervention, reassess to see if changes occured The Basics of Evidence Based Practice: the best available published evidence clinical evidence collected using our clinical expertise the preferences of the client The Published Evidence: the best is randomized the lowest level is expert opinion the more similar our clients to the participants in a study, the more likely they are going to achieve similar outcomes Clinical Evidence: includes the ability to judge whether change is happening and whether this change is due to therapy or something else measuring change: there are three types of changes to consider; 1. the overall change that reflects progress toward the long-term goal to measure this, repeating a norm-referenced test is a bad idea, because; 1) we will face a statistical problem (regression to the mean) 2) the child may have practiced the words in the test 3) the child might become hypersensitive to this word because of his failure and continue to find it difficult, even if they were capable of producing the same sound in other words a better option to measure this type of change is recording and transcribing conversational samples 2. moment-to-moment performance on the specific therapy targets being practiced sometimes referred to as treatment data track progress on specific targets, such as producing the sound in isolation, words, or conversations this performance is recorded at the end of each session 3. the degree of generalization beyond what was taught in therapy we measure the degree to which skills are generalizing using probes we use words that were not practiced in therapy to determine whether the child actually learned the sound and generalized it into new words into his sound system probes are not administered in every session so the child doesn’t become overly familiar with the words it’s better do it every four or five sessions or once a month determining what caused the change: read pg 460 - 463 sometimes changes occur but not because of therapy, these changes are caused by extraneous effects one of the extraneous effects is normal development or maturation another one is the placebo effect (where improvement happens regardless of the used intervention type) one variation of the placebo effect is the Hawthorne effect; where the client improves because he is convinced that the particular treatment they’re receiving is working the experimenter effect, or Pygmalion effect, in which the client responds positively to clinician attention, signals, and/or interactions with the clinician so that change occurs (the client may have such high confidence in the skill of the clinician that they assume the treatment must be working.) Regression to the mean is a statistical phenomenon where an extremely low or high score on a measurement is likely to move closer to the mean in subsequent measurements, often due to natural variations in behavior rather than actual improvement. (If the child produces a very low score, part of the reason for that low score may be because they were not performing at their best on that particular day. the child may have been performing at their worst. Statistically, when the clinician measures their performance at a later time, the probability is very high that the child will have a better day and their score will go up. the higher score may have nothing to do with therapy) adding control data: control data is data obtained from treatment targets for which no therapy is being applied and which are different enough from the current treatment targets so that no generalization would be expected. It is similar to a research strategy known as a single subject design, also called a multiple baseline design Progress on treated targets is compared against progress on untreated control targets. Change is expected to only occur on the treated targets (and on the generalization probes) but not on the control targets. Eventually, treatment would be applied to the control targets and, at that point, change would be expected on those targets. This is known as experimental control, in which change only occurs when treatment is applied and not at any other time. Client Preference: the clients and their families rarely have the knowledge to select treatment approaches, but engaging in EBP means educating them about the nature of treatment options so they can make informed choices there are times where the clients or caregivers have strong preference for speech sound targets important to them (names of family members or pets) some parents don’t like certain types of reinforcements such as foods Chapter 11; Linguistically Based Treatment Approaches: linguistic approaches are focused on the rules of the language, including sound contrasts and appropriate phonological patterns The primary focus of linguistic approaches to remediation is the establishment of the adult phonological system, including the inventory of phonemes (i.e., sounds used to contrast meaning), allophonic rules (i.e., use of different allophones in different contexts), and phonotactic rules (i.e., how sounds are combined to form syllables and words). to acquire the phonological system, we need three elements: the focus is on the meaning (function/ communication) rather the form the selection of target behavior is based on the child’s phonological patterns the instructional procedures being used. In order to demonstrate that a change in the sound being produced results in a change in meaning, naturalistic consequences are typically used. Contrast Approaches: The specific focus of contrast approaches is to replace error patterns with appropriate phonological patterns. The error patterns often result in production of homonyms (one word being mistakenly used for two or more referents; e.g., shoe used for both chew and shoe). The goal is to eliminate the homonyms by establishing new sounds or sound classes in the child's language (phonological) system. contrast approaches may also target error patterns that limit the syllable and word shapes that a child uses. for example, A client who deletes final consonants may produce initial consonants correctly but delete them at the end of words, creating open syllables (e.g., “two” and “tooth” both become “two”).This suggests a conceptual problem (believing only open syllables are allowed) rather than a motor production issue. Therapy focuses on building awareness of final consonant contrasts and the importance of syllable closure for correct meaning (e.g., highlighting differences like “bee” vs. “beet”). the contrast approach, also termed a phonological oppositions approach, teaches the client that different sounds or different word shapes signal different meanings. Contrast Training: A production-based contrast pair task requires the client to produce both words as recognizably different words. For example, a client who deletes final consonants might ask the clinician to give them the picture of either a bee or a beet and then be reinforced by the clinician for the appropriate production. In this task, the client must be able to produce the distinction between bee and beet. If they produce the wrong word, the clinician would pick up the wrong picture (i.e., the picture representing what the client said, not what they may have intended). This creates a communication problem or mismatch for the client that must be resolved by a change in the production. basic protocol for contrast training: read pages 583-584 Different Kinds of Contrasts: minimal pairs differ, and these differences may influence treatment decisions and treatment outcomes. sometimes the sounds differ on only a single articulatory feature. For example, in the pair sun, ton the /S/ and /t/ differ only on manner of articulation (fricative vs. stop). in the word pair lick, limb the /k/ and /m/ are contrasted, and they differ on three articulatory features (place: velar vs. bilabial, manner: stop vs. nasal, and voicing: voiceless vs. voiced)p Conventional Minimal Pairs Approach: The word pairs are typically chosen to reflect the contrast between the child's error and the adult target. Treatment often begins with those contrasts that differ by the smallest number of articulatory features It also involves working on stimulable sounds strengths: focusing on contrasts between the child's error and the adult target makes identifying the contrast targets straightforward + It targets the use of homonyms + it improves intelligibility Complexity Approach: The complexity approach works on the assumption that there is an advantage to using later-developing rather than early-developing targets. this approach has three concepts: the first is the need to maximize learnability larger and more obvious (maximal) contrasts would be preferable to minimal contrasts and may lead to greater gains in therapy. the second is the notion of the empty set for children with multiple sounds missing from their sound system, targeting a contrast between two unknown sounds (an empty set) may be more efficient. the third is that selection of the contrasts should consider implicational relationship These are patterns within languages wherein, if a language includes a complex form, it also always includes related simpler forms. Some examples include: Fricatives imply stops : languages that include fricatives include stops Liquids imply nasals: languages that include liquids include nasals Clusters imply singletons: languages that allow consonant clusters include singleton consonants within syllables strength: one of the most theoretically grounded approaches available limitation: no use of natural consequences Multiple Oppositions Approach: A foundational observation for this approach is that multiple errors are often collapsed into a single sound (one sound is used in place of two or more other sounds) this also called a phoneme collapse, or systematic sound preference For example, if a child substitutes /t/ in the initial word position for these sounds:/θ/, /t∫/, /s/, the words thick, chick, sick, and tick would all be produced as tick. One sound is being used in place of four sounds. the treatment of several of the contrasts within a collapse occur simultaneously within the same activity there are four different treatment phases, which have been suggested for multiple oppositions: Phase 1 involves familiarizing the child with the target items. (pointing out the sound differences and how the different productions yield different meanings) Phase 2 involves focused practice of the individual items in interactive play. (begins with imitative productions and then transitions to spontaneous production) Phase 3 involves production of the contrasts in structured games at the word and phrase level. Phase 4 involves practice in natural conversation. For the last two phases, corrective recasts are provided to the child whenever errors occur. For example, "Oh, you wanted sip, but I heard you say tip. Remember, the s in sip is a long sound, not a short sound" strengths: the potential to remediate multiple speech sound targets all at the same time and the four planned phases include specific planning for generalization. limitation: presenting multiple contrasts at the same time may be confusing for some children, particularly those with significant comorbid cognitive or language impairments. Non-contrast Approaches: Cycles Phonological Patterns Approach: The CPPA is a bottom-up approach, but it does not use contrasts except in a peripheral way. It is intended for children with multiple speech error patterns and highly unintelligible speech. this approach uses both focused auditory input and repeated practice of correct productions to help the child make strong connections between what a word feels like, what it sounds like, and what it means. The CPPA was built on the principle of gradualness in acquisition, which led to the development of the cyclical goal attack strategy. This strategy gives the child some concentrated exposure to and practice producing the correct forms related to each of their error patterns. It then allows the child's cognitive-linguistic system to reorganize itself on its own. the unique features of this approach: using the cyclical goal attack strategy (treatment cycles may range from 5 to 16 weeks) errorless learning (not practicing errors, only targeting stimulable sounds and only practicing those specific words containing the target that can be produced correctly) amplified auditory stimulation (auditory bombardment, where the child listens to lists of words containing the target sound or target pattern for a few minutes at the begging and end of the session) The instructional sequence for each CPPA session is as follows: Review: At the beginning of each session, the prior week's production practice word cards are reviewed. Listening activity: This is amplified auditory stimulation and requires listening for about 30 seconds while the clinician reads approximately 20 words containing the target pattern. Target word cards: The client draws, colors, or pastes pictures of three to five carefully selected target words based on phonetic environment of the words on cards. The name of the picture is written on each card, and the child says each word prior to its selection as a target word to evaluate it for difficulty. Production practice: The client participates in experiential play production practice activities (i.e., games). The client is expected to have a very high success rate in terms of correct productions. Shifting activities every 5-7 minutes helps maintain a child's interest in production practice. The client is also given the opportunity to use target words in conversation. Production practice incorporates auditory, tactual, and visual stimulation and cues as needed for correct production at the word level. Usually, five words per target sound are used in a single session. The client must produce the target pattern in words in order to get their turn in the activity. Stimulability probing: The target phoneme in the next session for a given pattern is selected based on stimulability probing (checking to see what words a child can imitate), which occurs at this point in the treatment session. Listening activity: Auditory stimulation with amplification is repeated using the word list from the beginning of the session. Phonological awareness activities: Activities such as rhyming and syllable segmentation are incorporated in each session because many children with SSDs are at risk for later problems with literacy skills. Home program: Parents are instructed to read a word list (5-10 words) to the child at least once a dav and then have the child name the words on the picture cards used in the listening activity. The five cards used during the session for production practice are also sent home for the child to practice daily. strengths: adaptability, tested on many different populations, appealing activities for young children limitations: includes many elements, we don’t know which one is the reason of success. and the effectiveness of auditory bombardment is questionable Broader-Based Language Approaches: These approaches are founded on two basic premises: 1) phonology is a part of the overall language system and should be treated in acommunication context 2) improvement in phonologic behaviors co-occurs when instruction is focused on higher levels of language these approaches emphasize the communicative context and focus on the interactive nature of communication. these broader-based language approaches may be most appropriate for individuals where a SSD is secondary to other difficulties or disorders. In addition to those with comorbid language impairments. For children with autism, these approaches offer the benefit of simultaneously working on social interactive skills, which are a common deficit area for those individuals. They may also be appropriate for children with comorbid fluency disorders, as the focus is on the interaction and less on the fine details of speech production; thus, it may be less likely to induce anxiety that may trigger dysfluency. Finally, for children with Down syndrome, the initial focus on intelligibility targets a major area of concern for most parents. Whole Language Intervention: states that learning the sound system should not be isolated from the rest of language. suggests that intervention should be language-oriented, as well as naturalistic and interactive. the clinician simultaneously improves semantics, syntax, morphology, pragmatics, and phonology. Such an approach puts the perceptual and motor cues of speech sound production into a broader communication context and integrates all aspects of communication, which speakers must ultimately do. For this approach, in terms of treatment priorities, phonology is the last component emphasized because intelligibility is a concern only after children have expressive language. Child-clinician interactions should be based on spontaneous events or utterances and communicative situations that arise in the context of daily play routines and instructional activities. there are three steps for this intervention: Provide appropriate organization of the environment/stimulus materials for the child to attend to, which enables the clinician to alter language complexity systematically throughout the course of therapy. Provide a communicative opportunity, including scaffolding strategies that consist of various types of prompts, questions, information, and restatements that provide support to the child who is actively engaging in the process of communicating a message. Provide consequences or feedback directly related to the effectiveness of the child's communication. read the example on pages 611 - 612 strengths: targets several aspects of communication simultaneously + the interactive nature of the activities and incorporating stories is appealing for young children limitation: limited evidence to support it, requires skills for the SLP to interact and engage the client Naturalistic Recast Intervention: a top-down approach to improving speech sound skill is intended to improve speech sound production by initially targeting improvement of overall speech intelligibility. It is based on two ideas: 1) the primary presenting symptom for many children with SSDs is reduced intelligibility 2) accuracy of production of speech sounds isn’t the only factor influencing how well speech is understood the initial step is to increase the proportion of messages that are being understood by the listener. Once intelligibility has improved, we can turn to accuracy of production of individual speech sounds. strengths: potential to target other deficit areas within the therapy activities, activities are appealing limitation: the informal structure of the treatment sessions may limit opportunities for practice. Remediation Guidelines For Linguistically Based Approaches: 1. A linguistic approach is recommended when there are multiple sound errors that reflect one or more phonologic error patterns. These approaches are particularly useful with young children who are unintelligible. 2. Once error patterns have been identified, a review of the child's phonetic inventory assists in the identification of target sounds (exemplars) to facilitate correct usage. This review usually includes examination for stimulability and may include phonetic contexts that facilitate correct production of a target, frequency of occurrence of potential target sounds, and the developmental appropriateness of targets. 3. Selection of training words should reflect the syllabic word shapes the child uses. For example, if the child uses only CV and CVC shapes, multisyllabic target words would not be targeted. This guideline is obviously inappropriate if the focus on remediation is on syllable structure simplifications and/or word structure complexity. 4. Selecting target words that facilitate the reduction of two or more patterns simultaneously could increase treatment efficiency. For example, if a child uses stopping and deletes final fricatives, the selection of a final fricative for training could aid in the simultaneous reduction of the patterns of stopping and final consonant deletion. 5. When errors cross several sound classes (e.g., final consonant deletion affecting stops, fricatives, and nasals), exemplars that reflect different sound classes or possibly the most complex (production) sound class should be selected. 6. Instruction related to phonologic patterns may focus on the broader pattern and less on the phonetic accuracy of individual sounds used in treatment. For example, if a child deletes final consonants but learns to say [dod] for [dogl, the /d/ for /g/ replacement might be overlooked during the initial stage of instruction because the child has begun to change their phonologic system to incorporate final consonant productions. 7. Instruction focused on both perception and production of contrasts is commonly used and would appear appropriate in many cases. 8. When using contrast approaches, clinicians may wish to probe each client's response to both minimal and maximal oppositions contrasts. 9. For children with many sound collapses, a multiple oppositions approach might be an efficient way to impact the child's overall sound system. 10. Noncontrast approaches should be considered, especially in cases where the child is not responsive to the more structured contrast approaches 11. For children with coexisting language impairments, a broader-based language (top-down) approach might be appropriate. Although this approach may work best with children evidencing milder phonological impairments, for those who are more severely involved, direct instruction related to production of speech sounds will likely be necessary. This may be approached either by beginning with work on language and introducing specific work on speech sounds later, or by working on both language and speech sounds concurrently. Case Study Example: read pages 619 - 621 Chapter 10; Motor-Based Treatment Approaches: approaches to intervention: motor-based: involves teaching the correct production of an individual sound (articulation) linguistic-based: ensuring correct production of a target along with some contrasting sounds (phonology) normal speech production includes both the production of a sound at a motor level and their use in accordance with the phonological/ linguistic rules of the language treatment continuum: the three phases of treatment: establishment: motor-based establishment procedures are often based on production tasks generalization: positional, contextual, linguistic unit, sound, and situational. this phase includes instructional activities or strategies designed to facilitate generalization or carryover of correct sound productions to sound contrasts, words, and speaking situations that have not been specifically trained. During the generalization phase, clinicians usually follow a progression from smaller to larger linguistic units (e.g., sounds to syllables to words to sentences to conversation). maintenance: designed to stabilize and facilitate retention of those behaviors acquired during the establishment and generalization phases. Frequency and duration of instruction are often reduced during the maintenance phase. motor learning principles: Motor-based approaches to treating SSDs are designed to focus primarily on the motor (or movement) skills involved in producing target sounds. They also include perceptual tasks as part of the treatment procedures. often referred to as the traditional approach or traditional articulation therapy. Treatment based on an articulation/phonetic or motor perspective focuses on the placement and movement of the articulators combined with some form of perceptual training (e.g., ear training and focused auditory input). pre-practice goals: help ensure the child is motivated for learning by including them (and/or their parents) in establishing goals to work on and making those goals functionally relevant. we need to ensure that the child understands the tasks, so we use simple instructions and good models we need to be sure of the child's perceptual abilities (i.e., hearing acuity and sound contrast perception) to avoid frustration principles of practice: shorter treatment sessions have been shown to be more productive than fewer but longer sessions. Practice under a variety of conditions (e.g., different rates with different intonation patterns) is preferable to repeating the targets many times under the same conditions. Random presentation of targets is better than multiple attempts at the same target. Having the child focus on correct productions of a sound is preferable to having them focus on the details of the individual articulator movements. Practicing the entire speech target (even if it is only the sound in isolation) is better than breaking that target down into tiny pieces and repeating those pieces multiple times. For example, practicing production of /r/ is better than repeatedly sticking the tongue in and out of the mouth without making any sound to simulate the tongue retraction gesture of /r/. principles of feedback: it appears best to provide knowledge of performance or feedback about what specifically they are doing correctly or incorrectly (e.g., "Don't forget to keep your teeth together when you say that /s/ sound.") But once the target begins to be established, feedback should quickly change to knowledge of results, or a focus on whether the target was produced correctly (e.g., "Excellent. That was a very good /S/ sound." or "No, good try but not quite right. Try that one again) less feedback is better than more because it gives the child the opportunity to reflect internally on their productions the child may be asked to express their own opinion about their attempts (to engage in self-monitoring) Optimizing Learning: The Challenge Point Framework: (read pages 527 - 528) Performance 80% correct = Make the task harder how to make tasks easier/harder? Practice intensity: more or fewer trials in the session (either by faster or slower presentation of stimuli or making the session longer or shorter) Task difficulty: embed the target in more or less complex word shapes or longer or shorter linguistic units Degree of stimulation: move up or down the continuum from coproduction (easiest) to direct imitation to delayed imitation to spontaneous production (hardest) Nature of the feedback provided: move from knowledge of performance (less challenging) to knowledge of results (more challenging) to no feedback (most challenging) Frequency of the feedback: less feedback increases the challenge Teaching Sound/Establishment: perceptual training: 1) traditional ear training: read page 530 it is the most common, also called speech sound discrimination training or sensory-perceptual training. it is recommended that discrimination training occur prior to production training during the establishment phase of the treatment continuum. it is more appropriate to use discrimination (or perceptual) training only in cases in which perceptual difficulties have been documented an example is (tell me if these two are the same words or different “key” - ”tea”) methodology for traditional ear training: Identification: Call the client's attention to the target sound what it sounds like, what it looks like as you observe the lips and mouth and, as best you can, help them be aware of kinesthetic sensations or what it feels like inside the mouth. Isolation: Have the client again listen for the target sound by identifying it in increasingly complex environments. Begin by having the child raise their hand, show a happy face, or otherwise indicate when they hear the sound in a word (begin with the initial position). Then progress to having the child listen for the sound in phrases and sentences. This step might also include practice identifying the presence of a sound in the middle or at the end of the word. Stimulation: Provide the client an appropriate auditory model of the target sound in both isolation and words. Discrimination: Ask the client to make judgments of correct and incorrect productions you produce in increasingly complex contexts (i.e., words, phrases, sentences).  2) perceptual training of sound contrasts: (minimal pairs) read page 532 Introduction of the minimal pair: Present to the client a word that contains the target sound. For example, if the child is substituting /t/ for the fricative /ʃ/, the word shoe might be used in a perceptual training activity. The child listens as the clinician points to five identical pictures of a shoe and names each one. Next, present to the client a second word, also with associated pictures of the word, which contain a contrasting sound that is very different from the target sound (i.e., has several different features from the target sound). For example, shoe might be contrasted with boo (ghost picture). The phonemes // and /b/ differ in voicing, manner, and place of articulation. For this step, the clinician identifies the original five pictures of a shoe plus the five pictures of boo. Contrast training: Practice differentiating the two contrasting words at a perceptual level. Line up the 10 pictures, 5 of which are of a shoe and 5 of boo. Ask the client to hand you the picture you name. Make random requests for either boo or shoe. If the child can readily do this, they have established at a perceptual level the contrast between /ʃ/ and [b]. If the child has difficulty with this task, it should be repeated, possibly with different words. Once the child can do this task, contrast training should be repeated with minimal pairs involving the target and error sound (e.g., shoe-two; shop-top). When the clinician is satisfied that the client can discriminate the target sound from other sounds and that they can perceive the target in minimal pairs involving the target sound and error sound, the client is ready for production training. 3) perceptual training software: SAILS program: A tablet-based app for improving speech perception in children with SSDs using correct/ incorrect speech examples. Provides visual feedback, tracks progress, and can be used before or during production training. Three randomized controlled trials show SAILS improves speech production, especially for children with poor perceptual skills. 4) ampli ed auditory stimulation: auditory bombardment: involves presentation of lists of up to 20 words containing the target sound or sound pattern at the beginning and end of each treatment session. a mild gain amplification device is used to ensure that the input is loud enough but not distorted (note that there is a natural tendency to distort speech when speaking louder than normal). The child merely listens; no production or judgment is required of the child. production training: Teaching sounds in isolation or context: Isolated sounds are less complex but may not work for all sounds (e.g., stops, glides). Syllables (e.g., CV patterns) or words might be better for some sounds. Contextual or meaningful productions (real words) can aid learning and communication. Some recommend starting with isolated sounds, while others recommend starting with words for contextual and communicative benefits. Clinicians should choose the most facilitative level for correct production. Methods to establish target sounds: Imitation, phonetic placement, shaping (successive approximation), and contextual utilization. Imitation: it is recommended that the clinician attempt to elicit responses through imitation as an initial instructional method for production training, even if the client wasn’t stimulable the clinician presents the model of the target behavior and then asks the client to repeat it fi  Phonetic Placement: When the client is unable to imitate a target sound, the clinician typically begins to cue or instruct the client regarding where to place their articulators. Instruct the client where to place the articulators to produce a specific speech sound Provide visual and tactile cues analyze and describe differences between the error production and the target production we could use; mirrors, pictures and drawings of the articulators positions, tongue blades and straws Successive Approximation (Shaping): read page 540 involves shaping a new sound from one that is already in a client's repertoire the first step in shaping is to identify an initial response that the client can produce that is related to the terminal goal. Instruction moves through a series of graded steps or approximations, each progressively closer to the target behavior. Contextual Utilization: isolating a target sound from a particular phonetic context in which a client may happen to produce a sound correctly, even though they typically produce the sound in error. sounds are affected by phonetic and positional context, some contexts may facilitate the correct production of a sound. for example, word initial/r/ may be easier to produce in the clusters /tr/ , /dr/ , /gr/ Motor Establishment Guidelines: Perceptual training: contrast training using minimal pairs, is suggested as part of establishment when there is evidence that the production errors are due to perceptual problems When teaching production of a target sound, look for the target sound in the client's response repertoire through stimulability (imitation) testing, contextual testing (including consonant clusters, other word positions, and phonetic contexts), and observation of a connected speech sample. the recommended hierarchy for eliciting sounds that cannot be produced on demand is: a) imitation b) phonetic placement c) successive approximation (shaping) d) contextual utilization Beyond Individual Sounds: Traditional Approach: 1) isolation 2) syllables: suggested sequence for syllable practice: CV, VC, VCV, CVC 3) words: begin with monosyllabic words, then monosyllabic words with clusters to more complex words 4) phrases: two to four word phrases 5) sentences 6) conversation the traditional approach might not be the most efficient fir clients with multiple errors, especially those whose errors are rather linguistic than motor based Modi cations to the Traditional Approach: speech motor chaining (SMC): appropriate for both older children with persistent or residual speech sound errors those with CAS SMC aims to teach the child to generate complex speech by combining core movements with principles of motor learning complexity is slowly built up via a chain. a chain is a series of five steps, each consisting of progressively longer stimuli with the target sequence embedded within it. SMC adds efficiency to traditional therapy by compressing much of the therapy hierarchy into a much shorter period. /gu/ - gum - gumball - small gumball - [self-generated: "I can see the small gumball."] fi Concurrent Treatment: begins with establishment of the sound using any of the available elicitation procedures. However, the rest of the therapy sequence is then completely randomized. Each target sound is taught in a different random order. strength: by randomizing the therapy sequence, generalization is built in from the very beginning. limitation: is that the rapid switching of task demands that this approach requires may be very confusing for some younger children or for those with comorbid cognitive or language impairments. Systematic Articulation Training Program Accessing Computers: (SATPAC) is a context utilization approach that makes use of the traditional therapy sequence. the most unique feature of SATPAC is its use of nonwords (also called nonsense words) to establish the target sounds. Nonwords are sound sequences that follow the phonotactic rules of English but have no meaning. strengths: SATPAC offers a high level of structure to keep therapy focused and moving forward. Its use of nonwords avoids the practice of over-learned bad habits; the use of facilitating contexts helps ensure a high level of success. limitations: it focuses on drill, which some children resist + the cost of the software Context Utilization Approaches: articulatory (motor-based) errors can be corrected by motor practice of articulatory behaviors, with syllabic units as a basic building block for later motor practice at more complex levels. To employ this approach, a sound must be in the client's repertoire. strength: it builds on behaviors (segmental productions in particular phonetic contexts) that are in a client's repertoire and capitalizes on syllables plus auditory, tactile, and kinesthetic awareness of motor movements. limitation: the difficulty in motivating many children to engage in the extensive imitation and drill that this approach uses Remediation Guidelines for Motor Approaches: A motor approach to remediation is recommended as a teaching procedure for clients who evidence motor production problems. A motor approach can also be incorporated into treatment programs for clients reflecting linguistically based errors. Instruction should be initiated at the highest linguistic unit level (isolation, syllable, word) at which a client can produce target sounds. Perceptual training for those clients who evidence perceptual problems related to their error sounds is recommended as part of a motor remediation program. Remediation of Vowels: most speech sound intervention in english focuses on consonants four different clinical populations are likely to present with difficulty with vowels: the birth-3 population second-language learners individuals with significant hearing impairment individuals with CAS targeting vowel errors may improve overall message intelligibility, improve speech acceptability (i.e., make it sound more similar to the intended dialect), potentially accelerate therapy progress, and make the child's overall speech system more consistent with the normal developmental pattern (i.e., given that vowels are typically mastered before consonants). Treatment Approaches for Vowels: vowel errors could be caused by: delayed languages learning, structural anomalies, motor impairments a series of suggestions for teaching vowels that use general procedures that are very similar to those used for consonants (i.e., phonetic placement, successive approximation, etc.). frameworks used for consonants may be equally effective for vowels The Use of Non-Speech Motor Activities: also referred to as mouth gymnastics, they include: horn or whistle blowing, sucking through straws, and tongue wagging with no speech sounds produced no strong evidence suggests that NSOMTs are an effective treatment or an effective adjunctive treatment for children with developmental speech sound disorders NSOMT is of no value for improving velopharyngeal function or correcting compensatory articulation errors in children with cleft palate. Case Study Example: read pages 572 - 573