Phonological Intervention 1 PDF

14 CHAPTER Cycles Approach LEARNING OBJECTIVES After reading this chapter and completing the learning activities, you should be able to: Explain the principles related to the...

14 CHAPTER Cycles Approach LEARNING OBJECTIVES After reading this chapter and completing the learning activities, you should be able to: Explain the principles related to the cycles approach Describe the treatment model of cycles utilized in the approach Design an intervention session plan with goals and activities Summarize a therapy session in the form of a SOAP (the acronym for subjective, objective, assessment, plan) note INTRODUCTION The cycles approach (Hodson, 2006, 2007; Hodson & Paden, 1983, 1991) is designed for children with speech sound production errors that affect classes of sounds. The approach is specifically beneficial for children with severe to profound speech sound disorders charac- terized by phonological processes. Treatment is planned in a cyclical pattern. Based on a percentage of occurrence, phonological processes are identified as targets for intervention rather than individual phonemes. Several sounds are selected for each of the phonological patterns and are targeted for a predetermined amount of time. Each phonological pattern is treated individually. All phonological patterns identified for intervention are treated. Once the patterns have each been treated one time, this completes one cycle. Cycles are repeated until the child demonstrates the acquisition of the phonological patterns. The cycles approach is based on seven important principles (Prezas & Hodson, 2010). The first two principles reflect that the cycles approach is based on the gradual, developmental acquisition of speech sounds (Hodson, 2006), and that children primarily learn speech sounds through auditory input (Van Riper, 1939). This method of therapeutic progression is modeled after the gradual nature of normal phonological development. As such, each cycle for inter- vention continues for a predetermined period of time and not according to the achievement of a criterion level of performance. Further, amplified auditory stimulation is incorporated to 257 258 Chapter 14 Cycles Approach help children become more aware of the sounds that they are hearing (Hodson, 2007). Treat- ment activities emphasize auditory bombardment, play, and drill-play activities to facilitate the acquisition of phonological patterns. The third principle is that children learn about the kines- thetic and auditory properties of speech sound production as they are learning how to produce them. Therefore, targets are selected for which the child is stimulable. The fourth principle emphasizes the importance of phonetic environments that facilitate the accurate production of target words or patterns. This principle utilizes the previously discussed intervention strate- gies of stimulability or of a facilitating context which is the phonetic environment that is most conducive to a correct production (Hodson, 2007; Rvachew & Nowak, 2001). Utilizing pho- nemes for which a child is stimulable, or a facilitating phonetic context, ensures that practice involves correct sound productions and reduces the potential impact of negative practice asso- ciated with error productions. The fifth principle emphasizes the active engagement children demonstrate as they are learning the phonological system of their language. Activities which foster mental and physical participation facilitate phonological learning. Production practice for the cycles approach occurs during the drill, and fun, drill-play-types of activities (Prezas & Hodson, 2010). The sixth principle builds on the concept of generalization. As such, a small group of speech sounds or syllable shapes are utilized to facilitate progress with each pattern targeted. A few sounds are targeted within each pattern with the expectation that generaliza- tion will occur across the child’s phonological system (McReynolds & Bennett, 1972). The seventh principle acknowledges Vygotsky’s (1978) concept of the zone of proximal develop- ment. This concept emphasizes the zone of proximal development as the skills to which a child could developmentally progress with assistance or skilled instruction (Berk, 2007). Clinically, this means that intervention focuses on skills and tasks just beyond the child’s current level of functioning in order to challenge, yet allow the child to experience success (Hodson, 2007). TARGET SELECTION Target selection begins with a review of assessment and analysis results. Treatment planning begins with the results of standardized assessments that provide a frequency of occurrence score for phonological processes that a child is demonstrating. Assessment results are utilized to identify deficit patterns that will be cycled for a predetermined time period according to a sequence of structured sessions (Hodson, 2011). The Hodson Assessment of Phonological Patterns (HAPP-3) (Hodson, 2004) is a commonly utilized assessment tool that provides a percentage of occurrence score for common phonological processes or patterns. The Khan-Lewis Phonological Analysis-3 (KLPA-3) (Khan & Lewis, 2015), used in conjunction with the Goldman-Fristoe Test of Articulation-3 (GFTA-3) (Goldman & Fristoe, 2015), also provides the analysis and the results that reflect frequency of occurrence for phono- logical processes. Patterns observed during the comprehensive assessment at greater than 40% of opportunities are identified as intervention targets (Hodson, 2007). The phono- logical patterns are then organized into primary, secondary, and advanced target patterns. See TABLE 14.1 for target patterns and phonemes targeted to facilitate the acquisition of phonological patterns.  Target Selection 259 TABLE 14.1 Sequence of Primary, Secondary, and Advance Target Patterns for Cycles Approach Pattern Subtype Description Suggested Phoneme Sample Target Targets Words Primary Word Maintaining Two- and three-syllable teepee, tummy, party target structures syllableness and word word combinations and hat, elefant, patterns shapes singleton consonants up, pa, pop, and opa in CV, VC, CVC, and (for “open”) VCV word shapes /s/ clusters or Producing all sp-, st-, sm- spot, stop, smart, consonant elements of the (beginnings of words) dots, and dips sequences consonant sequences -ts, -ps (ends of words) Anterior- Demonstrating Word-final and word- cook, kick, tick, posterior contrasts of velars, initial velars /k, g, h/ tock, coat, and cat contrasts alveolars, and combine with alveolars bilabials Liquids Production of liquid /l, r/; word initial green, grow, crazy, phonemes clusters when the child cream, is able to produce blue, and plate velars and /l/ Secondary Palatals Production of glides, /j, ʒ, ʃ, ʧ, ʤ, ɝ, ɚ/ yes, beige, shoe, target sibilants, and vocalic chop, jaw, bird, and patterns /ɝ, ɚ/ letter Other Consonant sequences /kw, pr, bl, spl, spr, str/ quiet, quick, black, consonant in the medial and print, sprout, split, sequences final word positions; and straw combining sonorants and glides, liquids, and three-element consonant sequences Singleton Production of /f, s/ foot, food, soap, and stridents strident phonemes soup Prevocalic Production of voiced /d, g, b/ dog, bee, and go voicing phonemes in the prevocalic position Nondialect vowel contrasts Assimilations Not phoneme-specific (continues) 260 Chapter 14 Cycles Approach TABLE 14.1 Sequence of Primary, Secondary, and Advance Target Patterns for Cycles Approach (Continued) Pattern Subtype Description Suggested Phoneme Sample Target Targets Words Idiosyncratic Backing, initial Backing may be dog, cat, duck, doc, processes consonant deletion targeted in anterior- tack, take, and coat posterior contrasts Advanced Complex Maintain syllable Not phoneme-specific ambulance, target multisyllabic structure of cinnamon, patterns words; multisyllabic hippopotamus, complex words; maintain all strengths, extra, and consonant elements of complex excuse sequences consonant sequences CV = consonant-vowel; VC = vowel-consonant; CVC = consonant-vowel-consonant; VCV = vowel-consonant-vowel. Adapted from Hodson, B.W. (2007). Evaluating and enhancing children’s phonological systems: Research and theory to practice. Greenville, SC: Thinking Publications. STRATEGIES/PROCEDURES Once the patterns are identified and characterized as primary, secondary, and advanced, the first cycle is planned. A cycle is a phase of intervention during which select phonemes for each target pattern are targeted. The therapeutic progression for the cycles approach begins with the primary target patterns. Each phoneme or consonant sequence selected for the pattern is targeted for approximately 1 hour. Hodson (2007) suggests that each pattern is targeted for 2–6 hours per cycle. A cycle may continue for up to 16 weeks. Once a cycle is completed, a phonological assessment is completed to assess the child’s progress. The results will determine the processes or patterns that will comprise the next cycle. Patterns which have a frequency of occurrence of less than 40% can be eliminated from the cycle. Patterns that persist are recycled until they are observed in connected speech. Secondary patterns are introduced during subsequent cycles once the child has established the following patterns: syllableness, word structure (no consonant singleton omissions), anterior-posterior contrasts, evidence of the emergence of stridency, and the suppression of gliding (Hodson, 2007). Intervention sessions utilizing the cycles approach will incorporate the following critical elements: Review of target words from a previous session, when applicable. Amplified auditory stimulation of the list of target words for the session; typically 20 words for the intervention target. Focus on a subset of target words that have a facilitating phonetic context; four to five target words are selected for the creation of cards with the word written on the card and the child draws a picture to illustrate the target words.  Strategies/Procedures 261 Activities that are in drill-play format to provide production practice; two to six activities may be needed, depending on the length of the therapy session. Stimulability probes to determine the target phoneme to be utilized for the target pattern in the next therapy session. Emergent literacy activity for phonological awareness. Amplified auditory stimulation. Review of homework. Amplified auditory stimulation builds from the theoretical perspective that children learn about the sounds system of the language through auditory input. The amplified mode of presentation is designed to maximize the child’s attention to the acoustic features of the sounds. From a multisensory perspective, cueing the child to also watch the clinician’s mouth during presentation will provide visual information about the position and movement of the articulators. Amplified auditory stimulation of the word list involves verbal recitation of the target words at the word level. From a language development perspective, consideration for reading each word individually and then presenting the word in a sentence provides addi- tional linguistic information related to vocabulary and syntax. The child is provided a model of the word being used appropriately in context which may facilitate the development of vocabulary. See Appendix 14-A for a sample cycles session planning template. The cycles approach can be modified for younger children. The modified approach for toddlers utilizes auditory stimulation of primary patterns (Hodson, 2011). Intervention goals for the cycles approach follow the guidelines for operationally defined behavioral objectives. In addition, the goals for the cycles approach should reflect that the frequency of occurrence of phonological processes is to be reduced. Therefore, the do state- ment of the objective will reflect the reduction in the use of the phonological processes with a statement similar to “produce the phonemes /p, t, k/ in the final word position at the word level to reduce the frequency of occurrence of final consonant deletion to less than 40%.” Clinical Application: Objective Writing for the Cycles Approach Write a behavioral objective for a child working on final consonant deletion: Do: produce the phonemes /p, t, k/ in the final word position at the word level Conditions: in imitation of the clinician or in response to pictures Criterion: reduce the frequency of occurrence of final consonant deletion to less than 40% Combine the above components into a behavioral objective. 262 Chapter 14 Cycles Approach CHAPTER SUMMARY The cycles approach (Hodson, 2006, 2007; Hodson & Paden, 1983, 1991) as well as the modified cycles approach (Hodson, 2011) have been shown to be effective treatment approaches for children who have highly unintelligible speech characterized by a high frequency of phonological processes or patterns (Almost & Rosenbaum, 1998; Contour, Louko, & Edwards, 1993; Culatta, Setzer, & Horn, 2005; Gillon, 2005; Glaspey & MacLeod, 2010; Glaspey & Stoel-Gammon, 2005, 2007; MacLeod & Glaspey, 2014; Rvachew, Nowak, & Cloutier, 2004; Tyler & Watterson, 1991). The approach is based on the gradual nature of speech sound and pattern acquisition and the primarily auditory means through which children acquire speech sounds. The cycles approach is designed to provide stimulation for specific subset of phonemes within a particular pattern for a determined time period. The patterns are arranged in cycles and are repeated in subsequent cycles as needed. CHAPTER CASE STUDY—CLINICAL APPLICATION Using the test results obtained from the administration of GFTA-3 and KLPA-3, identify potential targets for the first cycle of intervention. Write behavioral objec- tives to reflect the intervention goals for the target sounds selected. Design a therapy session that reflects activities to facilitate learning and achieving the identified goals, the procedures utilized to elicit, and the cueing strategies to modify or reinforce pro- duction attempts. Next, write a session note in the SOAP format for a session that you can envision may have occurred as a result of the session planned. Lastly, write a hypothetical progress note that summarizes progress over a 3-month time period. The Therapy Session Planning Template in Appendix 14-B can be used for this activity. The following responses were obtained for Anna, 5 years, 8 months of age. Target Response Target Response Target Response house [haʊt] slide [taɪ] blue [bwu] door [dor] swing [tɪ] yellow [wɛwo] pig [pɪg] guitar [dɪta] brother [bʌdo] cup [tʌp] lion [waɪə] frog [fwɔd] boy [boɪ] chair [ ʃɛə] green [dwi] apple [æpl] soap [top] that [dæt] go [do] glasses [dætɪ] leaf [wif ] duck [dʌt] tiger [taɪdə] cookie [tʊtɪ] quack [tæ] puzzle [pʌdo] cheese [ ʃi] table [tebo] finger [bɪndə] pajamas [pʌdæmə]  Key Terms 263 monkey [mʌnti] ring [wɪn] teeth [tif ] hammer [hæmə] thumb [ϴʌm] princess [pwɪntə] fish [fɪʃ ] elephant [ɛwəfɪ] crown [taʊn] watch [waʃ ] vacuum [bætu] truck [twʌ] spider [paɪdə] shovel [ ʃʌbə] red [wɛ] web [wɛ] teacher [tiʃə] juice [du] drum [dʌm] zebra [dibə] zoo [du] plate [pet] giraffe [dəwæ] star [ta] knife [naɪ] vegetable [bɛdəbo] five [faɪ] shoe [ ʃu] brushing [bʌʃɪ] seven [tɛbən] Anna achieved the following percentages of occurrence for core phonological processes on the KLPA-3: Phonological Process Number of Total Possible Percentage of Occurrences Occurences Occurrences (%) Deaffrication 7 8 87.5 Gliding of liquids 12 20 60 Stopping of fricatives and 21 48 44 affricates Stridency deletion 25 42 60 Vocalization 9 15 60 Palatal fronting 4 12 33 Velar fronting 17 23 74 Cluster simplification 16 23 70 Deletion of the final consonant 18 36 50 Syllable reduction 1 25 4 Final devoicing Initial voicing 1 33 3 KEY TERMS Advanced target patterns Cycle Phonological process Amplified auditory Phonological awareness Primary target patterns stimulation Phonological patterns Secondary target patterns 264 Chapter 14 Cycles Approach CHAPTER EXERCISES 1. Outline the progression of therapy using the cycles approach. 2. Describe the theoretical bases for the cycles approach. 3. Provide an explanation for the amplified auditory stimulation strategies. REFERENCES Almost, D., & Rosenbaum, P. (1998). Effectiveness of speech intervention for phonological disorders: A randomized controlled trial. Developmental Medicine and Child Neurology, 40, 319–325. Berk, L. (2007). Development through the lifespan. Boston, MA: Pearson Education. Contour, E. G., Louko, L. J., & Edwards, M. L. (1993). Simultaneously treating stuttering and disor- dered phonology in children. American Journal of Speech-Language Pathology, 2(3), 72–81. Culatta, B., Setzer, L. A., & Horn, D. (2005). Meaning-based intervention for a child with speech and language disorders. Topics in Language Disorders, 25(4), 388–401. Gierut, J. (2001). Complexity in phonological treatment: Clinical factors. Language, Speech, and Hear- ing Services in Schools, 32, 229–241. Gierut, J. (2005). Phonological intervention: The how or the what? In A. G. Kamhi & K. E. Pollock (Eds.), Phonological disorders in children: Clinical decision making in assessment and intervention (pp. 201–210). Baltimore, MD: Paul H. Brookes. Gierut, J. (2007). Phonological complexity and language learnability. American Journal of Speech- Language Pathology, 16(1), 6–17. Gillon, G. T. (2005). Facilitating phoneme awareness development in 3- and 4-year old children with speech impairment. Language, Speech, and Hearing Services in Schools, 36, 308–324. Glaspey, A. M., & MacLeod, A. A. N. (2010). A multi-dimensional approach to gradient change in phonological acquisition: A case study of disordered speech development. Clinical Linguistics and Phonetics, 24(4–5), 283–299. Glaspey, A. M., & Stoel-Gammon, C. (2005). Dynamic assessment in phonological disorders: The scaffolding scale of stimulability. Topics in Language Disorders, 25(3), 220–230. Glaspey, A. M., & Stoel-Gammon, C. (2007). A dynamic approach to phonological assessment. Inter- national Journal of Speech-Language Pathology, 9(4), 286–296. Goldman, R., & Fristoe, M. (2015). Goldman-Fristoe test of articulation-3 (GFTA-3). Circle Pines, MN: American Guidance Service. Hodson, B. W. (2004). Hodson assessment of phonological patterns: Third edition. Austin, TX: Pro-Ed. Hodson, B. W. (2006). Identifying phonological patterns and projecting remediation cycles: Expediting intelligibility gains of a 7 year old Australian child. International Journal of Speech-Language Pathol- ogy, 8(3), 257–264. Hodson, B. W. (2007). Evaluating and enhancing children’s phonological systems: Research and theory to practice. Greenville, SC: Thinking Publications. Hodson, B. W. (2011). Enhancing phonological patterns of young children with highly unintelligible speech. The ASHA Leader, 16(4), 16–19. Hodson, B. W., & Paden, E. P. (1983). Targeting intelligible speech: A phonological approach to remediation. San Diego, CA: College-Hill. Hodson, B. W., & Paden, E. P. (1991). Targeting intelligible speech: A phonological approach to remediation. Austin, TX: Pro-Ed.  References 265 Khan, L. M. L. & Lewis, N. P. (2015). Khan-Lewis phonological analysis—3rd edition (KLPA-3). Upper Saddle River, NJ: Pearson Education. Lowe, R. J. (1994). Phonology: Assessment and intervention application in speech pathology. Baltimore, MD: Williams & Wilkins. MacLeod, A. A. N., & Glaspey, A. M. (2014). A multidimensional view of gradient change in velar acquisition in three-year-olds receiving phonological treatment. Clinical Linguistics and Phonetics, 28(9), 664–681. McReynolds, L. V., & Bennett, S. (1972). Distinctive feature generalization in articulation training. Journal of Speech and Hearing Disorders, 37, 462–470. Prezas, R. F., & Hodson, B. W. (2010). The cycles phonological remediation approach. In A. L. Williams, S. McLeod, & R. J. McCauley (Eds.), Interventions for speech sound disorders in children (pp. 137– 157). Baltimore, MD: Paul H. Brookes. Rvachew, S., & Nowak, M. (2001). The effect of target-selection strategy on phonological learning. Journal of Speech, Language, and Hearing Research, 44, 610–623. Rvachew, S., Nowak, M., & Cloutier, G. A. (2004). Effect of phonemic perception training on the speech production and phonological awareness skills of children with expressive phonological delay. American Journal of Speech-Language Pathology, 13(3), 25–263. Stoel-Gammon, C., & Dunn, C. (1985). Normal and disordered phonology in children. Baltimore, MD: University Park Press. Tyler, A. A., & Watterson, K. H. (1991). Effects of phonological versus language intervention in pre- schoolers with both phonological and language impairment. Child Language Teaching and Therapy, 7(2), 141–160. Van Riper, C. (1939). Speech correction: Principles and methods. Englewood Cliffs, NJ: Prentice-Hall. Vygotsky, L. (1978). Mind in society: The development of higher psychological processes (M. Cole, V. John-Steiner, S. Scribner, & E. Souberman, Eds. & Trans.). Cambridge, MA: Harvard Univer- sity Press. Weiner, F. F. (1981). Treatment of phonological disability using the method of meaningful minimal contrast: Two case studies. Journal of Speech and Hearing Disorders, 46, 97–103. 266 Chapter 14 Cycles Approach APPENDIX 14-A SAMPLE CYCLES SESSION ACTIVITY PLANNING TEMPLATE Child: cycle # Session date: Session pattern target: Session phonemes for pattern: 1. Review of previous session words. 2. Auditory stimulation words (up to 20). 3. Target words for activities (words with facilitating phonetic contexts; usually 4–5). 4. Description of activities for production practice. 5. Stimulability for phoneme or pattern to be targeted next. 6. Description of emergent literacy activity/phonological awareness. 7. Repetition of auditory stimulation. 8. Review homework.  Appendix 14-B Therapy Session Planning Template 267 APPENDIX 14-B THERAPY SESSION PLANNING TEMPLATE Intervention approach: Cycles approach Client: Anna Age: 5 years, 8 months Target selection for cycle 1 Writing behavioral objectives Designing a session plan/procedures (utilize the template provided in Appendix 14-A) Writing a session note S: O: A: P: Progress report  15 CHAPTER Minimal Pairs/Minimal Oppositions Contrast Approach LEARNING OBJECTIVES After reading this chapter and completing the learning activities, you should be able to: Explain the principles related to the minimal pairs approach Explain the principles related to minimal oppositions approach Describe the target selection guidelines utilized in the minimal oppositions approach Design an intervention session plan with goals and activities Summarize a therapy session in the form of a SOAP (the acronym for subjective, objective, assessment, plan) note INTRODUCTION Historically, the minimal pairs approach emphasizes the use of word pairs that differ by one phoneme to highlight the change in meaning that is a result of the error (Barlow & Gierut, 2002). Thus, the error signals a deficit in knowledge of the function of sounds to result in the intended meaning. For example, a child may say [ti] for tea, but also for see. The words are produced as homonyms and the phoneme [s] is not used contrastively to establish the different meaning represented in the word see. The minimal pairs approach was originally conceptual- ized to contrast the error and the target (Weiner, 1981). The word pairs differed by one pho- neme. Using the present example, a child that consistently substitutes [t] for [s], other minimal word pairs that might be used in therapy could include toe/sew, two/sue, tap/sap, team/seam, and toon/soon. The error and the target are used contrastively in the minimal word pairs and highlighted to the child the need to produce a different phoneme to eliminate the homonymy. This is the original application of the concept of minimal pairs as proposed by Weiner (1981). 269 270 Chapter 15 Minimal Pairs/Minimal Oppositions Contrast Approach The minimal pair approach originally described by Weiner (1981) has been implemented in a variety of ways by researchers (Baker, 2010; Crosbie, Holm, & Dodd, 2005; Elbert, Dinnsen, Swartzlander, & Chin, 1990; Gierut, 1990, 1992; Williams, 2000). This minimal pair approach has served as the basis or foundation from which other contrastive therapeutic approaches have evolved. Primarily, the different approaches focus on how targets are selected for the minimal pairs. Each approach establishes minimal pairs as the treatment targets. The criteria for how the word pairs differ is what makes each of the approaches unique (Barlow & Gierut, 2002). Phonemes are consisted of features. Different combinations of features result in different phoneme realizations. Therefore, it is the combination of features of the phonemes that served to differentiate and create contrasts among phonemes. Phonemes are characterized and categorized according to the acoustic and production features called distinctive features, and according to the features of the place of articulation, manner of articulation, and voicing. The features of place, manner, and voicing are considered to be nonmajor class features. The examination of the number of feature differences that may be represented in minimal pairs also contributed to the distinction of different approaches that emphasized how sounds differed in minimal pairs. For example, the word pair of key and tea differs by one feature, the place of articulation. The phoneme [k] is a velar, stop, and is voiceless. The phoneme [t] is an alveolar, stop, and is voiceless. Thus, they differ only by one feature, the place of articulation. The word pair of my and buy differ by one feature, the manner of articulation. The phoneme [m] is a bilabial, nasal, and is voiced. The phoneme [b] is a bilabial, stop, and is voiced. Thus they differ by one feature, the manner of articulation. The word pair of two and do differ by one feature, voicing. The phoneme [t] is an alveolar, stop, and is voiceless. The phoneme [d] is an alveolar, stop, and is voiced. Thus, they differ by one feature, voicing. Extending this exercise in comparing the number of feature differences represented in minimal pairs, the minimal pair of keys and cheese can be examined. The two words differ by one phoneme. The phoneme [k] is a velar, stop, and is voiceless. The phoneme [ʧ] is a palatal, affricate, and is voiceless. Therefore, the phonemes differ across the two features of place and manner of articulation. One last set of minimal pairs is presented for consideration. The words go and sew are minimal pairs as they differ by one phoneme. Closer examination reveals that they differ across three features. The phoneme [g] is a velar, stop, and is voiced. The phoneme [s] is an alveolar, fricative, and is voiceless. Therefore, not all minimal pairs are the same. Thus, consideration must be made for how the phonemes in minimal pairs are different. Therefore, the term minimal pairs represents several approaches that utilize minimal word pairs as target word stimuli during intervention. The term minimal oppositions has been introduced to signify more specifically, minimal pairs that are minimally opposed and that differ by one feature. The remainder of this chapter will focus of the intervention strate- gies related to minimal oppositions. The minimal oppositions intervention approach is best suited for preschool-age children with several substitution errors. Forrest, Dinnsen, and Elbert (1997) also reported that the minimal oppositions approach is more appropriate for children who demonstrate consistent substitution errors. It is also suggested that a candidate for this approach would have intact cognitive skills so that the strategy of semantic confusion can be utilized effectively. The child would need to have sufficient skills to recognize the confusion created by the error.  Target Selection 271 TARGET SELECTION Target selection begins with a review of the assessment and analysis results. Treatment planning begins with the results of standardized assessments and informal analysis that provide information about the nature of the errors that a child is demonstrating. The place-manner-voice analysis provides additional information related to the number of feature differences among the wide range of substitutions demonstrated by a child. FIGURE 15.1 shows the place-manner-voicing analysis worksheet. Intervention targets for the minimal oppositions approach is selected from the substitution errors that are characterized by one feature difference. By doing so, the target is contrasted with the substitution error, consistent with the original format of the minimal pairs intervention. The consistency of error is also an indication for the intervention and target selection decisions. Therefore, the consistency of error analysis is considered when making target selection decisions. Consistent substitution errors are more appropriate for the mini- mal oppositions approach (Crosbie et al., 2005). FIGURE 15.2 represents the worksheet for the consistency of error analysis. Additional consideration is also given to other target selection guidelines such as developmental norms, stimulability, and impact on intelligibility. Clinical Application: Target Selection for Minimal Oppositions Audrey, age 6 years, 1 month, consistently substitutes [t] for [k]. This has been identified as a target pair for intervention using minimal oppositions contrast word pairs. Develop a list of five word pairs for Audrey. Summary of Place-Manner-Voicing Changes: Target Substitution Place-Manner Voicing Differences and Specific Number of Phoneme Feature Changes Occurrences in Sample P M V P M V P M V (Continues) 272 Chapter 15 Minimal Pairs/Minimal Oppositions Contrast Approach P M V P M V P M V P M V P M V Most frequent changes: Changes in Place of How Changes in Manner How Changes in How Production: many? of Production: many? Voicing: many? FIGURE 15.1 Place-Manner-Voicing Analysis Form. Courtesy of Carol Koch STRATEGIES/PROCEDURES Once the place-manner-voicing and consistency analyses are completed, the minimal pairs are selected for intervention. Typically, intervention utilizes three to five word pairs for production practice. Research has suggested that 6–10 target words are sufficient to teach contrastive use of the paired phonemes and generalization (Elbert, Powell, & Swartzlander, 1991). Intervention sessions utilizing any of the contrast approaches, of which minimal oppositions is one, will incorporate the types of activities:  Strategies/Procedures 273 Substitution Error Substitution Error Consistent Consistent Inconsistent Inconsistent Consistent Consistent Inconsistent Inconsistent Consistent Consistent Inconsistent Inconsistent Consistent Consistent Inconsistent Inconsistent Consistent Consistent Inconsistent Inconsistent Consistent Consistent Inconsistent Inconsistent Consistent Consistent Inconsistent Inconsistent FIGURE 15.2 Consistency of Error Analysis. 1. Familiarization of vocabulary and contrasted phonemes. This activity is geared to estab- lishing familiarity with the vocabulary represented in the target words as well as the phonemes that create the minimal pair contrast. The clinician would present the picture cards to the child, “This is a key. It starts with the ‘k’ sound. You use a key to start a car. This is a picture of tea. It starts with the ‘t’ sound. Some people like to drink tea.” 2. Familiarization training may also include perceptual training. Perceptual training is intended to establish that the child can hear the difference in the contrasted word pairs. In the same format as the above scenario, the clinician would present the set of target words to ensure familiarity with the vocabulary represented in the target words. Next, the pictures would be spread out on the table. The clinician would then be asked to point to, show, pick up, or touch the targets that are presented verbally. When the child can identify the targets with 90% accuracy, perceptual training is considered complete. 3. Production practice activities. Intervention practice involves activities that elicit imitative or spontaneous production of the target word pairs. The picture cards may be presented for the child to name. Or, alternately, the child may play the role of the clinician and instruct the clinician in which picture to select. 274 Chapter 15 Minimal Pairs/Minimal Oppositions Contrast Approach 4. Articulation instruction. During the production practice, the child may demonstrate difficulty with the accurate production of target phonemes. In this case, instructional strategies or cues are provided to facilitate accurate production. Auditory models for imitation, verbal or visual phonetic placement cues, metaphoric descriptions of the target sounds, successive approximation/shaping, or physical/tactual cues can be provided as instructional strategies or feedback. 5. Semantic confusion. During production practice activities, the clinician may indi- cate confusion to allow the child insight into the communication breakdown that occurred as a result of a production error. For example, the child is playing the role of the “teacher” and prompts the clinician to pick up the “tea,” but was looking at the picture of a “key.” The clinician would select the picture of a “tea.” Even though the clinician knew what the child intended to say, the response provided to the child reflects what was actually produced. This may also be called semantic confusion. The child is confronted with the result of the incorrect production. When the child indicates that the wrong picture was selected, the clinician might then offer, “Oh, I thought you said ‘tea’, but you actually meant to say ‘key’!” When the clinician produces the child’s production and the targeted contrast word in the clarification, the contrast is highlighted. This strategy highlights the breakdown in the communication that resulted from the wrong production. If the child is not able to repair the breakdown with a correct production of the target, additional production prompts such a phonetic cue may be offered in an attempt to elicit an accurate production. 6. Phrase and sentence level practice. To facilitate carryover to conversation, activities are designed to facilitate phrase and sentence level practice. 7. Parent involvement. Parents are important members of the intervention team. Parents will help with the completion of homework practice that is assigned between therapy sessions, provide guided therapeutic instruction, and offer feedback during unstruc- tured, conversational activities to facilitate carryover. As the child progresses and reaches criterion performance for demonstrating contrastive use of the phonemes targeted, additional minimally opposed target word pairs can be introduced, if appropriate, based on the analysis of errors completed. Intervention goals for minimal oppositions follow the guidelines for operationally defined behavioral objectives. In addition, the goals for minimal oppositions should reflect that a contrast between two words is being highlighted to illustrate the function of the target sounds in creating different, minimally opposed words. Therefore, the do statement of the objective will reflect the contrast nature of the minimal oppositions approach with a statement similar to, “will produce the phonemes /t, s/ in minimally opposed word pairs.”  Chapter Summary 275 Clinical Application: Objective Writing for the Minimal Oppositions Approach Write a behavioral objective for a child working on contrasting the sounds [t, s]: Do: produce the phonemes /t, s/ in minimally opposed word pairs at the word level Conditions: in imitation of the clinician or in response to pictures Criterion: 90% accuracy over two consecutive sessions Combine the above components into a behavioral objective. CHAPTER SUMMARY The minimal oppositions approach has been shown to be an effective treatment approach for children who demonstrate consistent sound substitution errors and who can attend to mini- mal feature differences between target word pairs (Baker, 2010; Dodd et al., 2008; Ruscello, Cartwright, Haines, & Shuster, 1993). Baker and McLeod (2011) provide a narrative review of 134 published articles in peer-reviewed scholarly journals on phonological interventions. Of those studies, 43 involved the minimal pair approach. Despite methodological differences between research design, focus of therapy, and level of production, overall, the minimal pair approach is effective. CHAPTER CASE STUDY—CLINICAL APPLICATION Continuing to utilize the Case Study “Sean,” the place-manner-voice analysis can be seen in FIGURE 15.3. The place-manner-voice analysis provides additional informa- tion related to the number of feature differences among the wide range of substitutions demonstrated by Sean. The consistency analysis for Sean is represented in FIGURE 15.4. Identify potential targets for minimal oppositions intervention. For minimal oppo- sitions, consideration is first given to substitution errors that involve one feature difference. Therefore, review the place-manner-voice analysis and identify the sub- stitutions with one feature change noted. Next consider the consistency of errors of the substitutions that involve one feature change. Optimally, consistent errors are selected for intervention. Inconsistent errors may be considered as targets for inter- vention. Write behavioral objectives to reflect the intervention goals for the target 276 Chapter 15 Minimal Pairs/Minimal Oppositions Contrast Approach Target Substitution Place-Manner Voicing Differences and Specific Number of Phoneme Feature Changes Occurrences in Sample P Z d M fricative → Stop 3 V P Z t M fricative → Stop 1 V Voiceless → Voiced 1 P Velar → lingua-alveolar 1 ŋ nd M nasal → nasal / stop 1 V P Velar → lingua-alveolar 1 ŋ n M V P lingua-alveolar → bilabial 3 M liguid → glide 3 l w V P M liguid → fricative 1 l f V Voiced → Voiceless 1 P lingua-palatal → lingua - alveolar 3 t∫ t M affricate → Stop 3 V P lingua-palatal → lingua - alveolar 2 ∫ t M fricative → Stop 2 V Target Substitution Place-Manner Voicing Differences and Specific Number of Phoneme Feature Changes Occurrences in Sample P bilabial → lingua-alveolar 2 p d M V Voiceless → Voiced 2 P labiodental → bilabial 3 f b M fricative → Stop 3 V Voiceless → Voiced 3 P labiodental → bilabial 1 v M fricative → Stop 1 b V P labiodental → lingua - alveolar 1 M fricative → Stop 1 v d V P velar → lingua-alveolar 3 t M k V P velar → lingua-alveolar 1 g t M V Voiced → Voiceless 1  f b M op V Voiceless → Voiced 3 P labiodental → bilabial 1 v M fricative → Stop 1 b Chapter Summary 277 V P labiodental → lingua - alveolar 1 M fricative → Stop 1 v d V P velar → lingua-alveolar 3 t M k V P velar → lingua-alveolar 1 g t M V Voiced → Voiceless 1 P velar → lingua-alveolar 1 g d M V P t M fricative → Stop 3 S V Target Substitution Place-Manner Voicing Differences and Specific Number of Phoneme Feature Changes Occurrences in Sample P lingua-palatal → lingua-alveolar 1 ∫ S M V P lingua - palatal → lingua - alveolar 4 ʤ d M affricate → Stop 4 V P interderntal → lingua - alveolar 1 ð d M fricative → Stop 1 V P interdental → bilabial 1 θ b M fricative → Stop 1 V Voiceless → voiced 1 P M V P M V P M V P M V 278 Chapter 15 Minimal Pairs/Minimal Oppositions Contrast Approach Changes in Place of How Changes in Manner How Changes in How Production: Many? of Production: Many? Voicing: Many? bilabial → lingua-alv. 2 fricative → Stop 16 Voiceless → Voiced 7 labiodental → bilabial 4 liquid → glide 3 Voiced ŋ → oiceless 2 labiodental → lingua-alv. 1 liquid → fricative 1 velar → lingua-alv. 7 affricate → Stop 7 lingua-alv → bilabal 3 lingua-pal → lingu a-alv. 10 FIGURE 15.3 Place-Manner-Voice Analysis for Sean. sounds/patterns selected. Design a therapy session that reflects activities to facilitate learning and achieving the identified goals, the procedures utilized to elicit, and the cueing strategies to modify or reinforce production attempts. Next, write a session note in the SOAP format for a session that you can envision may have occurred as a result of the session planned. Lastly, write a hypothetical progress note that summa- rizes progress over a 3-month time period. The Therapy Session Planning Template in Appendix!15-A can be used for this activity. Substitution Target Substitution Target d p Consistent t S Consistent Inconsistent Inconsistent b f Consistent d Z Consistent Inconsistent Inconsistent b v Consistent t Z Consistent Inconsistent Inconsistent d v Consistent nd ŋ Consistent Inconsistent Inconsistent t k Consistent n ŋ Consistent Inconsistent Inconsistent t g Consistent w l Consistent Inconsistent Inconsistent d g Consistent f l Consistent Inconsistent Inconsistent  References 279 Substitution Target Substitution Target w r Consistent d θ Consistent Inconsistent Inconsistent d r Consistent Consistent Inconsistent Inconsistent t t∫ Consistent Consistent Inconsistent Inconsistent t ∫ Consistent Consistent Inconsistent Inconsistent s ∫ Consistent Consistent Inconsistent Inconsistent d ʤ Consistent Consistent Inconsistent Inconsistent d ð Consistent Consistent Inconsistent Inconsistent FIGURE 15.4 Consistency Analysis for Sean. KEY TERMS Consistency of error Manner of articulation Place of articulation Contrast Minimal oppositions Voicing Distinctive features Minimal pairs Homonymy Nonmajor class features CHAPTER EXERCISES 1. Describe the theoretical bases for the minimal pairs approach. 2. Describe the history for how the selection of minimal pair word sets has changed or evolved. 3. Describe and give examples of the strategies/activities that are utilized in minimal oppositions intervention. REFERENCES Baker, E. (2010). Minimal pair intervention, In A. L. Williams, S. McLeod, & R. J. McCauley (Eds.), Interventions for speech sound disorders in children (pp. 41–72). Baltimore, MD: Paul H. Brookes. Baker, E., & McLeod, S. (2011). Evidence-based practice for children with speech sound disorders: Part 1 narrative review. Language, Speech, and Hearing Services in Schools, 42(2), 102–139. 280 Chapter 15 Minimal Pairs/Minimal Oppositions Contrast Approach Barlow, J. A., & Gierut, J. A. (2002). Minimal pair approaches to phonological remediation. Seminars in Speech and Language, 23(1), 57–67. Berk, L. (2007). Development through the lifespan. Boston, MA: Pearson Education. Crosbie, S., Holm, A., & Dodd, B. (2005). Intervention for children with severe speech disorder: A compar- ison of two approaches. International Journal of Language and Communication Disorders, 40(4), 467–491. Dodd, B., Crosbie, S., McIntosh, B., Holm, A., Harvery, C., Liddy, M., … Rigby, H. (2008). The impact of selecting different contrasts in phonological therapy. International Journal of Speech-Language Pathology, 10(5), 334–345. Elbert, M., Dinnsen, D. A., Swartzlander, P., & Chin, S. B. (1990). Generalization to conversational speech. Journal of Speech and Hearing Research, 55, 694–699. Elbert, M., Powell, T. W., & Swartzlander, P. (1991). Toward a technology of generalization: How many exemplars are sufficient? Journal of Speech and Hearing Research, 34, 81–87. Forrest, K., Dinnsen, D. A., & Elbert, M. (1997). Impact of substitution patterns on phonological learning by misarticulating children. Clinical Linguistics and Phonetics, 11, 63–76. Gierut, J. A. (1990). Differential learning of phonological oppositions. Journal of Speech and Hearing Research, 33, 540–549. Gierut, J. A. (1992). The conditions and course of clinically induced phonological change. Journal of Speech and Hearing Research, 35, 1049–1063. Ruscello, D. M., Cartwright, L. R., Haines, K. B., & Shuster, L. I. (1993). The use of different service deliv- ery models for children with phonological disorders. Journal of Communication Disorders, 26, 193–203. Weiner, F. F. (1981). Treatment of phonological disability using the method of meaningful minimal contrast: Two case studies. Journal of Speech and Hearing Disorders, 46, 97–103. Williams, A. L. (2000). Multiple oppositions: Theoretical foundations for an alternative contrastive intervention approach. American Journal of Speech-Language Pathology, 9, 282–288.  Appendix 15-A Therapy Session Planning Template 281 APPENDIX 15-A THERAPY SESSION PLANNING TEMPLATE Intervention approach: Minimal oppositions approach Client: Sean Age: 5 years, 2 months Target selection Writing behavioral objectives Designing a session plan/procedures Writing a session note S: O: A: P: Progress report  16 CHAPTER Multiple Oppositions Contrast Approach LEARNING OBJECTIVES After reading this chapter and completing the learning activities, you should be able to: Explain the principles related to the multiple oppositions approach Describe the target selection guidelines utilized in the approach Design an intervention session plan with goals and activities Summarize a therapy session in the form of a SOAP (the acronym for subjec- tive, objective, assessment, plan) note INTRODUCTION The multiple oppositions approach is an adaptation of minimal pairs. Multiple oppositions is a contrastive approach that targets several error sounds that are represented in a collapse of phonemes (Williams, 1991, 2000b, 2003, 2005a, b, c). A collapse of phonemes is identi- fied when a child substitutes one sound across several different target sounds. The underly- ing premise is that the child’s system requires systematic reorganization through contrasting the error with several of the target sounds, thus creating multiple sets of minimal pairs. For example, if a child substitutes the phoneme [t] for [k, s, ʃ, ʧ], the words two, coo, sue, shoe, and chew, would all be produced as [tu]. Thus, the [t] substituted for the target phonemes of [k, s, ʃ, ʧ] represents a collapse of phonemes. The strategy for targeting several phonemes from a collapse is designed to facilitate the most learning about the phonological system. Williams (2010) proposed that children with significant speech sound disorders, characterized by mul- tiple phoneme collapses, have deficits in both the motor aspects of articulation as well as the phonemic difficulties related to the contrastive use of phonemes to create meaning. In other words, the deficits lie in both the form (production) and function of the sound system. Thus, 283 284 Chapter 16 Multiple Oppositions Contrast Approach the multiple oppositions approach addresses skills in both areas. Williams (2005c) proposed that the multiple oppositions approach achieves addressing both phonetic and phonemic skills through the following guiding principles: 1. The child must learn the phonological rules selected for intervention. 2. Intervention must include focused practice to result in the accurate production of targets. 3. Feedback must include information about how the different sounds create different meanings (semantic information). 4. Naturalistic activities will be utilized to provide the child the opportunity to learn the targets in a communicative context. TARGET SELECTION Target selection begins with a review of assessment and analysis results. Treatment planning begins with the results of standardized assessments and informal analysis that provide infor- mation about the nature of the errors that a child is demonstrating. The phoneme collapse of contrasts analysis provides additional information related to the multiple targets that are realized by one phoneme substitution. Refer to FIGURE 16.1 for the phoneme collapse of contrasts worksheet. Intervention targets for the multiple oppositions approach would be selected from the substitution errors that are represented in a phoneme collapse. In a phoneme collapse that involves up to four target phonemes, a clinician may decide to utilize all target phonemes in the treatment target words. If a child is demonstrating a significant collapse that involves more than four target phonemes, selecting phonemes across different phoneme classes is suggested. (Williams, 2005c). For example, an extensive collapse might be represented in a child that substitutes [b] for [d, k, g, m, n, s, l, r, ʃ, ʧ, j, h]. See FIGURE 16.2 for the conventional graphic representation of a phoneme collapse. Substitution Targets FIGURE 16.1 Collapse of Contrasts.  Target Selection 285 d k g m n b s l r ∫ t∫ j h FIGURE 16.2 Phoneme Collapse. d do dee m moo me b boo bee s sue see ʃ shoe she FIGURE 16.3 Treatment Set Selected from Extensive Phoneme Collapse. Rather than attempt to develop a list of target words for this extensive collapse, phonemes are selected to represent different phoneme classes. As previously discussed, the contrast approaches promote generalization across sound classes, thus each individual phoneme in the collapse does not need to be targeted. Using the significant collapse where the child substitutes [b] for [d, k, g, m, n, s, l, r, ʃ, ʧ, j, h], the collapse represents multiple errors related to each of the phoneme classes of stops, nasals, fricatives, liquids, glides, and affricates. Targets for interven- tion might include [b, d, m, s, ʃ] which would result in a target word set of boo, do, moo, sue, and shoe This set of minimal pair target words represent the phoneme classes of stops, nasals, and fricatives. Intervention sessions utilizing the multiple oppositions approach may incorpo- rate multiple treatment sets for the same phoneme collapse or for multiple phoneme collapses. Two treatment sets of multiple oppositions for the same phoneme collapse are represented in FIGURE 16.3. 286 Chapter 16 Multiple Oppositions Contrast Approach STRATEGIES/PROCEDURES Once the phoneme collapse is identified and the targets are selected for intervention, inter- vention sessions follow a four-phase progression. Williams (2000a, 2003, 2005b) outlines a four-phase approach that resembles the strategies utilized in minimal oppositions. Phase 1 focuses on familiarization and production of the contrasts. This phase is conducted in three steps. Phase 2 involves production of the contrasts within the context of interactive play activities. This phase is also conducted in three steps. Phase 3 focuses on the use of the con- trasts in spontaneous communicative contexts. Phase 4 involves naturalistic intervention strategies during conversational speech activities. TABLE 16.1 outlines the phases and steps for multiple opposition intervention. TABLE 16.1 Phases and Steps of Multiple Oppositions Approach Phase Step Description Example Phase 1: Step 1 The child learns The child is asked to identify target familiarization and about the target words production of target sounds that are If the contrasted sounds are [b, d, m, contrasts contrasted through s, ʃ ]: auditory models as [b] may be “the two lip sound” well as metaphors and descriptions of [d] the “short sound” the features of the [m] the “nose sound” sounds [s] the “snake sound” [ ʃ ] the “quiet sound” Step 2 The child learns The clinician presents the pictures, the vocabulary as models the words, uses the words in a represented in the sentence or a story, and continues to picture stimuli discuss the features of the target sounds as introduced in Step 1 Step 3 Production of the This step involves the imitation of the contrasts clinician model in addition to other cueing strategies such as phonetic placement, metaphor descriptions, successive approximations, and physical manipulation Phase 2: production Step 1 Imitative production The clinician models the target words of contrasts during of the contrasts and the child imitates them interactive play  Strategies/Procedures 287 Step 2 Production of the Targets are incorporated in contrasts during play!activities at the end of each interactive play session activities Activities could be crafts, farm or house play, or a pretend picnic Phase 3: contrasts Spontaneous use Target words can be arranged in a utilized in of the contrasts in concentration-style game or some type communicative a communicative of matching card game contexts context Phase 4: The clinician and The clinician presents conversational conversational the child engage in recasts to allow the child to self-correct recasts conversation production errors Intervention goals for multiple oppositions follow the guidelines for operationally defined behavioral objectives. In addition, the goals for multiple oppositions should reflect that a contrast set will be used from the collapse to illustrate the function of the target sounds in creating different words. Therefore, the do statement of the objective will reflect the contrast nature of the set of sounds being utilized from the collapse with a statement similar to “will produce and contrast the phoneme [b] with the phonemes [d, m, s, ʃ ] in minimal pair treat- ment sets using the multiple oppositions approach.” Clinical Application: Objective Writing for the Multiple Opposition Approach Write a behavioral objective for a child working on contrasting the sounds [b, d, m, s, ʃ ]: Do: produce and contrast the phoneme [b] with the phonemes [d, m, s, ʃ] in minimal pair treatment sets using the multiple oppositions intervention approach at the word level Conditions: in imitation of the clinician or in response to pictures Criterion: 90% accuracy over two consecutive sessions Combine the above components into a behavioral objective. 288 Chapter 16 Multiple Oppositions Contrast Approach CHAPTER SUMMARY The multiple oppositions approach has been shown to be an effective treatment approach for children who have highly unintelligible speech characterized by a collapse of phonemic contrasts (Allen, 2013; Liles & Williams, 2006; Williams, 2000a, b, 2005a, 2012). Allen (2013) emphasizes the importance of frequency of sessions, or intensity, as an important factor in opti- mal progress. Twice weekly sessions utilizing the multiple oppositions approach lead to optimal outcomes. Further, Williams (2000a, 2012) found that the number of sessions, or the recom- mended dose was 50–70 intervention sessions, each lasting 30 minutes. The approach is based on the premise that the child’s phonological system needs to be reorganized in order to eliminate the extensive homonymy represented in the collapse of phonemic contrasts. In the case of extensive phonemic collapses, phonemes are selected to represent 3–4 different classes. Generalization within and across phoneme classes facilitates the organization of the child’s sound system. CHAPTER CASE STUDY—CLINICAL APPLICATION Continuing to utilize the Case Study “Sean,” the collapse of contrasts analysis can be seen in FIGURE 16.4. The collapse of contrasts analysis provides additional informa- tion related to the extent of the substitutions demonstrated by Sean. Identify two sets of four phonemes that represent two different phoneme collapses. Next, develop three target sets for each collapse to be used with a multiple oppositions intervention approach. Write behavioral objectives to reflect the intervention goals for the target sounds selected. Design a therapy session that reflects activities to facilitate learning and achieving the identified goals, the procedures utilized to elicit, and the cueing strategies to modify or reinforce production attempts. Next, write a session note in the SOAP format for a session that you can envision may have occurred as a result of the session planned. Lastly, write a hypothetical progress note that summarizes progress over a 3-month time period. The Therapy Session Planning Template in Appendix!16-A can be used for this activity. Substitution Targets d p, v, g, z, r, ʤ, " t k, g, s, z, ʧ, ʃ b f, v, θ FIGURE 16.4 Collapse of Contrasts for Sean.  References 289 KEY TERMS Collapse of phonemes Multiple oppositions Collapse of phonemic Treatment set contrasts CHAPTER EXERCISES 1. Outline the progression of therapy using the multiple oppositions approach. 2. Describe the theoretical bases for the multiple oppositions approach. 3. What phonological analyses are important for making the clinical decision for imple- menting the multiple oppositions approach? 4. How are targets selected for the multiple oppositions approach? How is this different from target selection for the minimal oppositions approach. REFERENCES Allen, M. M. (2013). Intervention efficacy and intensity for children with speech sound disorders. Journal of Speech, Language, and Hearing Research, 56, 865–877. Liles, T., & Williams, A. L. (2006). A multiple oppositions approach with a mixed phonetic-phonemic speech disorder: Poster session presented at the annual convention of the American Speech-Language- Hearing Association, Miami, FL. Williams, A. L. (1991). Generalisation patterns associated with least knowledge. Journal of Speech and Hearing Research, 34, 722–733. Williams, A. L. (2000a). Multiple oppositions: Case studies of variables in phonological intervention. American Journal of Speech-Language Pathology, 9, 289–299. Williams, A. L. (2000b). Multiple oppositions: Theoretical foundations for an alternative contrastive intervention approach. American Journal of Speech-Language Pathology, 9, 282–288. Williams, A. L. (2003). Speech disorders resource guide for preschool children. Clifton Park, NY: Delmar Learning. Williams, A. L. (2005a) Assessment, target selection, and intervention: Dynamic interactions within a systemic perspective. Topics in Language Disorders, 25(3), 231–242. Williams, A. L. (2005b). From developmental norms to distance metrics: Past, present, and future direction for target selection practices. In A. G. Kamhi & K. E. Pollock (Eds.), Phonological disor- ders in children: Clinical decision making in assessment and intervention (pp. 101–108). Baltimore, MD: Paul H. Brookes. Williams, A. L. (2005c). A model and structure for phonological intervention. In A. G. Kamhi & K. E. Pollock (Eds.), Phonological disorders in children: Clinical decision making in assessment and inter- vention (pp. 189–199). Baltimore, MD: Paul H. Brookes. Williams, A. L. (2010). Multiple oppositions. In A. L. Williams, S. McLeod, & R. J. McCauley (Eds.), Interventions for speech sound disorders in children (pp. 73–93). Baltimore, MD: Paul H. Brookes. Williams, A. L. (2012). Intensity in phonological intervention: Is there a prescribed amount? Interna- tional Journal of Speech-Language Pathology, 14(5), 456–461. 290 Chapter 16 Multiple Oppositions Contrast Approach APPENDIX 16-A THERAPY SESSION PLANNING TEMPLATE Intervention approach: Multiple oppositions approach Client: Sean Age: 5 years, 2 months Target selection Writing behavioral objectives Designing a session plan/procedures Writing a session note S: O: A: P: Progress report  17 CHAPTER Maximal Oppositions Contrast Approach LEARNING OBJECTIVES After reading this chapter and completing the learning activities, you should be able to: Explain the principles related to the maximal oppositions approach Describe the target selection guidelines utilized in the approach Design an intervention session plan with goals and activities Summarize a therapy session in the form of a SOAP (the acronym for subjective, objective, assessment, plan) note INTRODUCTION The maximal oppositions approach is an adaptation of minimal pairs. Maximal oppositions approach emphasizes the specific ways in which contrasted word pairs are different. Gierut (1990, 1991, 1992) proposed that minimal word pairs can be different along three differ- ent dimensions: major class features, the nonmajor class features of distinctive features or place-manner-voicing, and whether a sound is in a child’s phonetic inventory. Major class features can be utilized to categorize phonemes by making a distinction between sonorants and obstruents. Thus, /s/ as an obstruent would be maximally different from /r/ which is a sonorant. The two words in a contrasted minimal pair may also be different according to maximal feature distinctions by the number of distinctive features by which the two sounds are different. As an example, /k/ and /l/ differ by eight distinctive features. The comparison can be viewed in TABLE 17.1. One or both sounds contrasted in the minimal pair set may also be sounds in the child’s phonetic inventory. Alternately, the child may not demon- strate knowledge of the two contrasted sounds, and the sounds are not present in the child’s 291 292 Chapter 17 Maximal Oppositions Contrast Approach TABLE 17.1 Distinctive Features Comparison Phoneme Distinctive Features Phoneme /k/ + Consonantal + /l/ ! Vocalic ! ! Sonorant + + Interrupted ! ! Strident ! + High ! ! Low ! + Back ! ! Anterior + ! Coronal + ! Rounded ! ! Distributed ! ! Lateral + ! Nasal ! ! Voiced + Note: Feature differences are highlighted. phonetic inventory. When sounds not in the child’s inventory are contrasted, this is referred to as the empty set. Another related dimension that can be utilized to examine the nature and extent of the distinction between two contrasted phonemes is place-manner-voicing. As such, phonemes may differ in one- two- or three- production features. See TABLE 17.2 for examples. The more feature differences, the more maximally different the contrasted word pairs. Recently, this approach has been associated with the complexity approach for target selection (Gierut, 2007). Selecting target sounds on the basis of complexity refers to sounds that are more complex, later developing, and nonstimulable. The analysis of distinctive features and place-manner-voicing provide the clinician with information related to nonmajor class features. Nonmajor class features offer another dimen- sion for determining the degree of maximal opposition for target word pairs. The strategy for selecting target word pairs that are maximally different is to facilitate more overall change to the child’s speech sound system. By emphasizing greater salient differ- ences in sounds through greater feature differences, intervention may result in more change in the acquisition of the features of the contrasts and more generalization to other sounds (Gierut, 1989, 1990). The strategy for targeting one or two unknown sounds that are not in the child’s inventory is also designed to facilitate the most learning about the phonological system. Additionally, targeting two new sounds not in the child’s phonetic inventory, the empty set, results in more generalization to untreated sounds. Thus, in maximal oppositions,  Introduction 293 TABLE 17.2 Examples of Production Feature Differences of Contrasted Word Pairs Word Pair Place Manner Voicing Number of Differences key-tea /k/ velar Both are stops Both are voiceless 1 /t/ lingua-alveolar place toe-sew Both are /t/ stop Both are voiceless 1 lingua-alveolar /s/ fricative manner bat-pat Both are bilabial Both are stops /b/ voiced 1 /p/ voiceless voicing keys-cheese /k/ lingua-velar /k/ stop Both are voiceless 2 /ʧ/ lingua-palatal /ʧ/ affricate place-manner go-sew /g/ lingua-velar /g/ stop /g/ voiced 3 /s/ lingua-alveolar /s/ fricative /s/ voiceless place-manner-voicing Note: Production feature differences are highlighted. there are several different combinations of the factors that are considered for target selection. FIGURE 17.1 illustrates the various ways that the factors can be combined and how these fall along a continuum of predicted change to the child’s phonological system. The theoretical foundation for maximal oppositions is that emphasizing the feature differences between sounds prompts change in the child’s phonological system. This is in Least predicted change A new phoneme paired with a functional phoneme. A non major feature difference (distinctive features or PMV). Two new paired phonemes. A non major feature difference (distinctive features or PMV). A new phoneme paired with a functional phoneme. A major class feature difference. Two new paired phonemes. A major class feature difference. Most predicted The empty set. change FIGURE 17.1 Factors along the Continuum of Maximal Opposition. 294 Chapter 17 Maximal Oppositions Contrast Approach contrast to the functional nature of contrasting meaning differences in the other minimal pairs approaches (Geirut, 1991). TARGET SELECTION Target selection begins with a review of assessment and analysis results. Treatment plan- ning begins with the results of standardized assessments and informal analysis that provide information about the nature of the errors that a child is demonstrating. The feature analysis utilizing place-manner-voicing provides additional information related to the extent of the feature differences among error phonemes or phonemes that are not in the child’s phonetic inventory. See TABLE 17.3 for the place-manner-voicing (PMV) analysis worksheet that can be utilized to determine the type of feature differences that will support target selection. The more differences between phonemes along the dimensions of PMV, the more maximally opposed the word pairs. The distinctive feature analysis can also be completed. See Table 17.1 for a sample worksheet for distinctive feature analysis. Intervention targets for the maximal oppositions approach fall along a continuum of the degree of maximal oppositions, according to the degree of expected change in the child’s phonological system as a result of interven- tion (Ruscello, 2008). Figure 17.1 presents the continuum. Once the sounds for intervention have been identified, minimal pairs are created. According to Gierut (2008), eight novel word pairs are created. Novel words are words that are created to contrast the two phonemes. Often in maximal oppositions intervention it is challenging to identify true words for which the word initial phonemes are maximally contrasted. Additionally, in maximal oppositions intervention, the emphasis is not on the TABLE 17.3 Place-Manner-Voicing Analysis Worksheet Summary of Place-Manner-Voicing Changes: Target Substitution Place-Manner Voicing Differences and Number of Phoneme Specific Feature Changes Occurrences in Sample P M V P M V P M V  Target Selection 295 P M V P M V P M V P M V P M V Most frequent changes: Changes in Place How Changes in Manner How Changes in How of Production: Many? of Production: Many? Voicing: Many? conversational repair strategies needed through functional confrontation when homonymy interferes with the intended message. Rather, maximal oppositions intervention is designed to contrast a set of feature differences among sounds (Gierut, Morrisette, & Ziemer, 2010). Therefore, target selection often results in the creation of novel words. The novel words are then assigned lexical meaning to create concrete associations for the child. Novel words may become the names for pets or other animals, names for characters from video games, or labels from unusual objects. As an example, a picture of a dog whose name is “Zot” may be utilized. Prior to the two phases of formal intervention, the child is familiarized with the newly created words. 296 Chapter 17 Maximal Oppositions Contrast Approach STRATEGIES/PROCEDURES Once the phoneme contrasts are identified, the targets are selected for intervention, and the child has been familiarized with the novel words selected as the targets, the intervention ses- sions follow a two-phase progression. Phase 1 focuses on imitation of the contrasts. During this phase, the child is asked to imitate the clinician’s model of the target words. Verbal feedback is provided in the form of positive reinforcement for correct productions and instructional feed- back for incorrect productions. The wide range of prompting strategies, such as metaphors, visual cues, placement cues, manual manipulation, and successive approximations can be used as needed to facilitate correct production. Production practice in a drill-play format allows for maximum opportunities for practice while maintaining the client’s interest and motivation. A criterion of 80% accuracy is a common guideline for advancing to Phase 2. Phase 2 involves spontaneous production. Activities common for spontaneous production might include: picture card naming of target words without a verbal model, matching-type card games, silly stories composed of target words, or the use of target words in child-generated sentences. The intervention goals for maximal oppositions follow the guidelines for operationally defined behavioral objectives. In addition, the goals for maximal oppositions should reflect that a contrast between two words is being highlighted to illustrate the nature of the feature differ- ences of the target sounds in creating different, maximally opposed words. Therefore, the do statement of the objective will reflect the contrast nature of the maximal opposition approach with a statement similar to “will produce the phonemes /k, l/ in maximally opposed word pairs.” Clinical Application: Objective Writing for the Maximal Oppositions Approach Write a behavioral objective for a child working on contrasting the sounds [k, l]: Do: produce the phonemes /k, l/ in maximally opposed, empty set word pairs at the word level Conditions: in imitation of the clinician or in response to pictures Criterion: 90% accuracy over two consecutive sessions Combine the above components into a behavioral objective. Clinical Application: Target Selection for Maximal Oppositions Ben, age 5 years, 10 months, does not demonstrate the phonemes [l] for [k] in his phonetic inventory. These two phonemes have been identified as the targets for intervention using maximal oppositions contrast word pairs that are also considered to be an empty set along the continuum of expected change. Develop a list of five word pairs for Ben.  Chapter Summary 297 CHAPTER SUMMARY The maximal oppositions approach is emerging as an effective treatment approach for children who have highly unintelligible speech characterized by a phonetic inventory that excludes six or more speech sounds (Gierut, 1989, 1992; Topba & Ünal, 2010). Treatment using the empty set also appears to be effective (Gierut, 1991, 1992; Gierut & Neumann, 1992). Researchers have reported that the selection of more complex targets, such as the empty set, for intervention result in more system-wide change in the child’s phonological system than less complex targets. The maximal oppositions approach is based on the premise that the child’s phonological system needs widespread change in order to promote improved speech intelligibility. Generalization within and across phoneme classes facilitates the orga- nization of the child’s sound system. CHAPTER CASE STUDY—CLINICAL APPLICATION Continuing to utilize the Case Study “Sean,” the place-manner-voice analysis can be seen in FIGURE 17.2. In addition, the following phonemes were not observed in a spontaneous speech sample: /k, g, l, r, ʃ, ʧ, ʤ, ʒ, s, z, v, θ, "/. Identify potential targets for intervention. Select a known phoneme and an unknown phoneme that are maxi- mally different to create a set of eight pairs of maximally opposed target words. Also, select two unknown phonemes, considered to be an empty set, to create a set of eight pairs of target words. Write behavioral objectives to reflect the intervention goals for the target sounds/patterns selected. Design a therapy session that reflects activities to facilitate learning and achieving the identified goals, the procedures utilized to elicit, and the cueing strategies to modify or reinforce production attempts. Next, write a session note in the SOAP format for a session that you can envision may have occurred as a result of the session planned. Lastly, write a hypothetical progress note that summarizes progress over a 3-month time period. The Therapy Session Planning Template in Appendix 17-A can be used for this activity. Target Substitution Place-Manner Voicing Differences and Specific Number of Phoneme Feature Changes Occurrences in Sample P bilabial → lingua-alveolar 2 p d M V voiceless → voiced 2 P labiodental → bilabial 3 b M fricative → stop 3 f V voiceless → voiced 3 P labiodental → bilabial 1 v b M fricative → stop 1 V P labiodental → lingua-alveolar 1 d M fricative → stop 1 v V P velar → lingua-alveolar 3 t M k V  p d M V voiceless → voiced 2 P labiodental → bilabial 3 M fricative → stop 3 298 Chapter f 17b Maximal Oppositions Contrast Approach V voiceless → voiced 3 P labiodental → bilabial 1 v b M fricative → stop 1 V P labiodental → lingua-alveolar 1 d M fricative → stop 1 v V P velar → lingua-alveolar 3 t M k V P velar → lingua-alveolar 1 g t M V voiced → voiceless 1 P velar → lingua-alveolar 1 d M g V P s t M fricative → stop 3 V Target Substitution Place-Manner Voicing Differences and Specific Number of Phoneme Feature Changes Occurrences in Sample P z d M Fricative → stop 3 V P z M fricative → stop 1 t V voiceless → voiced 1 P velar → lingua-alveolar 1 nd M nasal → nasal / stop 1 g V P velar → lingua-alveolar 1 n M g V P lingua-alveolar → bilabial 3 l w M liguid → glide 3 V P f M liguid → fricative 1 l V voiced → voiceless 1 P lingua-palatal → lingua-alveolar 3 t M affricative → stop 3 t∫ V P lingua-palatal → lingua-alveolar 2 t M fricative → stop 2 ∫ V  Chapter Summary 299 Target Substitution Place-Manner Voicing Differences and Specific Number of Phoneme Feature Changes Occurrences in Sample P lingua-palatal → lingua-alveolar 1 ∫ s M V P lingua-pala