Phonological disorders II: a conceptual framework for management

Outcome measures for children with speech sound disorder: an umbrella review

OBJECTIVE

Speech sound disorder (SSD) describes a 'persistent difficulty with speech sound production that interferes with speech intelligibility or prevents verbal communication'. There is a need to establish which care pathways are most effective and efficient for children with SSD. Comparison of care pathways requires clearly defined, evidence-based, interventions and agreement on how to measure the outcomes. At present, no definitive list of assessments, interventions or outcomes exists. The objective of this umbrella review paper is to provide a rigorous and detailed list of assessments, interventions and outcomes which target SSD in children.

DESIGN

In December 2022, a systematic search of Ovid Medline, OVID Embase, CINAHL, PsycInfo and Cochrane and a number of grey literature platforms were undertaken. 18 reviews were included, and subsequently 415 primary research articles were assessed for data related to assessments, interventions or outcomes. The AMSTAR (Assessing the Methodological Quality of Systematic Reviews) framework was used to assess the quality of the retained reviews.

SETTING

Reviews were retained which took place in any setting.

PARTICIPANTS

The population is children of any age with a diagnosis of SSD of unknown origin.

PRIMARY AND SECONDARY OUTCOME MEASURES

Reviews reporting outcomes, assessment and interventions for children with SSD.

RESULTS

Extraction and analysis identified 37 assessments, 46 interventions and 30 outcome measures used in research reporting of SSD. Not all of the listed outcomes were linked to specific outcome measurement tools, but these were measurable through the use of one or more of the assessments extracted from the retained reviews.

CONCLUSIONS

The findings of this review will be used to develop a Core Outcome Set for children with SSD. The findings are part of a rigorous process essential for advancing healthcare research and practice in the specific area of speech and language therapy for children with SSD.

PROSPERO REGISTRATION NUMBER

CRD42022316284.

Improving the oral function of patients with upper and lower lip tensor fascia lata slings for patients with flaccid facial nerve palsy

BACKGROUND

Facial nerve paralysis (FNP) often causes decreased quality of life and may lead to significant facial dysfunction. Oral competence is frequently raised as a concern by patients as it impacts nutrition, hydration, social participation, and mental health. This can result in social isolation and reduced capacity to return to vocational roles. Despite its prevalence, it is incompletely understood and rarely described. This study prospectively evaluated the impact that facial nerve static and dynamic reanimation has on oral competence, with a specific focus on speech intelligibility and the oral phase of the swallow.

MATERIALS AND METHODS

Patients who had a static or dynamic facial reanimation at Chris O'Brien Lifehouse due to facial nerve paralysis were recruited consecutively between September 2020 and October 2022. Their speech and swallow were analysed using patient reported outcome measures including the speech handicap index and the oral competence questionnaire, and speech intelligibility rated by the patient and their speech pathologist at baseline (up to 2-weeks prior to surgery), then at 6- and 12- months post-surgery. Outcomes were evaluated firstly by a paired analysis (pre- compared to post-operative oral competence outcomes), and secondly by a cohort analysis of static, compared to dynamic reanimation.

RESULTS

19 participants underwent a facial nerve reconstruction (10 static, 9 dynamic and static) due to pre-operative facial nerve paralysis. At 12-months improvements in both the oral competence questionnaire (OCQ) and the speech handicap index (SHI) (score reduced at a rate of 0.3 points per week and the 0.2 points respectively) and that this change met statistical significance (OCQ; p = p < 0.003, SHI; p < 0.001). Patient rated intelligibility increased 0.3 and clinician rated intelligibility increased 0.2 points per week which also significantly improved (p = 0.001 and p < 0.001 respectively).

CONCLUSIONS

Both static and dynamic facial reanimation procedures significantly improved both speech and swallowing measures for oral competence at 6- and 12- months post-procedure. There was not a significant difference found between static and dynamic procedures.

Gender differences in perceived speech intelligibility in patients with facial nerve palsy

PURPOSE

Facial nerve palsy (FNP) affects physical and social function, including speech. There exists discrepancy between professional and patient perception of appearance following FNP; however, speech differences remain unknown. We aimed to compare ratings of speech intelligibility by different listeners.

METHOD

Patients were identified through the Sydney Facial Nerve Service. FNP related scoring was obtained using the Sunnybrook Facial Grading System, Sydney Facial Grading Score, Facial Disability Index, and Speech Handicap Index. Intelligibility was scored by a speech-language pathologist, member of the public, and patient using a standardised passage. FNP scoring and intelligibility were compared using interclass coefficients (ICC).

RESULT

Forty patients were recruited (females = 20). There was no difference in FNP scoring, nor between the frequency or types of phonemic errors. Observers' rating of intelligibility had an ICC of 0.807, compared with 0.266 and 0.344 for patients compared to the member of the public and speech-language pathologist respectively. Observers rated males and females intelligibility similar (p > 0.05), but females rated their intelligibility lower than males (74.5 ± 12.8 vs. 82.5 ± 8.4, p = 0.025).

CONCLUSION

Patients, particularly females, perceive their speech to be less intelligible than observers. Clinicians should be aware of this discrepancy, which does not correlate with physical function.

A randomized study of parent- versus child-directed intervention for Dutch toddlers with DLD

BACKGROUND

Indirect speech and language therapy, such as parent-implemented intervention, has been shown to be an effective approach for young children with speech and language disorders. However, relatively few studies have compared outcomes of parent-directed therapy with child-directed intervention, that is, individual therapy of a child delivered by a speech and language therapist (SLT). Although speech and language therapists (SLTs) regard parental engagement as imperative for successful intervention, currently they predominantly use child-directed intervention.

AIM

To evaluate the effect of parent- versus child-directed speech-language therapy embedded in usual care intervention for young children with developmental language disorder (DLD).

METHODS & PROCEDURES

In a randomized trial, forty-six 3-year-old monolingual children with DLD were assigned to parent-directed intervention or child-directed intervention groups. In addition, all children received usual care in special-language daycare centres. Outcomes included children's language development and functional communication, parents' language output, parents' perceptions and their self-efficacy. These were assessed at three time intervals, that is, at baseline, immediately after 6 months of treatment, and 1 year after baseline. The parent-directed intervention consisted of twelve 50-min sessions every 2 weeks with parent and child, consisting of parental training with immediate feedback by (SLTs. Children in the child-directed intervention group received individual speech-language therapy in weekly 30-min sessions for 6 months.

OUTCOMES & RESULTS

Intervention in both groups was equally effective. All children improved significantly in receptive and expressive language measures as well as in functional communication at all intervals. All parents used significantly more language support strategies and were less concerned about their child's participation in communication. Parents in the parent-directed intervention group reported increased self-efficacy in stimulating their child's language development. In contrast, parents in the child-directed intervention group reported a decrease in self-efficacy. Though modest, these group differences were significant in both the short and long terms. Both parents and SLTs were positive about the parent-directed intervention.

CONCLUSIONS & IMPLICATIONS

The effects of parent- and child-directed intervention for young children with DLD are similar. The parent-directed intervention adds to treatment options for parents as well as for SLTs and creates choices for shared decision-making.

WHAT THIS PAPER ADDS

What is already known on the subject Language therapy for young children with DLD comprises various delivery models. Two of these are child- and parent-directed therapy by SLTs. Compared with no treatment, both delivery models are effective, but it is unclear if one of these results in better language outcomes than the other. SLTs value child-directed intervention more highly than indirect approaches where treatment is delivered by others. This study aims to compare the relative effectiveness of parent-directed intervention with child-directed intervention, both parts of multi-component usual care intervention. What this paper adds to existing knowledge This randomized trial indicates that a parent-directed intervention model is as effective as child-directed intervention by SLTs for children's language development and functional communication. Parents' use of language support strategies was also similar in both intervention models, in the short and long terms. Like in child-directed therapy, parent-directed intervention reduces parents' concerns. Contrary to child-directed treatment, parent-directed intervention increases parents' self-efficacy, that is, supporting their child's language development. What are the potential or actual clinical implications of this work? Though SLTs predominantly choose a child-directed intervention model, the study results show that they can consider parent-directed approaches too. There are no significant differences in children's language outcomes as a function of parent- or child-directed intervention. Furthermore, parents and SLTs were positive about the parent-directed intervention program and the SLTs evaluated it as valuable and feasible.

Word-final complexity in speech sound intervention: two case studies

In speech sound intervention, consonant clusters promote generalisation (i.e. improvement in untreated sounds and words), ostensibly due to their relative complexity compared to other phonological targets. However, our understanding of clusters as intervention targets is largely restricted to those in word-initial position (e.g. [fl-], flip). The present study extends available work to consider the effects of word-final consonant cluster targets (e.g. [-ks]). Phonologically complex word-final clusters may be morphologically simple (e.g. mix) or morphologically complex (e.g. packs, inflected with third-person singular) - yet this cross-domain complexity remains an understudied phenomenon. Presently, two case studies provide an initial investigation of word-final cluster intervention targets for children with phonologically based speech sound disorders. Intervention targets for both Anna (3;7 [years;months]) and David (4;1) featured the phonologically complex word-final cluster [-ks], with Anna's target being morphologically simple and David's being morphologically complex. Intervention was provided in 45-minute, individual sessions three times per week for a maximum of 18 sessions. Both children demonstrated high target accuracy by intervention's end. Following intervention, both children demonstrated progress in intelligibility and ability to produce word-final consonant clusters; David further demonstrated generalisation across multiple measures. Results are interpreted with consideration of individual differences and existing research on complexity in phonological intervention. Overall, present findings motivate continued research, as manipulation of word-final complexity allows for emphasis on a context that is relevant for children with speech sound disorders, for peers with difficulties in morphology (including word-final grammatical morphemes) and for the substantial proportion of children demonstrating weaknesses in both domains.

Speech Development Across Subgroups of Autistic Children: A Longitudinal Study

Subgroups of children with different speech profiles have been described however, little is known about the trajectories of speech development or stability of subgroups over time. This longitudinal study described both speech trajectories and subgroup stability of 22 autistic children, aged 2;0-6;11 years, over 12 months. Independent and relational speech analyses, vocabulary size and nonverbal communication were used in clustering. Results suggest varied speech trajectories, particularly for children with 'low language and low speech' at Time 1. Receptive vocabulary and consonant inventory at Time 1 may predict speech outcomes after 12 months. A small subgroup of children (n = 3) present with low expressive vocabulary and speech but higher receptive vocabulary and use of gestures. This unique profile remained stable.

Acoustic and Articulatory Characteristics of English Semivowels /ɹ, l, w/ Produced by Adult Second-Language Speakers

PURPOSE

This study presents the results of acoustic and kinematic analyses of word-initial semivowels (/ɹ, l, w/) produced by second-language (L2) speakers of English whose native language is Korean. In addition, the relationship of acoustic and kinematic measures to the ratings of foreign accent was examined by correlation analyses.

METHOD

Eleven L2 speakers and 10 native speakers (first language [L1]) of English read The Caterpillar passage. Acoustic and kinematic data were simultaneously recorded using an electromagnetic articulography system. In addition to speaking rate, two acoustic measures (ratio of third-formant [F3] frequency to second-formant [F2] frequency and duration of steady states of F2) and two kinematic measures (lip aperture and duration of lingual maximum hold) were obtained from individual target sounds. To examine the degree of contrast among the three sounds, acoustic and kinematic Euclidean distances were computed on the F2-F3 and x-y planes, respectively.

RESULTS

Compared with L1 speakers, L2 speakers exhibited a significantly slower speaking rate. For the three semivowels, L2 speakers showed a reduced F3/F2 ratio during constriction, increased lip aperture, and reduced acoustic Euclidean distances among semivowels. Additionally, perceptual ratings of foreign accent were significantly correlated with three measures: duration of steady F2, acoustic Euclidean distance, and kinematic Euclidean distance.

CONCLUSIONS

The findings provide acoustic and kinematic evidence for challenges that L2 speakers experience in the production of English semivowels, especially /ɹ/ and /w/. The robust and consistent finding of reduced contrasts among semivowels and their correlations with perceptual accent ratings suggests using sound contrasts as a potentially effective approach to accent modification paradigms.

The Relationship Between Single-Word Speech Severity and Intelligibility in Childhood Apraxia of Speech

PURPOSE

The purpose of this study was to investigate the association between perceived single-word speech severity and intelligibility in children with childhood apraxia of speech (CAS), with and without comorbid language impairment (LI), and to investigate the contribution of different CAS signs to perceived single-word speech severity and single-word intelligibility.

METHOD

Thirty children with CAS, 18 with comorbid LI, completed the Goldman-Fristoe Test of Articulation-Second Edition (GFTA-2). Trained judges coded children's responses for signs of CAS and percent phonemes correct. Nine listeners, blind to diagnoses, rated speech severity using a visual analog scale. Intelligibility was assessed by comparing listeners' orthographic transcriptions of children's responses to target responses.

RESULTS

Measures of speech severity (GFTA-2 standard score, number of unique CAS signs, total CAS signs, and mean severity rating) were significantly correlated with measures of intelligibility (GFTA-2 raw score, percent phonemes correct, and mean intelligibility score). Speech severity and intelligibility did not differ significantly between children with and without LI. Only consonant errors contributed significant variability to speech severity. Consonant errors and stress errors contributed significant variability to intelligibility.

CONCLUSIONS

Findings suggest that visual analog scale ratings are a valid and convenient measure of single-word speech severity and that GFTA-2 raw score is an equally convenient measure of single-word intelligibility. The result that consonant errors were by far the major contributor to single-word speech severity and intelligibility in children with CAS, with stress errors also making a small contribution to intelligibility, suggests that consonant accuracy and appropriate lexical stress should be prime therapeutic targets for these children in the context of treatment addressing motor planning/programming, self-monitoring, and self-correcting.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19119350.

Phonological complexity in intervention for Spanish-speaking children with speech sound disorder

The efficiency of intervention for children with speech sound disorder may be influenced by linguistic complexity of the phonological intervention target. Complex targets, particularly, later-acquired, less-known consonants and consonant clusters, have been linked to greater post-intervention generalization to untargeted phonological structures. Yet there is little direct evidence to support target selection based on linguistic complexity for Spanish-speaking children with speech sound disorder. This intervention study utilizes an experimental single-case design to examine the efficacy of intervention in Spanish using different complex targets (i.e. /ɡɾ/, /bɾ/, and /l/). For each of the four Spanish-speaking children with speech sound disorder, sounds at 0% accuracy during baseline were monitored across the baseline period, during and post-intervention, and at one- and two-month follow-up visits. Over the course of intervention, only one participant achieved mastery of the targeted structure in practiced words. However, all participants demonstrated some amount of broad phonological generalization to untargeted consonants or clusters. Variable learning trajectories and broad phonological generalization are discussed as they relate to participant characteristics and linguistic complexity.

Speech Abilities in a Heterogeneous Group of Children With Autism

PURPOSE

This study aimed to provide detailed descriptive information about the speech of a heterogeneous cohort of children with autism spectrum disorder (ASD) and to explore whether subgroups exist based on this detailed speech data. High rates of delayed and disordered speech in both low-verbal and high-functioning children with ASD have been reported. There is limited information regarding the speech abilities of young children across a range of functional levels.

METHOD

Participants were 23 children aged 2;0-6;11 (years;months) with a diagnosis of ASD. Comprehensive speech and language assessments were administered. Independent and relational speech analyses were conducted from single-word naming tasks and spontaneous speech samples. Hierarchical clustering based on language, nonverbal communication, and spontaneous speech descriptive data was completed.

RESULTS

Independent and relational speech analyses are reported. These variables are used in the cluster analyses, which identified three distinct subgroups: (a) children with high language and high speech ability (n = 10), (b) children with low expressive language and low speech ability but higher receptive language and use of gestures (n = 3), and (c) children with low language and low speech development (n = 10).

CONCLUSIONS

This is the first study to provide detailed descriptive speech data of a heterogeneous cohort of children with ASD and use this information to statistically explore potential subgroups. Clustering suggests a small number of children present with low levels of speech and expressive language in the presence of better receptive language and gestures. This communication profile warrants further exploration. Replicating these findings with a larger cohort of children is needed. Supplemental Material https://doi.org/10.23641/asha.16906978.

Speech in children with cerebral palsy

AIM

To examine the frequency, characteristics, and factors associated with speech delay and disorder in a community sample of children with cerebral palsy (CP).

METHOD

Participants were 84 children (37 females, 47 males; aged between 4y 11mo-6y 6mo) with CP identified through a population-based registry. Speech and oromotor function were systematically evaluated to provide a differential diagnosis of articulation, phonological, and motor speech disorders.

RESULTS

In total, 82% (69/84) of participants had delayed or disordered speech production, including minimally verbal presentations (n=20). Verbal participants (n=64) presented with dysarthria (78%), articulation delay or disorder (54%), phonological delay or disorder (43%), features of childhood apraxia of speech (CAS) (17%), or mixed presentations across these conditions. Speech intelligibility was poorest in those with dysarthria and features of CAS. Speech delay or disorder in verbal participants was associated with language impairment (p=0.002) and reduced health-related quality of life (p=0.04) (Fisher's exact test). Poorer speech accuracy (i.e. lower percentage consonants correct) correlated with greater impairments in both language (p<0.001) and oromotor function (p<0.001) (Spearman's test).

INTERPRETATION

The speech profile of children with CP is characterized by impairment at multiple levels of speech production (phonetic, cognitive-linguistic, neuromuscular execution, and high-level planning/programming), highlighting the importance of a personalized differential diagnosis informing targeted treatment.

Scandcleft Project Trial 2-Comparison of Speech Outcome in 1- and 2-Stage Palatal Closure in 5-Year-Olds With UCLP

OBJECTIVE

To investigate in-depth speech results in the Scandcleft Trial 2 with comparisons between surgical protocols and centers and with benchmarks from peers without cleft palate.

DESIGN

A prospective randomized clinical trial.

SETTING

Two Swedish and one Finnish Cleft Palate center.

PARTICIPANTS

One hundred twelve participants were 5-years-old born with unilateral cleft lip and palate randomized to either lip repair and soft palate closure at 4 months and hard palate closure at 12 months or lip repair at 3 to 4 months (Arm A), or a closure of both the soft and hard palate at 12 months (Arm C).

MAIN OUTCOME MEASURES

A composite measure dichotomized into velopharyngeal competency (VPC) or velopharyngeal incompetency (VPI), overall assessment of velopharyngeal function (VPC-Rate), percentage of consonants correct (PCC score), and consonant errors. In addition, number of speech therapy visits, average hearing thresholds, and secondary surgeries were documented to assess burden of treatment.

RESULTS

Across the trial, 53.5% demonstrated VPC and 46.5% VPI with no significant differences between arms or centers. In total, 27% reached age-appropriate PCC scores with no statistically significant difference between the arms. The Finnish center had significantly higher PCC scores, the Swedish centers had higher percentages of oral consonant errors. Number of speech therapy visits was significantly higher in the Finnish center.

CONCLUSION

At age 5, poor speech outcomes with some differences between participating centers were seen but could not be attributed to surgical protocol. As one center had very few participants, the results from that center should be interpreted with caution.

Tutorial: Speech Motor Chaining Treatment for School-Age Children With Speech Sound Disorders

Purpose Operationalized treatments for school-age children with speech sound disorders may result in more replicable and evidence-based interventions. This tutorial describes Speech Motor Chaining (SMC) procedures, which are designed to build complex speech around core movements by incorporating several principles of motor learning. The procedures systematically manipulate factors such as feedback type and frequency, practice variability, and stimulus complexity based on the child's performance. Method The rationale and procedures for SMC are described. Examples are presented of how to design stimuli, deliver feedback, and adapt the approach. Free resources are provided to guide clinicians through implementation of the procedure. Data on fidelity of implementation and dose per session are presented. Clinical and research evidence is provided to illustrate likely outcomes with the procedure. Results SMC is a method that can result in successful acquisition of target speech patterns and generalization to untrained words. Most clinicians can implement the procedure with over 90% fidelity, and most children can achieve over 200 trials per session. Conclusion Clinicians and researchers can use or adapt the operationally defined SMC procedures to incorporate several principles of motor learning into treatment for school-age children with speech sound disorders. Supplemental Material https://osf.io/5jmf9/.

Treatment Targets for Co-Occurring Speech-Language Impairment: A Case Study

PURPOSE

The intersection of speech and language impairments is severely understudied. Despite repeatedly documented overlap and co-occurrence, treatment research for children with combined phonological and morphosyntactic deficits is limited. Especially little is known about optimal treatment targets for combined phonological-morphosyntactic intervention. We offer a clinically focused discussion of the existing literature pertaining to interventions for children with combined deficits and present a case study exploring the utility of a complex treatment target in word-final position for co-occurring speech and language impairment.

METHOD

Within a school setting, a kindergarten child (age 5;2) with co-occurring phonological disorder and developmental language disorder received treatment targeting a complex consonant cluster in word-final position inflected with third-person singular morphology.

RESULTS

For this child, training a complex consonant cluster in word-final position resulted in generalized learning to untreated consonants and clusters across word positions. However, morphological generalization was not demonstrated consistently across measures.

CONCLUSION

These preliminary findings suggest that training complex phonology in word-final position can result in generalized learning to untreated phonological targets. However, limited improvement in morphology and word-final phonology highlights the need for careful monitoring of cross-domain treatment outcomes and additional research to identify the characteristics of treatment approaches, techniques, and targets that induce cross-domain generalization learning in children with co-occurring speech-language impairment.

A shift of treatment approach in speech language pathology services for children with speech sound disorders - a single case study of an intense intervention based on non-linear phonology and motor-learning principles

Even though there are documented benefits of direct intensive intervention for children with speech sound disorders (SSDs), the intensity given at Swedish Speech Language Pathology services rarely exceeds once a week. Also, indirect therapy approaches are commonly employed. The purpose of the present case study was to investigate the effects of an intensive specialist therapy, based on non-linear phonological analysis and motor learning principles. The participant was a boy aged 4:10 years with severe SSD, who previously had received indirect therapy from age 3 with, very limited results. A single subject ABA design was used. At baseline, whole word match was 0%, Word shape CV match was 39% and PCC was 22, 7%. He had no multisyllabic words, no consonant clusters and no established coronals. Intervention was given 4 days weekly for 3 weeks in two periods with a 7-week intervening break and a post therapy assessments. Therapy was focused on establishing multisyllabic words, iambic stress pattern, clusters and coronals with the principle of using already established elements for targeting new elements. At post therapy assessment, whole word match was 39%, word shape CV match was 71% and PCC 69.1%. Multisyllabic words (86%), coronals (82%) and word initial clusters (80%) were established. Without being targeted, back vowels were also present and segment timing improved. The strong treatment effects of this study demonstrate that at least severe cases of SSD require the clinical knowledge and skills that only a SLP can provide and that frequent direct therapy is both beneficial and needed.

Diagnostic Accuracy of Traditional Measures of Phonological Ability for Bilingual Preschoolers and Kindergarteners

Purpose

Bilingual children whose phonological skills are evaluated using measures designed for monolingual English speakers are at risk for misdiagnosis of speech sound disorders (De Lamo White & Jin, 2011).

Method

Forty-four children participated in this study: 15 typically developing monolingual English speakers, 7 monolingual English speakers with phonological disorders, 14 typically developing bilingual Spanish-English speakers, and 8 bilingual children with phonological disorders. Children's single-word speech productions were examined on Percentage Consonants Correct-Revised (Shriberg, Austin, Lewis, McSweeny, & Wilson, 1997a) and accuracy of early-, middle-, and late-developing sounds (Shriberg, 1993) in English. Consonant accuracy in English was compared between monolinguals and bilinguals with and without speech sound disorders. Logistic regression and receiver operating characteristic curves were used to observe diagnostic accuracy of the measures examined.

Results

Percentage Consonants Correct-Revised was found to be a good indicator of phonological ability in both monolingual and bilingual English-speaking children at the age of 5;0. No significant differences were found between language groups on any of the measures examined.

Conclusions

Our results suggest that traditional measures of phonological ability for monolinguals could provide good diagnostic accuracy for bilingual children at the age of 5;0 years. These findings are preliminary, and children younger than 5;0 years should be examined for risk of misdiagnosis.

A Standard Set of Outcome Measures for the Comprehensive Appraisal of Cleft Care

Care of the patient with cleft lip and/or palate remains complex. Prior attempts at aggregating data to study the effectiveness of specific interventions or overall treatment protocols have been hindered by a lack of data standards. There exists a critical need to better define the outcomes- particularly those that matter most to patients and their families-and to standardize the methods by which these outcomes will be measured. This report summarizes the recommendations of an international, multidisciplinary working group with regard to which outcomes a typical cleft team could track, how those outcomes could be measured and recorded, and what strategies may be employed to sustainably implement a system for prospective data collection. It is only by agreeing on a common, standard set of outcome measures for the comprehensive appraisal of cleft care that intercenter comparisons can become possible. This is important for quality-improvement endeavors, comparative effectiveness research, and value-based health-care reform.

A Systematic Review of Speech Assessments for Children With Autism Spectrum Disorder: Recommendations for Best Practice

PURPOSE

The purpose of this systematic review was to provide a summary and evaluation of speech assessments used with children with autism spectrum disorders (ASD). A subsequent narrative review was completed to ascertain the core components of an evidence-based pediatric speech assessment, which, together with the results of the systematic review, provide clinical and research guidelines for best practice.

METHOD

A systematic search of eight databases was used to find peer-reviewed research articles published between 1990 and 2014 assessing the speech of children with ASD. Eligible articles were categorized according to the assessment methods used and the speech characteristics described.

RESULTS

The review identified 21 articles that met the inclusion criteria, search criteria, and confidence in ASD diagnosis. The speech of prelinguistic participants was assessed in seven articles. Speech assessments with verbal participants were completed in 15 articles with segmental and suprasegmental aspects of speech analyzed. Assessment methods included connected speech samples, single-word naming tasks, speech imitation tasks, and analysis of the production of words and sentences.

CONCLUSIONS

Clinical and research guidelines for speech assessment of children with ASD are outlined. Future comparisons will be facilitated by the use of consistent reporting methods in research focusing on children with ASD.

Auditory-Motor Mapping Training: Comparing the Effects of a Novel Speech Treatment to a Control Treatment for Minimally Verbal Children with Autism

This study compared Auditory-Motor Mapping Training (AMMT), an intonation-based treatment for facilitating spoken language in minimally verbal children with autism spectrum disorder (ASD), to a matched control treatment, Speech Repetition Therapy (SRT). 23 minimally verbal children with ASD (20 male, mean age 6;5) received at least 25 sessions of AMMT. Seven (all male) were matched on age and verbal ability to seven participants (five male) who received SRT. Outcome measures were Percent Syllables Approximated, Percent Consonants Correct (of 86), and Percent Vowels Correct (of 61) produced on two sets of 15 bisyllabic stimuli. All subjects were assessed on these measures several times at baseline and after 10, 15, 20, and 25 sessions. The post-25 session assessment timepoint, common to all participants, was compared to Best Baseline performance. Overall, after 25 sessions, AMMT participants increased by 19.4% Syllables Approximated, 13.8% Consonants Correct, and19.1% Vowels Correct, compared to Best Baseline. In the matched AMMT-SRT group, after 25 sessions, AMMT participants produced 29.0% more Syllables Approximated (SRT 3.6%);17.9% more Consonants Correct (SRT 0.5); and 17.6% more Vowels Correct (SRT 0.8%). Chi-square tests showed that significantly more AMMT than SRT participants in both the overall and matched groups improved significantly in number of Syllables Approximated per stimulus and number of Consonants Correct per stimulus. Pre-treatment ability to imitate phonemes, but not chronological age or baseline performance on outcome measures, was significantly correlated with amount of improvement after 25 sessions. Intonation-based therapy may offer a promising new interventional approach for teaching spoken language to minimally verbal children with ASD.

SVANTE - The Swedish Articulation and Nasality Test - Normative data and a minimum standard set for cross-linguistic comparison

Normative language-based data are important for comparing speech performances of clinical groups. The Swedish Articulation and Nasality Test (SVANTE) was developed to enable a detailed speech assessment. This study's aim was to present normative data on articulation and nasality in Swedish speakers. Single word production, sentence repetition and connected speech were collected using SVANTE in 443 individuals. Mean (SD) and prevalences in the groups of 3-, 5-, 7-, 10-, 16- and 19-year-olds were calculated from phonetic transcriptions or ordinal rating. For the 3- and 5-year-olds, a consonant inventory was also determined. The mean percent of oral consonants correct ranged from 77% at age 3 to 99% at age 19. At age 5, a mean of 96% was already reached, and the consonant inventory was established except for /s/, /r/, /ɕ/. The norms on the SVANTE, also including a short version, will be useful in the interpretation of speech outcomes.

Application of a Motor Learning Treatment for Speech Sound Disorders in Small Groups

Speech sound treatment in the public schools is often conducted in small groups, but there are minimal data on the efficacy of group treatment. This study evaluated the efficacy of a motor learning-based treatment (Concurrent Treatment) provided to elementary-school students in small groups. Concurrent Treatment incorporates the randomized sequencing of various practice tasks (e.g., words, sentences, or storytelling) and can result in rapid speech sound acquisition during individual treatment settings. Twenty-eight 6- to 9-year-old children participated in a randomized pretest–posttest control group design. The experimental group received Concurrent Treatment, while the control group received treatment (if needed) after the study. Participants in the experimental group acquired their target speech sounds within 40 30-minute sessions in groups of up to four participants (effect size, d = 1.31).

Dense neighborhoods and mechanisms of learning: evidence from children with phonological delay

There is a noted advantage of dense neighborhoods in language acquisition, but the learning mechanism that drives the effect is not well understood. Two hypotheses--long-term auditory word priming and phonological working memory--have been advanced in the literature as viable accounts. These were evaluated in two treatment studies enrolling twelve children with phonological delay. Study 1 exposed children to dense neighbors versus non-neighbors before training sound production in evaluation of the priming hypothesis. Study 2 exposed children to the same stimuli after training sound production as a test of the phonological working memory hypothesis. Results showed that neighbors led to greater phonological generalization than non-neighbors, but only when presented prior to training production. There was little generalization and no differential effect of exposure to neighbors or non-neighbors after training production. Priming was thus supported as a possible mechanism of learning behind the dense neighborhood advantage in phonological acquisition.

Ultrasound visual feedback treatment and practice variability for residual speech sound errors

PURPOSE

The goals were to (a) test the efficacy of a motor-learning-based treatment that includes ultrasound visual feedback for individuals with residual speech sound errors and (b) explore whether the addition of prosodic cueing facilitates speech sound learning.

METHOD

A multiple-baseline, single-subject design was used, replicated across 8 participants. For each participant, 1 sound context was treated with ultrasound plus prosodic cueing for 7 sessions, and another sound context was treated with ultrasound but without prosodic cueing for 7 sessions. Sessions included ultrasound visual feedback as well as non-ultrasound treatment. Word-level probes assessing untreated words were used to evaluate retention and generalization.

RESULTS

For most participants, increases in accuracy of target sound contexts at the word level were observed with the treatment program regardless of whether prosodic cueing was included. Generalization between onset singletons and clusters was observed, as was generalization to sentence-level accuracy. There was evidence of retention during posttreatment probes, including at a 2-month follow-up.

CONCLUSION

A motor-based treatment program that includes ultrasound visual feedback can facilitate learning of speech sounds in individuals with residual speech sound errors.

Consonant production and overall speech characteristics in school-aged children with cerebral palsy and speech impairment

The aim of the present study was to investigate the speech characteristics of school-aged children with cerebral palsy (CP) and speech impairment at various cognitive levels. Nineteen children with a mean age of 11;2 years (9;2-12;9 years) with spastic, dyskinetic, and ataxic CP and speech impairment participated. Phonetic transcription of oral consonants, ratings of hypernasality, and severity of overall dysarthria, together with free field descriptions of respiration, voice quality, and prosody, were performed independently by two speech-language pathologists. The non-verbal cognitive level was also studied. More than half of the children had large problems with the articulation of consonants, and the children with ataxic CP were most affected. The majority was rated as having dysarthria, mostly mild, but hypernasality was rare. Gross motor problems were not significantly associated with the articulation of consonants or the severity of dysarthria, whereas non-verbal cognitive level was. This underlines the importance of taking non-verbal cognitive level into account, when designing individual speech treatment programs for this group of children. Finally, a careful examination of the articulation of consonants is recommended in order to study speech production thoroughly in children with CP.

Proximate factors associated with speech intelligibility in children with cochlear implants: A preliminary study

The purpose of this descriptive pilot study was to examine possible relationships among speech intelligibility and structural characteristics of speech in children who use cochlear implants. The Beginners Intelligibility Test (BIT) was administered to 10 children with cochlear implants, and the intelligibility of the words in the sentences was judged by panels of naïve adult listeners. Additionally, several qualitative and quantitative measures of word omission, segment correctness, duration, and intonation variability were applied to the sentences used to assess intelligibility. Correlational analyses were conducted to determine if BIT scores and the other speech parameters were related. There was a significant correlation between BIT score and percent words omitted, but no other variables correlated significantly with BIT score. The correlation between intelligibility and word omission may be task-specific as well as reflective of memory limitations.

Intervention efficacy and intensity for children with speech sound disorder

PURPOSE

Clinicians do not have an evidence base they can use to recommend optimum intervention intensity for preschool children who present with speech sound disorder (SSD). This study examined the effect of dose frequency on phonological performance and the efficacy of the multiple oppositions approach.

METHOD

Fifty-four preschool children with SSD were randomly assigned to one of three intervention conditions. Two intervention conditions received the multiple oppositions approach either 3 times per week for 8 weeks (P3) or once weekly for 24 weeks (P1). A control (C) condition received a storybook intervention. Percentage of consonants correct (PCC) was evaluated at 8 weeks and after 24 sessions. PCC gain was examined after a 6-week maintenance period.

RESULTS

The P3 condition had a significantly better phonological outcome than the P1 and C conditions at 8 weeks and than the P1 condition after 24 weeks. There were no significant differences between the P1 and C conditions. There was no significant difference between the P1 and P3 conditions in PCC gain during the maintenance period.

CONCLUSION

Preschool children with SSD who received the multiple oppositions approach made significantly greater gains when they were provided with a more intensive dose frequency and when cumulative intervention intensity was held constant.

Phonological mean length of utterance in specific language impairment: a multi-case study of children acquiring Finnish

This study assesses the phonological development of four Finnish-speaking children (ages 4;8, 4;9, 4;9 and 5;5) with specific language impairment (SLI) and dyspractic features in speech. The analysis is performed using the phonological mean length of utterance (pMLU) method. Moreover, the children's phonological abilities are evaluated qualitatively in relation to segments, phonotactics and word structure. The results are compared with those obtained from four age-matched typically developing peers and with the data from an earlier study using the pMLU method on younger, typically developing Finnish children. In the pMLU analysis, the children with SLI performed roughly at the level of typically developing 2-year-old children. The qualitative analyses revealed that children with SLI had difficulties in producing word-medial clusters and word-initial consonants and that they exhibited frequent consonant assimilations, infrequent errors and vowel errors. The pMLU method did differentiate between children with SLI and typically developing children. However, qualitative analyses revealed some weaknesses of the pMLU method when assessing Finnish children with SLI.

Identifying residual speech sound disorders in bilingual children: a Japanese-english case study

PURPOSE

To describe (a) the assessment of residual speech sound disorders (SSDs) in bilinguals by distinguishing speech patterns associated with second language acquisition from patterns associated with misarticulations and (b) how assessment of domains such as speech motor control and phonological awareness can provide a more complete understanding of SSDs in bilinguals.

METHOD

A review of Japanese phonology is provided to offer a context for understanding the transfer of Japanese to English productions. A case study of an 11-year-old is presented, demonstrating parallel speech assessments in English and Japanese. Speech motor and phonological awareness tasks were conducted in both languages.

RESULTS

Several patterns were observed in the participant's English that could be plausibly explained by the influence of Japanese phonology. However, errors indicating a residual SSD were observed in both Japanese and English. A speech motor assessment suggested possible speech motor control problems, and phonological awareness was judged to be within the typical range of performance in both languages.

CONCLUSION

Understanding the phonological characteristics of the native language can help clinicians recognize speech patterns in the second language associated with transfer. Once these differences are understood, patterns associated with a residual SSD can be identified. Supplementing a relational speech analysis with measures of speech motor control and phonological awareness can provide a more comprehensive understanding of a client's strengths and needs.

Evidence-Based Practice for Children With Speech Sound Disorders: Part 1 Narrative Review

Purpose

This article provides a comprehensive narrative review of intervention studies for children with speech sound disorders (SSD). Its companion paper (Baker & McLeod, 2011) provides a tutorial and clinical example of how speech-language pathologists (SLPs) can engage in evidence-based practice (EBP) for this clinical population.

Method

Studies reporting speech sound intervention for children with SSDs published from 1979 to 2009 were identified and coded.

Results

One hundred thirty-four intervention studies were identified. Intervention typically was conducted by an SLP in a one-to-one individual format for 30- to 60-min sessions 2 to 3 times per week. Total duration of intervention (from assessment to discharge) was reported for 10 studies and ranged from 3 to 46 months. Most studies were either Level IIb (quasi-experimental studies, 41.5%) or Level III (nonexperimental case studies, 32.6%). Single-case experimental design (29.6%) was the most frequently used experimental research design. There were 7 distinct approaches to target selection and 46 distinct intervention approaches, with 23 described in more than 1 publication. Each approach was associated with varying quantities and levels of evidence, according to research design.

Conclusion

Collaborative research reflecting higher levels of evidence using rigorous experimental designs is needed to compare the relative benefits of different intervention approaches.

Phonetic variability in residual speech sound disorders: Exploration of subtypes

PURPOSE: To explore whether subgroups of children with residual speech sound disorders (R-SSDs) can be identified through multiple measures of token-to-token phonetic variability. METHOD: Children with R-SSDs were recorded during a rapid multisyllabic picture naming task and an oral diadochokinetic task. Transcription-based and acoustic measures of token-to-token variability were derived. Articulation accuracy and general indices of language skills were also measured. RESULTS: Low correlations were observed between transcription-based and acoustic measures of phonetic variability, and among the acoustic measures themselves. Children who were the most variable on one measure were not necessarily highly variable on other measures. Transcription-based measures of variability were associated with language skills. CONCLUSIONS: Measures of phonetic variability did not identify children in the sample as consistently high or low. Data do not support the notion that clear subgroups based on phonetic variability can be reliably identified in children with R-SSDs. The link between highly variable phonetic output (quantified by transcription-based measures) and lower language skills requires further exploration.

Developing a weighted measure of speech sound accuracy

PURPOSE

To develop a system for numerically quantifying a speaker's phonetic accuracy through transcription-based measures. With a focus on normal and disordered speech in children, the authors describe a system for differentially weighting speech sound errors on the basis of various levels of phonetic accuracy using a Weighted Speech Sound Accuracy (WSSA) score. The authors then evaluate the reliability and validity of this measure.

METHOD

Phonetic transcriptions were analyzed from several samples of child speech, including preschoolers and young adolescents with and without speech sound disorders and typically developing toddlers. The new measure of phonetic accuracy was validated against existing measures, was used to discriminate typical and disordered speech production, and was evaluated to examine sensitivity to changes in phonetic accuracy over time. Reliability between transcribers and consistency of scores among different word sets and testing points are compared.

RESULTS

Initial psychometric data indicate that WSSA scores correlate with other measures of phonetic accuracy as well as listeners' judgments of the severity of a child's speech disorder. The measure separates children with and without speech sound disorders and captures growth in phonetic accuracy in toddlers' speech over time. The measure correlates highly across transcribers, word lists, and testing points.

CONCLUSION

Results provide preliminary support for the WSSA as a valid and reliable measure of phonetic accuracy in children's speech.

The impact of speech impairment in early childhood: investigating parents' and speech-language pathologists' perspectives using the ICF-CY

PURPOSE

To explore the application of the Activities and Participation component of the International Classification of Functioning, Disability and Health - Children and Youth (ICF-CY, World Health Organization, 2007) as a framework for investigating the perceived impact of speech impairment in childhood.

METHOD

A 32-item questionnaire based on six ICF-CY domains was distributed to (a) a national sample of speech-language pathologists (SLPs; n=205), and (b) parents (n=86) of preschool children identified with speech impairment.

RESULTS

Factor analysis of the SLP data revealed six coherent factors with moderate-high internal reliability: Verbal communication (e.g., Conversation, Speaking), Advanced learning (e.g., Learning to read/write), Interpersonal interactions (e.g., Relating with strangers, Informal social relationships), Basic learning (e.g., Copying, Rehearsing), Applied learning and general tasks (e.g., Focussing attention, Handling stress), and Non-verbal communication. The first five factors were also confirmed by the parent data. Both SLPs and parents rated the first two factors, Verbal communication and Interpersonal interactions, as the most difficult activities for children with speech impairment.

CONCLUSION

The ICF-CY Activities and Participation component is a useful framework for considering the breadth of activities that may be impacted by speech impairment in childhood.

LEARNING OUTCOMES

(1) Discuss the potential use of the ICF-CY in speech-language pathology; (2) Describe the breadth of activities that may be difficult for children as a result of speech impairment; and (3) Recognize that SLPs and parents may have different perspectives regarding the impact of speech impairment on children's activities and participation.

Phonological awareness and types of sound errors in preschoolers with speech sound disorders

PURPOSE

Some children with speech sound disorders (SSD) have difficulty with literacy-related skills, particularly phonological awareness (PA). This study investigates the PA skills of preschoolers with SSD by using a regression model to evaluate the degree to which PA can be concurrently predicted by types of speech sound errors.

METHOD

Preschoolers with SSD (n = 43) participated in PA and speech sound production assessment. Errors from a 125-item picture naming task were coded in 2 ways: (a) considering all consonant errors equally (percentage of consonants correct [PCC]) and (b) using a 3-category system that captures component features of sound errors (typical sound changes, atypical sound changes, and distortions). PA tasks included rhyme matching, onset matching, onset segmentation and matching, and blending.

RESULTS

Variance in a PA composite score could be predicted partly by vocabulary and age (33%). Atypical sound changes accounted for an additional 6% of variance in PA, but distortions and typical errors did not account for significant variance. When the same consonant errors were analyzed using PCC, speech errors did not predict significant variance in PA.

CONCLUSIONS

Poorer PA is associated with lower receptive vocabularies and more atypical sound errors. Results are interpreted in the context of the accuracy of phonological representations.

The Use of Nonspeech Oral Motor Treatments for Developmental Speech Sound Production Disorders: Interventions and Interactions

Purpose

The use of nonspeech oral motor treatments (NSOMTs) in the management of pediatric speech sound production disorders is controversial. This article serves as a prologue to a clinical forum that examines this topic in depth.

Method

Theoretical, historical, and ethical issues are reviewed to create a series of clinical questions that should be considered before one incorporates new methods into clinical practice.

Conclusion

Speech production disorders are complex and multifaceted. Speech-language pathologists are encouraged to advocate on behalf of clients by adopting the highest standards of clinical practice and by evaluating treatment options in a systematic, critical, and ethical manner.

Phonological processing skills of adolescents with residual speech sound errors

PURPOSE

Research has shown that young children with speech sound disorders may have weaknesses in phonological processing. However, such skills have not been thoroughly examined in adolescents with residual speech sound errors. Therefore, this study compared the phonological processing abilities of adolescents with residual speech sound errors to those of normally speaking peers.

METHOD

Two nonword repetition tasks, multisyllabic word repetition, spoonerisms, phoneme reversals, and an elision task were used to compare the phonological processing skills of 10-14-year-olds with residual speech sound errors that include rhotic phonemes (RE, n = 13) to those of normally speaking (NS, n = 14) adolescents of similar age and receptive vocabulary abilities.

RESULTS

The 2 groups were found to differ on 5 of the 6 phonological processing tasks. Discriminant analysis showed that 85% of the participants could be correctly classified into the RE and NS groups based solely on phonological processing skills.

CONCLUSION

The possible nature of the phonological processing impairment is discussed in the context of current theoretical understanding. It is recommended that when planning assessment and intervention for adolescents with residual speech sound errors, clinicians be cognizant of the fact that the adolescents may also have weaknesses in phonological processing.

Acoustic correlates of inflectional morphology in the speech of children with specific language impairment and their typically developing peers

The development of the use of the third-person singular -s in open syllable verbs in children with specific language impairment (SLI) and their typically developing peers was examined. Verbs that included overt productions of the third-person singular -s morpheme (e.g. Bobby plays ball everyday; Bear laughs when mommy buys popcorn) were contrasted with clearly bare stem contexts (e.g. Mommy, buy popcorn; I saw Bobby play ball) on both global and local measures of acoustic duration. A durational signature for verbs inflected with -s was identified separately from factors related to sentence length. These duration measures were also used to identify acoustic changes related to the omission of the -s morpheme. The omitted productions from the children with SLI were significantly longer than their correct third-person singular and bare stem productions. This result was unexpected given that the omitted productions have fewer phonemes than correctly inflected productions. Typically developing children did not show the same pattern, instead producing omitted productions that patterned most closely with bare stem forms. These results are discussed in relation to current theoretical approaches to SLI, with an emphasis on performance and speech-motor accounts.

A Meme’s Eye View of Speech-Language Pathology

In this article, the reason why certain terms, labels, and ideas prevail, whereas others fail to gain acceptance, will be considered. Borrowing the concept of "meme" from the study of evolution of ideas, it will be clear why language-based and phonological disorders have less widespread appeal than, for example, auditory processing and sensory integration disorders. Discussion will also center on why most speech-language pathologists refer to themselves as speech therapists or speech pathologists, and why it is more desirable to have dyslexia than to have a reading disability. In a meme’s eye view, science and logic do not always win out because selection favors ideas (memes) that are easy to understand, remember, and copy. An unfortunate consequence of these selection forces is that successful memes typically provide superficially plausible answers for complex questions.

The effect of clinical experience on cue trading for the /r-w/ contrast

Although the ability of clinicians to perceptually process speech sound productions is a key ingredient in the evaluation and remediation of articulatory disorders, very little attention has been given to this important skill. This study explored the potential of a perceptual task, known as cue trading, to assess perceptual skill among students with varying clinical experience. A cue-trading paradigm for the /r-w/ contrast was used in which a temporal-spectral cue on F2 was balanced against a spectral cue on F3. Results indicated a trading relationship for all students. However, students without clinical experience demonstrated reduced sensitivity to the acoustic cues for /w/ and identification functions that were less clearly separated compared to students with clinical experience. Furthermore, the magnitude of the difference between functions (the trading relationship) was significantly smaller for students without practicum experience: They showed weaker phonetic percepts for /r/ and /w/ than did the students with practicum experience. Preliminary results suggest that a task based on cue trading could be useful in assessing perceptual sensitivity to the acoustic cues representative of misarticulated /r/.

Evidence of motor programming deficits in children diagnosed with DAS

In this study the hypothesis of motor programming involvement in developmental apraxia of speech (DAS) was investigated by studying articulatory compensation. Five children with DAS and 5 normally speaking children (age 5;0 [years;months] to 6;10), and 6 adult women produced utterances in a normal speaking condition and in a bite-block condition in which the mandible was kept in a fixed position. Throughout the utterances, the course of the second formant was used to determine articulatory compensation and the effect of the bite block on anticipatory coarticulation. Results showed that the bite-block condition in normally speaking children, like in adult women, did not affect the extent of anticipatory coarticulation. In the speech of children with DAS, the bite block had large effects on coarticulatory patterns and on vowel quality, which, contrary to expectations, had improved. These results are interpreted as a clear demonstration of deficient motor programming in DAS.

Practice Makes Perfect

In this article, the possibility is raised that some children may implicitly view the therapy situation as one in which new sounds and language forms are learned and practiced. In contrast, the primary purpose of talking outside of therapy is meaningful communication. Inherent in this view of therapy and non-therapy is the incompatibility or inconsistency between practicing speech and communicating effectively. What led me to recognize this inconsistency and consider its potential clinical implications was the way in which my daughter Franne dealt with her phonological disorder.

Syllable onsets: clusters and adjuncts in acquisition

The Sonority Sequencing Principle is a presumed universal that governs the permissible sequences of consonants within syllables. In two single-subject experiments, we evaluated this principle as applied to the acquisition of onset clusters and adjuncts by children exhibiting functional phonological delays (age in years;months: 3;2 to 7;8). Experiment 1 tested the hypothesis that children abide by the Sonority Sequencing Principle in development, such that the occurrence and use of marked true clusters implies unmarked clusters, but not vice versa. This claim was validated, in part, by the gradient generalization learning patterns of children who were taught marked clusters. Others who were taught unmarked clusters exhibited limited learning characteristic of within-class generalization, with apparent gaps in sonority sequencing. Experiment 2 examined the role of adjunct sequences /sp, st, sk/, whose markedness status is questionable given their violation of the Sonority Sequencing Principle. Results indicated that children learned adjuncts consistent with patterns of within-class generalization, thereby supporting the view that these sequences are unmarked in structure. Experimental findings are integrated in discussion of the representation of onset clusters and their course of emergence in phonological acquisition relative to the Sonority Sequencing Principle.

Constructivist Strategies in Phonological Intervention

This tutorial describes an instructional approach for school-age children who have difficulty achieving phonological carryover. Behavioral, cognitive, and constructivist instructional strategies are examined in regard to their usefulness during the establishment, transfer, and carryover phases of phonological intervention. The advantages of using constructivist strategies to facilitate carryover are presented. A model of self-regulated learning is then applied to constructivist carryover activities (performances) so that children who have difficulty attaining carryover might develop metacognitive abilities similar to those of children who easily achieve carryover. Ideas for implementing a constructivist approach to facilitating self-regulated carryover are presented and examples are provided.

Treatment efficacy: functional phonological disorders in children

This report addresses the efficacy of treatment for functional phonological disorders in children. The definition of phonological disorders and their incidence and prevalence are first presented. The impact of this disorder on the lives of children and the role that speech-language pathologists play in treating this disorder are then discussed. Evidence of the positive outcome of phonological treatment is reviewed, with particular emphasis on treatment procedures that have been deemed effective, the specific effects of these treatments on improving intelligibility, and comparisons between treatments in facilitating improved sound production.

The Interactional Dimensions of Language Therapy

This article distinguishes between adult- and child-centered intervention practices according to five interrelated dimensions of therapy context: the event, the agenda, the interactional lead, evaluation, and repair. To illustrate how these five dimensions could potentially manifest themselves during interaction, clinicians were asked to engage a child of their own choosing in both adult- and child-centered intervention.

The present discussion focuses on a turn-by-turn analysis of an excerpt from one of the child-centered language therapy sessions. Analysis reveals that simply doing away with three-part quiz question sequences, eliminating explicit verbal evaluations of a child's communicative performance, and changing the function of repair does not necessarily result in a more child-centered interaction. To evaluate the child-centeredness of intervention, one must understand the communicative relationships between speakers as they manifest themselves during ongoing sequences of interaction that are embedded in therapeutic events.

Treating the Child Who Stutters With Concomitant Language or Phonological Impairment

When children who stutter also demonstrate speech or language problems, establishing efficacious and reasonable therapy objectives can be difficult. This article discusses diagnostic considerations in identifying coexisting communication disorders and in differentiating between stuttering and secondary fluency disorders related to language formulation. A number of options for structuring therapy for coexisting problems are evaluated, including blended, lagged, and cycled approaches. Concerns implicit in the treatment of coexisting linguistic and fluency problems also are reviewed.

The phonological system of a specifically language-impaired population

This paper provides a characterization of the phonological system of a family of specifically language-impaired (SLI) individuals. Morphological and syntactic data from these same subjects have previously been presented in Gopnik and Crago (1991) and Guilfoyle (1991). Data were collected from eight subjects, all family members, ranging from 7 to 46 years of age. Language samples were obtained at two sessions, 17 months apart, and analysed according to a revised version of the phonological assessment procedures outlined in Ingram (1981, 1989). Results indicated that these SLI subjects acquired the phonological inventory of English following the normal developmental sequence, but at an extremely delayed rate. In contrast, these subjects never achieved adult competency in reproducing the complex syllable patterns of English, as evidenced by the fact that consonants in syllable-final position and clusters were particularly susceptible to deletion or substitution errors. It is argued that these data are consistent with a linguistically based account of this impairment, which is manifested in the phonological component by the inability to construct learned, language-specific rules.

Speech Normalization in Developmental Phonological Disorders

A two-factor theory is proposed to explain individual differences in intervention outcomes for children with speech delays. Indices of Capability include linguistic measures of a child's comprehension and production phonology and risk factors. Indices of Focus include clinical responses to children's motivation for speech change and level of effort. Retrospective data from clinical records of 75 children who received intervention services in a phonology clinic provide a preliminary test of the proposed two-factor theory. Discriminant function analyses suggest that correlates of Focus are sensitive to factors associated with failure to make progress during intervention. Implications of these findings for prospective predictive research are discussed.

Applied Phonology

Phonological principles and procedures provide a framework for identifying broad deviation patterns and for expediting intelligibility gains. The number of clinicians currently incorporating phonological research findings in their assessment and remediation procedures, however, is rather small. In this article, possible factors that may have deterred clinicians from employing phonological constructs are explored, and phonological assessment and remediation issues, principles, and practices are discussed. In addition, underlying concepts and target patterns that have helped expedite intelligibility gains are explained.

The Need for a Broad-Based Model of Phonological Disorders

My response to Fey’s article (1985; reprinted 1992, this issue) focuses on the confusion caused by the application of simplistic phonological definitions and models to the assessment and treatment of children with speech delays. In addition to having no explanatory adequacy, such definitions/models lead either to assessment and treatment procedures that are similarly focused or to procedures that have no clear logical ties to the models with which they supposedly are linked. Narrowly focused models and definitions also usually include no mention of speech production processes. Bemoaning this state of affairs, I attempt to show why it is important for clinicians to embrace broad-based models of phonological disorders that have some explanatory value. Such models are consistent with assessment procedures that are comprehensive in nature and treatment procedures that focus on linguistic, as well as motoric, aspects of speech.