Speech Intervention: Articulation and Phonology for Children

This comprehensive study material provides an in-depth exploration of speech intervention strategies for articulation and phonology difficulties in children, as covered in SPCH2212 and SPCH7121, specifically focusing on Topic 4: Speech Intervention: Articulation and Phonology. The content introduces various phonological therapy approaches for young children, detailing their overarching principles, characteristics, implementation phases, and target populations.

Introduction to Phonological Therapy for Young Children

Phonological therapy for young children is a critical area within speech-language pathology, aiming to address difficulties children experience in organizing speech sounds into a system of contrasts and patterns. These difficulties can impact a child's intelligibility and overall communication effectiveness. The approaches discussed herein are designed to facilitate the acquisition of an adult-like phonological system, enabling children to produce speech sounds accurately and use them meaningfully to differentiate words.

Overarching Principles of Phonological Intervention

The primary goal of phonological intervention is to reduce the presence of phonological processes (patterns of sound errors) and to increase a child's phonemic inventory (the set of sounds a child can produce and use contrastively). A visual representation of these principles highlights a sequential and interconnected process, emphasizing several key aspects:

Learn Phonological Systems: Children need to understand how sounds function within a language system, not just how to produce individual sounds in isolation.
Discover and Learn Rules: Therapy guides children to discover the phonological rules of their language and learn how to apply them correctly.
Select Targets to Facilitate Generalisation: The selection of therapy targets is strategic, aiming for sounds or patterns that, once learned, will generalize to other untreated sounds or contexts, leading to broader improvements in speech.
Meaning-Based: Intervention is grounded in meaning, ensuring that children understand how sound differences create meaning differences in words. This helps them grasp the communicative impact of their speech errors.
Include Conversational Repair Sequences: Therapy incorporates opportunities for children to practice repairing their communication breakdowns in conversational contexts, fostering self-monitoring and problem-solving skills.

Contrastive vs. Non-Contrastive Approaches

Phonological intervention approaches are broadly categorized into contrastive and non-contrastive methods, each with distinct philosophies and techniques.

Phonological Contrastive Approaches

These approaches focus on improving phonemic contrasts in a child's speech. The core idea is to emphasize the sound differences necessary to distinguish one word from another. Instead of targeting individual sounds in isolation, contrastive approaches typically use contrasting word pairs as targets. This helps children understand that changing a sound can change the meaning of a word, thereby highlighting the communicative function of phonemes.

Examples of Phonological Contrastive Approaches include:

Minimal Pairs (Weiner, 1981; Blache, Parsons, & Humphreys, 1981)
Metaphon (Howell & Dean, 1987)
Maximal Oppositions and Treatment of the Empty Set (Gierut, 1989, 1990-1992)
Parents and Children Together (PACT) therapy (Bowen, 1996)
Meta Phonological Intervention (phonological awareness; Hesketh, Adams, Nightingale & Hall, 2000; Gillon, 2000, 2005)
Multiple Oppositions (Williams, 2000a, b)

Non-Contrastive Approaches

In contrast, non-contrastive approaches consider minimal pair words an optional component. Their primary focus is on broader aspects of a child's speech development, including complexity, intelligibility, and/or function. These approaches often aim to stimulate overall system change rather than specific phonemic contrasts.

Examples of Non-Contrastive Approaches include:

Cycles Approach (Hodson, 1978; Hodson & Paden, 1983)
Core Vocabulary Therapy (Doo & Iacano, 1989)
Dynamic Systems and Whole Language Intervention (Hoffman, Norris & Monjure, 1990)
Nonlinear Phonological Intervention (Bernhardt, 1992)
Naturalistic Intelligibility Training (Camarata, 1993)
Speech Perception Intervention using Speech Assessment and Interactive Learning System (Rvachew, 1994; Rvachew, Nowak & Cloutier, 1994)
Stimulability Intervention (Miccio & Elbert, 1996)
Non-contrastive Intervention using Complex Targets (Gierut, Morrisette, Hughes & Rowland, 1996)
Psycholinguistic Approach (Stackhouse & Wells, 1997)
Phonotactic Therapy (Velleman, 2002)
Morphosyntactic Intervention (Tyler, Lewis, Haskill & Tollbert, 2002)

Source: Adapted from McLeod and Baker (2016).

Clinical Decision-Making for Children with Speech Sound Disorders (SSDs)

Choosing the appropriate therapy approach and targets for children with Speech Sound Disorders (SSDs) involves complex clinical decision-making. A research report published in the International Journal of Communication Disorders (Furlong et al., 2018) identified four key themes influencing this process:

Procedures are highly individualized: Intervention plans must be tailored to the unique needs and characteristics of each child.
Parental involvement is central to intervention success and progression: Active participation from parents/carers significantly contributes to positive therapy outcomes.
Therapy is influenced by practice setting constraints: The environment in which therapy is delivered (e.g., clinic, school, home) can impact the choice and delivery of interventions.
Engaging in Evidence-Based Practice (EBP) was seen as challenging: Clinicians sometimes face difficulties in consistently integrating the best available research evidence with clinical expertise and client values.

Systematic Review of Interventions for SSDs (Wren et al., 2018)

A systematic review by Wren et al. (2018) provides insights into the evidence base for various intervention approaches for SSDs:

Strong Evidence for 3 Intervention Approaches:

Imitation and drill: These techniques involve direct modeling and repetitive practice of target sounds or words.
Meaningful minimal contrasts: Approaches that highlight the semantic differences created by sound contrasts, such as Minimal Pairs therapy.
Complexity: Interventions that target more complex linguistic elements, aiming for greater generalization to simpler, untreated sounds.

No/Limited/Some Evidence for:

Oromotor exercises
Phonetic placement
Metalinguistic approaches
Phoneme perception training
Focussed auditory stimulation

Clinicians are encouraged to consult resources like the 'What Works' database of interventions (Law et al., 2015) for evidence-based guidance on effective practices for children's speech, language, and communication difficulties. This database, endorsed by the Royal College of Speech and Language Therapists, provides a valuable resource for making informed treatment decisions.

Underlying Principles of Phonological (Linguistic) Approaches

Phonological (linguistic) approaches are guided by several core principles aimed at restructuring a child's phonological system:

Target the elimination of homonyms: A key goal is to reduce instances where a child uses one word for two different referents (e.g., saying "tea" for both "tea" and "key"). This highlights the importance of phonemic contrasts for meaning differentiation.
Aim to establish contrasts: This involves addressing both system contrasts (e.g., differentiating alveolar sounds like /t, d/ from velar sounds like /k, g/) and structure contrasts (e.g., the presence versus absence of an initial consonant).
May include some motor aspects: While primarily linguistic, these approaches may incorporate motor aspects, especially if a target sound is not yet in the child's phonetic inventory (i.e., the child cannot produce the sound at all).
Target distinctive feature acquisition: Intervention often focuses on teaching children to acquire distinctive features (e.g., voicing, place, manner of articulation) that differentiate phonemes.
Focus on the establishment of features / stopping of processes: The ultimate aim is to help children establish the correct use of distinctive features and eliminate maladaptive phonological processes.

An illustrative diagram shows examples of homonyms that might arise from phonological errors, such as "Bat," "Palm," "Iron," and "Seal," all potentially being produced as the same sound if certain contrasts are not established.

Characteristics of Phonological (Linguistic) Approaches

Effective implementation of phonological (linguistic) approaches incorporates several key characteristics:

Discover the Rule(s): Provide children with opportunities to discover the phonological rules being targeted. This active learning promotes deeper understanding.
Salient Contrastive Sounds: Offer frequent exposure to salient contrastive sounds, using physical prompts where appropriate (e.g., demonstrating long vs. short contrasts for /s/ and /t/).
Contrastive Words: Integrate contrastive words into functional, meaningful play activities (e.g., using "see" and "tea" in a game).
Give Feedback on Contrasts: Provide explicit feedback to the child regarding the meaning implications of their productions, highlighting how different sounds create different meanings.
Meaningful Words: Ensure that all words used in therapy are meaningful to the child. Avoid using nonsense words in linguistic approaches, as the focus is on communicative function.
Keep Sets Together: Maintain contrastive sets together during sessions (e.g., do not separate the pair "tea/key"). Aim to use approximately 5 contrastive sets per session.
Provide Communicative Feedback: Offer feedback that explains the success of their production, indicating what they did right, what went wrong, and how to make changes to achieve the desired communicative outcome.
High Productions: Aim for a high number of productions per session, typically around 60-100 productions within approximately 30 minutes, to maximize practice opportunities.

Four Phases of Phonological (Linguistic) Intervention

Phonological (linguistic) intervention typically progresses through four distinct phases, designed to systematically build a child's phonological and communicative awareness:

Phase 1: Familiarisation and Production of Contrasts

This initial phase focuses on introducing the child to the target phonological rule and the vocabulary associated with the contrastive word pairs. It is a brief phase, typically lasting only 1-2 sessions.

Familiarise the child with the rule: The rule is defined by the phonological process the child is using (e.g., stopping of fricatives, or the long vs. short sound rule).
Familiarise child with vocabulary/pictures: Introduce the specific words and their corresponding pictures. For example, for the contrast between /s/ and /t/, you might introduce "see" (long /s/ sound, looking) and "tea" (short /t/ sound, hot drink). Discuss the meaning and characteristics of each word.
Ask the child to first imitate and then produce target contrasts: Initially, the child imitates the clinician's production of the contrastive words. As they become familiar, they are encouraged to produce the target contrasts independently.

Phase 2: Working on Contrasts and Interactive Play

In this phase, the focus shifts to practicing minimal pairs or contrastive sets within interactive play activities. The goal is to achieve accurate production of these contrasts.

Aim for imitation, then spontaneous production: Begin by aiming for 70% accuracy in the imitation of minimal pairs during activities. Once this is achieved, progress to spontaneous production in play, targeting 90% accuracy.
Focus on production in play/games: The emphasis is on producing the target sounds within engaging play contexts. The percentages (70%, 90%) serve as clinical guides, and clinical judgment is used to determine progression.

Phase 3: Contrasts within Communicative Contexts

This phase encourages more spontaneous production of target words within communicative games, where the child's attention is on the game itself rather than just the word or picture. This helps integrate the target sounds into functional communication.

Focus on spontaneous production in games: The child uses the target words in games like "Go Fish," bingo, or memory, where the production of the word has a communicative outcome related to the game.
Contrasts do not need to stay paired: Unlike earlier phases, words do not necessarily need to be presented as pairs. The child might use one word/picture at a time.
Achieve 90% accuracy: The child needs to reach 90% accuracy with target words before moving to the next phase.

Phase 4: Conversational Recasts

The final phase aims for maintenance and generalization of the learned contrasts into more naturalistic conversational settings. The focus is on correcting errors and encouraging self-monitoring.

Move into a maintenance phase: This phase involves naturalistic training within play and functional activities, designed to encourage conversational repairs.
Correction of errors: When a child makes an error, the clinician immediately provides the correct target sound, often with a verbal prompt (e.g., "Uh oh, I think you meant key") or a non-verbal prompt (e.g., not receiving the correct card in Go Fish).
Encourage self-monitoring/prompting: The goal is for the child to begin self-monitoring and self-correcting their speech.
Can be done at home: Phases 2 and 3 are typically the core of phonological therapies in the clinic, while Phase 4 can often be effectively carried out at home by parents/carers.

1. Minimal Pairs: A Phonological Contrastive Approach

Minimal Pairs therapy is one of the most common linguistic-based interventions for phonological disorders.

What is Minimal Pairs?

It is a contrastive approach that aims to increase a child's awareness of the semantic difference between their erroneous production and the adult target model.
It uses pairs of words that differ by a single phoneme, and these phonemes differ by only one or two distinctive features (e.g., voice, manner, place of articulation). Examples include pat-bat (differing by voicing), four-pour (differing by manner), and tea-key (differing by place).
The approach directly addresses homonymy, where a child uses one sound to represent multiple different words, leading to communication breakdowns.

An example visual shows a grid of t/k minimal pairs, illustrating how a child might confuse words like "key" and "tea," "cop" and "cap," "sick" and "sit," or "tear" and "kick" if they do not differentiate between /t/ and /k/.

How to Implement Minimal Pairs

The implementation of Minimal Pairs therapy typically involves three main steps:

Familiarisation: The child is introduced to the minimal pair words and their meanings. This ensures they understand the vocabulary and the concept of the contrast.
Discrimination: The child learns to discriminate between the two sounds in the minimal pair. This might involve tasks where the child points to the correct picture when the clinician says one of the words.
Production: The child practices producing the target sounds in the context of the minimal pair words, aiming to establish the sound contrasts that mark a difference in meaning.

Choosing Minimal Pair Words for Production

When selecting minimal pair words for the production phase, several criteria are important:

Intervention is designed to establish sound contrasts that mark a difference in meaning.
Targets should be selected based on the child's assessment data, focusing on the patterns and processes they are using.
Choose target words that are within a child's vocabulary and can be easily represented with pictures.
Include words that do not appear on the assessment tool used, to test for generalization.
Avoid words that could be called something different (e.g., "toffee" might also be called "lolly" or "sweet"), as this could introduce confusion.
Avoid words that could confuse the child due to similar sounds or meanings (e.g., "tick/kick").

For instance, if a child confuses /t/ and /k/, and we have pictures of "tea" and "key," the child will learn that if they say "tea" when they mean "key," the listener will think they are referring to the cup of tea. This highlights the communicative consequence of their error.

A "Blackboard Activity" example illustrates a matching exercise where a child pairs words like "Crane" with "train," "School" with "stool," "Book" with "foot," "Shock" with "sock," "Mouse" with "mouth," "Sea" with "tea," "Fan" with "pan," "Ring" with "wing," "Lizard" with "wizard," "Pear" with "bear," and "Cub" with "cup." This type of activity helps reinforce the minimal pair contrasts.

Who Would Benefit from the Minimal Pairs Approach?

Minimal Pairs therapy is generally appropriate for:

Children with mild-moderate phonological difficulty.
Children typically between 3-6 years old.
Children with no organic or hearing difficulties.
Children who exhibit fewer omissions and/or substitutions (65-85% consonants correct).
Children whose errors are consistent.
Children who are stimulable for target sounds (meaning they can produce the sound with some prompting).

NOT appropriate for: Clients who display many sound distortions and/or omissions (e.g., articulation errors, inconsistent deviant productions).

2. Multiple Oppositions: A Phonological Contrastive Approach

Multiple Oppositions therapy is a variation of the minimal pair approach, designed for children with more extensive phonological difficulties.

What is Multiple Oppositions?

It is a contrastive approach that contrasts a child's error sound with three or four strategically selected sounds. These selected sounds reflect maximal classification (differing across major sound classes like stops, fricatives, nasals) and maximal distinction (differing by multiple distinctive features like place, manner, and voicing).
The approach is based on the assumption that learning is facilitated by presenting larger "chunks" of linguistic information to the child.
It is particularly useful when a child's multiple errors result in one sound being used in place of two or more others (known as a "phoneme collapse").

An example diagram illustrates a phoneme collapse where the sound /t/ is used in place of /s/, /sh/, /ch/, and /tr/. The therapy would then contrast /t/ with these three or four target sounds simultaneously.

Considerations for Multiple Oppositions

This approach is considered when a sound's "function" takes the place of many other sounds, indicating multiple sound collapses (i.e., many sounds are replaced by one sound).
Target selection is directly linked to the child's phonological system and does not primarily consider external factors like whether a sound is early developing.
Multiple Oppositions therapy targets both systemic (patterns of sound errors affecting a class of sounds) and structural process errors (errors affecting word or syllable structure).

An example of a "Multiple Phoneme collapse: Deletion of initial consonants" shows how "eat" might be produced for "feet," "beat," "sheet," and "treat." Similarly, a "Multiple Opposition Contrasting Set" might involve contrasting "tip" with "sip," "ship," "chip," and "trip" if /t/ is the child's error sound for these targets.

Minimal Pairs vs. Multiple Oppositions

A comparison highlights the key differences between these two contrastive approaches:

Feature	Minimal Pair Contrast Therapy	Multiple Oppositions Therapy
Comparison sound is the child's error production for the target sound	Yes	Yes
Targets homonymy	Yes	Yes
Number of oppositions/contrasts	Single	Multiple
Example	Child might substitute /t/ for /k/ (e.g., "tea" for "key")	Child might produce one sound for several adult sounds (e.g., /t/ for /s, k, ∫, tr/)

Who Would Benefit from the Multiple Oppositions Approach?

Multiple Oppositions therapy is suitable for:

Children with moderate-severe to profound phonological disorders.
Children typically between 3-6 years old.
Children with no organic or hearing difficulties.
Children who have at least 6 sounds in error across 3 different manner classes, or who substitute one phoneme for several very different phonemes (indicating a phoneme collapse).
Children with some to many omissions.
Children with some to extensive substitutions (50-65% consonants correct).

3. Maximal Oppositions: A Phonological Complexity Approach

Maximal Oppositions therapy is a phonological complexity approach that operates on the principle that targeting more complex linguistic elements leads to greater system-wide change and generalization.

What is Maximal Oppositions?

It is a Complexity Approach to SSD intervention.
The underlying belief is that choosing more complex targets leads to greater change and greater generalization across the child's phonological system.
It uses pairs of words containing contrastive sounds that are maximally distinct and vary on multiple dimensions (e.g., voice, place, and manner of articulation) to teach an unknown sound. The goal is to introduce a sound that is absent from the child's inventory by contrasting it with a sound that is maximally different.

A "Classification of NAE Consonant Phonemes" chart (Place, Manner, and Voicing Chart for English Consonants, informed by Roth and Worthington, 2018) is used to identify sounds that are maximally distinct. This chart categorizes consonants by their manner of articulation (Stop, Fricative, Affricate, Nasal, Liquid, Glide) and place of articulation (Bilabial, Labiodental, Dental, Alveolar, Palatal, Velar, Glottal), also indicating voicing.

3 Key Factors for Target Selection

When choosing a target sound to be compared (opposed) in Maximal Oppositions, three key factors are considered:

The number of feature differences: Select sounds that differ by multiple distinctive features (e.g., +/- voice, +/- continuant, +/- velar).
The nature of feature differences: Prioritize differences in major class features, such as:
- +/- vocalic (liquid vs. stop)
- +/- consonantal (stops vs. vowel)
- +/- sonorant (liquids, glides, nasals vs. stops, fricatives, affricates)
Known vs. unknown targets (most vs. least phonological knowledge):
- Most: Refers to a sound that is already in the child's inventory.
- Least: Refers to a sound that is not in the child's inventory and is not stimulable. Maximal Oppositions typically contrasts a known sound with an unknown, non-stimulable sound.

Example: Think Aloud

Consider a child who produces /t/ for /sh/. If the comparison sound chosen is /m/, the contrastive pairs would be:

'me' - 'she'
'my' - 'shy'
'mack' - 'shack'
'mall' - 'shawl'

To determine the maximal distinction between /m/ and /sh/, one would analyze their distinctive features:

Place: /m/ is bilabial, /sh/ is palatal. (Different)
Manner: /m/ is a nasal, /sh/ is a fricative. (Different)
Voicing: /m/ is voiced, /sh/ is voiceless. (Different)

Since /m/ and /sh/ differ across all three major dimensions (place, manner, voicing), they are considered maximally distinct.

Who Would Benefit from the Maximal Oppositions Approach?

Maximal Oppositions therapy is beneficial for:

Children with moderate to severe phonological disorders.
Children typically between 2;8 – 7;11 years old.
Children with no organic/structural basis or hearing difficulties.
Children who exhibit omission of at least 6 or more speech sounds from their phonetic and phonemic inventories.

4. Treatment of the Empty Set: A Phonological Complexity Approach

Treatment of the Empty Set is another phonological complexity approach, similar in principle to Maximal Oppositions, but with a specific focus on targeting sounds that are entirely absent from a child's system.

What is Treatment of the Empty Set?

It is a Complexity Approach to SSD intervention.
It uses pairs of words containing two maximally opposing sounds (e.g., /r/ and /d/) that are both unknown to the child and are not homonyms (e.g., 'row' vs 'doe').
Crucially, both sounds that are contrasted are produced as errors by the child. This means the child cannot produce either sound correctly.
The child receives intervention on these two target sounds simultaneously.

Comparison with Other Contrastive Approaches

A comparison table highlights how Treatment of the Empty Set differs from Minimal Pairs and Maximal Oppositions in terms of the child's ability to produce the target sounds:

Approach	Child's ability to produce the sound used in the contrast
Minimal Pairs	Uses a sound the child can say (at least they will have cues on one sound).
Maximal Oppositions	Uses another (different) sound the child can say (contrasted with an unknown sound).
Treatment of Empty Set	Both sounds are challenging for the child (i.e., neither sound is in the child's inventory).

For Example...

For a child who produces /t/ for /f/, contrastive pairs would be constructed to contrast the target /f/ with another sound in error that was also maximally distinct from /f/, such as /r/ or /l/. Examples of such pairs might be:

'ship' - 'rip'
'Shane' - 'rain'
'shake' - 'rake'
'shoe' - 'roo'

Assuming a child produced /w/ for the target /r/, the contrastive pairs would be produced by the child as:

/tip/ - /wɪp/ (for 'trip' - 'whip')
/teɪn, tæn/ - /weɪn, wæn/ (for 'train' - 'wane')
/teɪk, tæk/ - /weɪk, wæk/ (for 'rake' - 'wake')
/tu, tu:/ - /wu, wu:/ (for 'roo' - 'woo')

The key here is that the pairs would not be homonyms, as each target sound represents a different error production, and the goal is to establish the contrast between two sounds that are both absent from the child's system.

Who Would Benefit from the Treatment of the Empty Set Approach?

Treatment of the Empty Set is suitable for:

Children with moderate to severe phonological disorders.
Children typically between 2;8 – 7;11 years old.
Children with no organic/structural basis or hearing difficulties.

5. Metaphon: A Phonological Contrastive Approach

Metaphon therapy is a phonological contrastive approach that emphasizes metalinguistic awareness, encouraging children to think and talk about speech sounds and how they differ.

Metaphon Principles

Metaphon therapy is guided by five core principles:

Based on precise and detailed linguistic assessment: Therapy requires a thorough speech sound assessment. While Metaphon has its own assessment tools, other comprehensive assessments like the DEAP (Diagnostic Evaluation of Articulation and Phonology) can also be used.
Focus on increasing metalinguistic awareness: This is the biggest difference from traditional minimal pairs therapy. Metaphon aims to get children to actively think and talk about speech and language, fostering a higher awareness of how sounds differ and the communicative impact of these differences. Feedback is provided in a way that encourages this meta-awareness.
Children as active learners: Children are not passive recipients of information; they are encouraged to take an active role in the therapy process, making them active learners.
Maximizing learning opportunities (dosage): Attention is paid to maximizing the "dosage" or the number of learning opportunities provided to the child during sessions.
Increasing phonemic inventory: The ultimate aim is to increase the number of sounds in a child's phonemic inventory. By providing awareness and practice opportunities, children should add new sounds. For example, targeting velar fronting aims to add velar sounds (/k, g/) to their inventory.

Phases of Metaphon

Metaphon therapy is structured into two main phases, with Phase 1 having four distinct levels:

Phase 1: Develop Phonological Awareness

This phase focuses on developing the child's awareness of phonological concepts and how sounds are produced and contrasted. It addresses both systemic processes (where sounds are substituted or changed) and structural processes (where word or syllable structure is altered).

A quick recap on processes:

Systemic processes: These are processes where a sound changes or is substituted (e.g., gliding of liquids, where /l/ becomes /w/). Essentially, any process where sounds are changed or replaced but not removed.
Structural processes: These are processes where the structure of the word is changed (e.g., cluster reduction, where "spoon" becomes "poon," or consonant deletions).

1. Concept Level

At this level, abstract phonological concepts are explained to children using simple, relatable terms and visual aids:

Stopping: Explained as "long vs. short" sounds (e.g., fricatives are long, stops are short).
Voicing: Explained as "loud vs. soft/whisper" sounds.
Cluster reduction: Explained as "two vs. one" sound (e.g., a consonant cluster is two sounds, a single consonant is one).
Fronting: Explained as "front vs. back" sounds. A diagram (Figure A) might show a "front" face (e.g., a person's face) and a "back" face (e.g., the back of a head) to illustrate this concept.
Final consonant deletion: Explained as "objects with and without something at the end." A diagram (Figure B) might show a mouse with a tail (representing a final consonant) and a mouse without a tail (representing final consonant deletion).

2. Non-speech Sounds Level

This is a quick phase, lasting about 5 minutes maximum, where the child associates the phonological concepts with non-speech vocalizations.

Non-speech sounds are chosen to be contrasting and related to the concept. For example, "front sounds" might be represented by a kiss/blow, while "back sounds" might be represented by a cough/yawn.
The child makes sense of the concepts in response to a referent. For instance, if shown a picture representing "front," the clinician might say, "Oh, that's front! I can make a front sound" and make a kiss. Then, for a "back" referent, "I can make a back sound too! - do a cough." The child is then encouraged to imitate these non-speech sounds.
This level involves scaffolding for fun, making the therapy engaging. For example, a child might pick up a picture of a long snake and make a long /m/ sound ('mmmmmmm').

3. Phoneme Level

At this level, the focus shifts to the sound level, building the child's awareness of contrasts using actual phonemes.

Contrast one class of sounds with another: Illustrate the difference between sound classes (e.g., front sounds vs. back sounds, or stops vs. fricatives).
Introduce all sounds within the class: Unlike some approaches, Metaphon introduces the child to all sounds within a target class, not just the ones they have errors on (e.g., all front sounds for fronting, all stops for stopping).
Clinician models, child observes: The child is primarily observing the clinician making the sounds in response to a referent (e.g., picking up a "long" card and saying "long," then picking up a "short" card and saying "short"). The clinician might say, "I can make a short sound, watch! /p/."
Encourage discovery and discussion: The clinician uses engaging language like "I wonder if you know any short sounds?" to encourage curiosity and less directive learning.
Child identifies sound characteristics: The clinician might say a sound (e.g., /p/) and ask the child if it's a short/long sound or a front/back sound.
Encourage a range of sounds: The child is encouraged to make a range of sounds within the target class.
Play games to reward attempts: Games are used to reinforce concepts and encourage discussion.

Important note on nonsense syllables: Nonsense syllables are not used in Metaphon therapy for systemic processes (e.g., substitutions). For systemic processes, the focus is on real words using minimal pairs. However, for structural processes (e.g., cluster reduction, final consonant deletion), nonsense words are used at the word level.

4. Word Level (Real Words for Systemic Processes)

For systemic processes, this level involves working at the word level using minimal pairs that demonstrate examples of the particular phonological process (e.g., 'tea/sea' for stopping, 'top/shop' for fronting, 'bow/blow' for gliding).

Use 5-6 different minimal pair sets: Work with multiple copies (5-6) of each picture, focusing on one pair at a time.
Referents on the back of cards: Each pair has referents drawn on the back of the cards to reinforce concepts from the phoneme level. This acts as a "checking" mechanism. For example, a card for "car" (if targeting velar fronting) might have a drawing of the back of a head on its reverse side, representing a "back sound."
Use pictures, not written words: For young children, therapy relies on visual aids rather than text.

Structural Processes (Considerations for Phase 1)

For structural processes, Phase 1 also involves developing phonological awareness, but the levels are slightly different:

Concept level: Similar to systemic processes, explaining concepts like "two vs. one" for cluster reduction.
Syllable level: Focus on syllable awareness and manipulation.
Word level (nonsense words): Unlike systemic processes, structural processes use nonsense words at the word level to practice the structural changes without the confounding factor of meaning.

When to Move Phases?

Progression from Phase 1 to Phase 2 is considered when a child:

Can accurately identify sounds/syllables with correct concepts (all the time).
Can accurately identify sounds in words with correct concepts (all the time across activities).
Can successfully attempt production of sound/syllable with correct concept (production of a range of sounds or syllables).

As a reference, Phase 1 typically lasts about 3 sessions of 40-45 minutes. Clinicians should ensure children hear a number of contrasts (e.g., 'tea/see' and 'pin/fin' for stopping) and do not need to use all fricatives, but a range of exemplars from different classes.

Phase 2: Develop Communicative Awareness

This phase focuses on developing the child's metacommunicative skills, enabling them to understand and repair communication breakdowns.

1. Word Level

Metacommunicative skills: The child learns that an error in production results in saying a word with a different meaning. This phase helps develop phonological awareness so children can repair their erroneous productions.
Critical feedback: Feedback is crucial for developing communicative awareness. For example, if a child says "noukiou, nəuki:əu" for Pinocchio (WSD - word-final devoicing, velar fronting), and a researcher produces a different response as a question "fənoutiou, fənəuti:əu" (velar fronting), the child might self-correct to "pənovkiou, pənəuki:əu."
Minimal pairs activity: A critical activity involves saying minimal pairs. This can be done with a pile of cards, where the child and clinician take turns selecting a card, naming the item, and the listener indicates which word they heard by pointing to a picture. The comparison of what was said and heard helps identify matches or mismatches.

2. Phrase and Sentence Level

This level extends practice to phrases and sentences, maintaining the target contrast within a broader linguistic context.

Criteria for moving levels: Metaphon does not specify strict criteria for moving from word to phrase and sentence level, but a general guideline of 80-90% accuracy is suggested.
Maintaining contrast in sentences: Minimal pairs used at the word level are placed within constant carrier sentences (e.g., for Final Consonant Deletion, "I caught a 'roo'" or "I found a 'roof'").
Structured phrases in games: Introduce structured phrases into games. For example, with 4 pictures ('car/calf'), the child could pick two words and say, "I've got 'car' and 'I like the roof'," and then point to the corresponding pictures.
Feedback on sound nature: Feedback at this level focuses on getting the child to think about the nature of the target sound (e.g., long vs. short) and what they need to do to convey the intended meaning. For example, "I can see you were trying to put a tail sound on but I didn't hear a sound, can you try again?"

Who Would Benefit from Metaphon Therapy?

Metaphon therapy is suitable for:

Children with mild to severe phonological disorders.
Children with at least 2-3 phonological processes (often more).
Children typically between 3;6 years old to middle primary school age (the mode of therapy would adapt for older children).
Children with no organic/structural basis or hearing difficulties.

6. Core Vocabulary: A Phonological Non-Contrastive Approach

Core Vocabulary therapy is a non-contrastive approach specifically designed for children with inconsistent speech sound production who may not respond well to traditional therapy methods.

What is Core Vocabulary?

It focuses on whole-word production.
It is used for children with inconsistent speech sound production who may be resistant to more traditional therapy approaches.
Words are selected based on the child's functional communication needs.
A list of frequently used words is developed (e.g., through observation, parent/carer, and/or teacher report). A subset of these words is selected each week for treatment.
The child is taught their "best" word production, and these words are practiced until consistently produced.
The main aim is to facilitate the consistency of production, making this approach suitable only for children who are inconsistent in their speech.

Quick Inconsistency Recap

Inconsistency in speech production is common in typically developing children as their phonological systems develop. By 3 years, the mean inconsistency is 13%, decreasing to 6% by 4 years of age. In the DEAP Inconsistency Assessment, 25 pictures are named three times in one session to calculate an inconsistency score. Children are diagnosed with an inconsistent speech disorder (Dodd's 2005 classification) if they have at least 40% of words produced variably (inconsistently), meaning their token-to-token variability is 40% or greater. Children with at least two atypical patterns and inconsistency less than 40% are considered to have consistent speech disorders (Holm, Crosbie & Dodd, 2007; Dodd, 2011).

Core Vocabulary Focuses on Three Main Aspects

Phonological assembly: This refers to the child's knowledge of how to put sounds together in a word. It takes place when sounds are heard and spoken.
Maintaining auditory attention: While children are expected to focus on sounds generally, the primary focus is on consistently putting sounds together in the same way every single time.
Provision of as much information as possible about words: This involves giving the child detailed information on how to make sounds and how to construct a word.

Service Delivery Options in Core Vocabulary

How often? Two 30-minute sessions per week are recommended, but once a week can also be successful.
Length of therapy block? 6-8 weeks (or 6-8 hours of therapy) are usually sufficient for most children.
Agent of therapy? The speech pathologist is the primary agent, but parental involvement is essential for success.

Core Vocabulary - Procedure

The Core Vocabulary approach follows a structured, five-step procedure:

Step 1: Choosing Words

The goal is to teach children to produce approximately 50 functionally powerful words that are important and frequently used by the child in their daily life. These are words they have to say every day.
When choosing words, consider the child's life and environment.
Some chosen words should be more complex, including multisyllabic words, words with clusters, and words with more complex phonotactic structures.
An example scenario for choosing functional words for a 4-year-old might include words related to their childcare, family members (e.g., Siri, Sandy, Matthew), pets (e.g., Nemo), favorite games/activities, places, TV shows, and foods.

Step 2: First Word Session

This session focuses on teaching the child their "best" production of the initial set of words.

Choose the first set of words: Select about 10 words from the total 50. This is done weekly, with parents/carers providing at least 10 words for the first session.
Each word has a corresponding card with a picture.
The number of words practiced in a session can vary, but typically aims for about 10 words (fewer for younger children or those with more complex disabilities). Children can randomly select targets (e.g., pull from a bag).
The speech pathologist teaches the child a target word to elicit their best production of that word. This "best production" may not be phonetically correct (e.g., /dowofee/ for "toffee"), which is a key difference from other approaches.
Teaching principles to establish consistency:
- Number of syllables: Clap out the beats in the word (e.g., "Thank you" has two syllables: -thank- and -you-).
- Starting and ending sounds: Explain how to produce these sounds (e.g., "Thank starts with 'th'. Start with your tongue between your teeth for 'th'").
- Number of sounds: Break down the word into its constituent sounds (e.g., "Thank" has 4 sounds: /th/, /a/, /ng/, and /k/).
- Imitation: Encourage imitation of sounds or parts of words, but not the whole word.
- Cued articulation: Use hand cues, videos, or cues focusing on place, manner, and voicing to teach the sound.
- Linking sounds to letters: For older children with formal education, link sounds to letters.
- Specific and clear feedback on error: Provide crucial feedback, reinforcing what the child needs to do to achieve their best production (e.g., "remember that ends with the sound /k/").
- Emphasize the best production: Stress that the child must produce the word with their best production each time ("Give me your best word"). Use shaping and specific feedback to guide gradual approximations to the target.
These teaching principles help children establish strong auditory cues for correct or best sounds and support the development of metaphonological awareness, enhancing consistency in production.

Step 3: Parent/Carer Involvement

Parents/carers are integral to this therapy approach and work with the child twice per day on the word list at home.

Encourage parents/carers to elicit (and accept) the child's best production using cues from the session.
Ask them to keep a list of the child's best productions to track progress.
Reinforce the aim of consistent word production. Once consistency is achieved, the focus shifts to accuracy.
Parents/carers play a key role in providing words, engaging in sessions, monitoring progress, and communicating changes over time.

Step 4: Further Sessions

These sessions involve ongoing practice and target management.

Once a word is produced consistently, it is replaced with another word from the list. The goal is to achieve consistency on all 50 words.
Once the child becomes consistent on around 50 words, consistency is achieved. At this point, regular phonological therapy (e.g., Cycles therapy, Metaphon) can begin to address accuracy.
The second session continues with massed practice of the 10 words introduced in the previous session to maintain high dosage during motivating activities or games.
Focus on drilled production: Games are used to elicit numerous productions.
- Aim for approximately 100 responses in 30 minutes, or each of the 10 words produced 10 times in 30 minutes (child's best production).
- Increase the number of productions: Instead of saying a word once per turn, have children say it 5 times. Use dice to determine the number of repetitions, and also encourage incidental productions (e.g., "Yes, there's Dorothy, what's her name again?").
Example of a second session summary:
1. Elicit a high number of productions of target words (aim for ~100 responses in 30 minutes, or 10 productions per word).
2. Use games to elicit numerous productions.
3. Provide feedback, explaining errors and how to achieve correct production.
4. Aim for spontaneous word production (not imitated).
5. At the end of the session, check consistency of target words (child produces words three times). Any consistently produced word is removed and replaced with a new one.

Step 5: Generalisation

This final step involves monitoring whether the learned consistency generalizes to untreated items.

To monitor generalization, a set of untreated items should be tested. This could include 10 words from the DEAP, 10 other words familiar to the child, and the full DEAP inconsistency assessment.
When the child's speech is consistent, the intervention transitions to other phonological therapies (e.g., minimal pairs therapy, metaphon, cycles therapy) to address accuracy and further refine their phonological system.

Who Would Benefit from Core Vocabulary Therapy?

Core Vocabulary therapy is specifically designed for:

Children with inconsistent speech disorder (i.e., inconsistency is 40% or higher on assessment).
Children typically around 3 years old (Broomfield & Dodd, 2005).

7. Cycles Therapy: A Phonological Non-Contrastive Approach

Cycles Therapy is a non-contrastive phonological approach developed by Hodson and Paden, designed to approximate the natural process of phonological acquisition.

Seven Principles of Cycles Approach (Prezas & Hodson, 2010)

Phonological acquisition is a gradual process: Cycles therapy mirrors natural acquisition by targeting one process/pattern at a time, followed by a review. Intervention patterns follow a developmental sequence.
Children with normal hearing typically acquire the adult sound system primarily by listening: Cycles incorporate slightly amplified auditory stimulation, known as auditory bombardment. This increases the perceptual saliency of the sound, helping children acquire the adult sound.
As the child learns new speech patterns, they associate kinaesthetic with auditory sensations which enable later self-monitoring: Children learn to connect what they hear with what they feel when making sounds. The therapist provides information to help them use this connection for self-monitoring.
Phonetic environment can facilitate (or inhibit) correct sound production: The context in which a target sound is said influences its production. Therefore, words with appropriate phonetic environments are selected to help children focus their attention on the target sound. Simple phonetic environments are preferred.
Children are actively involved in phonological acquisition: Therapy should be fun and engaging to ensure active participation from children.
Children tend to generalize new articulation skills to other targets: Children often generalize newly acquired articulation skills. Therefore, target speech sounds or syllable shapes that match those present in a child's system are chosen to promote generalization.
Optimal ‘match’ facilitates learning: Teaching occurs within the zone of proximal development, meaning targets are just beyond the child's current ability, providing a challenge but also a high chance of success.

Cycles Therapy Overview

Treatment is scheduled in cycles, typically ranging from 5-16 weeks.
Each cycle targets one or more phonological patterns.
Once a cycle is completed, a new cycle begins, targeting different phonological patterns.
The goal is to approximate the gradual, typical phonological developmental process.
Cycles therapy focuses on the elimination of phonological processes and the development of individual phonemes, rather than solely on motoric production.
Most approaches use a vertical attack strategy, targeting one sound/pattern until a set level of mastery is gained. In contrast, Cycles uses a horizontal goal attack strategy, targeting several sounds/patterns for periods of time in succession. This is visually represented by a grid where a vertical strategy would focus on mastering one column before moving to the next, while a horizontal strategy would move across rows, touching on multiple targets before cycling back.

Basic Procedures in Cycles Therapy

Key components of a Cycles therapy session include:

Auditory bombardment/stimulation: Intensive listening to target sounds.
Use of cues: Providing various prompts and supports.
Production: Opportunities for the child to produce target sounds.
Dose: Ensuring sufficient practice opportunities.

A visual representation of typical cycles progression shows:

Sessions 1-4: Focus on initial consonants like /p/, /t/, /g/, /s/.
Sessions 5-6: Focus on Velar Fronting (VF), targeting /k/ and /g/.
Sessions 7-9: Focus on Stridency Fronting (SF), targeting /s/, /z/, /f/.
Sessions 10-12: Focus on Cluster Reduction (CR), targeting /st/, /sp/, /sk/.

Target Patterns (Hodson, 2007)

Hodson (2007) outlines optimal primary and secondary target patterns, as well as inappropriate patterns for preschoolers.

Optimal Primary Target Patterns:

Word structures: Omissions of obstruents (fricatives, stops, affricates) and liquids (e.g., initial or final consonant deletion).
Syllableness: Omissions of syllables (e.g., weak syllable deletion).
Singleton consonants: Targeting individual consonants, not clusters.
Stridency: Working on fricatives, particularly /s, z, f, v/. Also, /s/ final clusters like /ts/ and /ps/ can be targeted to help achieve /s/ production.
Anterior/posterior contrasts: Addressing errors like velar fronting (e.g., /t/ for /k/) and backing (e.g., /k/ for /t/).
Liquids: Targeting gliding of liquids (/l/ and /r/) at the end of the cycle. These are later developing sounds, impact only two sounds, and have less impact on intelligibility compared to other processes.

Optimal Secondary Target Patterns:

Palatal sibilants: /ʃ, ʒ, tʃ, dʒ/.
Medial /r/: If initial /r/ is worked on, medial /r/ will likely generalize.
Word medial and final /s/ plus stop clusters.
Glide clusters.
Voicing contrasts.
Vowel contrasts.
Assimilations.
Idiosyncratic patterns: The most common are Initial Consonant Deletion (ICD) and backing.

Inappropriate Patterns to Focus on Preschoolers:

Voiced word-final obstruents: Fricatives, stops, affricates that are voiced in word-final position, often a result of word-final devoicing.
Post-syllabic/vocalic /l/: For example, in words like 'apple' and 'table' where /l/ takes up a syllable.
'th' sounds: These are later developing sounds and are typically not targeted in early cycles.

What Does a Typical Cycles Session Look Like?

A typical Cycles session is structured to maximize learning and engagement:

Review: Review the previous week's production practice word cards. Accurate cards are set aside; inaccurate ones are incorporated into current production activities.
Auditory bombardment/stimulation: Listen for 30 seconds to approximately 20 words containing the target pattern. Slight amplification is provided, and the clinician demonstrates the error and contrasts it with the target (e.g., saying 'tar' for 'car' and then correcting to 'car').
Target Word Cards:
1. The child draws, colors, or pastes pictures of up to 4-5 words on large index cards.
2. The name of the picture is written on each card.
3. The child's production of a word is checked before confirming the target word. Ensure it's an appropriate phonetic environment and doesn't have confusing sounds or assimilatory effects (e.g., 'kite' could generalize to 'kike').
4. Word cards should be simple, with CV or CVC structures.
5. Words containing phonemes produced at the same place of articulation as the substitute phoneme should be avoided during early cycles (e.g., 'cat', 'coat' would be inappropriate for velar fronting).
Production Practice: This is the main part of the session. Words from previous sessions (e.g., /g/ words if working on /k/) can be included. The child engages in auditory, tactile, and visual stimulation for correct word-level production. Usually, 5 words per target sound are used in a single session (these may be combined with previous session's words). The child must produce a target pattern in words aiming for 100% accuracy. Activities shift every ~7 minutes to maintain interest (5-6 activities per 1-hour session).
Stimulability Probing: Identify what to work on next by selecting words/targets for the next session within the targeted phonological pattern. The most stimulable sound/cluster is chosen. For example, if working on /f/, check stimulability for other fricatives like /s/ and choose the most stimulable one.
Metaphonological activities: Engage in segmenting and blending activities. This refers to the child's knowledge and awareness of phonemes (e.g., rhyming words like 'tie' with 'sigh'), identifying the first sound (e.g., what does 'sigh' start with), segmenting (breaking up 'sigh' into /s/-/i/), and blending (putting together /s/ and /i/).
Auditory bombardment (repeated): Briefly repeat auditory bombardment using the word list from the beginning of the session.
Home practice: Parents/carers are instructed to focus on key aspects. They read a 20-item word list to the child at least once daily, practice with 5 production word cards, and do brief metaphonological activities at home.

Who Would Benefit from Cycles Therapy?

Cycles Therapy is particularly effective for:

Children with highly unintelligible speech.
Children with multiple phonological processes.
Children with severe to profound SSD, including those with dyspraxia, special needs, and co-morbid communication impairments.

NOT for children with mild speech disorders.

Termination Criteria for Phonological Intervention

Deciding when to discharge a child from phonological therapy involves specific criteria focused on the child's ability to maintain contrasts and make changes to their production:

Children can be considered for discharge when they are able to maintain contrast between words at the sentence level. This indicates that they can consistently differentiate word meanings through their speech sounds in connected speech.
Children do not necessarily need to have generalized the sound(s) to all external environments. However, they must be able to make changes to production if reminded of a concept. For example, if a child says "Mummy, where's the 'ta'?" (instead of 'car'), and is prompted with a concept related to "back sounds," they should be able to self-correct.

Key Takeaways from Speech Intervention: Articulation and Phonology

Several crucial points summarize the principles and practices of speech intervention for articulation and phonology difficulties:

Treating articulation disorders should be a straightforward process, as it primarily aims at the correct motor production of speech sounds.
There is a wide array of approaches to treating phonological disorders. Some are more holistic and system-wide in nature (e.g., Cycles approach), while others focus specifically on the knowledge and use of phonological contrasts (e.g., Minimal Pairs).
Choosing the most appropriate approach is often challenging and can be controversial, as the best fit depends on each child's unique strengths, difficulties, and specific intervention goals.
Generally speaking, speech intervention is more effective when it is intense (involving many practice trials per session) and administered in a distributed practice schedule (e.g., short, intensive periods of practice spread out over time).
During intervention sessions, it is possible and often beneficial to target different speech sounds and goals, allowing for practice to be distributed across a series of sessions within a treatment block.
Active parent/carer involvement is a critical factor that significantly increases the intensity and effectiveness of the intervention.

Speech Intervention: Articulation and Phonology for Children - Detailed Overview of Phonological Therapy Approaches

Speech Intervention: Articulation and Phonology for Children - Detailed Overview of Phonological Therapy Approaches