Banter Speech & Language

Sydney speech pathologists helping adults and children speak for themselves.

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Stuttering: what do we mean by ‘recovery’?

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We’ve been asking ourselves an important question recently: What, exactly, does ‘recovery’ from stuttering mean? 

We work with toddlers, preschoolers, primary school-aged children, teenagers, and adults who stutter. We work with clients with mild stuttering; and others with severe stuttering. We work with clients who stutter consistently with all people in all situations, others who stutter only in some situations (e.g. when reading, or talking on the phone, or during presentations), and yet others who stutter only occasionally (e.g. when tired, angry or nervous). 

We listen to our clients, read the peer-reviewed research, and reflect on our clinical data. And we still struggle to answer the most basic of questions: 

When can we say a client has recovered from stuttering?

Fortunately, a group of researchers has been looking at this question recently in the context of early stuttering (Einarsdóttir et al., 2020 – see below for full citation).  

Before we get to their interesting findings, let’s revisit some of what the evidence tells us (and doesn’t tell us) about stuttering and recovery:

Not everyone recovers

Stuttering usually starts in early childhood. Most children recover. But a sizeable minority don’t. 

No cure for persistent stuttering

For children (and teenagers and adults) who do not recover in the preschool years, stuttering can be persistent – even with good, evidence-based treatment and improvements in fluency. To date, there is no cure for persistent stuttering (although there are some very smart people working hard on it). Treatment goals often involve learning coping strategies to manage stuttering and its effects.

Predictors of recovery

Can we predict who will recover and who won’t? Some researchers have identified a few factors that seem to increase the chance of recovery, including being a girl. More recent research suggests that children who start to stutter at earlier ages are more likely to recover; and that children who have been stuttering for less than 18 months are more likely to recover than those who stutter for longer than 18 months. Children who receive treatment within 15 months of stuttering onset are more likely to recover than those who receive treatment later. Children with advanced speech, language and literacy skills may be more likely to recover than those with delayed or disordered speech or language (e.g. Einarsdóttir et al., 2020.)

In truth, we don’t know whether a particular child will recover. This is why we recommend early treatment for all young children who stutter. 

Some reported recovery rates in published research might be inflated

As we’ll discuss below, recovery rates depend a great deal on your definition of ‘recovery’. But there are a few other factors that probably inflate some of the published findings: 

(a) Many families drop out of research studies and therapy before finishing

  • One frequently cited study reported a recovery rate of of 79.2%, but 33.2% of the participants in that study dropped out (Andrew & Harris, 1964), making it hard to interpret. We see high drop out rates in many stuttering studies, most notably in some of the Westmead Program studies.
  • Many families drop out of speech therapy before completing treatment. Sometimes, it’s because they are satisfied with their child’s fluency – they decide that the child is recovered or at least ‘fluent enough’ or that stuttering is no longer affecting the child is a material way. But, at other times, it’s because they don’t think the therapy is working, or that the costs of continuing with therapy exceed the benefits.

If we only look at people who finish treatments, we may think we are more successful in treating early stuttering than we actually are.

(b) Unrepresentative participants used in some (not all) studies

Many (but not all) peer-reviewed studies of children who stutter exclude children with speech-language disorders, attention disorders, Autism Spectrum Disorders, and intellectual disabilities. Many of my clients who stutter have speech and language challenges as well. If advanced speech and language skills are possible predictors of recovery, aren’t we at risk of reporting inflated recovery rates because we are excluding children with delayed or disordered speech? 

There are other problems with inclusion criteria used in some studies, too. Many studies, for example, exclude bilingual children. My case load includes many children who are learning more than one language. Are recovery rates different for bilingual children? We don’t know enough about this yet.

(c) Limited long-term follow up of ‘recovered’ children into adulthood

Few studies follow people who stutter from preschool to adulthood, middle-age and late ages. Children who complete preschool treatments and are deemed to have ‘recovered’ may relapse or otherwise start stuttering at some later point. We see lots of older clients who report they were treated successfully as preschoolers.

Some clients learn to mask their symptoms successfully

Low levels of stuttering can be hard to distinguish from the speech of people who do not stutter. If a client stutters so mildly that no one can tell, are they ‘recovered’? If not, why not?

Many people who stutter find effective ways to self-manage their symptoms. For example, some of my clients:

  • gravitate to jobs, hobbies and interests that don’t require much speech;
  • replace or work around potentially difficult speaking situations with other kinds of communication:
    • using an app to order food rather than the phone;
    • using picture or text-based social media, messaging and blogging platforms like Instagram, Messenger, WhatsApp, Discord or Medium to express themselves;
    • using gestures, gifs, infographics and other visuals to supplement their words in presentations;
  • reduce the social pressure of speaking by pre-scripting or rehearsing important speeches, or pre-recording video responses, rather than presenting them live; or
  • work around particular difficulties by substituting words they find difficult to say with synonyms, or simplifying the complexity of their sentences to reduce the length of each utterance. 

Adults who stutter are at a greater risk of developing social anxiety and other mental health issues. But many people who stutter do not have social anxiety or other problems and lead very full, healthy lives. Do we count clients who stutter but mask their stuttering symptoms and participate in life effectively ‘recovered’? If not, why not?

Does the definition of ‘recovery’ depend on the goal of stuttering therapy?

Is the goal of therapy to get rid of the stuttering – to ‘fix the impairment’ –  or to help clients manage the effects stuttering on their participation and mental health and maximise quality of life outcomes? Do we measure recovery differently depending on the goal?

For preschoolers who stutter, there are very good, evidence-based treatments, including the Lidcombe Program and the Westmead Program. The stated aim of these programs is to eliminate stuttering. 

Once a child starts school, stuttering gets much harder to treat and is rarely eliminated altogether. The treatment focus switches away from the elimination of stuttering to helping children self-manage their stuttering in situations that matter most to them, like talking in class and in the playground, giving speeches, performing in school plays or in sports. 

For teenagers and adults, speech restructuring or prolonged speech treatments, like the Camperdown Program have the highest level of evidence. But, again, they don’t work for everyone. For example, in some situations, some clients would rather stutter than use speech restructuring techniques.

Over the years, we’ve observed that stuttering affects people in very different ways. For some clients, it is a really big deal that has a profound, negative effect on their mental health, social participation, and school or work goals. For other clients, stuttering seems to have little obvious effect on their lives. 

Stuttering severity alone is not always the main issue. Some people seem to be fairly untroubled by even quite severe stuttering. For others, very mild stuttering can have a big, negative effect on their quality of life and health.  

Is recovery determined by the reduction of stuttering severity or symptoms, by the quality of the client’s life despite the effects of stuttering, or a combination of factors?

The answer must be different for different clients.

What does ‘recovery’ from early stuttering really mean? 

In a recent study, Einarsdóttir and her colleagues reviewed 23 longitudinal studies to examine the persistence and/or recovery rates in children who stutter. They found a mean recovery rate of 58.7% across studies. But they also found reported recovery rates ranging from 6.3% to 94%! 

One reason for this startling inconsistency across studies is that different stuttering researchers defined ‘recovery’ very differently. Some:

  • used speech measures, like percentage of syllables stuttered and/or a subjective rating system (e.g. from 0-9, 0-7, or 1-10);
  • relied on expert opinion from experienced speech pathologists; 
  • relied on self-reports from families and from children themselves; and
  • used a combination of measures.  

In defining recovery, some researchers used stringent measures – e.g. requiring no stuttering whatsoever measured by experienced clinicians across multiple speech tasks. Others allowed some stuttering (e.g. less than 3% of syllables stuttered, or severity ratings of 2 or less on a rating scale of 0-7). Others used purely subjective measures like family reports, or didn’t specify their definition of recovery at all. Far too few studies asked the child to report whether they felt like they had recovered. 

All this inconsistency makes it very difficult to give families good information about the ‘true’ recovery rate or even what recovery might look like. To help improve the evidence-base, Einarsdóttir and her colleagues studied 38 monolingual children who stuttered, measuring stuttering on two occasions: (1) when they were aged 2-5 years; and (2) seven years later, when they were 9-13 years of age. They applied four different criteria for the definition of ‘recovery’, based on previous research:

(A) A child has a stuttering frequency of less than 3% syllables stuttered in video recorded speech samples.

(B) A child meets all four of the following criteria: (i) two speech pathologists and parents agree that the child no longer stutters; (ii) parents had to be able to report when the stuttering stopped and confirmed that the child had not stuttered for the previous 12 months; (iii) stuttering severity was rated as ‘borderline or no stuttering’ by speech pathologists based on the speech sample; and (iv) the average percentage of stuttered syllables was 3% or less. 

(C) A child meets all the criteria in (B) + the child self-reported that he was no longer stuttering.

(D) A child meets all the criteria in (C) and no stuttered speech at all was present in the speech sample.

They found that all children became more fluent with age. But the recovery rate varied greatly depending on the criteria used. If:

  • criteria (A) were applied, 94.7% recovered;
  • criteria (B) were applied, 71.1% recovered;
  • criteria (C) were applied, 55.3% recovered; and
  • criteria (D) were applied, only 13.2% recovered (5/38 children).

So the rate of recovery ranged from 13.2%-94.7%, depending on the criteria applied – broadly consistent with the results of their analysis of previous longitudinal studies. The most common criteria applied in previous research is (B). But, interestingly, by including children’s self-reports on whether they felt they had recovered (Criteria C), far more children were classified as not-recovered. 

A few caveats to this study: It was fairly small – 38 children (28 male, 10 female). All participants lived in Iceland. The study excluded bilingual children and children where ‘there was evidence of severe language impairment’ or signs of ‘neurological disorder’. The first author was not blinded to which clients identified as recovered. Selection bias may have affected recruitment. The children were only assessed at two points, and in clinical contexts (mitigated by obtaining multiple speech samples on different tasks). Importantly, some children were treated during the study term; and others were not, so no conclusion could be made on whether treatment may have affected outcomes.

Clinical Bottom line

When we talk about ‘recovery’ from stuttering, we need to be clear on exactly what we mean; clear about what the evidence tells us about recovery rates for early and persistent stuttering (including what we don’t know, and some of the limitations of the published studies); and clear about the goals of stuttering therapy.

Recovery means different things to different people – including to different people who stutter. For many clients, requiring completely fluent speech as a criteria for recovery is unrealistic and potentially demotivating and demoralising. Ultimately, the most important view is the client’s, recognising that there is as yet no cure for persistent stuttering.

Related articles:

Principal source: Einarsdóttir, J.T, Crowe, K., Kristinsson, S.H., & Másdóttir, T. (2020). The recovery rate of early stuttering. Journal of Fluency Disorders, 64, 105764.

Introducing The Scatter-Slayer Adventures: a decodable digital ‘select-your-sequel’ series for reluctant readers

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Hello, friends and followers! We’re excited to introduce our new FREE resource for reluctant readers, aged 7-12:

The Scatter-Slayer Adventures: Book 1 – Don’t Stay! Be Afraid.

You are the Scatter-Slayer: a super spy hired to track down the mysterious Miss Sunday.

But there’s a problem: you are trapped, in chains, in a cage, on a train!

Can you escape? And, even if you can get away, what about the main bad guy with the mace?

This is the first of our decodable digital ‘select-your sequel’ adventure series, focusing on the extended code and increasing reading fluency. Where you decide what happens next.

Designed for devices. Download as a pdf or – for bonus animations – as Google Slides. As the first (FREE) instalment of our 12-part select-your-sequel series, we cover the extended code, targeting increased reading fluency: word accuracy, reading speed and expression.

Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language

Our talented team of certified practising speech pathologists provide unhurried, personalised and evidence-based speech pathology care to children and adults in the Inner West of Sydney and beyond, both in our clinic and via telehealth.

Lifting the lid on speech therapy: How we assess and treat children with unclear speech – and why

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We work with many children who have unclear speech. For some families, speech therapy can be mysterious, confusing, tedious, or even intimidating. It shouldn’t be any of those things.

In this article, we will explain what we do and why we do it. We’re going to answer some questions we get asked a lot. We’re going to try to avoid (or at least explain) jargon and acronyms that plague the topic. Where possible, we’ll link to some other articles that address some of the points we cover in more depth. 

Speech sound disorders – when to be concerned

Most children learn to speak without any help. But some experience significant delays in learning to use speech sounds correctly in speech. We call these delays ‘speech sound disorders’. 

Learning to speak like an adult takes time; and all young children make at least some speech errors. When should you be concerned?  

Unfamiliar adults should be able to understand about 80% of a typically developing 3-year old child’s speech. By four years of age, children should be fully intelligible to unfamiliar adults (Gordon-Brannan & Weiss, 2006). 

Here are some rules of thumb. If:

  • your child is 3 years old (or older) and adults can’t understand most of what he or she says; or
  • your child’s speech is getting negative attention from peers or others, e.g. teasing or bullying at preschool; or
  • your child is 4 years old and isn’t 100% intelligible to unfamiliar adults; or
  • an early educator or carer working with your child is concerned about your child’s communication skills; or
  • you are concerned for any other reason about your child’s communication skills,

you should touch base with your local speech pathologist for a chat.

Aren’t speech delays temporary? Why does it matter?

About 75% of children with speech sound disorders correct their speech by the age of 6 years. Of the remaining 25%, most resolve by the age of 9 years. A small percentage continue to have residual problems, often with sounds like /r/, /s/ and the ‘th’ sounds (e.g. in ‘thing’, and ‘this’) (Shriberg et al., 1997; Kamhi, 2006).

So why not just wait?

The evidence is clear: children with speech sound disorders are at a higher risk for problems down the track. Systematic reviews have shown that children with speech sound disorders are at greater risk than typically developing children when it comes to:

  • learning to read;
  • learning to write;
  • focusing their attention and thinking;
  • communicating with others;
  • caring for themselves independently;
  • relating to people in authority (e.g. teachers, older children, managers);
  • informal social relationships with friends and peers;
  • relationships with their parents;
  • relationships with their brothers and sisters;
  • school readiness and academic success; and
  • getting and keeping a job.

(e.g. McCormack et al. 2009.)

As we explain here, a child’s school readiness is:

  • predictive of academic outcomes (e.g. Snow, 2006); and
  • a strong indicator of ongoing and future success (e.g. Prior et al., 1993).

As a speech pathologist with a special interest in school-aged language and reading, I am particularly concerned when I meet a child about to start school with unclear speech, difficulty distinguishing speech sounds, and difficulties expressing their thoughts and feelings in sentences. 

Does evidence-based speech therapy work?

Yes: this has been proven by systematic reviews of peer-reviewed research evidence (e.g. Law et al., 2004). Similarly, evidence from a comprehensive 2011 narrative review suggests that it is better for children who have phonological impairments to receive intervention than no intervention at all (Baker & McLeod, 2011).

Children have their best chance of fulfilling their potential if they are provided with effective and efficient treatment before starting school (Baker & McLeod, 2011; Beitchman et al., 2001, Nathan et al., 2004). But it is never too late to get help with your speech, and we work with many adults with speech sound issues.

Are there different kinds of Speech Sound Disorders? 

Yes. Some researchers have tried to classify them. For example, the Speech Sound Disorder Classification System looks like this:

(Shriberg et al., 2010). 

This classification system is very complicated, and not everyone agrees with it. I like it in concept, but find it hard to apply in practice. Instead, in our clinic, we tend to group speech sound disorders into three broad categories that are not mutually exclusive: language-based, articulation-based, and motor speech-based speech disorders.

Language-based speech disorders: 

  • The most common kind of speech sound disorder is something called a ‘phonological impairment’ (Baker & McLeod, 2011). This sounds scary, but ‘phonology’ is simply the science of speech sounds; and ‘impairment’ just means there is a delay, difficulty or problem with speech.
  • The important thing to know is that this type of disorder is a language-based impairment. It affects more boys that girls, and often (but not always) runs in families. (You can read more about risk factors for language disorders here and here.)
  • Children with phonological problems, tend to have patterns of errors called ‘phonological processes‘ e.g. they may leave out weak syllables, sounds in consonant clusters or the final sounds in words, or they may switch sounds (like /w/ for /r/, or /d/ for voiced ‘th’).  
  • Most of our clients who have unclear speech have this kind of speech sound disorder. 

Articulation-based speech disorders: 

  • Sometimes, children simply don’t know how to produce a speech sound correctly.
  • For example, some children with interdental lisps have no problems hearing the difference between /s/ and unvoiced ‘th’. They know that they are saying /s/ incorrectly. But they have not yet learned to put their tongue tip in the right place.  

Motor-based speech disorders: 

  • Far less often, we work with children with motor speech disorders.
  • They include rare disorders like childhood apraxia of speech (problems planning or programming speech movements) and dysarthrias (poor articulation caused by damage to the nervous system).
  • Every now and then, children present with speech motor delays or difficulties that are neither childhood apraxia of speech or dysarthria. 

Classifying a given client’s speech sound disorder is not always clear cut. Children don’t tend to fit into neat categories. For example:

  • some children make errors that are both language-based and articulation based. For example, a child may not be able to hear the difference between /s/, ‘th’ and /f/ (a language-based issue), and may also not know how to produce ‘th’ with the tongue tip between their teeth (an articulation issue); and
  • some children present with lots of phonological error patterns (a language-based issue) but also have visible difficulties coordinating their tongue, teeth, lips and voice to make speech sounds correctly in words with three or more syllables or in connected speech (articulation and motor speech issues).

You have to look at the child in front of you and work out what’s going on with their speech.

What do we assess and how do we assess speech?

Our speech assessments are designed to help us figure out:

  • whether a client has a speech sound disorder; and
  • if so, whether language-based, articulation, and/or motor speech issues are contributing to the difficulties.

To get this information, we:

  • interview the family and ask them lots of questions before their first appointment, particularly to identify risk factors, get an idea of the child’s personality and interests, and understand what matters most to the family;
  • observe the child doing something natural, like play;
  • administer standardised speech tests, like the Diagnostic Evaluation of Articulation and Phonology, to obtain single word and short connected speech samples, or the Nonword Repetition Test to test – you guessed it – nonword repetition skills;
  • assess the child’s ability to produce polysyllabic words. We explain why we do this here;
  • elicit language samples, usually through a combination of conversation, picture descriptions, and narrative retelling tasks;
  • assess (or at least screen) oral language development, so we can evaluate whether expressive language issues, e.g. with vocabulary, semantics, morphology, syntax and use may also be present (as they frequently are);
  • conduct an oromotor examination focused on speech coordination tasks, to assess whether any structural issues (e.g. cleft palate, muscle weaknesses) might be contributing to speech difficulties, and to assess how the child plans and executes speech tasks, including syllable repetitions and sequences; and
  • assess phonological awareness for preschoolers (particularly if they are soon to start school), focusing on speech sound blending and segmenting skills, and letter-sound links for reasons explained here.

Depending on the results, we might need to do other tests and assessment tasks, e.g. if we are concerned about whether a client might have childhood apraxia of speech.

So what, exactly, do we do in therapy? 

This is a question we spend a lot of time asking ourselves. It’s a question we expect to keep asking ourselves as more research is published and as we become better at what we do.

As health professionals, we are committed to evidence based-practice. This means we need to consider and then integrate three things:

  1. the best peer-reviewed research;
  2. our clinical expertise; and
  3. our clients’ (and their families’) values and goals (Sackett et al., 2000). 

(1) The best research 

It’s hard to find and apply the best research for clinical use. Key challenges include:

  • the number of studies. People have been working on therapies for speech sound disorders for over 100 years; and there are at least 135 published studies (Baker & McLeod, 2011). More are being published every year. For example, just before I started writing this article, I read a new randomised control trial of an intervention for children with motor speech difficulties (Namasivayam et al., 2020). It can be hard to keep up!
  • the number of different treatments. There are at least 46 (Baker & McLeod, 2011);
  • the number of different treatments goals. There are at least seven different ways to choose what to work on (Baker & McLeod, 2011);
  • the mixed quality of studies. Not all studies are of equal value. Some treatments are supported by high quality, replicated studies (e.g. randomised controlled trials). Others are more prone to bias, like case reports and book chapters written by people who developed the therapy;  
  • poor clarity of some studies. To implement a treatment, we need clear descriptions of the invention, including who it is for, what it involves, the elements of the intervention itself, including what we need to do in therapy, the materials we should use to do it, and information about treatment frequency and dose. Unfortunately, many intervention studies don’t give us enough detail to do the actual therapy. Some studies contain enough information to allow us to get the basic idea and trial it, but not enough procedural detail on the nuts and bolts of the therapy to know whether we are doing the treatment in the same way as the researchers. For example, the randomised study I read this morning contains almost no information about the treatment and how to do it. This is incredibly frustrating for speech pathologists in clinical practice who want to apply new research to help their clients;
  • diversity of clients with speech sound disorders. Every child with a speech sound disorder is unique. Some have severe impairments, others only mild issues. Some have motor speech issues, others have language-based error patterns, still others have articulation issues, and yet others have elements of all three. For some clients, their only area of challenge is with speech sounds. Most of my speech clients have additional challenges, including language disorders, stuttering, voice disorders, ADHD, Autism Spectrum Disorders, sleep disorders, behavioural and emotional difficulties, adenoid and tonsil issues, or hearing issues, just to name a few. It can be hard to know up-front which approach is likely to work with which client – especially when studies routinely screen out participants with more than one area of challenge; and
  • few studies pit one treatment against another. With a few exceptions, there are not many studies showing that one phonological intervention is better than another.  

Despite these difficulties, it is our job to do our best to translate new research on effective treatments into practice. Examples of evidence-based therapies we have been able to translate or adapt and use in our clinical practice include:

Sometimes, we’ve had to send staff off on expensive post-graduate training courses to learn therapies. But, increasingly, researchers are making their training materials freely available and accessible at any time, which is a huge help for busy clinicians. Two examples are ReST and DTTC – both treatments for childhood apraxia of speech. 

(2) Clinical expertise – what do we do in speech therapy?

When I think about the multitude of phonological interventions, I’m reminded of a funny quote from the (now terribly dated) 1980s English comedy, ‘Allo ‘Allo:

“He was the man of a thousand faces – every one the same.”

With the experience of using several different approaches, common features and patterns emerge: elements that seem to work most of the time, regardless of which therapy approach we take. 

Of course, many brighter minds than mine have observed the same thing. Noting that many therapy approaches seem to work, some researchers have questioned the importance of finding ‘the’ best treatment approach, and highlighted instead the importance of identifying the best therapy targets (e.g. Gierut, 2005). In other words, what is treated may be more important than how it is taught (e.g. Kamhi, 2006). But I think it goes further than just targets and approaches: beneath the surface, many therapies share more similarities than differences – especially when they are translated into practice.

What follows are some examples of therapy elements and practices that we have found help our clients to improve their outcomes in speech therapy, regardless of which approach we take. Some are consistent with principles of effective language therapy (e.g. Bayles, 2011; Gillam & Loeb 2010). Others are more consistent with principles of motor learning. Some are principles distilled by researchers thinking about how we move speech pathology practices forward (e.g. Kamhi, 2006; Rvachew, 2017; Baker et al., 2018). Others are just things we have found work for many families.

(a) General elements

  • Engaged client and family. Motivated, focused clients tend to do better than disengaged or inattentive clients.
  • Client as the focus. We start each session by explaining our goal and why it matters in language that the child can understand. We use visuals to explain what we are doing and why. We make the client the most important part of therapy: not family members, and certainly not ourselves! 
  • Informed families: Children with families who understand and support the therapy goals and the approach – including the importance of the core elements of the treatment – tend to do better in therapy than those who don’t. It’s our job to make sure our clients’ families make informed decisions about their child’s therapy.
  • Families as therapy partners. Families who understand the importance of doing the work between sessions and feel confident to do it – understanding the whys, whats and hows of therapy – do better than families who feel removed from therapy.
  • Regular sessions and attendance. It is not always possible to see a client multiple times a week. But we usually recommend an initial therapy block of at least weekly sessions to maintain our high dose of therapy and treatment momentum. Children who miss sessions frequently don’t tend to do as well as clients that attend regularly as scheduled.
  • Structured and routine-based. Our speech therapy is highly structured, especially in the early weeks. We use visual timetables to outline the order of activities, with structured activities gradually opening up to more naturalistic play activities to promote conversation. We try to keep the flow of the sessions (including the order of tasks) constant, so we can turn therapy into a fast-flowing routine. Clients don’t need to guess what’s next.
  • Clinic- and telehealth-based. This is both a strength and constraint of our therapy. Most of our work happens in small clinic rooms designed to remove distractions and to motivate clients to do the work. For remote clients (and for all clients during pandemics) we deliver therapy by telehealth. 
  • Challenging. We set ambitious goals for clients, especially if they are starting school soon. Sometimes, this means our therapy sessions are less fun than they could be (e.g. if we spent more time playing games or went for fewer repetitions). But we find that many of our clients thrive with our high expectations. 
  • Outcomes measured and shared: We measure changes in the percentage of consonants a child can say correctly. At a bare minimum, we want a 5% change (Thomas-Stonell et al., 2013) over a 3-6 month period – any less than that and we can’t be sure we are making a difference. I like to push for a 10-15% increase in percentage of consonants correct measured in a single word naming task – an ambitious goal that is not achieved by every client.
  • Pragmatic approach to finding something that works: Research tells us that about 1/10 children do not improve meaningfully over 3-6 month treatment, even when the treatment is effective for others (Rvachew, 2017). We need to spot these children early, explain what’s happening to families, and try different approaches. In clinical practice, we have to be prepared to switch treatments if the one we recommended isn’t working for the particular child in front of us.   
  • Regular therapy breaks and discharge: If therapy blocks go on for too long, they can become unfocused and drift. Clients (and families, and speech pathologists) can lose motivation and perspective on what they are working on (and why). Therapy breaks can help keep things fresh. We are constantly impressed with gains made by clients during breaks in therapy. Obviously, when clients have met their goals, we discharge them.

(b) In the sessions

  • Parent/carer in the room. Most clients seem to do better when the parent in the room while therapy is done. Apart from helping us to comply with our child safety procedures, this helps parents to understand what we are doing in therapy. It also provides an opportunity for us to model therapy for the parent so they can do the practice at home.
  • Practice speech! We do not waste time doing non-speech motor exercises like tongue wiggling or blowing exercises because they don’t improve speech. If you want to get better at speech, you have to practice speaking. This can sometimes be tricky if you are working with a shy or anxious child (and especially if the child is selectively mute). But we have lots of tricks to encourage speech!
  • Intense Dose: Repetition, repetition, repetition. Ideally, we go for 150-200 repetitions in a 45 minute session, especially when working with children with motor speech difficulties. Sometimes we get more repetitions, sometimes we get fewer. But when it comes to therapy dose, the research shows that more is often more! Introducing a sense of ‘urgency’ into speech therapy, e.g. through simple ‘races’, or other competitive or collaborative games, can help to ratchet up the repetitions while keeping the sessions engaging. We just have to take care to ensure that the reinforcement doesn’t take over the session, and that the activity doesn’t replace the goal.
  • Words as targets: The entry level for speech and language development is babbled syllables and first words – not sounds on their own, or morphemes (Walley et al., 2003). For this reason, we use words in therapy. For some approaches, we start with simple vowel-consonant, consonant-vowel, consonant-vowel-consonant combinations (e.g. ‘it’, ‘car’ (with an Australian accent) and ‘bat’). For others, we focus on words containing complex clusters of consonants, e.g. ‘play’ or ‘splash’, and polysyllables like ‘helicopter’. But we don’t spend much time on sounds in isolation.
  • Preference for real words:  Particularly for children with language and speech disorders, we prefer to use real words. Where possible, we choose targets that are functional – I like to include verbs where possible. For very young children, I look for developmentally typical first words often with simple phonology. For older children, I use words taken from the General Service List-Spoken. Less often, we use non-words (e.g. in the ReST treatment for Childhood Apraxia of Speech).  
  • Pictures with words: We use pictures to help preliterate children to say the words. But we always include the written words as well to help young children increase their print awareness and older children to build letter-sound links, and phoneme blending and segmenting skills, which are related to reading development.  
  • Not too many examples of each target. Provided we get in enough total repetitions, we find that targeting as few as five words a session (say 40 times each) is often enough to get transfer to other words with the same target. We started this practice with Cycles, but now use it with other approaches, including Complexity and Minimal Pairs.
  • Modified signal, less noise: modelling target words slowly (but without segmenting them into individual speech sounds), manipulating primary stress when presenting words in sentences, and using word order to highlight the target at the end of phrases all seem to help. We try to keep outside noise to a minimum (even if that means banishing the sibling to the reception play area).
  • Auditory bombardment and discrimination tasks: starting out with our experience in Cycles, we have found that working on speech perception seems to improve speech production outcomes – although we know they are separate concepts, and we are not entirely sure why it helps. We know that many children with speech sound disorders have problems with speech perception. Recent research seems to support our clinical observations (e.g. Hearnshaw et al., 2019). Routinely, we use auditory bombardment and/or speech discrimination tasks to help children to tune into different speech sound targets, especially for children with phonological impairments.
  • Distributed and interleaved practice; cyclical goal attack. We’ve found it is better for many clients if we take a cyclical approach to goal-setting. We don’t spend too long in therapy on one sound, but keep moving, circling back to targets that are yet to be acquired. This reduces frustration for everyone, and tends to promote greater overall gains.
  • Targets: improving the child’s overall speech system is more important than any particular sound. We want our therapy to work (be effective). But we also want it to be efficient – for many children with severe speech sound disorders, we don’t have time to target sounds one at a time. We prefer approaches that seek to make system wide changes to the child’s speech, rather than just improving single sounds. We prefer to target error patterns, rather than individual errors. We use the Complexity Approach, Cycles and/or Multiple Oppositions most often to do this, and don’t tend to use traditional articulation therapy very often.   
  • Errors of omission before errors of substitution. We learned this one from Cycles, and from reading some of the research about the effects of speech sound disorders and early reading outcomes. If our goal to increase a child’s intelligibility (as it almost always is), we find the targeting error patterns where children leave out sounds in words gives us better results than targeting error patterns where the child switches one sound for another. For example, we’ve found that working on syllable deletion, initial and final consonant deletion, and cluster reduction increases many children’s overall intelligibility more than working on, say, gliding of /r/ to /w/ or simplification of ‘th’ to /f/. We also find that we can combine targets for children with severe difficulties, e.g. teaching children to produce /f/ at the end of words allows us to work on fricatives (hissy sounds) and final consonant deletion at the same time. 
  • Carrier phrases as a bridge to sentences and conversation. We’re big fans of using carrier phrases to practice target words in sentences, especially for children with speech and expressive syntax delays, and children with speech disorders who also stutter. Helping children to acquire simple subject verb object word order, and more complex sentences, e.g. containing because and if, helps you to work on multiple goals at once, even if you are focusing your direct treatment on speech sounds. Even with older school aged children, we frequently work on improving speech sounds while also working to improve their decoding skills, vocabulary, categories and other semantic knowledge, complex syntax, and social use of language, e.g. with sequencing, narrative tasks, conversation skills or other discourse level language tasks.  
  • Lots of feedback on accuracy, especially in the early stages of therapy.
  • Reinforcement for correct responses (including self-corrections). Many speech therapies are based on behavioural science. While I’m ambivalent about the use of external reinforcement, it certainly has a role in reinforcing success and changing behaviour, and can be a big help to increase motivation and focus, especially when working with very young children. We find that praising children for noticing and ‘fixing up’ (correcting their own errors) has a positive effect, a practice we learned from Dr Caroline Bowen and her incredible website.
  • Some children respond to complex targets. Others don’t. Children need some resilience to engage in therapy using the complexity approach. Some children do better by following a developmental sequence – targeting earlier developing, less complex sounds and error patterns so can get some success straight away. We also find that some children start out with developmental targets and, after success, are willing to have a go at more complex targets. Interestingly, we see transfer to other sounds both ways.
  • Phonological awareness for preschoolers: For children getting ready for school, we include at least one phonological awareness target in therapy, usually working on letter-sound links, or blending or segmenting tasks. Again, we do this because these skills are important for later literacy development. 
  • Randomised practice: Once the child has achieved the target with simple words, I like to randomise exercises, mixing up activities at the word, phrase, sentence, verbal problem solving, and discourse levels, and adding in extra challenges like dual tasking. I do this with my nerdish collection of Dungeons & Dragons dice, or even by pasting exercise numbers to random items and pulling them out of a bag. 

(c) Home practice

  • Regular home practice: Kids who do daily home practice, even just for a few minutes, seem to improve more than those that don’t.
  • Using technology to make home practice easy: Historically, most of our resources were pen and paper – we killed many trees – and filled many ugly scrap books. Now, for many clients, we use iPads and digital resources. We share condensed packs of organised materials, usually composed of all the target words on one page, sound cards, carrier phrase lists, and an mp3 auditory bombardment file recorded by us that can be played straight from a device or in the car. For children with language and/or phonological awareness deficits, we often also share picture books for shared reading, and high quality audiobooks. Increasingly, we give clients access to our online libraries of resources to keep practicing between therapy blocks and after therapy.

(3) The child and family in front of us

No speech treatment works for all clients or families in all conditions. At intake, we look at known risk factors, such as family histories of speech difficulties, gender, and hearing issues. During the initial assessment, we evaluate the client’s language skills so that we can explain what we are doing in a way the client can understand. To make treatment recommendations to families after the assessment, we consider the nature and severity of the client’s speech disorder, the child’s age, when the child is going to start school, the success (or failure) of any previous therapy, and the child’s motivation, attention, and interests (Kamhi, 2006). 

In therapy, we try to use the child’s current speech strengths and abilities. We need to have a good idea about the amount of support we will need to give the client to stay focused and motivated to work on difficult speech tasks (Shriberg & Kwiatkowski, 1994). For some children, we need to get creative and use the child’s interests to encourage them to do the work. That’s why I know way too much about Pokemon and sharks, Disney Princesses and scorpions, dinosaurs and pirates, Minecraft and Roblox, Batman Lego and semiprecious stones, diesel trains and NBA basketball. 

We need to know what the family thinks about the child’s speech and speech therapy. The level of concern a parent has can play an important role in whether the child is assessed, attends therapy, and does the work between sessions (Kamhi, 2006). 

We need to answer questions – even when the answer is ‘I don’t know’. Whenever we get asked a question a second time, we try to write an article about it to share with clients. For example, children’s speech development can be affected, at least temporarily, by chronic middle ear infections or other types of conductive hearing loss. Tonsil and adenoid problems can affect speech clarity, as can allergies, colds and other things that leave kids with blocked noses. Sleep disorders can affect language development. Stuttering and cluttering can make speech hard to understand. Rate control issues can reduce intelligibility. Bilingual children are learning two speech sound systems. Braces can cause mild speech distortions for a while; and some older children continue to have residual speech difficulties that have social and work implications. Some people think that tongue ties and sucking a dummy for too long or thumb sucking affect speech development, but I’m not convinced (based on the evidence to date).

For time, logistical or financial reasons, some of our clients can only attend therapy once a fortnight or less frequently. This can be a challenge, e.g. for motor speech treatments that require high treatment dosage. 

Some of our clients have other health issues, like hearing problems, attention difficulties or sleep disorders. For some clients, speech isn’t always the family’s highest priority – the client may have other health challenges, or simply be focused on other goals that are important to them, e.g. sport or music. Many of our clients have more than one communication challenge (e.g. speech disorders plus stuttering, language difficulties, social difficulties, voice problems, and/or dyslexia).  

We have to consider all these issues and tailor our therapy to each client and family. Again, this is difficult, but it’s our job.

Clinical bottom line

Lots of elements go into providing good speech therapy. Research, clinical experience and information about clients and their goals all need to be integrated to provide evidence-based, quality care. 

In this article, we’ve tried to explain what we do in speech therapy and why we do it. We’ve identified some things that we think make a difference in our client’s results to date. But we need to keep reading new research, improving our systems and resources, training ourselves in new techniques, measuring our results, and sharing information with families about new developments to do our job properly. Most importantly, we need to work with families and children with speech sound disorders to make sure they know what we are doing and why, and to do all we can to ensure our therapy works for them. 

Principal sources: 

As always, any errors of interpretation are mine alone.

Baker, E., Williams, A.L., McLeod, S., & McCauley, R. (2018). Elements of Phonological Interventions for Children with Speech Sound Disorders: the Development of a Taxonomy, American Journal of Speech-Language Pathology, 27, 906-935. This is an incredibly useful article, and provided a framework to explain our current clinical practices. Every speech pathologist treating children with speech sound disorders should read it.

Rvachew, S. (2017). How effective is phonology treatment?, last accessed on 17 May 2020, available here. This short article asks (then answers) the important question: do we really want to know whether the child’s rate of change is bigger during treatment than it was when the child was not being treated? The answer is of course ‘yes’, and I use the insights in this article to set measurable goals for my clients.

Kamhi, A. (2006). Treatment Decisions for Children with Speech-Sound Disorders. Language, Speech and Hearing in Schools, 37(4), 271-279. I first read this article several years ago when I was struggling to understand why the treatment approach didn’t seem to make much difference to my clients’ outcomes. It provided a framework that helped us design our intake, assessment and reporting procedures to integrate research, client and clinical factors. 

Baker, E., & McLeod, S. (2011). Evidence-Based Practice for Children with Speech Sound Disorders: Part 1 Narrative Review, Language, Speech, and Hearing in Schools, 42, 102-139.

Baker, E., & McLeod, S. (2011). Evidence-Based Practice for Children with Speech Sound Disorders: Part 2 Application to Clinical Practice, Language, Speech, and Hearing in Schools, 42, 140-151.

Shriberg, L.D., Fourakis, M., Hall, S.D., Karlsson, H.B., Lohmeier, H.L., McSweeny, J.L., Potter, N.L., Scheer-Cohen, A.R., Strand, E.A., Tilkens, C.M., & Wilson, D.L. (2010). Extensions to the Speech Disorders Classification System, Clinical Linguistics & Phonetics, 24(10), 795-824. 

Related articles:

Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language

Our talented team of certified practising speech pathologists provide unhurried, personalised and evidence-based speech pathology care to children and adults in the Inner West of Sydney and beyond, both in our clinic and via telehealth.

Exam and Essay Verbs you need to know and use in High School: library now available

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Our library of language exercises to help high school students understand and use key academic verbs to answer test, exam and essay questions correctly is now available.

Verbs covered: evaluate, describe, discuss, explain, identify, assess, outline and analyse. 

Go to Exam and Essay Verbs you need to know and use in High School library

For each verb, we have prepared a fully scripted slide-pack composed of 10 activities, all focused on the target word. Consistent with the research, in these exercises, we:

  • read a short passage so students can see and hear the word in action;
  • define the word so students know what it means;
  • look closely at the word and its variants, as well as the word origin so students understand the word better;
  • listen to recorded sentences containing the word in everyday situations so students can hear how it is used;
  • teach practical strategies to answer questions containing the word with real world examples;
  • help the students answer questions using the relevant verb based on their general knowledge of the world; and
  • look and talk about some real examples of how the the word has been used in different subjects in recent senior exam questions.

Watch our video to learn more:

The slides can be used one-to-one with a student, with small groups, or in whole class teaching.

They are suitable for children aged 12-18, and older children with language, reading or other learning disorders. They are also suitable for high school children who are learning English as an additional language.

Go to Exam and Essay Verbs you need to know and use in High School library

Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language

Our talented team of certified practising speech pathologists provide unhurried, personalised and evidence-based speech pathology care to children and adults in the Inner West of Sydney and beyond, both in our clinic and via telehealth.

Too many children can’t read. We know what to do. But how should we do it?

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The goal is clear.

You wouldn’t know it from Twitter, but literacy researchers, teachers, speech-language pathologists, education psychologists, and reading tutors all want the same thing when working with someone who can’t read. 

We want them to be able to read. More specifically, we want them to understand what they read.

What we disagree about is how we should teach reading. 

The stakes are high

When we get it wrong, students suffer the most. But, actually, we all pay for it:

  • Illiteracy costs the global economy more than $1 trillion a year in direct costs.
  • Low literacy is a major contributor to inequality.
  • Low literacy increases the likelihood of workplace accidents, medication errors, involvement in crime  and welfare dependency (World Literacy Foundation, 2015).
  • Even in rich countries, around 20% of 15-year olds can’t read well enough to participate effectively in life (OECD, 2016).

Individually, and as a group, we can do better.

The science is solid. Gaps remain.

A growing body of peer-reviewed research evidence (sometimes called ‘the science of reading’) tells us a lot – but not everything –  about how we should teach reading. But, too often, ideological, political and professional differences distort or drown out the key ideas. Too often, teachers, speech pathologists, and others are not taught the science of reading in university or college. Too often, sunk costs and other biases, training gaps, and resource and time limitations get in the way of us putting the science to work. 

We can all get better at teaching reading. We need to be honest about what we know, and don’t know. We need to reflect on the limits of our own skills and resources and invest in reducing them. We need to listen to feedback. We need to read new research.  

It’s hard work. But we must do it. 

We owe it to our students. Our job is to:

  • know which approaches work best;
  • explain why they work to others, including students, teachers and parents;
  • know how to teach reading by working on the right things at the right time;
  • stay open and honest about the many things we don’t know;
  • keep questioning what we’re doing, keep learning, and be prepared to abandon practices no longer supported by evidence;
  • measure our results; and
  • keep improving our knowledge, systems, processes, techniques and resources to seek better results.

Teaching reading: how? 

We’ve written at length about what works. 

In this article, we outline how we go about translating reading science into practice – explaining what we do – recognising that we still have much to learn. That we all have much more to learn. We’ve tried to focus on evidence-based practices, rather than broad theories or ideologies, but we’ve referred to some of the key mental models we use when necessary to explain why we do (or don’t) do something.  

We organised our thoughts on this very important topic after reading a great paper by Professor Anne Castles and colleagues (a citation and link to the full text of the article appear below), and reflecting on our clinical experiences and changing practices over the years.

The basic recipe (with messy ingredients)

Let’s start at…the start. To read well, students need to learn:

To teach reading well, you need to know how these skills typically develop over time. You need at least some idea of how they interact with each other. You then need to apply that knowledge to the student in front of you.

We think our practices are supported by evidence. But we’re open to different views and criticism. We will – no doubt – abandon some practices and adopt others as we learn more. Where possible, we have linked to articles we have written summarising the evidence we rely on to support our practices.

How we support preschoolers to set the stage for later reading success 

(a) Oral language and speech development are essential for later reading success

We are hard wired to understand oral language and to speak it. Most (but not all) of us learn to do it without needing to be taught. Parents, early educators and others can play a big role in helping to stimulate early language development by using language stimulation strategies, and engaging activities like play and simply exploring the world. We written hundreds of articles about promoting oral language and speech development. (We’ve created quite the rabbit hole of information, if you have the time.)

(b) Early treatment of speech and language disorders is very important

A child’s oral language competencies (listening and talking) are highly predictive of school readiness and success. And many (but not all) preschoolers with unclear speech go on to have problems with reading. Early intervention is important for children with language disorders and speech sound disorders. But it’s never too late to seek help.

(c) Some phonemic awareness skills are important for later reading

Many preschoolers, including some children with speech and language disorders,  need extra help to figure out, for example, that the first sound in ‘pot’ is /p/, or that the last sound in ‘pot’ is /t/, and that the sounds /p/, /ɒ/ and /t/ can be blended together to make the word ‘pot’. These skills can be taught to preschoolers. For school-aged children, we do not teach phonemic awareness in isolation. Instead, we build phonemic awareness skills through letter-sound and early decoding exercises. In other words, we teach sounds with letters, and sound blending and segmenting skills with written words. Read more here.

(d) Letter knowledge is an important precursor to learning letter-sound links 

Here are some things you should know when teaching the alphabet to your child.

(e) Increasing print awareness can help preschoolers prepare for reading

Here is a summary of some of the research.

(f) Read quality picture books with preschoolers every day

Here’s how to do it. Here’s why you should do it. This practice should continue well into primary school.

(g) Read nonfiction to your preschoolers to build world knowledge

Read more non-fiction books to your preschoolers. Here’s why.

(h) Listen to audio books and high quality read-alouds with your child

We include some suggestions here. This practice should also continue into primary school, and we make some specific recommendations of audiobooks, with links, for school age children here (Kindergarten and Year 1) and here (Years 2-6).  

How we support school-aged students and adults

(1) Reading needs to be taught.

Unlike with talking and listening, we are not biologically primed to read. Everyone needs to be taught. But some children need more help than others.

(2) Use the ‘Simple View of Reading’.

When we look at a student’s reading strengths and challenges, we apply the ‘Simple View of Reading’. You can watch our short video summarising what we think about here. Or you can read a longer article we have written here. In summary, we see the ultimate goal – reading comprehension – as the product of two elements: Word Reading x Listening (language) Comprehension.

(3) Beginners are not experts. 

Beginning piano players can’t play Chopin’s Etude Op. 10 No 4. Beginning artists can’t paint The Lady with the Ermine. I’ve been reading, nerdishly, for more than 40 years. Why would we expect a beginning reader to read like we do: automatically and effortlessly, understanding what we read, as we read it? If you can’t read the words on the page, you can’t understand what you are reading, even with excellent oral language skills. So we have to start with the squiggles on the page.

(4) Unlike, say with Chinese or Japanese, English has an alphabetic writing system.

In alphabetic systems like English, the speech sounds (phonemes) of the language are represented by letters or groups of letters (graphemes). Most children need to be taught these letter-sound links because they don’t pick them up without being taught. Early in reading development, reading comprehension is highly constrained by decoding limitations. Poor decoding can be a bottleneck that stops students from understanding what they are reading about. 

(5) Systematic phonics instruction.

There is a strong scientific consensus on the effectiveness of systematic phonics instruction during the initial period of reading instruction (Castles et al., 2018).  

(6) Systematic phonics systems teach letter-sound links in an ordered way. 

In English, we have 26 letters that, in different combinations, are used to represent the roughly 44 phonemes (speech sounds) we use (depending on our dialect). There are many evidence-based letter-sound sequences around. In our clinic, we used to use the UK Letter-Sound sequence. But we have now adopted the Sounds-Write letter-sound Sequence because it is logical. This sequence teaches children the basic code first (including the sounds most commonly linked to the 26 letters of the alphabet), and then an extended code of frequent letter combinations and the sounds most commonly associated with them, e.g. <ai>, <oo>, <er>, <oy>, <ew>.

(7) One sound per letter to start with.  

In English, some letters and letter combinations are linked to more than one speech sound. For example, <c> is linked to /k/ in ‘kangaroo’ but /s/ in ‘city’; <g> is linked to /g/ in ‘get’ but /dʒ/  ‘giraffe’; <ch> is linked to /tʃ/ in ‘chicken’, /k/ in school, and /ʃ/ in ‘chef’); and, infamously, the letter combination ‘ough’ is linked to at least six different speech sounds (e.g. ‘though’, ‘through’, ‘rough’, ‘cough’, ‘thought’, ‘thou’). 

Before 2016, we followed the Spalding approach of explicitly teaching multiple sounds linked to letters and letter-sounds. But, since then we have opted – initially – to teach the sound most commonly associated with each letter or letter combination, and to later teach context-sensitive rules once children have mastered the basic mappings. 

For example, once beginning readers have mastered the basic mappings, we will teach them that <c> is linked to /s/ in words where the <c> is followed by <i>, <e> or <y> (as in ‘circle’, ‘ceiling’ or ‘cycle’), and that <oo> is linked to  /ʊ/ when followed by /d/, e.g. ‘hood’, ‘stood’, and ‘good’. We have found, clinically, that many children (including some children with working memory, speech or language disorders) have difficulty mapping different sounds to letters; and some children rote learn the multiple sounds, but cannot then apply them when decoding words. We have also found that starting out with a limited set of letter-sound links, puts many children on the path to independent reading earlier than if we dedicate too much time to teaching context-sensitive and less common links early. 

(8) We take a synthetic phonics approach to systematic phonics instruction.

I wish it had a better name. Synthetic doesn’t mean ‘fake’. It means that we teach children early to blend individual phonemes together to make words. Another word for blending is ‘synthesise’, which is where we get the term ‘synthetic phonics’.

Note: we don’t wait until children have mastered all their letter-sound links to start reading words. As soon as they have mapped the first five letter-sound links in our sequence (<a>, <i>, <m>, <s>, <t>), we practice blending the related sounds together in different combinations, so we can read words like ‘mat’ and ‘sat’ and ‘tim tam’). (There are other approaches to phonics instruction. One is called analytic phonics, which teaches children to break down whole words into parts. We’ve seen some evidence that synthetic phonics is better, e.g. Johnson & Watson, 2004, 2005, but I would love to see more evidence and am keeping an open mind.) 

(9) We consolidate early decoding skills with encoding (spelling) practice, following the same letter-sound sequence.

There’s good evidence it helps to improve phonological awareness skills, including letter-sound links and word reading skills, which you can see summarised here. We are big fans of the inexpensive Spelfabet resources to support this practice, although you can make your own.

(10) We focus on real words in reading instruction.

Nonword reading and writing tests are a great way to test a child’s phonological awareness, and to figure out if a child is learning to decode words phonically. That’s why we support the Phonics Check.

But, for most students, we focus on real words. Children with small vocabularies can find it hard to know whether a word is ‘real’ or not, and we’d rather spend the time helping them to build their vocabularies. One caveat: some children with excellent language skills are able to pretend they are decoding, when in fact they are guessing from context, from pictures or because they are reading predictable books (e.g. ‘I see a square. I see a circle. I see a triangle.’). For these children, we sometimes use non-words in instruction to help them to break the habit of guessing words. 

(11) We are not against supplementing early phonics with 100 or so high frequency ‘sight words’.

Most alphabetic writing systems have at least some degree of spelling-to-sound irregularity. English includes many high frequency words that are highly unusual. Teaching sight words is controversial, and some people think it confuses children. The evidence doesn’t support these concerns. There is a case for teaching children the pronunciations of a small number of high frequency sight words directly, including words like ‘the’, ‘come’, ‘have’, ‘said’. One study shows that teaching the 64 most common letter-sound mappings combined with 100 or so of the most frequent sight words allows children to read aloud 90% of the words in texts they typically encounter, again promoting independent reading (Solity & Vousden, 2009).

Many evidence-based reading programs, like MultiLit, include sight word lists. We think that sight word learning is likely to be most successful when children have basic letter knowledge.

(12) We think that there is a role in early reading for decodable books.

Decodable books are texts written for children that consist mostly of words that they can read correctly using the letter-sound links they have learned and some high frequency sight words like ‘the’ and ‘said’. These books give children an opportunity to practice what they have learned and to experience success in reading independently. 

We use decodable books while children are learning the basic and extended codes. Some of our favourites include the InitialLit, Moon Dogs, SPELD SA, and Talisman readers. We have also made our own without pictures, and mapped to the Sounds Write Sequence to check that children are reading (and not guessing from pictures). We’ve made them available for free.

Once children have acquired basic decoding skills, we fade out decodable books, and move on to books with a wider variety of vocabulary and knowledge, in part to support ongoing language development, and in part to keep children motivated to read about the things that interest them the most. 

(13) We supplement early reading lessons with access to high quality audio books and books. 

As noted above, during the early years of primary school, we should continue to expose children to high quality books to support oral language development and later reading skills. There is no reason why this can’t happen at the same time as early phonics instruction, and both practices are supported by evidence. 

(14) For skilled readers, we know word reading involves more than just alphabetic decoding (but you have to walk before you can run).

Although the focus on our reading work with beginner readers is on letter-sound links and blending speech sounds to make words, we know that skilled readers use more than just decoding. There are two key processes in word reading: one that involves effortful phonics-based decoding, and another that involves gaining access to meaning directly from the spelling.

In skilled readers, both processes are used: we use the (more efficient) direct access from spelling method for familiar words, and (effortful) decoding for new and unfamiliar words. For example, when reading the Castle et al., 2018 article, I was flying through, until I hit the word ‘pseudohomophone’. I had to pause and decode this word using both my knowledge of the extended code letter sound links (<ps> is sounded out as /s/, <ph>, as /f/) and my morphological awareness skills (e.g. knowing the meanings of pseudo-, homo- and -phone). More on morphological awareness in a minute.

(15) As children become skilled and get more reading practice, the need to decode word-by-word decreases.

When you see a young reader go from laborious word-by-word decoding, and start to read fluently, it seems like a miracle. Complex computational ‘dual pathway’ models far beyond my ken, like the DRC model (Coltheart et al., 2001), the Triangle Model (Harm & Seidenberg, 2004) and the CDP+ model (Perry et al., 2010) recognise that reading involves both knowledge of learned words and knowledge of the relationship between spelling and sounds. We all want kids to recognise words rapidly and automatically without having to decode them sound-by-sound. We all want kids to read independently as soon as possible.

The self-teaching hypothesis (e.g. Share, 1995) suggests that the act of decoding itself provides opportunities for children to become more familiar with the spelling of words. As children build mental representations of words, cognitive resources are freed up for comprehension. Through repeated exposure to words, a child develops word-recognition optimised for reading for meaning. 

What seems to matter most are increasing a child’s exposure to print, getting lots of experience reading, increasing the frequency of times a child reads particular words over time, and the diversity of contexts in which they read particular words. You can read more about the importance of reading fluency here.

(16) For some readers who have mastered the basic and at least some of the extended code, teaching morphological awareness can help to increase reading skills.

This includes explicitly teaching children things like the spellings of high frequency prefixes and suffixes, and Greek and Latin roots of words.  You can read more about morphological awareness here. Importantly, for beginning readers, we think it is better to prioritise letter-sound links and basic decoding skills. But some people disagree – the science is not settled – and we are keeping an open mind. We see an important role for early oral morphological awareness and explicit grammar instruction for many children, including many children with language disorders, including targeting Brown’s 14 morphemes.

(17) Do what it takes to motivate children to read! 

The most effective pathway to fluent word reading is print experience: children need to see as many words as possible, as frequently as possible in print. There are extreme variances here.

One older (pre-digital era) study of Year 5 children found that children at the 10th percentile read about 60,000 words a year; those at the 50th percentile read 900,000 words; and those at the 90th percentile read more than 4 million words a year (Anderson et al., 1988). This contributes to the Matthew Effect: where good readers keep getting better, and poor readers fall further behind over time (Stanovich, 1986). 

So how do we motivate children to read? We have written about reinforcements in detail here. Some behavioural scientists suggest external rewards can help (e.g. iPad time for doing enough reading), but other experts suggest that external rewards can in some circumstances reduce the intrinsic (internal) motivation to do the activity (here reading) for its own sake (e.g. Deci et al. 1999). Effective practical strategies suggested by Willingham (1997) and others include to: 

  • increase availability of reading matter about topics of personal interest, e.g. comics, car manuals, sports magazines, movie tie in novels, movie scripts, YouTube scripts, reading movies from subtitles (with no sound), DIY books, etc;
  • make reading materials highly visible and easy to pick up. This is why we have piles of books scattered throughout our clinic, free to borrow, including reception areas and clinic rooms; and
  • allow you child to go on ‘library sprees’ where the student can borrow any book they want (within reason and subject to parent discretion!).

For more strategies, read this.

(18) The better students become at reading, the more they want to read.

This seems obvious. But children are motivated to read more when they know they are good at it (e.g. Willingham, 2017). Ideally, we want students to see themselves as readers.

(19) Reading comprehension is really complex. It is not a single idea and cannot be explained by one model. 

To understand what you are reading, you need a whole host of skills:

(20) Don’t forget to keep working on higher level language and other language skills

These include academic vocabulary and evidence-based study skills.  

In skilled readers, the correlation between oral language and reading comprehension is almost perfect, meaning oral language limitations will limit reading comprehension (and vice-versa). 

(21) Some people with reading difficulties benefit from compensatory strategies.

For some people, e.g. with severe dyslexia or otherwise protracted and severe reading difficulties, consider compensatory strategies like text-to-speech and speech-to text tools and, of course, audiobooks. Read more about these strategies here. 

Clinical bottom line

To help children and adults to read, we should:

  • foster oral language development, including of vocabulary, semantics, phonology, word forms, sentence level syntax, narratives and nonfiction books in the preschool and school years; 
  • start reading instruction by understanding that the English writing system is alphabetic: letter-sound links and the ability to blend speech sounds to form words are crucial to develop more advanced reading skills;
  • recognise that early decoding problems can be a major bottleneck in the early reading comprehension, and that even modest improvements in decoding can make a big difference to a student’s understanding;
  • encourage children to read as much and as widely as possible to increase fluent, automatic word-reading;
  • recognise that reading comprehension – the ultimate goal of learning to read – is very complex. Reading comprehension problems can be caused by decoding problems, oral language problems, or both;
  • carefully assess people with reading difficulties, so that we know where the breakdowns are happening and can develop evidence-based plan to address them; and
  • keep up-to-date with the research evidence, and apply it – even when it means abandoning long-standing practices.   

Principal source: Castles, A., Rastle, K., Nation, K. (2018). Ending the reading wars: reading acquisition from novice to expert. Psychological Science in the Public Interest, 19(1), 5-51.  

This is one of the most influential, practical papers I have read in the last couple of years.  Even better, it’s available for free via Sage Journals. In my view, this paper should be required reading for all reading professionals. (Note that any errors of interpretation above are mine and mine alone.)

Related articles:

Once upon a… ‘who’?

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Just in case you need a laugh, here’s me being a bit silly on a free oral language video resource. Back in the late ’90s, I would not have imagined spending my Saturday night this way. Strange times!

If you think you can do a better soundtrack than me, the PDF is available to download here.

Also, part of our Once Upon a… series, is our Once upon a…where? resource.

Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language

Our talented team of certified practising speech pathologists provide unhurried, personalised and evidence-based speech pathology care to children and adults in the Inner West of Sydney and beyond, both in our clinic and via telehealth.