Speech

My child’s speech is unclear to adults she doesn’t know. Is that normal for her age? (An important research update about child speech intelligibility norms)

David Kinnane · 20 September 2021 ·

Parents ask us this question regularly.

1. New research and evidence-based practice

Thanks to some great new research, speech pathologists have better information to share with families. But clinical speech pathology requires us to do more than just read, summarise, and apply the research uncritically.

To answer parents’ questions about their children’s unclear speech, we have to integrate new information with other peer-reviewed research, our clinical experience, and – most importantly – the real world views, concerns, and goals of the families and children we work with, within the communities we serve.

2. It takes time and effort to learn how to speak clearly

We’ve written a lot about how we assess and treat children with unclear speech – and why. In brief, it takes years and thousands of hours of talking for typically developing children to learn to speak like adults. It’s normal for young children to make lots of speech errors as they develop. Most children’s speech clarity and fluency continues to improve even into the later years of primary school.

3. Disordered speech is a concern, but can be treated

Unusually unclear speech – disordered speech – is worth worrying about, and many, good, evidence-based treatments are available and early intervention is often recommended. Speech sound disorders are not that rare: about 10% of children have developmental speech sound disorders (e.g. Bishop, 2010), and there are many other things that can cause or contribute to unclear speech (see below).

4. What do we mean by “intelligible speech”?

“Intelligible”:

means “able to be understood”(OED 2000); and
comes from the Latin word “intelligibilis” meaning “that can understand; that can be understood,” from intellegere “to understand, come to know”.

When it comes to speech, intelligibility often means clear enough to be understood by an unfamiliar adult in conversation.

5. At my child’s age, how intelligible should her speech be to unfamiliar adult listeners?

Views differ:

According to some experts, a child of 3 years or older who is unintelligible is a candidate for speech therapy (Bernthal & Bankson, 1988).
According to one highly cited study – where parents were asked to rate how much of their child’s speech they believed a stranger would understand in conversation – typically developing children should be:
- 50% intelligible by 22 months of age;
- 75% intelligible by 3 years, 1 month of age; and
- nearly 100% intelligible by 3 years, 11 months of age (Coplan & Gleeson, 1988).

In a recent study (cited and linked below), researchers reported that, on average, typically developing children hit intelligibility milestones objectively later than the parent-estimate studies would suggest, as follows:

The researchers found lots of variability in intelligibility development among typical children. They concluded that, in multiword utterances, children should be at least:

50% intelligible to unfamiliar adult listeners by 4 years of age;
75% intelligible by 5 years of age, and
90% intelligible at just over 7 years of age (Hustad et al., 2021 – see full citation below).

At first glance, these recent findings were surprising. I think many families (and speech pathologists) would be shocked to think that the average, typically-developing child’s speech only becomes 90% intelligible at the word level at the ripe old age of 6 years, 11 months! But, when you look more closely at how the study was conducted, what it set out to measure (and not measure), and its limitations, the findings make more sense and fit better with the wider body of speech pathology research.

6. Beyond lab norms: real world intelligibility matters more

Peer-reviewed intelligibility studies conducted in ideal laboratory conditions like those reported in Hustad et al., 2021 are very helpful. But assessing the intelligibility (or unintelligibility) of an individual child requires us to consider a number of factors in addition to norms.

In some ways, lab tests of intelligibility set the bar higher than we do in clinic or real world settings. For example, in lab studies, speech samples may be audio-recorded only, and may involve speech targets with limited context for the listener.

In other ways, lab tests can be less demanding than in the clinic or in the real world. In lab studies, listeners are usually fully focused on the child’s speech, and the recordings they listen to may be modified to remove background noise and other distractions.

In accent modification studies, researchers distinguish between:

intelligibility – how understandable speech is when a listener is paying full attention in a controlled environment; and
comprehensibility – how easy speech is for a listener to understand in the real world, e.g. when you may not be paying full attention to the speaker (e.g. Munro & Derwing, 1995).

This is a useful distinction that could be applied to the discussion of child speech sound disorders. In any event, a child’s speech intelligibility to others in the real world depends on the child’s total communication skills, the listeners’ speech and language skills and experiences, and the environment and context in which the child speaks:

A. Child communication factors

Lots of things can affect a child’s ability to speak clearly. Here are just a few examples:

A child may have a neuro-developmental disorder, a genetic syndrome (e.g. Down’s syndrome), or a hearing impairment that affects their speech development and/or ability to speak clearly.
A child may have a physical disability that affects their movement (e.g. cerebral palsy).
A child may have difficulties planning the movements needed to speak clearly or with appropriate prosody – things like primary stress and intonation (e.g. Childhood Apraxia of Speech).
A child may have difficulties speaking fluently (e.g. they may stutter or clutter).
A child may simply not yet be able to produce some speech sounds.
A child’s speech may contain typical, delayed, and/or unusual speech error patterns or phonological processes, including substituting different sounds and/or leaving sounds out.
A child may have a Developmental Language Disorder that affects their ability to use spoken words to express their thoughts and feelings clearly. Language disorders can also affect a child’s ability to recall and repeat words and sentences (which can affect their performance on speech tests).
A child may have suffered a traumatic brain injury that affects their speech, e.g. by causing dysarthria.
A child may have a voice disorder (e.g. because of reflux or nodules) that makes them hard to understand.
A child may be learning more than one language – and speech sound system – and/or may speak with an accent that is difficult for people from a different language background or culture to understand easily (note: this is not a disorder).
A child may be reluctant to speak in one or more environments or be selectively mute.
A child may grow up in a household where they are unsafe, or may grow up in abject poverty, or in a home with limited speech, language and literacy stimulation.

Hustad and her colleagues set out to study typical children. As such, they were deliberately very selective in who they chose to recruit for their lab study.

All of the 538 children studied had normal speech, language and hearing. All were recruited from one mid-western region of the United States. Almost all the children were white. A very large proportion of children had mothers who had at least one college or university degree (a proxy for high socioeconomic status). It is unclear if any of the children were bilingual or learning English as an additional language. While the sample may have reflected demographics of the community studied, it is very different to the communities we work with.

In the Hustad study, intelligibility was not measured from the child’s speech in natural conversation with an adult. Instead, the children repeated standardised recordings of an adult saying a set list of words and sentences while looking at pictures of the targets on an iPad. Not all children were able to repeat all the test items, probably due to language constraints.

B. Listener factors

Intelligibility is about being understood. If I attempt to speak in English to someone who does not understand the language, I will be unintelligible to them. If they ask me to clarify my meaning in Mandarin Chinese or in Australian Sign Language, they will be unintelligible to me.

If, instead, we both speak English, but I proceed to speak with a broad Australian accent and they reply quickly with a strong Glaswegian accent, we may struggle to understand each other’s speech, even though we share a language.

A child’s intelligibility depends, in part, on who is listening to the child. For example:

some adults seem to understand young children’s speech more easily than others;
as you would expect, parents can almost always understand their child’s speech better than adult strangers;
many health and early education professionals become adept at understanding children’s speech through experience, including working with children with speech sound disorders;
some adult listeners have hearing, language, learning, and cognitive difficulties themselves; and
some adult listeners may understand and speak the child’s language as a second (or later) language or may speak a different dialect of the child’s language.

Again, the researchers in the Hustad study had to be selective in who they asked to assess the children’s intelligibility. To qualify, you had to be a normal-hearing adult who: (i) spoke American English natively; (ii) had limited experience listening to children with communication disorders; and (iii) reported no language, learning or cognitive disabilities.

In the real world, lots of people of different abilities and experiences will listen to your child, and their ability to understand your child may vary widely.

C. Language and environmental context

The context in which speech happens can make a big difference to intelligibility. For example:

In the real world, many children supplement their speech with gestures like pointing, showing, nodding and facial expressions (e.g. to protest or express disgust). If you can’t see a young child’s face or gestures (e.g. on a phone call), their speech is often harder to understand.
The physical environment we’re interacting in often increases intelligibility. If I am working with an 18-month-old who says /ba/ while pointing to a bubble machine, I am likely to interpret the syllable as an attempt at “bubble”. If she does it while pointing at a sheep at a petting zoo, I will probably interpret it as a reference to a sheep sound (“baa”). In both cases, I think I understand the word attempt even with just a syllable to go on (and even if the child actually meant something completely different). If I hear a recording of /ba/ with no context, I am more likely to interpret it as babble, rather than an early word attempt, and I’m less likely to know what the child meant.
In the Hustad study, the researchers found that, from the age of around 4 years old until around 10 years of age, children were more intelligible to adult strangers when they spoke in word combinations and sentences, compared to single words. One explanation for this finding was that context allowed listeners to infer missing or distorted speech information compensating for children’s speech errors. (This is one reason children with good oral language but unclear speech often seem more intelligible than children with both DLD and unclear speech.)
People are harder to understand if there is a lot of background noise or if you are otherwise distracted. Much of our communication with young children outside the clinic happens in noisy and distracting places, like preschools or parks. In the presence of background noise, adults tend to use more gestures and exaggerated facial expressions. We also increase our volume and check for comprehension more often.
The assessment task can make a big difference to intelligibility. Some children speak more clearly when they repeat an adult model than in spontaneous conversation. This is why naturalistic language sampling tasks like conversation samples and story retelling tasks are such an important part of our assessments of children with suspected speech sound and other communication difficulties.

The Hustad study required the adults to listen to digital audio recordings of standard words and sentences. Background noise was digitally removed and the speech signal was ‘normalised’. The word and sentence lists were presented in random order (although delivered in separate blocks). The listeners heard each word and sentence once only, and then had to type what they thought the child said. Two listeners listened to each child’s samples and their scores were averaged.

In other words, the children’s speech intelligibility was assessed by adults who: (i) did not see the children; (ii) had no environmental context; and (iii) listened to audio recordings that had no background noise or other distractions. In these conditions, I was not surprised that the intelligibility ratings were lower than parent estimates of intelligibility in the real world, and our real world clinical observations of children with and without speech sound disorders.

7. So does the new research mean we shouldn’t worry if no-one understands my 3 or 4 year-old child?

That is not the key takeaway from the new research.

Intelligibility norms are just one factor we think about clinically when we meet a child with unclear speech. We focus on other things, too, including:

A. The functional impact of unclear speech on the child

For example, we look at whether (and if so how) the child’s unclear speech is:

affecting their participation, e.g. on playdates, at preschool, at home with family members, in sport and other team activities;
affecting their confidence in communicating their thoughts and feelings and their overall oral language development, including language content, structure and social uses;
attracting negative social attention, e.g., teasing, bullying or contributing to emotional and behavioural problems, or or labelling and lower expectations from adults (e.g. family members or educators); or
worrying their parents or other loved ones.

Through clinical practice, I’ve learned that the objective severity of a child’s speech sound disorder does not automatically correlate with the effect it has on their life and the lives of family members. A functional approach is better than a pure impairment-based approach:

B. Risk factors and other communication challenges

We look at known risk factors for communication disorders, like family histories of speech sound disorders, and assess to see if the child has any other communication challenges. For example, if the child has unclear speech and DLD, or unclear speech and stuttering, or unclear speech and reading difficulties, we are more likely to recommend early intervention.

We also look at whether the child has any other health or learning challenges that might be contributing to their communication difficulties or participation.

C. Risks of future communication difficulties

Here, we look at the evidence about the short, medium and long term effects of speech sound disorders. For example, we know that speech sound disorders can affect a child’s school readiness, hamper social participation and relationships with parents, siblings, teachers and schoolmates, contribute to reading and writing difficulties, reduce school success, and lower a child’s overall quality of life (e.g. McCormack et al., 2009).

Ideally, we want a child’s speech to be intelligible to their teachers and peers on their first day of ‘big school’ in light of the school readiness literature. We also know that residual speech sound errors can have ongoing negative social and other effects, even if they don’t get in the way of speech being understood.

8. Bottom line

We are, as always, grateful to be living in a time when so many researchers around the world are doing such clinically useful research into child speech sound disorders. New intelligibility norms help us recognise the variability of intelligibility development among typical children in lab settings.

On balance, the new norms have not changed our general guidance to families in any radical way. If:

your child is 3 years old (or older) and adults can’t understand most of what they say; or
your child’s speech is getting negative attention from peers or others; or
your child is 4 years old and isn’t generally intelligible to unfamiliar adults in real world, face-to-face conversations; or
a health or early education professional working with your child is concerned about your child’s communication skills; or
your child is frustrated or upset that others can’t understand them; or
you are concerned for any other reason about your child’s communication skills or development,

we suggest that you give your local speech pathologist a call for a chat.

Principal source: Hustad, K.C., Mahr, T.J., Natzke, P., and Rathouz, P.J. (2021). Speech Development Between 30 and 119 Months in Typical Children I: Intelligibility Growth Curves for Single-Word and Multiword Productions. Journal of Speech, Language, and Hearing Research, 1-13.

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.

LSVT LOUD Speech Treatment for people with Parkinson’s Disease

David Kinnane · 24 January 2021 ·

Up to 89% of people with Parkinson’s disease (Parkinson’s) develop speech problems.

Speech signs may appear early and have a big effect on quality of life. Common speech issues for people with Parkinson’s include problems with:

voice: reduced loudness, and monotone, hoarse and breathy voice quality;
articulation: imprecise consonants and vowels; and
speech rate: increased, decreased, or variable.

The problems are caused by: reduced amplitude of movement; increased rigidity; and sensory processing abnormalities, including a reduced awareness of soft voice.

Since the 1990s, the Lee Silverman Voice Treatment (LSVT) LOUD has been a gold standard speech treatment for people with Parkinson’s.

LSVT LOUD:

has a single target – vocal loudness;
is intense – 16, 1-hour sessions over 4 consecutive weeks, with a high-effort mode of treatment; and
retrains sensory perception of normal loudness and internal cuing.

To date, three randomised controlled trials have shown, collectively, that LSVT LOUD is:

effective in producing significant immediate and long term improvements in loudness (up to 2 years);
more effective than no treatment; and
more effective than an articulation therapy delivered with the same intensity and dose.

Apart from volume, LSVT LOUD may have positive knock on effects to other aspects of communication.

Lower quality studies have shown that LSVT LOUD may improve articulation; rate; intonation; speech intelligibility; voice quality; and facial expression.

LSVT LOUD can treat people with:

mild-moderate Parkinson’s to maintain functional communication and quality of life; and
advanced Parkinson’s, including those with atypical Parkinson’s and after deep brain stimulation.

Banter has two speech pathologists certified to provide LSVT LOUD treatment. Listen to David’s radio interview about LSVT LOUD here.

For an accessible audio version of the infographic, check out our video below:

Primary source: Ramig, L., Halpern, A., Spielman, J., Fox, C. (2018). Speech Treatment in Parkinson’s Disease: Randomized Control Trial (RCT). Movement Disorders, 33(11), 1777-1791.

Related articles:

Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language

My child’s speech is hard to understand. Which therapy approach is appropriate?

David Kinnane · 17 January 2021 ·

Speech sound disorders are some of the most common communication disorders for preschoolers.

Having a speech sound disorder increases risks for later difficulties with school performance, reading, social skills, and employment opportunities. Early help from a speech pathologist is recommended.

No universal treatment solution exists for speech sound disorders, in part because of the:

diversity of people with speech issues; and
number of speech sound disorder subtypes and causes, including motor programming issues (as in childhood apraxia of speech), and speech issues associated with sensory or anatomical differences (e.g. hearing impairments and cleft palates).

For the majority of children with speech sound disorders, there is no known cause.

Speech error types include:

articulation-based errors that don’t on their own have a major impact on speech clarity, like lisps; and
phonologically-based, patterns of errors, which affect multiple speech sounds across different classes, and which can make children hard to understand.

Some children make both types of errors.

Which approaches are appropriate?

For children with isolated articulation errors, traditional motor-based articulation approaches and treatments based on principles of motor learning may be appropriate.
For children with mild-to-moderate, consistent phonological deficits, Minimal Pairs therapy may be appropriate.
For children with moderate-to-severe phonological deficits that include the use of a “preferred” speech sound, Multiple Oppositions therapy may be appropriate.
For children with phonological deficits and who cannot say six or more speech sounds, Maximal Oppositions therapy may be appropriate.
For children with multiple patterns of phonological errors who are very hard to understand, Cycles phonological remediation and Complexity therapy approaches may be appropriate.

Summaries of these treatment approaches are available here on our website (see ‘Related articles’ below). In practice, many speech pathologists ‘mix and match’ different approaches to tailor therapy for the client in front of them.

We need more, higher quality research studies to guide us on which approaches are more effective than others, and when, to help children with speech sound disorders.

For an accessible audio version of the infographic, check out our video below:

Principal source: Cabbage, K.L. and DeVeney, S.L (2020). Treatment Approach Considerations for Children with Speech Sound Disorders in School-Based Settings. Topics in Language Disorders, 40(4), 312-325.

Related articles:

Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language

Ask Us Anything: 17 things our readers and followers really want to know about speech pathology (but were too shy to ask)!

David Kinnane · 28 June 2020 ·

For more than seven years we’ve been writing about evidence-based speech pathology assessments and treatments for children and adults. Our website has had more than 1.3 million views, and we hope we’ve helped share useful information with families and adults who are considering speech therapy.

Whenever two clients ask us the same question, we write an article about it. But, sometimes, a gap opens between what we might think people want to know, and what people actually want to know. Sometimes, clients, readers and followers may not want to ask us a question directly because it might be, well, difficult or even embarrassing.

By looking at the questions people actually use when searching for us, we’ve come to the conclusion that we need to work harder to figure out what people want. So, in this article, we try to answer our readers’ 17 most frequently asked questions about speech pathology. (For context, we include real world examples of what people searched to get to us.)

Why 17 questions and not, say, 10 or 20? Well 17 is as many as we could answer this weekend! (We may keep adding to this article when we get more time.)

Why these questions and not others? These are simply the most common things people ask about. They are not necessarily the things I thought people would want to know, which is of course the point of this article.

Disclaimer: Obviously, our answers are ours, based on our experiences managing a speech pathology clinic and working with children and adults in Sydney, Australia, and by telehealth. We do not pretend to speak for the whole profession in all settings, globally: others will no doubt have different views on some of these questions.

1. Is speech therapy the same as speech pathology?

Yes.

An easy one to start with!

Speech pathologists and speech therapists are the same people. Speech pathology and speech therapy are the same thing. I use both terms to describe what I do. I use the terms speech therapy and speech pathology interchangeably because. They. Mean. The. Same. Thing!

Searches: Speech pathology vs speech therapy. Speech pathologist vs speech therapist. Speech therapy vs speech pathology. Speech pathology and therapy. Speech pathology or communication disorders. Speech pathologist v therapist. Speech pathology or therapy? Speech pathology v therapy.

2. What are speech pathologists? What do speech pathologists do?

We are professionals who are university-trained to help people with communication challenges, including speech and language difficulties. We work with children and adults; from babies to senior citizens. For example, in our clinic, we work with late talkers, preschoolers, school-aged children, teenagers, young professionals, middle-aged adults, and seniors with communication issues.

Not all speech therapists work with everyone. At Banter Speech & Language, we work with adults and children from many walks of life, including:

people with speech sound problems like lisps, phonological speech sound disorders, motor speech difficulties like childhood apraxia of speech and other difficulties being understood by others;
people with developmental language delays and disorders;
people with reading difficulties, including dyslexia;
people with lifelong language, speech or other communication challenges associated with lifelong disorders or disabilities, like Autism Spectrum Disorder, Cerebral Palsy, and Down Syndrome;
people with communication disorders like aphasia, dysarthria or cognitive communication issues caused by strokes or traumatic brain injuries;
people with communication challenges associated with neuro-degenerative diseases like Parkinson’s Disease and dementia; and
people who want to improve their communication skills, e.g. to be understood or to write more effectively at school or work.

Many speech pathologists – not us – work with people with feeding and swallowing difficulties and disorders. We do not practice in this area. (We refer people with swallowing disorders on to speech pathologists who do that work every day.)

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3. When should I speak with a speech pathologist?

For children, here are some rules of thumb.

In general, we suggest you speak with a speech pathologist:

if communication challenges are getting in the way of what you or your child want to achieve; or
when communication challenges are stopping you or your child from fully participating in life; or
if you have any concerns about your communication skills or the communication skills of a child or someone you are caring for.

Searches: When speech pathology needed? Speech therapy where to start? Why speech pathology is important. Why speech pathology?

4. How does speech pathology work?

Here’s our overview of how speech pathology for children works.

Here’s our overview of how language therapy for children works.

Here are two overviews for how reading and dyslexia interventions work:

Here’s our overview of speech pathology treatments for adults who stutter.

Here’s our overview of speech pathology for preschoolers who stutter.

Here’s our overview of speech pathology for school-aged children who stutter.

Here’s our overview of how principles of motor speech and neuroplasticity can help adults improve their speech.

Here’s our overview of how speech pathology can help people with Parkinson’s Disease.

Many (not all) speech pathology treatments are based on behaviourist scientific principles. You can real more about these principles here.

Most of our articles focus on why speech pathology works, so look around our website if none of the articles above answer your question.

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5. Can speech therapy help toddlers?

Yes.

This is a very – VERY – common question from our readers.

Here’s what we want parents of late talkers to know.

Here’s our overview of how we assess toddlers.

Here are some principles we use to help families:

Searches: Will speech pathology help my toddler? What’s speech therapy for toddlers? Will speech therapy help my child talk? Speech therapy for toddlers at home. Speech therapy 2 year old. Speech therapy for toddlers. Speech therapy for 2 year old. What is speech pathology like for toddlers? Speech therapy books for toddlers. Speech therapy toys for 2 year olds. Speech therapy words. Will speech pathology help my child talk? Speech pathology with toddlers. When speech pathology for toddler?

6. Can speech therapy help preschoolers?

Yes.

Here is some information about how and when preschoolers typically learn their speech sounds.

Here is some information about preschoolers’ speech sound error patterns (and when they should disappear).

Here’s how unclear speech can affect later reading outcomes.

Here’s our overview of why speech and language are so important for school readiness:

What teachers want (is your child ready for school)?
Is your child ready for school? What matters most.

Here an overview of three evidence-based treatments we use to treat speech sound issues:

Here are overviews of some common language targets for preschoolers, including:

Here’s an overview of the Lidcombe Program for preschoolers who stutter.

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7. Can speech pathology help kids at school?

Yes.

But we are not teachers or tutors, as we explain here.

Here are some overviews of speech therapy interventions for common issues including:

reading difficulties;
reading comprehension issues;
Tier 2 and academic vocabulary;
inferencing;
writing; and
higher level oral language like homophones, homonyms, homographs, metaphors and similes, analogies, idioms, sayings, and discourse level tasks like narratives.

We’ve also written about common related issues like working memory, auditory processing disorder, ADHD, sleep disorders and social and emotional issues.

We’ve also published tips for teachers and others working with students with language, reading and learning disorders, social skills and Do-It-Yourself evidence-based study techniques.

Some children have residual speech sound issues, which cause ongoing social and employment issues. We’ve written about it here.

Searches: Will speech pathology help? Will speech pathology help my child? Speech pathologist schools. Speech pathologist and academic. Speech pathologist and vocabulary. Higher level language.

8. Can Speech pathologists help with dyslexia and other reading difficulties?

Yes.

We’ve written a free book for parents about this.

Since then, we’ve added more information:

We outline how speech pathologists approach reading difficulties.

We outline our approach to teaching children to read here.

We outline what to do if your child is struggling to read and what works here.

Searches: Speech therapy for dyslexia. Speech therapy reading difficulties.

9. Can speech pathology help with lisps?

Yes.

For our overview of lisps, including an explanation of different types of lisp, see our FAQs.

For our home program for children who have interdental lisps, see our Pesky Lisp Fixer.

For our home program for children who have lateral lisps, see our Slushy /s/ Zapper.

For adults who lisp, see our Lisp Fixer online course.

Searches: Can speech therapy get rid of a lisp? Speech therapy lisp. Speech therapy s sound. Can speech pathologist fix a lisp?

10. Can speech pathology help my child to say sounds properly?

Yes.

For an overview of speech sound treatments, see here.

For information about when children should be able to say each sound, see here.

For information about common error patterns like leaving out sounds and ‘gliding’ of /r/, /l/ and ‘y’ (/j/) sounds (and when they should be gone), see here.

For a home program for trouble with the /r/ and/or /w/ sounds, see our /r/ Remedy.

Searches: Speech therapy can’t say r. Speech therapy r sound. Speech therapy r sounds like w. Speech therapy k sound. Speech therapy letter l. Speech therapy y sound.

11. Can speech pathologists help with mumbling?

Yes.

The first step is to find out what is contributing to it – is it caused by difficulties with speech sounds or a language problem (or both), or something else? Are other things, like hearing difficulties, middle ear infections, or tonsil and adenoid problems contributing? A speech pathologist can help you get to the bottom of what’s going on and treat speech sound issues.

Behavioural speech therapy may be an option when there are no speech sound or physical issues contributing to the mumbling. For children with no speech sound issues, we have a simple home program – Mumble Buster.

Searches: Speech therapy to stop mumbling. How to stop mumbling.

12. Can speech pathology help with stuttering?

Yes.

Stuttering and stammering mean the same thing. You can read more here.

Many young children recover from stuttering, although recovery means different things to different people.

If you have a child who is stuttering, should you wait and see what happens? No. Here’s why.

There is – as yet – no cure for stuttering. But there are several treatments available to help people manage stuttering and its effects.

For preschoolers, see here.

For school-age children, see here.

For adults, see here.

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13. Can speech pathology help me with my accent?

Yes.

Accent modification is controversial and often unnecessary. There is no one right way to speak English (or any other language). English is a global language, and we should celebrate local differences, like Singlish or Indian English, rather than criticise them.

Sometimes, accents get in the way of being understood. Sometimes, they can get in the way of important life goals like getting a job or a promotion. For most adults, ‘getting rid of an accent’ is not realistic. But there are evidence-based principles of clear speech that can help increase your intelligibility and comprehensibility while staying true to yourself and your heritage.

Here’s our overview of how speech therapy can help people to modify their accents.

Here are things you can do to increase your intelligibility.

Here’s why some people choose to modify their accents.

Search: Speech therapy to lose accent.

14. Can speech pathologists and speech pathology be more convenient for people?

Yes.

The great thing with technological advances in recent years is that we can provide speech therapy anywhere. We have lots of rural and international clients, including in remote areas without another service.

We can use Zoom, Skype, Coviu, or Google Meet or Hangouts to help children and adults in their homes by telehealth. Speech pathology is nearby anyone with an Internet connection!

We’ve been doing stuttering therapy by telehealth for years.

We also make home programs and online courses for people who want to do speech therapy in their home. A good example of this is our self-paced preschool language readiness course.

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15. Do you need a referral to see a speech therapist?

No.

You can call and have a chat with us any time Monday-Saturday. If you decide to book in, you do not need a referral and can get started straight away.

For people with reading difficulties, you do not need to wait for a formal diagnosis of dyslexia to get started. Evidence-based treatment for reading difficulties is the same for people with and without a formal diagnosis of dyslexia, and the earlier you get started, the better.

To get in touch with us, go here.

Searches: Do you need referral for speech pathologist? Speech pathology without IEP.

16. Are rebates and insurance available?

This depends on your circumstances, but usually, in Australia, yes. You can read more about rebates and insurance here.

Searches: Speech pathology Medicare. Speech pathology private health insurance.

17. Where can I find quality speech pathology resources, exercises, worksheets and games?

Here. We love to share our knowledge and to make practical resources to help people.

We’ve seen a surge of interest in our therapy resources recently, both from families and other speech pathologists. Our library of resources continues to grow.

By way of overview, we have published:

hundreds of free, evidence-based articles and speech pathology facts on this blog, including speech therapy games and reinforcements, and parent tips and strategies;
free books for parents about speech pathology and reading;
a popular free eBook with therapy activities for the Lidcombe Program for children who stutter;
a free vocabulary scaffold;
free speech sound cards;
free carrier phrases for language, stuttering and voice therapy;
free picture description and image-based resources for telehealth;
a free story-builder scaffold for narrative writing;
a free online course about higher level language;
a free video library of early prepositions for toddlers;
a self-paced online preschool language readiness workshop for children aged 3 years and older;
a book of evidence based communication tips for parents of babies and toddlers;
a Blanks levels of questioning resource library for preschoolers and young school-aged students;
Listen then Speak, an oral language course for children in Years 2-5, including 10 fully scripted therapy slide-pack books;
an online library of scripted resources: Exam and Essay Verbs students in high school should know;
an audio and therapy material library for consonant clusters for Developmental, Contrast, Cycles, and Complexity approaches;
Level Up Your Language, a fully scripted higher level language course, including five therapy slide packs;
a wide range of simple, compound and complex sentence builders to help children and adults master English syntax;
home programs for interdental lisps, lateral lisps and the gliding of ‘r’;
the Lisp Fixer, an online lisp correction course for adults;
free letter-sound link videos focusing on direct instruction of the extended code;
7 free mini-decodable stories to check if your Kindergarten kid is really decoding the basic code;
a series of ‘select a sequel’ decodable readers for working on the extended code and reading fluency at the same time – the first one is free here;
a large (and growing) library of therapy and intervention resources on our Teachers Pay Teachers store; and
a Lidcombe Program starter series for preschoolers.

And we’re just getting started!

Searches: Speech therapy activities. Speech pathology facts. Speech therapy books. Speech pathology blog. Speech therapy books for parents. Speech therapy tips for parents. Speech therapy exercises for 3 year olds at home. Speech therapy games. Speech therapy game apps. Speech therapy home exercises. Speech therapy materials. Speech therapy materials pdf. Speech therapy online free. Speech therapy pictures. Speech therapy questions. Speech therapy resources. Speech therapy resources for parents. Speech therapy sentences. Speech therapy toys. Speech therapy videos. Speech therapy worksheets. Speech therapy websites. Speech therapy webinars. Speech therapy YouTube. Speech therapy you can do at home. Speech therapy courses. Speech pathology images.

Any unexpected searches you came across?

Yes. Here are our four favourites, with our answers in brackets:

Is speech pathology hard? (Yes. It is.)
Is speech pathology a good career? (Yes. It’s great.)
Can speech pathologists have tattoos? (Of course.)
Speech pathologist with a dog. (You must be looking for someone else. We’re cat people!)

Bottom line

With this website, we set out to make speech pathology less mysterious and more transparent. This whole enterprise exists to share quality information with you about speech pathology and to answer your questions. We welcome any questions you may have about speech pathology, speech therapists or communication disorders – even tricky and confronting ones.

Readers and followers: You can ask us anything!

Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language

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

David Kinnane · 17 May 2020 ·

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:

the best peer-reviewed research;
our clinical expertise; and
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:

the Complexity Approach for phonological impairments;
the normative (or developmental) approach based on knowledge of typical consonant acquisition and ages at which phonological error patterns are typically eliminated.
the Cycles Phonological Remediation Approach for children with severe phonological impairments;
Minimal Pairs, Multiple Oppositions and other contrastive approaches, sometimes based on developmental sequences of sounds, and sometimes based on complexity principles;
DTTC therapy for younger children with severe childhood apraxia of speech; and
ReST treatment for older children with childhood apraxia of speech.

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.

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Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language