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Sydney speech pathologists helping adults and children speak for themselves.

treatment for speech sound disorders

How to treat speech sound disorders 3: Contrastive Approach – Minimal and Maximal Pairs (with demo)

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Apart from the Cycles Approach and the Complexity Approach, the “Contrastive Approach” is another common way to treat children with phonological speech disorders. In this article, we explore both the so-called “Minimal Pairs Approach” and the “Maximal Pairs Approach”. Both are contrastive approaches and are used for phonological intervention.

Contrastive Approaches for phonological intervention

Let’s dive into the nuts and bolts of these two approaches.

Who developed them?

The Minimal Pairs Approach was developed by Dr Frederick F. Weiner, whilst the Maximal Pairs Approach was developed by Professor Judith Gierut and her colleagues at Indiana University.

Who is it for?

  • The Minimal Pairs Approach is suitable for children with mild or moderate speech sound disorders, with one or two phonological processes that are no longer age-appropriate. It can also be used with people who are looking to modify their accent.
  • The Maximal Pairs Approach is geared towards children with at least six sounds missing from their speech sound inventories with normal oral and speech motor abilities.

What are they?

In essence, both approaches focus on contrasting differences between phonemes (i.e. speech sounds) in order to reorganise a child’s sound system.

Phonemes can differ by:

  1. Place – some sounds are made with the lips, tongue tip or the back of the tongue.
  2. Manner – some sounds uses a long continuous flow of air (e.g. /s/, /z/), some sounds are short and stop as soon as they begin (e.g. /t/, /p/), etc.
  3. Voicing – we switch our voices on to make some sounds (e.g. /b/, /g/), but turn our voices off for others (e.g. /p/, /k/).

In the case of a minimal pair, the two words differ by a single phoneme and by one or two features across place and manner of articulation and voicing.

For example, let’s look at the pair “cap” and “tap”. These two words are identical in terms of the vowel /ae/ and final consonant /p/. They only differ by the initial phoneme – /k/ and /t/ – and this involves a small difference in place of production (velar vs alveolar).

In comparison, a maximal pair includes two words that differ by a single phoneme across many featural dimensions of place, manner and voicing. An example would be the pair “be” and “see”, where the phonemes /b/ and /s/ differ across all three aspects of place (labial vs coronal), manner (stop vs fricative) and voicing (voiced vs voiceless).

In both approaches, the paired words would contain a sound a child is familiar with and a target (unfamiliar) sound.

What happens in the sessions?

For the Minimal Pairs Approach:

  1. Identify the target phonological process. For example, a 3-year-old boy, Ben, has voicing errors. He “turns off” his voice at the start of his words when he should be “turning it on” (e.g. he says “pig” instead of “big”). In this case, we want Ben to say /b/. We call this the “target”.
  2. Before the session, select 3-5 minimal pairs of words that contrast the paired phonemes. According to research, only three to five word pairs are needed to make permanent changes in a child’s phonological system (Elbert et al., 1991). In Ben’s case, we can choose pig/big, pay/bay, park/bark, peg/beg, pea/bee.
  3. Introduce the minimal pair words to the child by showing them pictures of the pairs and naming them aloud. We want to make sure Ben knows the vocabulary – this is sometimes tricky when contrasting sounds with few word options.
  4. Have the child point to the words you name. This gives us an idea whether the child can hear the difference between the two contrasting phonemes (e.g. /p/ vs /b/). This is sometimes called auditory discrimination.
  5. Now, reverse the roles and have the child name the words.
  6. When the child uses the “wrong sound” (e.g. pig) for the target (e.g. big), pick up the picture that the child named and not the one intended. For example, when Ben points to the picture card big but says, ‘pig’, pick up the picture of the pig.
  7. Give the child feedback to signal he/she has made a mistake. In Ben’s case, I might say, “Oh, do you mean pig or big? I’m not sure what you mean, tell me again.” This is the teaching moment, where Ben learns he needs to say the word differently for others to understand him.
  8. Work with the child till he/she gets it right about 60% of the time.
  9. Move onto the other paired words (one set at a time) at sentence level. You can use carrier phrases at this stage.

Here’s a demonstration (voice and hand talents Vivien Wong and Cherie Finocchiaro):

For the Maximal Pairs Approach:

  1. Identify the two target phonemes. For example, the sounds /m/ and /f/ are maximally opposed across by place, manner and voicing (with /m/ being a bilabial voiced nasal and /f/ being a labiodental voiceless fricative). Remember the pair should include a known versus an unknown phoneme. 
  1. Create eight pairs of words containing the target phonemes. Where no true words are available, use nonsense words, which could be associated with different monster or fairy names. For example, Mip/Fip.
  1. Have the child imitate you and then say it on their own.

In both approaches, we also plan to add auditory bombardment and discrimination tasks.

How long does it take?

Like other approaches, the duration of therapy required is dependent on the child, the child’s phonological processes, the amount of treatment within sessions and home practice. The more repetitions we could fit into our sessions, the better.

As both approaches are suited for children with mild-to-moderate phonological impairments, with only a few age-inappropriate errors remaining, in theory at least, it should take less time than more intensive treatment approaches such as Cycles.

The idea is that, once a difference between phonemes is introduced, the gains are likely to “transfer” to untreated phonemes. (You can read more about this here.)

What does this mean?

If we think back to our earlier example with Ben, the phonemes /p/ and /b/ differ only by voicing (voiceless vs voiced). If Ben learns to “turn on” his voice in treatment of /p/ vs /b/ pairs, this same voicing contrast should be carried over to other voiceless-voiced pairs such as /t/-/d/ or /k/-/g/. 

Does it work?

The Minimal Pairs Approach has been used for over twenty years, with a robust body of research supporting its clinical effectiveness (Barlow and Gierut, 2002). Tyler, Edwards and Saxman (1987) also found that this approach was best suited for children with only one or a select few phonological processes. Research comparing both the Minimal and Maximal Pairs Approach found that targeting a maximally opposed pair led to greater generalisation than a minimally opposed pair.

It is important to note that to date, most of the studies on contrast approaches are fairly small, without control groups. The current main body of available evidence is based primarily on non-randomised experimental and non-experimental studies (Baker & McLeod, 2004). More higher-quality research would help clinicians (and our clients).

Helpful Resources:

Head over to leading speech pathologist Caroline Bowen’s website, for her incredibly extensive library of useful information about both approaches, as well as her widely used resources for therapy.

Related articles:

Principal sources:

Baker, E., & McLeod, S. (2004). Evidence-based management of phonological impairment in children. Child Language Teaching and Therapy, 20(3), 261–285. Abstract available here.

Barlow, J., & Gierut, J. (2002). Minimal Pair Approaches to Phonological Remediation. Seminars In Speech And Language, 23(1), 057–068. Abstract available here.

Elbert, M., Powell, T., & Swartzlander, P. (1991). Toward a Technology of Generalization: How Many Exemplars Are Sufficient? Journal of Speech, Language, and Hearing Research, 34(1), 81–87.Abstract available here.

Tyler, A.A., Edwards, M.L., & Saxman, J.H. (1987). Clinical application of two phonologically based treatment procedures. Journal of Speech and Hearing Disorders, 52m, 393-409.

Image: https://tinyurl.com/yck6xsfg

Banter Speech & Language Banter Speech & Language
Banter Speech & Language is an independent firm of speech pathologists for adults and children. We help clients in our local area, including Concord, Concord West, North Strathfield, Rhodes, and Strathfield, and all other suburbs of Sydney.

Banter Speech & Language is owned and managed by David Kinnane, a Hanen- and LSVT LOUD-certified speech-language pathologist with post-graduate training in the PreLit early literacy preparation program by MultiLit, the Spalding Method for literacy, the Lidcombe and Camperdown Programs for stuttering, and Voicecraft for voice disorders. David is also a Certified PESL Instructor for accent modification.

David holds a Master of Speech Language Pathology from the University of Sydney, where he was a Dean’s Scholar. David is a Practising Member of Speech Pathology Australia and a Certified Practising Speech Pathologist (CPSP). David is a part-time Associate Lecturer at the University of Technology Sydney’s Graduate School of Health. David sits on Speech Pathology Australia’s Ethics Board and Professional Standards Advisory Committee.

How to treat speech sound disorders 2: The Complexity Approach – more bang for your buck?

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The “complexity approach” for treating children with phonological speech disorders has a lot of peer-reviewed research evidence to support it. But one study showed only 8% of speech pathologists use it (Brumbaugh & Smit, 2013). There are lots of reasons why:

  • Lack of knowledge: perhaps as many as 70% of speech pathologists aren’t familiar with it. Some speech pathologists have never heard of it.
  • Lack of time: the Complexity Approach requires a very detailed, technical analysis of a child’s speech sound system to plan treatment.
  • Limited assessment tools: traditional speech sound assessments don’t produce the type of results and the amount of information necessary to pull together a comprehensive treatment plan using the approach. Until very recently, few assessment Complexity Approach resources have been available to support busy speech pathologists. 
  • Heavy reliance on abstract concepts: You need to know a fair bit about phonetics and phonology to understand some of the treatment elements. Because of this theoretical complexity, the approach can be hard to explain to clients and their families.
  • It’s hard for clients! In our clinical experience, kids need to be fairly resilient and willing to give the treatment a go, despite what can sometimes seem like impossible targets, especially in the beginning. We find less resilient kids usually do better with Cycles or targets based on a developmental approach, at least in the early stages of their treatment when we are still building rapport.
  • It’s hard on speech pathologists! To do it properly, speech pathologists have to analyse and juggle four pieces of information, and then track them over time. This is hard for many of us (including me!) – especially when we are managing big caseloads with waiting lists. 

 

Never give up, never surrender!

Confession time: we’ve attempted to use the Complexity Approach in our clinic a few times, but given up because of the various obstacles to getting it to work for our clients and their families. Despite all the barriers, we’re trying hard to re-introduce the approach because we are committed to evidence-based practice. 

Fortunately, we’ve recently had a big morale boost from Professor Holly Storkel, who has produced some outstanding free resources to help us get the approach into our practice to help clients (see links below).

 

Here’s a summary of what the treatment involves:

1. Who developed the complexity approach?

Professor Judith Gierut and colleagues at Indiana University (e.g. Gierut, 1999, 2001, 2007; and Gierut & Hulse, 2010).  

 

2. Who is it for?

Children aged 3-6 years:

  • with very low scores on standardised speech assessments (i.e. below the 5th-6th percentile); and
  • who are missing at least 5 speech sounds from their phonemic inventories.  

 

3. What are its goals?

Children who benefit from this approach start from a long way behind most other children the same age. The goal of the Complexity Approach is to produce “system wide change” to children’s speech to make them easier to understand and to close the gap with typically developing children as quickly as possible.

 

4. How does it work?

Right. Strap yourself in!

To make system-wide changes, speech pathologists using the Complexity Approach try to choose speech sound targets that will give kids the “biggest bang for their buck”. The challenge with this approach is choosing the right speech sounds to target. To do this, speech pathologists think about four key things:

 
  1. Typical development of speech sounds. We need to know the age when most children can say a speech sound, and the order in which they learn different consonant sounds. For example, most toddlers can say the /b/ sound. But many 5-year-olds still struggle with /r/ and voiceless and voiced “th” sounds (as in “bath” and “bathe”). You can read more about typical consonant acquisition here.

 

2. So-called “Implicational Universals“. This sounds pretty academic, right? But stay with me! These ‘universals’ are simply patterns observed with speech sound systems around the world and the sounds they contain. Some consonant sounds are more complex than others. For example:

  • Long, “hissy” sounds called “fricatives” (like /f/ and /s/) are more complex than short “stops” like /p/ and /t/. What this means is that, usually, if a speech system includes fricatives like /f/ or /s/, it also includes stops, like /p/ or /t/. In other words, having fricatives in a system implies the system includes at least some stops (or the capacity to produce them).
  • “Affricate” consonants made up of a stop and a fricative like “j” or “ch” are more complex than fricatives like /f/ or /s/.
  • Semi-vowel ‘liquid’ and glide sounds like /l/ and /r/ are more complex than sounds made through your nose, like /n/.
  • ‘True consonant clusters’ like /pl/, /sw/ and /fr/ are more complex than affricates like “j” or “ch”.
  • So-called “small-sonority-difference clusters” like /sm/, /sn/ and /mj/ (as is “music”) are more complex than “large-sonority-difference clusters” like /tw/, /kw/ and /pl/*.
  • True consonant clusters (like /tw/, /pl/, /br/, and /fl/) are more complex than so-called “adjunct clusters” like /sp/, /st/ and /sk/.
  • Three sound clusters (like /spl/, /skw/ and /spr/) are more complex than two sound clusters (like /sl/ and /pr/).

 

3. Sounds the child with the speech sound problem “knows”. Phonological “knowledge” has a technical academic meaning well beyond the scope of this summary. In practical terms, what most clinical speech pathologists look at here is how accurately the child can say a given speech sound in different word positions (beginning, middle, and/or end of words), different tasks (e.g. on its own, in words, sentences, and in conversation), with different people (e.g. parents, speech pathologist, preschool educators) and in different places (e.g. home, clinic, preschool, play dates). Some kids can say a sound correctly on its own, or in a few words, or in one word position, or inconsistently. So-called “least-knowledge” targets are those speech sounds with no or very few correct productions. So-called “most-knowledge” targets are sounds the child can say accurately, at least about 20-40% of the time at word level. (Obviously, you wouldn’t target sounds the child could say accurately 100% of the time.)

 

4. Sounds for which the child with the speech sound problem is “stimulable”. Again “stimulability” has a technical meaning beyond the scope of this summary. In practical terms, speech pathologists choose speech sounds the child hasn’t yet learned or acquired and then try to encourage or stimulate the child to produce the sound by giving the child lots of models containing the sound to copy (sometimes with tips about how to make the sound). For example, if testing to see if /l/ were stimulable, you could ask the child to imitate you saying: l, li, ili, il, la, ala, al, lu, ulu and ul (e.g. Miccio, 2002; Storkel, 2018).

 

5. What on earth does all this stuff mean in practice?

When using the Complexity Approach, speech pathologists should prioritise speech sound targets that:

  • are late-acquired developmentally;
  • are complex/marked (e.g. targeting fricatives rather than stops, true clusters rather single sounds, clusters with low sonority differences, rather than high (or negative) sonority differences*);
  • the child doesn’t know/cannot yet produce accurately; and
  • the child is not yet stimulable for.

Again, the goal is to produce big, system-wide changes as quickly as possible. 

 

6. Do all speech sound experts support the complexity approach?

No. For example:

  • Professor Susan Rvachew and colleagues have published results that – at least on first reading – seem to contradict Professor Gierut’s findings (e.g. Rvachew & Nowak, 2011). For example, Rvachew and colleagues found that treating early-developing sounds that children can sometimes say correctly in some positions results in faster progress on the specific targets than treating later developing sounds that the child can’t say (although the gains do not transfer as much to other sounds, compared to complex targets);
  • as with our experiences to date, many speech pathologists working in busy clinics find the treatment hard to implement “in the real world” for all the reasons set out above; and 
  • clinically, some clients (and their families) find the Complexity Approach to treatment baffling, gruelling, and not very rewarding. I can’t fault them for this because it’s often true!

 

7. What happens in the therapy sessions?

Here’s the funny thing. Although it can take a long time to identify the right targets during the management planning stage, actual treatment sessions based on the Complexity Approach look a lot like many other phonological interventions – it’s just that the targets are more challenging.  

For example, we might assess a five-year-old boy, Danny, and discover that his speech sound system is very limited, and contains no word initial consonant clusters (e.g. /sw/ or /bl/ words) or initial affricates (like “ch” or “j”). He can say /b/, /w/ and /f/ in word initial position. Choosing aggressive targets – say /sw/ words and word starting with “ch” and “j”, you could:

  • do minimal pairs/near minimal pairs: get Danny to contrast /sw/ words with very similar words starting with a sound he knows, e.g. “sweet” v “wheat”, or “cheat” v “feet”, or “jam” v “bam”; and/or
  • do an “empty set”: get Danny to contrast two sounds he can’t yet produce, e.g. /sw/ words versus words starting with /bl/ (e.g. “sweet” v “bleat”); or to contrast words starting with “j” with words starting with “ch” (e.g. “cheap” v “jeep”); and/or
  • drill the target sound in words and sentences, in a similar to Cycles.

We also plan to add auditory bombardment and auditory discrimination tasks, the former borrowed from Cycles.

 

8. How long does it take?

This depends on the child, the child’s speech system, the targets, and the amount of in clinic treatment and home practice.  As a general rule, the more repetitions we can squeeze into our sessions and during homework, the better. For this reason, based on our positive experience with the Cycles Approach, we think focusing on one target only per session would help maximise treatment intensity in the clinic, although theoretically you can go after multiple targets per session.

As you would expect, treatment targeting complex sounds seems to take longer than when targeting earlier developing sounds. But, in theory at least, the gains are more likely to “transfer” to other, less complex sounds. For example, working on /sw/ words may transfer to /s/ initial and /w/ initial words, as well as other clusters. This results in system-wide phonological change: the goal of the treatment.

 

9. Does it work?

As far as phonological treatments go, the Complexity Approach has a fairly strong research evidence base (e.g. Baker & McLeod, 2011). But we don’t yet have much clinical evidence showing it actually working in the real world.

 

10. Are assessment and target selection resources available to help clinicians to try the Complexity Approach out in the real world?

Yes! Professor Holly Storkel has recently published a terrific tutorial for clinicians (see citation below):

  • summarising the treatment and its research base;
  • providing free, Creative Commons Attribution-NonCommercial licensed resources to help speech pathologists assess children, select targets and predict gains; and
  • working through three realistic case studies to help clinicians apply the resources in practice. (We’re using the case studies at present to train our speech pathologists.)

 

Finally, sincere thanks from some grateful speech pathologists

We’re very encouraged (and thankful) to Professor Storkel for publishing her tutorial, which removes at least some of the barriers to using the approach in our clinic. Thank you!

Related articles:

Principal source: Storkel, H.L. (2018). The Complexity Approach to Phonological Treatment: How to Select Treatment Targets. Language, Speech, and Hearing Services in Schools, 49, 463-481.

Professor Storkel’s free assessment and target selection resources (note the license terms).

* Sonority is hard to explain simply, and is probably a good topic for another day! Sonority refers to a sound’s resonance – like when my kids (in my dreams) tell me I have a sonorous voice. Sonority generally rises at the start of a syllable, peaks at the vowel, and then falls at the end, e.g. in the word “bat”. Voiceless stops and affricates like /t/ and “ch” have low sonority. Nasals, liquids and glides like /n/, /l/ and /r/ have high sonority. The sonority difference (also known as “distance”) between two consecutive speech sounds can be calculated by giving each consonant type an arbitrary sonority ranking, with very sonorous sounds like /r/ getting a low score, and consonants with very little sonority like /t/ getting a high score. In word initial clusters (as in ‘train’), you generally expect a positive difference between the two consonants in the cluster. For the purposes of understanding the complexity approach, word initial clusters with large sonority differences (as in /tr/) are seen as less complex/marked than clusters with a small sonority differences (e.g. /sm/) or negative differences (e.g. /sp/).

Image: https://tinyurl.com/y99hhfc4

Banter Speech & Language Banter Speech & Language
Banter Speech & Language is an independent firm of speech pathologists for adults and children. We help clients in our local area, including Concord, Concord West, North Strathfield, Rhodes, Strathfield and all other suburbs of Sydney’s Inner West.

Banter Speech & Language is owned and managed by David Kinnane, a Hanen- and LSVT LOUD-certified speech-language pathologist with post-graduate training in the PreLit early literacy preparation program by MultiLit, the Spalding Method for literacy, the Lidcombe and Camperdown Programs for stuttering, and Voicecraft for voice disorders. David is also a Certified PESL Instructor for accent modification.

David holds a Master of Speech Language Pathology from the University of Sydney, where he was a Dean’s Scholar. David is a Practising Member of Speech Pathology Australia and a Certified Practising Speech Pathologist (CPSP).

How to identify and treat young children with both speech and language disorders

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As speech pathologists helping children with communication problems, it can be tempting to speak of our “speech therapy kids” and “language therapy kids” as if they were mutually exclusive categories of children.  They’re not:

  • Around 15% of 3 year olds have a speech sound disorder (Shriberg et al., 2005).
  • 50-75% of these children also have a language impairment (Shriberg & Kwiatkowski, 1994).

Speech and language are not the same thing.  But, just as sentences are made up of words put together in a correct order and form, words are made up of sounds and syllables.  Speech sound comprehension and production problems can compromise language development.

Why it matters

Compared to children with speech sound problems only, children with both speech sound and language disorders have more problems with:

  • telling sounds apart (Nathan et al., 2004);
  • phonological awareness (Nathan et al, 2004);
  • phonological memory (Lewis et al., 2011);
  • vocabulary (Lewis et al., 2011);
  • narrative skills (Wellman et al, 2011); and
  • later reading, spelling and written language skills (Bird, Bishop & Freeman, 1995).

Red flags to identify children with both speech sound and language problems

A recent study compared children with speech sound problems only with children with both speech and language problems.  The researchers found no significant differences in the number of speech sound errors made by children in either group.  But there were significant differences in the types of speech errors made.  Compared to children with speech sound problems only, children with speech and language disorders made significantly:

The study had lots of limitations.  For example, the children in each group were originally recruited for different studies and were assessed using different assessment tools.  There were no measures of phonological awareness, which we know is related to atypical speech sound error patterns (Preston & Edwards, 2010) and may explain some of the results.

But, despite these and other limitations, the study is clinically useful in a few ways.  It suggests:

  • frequent omissions of sounds and syllables might be a useful red flag for possible language disorders;
  • children with speech sound disorders that include frequent omissions of sounds and syllables should be assessed comprehensively for language impairments as well; and
  • children with both speech and language disorders should receive treatment that prioritises their sound and syllable omissions, as these patterns are likely to affect both their speech and language development.

How to treat children with speech and language problems

For children with both speech and language disorders, there is some evidence to suggest that alternating speech and language goals on a weekly basis leads to:

  • better language gains; and
  • similar speech sound gains,

compared to approaches that target speech and language in separate blocks or within the same session (Tyler et al, 2003).

A more recent study suggests that, when treating speech sounds, we should prioritise children’s speech omission patterns over other patterns of error.  Interestingly, this is broadly consistent with the Cycles approach to phonological intervention, which first targets syllable and consonant omission patterns before targeting other phonological patterns or processes (Prezas & Hodson, 2010).

Bottom line

We need more research to help us: (i) identify speech sound “red flags” for possible language disorders; and (ii) prioritise therapy goals for children with both speech and language disorders. For example, we would benefit from further research exploring the possible link between unusual speech development patterns and language disorders – particularly for those children with severe speech sound disorders.  In the meantime, this study gives us some preliminary – but useful – guidance to make evidence-based decisions about the appropriate assessment and treatment of children with both speech and language disorders.

Source: Macrae, T. & Tyler, A.A. (2014). Speech abilities in preschool children with speech sound disorder with and without co-occurring language impairment. Language, Speech, and Hearing Services in Schools, 45, 302-313.

Image: http://tinyurl.com/ntkakzu

Banter Speech & Language Banter Speech & Language
Banter Speech & Language is an independent firm of speech pathologists for adults and children. We help clients in our local area, including Concord, Rhodes, Strathfield and all other suburbs of Sydney’s Inner West.

Banter Speech & Language is owned and managed by David Kinnane, a Hanen- and LSVT LOUD-certified speech-language pathologist with post-graduate training in the Spalding Method for literacy, the Lidcombe and Camperdown Programs for stuttering, and Voicecraft for voice disorders. David is also a Certified PESL Instructor for accent modification.

David holds a Master of Speech Language Pathology from the University of Sydney, where he was a Dean’s Scholar. David is a Practising Member of Speech Pathology Australia and a Certified Practising Speech Pathologist (CPSP).

How to treat speech sound problems 1: the Cycles Approach

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So we’ve written more than a few articles about speech sound disorders, including common and less common phonological problems.  So how do you treat them?

One of the most common methods for treating pre-schoolers and school-age kids with severe phonological problems is the “Cycles Approach”.

Who developed it?

This approach was developed by Barbara Hodson and her colleagues and is based on principles of developmental phonology, cognitive psychology and research in phonological acquisition.

Who is it for?

The Cycles Approach was developed for children with highly unintelligible speech.  But it has been used with children with a wide range of speech sound and other communication problems.

What is it?

The official name of the program is the “Cycles Phonological Remediation Approach”.  It consists of 4 parts:

1. Choosing therapy goals focusing on a child’s main patterns of speech sound problems (rather than individual sounds) – eligible targets are consistent patterns or errors that occur at least 40% of the time.  Hodson divides these potential targets into two categories:

a. primary patterns: these include (in order of importance) syllable structures, consonants on their own, velar sounds (/k/ and /g/), alveolar sounds (e.g. /t/ and /d/), hissy “fricative” sounds (e.g. /s/, “sh”, “ch”, /f/, /v/, j, but not “th” and s-clusters like “sm”) and liquid sounds (e.g. /l/ and /r/); and

b. secondary patterns: these include voicing errors like prevocalic voicing, distorted vowels, individual fricative sounds that have not been corrected after the primary patterns have been remediated, “glide sequences” and three consonant sequences (e.g. /str/).  The idea is that most secondary patterns take care of themselves;

2. Targeting one primary pattern of error intensively for a fixed time, before moving on to the next pattern (regardless of whether the child has corrected the first pattern of error), and then thee next primary pattern and so on until all primary patterns of error have been targeted, completing one cycle.  The second cycle then begins, starting again with the first pattern, but with more complicated targets;

3. Using focused auditory bombardment, where the child listens to amplified recordings of words and sentences containing the target patterns; and

4. Lots of practice producing words containing the target sound in treatment sessions.

Hodson considers all of these elements to be essential to the therapy.  The idea is that, by targeting patterns of errors (rather than individual sounds), the treatment results in a system wide transfer of the trained sounds to other sounds and targets.

What happens in the sessions?

Cycles sessions usually take an hour and consist of 7 steps:

  1. Review words from the last session.
  2. Auditory bombardment (1-2 minutes).
  3. Introduction of target words for the session (usually 5-6 words).
  4. Play games requiring the child to practice the target words.
  5. Probe for next session targets.
  6. Repeat auditory bombardment.
  7. Homework – typically 2 minutes of auditory bombardment a day plus, optionally, a list of target words for the week to practice every day.

How long does it take?

As designed, Hodson’s treatment protocol is quite intensive and based on the idea that phonological acquisition happens slowly: 1 hour sessions, 3 times a week.  Each pattern is targetted for 1-2 hours. Each cycle may last for up to 18 hours, depending on the number of error patterns the child’s speech contains.  This means it can take more than 40 hours of treatment for clients with severe speech sound disorders to become intelligible to strangers.  In practice, many researchers and clinicians have adapted Hodson’s approach to deal with research or service-delivery constraints (e.g. parents who are too busy or can’t afford to do three 1 hour sessions a week) (Baker & McLeod, 2011).

Does it work?

At least five studies have looked at the efficacy of cycles-based procedures using experimental designs.  A randomised controlled trial showed that children treated with a modified cycles approach showed significantly greater accuracy in single word and conversational contexts than untreated children (Almost & Rosenbaum, 1998).  However, other studies showed little or no improvement following cycles training (e.g. Tyler & Watson, 1991).  These mixed results are hard to interpret because each of the studies used different outcome measurements, and modified cycles in different ways.

In a very recent study (cited below), researchers found that two out of three pre-school children with moderate-severe speech sound disorders exhibited statistically and clinically significant improvements in speech sound production after 18 hours of treatment using an unmodified version of cycles.  They also found that target sound accuracy two months after therapy finished were stable or had improved for all three children.  These results generally support he efficacy of cycles.  However, they need to be interpreted with caution because of the small sample size (only 3 children), the lack of randomised controls and the fact that probes were administered by the clinician running the trial (which could perhaps have unconsciously biased the results).

One thing we don’t know is whether all components of the treatment are necessary to get good results.  This is an important question for future research – particularly given the significant time and financial costs  associated with implementing cycles in practice.

Principal source: Rudolph, J.M. and Wendt, O. (2014). The efficacy of the cycles approach: A multiple baseline design. Journal of Communication Disorders, 47, 1-16.

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Banter Speech & Language is an independent firm of speech pathologists for adults and children. We help clients in our local area, including Concord, Rhodes, Strathfield and all other suburbs of Sydney’s Inner West.

Banter Speech & Language is owned and managed by David Kinnane, a Hanen- and LSVT LOUD-certified speech-language pathologist with post-graduate training in the Spalding Method for literacy, the Lidcombe and Camperdown Programs for stuttering, and Voicecraft for voice disorders. David is also a Certified PESL Instructor for accent modification.

David holds a Master of Speech Language Pathology from the University of Sydney, where he was a Dean’s Scholar. David is a Practising Member of Speech Pathology Australia and a Certified Practising Speech Pathologist (CPSP).