Speech Sound Disorders

Speech Sound Disorders

Peter Flipsen Jr., Ph.D., CCC-SLPUniversity of Tennessee, Knoxville

http://web.utk.edu/~pflipsen

Outline

1. General Issues Assessment, Target Selection, Intervention,

Measuring Progress 2. Articulation vs. Phonological Disorders 3. Speech Discrimination 4. Childhood Apraxia of Speech 5. Oral-Motor Exercises 6. Dialects - Appalachian English 7. Approaches to Intervention

Articulation, phonological, discrimination, CAS

General Issues - Assessment

The goal of every assessment is to decide if there is a problem or not.

When we say there is a problem, we may be right or we may be wrong. Client may have had a really bad day

and performed poorly. Client may have been “in the zone” and

did better than they usually do.

General Issues - Assessment

Risk of errors in our decisions greatest for borderline cases, but always a concern.

Given our reliance on standardized tests, we need to remember to consider “standard error of measurement” or SEM. Accounts for the fact that all test scores are

really just “samples” of ability and scores may vary from day to day.

Gives us a sense of how much they might vary.

Standard Error of Measurement (SEM)

Allows us to see where the “true ability level” is.

If a child achieves a standard score (SS) of 80 and the SEM is 5, then: There is a 68% probability that his actual score

is really somewhere between 75 and 85. We are 68% confident that his true ability is

within 1 SEM of his score that day. There is a 95% probability that his actual score

is really somewhere between 70 and 90. We are 95% confident that his true ability is

within 2 SEMs of his score that day.

SEM

Not always available but is generally found in most newer test manuals.

E.g., Photo Articulation Test – 3

Age SEM

3 years 4

4 years 5

5 years 4

6 years 4

7 years 5

8 years 5

SEM

GFTA-2 gives us the 90% and 95% “confidence intervals” directly for every score.

Hodson’s new HAPP-3 does NOT provide SEM values or confidence intervals. Note: The HAPP-3 allows you to calculate

“Ability Scores” which look like standard scores, BUT the test manual recommends you use percentile ranks instead.

General Issues – Assessment

What about unusual errors? We know that unusual errors such as

“lateralization” of fricatives are very resistant to intervention especially if left too long. Need to avoid letting them become too

established. We need to find a way to justify working

on these errors much earlier. Any ideas?

General Issues - diagnosis

When we decide what the nature of the problem is, we assign a “category”. Differential diagnosis. Ultimately each category should mean

a different approach to treatment. We need to know how distinct each

category is from other related categories.

General Issues - treatment

Change happens – we see it every day. Many possible reasons:

Our intervention resulted in the change. Child “figured out” what they need to do on

their own (i.e., normal development). Adult relearned a skill as physiological

recovery progressed (i.e., spontaneous recovery).

Some outside influence led to the change (e.g., parent or spouse working with them).


How do we know what caused the change?

If we do something and change follows, did we cause the change? Even if the change is almost immediate, we

still CANNOT be sure! Something else may have been responsible for

the change. Still a long way to go here. See June 13/06 issue of ASHA Leader.


Recommended reading: Reilly, S., Douglas, J., & Oates, J. (2004).

Evidence Based Practice in Speech Pathology. Philadelphia, PA: Whurr Publishers.

General Issues - Measuring Progress

When we “monitor progress” we are really re-assessing skills to see if the client has learned what we’ve been teaching.

Re-administer a standardized test? May be necessary to make decisions

about whether a client is still “eligible for services”.

Need to consider SEM. Doing this doesn’t really tell us if

progress has happened.

Standardized Tests and “Measuring Progress” – Why Not?

1. These tests are intended for a wide range of ages. Designed for efficient administration and thus

don’t sample very many behaviors at any one particular age.

Only sample each ability level superficially. For speech sounds, they don’t test enough

examples of those sounds. Child may have over-learned those particular

words. Child may have a “fossilized form” for those

particular words.

Standardized Tests and “Measuring Progress” – Why Not?

2. Regression to the Mean. Scores at the very low end or the very high

end are not very common (relative to the entire population).

By sheer probability, when you retest, low scores are more likely to go up and high scores are more likely to go down.

Remember that statistically speaking, really tall parents tend to have shorter children than themselves and really short parents tend to have taller children than themselves.

More on Regression to the Mean

Every test score is a “sample” of ability and includes measurement error. That’s why we consider SEM in assessments.

With a very low score, it means that many “sources” of measurement error were working against the child that day. When we retest, it is much less likely that

those “sources” will again be working against the child.

Scores are likely to improve just by chance.

Alternatives for measuring progress

1. Conversational speech samples – for speech sound disorders the ultimate goal is performance in spontaneous speech. A. For younger children (many errors) -

have an unfamiliar listener transcribe (using regular spelling) and calculate % understood.

Track % understood over time. Expectations for % understood =

Age in years / 4.


May also do phonetic transcription. Calculate Percentage of Consonants

Correct (PCC) and Percentage of Vowels Correct (PVC).

Compare to reference data from Austin & Shriberg (1997). See handout

Alternatives to measuring progress

Use Means (and standard deviations) to calculate z-scores. Z-score = how many standard

deviations from the mean a raw score is.

z-score = (score –mean) / std. dev.


B. For older children (fewer errors) Have an unfamiliar clinician transcribe

phonetically and calculate % correct. Probably only need to focus on the

particular target sounds. Clinicians can act as transcribers for

each other.


2. Systematic Probes – for each target sound, set aside some (e.g., 10) words containing the target sound that you don’t use for practice in therapy. Bring these out every few weeks or so

and ask the child to produce them. Track % correct over time.

Articulation vs. Phonological Disorders

Now ASHA’s preferred term = Speech Sound Disorders.

Includes both “articulation disorders” and “phonological disorders”.

BUT is it reasonable to lump these two categories together? Are they just two different names for the same

thing? Even if they are different, do we treat them

differently?

Articulation Disorders

Group exercise. Answer the following:

What do we mean by an articulation disorder?

What specific behaviors do we observe?

Phonological Disorders


What do we mean by a phonological disorder?

What specific behaviors do we observe?

Speech Sound Disorders

Articulation vs. Phonological Disorders

Are they the same thing? If not, should we be doing

something different for each of them?

Articulation Disorders

Problems with the physical aspects of producing speech sounds.

Not stimulable (or very poorly so). Don’t ever produce the sound correctly. Don’t produce the sound accidentally in

place of some other sound. Sometimes called phonetic disorders.


Phonology = sub-domain of language.

The sound system. How the phonemes and allophones

are organized within a language. Phonological disorder = a type of

language disorder.


Not a “production” problem. Child appears capable of producing the target but isn’t using it correctly. Errors are stimulable, especially to the

word level or beyond, Target may also be produced

accidentally in place of something else. Sometimes called phonemic

disorders.

Natural Phonological Processes

What does it really mean when we say that a child exhibited final consonant deletion? Or velar fronting? Or cluster reduction?

By themselves, do these labels really tell us what’s going on inside a child’s head?

Which Process?

If a child leaves off the /s/ in words like “hats” and “ducks”, what process is operating? Final consonant deletion? Stridency deletion? Consonant sequence reduction (cluster

reduction)? Or is this just a failure to learn the

plural morpheme?

Natural Processes vs. Linguistic Processes

The natural process labels that SLPs use are not the same as the phonological processes that linguists talk about.

Serious potential for confusion.

Processes vs. Processing

With the emergence of discussions of “phonological awareness”, we‘ve begun to look at psycholinguistic models of how the brain manages information (processing). Are we talking about the same thing?

Processes vs. Processing

Just because we see errors that we can label as fronting, stopping, etc., this says ABSOLUTELY NOTHING about: phonological awareness skills short term memory skills, or how the brain “processes” linguistic

information. Whether the problem is phonological or

articulatory.

Processes vs. Patterns

There is no doubt that for many children their errors seem to follow patterns.

Capturing a child’s “pattern of errors” using labels such as stopping, fronting, etc. can be very useful clinically.

But even Barbara Hodson has suggested we call them “patterns” rather than “processes”.

What about speech discrimination?

If we assume normal hearing acuity (i.e., no hearing loss): Is it possible to have difficulty

producing speech sounds because of difficulty with speech discrimination?

Even if such a problem exists, is it possible to test it?

What about speech discrimination?

If the problem were one of “general inability to discriminate speech”, then no speech would be possible.

We do occasionally see children who have problems with discriminating speech specific to sounds they are not producing correctly. Not at all clear how common this is. Probably relatively uncommon, but we can’t

ignore the possibility.

Speech Discrimination

Two possible problems: 1. Problems discriminating sounds

as produced by others (external discrimination).

2. Problems discriminating sounds when produced by self (internal discrimination). One example of this is the “Fis”

phenomenon.

Can we test speech discrimination?

We can test external discrimination easily but ultimately we cannot ever really test internal discrimination. We all hear our own speech differently

than others do because of bone conduction.

Can’t get inside someone else’s head.

Testing Speech Discrimination

Common approach = minimal pairs test. Present two words side by side (one contains

the target, one contains the error). Only requires comparison within working

memory. Doesn’t require the child to compare what they

hear against their own internal representation. Often present only one example – could

guess.


Need a way to allow for comparison against internal representation and to prevent guessing.

Locke’s (1980) “Speech Production-Perception Task” (SP-PT) does both of these things. Still based on production by someone

else but probably as close as we’ll get.

SP-PT

Create a unique test for each of the child’s errors.

Compare child’s usual error to the target.

Include a similar sound that child can discriminate (ensures task is understood).

Present multiple examples to account for possible guessing.

SP-PT

Key = examiner presents one example at a time of a possible version of the target.

Child must compare what they hear with their internal representation and then decide: Was it correct or not correct?

Record child’s responses.

Target / / Error / / Control / /

Stimulus - Class Response

1. / / - Control yes - NO2. / / - Error yes - NO3. / / - Target YES - no4. / / - Target YES - no5. / / - Error yes - NO6. / / - Control yes - NO7. / / - Control yes - NO8. / / - Target YES - no9. / / - Error yes - NO10. / / - Target YES - no11. / / - Error yes - NO12. / / - Control yes - NO13. / / - Error yes - NO14. / / - Target YES - no15. / / - Control yes - NO16. / / - Error yes - NO17. / / - Target YES - no18. / / - Control yes - NO

Correct response shown in uppercase letters. Misperception = 3+ mistakes on Error.

Mistakes: Error ____ Control ____ Target____

Target / ‘ / Error / f / Control / s /

Stimulus - Class Response

1. / s / - Control yes - NO2. / f / - Error yes - NO3. / ‘ / - Target YES - no4. / ‘ / - Target YES - no5. / f / - Error yes - NO6. / s / - Control yes - NO7. / s / - Control yes - NO8. / ‘ / - Target YES - no9. / f / - Error yes - NO10. / ‘ / - Target YES - no11. / f / - Error yes - NO12. / s / - Control yes - NO13. / f / - Error yes - NO14. / ‘ / - Target YES - no15. / s / - Control yes - NO16. / f / - Error yes - NO17. / ‘ / - Target YES - no18. / s / - Control yes - NO

Correct response shown in uppercase letters. Misperception = 3+ mistakes on Error.

Mistakes: Error ____ Control ____ Target____


Another option is the SAILS software program. http://www.avaaz.com Computer program that is intended to

teach discrimination. Includes an assessment tool.

All or None?

For any given child, will all of their errors fall neatly into “articulation”, “phonological” or “perceptual” categories? Maybe but not necessarily.

Need to evaluate each error sound. Treat each sound based on the

type of error that it is.

Childhood Apraxia of Speech (CAS)

Now ASHA’s preferred term for “Developmental Apraxia of Speech”.


1. What are the core characteristics of CAS? [i.e., what behaviors set it apart from other speech sound problems?]

Childhood Apraxia of Speech (CAS)

See handout “ASHA’s draft position statement”. Based a thorough review of the

available evidence. Still being discussed and fine tuned

(i.e., not yet the final word but close).

CAS

“… (CAS) exists as a distinct diagnostic subtype of childhood (pediatric) speech sound disorder that warrants research and clinical services.” Note: even with this, there may still

remain some who claim it doesn’t exist.

CAS

“… (CAS) is a subtype of severe childhood speech sound disorder due to unidentified neurological differences likely of genetic origin. The core deficits arise at linguistic or early speech motor processing levels. Symptomatology, which changes with age, may include age-inappropriate vowel/diphthong errors, unusual and variable errors in repeated attempts at words, increased number and severity of errors with increasing word and utterance length, and prosodic disturbances. CAS places a child at risk for persisting problems in speech, language, and literacy.” ASHA Ad Hoc Committee on Childhood Apraxia of

Speech, 2006

CAS

“… subtype of severe speech sound disorder…” Involves speech

Remember that “oral apraxia”, “verbal apraxia” and “limb apraxia” are independent conditions but may co-occur.

Feeding and drooling problems may co-exist BUT ARE NOT PART OF THE DISORDER.

Manifests as a very severe form Helps us understand slow progress in therapy,

BUT SLOW PROGRESS IS NOT SUFFICIENT TO

JUSTIFY THE DIAGNOSIS.

CAS

“ … due to unidentified neurological differences.”

Unidentified – accounts for the fact that imaging studies often show nothing. Personal comment: many of these kids have a

history of some “event”. Neurological – some deficit or difference

in functioning of control over speech output.

CAS

“… likely of genetic origin.” Tends to run in families

Early genetic typing studies have suggested some possible genetic loci.

Takes the burden off parents (they did nothing wrong!).

CAS

“The core deficits arise at linguistic or early speech motor processing levels.” MY INFERENCE: As a motor speech

disorder, the problem includes sequencing of speech sounds (i.e., organizing the motor program).

Sequencing may yet be added to the definition.

May see problems with prosody and sequencing of syntactic units.

CAS

“Symptomatology, which changes with age, may include age-inappropriate vowel/diphthong errors …”

What these children present with does depend on their age. See vowel errors at younger ages (persist well

past age 5 in many cases). One of the few disorders where vowels are

an issue. Problems with consonant sequences and multi-

syllabic words seen early but persist longer.

CAS

“… unusual and variable errors in repeated attempts at words, increased number and severity of errors with increasing word and utterance length,...” Often several widely differing

productions of the same word within a session.

Greater programming demands of longer units are often a problem.

CAS

“… and prosodic disturbances.” Often see atypical stress patterns.

Tendency by some to equally stress syllables that normally get different stress levels.

May see intermittent nasality. May see intermittent monotone

quality mixed in with normal pitch patterns.

CAS

“ … places a child at risk for persisting problems in speech, language, and literacy.” Often see co-existing language impairments. Phonological awareness can be a problem for

these children which increases risk of reading problems.

Often very aware of their problem – panel called this “a special form of metalinguistic awareness”.

CAS – how common?

Solid prevalence estimates not available.

Evidence suggests it is probably much less common than currently assumed.

Likely 3-4 cases per 1000 children. Knox County?

CAS - Assessment

For children under 5 years: Look for vowel errors. Look at sequencing of simple syllables.

Performance breaks down with change in place of articulation.

Personal comment: formal DDKs probably unnecessary. Sequencing will likely break down at normal rate.

Do DDK tasks but use normal rate and don’t worry about the stopwatch.

Try presenting word lists multiple times and watch for variability.

CAS - Assessment

For children over 5 years: May still see vowel errors. Diphthong

errors still likely. Look at the nature of the consonant

errors. Often see multiple feature changes (e.g.,

both place and manner change). Ask for productions in progressively

longer units.

Oral-motor exercises


What does this term mean to you? What sorts of things do you do clinically

that you would fit into this category? Why do you use them?

Non-Speech Oral Motor Exercises

These are normally justified four ways:

1. May help speech by breaking it down into smaller steps NO. We don't learn motor activities

that way. We learn motor movements by practicing the entire movement.


2. These may help increase strength of the speech organs. NO. Two problems: a. Not necessary. Speech normally only

requires less than 20% of our strength capacity.

b. Strengthening requires many repetitions against resistance. Exercises being advocated don't involve resistance and never involve enough repetitions to be useful.


3. These may improve the connections between the nerves and muscles. NO. Research has shown that the only way to improve how the nervous system interacts with the muscles is to practice RELEVANT behaviors. Need to practice speech to improve connections for speech.


4. But doesn't speech develop from earlier non-speech behaviors? NO. Despite what would seem obvious, research has shown that the brain organizes the movements for speech in very different ways than for non-speech movements. There are common structures, but that's all.

Non-speechOral Motor Exercises

In addition to the above, clinicians say they do these “because they work”.

The question is “Do they?” As mentioned previously, change

happens and clinicians are very good observers of change.

But did the exercises result in the change.

Non-SpeechOral Motor Exercises

Several studies have attempted to prove that they work.

All failed to do so. Handout of recent study.

The only study that “appeared” to show an effect was badly flawed and thus, really didn’t show anything.

Non-SpeechOral-motor exercises

Should we use these, and if so, when?

Ask yourself, “what is my goal?” They may have some value:

1. To remediate documented chewing, feeding and swallowing problems.

2. As VERY BRIEF (i.e., no more than 2-3 minutes) initiating activities to heighten awareness of the articulators.

Dialects – Appalachian English

AppE is the non-standard dialect associated with the rural, working class population of the central and southern Appalachian mountains.

Primarily descendants of immigrants from Scotland (by way of Ireland) who arrived in the mid-late 1700s and early 1800s.

Mountainous region; very inaccessible until the 1940s.

The creation of both the Tennessee Valley Authority (1933) and the Great Smokey Mountains National Park (1934) greatly improved access.

AppE as a Dialect

Some debate about whether AppE is a single dialect or many dialects. “mountain talk” or /d8f5nt tek 8n 2vri hel5/

General consensus is that it can be called a single dialect with many local variations.

AppE as a Dialect

“Characterized by distinctive sounds, syntax, and originality, Appalachian speech has long served as an emblem of the region’s natives … Appalachians have been romanticized as surviving speakers of Elizabethan English yet simultaneously ridiculed as backward users of a lower-class, substandard dialect reflecting the region’s isolation and poverty.” Michael Montgomery, 2006, p. 999,

Encyclopedia of Appalachia.

AppE Phonology

As a dialect of American English, AppE includes a series of variations from General American English (GAE).

Includes variations in both consonants and vowels.

See handout for details. Unfortunately we know almost

nothing about how this dialect is acquired.

Acquisition of AppE Phonology

Two known studies. Davis (1998) – unpublished MA thesis.

recorded conversational speech from 42 children age 5-7 years from Knox county.

Reported that the % of children using any of nine AppE features tended to decline with age.

BUT 5/9 features were still being used by half of the 7 year-olds.

Suggests that as the children gained more school experience, they were becoming more proficient at code-switching into GAE.

Acquisition of AppE Phonology

Flipsen & Parker (2005) – unpublished paper still in process. Some preliminary results. recorded conversational speech and PAT-3

from 8 children age 3;1-5;11 from Wise, VA. Language analysis suggested they were “mild”

dialect users (low density of AppE morpho-syntax features).

Calculated PCC and PVC from conversations and converted to z-scores using reference data for GAE from Austin & Shriberg (1997).

Flipsen & Parker (2005)

ID Gender Age PAT-3 ss z-PCC z-PVC

1 Male 5;11 87 -2.17 -5.73

2 Female 5;3 111 1.33 -2.73

3 Female 4;4 114 0.42 -3.42

4 Male 3;4 114 1.34 -4.25

5 Female 3;1 103 0.21 -1.85

6 Male 3;4 110 0.14 -4.85

7 Female 4;10 102 1.6 -1.78

8 Male 4;0 94 -0.78 -6.80

Flipsen & Parker (2005)

All PAT-3 standard scores were within the normal range.

All vowel scores (z-PVC) were outside the normal range relative to GAE.

7/8 consonant scores (z-PCC) were within the normal range relative to GAE.

For one child, his consonant scores in conversation would identify him as disordered. BUT his PAT-3 score said he was normal. Produced many non-AppE errors (lateralized a

lot of fricatives and affricates).

Clinical Issues and AppE

Long history of mislabeling speakers of non-standard dialects as having speech/language impairments.

Clinicians in the Appalachian region regularly ask about how to differentiate use of this dialect from disorder. Many AppE variations resemble errors

in GAE.

Clinical Issues and AppE

Too little data available yet to really say how to make clinical decisions.

Available samples too small and may not be the most representative. Hopefully more to come.

Does appear that conventional articulation tests may not be enough to catch problems (regardless of dialect).

Intervention – Articulation Disorders

Not much new here. Conventional articulation therapy is

generally the way to go here. Modeling, phonetic placement,

sound shaping, etc.

Intervention – Discrimination

For those occasions where a child is unable to hear the difference between the sound they are supposed to use and the one they actually use, We need to teach them to do so.

Intervention – Discrimination

Several options: 1. Traditional ear training – ala Van

Riper. Very involved. Not very practical in most

circumstances. 2. SAILS software program. 3. Include Hodson’s auditory

bombardment as part of other treatment.

Auditory Bombardment

Hodson suggests we do this with every child that has a speech sound problem.

Not clear how helpful this is overall but easily warranted for children with specific discrimination problems.

Present word lists using SLIGHT MECHANICAL AMPLIFICATION. Talking louder only distorts the signal!!! See the following link for word lists: http://web.utk.edu/~pflipsen/Clinical_Re

sources.html

Intervention – Phonological

Child essentially is able to produce the sound but fails to do so appropriately.

A number of different approaches possible.

All based on the idea that the child needs to learn the “function” of the sound. When and where to use it to create

meaning.

Intervention - Phonological

Three underlying principles: 1. Phonological contrasts – focus on

function; teach how different sounds result in different meaning. Must use real words.

2. Focus on groups of sounds - treating patterns rather than individual sounds.

3. Naturalistic context – usually work with real words in meaningful contexts

Phonological Intervention – Basic Plan

1. Select target words. 2. Discuss target words to clarify

meaning. 3. Confirm discrimination between words. 4. Production practice – often use role

reversal; child attempts words and SLP picks up pictures (may need phonetic training here if incorrect).

5. Practice in units above word level.

Phonological Intervention - Selecting / Organizing Targets

Several options available a. Distinctive features approach b. Minimal opposition approach. c. Maximal opposition approach. d. Multiple opposition approach e. Natural patterns (processes)

approach.

Not all contrasts are equal

Consider the following contrast pairs: pin – bin; pin – sin; pin – gin.

All differ by one phoneme so we can call them all “minimal pairs”.

But the pairs are different in terms of numbers of features not shared: pin – bin (1; voicing). pin – sin (2; place, manner). pin – gin (3; place, manner & voicing).

a. Distinctive Features Approach

Based on the assumption that the child has failed to learn a particular feature.

Really teaching features, not phonemes. Usually focus on one feature at a time.

Select two sounds – one that includes the feature and one that does not.

As much as possible the two sounds should differ by as few features as possible (preferably only one).

a. Distinctive Features Approach

Video Illustrates basic plan for all

approaches.

b. Minimal Opposition Approach

Ultimate Targets = missing phonemes.

Contrast the target phoneme with another that child can produce. Contrasting sound should differ from

the target as little as possible. Ideal = only differs on one feature.

c. Maximal Opposition Approach

Based on the idea that error sounds should be contrasted with VERY different sounds. Contrasting sound differs from the target by as

many features as possible. Makes the error sound stand out more. E.g., /s/ vs. /b/ or /k/ vs. /l/

Several studies have suggested that generalization may be faster with this approach.

c. Maximal Oppositions Approach

Two versions of this now proposed: 1. error sound contrasted with a sound

child already has mastered. 2. contrast between two different error

sounds (i.e., neither currently correct). Sometimes referred to as the “empty-set”

approach.

d. Multiple Oppositions Approach

Most useful when one phoneme is being used for more than one other. E.g., child who uses /t/ for /k,s,c,./. Called a collapse (several phonemes collapsed

into one). Basic idea is to create a set of contrasting

words and focus on all of them at once. E.g., targets for above = two, Sue, shoe, chew E.g., ate, ache, ace, H (letter) (note – may not be able to find words for all

the targets every time; be sure to include error sound).

d. Multiple Oppositions

Idea is to create maximum "cognitive" stress on the sound system and force a complete reorganization.

Does impose great "semantic" demands on the child. Lots of different meanings to keep track

of. May not be appropriate for children with

poor cognitive skills.

e. Natural Patterns Approach

Create contrasts based on the patterns observed. Patterns can be derived from Khan-

lewis (after GFTA) or Hodson’s test or analysis of spontaneous speech.

Contrast child’s usual productions with the targets.

Intervention - CAS

Recall – it’s a motor speech disorder with sequencing the big issue.

Need to train to get consistency so lots of drill and practice needed.

Need to train flexibility – teaching them to organize programs, not memorize particular movements.

Intervention - CAS

These children often have a limited number of sounds they can produce correctly.

Often have a limited number of syllable shapes they can handle.

Need to improve both.

Intervention - CAS

How do we: Increase phonetic inventory Increase syllable shape inventory Improve consistency Maximize flexibility

all at the same time? AND not create demands that are

too hard to manage?

Intervention - CAS

Three basic principles: 1. Train new phonemes using syllable

shapes they can already handle. 2. Train new syllable shapes using

phonemes they have already mastered. 3. Cycle through a small number of

examples randomly to maintain flexibility.

General Q & A

Speech Sound Disorders

Documents

ability scores

general issues assessmentwhat

general issues diagnosiswhen

general issues treatmenthow

test scores

standard scores

actual score

standard score ss