Treating children with expressive phonological disorders: does phonological awareness therapy work in the clinic?

Phonological awareness training and phonological therapy approaches for specific language impairment children with speech sound disorders: a comparative outcome study

PURPOSE

Children with specific language impairment (SLI) might present with speech sound disorder (SSD) and phonological awareness (PA) deficits which put them at risk of potential reading problems. This work aimed to organize an intervention program in Arabic for phonological training and to assess the effect of PA training versus the phonological therapy (PT) for children with SLI and SSD.

METHODS

The study was carried out on 60 children with comorbid SLI and SSD, aged 5-7 years. Children were equally divided into two groups; each group received language therapy combined with (PT or PA training). Measures of language development, phonological output, and PA were taken before therapy and at 4 month post-therapy for all children.

RESULTS

The two therapy groups made nearly the same amount of progress in the development of language and phonological production, with no significant differences regarding language age and percent of consonants correct (PCC). The PA training group progressed more on the PA skills than children who received PT over the same time.

CONCLUSIONS

PA training could facilitate the development of phonological skills by targeting the child's awareness of phonemes and improving the production of sound patterns.

Effect of language therapy alone for developmental language disorder in children: A meta-analysis

Despite numerous studies on the treatment of developmental language disorder (DLD), the intervention effect has long been debated. Systematic reviews of the effect of language therapy alone are rare. This evidence-based study investigated the effect of language therapy alone for different expressive and receptive language levels in children with DLD. Publications in databases including PubMed, the Cochrane Library, the Wanfang Database and the China National Knowledge Infrastructure were searched. Randomized controlled trials were selected. The methodological quality of the included trials was assessed using the modified Jadad method. RevMan 5.3 software was used for the data analysis. Fifteen trials were included in this study. Compared with the control (no or delayed intervention) group, the intervention group showed significant differences in overall expressive language development [standard mean differences (SMD), 0.46; 95% confidence interval (CI), 0.12–0.80], mean length of utterances in a language sample (SMD, 2.16; 95% CI, 0.39–3.93), number of utterances in a language sample (SMD, 0.52; 95% CI, 0.21–0.84), parent reports of expressive phrase complexity (SMD, 1.24; 95% CI, 0.78–1.70), overall expressive vocabulary development (SMD, 0.43; 95% CI, 0.17–0.69) and different words used in a language sample (SMD, 0.62; 95% CI, 0.35–0.88). However, language therapy did not show satisfactory long-term effects on DLD. Although language therapy is helpful in improving the performance of children with DLD, its long-term effect is unsatisfactory.

Implementing Speech Perception and Phonological Awareness Intervention for Children With Speech Sound Disorders

PURPOSE

Children with speech sound disorders have more difficulties producing speech sounds accurately than same-age peers. In addition, they often have difficulties with speech perception, and weaker phonological awareness skills than their peers and are at risk for negative long-term academic and socio-emotional outcomes. In this tutorial, we describe ways in which clinicians can target speech perception and/or phonological awareness within the context of speech production practice.

METHOD

First, we briefly describe the speech perception and phonological awareness skills of children with speech sound disorders and summarize previous intervention studies that targeted speech production and speech perception and/or phonological awareness skills. Next, we demonstrate how clinicians may incorporate speech perception and phonological awareness intervention in speech therapy through example instructional objectives and activities and include a case study.

CONCLUSION

Incorporating speech perception and phonological awareness into speech production intervention may improve speech and literacy outcomes for children with speech sound disorders.

A Comprehensive Treatment Approach to Address Speech Production and Literacy Skills in School-Age Children with Speech Sound Disorders

Children with speech sound disorders (SSDs) represent a large proportion of clients served by school-based speech-language pathologists (SLPs). While considerable evidence is available regarding the identification of SSD in school-age children, there is a paucity of information regarding service delivery aspects of school-based speech therapy, such as frequency of sessions, number of trials, distribution of sessions over time, and format (individual or group intervention) that impacts the ability of SLPs to effectively treat SSD in the schools. School-age children with SSD are at risk for later literacy deficits, and strategically addressing their language and emerging literacy needs in addition to speech production accuracy may lead to increased intelligibility and better educational outcomes. In this article, we discuss the heterogeneity of school-age children with SSD with regard to weaknesses in phonological processing skills and language skills. We summarize the information currently available regarding the aspects of service delivery that contribute to gains in speech production accuracy. We conclude by sharing an example of how school-based SLPs could target speech production, phonological awareness, and morphological awareness in the same session with a child with SSD to maximize gains in speech and literacy skills.

Intervention for children with phonological impairment: Knowledge, practices and intervention intensity in the UK

BACKGROUND

Across the world, research has shown that intervention for children with phonological impairment can be both effective and efficient. However, it has also raised concerns about the translation of this evidence to practice, highlighting questions around clinician knowledge and the understanding of approaches, and the intensity of intervention provided within real-life clinical contexts.

AIMS

To investigate the clinical management of phonological impairment by speech and language therapists (SLTs) in the United Kingdom (UK).

METHODS & PROCEDURES

An anonymous, UK-wide, online survey was developed using Qualtrics. The target audience were UK-based SLTs who worked with children with phonological impairment. The following topics were explored: (1) SLTs' understanding of intervention approaches; (2) SLTs' use of intervention approaches to treat phonological impairment; and (3) SLTs' provision of intervention intensity for children with phonological impairment.

OUTCOMES & RESULTS

A total of 166 responses were analyzed. To remediate phonological impairment, SLTs most commonly used speech discrimination (79.5%), conventional minimal pairs (77.3%), phonological awareness therapy (75.6%) and traditional articulation therapy (48.4%). Participants least frequently used the complexity approaches targeting the empty set (82.9%) and two- to three-element clusters (75%) as well as the cycles approach (75.6%). Results also showed that some SLTs were uncertain of what the empty set and two- to three-element clusters approaches entailed. In terms of intervention intensity, participants predominantly provided intervention once per week (69%) for a total of 9-12 sessions (ranging from five to 30 sessions, 71.5%) and elicited targets 10-30 times in single words per session (59.4%) in sessions lasting 21-30 min (41.4%).

CONCLUSIONS & IMPLICATIONS

The most commonly used intervention approaches identified in the current survey (i.e., speech discrimination, conventional minimal pairs and phonological awareness therapy) may be used eclectically by SLTs, which could impact upon the effectiveness and efficiency of treatment for phonological impairment. The current study also highlighted that almost half the participants always/often used traditional articulation therapy to remediate phonological impairment, even though this approach has been found to be less effective for this difficulty. Additionally, it appears that the currently provided intervention intensity for phonological impairment in the UK is significantly lower than what is indicated in the literature. Therefore, a research-practice gap exists for SLTs in the UK working with children with phonological impairment.

Evidence for the treatment of co-occurring stuttering and speech sound disorder: A clinical case series

PURPOSE

There is a paucity of evidence to guide treatment for children with co-occurring stuttering and speech sound disorder. Some guidelines suggest treating the two disorders simultaneously using indirect treatment approaches; however, the research supporting these recommendations is over 20 years old. In this clinical case series, we investigate whether these co-occurring disorders could be treated concurrently using direct treatment approaches supported by up-to-date, high-level evidence, and whether this could be done in an efficacious, safe and efficient manner.

METHOD

Five pre-school-aged participants received individual concurrent, direct intervention for both stuttering and speech sound disorder. All participants used the Lidcombe Program, as manualised. Direct treatment for speech sound disorder was individualised based on analysis of each child's sound system.

RESULT

At 12 months post commencement of treatment, all except one participant had completed the Lidcombe Program, and were less than 1.0% syllables stuttered on samples gathered within and beyond the clinic. These four participants completed Stage 1 of the Lidcombe Program in between 14 and 22 clinic visits, consistent with current benchmark data for this programme. At the same assessment point, all five participants exhibited significant increases in percentage of consonants correct and were in alignment with age-expected estimates of this measure. Further, they were treated in an average number of clinic visits that compares favourably with other research on treatment for speech sound disorder.

CONCLUSION

These preliminary results indicate that young children with co-occurring stuttering and speech sound disorder may be treated concurrently using direct treatment approaches. This method of service delivery may have implications for cost and time efficiency and may also address the crucial need for early intervention in both disorders. These positive findings highlight the need for further research in the area and contribute to the limited evidence base.

Treating Children Ages 3–6 Who Have Speech Sound Disorder: A Survey

Purpose

In a national survey, speech-language pathologists (SLPs) were asked about service delivery and interventions they use with children ages 3–6 who have speech sound disorder (SSD).

Method

The survey was e-mailed to 2,084 SLPs who worked in pre-elementary settings across the United States. Of these, 24% completed part or all of the survey, with 18% completing the entire survey.

Results

SLPs reported that they provided children ages 3–6 who had SSD with 30 or 60 min of treatment time weekly, regardless of group or individual setting. More SLPs indicated that they used traditional intervention than other types of intervention. However, many SLPs also reported using aspects of phonological interventions and providing phonological awareness training. Fewer SLPs indicated that they used nonspeech oral motor exercises than in a previous survey (Lof & Watson, 2008). Recently graduated SLPs were no more familiar with recent advances in phonological intervention than were their more experienced colleagues.

Discussion

This study confirms previous findings (Mullen & Schooling, 2010) about the amount of service provided to children ages 3–6 who have SSD. Issues related to the use of traditional and phonological intervention with children who have phonological disorder are discussed, along with concerns related to evidence-based practice and research needs.

Optimal intervention intensity in speech-language pathology: discoveries, challenges, and unchartered territories

This article is the final response in a scientific forum on the optimal intensity of intervention in speech-language pathology. It is a reflection on the state of knowledge offered by the 13 commentaries in this issue, addressing the areas of early communication and language impairment, speech sound disorders in children, emergent literacy, reading, aphasia, dysphagia, stuttering, motor speech disorders, voice disorders, and traumatic brain injury. Although more intense intervention can lead to better outcomes, the relationship between intensity and outcome is not always linear. More is not always better. Non-intense and intense schedules can yield similar outcomes. Intensity can also reach a point of diminishing return. The insights offered by the authors illustrate the challenges involved in studying this complex issue. To establish the optimal intensity of interventions in speech-language pathology our field needs to: identify active ingredients of interventions; better understand how principles of motor learning and neural plasticity facilitate learning; appreciate the contribution of individuals characteristics, values, and preferences; discover the effect of specific combinations of intensity (including dose, dose form, dose frequency, session duration, and total intervention duration) on treatment outcomes, and find practical solutions when disparities exist between research recommendations and workplace limitations.

Characterizing optimal intervention intensity: the relationship between dosage and effect size in interventions for children with developmental speech and language difficulties

Although Warren, Fey and Yoder (2007) have described the key components of "dosage", one needs to go beyond description if one is to understand "optimal" dosage, specifically one needs to relate the characteristics of the intervention to the size of the intervention effect. This study examines the association between dose, intensity, and effect size in 20 randomized controlled studies taken from a few systematic reviews focusing on interventions aiming to ameliorate vocabulary, phonology, and syntax. Reporting of dosage characteristics is an important issue. Our analysis shows that "teaching episodes" and "dose form" are rarely reported in the included studies. The other dosage characteristics are present but not always reported in a transparent fashion. Session length and cumulative intervention intensity is lower for phonology interventions than it is for vocabulary intervention. Dosage, however defined, is not directly associated with outcome, although the level of association varies across the three interventions, for example appearing stronger for vocabulary and phonology than syntax. Taking the three interventions together the dosage components are related to the intervention effects size, but the sample is small and the association is not statistically significant. This study concludes that, while the framework suggested by Baker (2012) and adapted from Warren et al. (2007) is useful but without reference to the effect size of a study, it can only ever tell half the story. One needs to be able to relate dosage to outcome, asking questions about the relationship between the different dosage characteristics and the intervention effect size. Given the available data, it is not, at this stage, possible to make recommendations about optimal dosage.

Costing children's speech, language and communication interventions

BACKGROUND

There are few economic evaluations of speech and language interventions. Such work requires underpinning by an accurate estimate of the costs of the intervention. This study seeks to address some of the complexities of this task by applying existing approaches of cost estimation to interventions described in published effectiveness studies.

AIMS

The study has two aims: to identify a method of estimating unit costs based on the principle of long-run marginal opportunity costs; and to illustrate the challenges in estimating unit costs for speech and language interventions.

METHOD & PROCEDURES

Descriptions of interventions were extracted from eight papers and combined with information on the unit cost of speech and language therapists to identify information requirements for a full-cost estimation of an intervention.

OUTCOMES & RESULTS

Four challenges were found relating to the level of detail about the therapists, the participants, the scope of activities and parents. Different assumptions made about any of these elements will have a marked effect on the cost of the intervention.

CONCLUSIONS & IMPLICATIONS

Nationally applicable unit cost data for speech and language therapists can be used as a reference point, but sufficient descriptive data about delivery and receipt of the intervention are key to accuracy.

Phonemic discrimination and its relation to phonological disorder

It was performed a nonsystematic review on the importance of the phonemic discrimination to the phonological acquisition and its relation to the phonological disorder. Studies indicate that phonemic discrimination represents an essential ability in the process of acquiring sounds of speech and that children with phonological disorder present difficulties in that ability.

Desempenho de adultos não-letrados em avaliação das habilidades em consciência fonológica

OBJETIVO: verificar o desempenho das habilidades em consciência fonológica em adultos não-letrados e compará-lo com o de adultos letrados. MÉTODO: 31 adultos, ambos os sexos, divididos em não-letrados e letrados, submetidos à Prova de Consciência Fonológica. RESULTDOS: o desempenho dos adultos não-letrados foi insatisfatório e inferior ao dos letrados; os dois grupos apresentaram desempenho inferior em tarefas fonêmicas; em apenas dois subtestes não foi encontrada diferença estatisticamente significante entre os grupos. CONCLUSÃO: o desempenho inferior dos adultos não-letrados, especialmente nas tarefas fonêmicas, pode decorrer do fator escolaridade, pois não dominam o código alfabético.

Evidence-Based Practice for Children With Speech Sound Disorders: Part 1 Narrative Review

Purpose

This article provides a comprehensive narrative review of intervention studies for children with speech sound disorders (SSD). Its companion paper (Baker & McLeod, 2011) provides a tutorial and clinical example of how speech-language pathologists (SLPs) can engage in evidence-based practice (EBP) for this clinical population.

Method

Studies reporting speech sound intervention for children with SSDs published from 1979 to 2009 were identified and coded.

Results

One hundred thirty-four intervention studies were identified. Intervention typically was conducted by an SLP in a one-to-one individual format for 30- to 60-min sessions 2 to 3 times per week. Total duration of intervention (from assessment to discharge) was reported for 10 studies and ranged from 3 to 46 months. Most studies were either Level IIb (quasi-experimental studies, 41.5%) or Level III (nonexperimental case studies, 32.6%). Single-case experimental design (29.6%) was the most frequently used experimental research design. There were 7 distinct approaches to target selection and 46 distinct intervention approaches, with 23 described in more than 1 publication. Each approach was associated with varying quantities and levels of evidence, according to research design.

Conclusion

Collaborative research reflecting higher levels of evidence using rigorous experimental designs is needed to compare the relative benefits of different intervention approaches.

Population-based screening of children for specific speech and language impairment in Germany: a systematic review

OBJECTIVE

The study was aimed at evaluating the effectiveness of a systematic population-based screening programme for specific language impairment (SLI) in preschool children in Germany.

METHODS

The study question was divided into a review of (1) evidence from studies evaluating screening programmes, (2) diagnostic instruments in the German language, and (3) studies evaluating speech and language interventions. A systematic database search was conducted between June and October 2007 and was updated in January and again in May 2008. Relevant studies were identified by 2 independent reviewers based on screened titles/abstracts and full texts.

RESULTS

4,806 studies were screened. The only existing controlled screening study did not provide data for SLI. No diagnostic study met the inclusion criteria. Sixteen randomized intervention studies were included, 3 studies contributed to the appraisal of earlier against later initiation of treatment. Most studies were of limited quality. We found indications of short-term positive effects from language therapies in children with SLI. Long-term outcomes were not investigated. No evidence supporting the advantage of earlier treatment initiation was identified.

CONCLUSIONS

The benefit of population-based language screening of preschool children with SLI is not proven. Controlled screening studies are therefore necessary. For Germany, the accuracy of existing diagnostic instruments has not yet been sufficiently examined.

Propostas terapêuticas para os desvios fonológicos: diferentes soluções para o mesmo problema

TEMA: enfoque das pesquisas realizadas nos últimos dez anos sobre terapia para os desvios fonológicos. OBJETIVO: realizar análise dos estudos em terapia fonológica, nacionais e internacionais, publicados a partir do ano de 2000, a fim de verificar as contribuições destes para a clínica fonoaudiológica, além de apontar novas possibilidades em pesquisa. CONCLUSÃO: todas as pesquisas trazem contribuições que podem ser adotadas como recursos na clínica fonoaudiológica. No entanto, não foram encontrados estudos apontando o número médio de sessões necessárias para determinação da alta fonoaudiológica nos casos de desvio fonológico, bem como abordagens globais, que dessem conta de todos os aspectos que podem estar defasados nessas crianças, como processamento auditivo, memória de trabalho, discriminação fonêmica, alterações de consciência fonológica e desenvolvimento da linguagem escrita.

A consciência fonoarticulatória em crianças com desvio fonológico

OBJETIVO: verificar as habilidades em consciência fonoarticulatória de crianças com desvio fonológico, comparando-as com as habilidades em consciência fonoarticulatória de crianças com desenvolvimento fonológico normal. MÉTODOS: participaram do estudo 60 crianças, sendo 30 do grupo controle, com desenvolvimento fonológico normal e 30 do grupo estudo, com desvio fonológico. Todos os participantes foram submetidos à avaliação da consciência fonoarticulatória e os desempenhos dos dois grupos foram comparados. RESULTADOS: pode-se verificar diferença estatisticamente significante entre o grupo controle e o grupo estudo nas tarefas de consciência fonoarticulatória, com maiores escores para o grupo controle. CONCLUSÕES: crianças com desvio fonológico apresentam maior dificuldade em habilidades de consciência fonoarticulatória se comparadas a crianças com desenvolvimento fonológico normal.

Lexical and metaphonological abilities in preschoolers with phonological disorders

BACKGROUND

lexical and metaphonological abilities of phonologically disordered preschoolers.

AIM

to investigate the influence of Phonological Disorder on the lexical and metaphonological abilities of a group of preschoolers and the correlation between them.

METHOD

participants were 56 preschoolers - 32 boys and 24 girls - with ages between 4 years and 6 months and 6 years and 11 months, divided into two different groups: the Research Group, composed of 28 preschoolers with Phonological Disorder, and the Control Group, composed of 28 preschoolers with normal speech and no oral speech-related complaints, paired to the research group by gender and age. All of the participants were initially assessed by the ABFW Test - Phonology. After that, they were assessed on their lexical and metaphonological abilities by the ABFW Test - Vocabulary and phonological awareness test: sequential assessment instrument, CONFIAS - identification tasks and, rhyme and alliteration production, respectively.

RESULTS

regarding lexical ability, the preschoolers from both groups presented similar behavior. The disordered preschoolers presented the worst performance on the overall analysis of the metaphonological ability. Age had an influence on the performance of lexical ability for both groups and the metaphonological abilities only for the Control Group. Correlations were identified, mostly positive, good to moderate between lexical and metaphonological abilities.

CONCLUSION

the influence of Phonological Disorder may only be observed on the metaphonological performance. Phonological Disorder did not interfere with the development of the lexical ability of this group of preschoolers. Positive correlations were identified between both abilities in the studied age group.

Intervenção fonológica em crianças com distúrbio específico de linguagem com base em um modelo psicolinguístico

TEMA: intervenção fonológica em crianças com Distúrbio Específico de Linguagem, com base em um Modelo Psicolinguístico. PROCEDIMENTOS: participaram do processo de intervenção 4 pré-escolares, de ambos os gêneros, com idade entre 48 e 83 meses. O desempenho psicolinguístico dos sujeitos foi obtido em duas etapas (pré e pós-intervenção), mediante a utilização de instrumentos que avaliam diferentes níveis do processamento da informação: reconhecimento auditivo-fonético, consciência fonológica, codificação/ produção fonológica, memória de trabalho e acesso lexical. O Programa de intervenção teve duração de 4 meses. RESULTADOS: os pré-escolares apresentaram comprometimento em todos os níveis do processamento da informação avaliados (pré-intervenção), revelando que as dificuldades de organização fonológica estavam relacionadas a problemas no processamento receptivo e expressivo. Ao fim do Programa, todos apresentaram melhora no desempenho fonológico. CONCLUSÃO: o uso de procedimentos de avaliação que abordam os diferentes níveis de processamento possibilita a compreensão da natureza dos distúrbios de linguagem e permitem a programação de estratégias mais efetivas para as dificuldades de linguagem.

Effectiveness of Early Phonological Awareness Interventions for Students with Speech or Language Impairments

This article reviews research examining the efficacy of early phonological interventions for young students identified with Speech or Language impairments. Eighteen studies are included, providing results for nearly 500 students in preschool through third grade. Although findings were generally positive, there were large individual differences in response to intervention. Further, there was little evidence that interventions enabled students to catch up in phonological or reading skills to typically developing peers. Methodological issues are described and implications for practice and future research are discussed.

An Investigation of Treatment Scheduling for Phonemic Awareness With Kindergartners Who Are at Risk for Reading Difficulties

Purpose

This study examined 2 schedules of treatment for phonemic awareness.

Method

Forty-one 5- to 6-year-old kindergartners, including 22 English learners, with low letter-name and first-sound knowledge received 11 hr of phonemic awareness treatment: concentrated (CP, 3x/wk to December), dispersed (DP, 1x/wk to March), and dispersed vocabulary control (CON).

Results

English learners performed similarly to native English speakers. Participants with moderate deficits in letter-names and first sounds showed significant benefits after both treatment conditions. Three times the intensity had no additional effect on phonemic awareness. CP continued to increase significantly during the no-treatment interval. In March, CP and DP were significantly greater than CON, but the 2 conditions did not differ other than with a minor DP advantage on last sounds. By May, there were no significant differences among the 3 conditions in meeting grade-level expectations for phoneme segmenting.

Conclusion

For phonemic awareness, over the course of a school year, with concomitant classroom instruction, the gains made from short, intense treatment were similar to those made from continuous weekly treatment. At-risk kindergartners with moderate deficits benefited more than those with mild deficits. Children, particularly those with mild deficits, may improve substantially with only classroom instruction and incidental self-regulatory gains from treatment for another area.

A comparison between computer and tabletop delivery of phonology therapy

This paper reports on the development and evaluation of a software program aimed at assisting children with phonological impairment. An experimental approach was used whereby children's speech output was assessed pre- and post-therapy. Children were randomly assigned to a computer, a tabletop or a no therapy group. Those children receiving the computer therapy were exposed to an experimental software program that mirrored the tabletop activities using interactive computer games. The results showed no significant difference between any of the three groups with regard to change in speech output. These results may relate to the amount and frequency of therapy given and also to the heterogeneous nature of children included in the study. There was considerable variation in individual performance across all three groups and the data were therefore analysed to look for patterns that might predict performance. Stimulability and gender were identified as possible predictors. Female children and those who were able to produce a greater number of consonant speech sounds in isolation were more likely to make progress in their speech output. Future research might use a similar methodology to compare the therapy conditions but with a more homogenous group in terms of stimulability and using a greater intensity of intervention.