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Children’s Speech
An Evidence-Based Approach to
Assessment and Intervention
Sharynne McLeod
Charles Sturt University, Australia
Elise Baker
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Library of Congress Cataloging-in-Publication Data
Names: McLeod, Sharynne, author. | Baker, Elise author.
Title: Children’s speech: an evidence-based approach to assessment and
intervention / Sharynne McLeod, Elise Baker.
Description: Boston: Pearson, 2017, | Includes bibliographical references and.
index.
Identifiers: LCCN 2016006775} ISBN 9780132755962 (alk. paper) | ISBN 0132755963,
(alk. paper)
Subjects: LCSH: Speech therapy for children, | Speech disorders in children.
Classification: LCC R}496.87 M392 2016 | DDC 618.92/85506-de23 LC record available at
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ISBN-10:
ISBN-13:
etext
ISBN-10: _013-420527.8
Sto) ISBN-13: 978-0-13-420527-4 LEARNING OBJECTIVES
(13
KEY WORDS
Speech sound disorders ($50): phonology
(Phonological impairment, inconsistent speech
disorder), motor speech (articulation impairment,
childhood apraxia of speech [CAS], childhood
dysarthria)
Classification systems: Speech Disorders Classification
‘System, Differential Diagnosis System, Psycholinguistic
Framework, International Classification of Functioning,
Disability and Health — Children and Youth Version
(cF-cY)
SSD of known origin: genetic causes, craniofacial
anomalies, hearing loss, cognitive/intellectual
impairment, motor impairment (e.g, cerebral palsy),
autism spectrum disorders
Co-occurrence with SSD: language impairment,
literacy difficulties, stuttering, oromotor difficulties,
voice difficulties 38
OVERVIEW
‘TYPES OF SSD i
CHAPTER 2m -Clasifcation, Causes, and Co-occurrencé
This chapter describes ways that SSD have been studied and classified. You will learn
that there is no agreed-upon classification system, and that each system serves a differ
‘ent purpose for understanding the nature of the problem and how SSD can be treated,
You will also learn about known causes of SSD, including genetic causes, craniofa-
cial anomalies, hearing loss, cognitive/intellectual impairment, motor impairment
(including cerebral palsy), and autism spectrum disorders. You will learn about the co-
‘occurrence of SSD with other types of communication disorders including language
impairment, literacy difficulties, stuttering, and voice disorder in addition to oromotor
difficulties.
CHILDREN “guest
In the definition of SSD adopted in this book (Chapter 1), SSD can stem from difficulties
with the perception, articulation/motor production, and/or phonological
organization and representation’ of speech. A major focus of this book is to pro-
vide SLPs with guidance for clinical practice when working with children’s speech, par-
ticularly during assessment, analysis, goal setting, and intervention. Consequently, after
considering the literature on assessment and intervention for children with SSD, we
have structured this book around five types of SSD grouped into two broad categories:
phonology and motor speech (articulation) difficulties. The five different types of
SSD are:
1. Phonological impairment: a cognitive-linguistic difficulty with learning the
phonological system of a language. Phonological impairment is characterized by
pattern-based speech errors,
2. Inconsistent speech disorder: a phonological assembly difficulty (Le. diffi
culty selecting and sequencing phonemes for words) without accompanying oro.
motor difficulties (Dodd, 2013, 2014). Inconsistent speech disorder is characterized
by inconsistent productions of the same lexical item (word),
3. Articulation impairment: motor speech difficulty involving the physical pro:
duction (i.e., articulation) of specific speech sounds. Itis characterized by speech
sounds errors typically only involving the distortion of sibilants and/or thotics
(typically /s, z, 1, »). (This definition is narrower than some historical uses of the
term)
4. Childhood apraxia of speech (CAS): a motor speech disorder involving dif-
ficulty planning and programming movement sequences, resulting in errors in
speech sound production and prosody (ASHA, 20070).
5. Childhood dysarthria: a motor speech disorder involving difficulty with the
sensorimotor control processes involved in the production of speech, typically
‘motor programming and execution (van der Merwe, 2009).
Figure 2-1 shows the interrelationship of these different categories, and Table 2-1
demonstrates the differences in production of the word seven that would be made by a
child in each of these groups. As you read more of this book, you will notice that these cat
egories provide you with guidance for working with children’s speech in clinical practice.
We have chosen to use this framework within the book because there are interventions
that specifically target each type of SSD. For example, contrastive phonological interven:
tlons are predominantly used with children with phonological impairment (Baker, 2010),
core vocabulary therapy is suited to children with inconsistent speech disorder (Dodd,
2014), while concurrent treatment guided by principles of motor learning is suitable for
children with articulation impairment (Skelton, 2004a)
eprecmation of speech can occur at« numberof levels of abstraction: acoustic, phonetic,
phsologieand meter (Munson, Edwards & Beckman, 208s sc Chapter 9) ‘Types of SSD'in Children 39
[EEEER conceptualization of childhood SSD used in this book
FEET examples of speech sound errors for the production of
seven /sevan/
fn Possi me
Phonological ‘Cognitive-linguistic difficulty [debon]
impairment ‘characterized by pattern-based errors.
Inconsistent speech Impaired phonological planning, [tebon},{seban},
disorder resulting in Inconsistent productions of _[deban}, etc.
the same word.
Articulation Difficulty with the production [evan] OR [tevan]
impairment (particularly phonetic placement) of
specific speech sounds,
Childhood apraxia Impairment in planning and {¢e-banl, fteban}
of speech (CAS) programming movement sequences
impacting speech segments and prosody.
Childhood Weakness, slowness, orincoordination [sehen]
dysarthria of speech movements impacting speech
systems including respiration, phonation,
resonance, and articulation,
Children’s speech may fit neatly into one of these categories, or may be classified
in a combination of ways. One reason for this is that throughout childhood, children are
learning all aspects of perception, production, and representation. Consequently, while
some children may have a primary difficulty with motor planning (e.g., CAS), their per-
ceptual and phonological skills are still maturing, so its possible that they may have some
difficulties with these areas too. Figure 2-1 includes one more box that is not attached to
the SSD framework. This box, labeled speech difference, is included to depict children
whose speech may not be deemed acceptable or intelligible by people within their envi-
ronment, but not because they have SSD. Although speech difference is not a focus of this,
book, speech differences asa result of speaking different dialects will be discussed briefly in.
Chapter 4. Our classification of SSD into these five types was driven by methods for assess
‘ment, analysis, and intervention reported in the literature. We now explain each type, 40
ead more about
Lake 3 years),
a boy witha phonological
InChapter 16 (Case 1),
CHAPTER 2m Classification, Causes, nd Co-occurrence
Il Speech sound disorders: Phonology
Phonology is about sounds (phono) and knowledge (ology). It refers to the speech sounds
in languages and the rules for how those sounds combine to form words and how they
are pronounced (Fromkin, Rodman, & Hyams, 2013). Phonology is one component of lan-
guage, along with semantics (vocabulary), morphology (grammar), and syntax (sentence
structure). Two types of SSD are considered phonological in nature: phonological impair
‘ment and inconsistent speech (phonological) disorder.
Phonological impairment
Children with phonological impairment have difficulty learning the phonological sys-
tem of their language. They can have difficulty knowing which features, speech sounds,
word shapes, and stress patterns are present in a language, how they are used, and how
they mentally represent and organize that system. As Bowen (2008) states, “a phonological
disorder isa language disorder that affects the phonemic organization level, The child has
difficulty organizing his/her speech sounds into a system of sound contrasts” (p. 50)
During the early 20th century, all children with speech difficulties were thought to
have problems with the physical production of speech (e.g,, Blanton & Blanton, 1919).
Around the 1970s and 1980s, phonological theories were applied to the study of chil-
dren’s speech, acknowledging that speech included a cognitive-linguistic component. This
‘opened up the possibility that children with SSD had an underlying language component
contributing to their unintelligibility. The application of phonological theories helped.
explain why some children with unintelligible speech could imitate particular speech
sounds in isolation but not use them contrastively in words and/or in accordance with the
phonotactic rules of a language
One of the major changes to SLPs' practice of this time was that SLPs no longer con-
sidered that children had problems with the articulation of individual speech sounds, but
had problems developing thetr phonological system. SLPs began to describe children’s
speech in terms of their error patterns or phonological processes. Children were
described as having difficulty learning the rules of how sounds are used in the language(s)
spoken, as well as learning how to perceive and produce speech sounds. As further research
has been conducted into the nature of the problem, children’s phonologically based
error patterns have been considered symptomatic of underspecified phonological repre:
sentations of words (¢.g., Sutherland & Gillon, 2005). Chapter 5 describes the theoretical
underpinnings of the shift in thinking from articulation to phonology and the abstract
representation of speech.
In this book, phonological impairment has been used as an overarching term to
include phonological delay and phonological disorder. A child with a phonological
delay may exhibit systematic error patterns such as final consonant deletion (e.g,, seat
‘sit/ ~ (sil) or cluster reduction (e.g., blue /blu/ ~> [bu]) that are typical in the speech
of younger children but should have been resolved. A child with a phonological
disorder may exhibit patterns such as initial consonant deletion (e.g, feet /fit/ > [it])
or glottal insertion (e.., feet /fit/ > [Zit]) that are not typical of the speech of younger
children. In Chapter 6 we will discover that typical patterns in one language may not
be typical patterns in others. For example, it is common for young children who speak
G APPLICATION: Luke (4;3 years), a child with a phonological impairment
Luke is 4;3 and has a phonological impairment. Luke's case history and speech sample are
found in Chapter 16. Look at Luke's speech sample in ight of what you are beginning to
learn about phonology. What patterns or rules do you notice in Luke's single-word sample of
\word-nitial and word-final consonant clusters? We will keep coming back to the information,
about Luke in other chapters e.g,, Chapter 9 about analysis and Chapter 10 about goal set:
ting) so that you can observe evidence-based speech-language pathology practice in action. Types of SSD in Children ar
Cantonese to realize some consonants as nasalized (e.g., producing /1/ as [n]) (To,
Cheung, & McLeod, 2013a), whereas this would not be a common pattern in English
(Shriberg & Kwiatkowski, 1980)
Inconsistent speech disorder
Inconsistent speech disorder Is a type of SSD describing children who have “difficulty
selecting and sequencing phonemes (i.., in assembling a phonological template or plan
for production of an utterance)” (Dodd, Holm, Crosbie, & McIntosh, 2010, p. 122), Dodd
and colleagues state that a child has an inconsistent speech disorder if 40% or more of 25
words are produced variably during the three separate productions on an inconsistency
assessment that mostly contains multisyllabie words (Dodd, Hua, Crosbie, Holm, &
‘Ozanne, 2002). Approximately 10% of children with SSD are thought to have inconsistent
speech disorder (Broomfield & Dodd, 2004b). The problem presents as lexical inconsis
tency—unpredictable pronunciations ofthe samie word, These children often know how to
articulate a range of speech sounds. Children with inconsistent speech disorder have dif
culty with the assembly of phonemes that make up a word, in the absence of any oromotor
signs of CAS (Dodd etl, 2010). For example, review Jatrod’s speech sample (in Chapter 16
and the APPLICATION box below). Did you notice how his productions ofthe word tongue
: =a /tan/ differed, inchuding (bans) (dan) (bs?) This occurred despite the fact that he could
eer produce all the phonemes that made up the word. When Jarrod imitated the word, his
boy wihincarsstent intelligibility improved, This is an important characteristic of inconsistent speech disor-
Speech disorder, der and highlights the type of intervention needed to address the problem. Children with
inChapter6(Case 3. __ inconsistent speech disorder need to learn how to phonologically plan words rather than
simply imitate words
I Speech sound disorders: Motor speech
Motor speech difficulties refer to problems with the coordination and production of
precise mouth movements, respiration, resonance, and/or phonation required for fluent
and rapid speech. To put it another way, children with motor speech difficulties have trou:
ble performing the articulatory gestures necessary for speech production. Motor speech,
difficulties may be simple or complex. A simple motor speech difficulty can be isolated
toa problem with the articulation of specific speech sounds. Complex motor speech
difficulties and the APPLICATION box, referred to as motor speech disorders (MSD),
encompass problems with one or more of the sensorimotor control processes needed 0
produce speech including motor planning, motor programming, and execution that dis-
rupt the respiratory, phonatory, resonatory, and/or articulatory systems used in speech
production (Duffy, 2013; van der Merwe, 2009), Motor speech disorders may “result from
aa speech production deficit arising from impairment of the motor system... MSDs may be
caused by disruption of high-level motor commands, neuromuscular processes, or both”
(Maas et al, 2008, p. 278). In this book we consider a simple motor speech difficulty (artic
ulation impairment) and two motor speech disorders (CAS and childhood dysarthria).
Principles of motor learning guide intervention for these three types of SSD.
erage
G APPLICATION: Jarrod, a child with an inconsistent speech disorder
‘We introduced you to Jarrod in Chapter 1. Jarrod’s spéech was 88% inconsistent (Dodd,
Holm, Crosbie, & Mcintosh, 2006) on the Diagnostic Evaluation of Articulation and Phonol-
ogy (DEAP): Inconsistency assessment (Dodd et al., 2002). What do you notice about his
productions of the following words?
= witch /w1i/ > [bws:2e§] (owae] (bwert}
f= fongue /tan/ -» [bans] [dan] [bx?m]
1 zebra /zebsn) > [dgeuwa] [jeiva] [je?dwa] (Dodd, Holm, et al,, 2006) 42 CHAPTER 2m Classiication, Causes, and Co-occurence
‘COMMENT: Undifferentiated tongue movements
‘There is evidence from instrumental studies that some children with SSD are unable to
perform precise tongue movements required for fluent and rapid speech. For example,
some children move their whole tongue using undifferentiated ingual gestures
(Gibbon, 1999), and in doing so, they demonstrate poor controf ofthe tongue tip and
‘poor lateral bracing and are unable to anchor the sides oftheir tongue along their teeth
during speech (McAuliffe & Comwell, 2008). Chapter 4 provides more information.
Articulation impairment
Articulation impairment isa type of motor speech difficulty typically reserved for speech
errors limited to rhotics and/or sibilants. Common clinical manifestations of articulation
impairment include distortions such as labialized /s/, dethotacized /s, >, »/, and lateral
ized or dentalized sibilants (typically /s, 2/) Shriberg, 1993). An articulation impairment is
also apparent when children present with substitutions of the developmentally easier con-
sonant [wi] for the developmentally later consonant /1/ in words like ring rock, and rabbit
and/or substitutions of interdental friatives (8, 0] for /s, 2 (In the absence of other speech
difficulties),
We identify distortion and substitution errors involving sibilants and/or rhotics
as an articulation impairment for three reasons. First, accurate perceptual distinction
between distortion and substitution errors (particularly involving /1/) can be challenging
as expert listeners have difficulty reliably classifying such errors as distortions versus sub- |
stitutions (McAllister Byun & Hitchcock, 2012). Second, ifa school-age child is identified |
as having an articulation error reminiscent of a younger child with typically developing |
speech (such as the substitution of {w] for /1/) then the older child’s difficulty might be
identified as an articulation delay. Ifa child presents with an error that is not observed in
typical speech acquisition (such as lateralized /s/) then the error might be identified as an
articulation disorder. In this book we use the term articulation impairment, given the chal-
lenge of perceptually differentiating substitution from distortion errors involving thot
ics and sibilants, and the subsequent potential for confusion about whether such errors,
constitute delayed versus disordered articulation. Third, distortion and/or substitution
errors involving sibilants and/or thotics (in the absence of other speech difficulties) are
suited to similar intervention approaches influenced by principles of motor learning
(eg., Hitchcock & McAllister Byun, 2015; McAllister Byun & Hitchcock, 2012; Skelton,
2004).
Within this book, we use a narrower definition of articulation than has been used
in the past. Prior to the 1970s and 1980s, the predominant view was that all children
with SSD had difficulties with articulation of speech sounds, and a major emphasis of
speech-language pathology practice was on children’s production of individual speech
sounds (articulation). By restricting the definition of articulation impairment in this
book to those children who have difficulties only with sibilants and rhotics, we are lim-
iting the co-occurrence of articulation and phonology. Typically, children with articula
tion impairment do not have a concurrent difficulty with phonology. They have learned
the phonological system and can make themselves understood. Children with articulation,
impairment have difficulty with the articulation (ic., physical production) of sibilants
and/or rhotics Shriberg, 2010a; Shriberg, Flipsen, Karlsson, & MeSweeny, 2001).
‘The underlying cause of articulation impairment limited to sibilants and/or thoties
is not well understood. It has been suggested that for some children, the problem lies in
their perception of the speech sounds in error Shuster, 1998) or difficulties with oromo-
tor structure (eg. dental occlusion, facial nerve palsy). Some children and adolescents
‘may have prior history of other speech difficulties whereas others do not (e.g., Karlsson,
Shiriberg, Flipsen, & MeSweeny, 2002; McAllister Byun & Hitchcock, 2012; McAllister Byun,
Hitchcock, & Swartz, 2014; Shriberg, Flipsen, et al., 2001), Acoustic studies of the sibi
lant and rhotic speech errors produced by children and/or adolescents with and without, Types of SSD in Children 43
a
COMMENT: Terminology for articulation errors
Some researchers differentiate between developmental articulation errors in childhood
and residual articulation errors that continue to occur beyond 9 years of age and
into adulthood (Shriberg, Austin, Lewis, McSweeny, & Wilson, 1997); Van Borsel, Van
Rentergem, & Verhaeghe, 2007) Residual articulation errors include common clinical
distortions, particularly with {s/ produced asa lateral [1] or interdental lisp [0] and /s/
produced as [w] ora dethotacized consonant [o], and "residual common distortions
and imprecise speech (omissions and substitutions)” (Shriberg et al, 1997b, p. 725)
Other terms include
‘& misarticulations; ‘
«= residual articulation errors;
= common clinical manifestations;
= residual common distortions; and
= persistent speech errors.
[MULTILINGUAL INSIGHTS: When saying {1} for see /si/ might not be an
articulation impairment
Se ee
A child who says see /si/ as [ti] and speaks both English and Welsh may not be consid-
fered as having an articulation impairment, since lateral ticaives ae part of the Welsh
consonant inventory. A comprehensive analysis ofthe child's speech would be needed
to determine why one consonant from one language is present in spoken words in
another language.
G APPLICATION: Susie, a child with an articulation impairment
Read mare abou , ‘
eae oa ents Susie is a 7-year-old girl with a lateral lisp. Review Susie's production of /s, z/ in single-words
2git with an articulation In singleton and consonant cluster contexts, in initial, medial, and final-word positions in
impairment dateral Isp, lapter 16. What do you notice?
in Chapter 16 (Case 2). Saree ene Yo ee
prior history of speech difficulties suggest that certain acoustic markers can differentiate
individuals according to their speech error history (ie., no history versus past history)
(Karisson eta, 2002; Shriberg,Flipsen, et al, 2001). Typically, children with articulation
impairment are intelligible, but their speech errors may impact acceptability or clarity.
E Whether or not childzen and adolescents require sifferent approaches to intervention for
sibilants and/or thotic errors based on prior history remains to be determined. Contem
porary intervention approaches for articulation impairment are offered based on the pres-
ence of sbilant/thotic errors, not speech error history (eg, Mcallister Byun & Hitcheock,
2012; Mesllister Byun etal, 201).
Childhood apraxia of speech (CAS)
CAS refers to a subgroup of children with SSD who have a motor speech disorder involv-
ing planning and programming movement sequences (ASHA, 2007b; Ozanne, 2013). CAS
occurs in approximately one to two childeen per thousand (Shriberg, Aram, & Kwiatkowski, 44
Read more about
Michael (4:2 yeas),
boy with chldhoed
Spraia of speech (CAS),
and jrrod 0 yer),
boy with inconsistent
Speech disorder,
inchapter 18
CHAPTER 2m Classiication, Causes, and Co-occurrence
1997), There have been a range of terms to describe the speech difficulties of this group of
children (including developmental dyspraxia, developmental verbal dyspraxia, and developmen:
tal apraxia of speech); however, this century, CAS has become the standard term. The fol-
lowing definition was prepared by a committee of the American Speech-Language-Hearing
Association (ASHA) and states:
Childhood apraxia of speech (CAS) Isa neurological childhood (pediatric) SSD in which the
precision and consistency of movements underlying speech are impaired in the absence
of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). Childhood apraxia of
speech may occur as a result of known neurological Impaltment, in association with com:
plex neurobehavioral disorders of known or unknown origin, ot as an idiopathic neurogenic
speech sound disorder. The core impairment in planning andor programming spatiotem.
poral parameters of movement sequences results in errors in speech sound production and
prosody. (ASHA, 2007b, pp. 3-4)
This definition means that children with CAS tend to have: “(a) inconsistent errors on
consonants and vowels in repeated productions of syllables or words, (b) lengthened and.
disrupted coarticulatory transitions between sounds and syllables, and (c) inappropriate
prosody, especially in the realization of lexical or phrasal stress” (ASHA, 2007b, p. 4). It has
been noted that although children with CAS have an underlying motor speech disorder,
this may impact their phonological and linguistic processing (Maassen, 2002),
Childhood dysarthria
Dysarthria is the term applied to a subgroup of children (and adults) with motor speech
disorders and is used to describe a disorder in the ability to control and execute speech
movements. Dysarthria is caused by a neurological impairment and can be described as
flaccid, spastic, hyperkinetic, hypokinetic, ataxic, or mixed. in children, this could occur
uring or after birth (e.g, cerebral palsy), through traumatic brain injury, ora neurological
condition (e.g., neurofibromatosis) (Pennington, Miller, & Robson, 2009). Children (and
adults) with dysarthria have “weakness, slowness, or incoordination of the musculature
used to produce speech” (Kent, 2000, p. 399). The speech of children with dysarthria has
been described as follows:
Children with dysarthria often have shallow, irregular breathing and speak on small, resi
ual pockets of air. They have low pitched, harsh voices, nasalized speech and very poor
articulation. Together, these difficulties make the children’s speech difficult to understand,
(Pennington, Miller, & Robson, 2009, p. 1)
Dysarthria is not as common as most other types of SSD. For example, cerebral palsy
in approximately 2 per 1,000 births (Anderson, Mjoen, & Vik, 2010), and approx.
Imately 35% of these children have a speech difficulty (Parks, Hill, Platt, & Donnelly,
2010),
Michael (4;2 years) has CAS. Review the speech sample for Michael in Chapter 16. Notice
how Michael produces the words birthday cake /bs@de kek/ as [bsf.de.kek], [bf.de.ke?], and
[bap.de.ket]. What similarities and differences do you notice between Jarrod's and Michael’
productions of the words birthday cake?
Answer:
Like Jarrod, Michael's speech can be inconsistent. However, unlike Jarrod, Michael struggles
with prosodic aspects of speech. The dots between the syllables in birthday cake reflect sya
ble segregation or short pauses between the syllables. Jarrod does not have this difficulty, Types of SSD in Children
ead more about
an (182 years,
2 gi with enldhood
ayant,
Inchapter 16 (Case).
45
G APPLICATION: Lian, a bilingual child with childhood dysarthria
Lian isa 14-year-old who speaks both English and Cantonese and has childhood dysarthria
due to cerebral palsy (specifically, right-sided spastic hemiplegia). Review Lian’s speech
sample in Chapter 16. What do you notice about Lian’s production of the word Jenny /dgeni
as [tsénil? The diacritic symbol above the vowel indicates that there was audible nasal air
emission on the vowel (Chapter 4). What do you think this suggests about Lian's oral muscu:
lature and function for speech?
Differentiating between inconsistent speech disorder, CAS,
and childhood dysarthria
Inconsistent speech disorder, CAS, and childhood dysarthria share some similarities such
as substitution errors and error inconsistency. However, they are different types of prob:
Jems requiring different approaches to intervention. For instance, Shriberg etal. (2006)
used several diagnostic features to differentiate between apraxia of speech and spastic dys-
arthria, They indicated that generally speech characteristics were not specific for either
disorder, Both groups of children had speech difficulties that ranged from mild to severe
and included inconsistent errors and distortion errors. However, there were differences
between prosody and voice characteristics. Children with CAS had the following charac
teristics
= prosody: inappropriate phrasing, rate, sentential stress, lexical stress, and emphatic
stress; and
= voice: appropriate loudness, pitch, laryngeal quality, and resonance.
Children with spastic dysarthria had the following characteristics
= prosody: inappropriate rate, sentential stress, but appropriate phrasing, lexical stress
and emphatic stress; and
= voice: inappropriate loudness (too soft), pitch (too low), laryngeal quality (harsh),
and resonance (hypernasal),
In contrast, children with inconsistent speech disorder typically do not have difficulty
with prosody, voice, and fluency (Bowen, 2009; Dodd, 2013). Their difficulty stems from
a problem with phonological planning rather than motor planning, motor pr
gramming, or execution. In addition, the speech intelligibility of children with incon-
sistent speech disorder is better in imitated than spontaneous contexts; children with CAS
are better in spontaneous than imitated contexts (Dodd, 2014)
COMMENT: Why consider different classification systems?
Children are different from one another; that is, they are heterogeneous. Researchers
hhave been working to Understand and classify different groups of children for a range
of reasons. As mentioned earlier in this chapter, in this book we use a symptomatology
Classification so that we can direct readers to appropriate intervention approaches.
Other researchers have classified children based on the cause of SSD, while others have
classified children using an explanatory framework. Each is valid, depending on the
purpose of classifying children. 46
CHAPTER 2 Mm Classifiation, Causes, and Co-dccurrence
CLASSIFICATION SYSTEMS OF CHILDREN WITH SSD
Children with SSD are heterogeneous. The conceptualization of SSD used in this book
(Figure 2-1) and described earlier has been driven by a need for understanding assessm
and intervention research about clinical practice. However, there are a number of other
‘ways to classify children with SSD. Waring and Knight (2013) provided an overview of,
broad and specific classification systems that are used to describe and differentiate sub-
‘groups of children with SSD. We will discuss four of these:
Speech Disorders Classification System (Shriberg, 2010a): an etiological framework
{or children with SSD;
Differential Diagnosis System (Dodd, 1995a, 2005, 2013): a descriptive-linguistic
framework for children with SSD;
= Psycholinguistic Framework (Stackhouse & Wells, 1997): a processing-based frame-
work for children with SSD; and
= International Classification of Functioning, Disability and Health (ICF-CY) (World
Health Organization, 2007); a biopsychosocial framework for all children (including
‘those with SSD).
‘The first three of classification systems are based on a medical model where impair
ment is located within the child and intervention focuses on “objective, separable and.
controllable parts of communication” (Duchan, 2001, p. 41). Some of these classification
systems incorporate a social model, which considers the personal and environmental
contexts that contribute to and impact a child’s life (Byng, 2001). The final classification.
system, ICF-CY (WHO, 2007), is based on a biopsychosocial model (Engel, 1977), since
it systematically considers biological, psychological, and social factors and their complex.
interactions.
I Speech Disorders Classification System (Shriberg, 1980; 2010a)
The Speech Disorders Classification System (SDCS) provides an etiological framework for
children with SSD. The SDCS initially was described by Shriberg in 1980, and over the years
Shriberg has conducted systematic research to further refine this classification system (¢.g,
Shriberg & Kwiatkowski, 1982a, b; Shriberg, 1993; Shriberg, Austin, et al., 1997a, b; Shriberg,
2010a; Shriberg, Fourakis, etal, 2010a, b). Shriberg and colleagues give the following overar-
ching rationale for the development ofthe SDCS: “the assumption is that next-generation
personalized medicine for assessment, treatment, and eventual prevention of diseases and
disorders will require international classification systems based on biological phenotypes
(Shriberg, Fourakis, ¢t al., 2010, p. 796). The SDCS can be used to support molecular genet-
ics research into SSD by categorizing “antecedents” (Shriberg, 1993, p. 105) and “etiologic
subtypes” (Shriberg, 2010a, p. 4) oF causes of SSD, and Shriberg’s ongoing publications
document his work towards the identification of phenotypes and endophenotypes for SSD
(eg, Shriberg, Lohmeier, Strand, & Jakielski, 2012). The original SDCS outlined 10 categories
to classify speech disorders in people from 2 years to adulthood (Shriberg, 1980).
‘In 2010 Shriberg and colleagues (Shriberg, Fourakis, et a., 2010a) described the SDCS
as comprising a typology and etiology (see Figure 2-2). In the typological classification
system there are children who have normal speech acquisition (NSA), and three types of,
speech disorders:
m Speech Delay (SD) (occurring between 3 and 9 years);
Motor Speech Disorder (MSD) (occurring between 3 and 9 years); or
Speech Errors SE) (occurring between 6 and 9 years),
From 9 years of age, children in any of these groups may have normalized speech acquisi-
tion (NSA). Alternatively, children may have persistent speech disorders that are associated
with their original typology:
= Persistent Speech Disorders - Speech Delay (PSD-SD);
f& Persistent Speech Disorders ~ Motor Speech Disorder (PSD-MSD); or
1m Persistent Speech Disorders ~ Speech Estors (PSD-SE) Classification Systems of Children with $SD a7
Speech Disorders Classification System
Speech Disorders Classification System
Noval Speed |
Abauiston (SA
(SDCs)
1
SDCS-TYPOLOGY ‘SDCS-ETIOLOGY
(SDCS-T) (sDCs-F)
I
DELAY (SD)| | Disrcer SSD) || ERRORS (SF
NORMALIZED || PERSISTENT [PERSISTENT —][ PERSISTENT eer] [Sempee | Seas Oa] [ Ne spe
Acquisition |] soRDERG-sp || psonbeRs xs |] pisonpens se |S] yp —
NSA SDD) || SDD) ‘I
a =o ee ee eR
Source: Shriberg, Foueakis, etal (2010a), Used with permission
In the etiological classification system, the five etiologies (or causes) of SSD (Shriberg,
Fourakis, etal, 2010a) are:
= Speech Delay ~ Genetic (SD-GEN): related to the cognitive/linguistic domain;
'= Speech Delay - Otitis Media with Effusion (SD-OME): related to the auditory/percep-
tual domain;
= Speech Delay - Developmental Psychological Involvement (SD-DP)): related to the
affective/temperamental domain;
& Motor Speech Disorder (MSD): related to the speech motor contro! domain and.
including Apraxia of Speech (AOS), Dysarthria (DYS), and Not Otherwise Specified
(NOS); and
‘Speech Errors (SE): related to speech attunement and including speech errors on sib-
ilants (SE-S) and rhotics (SE-R).
These etiologies are described by Shriberg, Fourakis, et al. (2010a) as being overlapping,
with origins in environmental and genetic domains,
‘Throughout the development of the SDCS, Shriberg and his colleagues created
metrics and terminology that are now commonly used throughout the speech-language
pathology profession, including:
im Percentage of Consonants Correct (PCC) (Shriberg & Kwiatkowski, 1982c; Shriberg,
Austin, Lewis, McSweeny, & Wilson, 19972);
= Articulation Competence Index (ACI) (Shiiberg, 1993);
= Eatly-, middle-, and late-8 consonants (Shriberg, 1993); and
Syllable Repetition Test (SRT) (Shriberg et al., 2009),
‘These and other assessment and analysis protocols have been described in the Madison
Speech Assessment Protocol (MSAP) (Shriberg, Fourakis, et al, 2010a). You will learn more
about early-, middle- and late-8 consonants in Chapter 6, assessments in Chapters 7 and 8,
and how to calculate PCC and ACI in Chapter 9. 48 CHAPTER 2 m_Classiication, Causes, and Co-occirrence
COMMENT: Incidence of subtypes of SSD based on Broomfield and
Dodd (2004b)
Broomfield and Dodd (2004b) studied 1,100 children who were referred for speech
language pathology services in one region of the United Kingdom. There were 320
‘with SSD (“primary speech impairment”) as their primary diagnosis, OF these 320
children:
1» 575% had phonological impairment;
1 12.5% had articulation impairment;
1 20.6% made consistent “rondevelopmental erors” (p: 135),
1» 9.4% made “inconsistent errors on the same lexical item” (p. 135); and
‘= no children were diagnosed with CAS.
I Differential Diagnosis System (Dodd, 1995a, 2005, 2013)
The Differential Diagnosis System (DDS) (Dodd, 199Sa, 2008, 2013) provides a
descriptive-linguistic framework for children with SSD. The DDS initially was developed
to provide a surface-level classification of functional speech disorders with direct clinical
application to decision-making regarding appropriate intervention techniques. The DDS
comprises four subgroups:
1 Articulation disorder: “an impaired ability to pronounce specific phonemes, usually
Js/ ot /t!” (Dodd, 2008, p. 9};
= Phonological delay: “all the error patterns ... occur during normal development but
are typical of younger children” (Dodd, 2005, p. 9);
= Consistent phonological disorder: “consistent use of some non-developmental error
patterns” (Dodd, 2005, p. 9};and
= Inconsistent phonological disorder: “children’s phonological systems show at least
40% variability (when asked to name the same 25 pictures on three separate occa-
sions in one session)” (Dodd, 2005; p. 9).
In addition to the differences in the speech output of these groups of children, Crosbie,
Holm, and Dodd (2009) found that children with consistent phonological disorder had.
greater difficulties with the executive functioning tasks of rule abstraction and cognitive
flexibility than children with inconsistent phonological disorders.
‘Throughout the course of development of the Differential Diagnosis System, Dodd
and colleagues developed assessments and intervention approaches to support the class-
fication system that are commonly used throughout the speech-language pathology pro-
fession, including:
= Diagnostic Evaluation of Articulation and Phonology (DEAP, Doda, Hua, et al., 2002,
2006); and
= Core vocabulary int
Dodd, 2005),
ervention for inconsistent speech disorder (Crosbie, Holm, &
You will learn more about the DEAP in Chapter 8 and core vocabulary intervention in
Chapter 13,
I Psycholinguistic Framework (Stackhouse & Wells, 1997)
The Psycholinguistic Framework described by Stackhouse and Wells (1997) provides
processing-based framework to describe the speech and literacy skills of children with SSD.
Itwas developed to explain rather than describe specific areas of difficulty for children with 49
Classification Systems of Children with SSD
8D, and consequently to identify areas for intervention. The Psycholinguistic Framework
draws on psycholinguistic explanations for children’s speech perception and production
that have been described for many years using box and arrow models (e.g., Smith, 1978;
Menn, 1983; see Baker, Croot, McLeod, & Paul, 2001, for a review). The simplest version
of the Psycholinguistic Framework is that a sound or word travels between a speaker and
a listener along the following pathway: input -» storage -> output. In the case of speech,
sound moves from the ear ~ brain -+ mouth, and in the case of writing (or sign language),
words (or signs) move from the eye -+ brain -+ hand. Stackhouse and Wells (1997) devel
oped this framework into the Speech Processing Model (see Figure 2-3), where an acous-
tic signal is heard as a sound (peripheral auditory processing), determined to be speech or
not (speech/non-speech discrimination), and recognized as a word (phonological recog.
nition). Stackhouse and Wells (1997) proposed a single underlying representation (called
a lexical representation), represented by broad arrows and shaded boxes to indicate pro-
cesses hypothesized to occur offline and including phonological and semantic represen.
tations. In order to produce speech, there is a pathway from motor programming, motor
planning, and motor execution to speech input. Over the years, Stackhouse and Wells have
created assessment and intervention resources to accompany the model (Pascoe, Wells, &
‘Stackhouse, 2006; Stackhouse & Wells, 2001). The Psycholinguistic Framework is described
in more depth in Chapter 5, and we illustrate how to address children’s risk of literacy diff
culties in Chapters 13 an
[ESTEE speech processing model
&
Ecce a
F Pomtoga =
F rece pa
s
Phonetic
aistrmintio|
4
sPesclnon see ‘motor planning
Peripheral
procesing
=
Source: From Childrens Speech and Literacy Difficulties: A Psycholinguistic Framework (Figure 63.00
page 166 and Appendix 4, p. 350) by J. Stackhouse and B, Wells, 1997. London, UK: Whurr. Copyright
© 1997 John Wiley and Sons. 50
CHAPTER 2 m Classification; Causes, and Co-occurrence
i International Classification of Functioning, Disability and
Health — Children and Youth Version (ICF-CY) (WHO, 2007)
‘The Children and Youth Version of the International Classification of Functioning, Dis-
ability and Health (ICF-CY) (World Health Organization, 2007) has been designed as a
biopsychosocial framework for promoting and supporting health and wellness in children
under 18 years (including those with SSD) so that they may participate fully in society.
There are six interacting components of the ICF-CY (Figure 2-4);
= Body Function: “Physiological functions of body systems (including psychological
functions)" (WHO, 2007, p. 9);
= Body Structure: “Anatomical parts of the body such as organs, limbs and their
components” (WHO, 2007, p. 9);
1 Activity: “The execution of a task or action by an individual” (WHO, 2007, p. 9);
= Participation: “Involvement in a life situation” (WHO, 2007, p. 9);
= Environmental Factors: “Make up the physical, social and attitudinal environ-
ment in which people live and conduct theis lives” (WHO, 2007, p. 9). Environmen-
tal factors may be barriers or facilitators or both; and
= Personal Factors: Include “gender, race, age, other health conditions ... habits,
upbringing, coping styles, social background, education, ... past and current experi
cence... overall behavior pattern and character style...” (WHO, 2007, p. 15).
Each of these components are described by a set of codes that can be used for statistical and
research purposes. The term SSD is not used within the ICF-CY (World Health Organiza-
tion, 2007). Using the ICF nomenclature, the closest domain that encapsulates the notion
of SSD would be an impairment of Voice and Speech Functions (b3), specifically Articula.
tion function (b320). This in turn would have an impact on a childs Activities and Partici
pation, particularly in the domain of Communication (43).
The importance of the ICF-CY is that it presents a holistic framework for considering
children in context. It focuses on capacity and performance and enables consideration of
the impact of the environment and personal factorsas ether barriers o facilitators to func:
tioning. As Tomblin and Christiansen (2010) argue, “the locus of the disorder in commu-
nication disorder will not be found in the characteristics or behavior of the individual but
rather in the cultural context” (p. 40). The following core set of ICF-CY codes is suggested
Interactions between the components of the
International Classification of Functioning, Disability
and Health — Children and Youth Version (ICF-CY)
Health conto
(disorder or diese)
v
Body Functions
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