Speech sound disorders-articulation and phonology

speech sound disorders

Speech sound disorders is a general term that refers to any difficulty or combination of difficulties with the
perception, motor production, or phonological representation of speech sounds and speech segments, including
the phonotactic rules governing speech sequences. permissible speech sounds in a language.
Speech sound disorders can be organic or functional in nature. Organic speech sound disorders are due to an
underlying motor/neurological, structural, or sensory/perceptual cause. Functional speech sound disorders are
idiopathic, they have no known cause. See the figure below.

Speech Sound Disorders

r Organic 1 j
Developmental Or
acquired J

r
Functional 1
Unknown
cause

• Articulation - motor ' Motor/ 1 t

aspects Neurological L Perceptual -
• Phonology -
linguistic aspects
Structural
• Execution
(Dysarthria) impairment

• Planning
(Apraxia) Cleft palate/other
orofacial anomalies

• Structural deficits due to

trauma or surgery

Organic speech sound disorders

Organic speech sound disorders include those resulting from motor/neurological disorders (e.g. e.g.,
childhood apraxia of speech and dysarthria), structural anomalies (e.g. e.g., cleft lip/palate and other structural
deficiencies or abnormalities) and sensory/perceptual disorders (e.g. e.g., hearing impairment).

Functional speech sound disorders

Functional speech sound disorders include those related to the motor production of speech sounds and those
related to the linguistic aspects of speech production. Historically, these disorders are known as articulation
disorders and phonological disorders , respectively. Articulation disorders focus on errors (e.g., distortions
and substitutions) in the production of individual speech sounds. Phonological disorders focus on predictable,
rule-based errors (e.g., fronting, stopping, and final consonant deletion) that affect more than one sound. It is
often difficult to cleanly differentiate between articulation and phonological disorders; Therefore, many
researchers and clinicians prefer to use the broader term, "speech sound disorder," when referring to speech
errors of unknown cause. See Bernthal, Bankson, and Flipsen (2017) and Peña-Brooks and Hegde (2015) for
relevant discussions.
This practice portal page focuses on functional speech sound disorders. The broad term, “speech disorder(s),” is
used throughout; Articulation error types and phonological error patterns within this diagnostic category are
described as necessary for clarity.
The procedures and approaches detailed on this page may also be appropriate for evaluating and treating organic
speech sound disorders. See Speech Characteristics: Selected Populations [PDF] for a brief summary of selected
populations and characteristic speech problems.
The incidence of speech sound disorders refers to the number of new cases identified in a specific period. The
prevalence of speech sound disorders refers to the number of children living with speech problems in a given
time period.
Estimated prevalence rates of speech sound disorders vary widely due to inconsistent classifications of the
disorders and the variance of the ages studied. The following data reflects the variability:

• Overall, it was estimated that between 2.3% and 24.6% of school-aged children had speech delay or
speech sound disorders (Black, Vahratian, & Hoffman, 2015; Law, Boyle, Harris, Harkness and Nye,
2000; Shriberg, Tomblin, & McSweeny, 1999;
• A 2012 survey from the National Center for Health Statistics estimated that, among children with a
communication disorder, 48.1% of children ages 3 to 10 and 24.4% of children ages 11 to 17 years they
only had problems with speech. Parents reported that 67.6% of children with speech problems received
speech intervention services (Black et al., 2015).
• Residual or persistent speech errors were estimated to occur in 1% to 2% of older children and adults
(Flipsen, 2015).
• Reports estimated that speech sound disorders are more common in boys than girls, with the ratio
ranging from 1.5:1.0 to 1.8:1.0 (Shriberg et al., 1999; Wren et al., 2016).
• Prevalence rates were estimated at 5.3% in African American children and 3.8% in White children
(Shriberg et al., 1999).
• Reports estimated that between 11% and 40% of children with speech sound disorders had comorbid
language disorders (Eadie et al., 2015; Shriberg et al., 1999).
• Poor speech sound production skills in kindergarten children have been associated with lower literacy
outcomes (Overby, Trainin, Smit, Bernthal, & Nelson, 2012). Estimates reported a higher likelihood of
reading disorders (relative risk:
2.5) in children with a preschool history of speech sound disorders (Peterson, Pennington, Shriberg, &
Boada, 2009).

Signs and symptoms of functional speech sound disorders include the following:

• omissions/deletions – Certain sounds are omitted or removed (e.g. "cu" for "cup" and "poon" for "spoon")
• substitutions: one or more sounds are substituted , which may result in loss of phonemic contrast (e.g., "thing"
for "sing" and "wabbit" for "rabbit")
• additions: one or more additional sounds are added or inserted into a word (for example, "buhlack" for "black")
• distortions: sounds are altered or changed (for example, a side "s")
• Syllable level errors : Weak syllables are removed (e.g. e.g., "tephone" for "telephone")

Signs and symptoms may appear as independent articulation errors or as error patterns based on phonological
rules (see ASHA's resource on selected phonological processes [patterns] for examples). In addition to these
common rule-based error patterns, idiosyncratic error patterns can also occur. For example, a child may
substitute many sounds with a favorite or default sound, resulting in a considerable number of homonyms (e.g.
For example, The shore, the wound, the task and the tear can be pronounced as door ; Grunwell, 1987;
Williams, 2003a)

Influence of accent
An accent is the only way speech is pronounced by a group of people who speak the same language and is a
natural part of spoken language. Accents can be regional; For example, someone from New York may sound
different than someone from South Carolina. Foreign accents occur when a set of phonetic features of a language
are transmitted when a person learns a new language. The first language acquired by a bilingual or multilingual
individual can influence the pronunciation of speech sounds and the acquisition of phonotactic rules in later
acquired languages. No accent is "better" than another. Accents, like dialects, are not disorders of speech or
language but, rather, only reflect differences. See ASHA's practice portal pages on Bilingual Service Delivery
and Cultural Competency .

Dialect influence
Not all sound substitutions and omissions are speech errors. Instead, they may be related to a feature of a
speaker's dialect (a rule-governed language system that reflects the regional and social background of its
speakers). Dialectal variations of a language can cross all linguistic parameters, including phonology,
morphology, syntax, semantics and pragmatics. An example of a dialect variation in phonology occurs with
speakers of African American English (AAE) when a "d" sound is used for a "th" sound (e.g., "dis" for "this").
This variation is not evidence of a speech sound disorder but, rather, one of the phonological characteristics of
AAE.
Speech-language pathologists (SLPs) must distinguish between dialect differences and communicative disorders
and must

• recognize all dialects as rule-governed linguistic systems;

• understand the rules and linguistic characteristics of the dialects represented by your clientele; and
• be familiar with nondiscriminatory testing and dynamic assessment procedures, such as identifying potential
 sources of test bias, administering and scoring standardized tests using alternative methods, and analyzing test
results in light of existing information on dialect use (see, for example, McLeod, Verdon, and The International
Panel of Experts on Multilingual Children's Speech, 2017).

The cause of functional speech sound disorders is not known; however, some risk factors have been investigated.
Frequently reported risk factors include the following:

• Gender: The incidence of speech sound disorders is higher in men than in women (e.g., Everhart, 1960;
Morley, 1952; Shriberg et al., 1999).
• Pre- and perinatal problems : Factors such as maternal stress or infections during pregnancy,
complications during childbirth, premature birth, and low birth weight were associated with delayed
speech sound acquisition and speech sound disorders. speech (e.g., Byers Brown, Bendersky, &
Chapman, 1986; Fox, Dodd, & Howard, 2002).
• Family history: Children who have family members (parents or siblings) with speech and/or language
difficulties are more likely to have a speech disorder (e.g., Campbell et al., 2003; Felsenfeld, McGue, &
Broen, 1995; Fox et al., 2002; Shriberg & Kwiatkowski, 1994).
• Persistent otitis media with effusion : Persistent otitis media with effusion (often associated with
hearing loss) has been associated with poor speech development (Fox et al., 2002; Silva, Chalmers, &
Stewart, 1986; Teele, Klein , Chase, Menyuk, & Rosner, 1990).

Speech-language pathologists (SLPs) play a central role in the examination, evaluation, diagnosis, and treatment
of people with speech sound disorders. Professional roles and activities in speech-language pathology include
clinical/educational services (diagnosis, evaluation, planning, and treatment); prevention and defense; and
education, administration and research. See ASHA Scope of Practice in Speech-Language Pathology (ASHA,
2016b).
Appropriate roles for SLPs include the following:

• Provide prevention information to individuals and groups known to be at risk for speech sound disorders,
as well as people who work with people at risk
• Educate other professionals about the needs of people with speech sound disorders and the role of SLPs
in the diagnosis and management of speech sound disorders.
• Evaluate individuals presenting with speech difficulties and determine the need for further evaluation
and/or referral for other services
• Recognize that students with speech sound disorders are at increased risk for later language and literacy
problems
• Conduct a comprehensive culturally and linguistically relevant assessment of speech, language and
communication
• Taking into account the rules of a spoken accent or dialect, the typical acquisition of two languages from
birth and the sequential acquisition of a second language to distinguish the difference from the disorder
• Diagnosis of the presence or absence of a speech sound disorder.
• Consult and collaborate with other professionals to rule out other conditions, determine etiology, and
facilitate access to comprehensive services.
• Make decisions about the management of speech sound disorders.
• Make decisions about eligibility for services based on the presence of a sound disorder
speech
• Develop treatment plans, provide intervention and support services, document progress, and determine
appropriate service delivery approaches and dismissal criteria.

• Counsel people with speech sound disorders and their families/caregivers on communication-related
issues and provide education aimed at preventing additional complications related to speech sound
disorders.
• Serving as an integral member of an interdisciplinary team working with individuals with speech sound
disorders and their family members/caregivers (see ASHA's resource on Interprofessional Education
/Interprofessional Practice [IPE/IPP] )
• Consult and collaborate with professionals, family members, caregivers, and others to facilitate program
development and provide supervision, evaluation, and/or expert testimony (see ASHA's resource on
person- and family - centered care )
• Stay informed of research in the area of speech sound disorders, help advance the knowledge base
related to the nature and treatment of these disorders, and use evidence-based research to guide
intervention.
• Advocate for people with speech sound disorders and their families at the local, state, and national levels

Screening
The evaluation is performed when a speech sound disorder is suspected or as part of a comprehensive speech
and language evaluation for a child with communication problems. The purpose of the evaluation is to identify
individuals who require additional speech and language evaluation and/or referral for other professional services.
Screening typically includes
 • detection of individual speech sounds in individual words and in connected speech (using formal and informal
detection measures);
• detection of oral motor functioning (e.g. strength and range of motion of oral musculature);
• orofacial examination to evaluate facial symmetry and identify possible structural bases for speech sound
disorders (e.g. e.g., submucosal cleft palate, malocclusion, ankyloglossia); and
• Informal assessment of language comprehension and production.

See ASHA's resource on assessment tools, techniques, and data sources .

Detection may result in

• recommendation to monitor speech and reevaluate;

• reference for multi-tiered support systems, such as response to intervention (RTI) ;
• reference for a comprehensive speech sound evaluation;
• recommendation for a comprehensive language evaluation, if a language delay or disorder is suspected;
• referral to an audiologist for a hearing evaluation, if hearing loss is suspected; and
• referral for medical or other professional services, as appropriate.

Comprehensive evaluation
The acquisition of speech sounds is a developmental process, and children often demonstrate "typical" errors and
phonological patterns during this period of acquisition. Developmentally appropriate errors and patterns are
taken into account during the evaluation of speech sound disorders to differentiate typical errors from those that
are unusual or not age-appropriate.
The comprehensive evaluation protocol for speech sound disorders may include an evaluation of spoken and
written language skills, if indicated. See ASHA's Practice Portal pages on Spoken Language Disorders and
Written Language Disorders .
Assessment is conducted using a variety of measures and activities, including standardized and non-standardized
measures, as well as formal and informal assessment tools. See ASHA's resource on assessment tools,
techniques, and data sources .
SLPs select assessments that are culturally and linguistically sensitive, taking into account current research and
best practices for assessing speech sound disorders in the languages and/or dialects used by the individual (see,
for example, McLeod et al. , 2017). Standard scores cannot be reported for assessments that are not normed on a
group that is representative of the person being assessed.
SLPs take into account cultural and linguistic differences in communities, including

• the phonemic and allophonic variations of the languages and/or dialects used in the community and how those
variations affect the determination of a disorder or difference and
• Differences between speech sound disorders, accents, dialects, and transfer patterns from one language to another.
Consult phonemic inventories and cultural and linguistic information in all languages .

In accordance with the World Health Organization (WHO) International Classification of Functioning,
Disability and Health (ICF) framework (ASHA, 2016a; WHO, 2001), a comprehensive assessment is conducted
to identify and describe

• deficiencies in body structure and function, including underlying strengths and weaknesses in speech sound
production and verbal/non-verbal communication;
• comorbid impairments or conditions, such as developmental disabilities, medical conditions or syndromes;
• limitations in activity and participation, including functional communication, interpersonal interactions with
family and peers, and learning;
• contextual factors (environmental and personal) that serve as barriers or facilitators to successful
communication and participation in life; and
• The impact of communication deficiencies on the quality of life of the child and family.

See ASHA's Person -Centered Approach to Function: Speech Sound Disorder [PDF] for an example of ICF-
compatible assessment data.
The evaluation may result in

• diagnosis of a speech sound disorder;

• description of the characteristics and severity of the disorder;
• recommendations for intervention objectives;
• identification of factors that could contribute to speech sound disorder;
• diagnosis of a spoken language disorder (listening and speaking);
• identification of written language problems (reading and writing);
• recommendation to monitor reading and writing progress in students with speech sound disorders identified by
SLPs and other professionals in the school setting;
• referral for multi-tiered support systems, such as response to intervention (RTI) to support speech and language
development; and
• Referral to other professionals as necessary.
Case history
The case history typically includes gathering information about

• the family's concerns about the child's speech;

• history of middle ear infections;
• family history of speech and language difficulties (including reading and writing);
• languages used at home;
• primary language spoken by the child;
• perceptions of intelligibility of family and other communication partners; and
•
speech
the teacher's perception of the child's intelligibility and participation in the school environment and how the child's
child compares himself with that of his peers in the classroom.

Please see the ASHA Practice Portal page on Cultural Competency for guidance on taking a clinical history for
all clients.

Examination of the oral mechanism

The oral mechanism examination evaluates the structure and function of the speech mechanism to evaluate
whether the system is suitable for speech production. This exam typically includes the evaluation of

• dental occlusion and specific dental deviations;

• Structure of the hard and soft palate (clefts, fistulas, bifid uvula); and
• Function (strength and range of motion) of the lips, jaw, tongue, and velum.

hearing exam
A hearing screening is performed during the comprehensive speech sound evaluation, if one was not completed
during the screening.
The hearing test usually includes

• otoscopic inspection of the ear canal and tympanic membrane;

• pure tone audiometry; and
• Immittance tests to evaluate middle ear function.

Speech sound evaluation

Speech sound assessment uses standardized assessment instruments and other sampling procedures to evaluate
production in individual words and connected speech.

The single-word test provides identifiable units of production and allows most consonants in the language to be
elicited in a range of phonetic contexts; however, it may or may not accurately reflect the production of the same
sounds in connected speech.
Connected speech sampling provides information about sound production in connected speech using a variety
of conversational tasks (e.g., storytelling or retelling, picture descriptions, normal conversations about a topic of
interest) and with a variety of communication partners (e.g., peers, siblings, etc.). parents and clinician).
The speech evaluation includes evaluation of the following:

• Precise productions
o sounds in various word positions (e.g., initial, within-word, and word-final position) and in different
phonetic contexts;
o sound combinations such as vowel blends, consonant clusters, and blends; and
o Syllable forms : Simple CV to complex CCVCC.
•Speech sound errors
o consistent sound errors;
o types of error (e.g., deletions, omissions, substitutions, distortions, additions); and o distribution of errors
(e.g., sound position in the word).
• Error patterns (i.e., phonological patterns): systematic sound changes or simplifications that affect a class of
sounds (e.g., fricatives), combinations of sounds (e.g., consonant clusters), or syllable structures (e.g., complex
syllables or polysyllabic words).

See Age of Consonant Acquisition in English (Roth & Worthington, 2018) and ASHA's resource on selected
phonological processes (patterns) . See also McLeod and Crowe (2018) for a linguistic review of consonant
acquisition.

Severity assessment
Severity is a qualitative judgment made by the clinician that indicates the impact of the child's speech sound
disorder on functional communication. It is typically defined along a continuum from mild to severe or
profound. There is no clear consensus regarding the best way to determine the severity of a speech sound
disorder: rating scales and quantitative measures have been used.
A numerical scale or disability continuum is often used because it is time efficient. Prezas and Hodson (2010)
use a continuum of severity from mild (omissions are rare; few substitutions) to profound (extensive omissions
and many substitutions; extremely limited phonemic and phonotactic repertoires). Distortions and assimilations
occur to varying degrees at all levels of the continuum.
A quantitative approach (Shriberg & Kwiatkowski, 1982a, 1982b) uses percent consonants correct (PCC) to
determine severity on a continuum from mild to severe.
To determine the PCC, collect and phonetically transcribe a speech sample. Then count the total number of
consonants in the sample and the total number of correct consonants. Use the following formula:
PCC = (correct consonants / total consonants) × 100
A PCC of 85 to 100 is considered mild, while a PCC of less than 50 is considered severe. This approach has
been modified to include a total of 10 indices, including percent vowels correct (PVC; Shriberg, Austin, Lewis,
McSweeny, & Wilson, 1997).

Intelligibility evaluation
Intelligibility is a perceptual judgment based on how much of the child's spontaneous speech is understood by
the listener. Intelligibility can vary along a continuum ranging from intelligible (the message is completely
understood) to unintelligible (the message is not understood; Bernthal et al., 2017). Intelligibility is frequently
used when judging the severity of a child's speech problem (Kent, Miolo, & Bloedel, 1994; Shriberg &
Kwiatkowski, 1982b) and can be used to determine the need for intervention.
Intelligibility may vary depending on a number of factors, including
• the number, type, and frequency of speech sound errors (when present);
• the speaker's speed, inflection, stress patterns, pauses, voice quality, volume, and fluency;
• linguistic factors (e.g. word choice and grammar);
• complexity of expression (p. e.g., single words versus conversation or conversation);
• the listener's familiarity with the speaker's speech pattern;
• communication environment (p. e.g., familiar vs. stranger communication partners, conversation one
• one versus group);

• communication cues to the listener (e.g., nonverbal cues from the speaker, including gestures and facial
expressions); and
• signal-to-noise ratio (i.e. amount of background noise).

Rating scales and other estimates that rely on perceptual judgments are commonly used to assess
intelligibility. For example, rating scales sometimes use numerical ratings such as 1 for completely intelligible
and 10 for unintelligible, or use descriptors such as not at all, rarely, sometimes, most of the time, or always to
indicate how well speech is understood. (Ertmer, 2010).
A number of quantitative measures have also been proposed, including calculating the percentage of words
understood in conversational speech (e.g., Flipsen, 2006; Shriberg & Kwiatkowski, 1980). See also Kent et al.
(1994) for a comprehensive review of procedures for assessing intelligibility.
Coplan and Gleason (1988) developed a standardized intelligibility screener that uses parents' estimates of how
intelligible their child sounded to others. Based on the data, the expected intelligibility cut-off values for
typically developing children were as follows:
22 months — 50%
37 months — 75%
47 months — 100%
See the Resources section for resources related to assessing intelligibility and participation in life in monolingual
children who speak English and in monolingual children who speak languages other than English.

Stimulation tests
Stimulation is the child's ability to accurately imitate a poorly articulated sound when the clinician provides a
model. There are few standardized procedures for testing stimulation (Glaspey & Stoel-Gammon, 2007; Powell
& Miccio, 1996), although some test batteries include stimulation subtests.
Stimulation tests help determine

• how well the child imitates the sound in one or more contexts (e.g., isolation, syllable, word, phrase);
• the level of localization necessary to achieve the best production (e.g., auditory model; auditory model
and visual; auditory, visual and verbal model; tactile signals);
• whether the sound is likely to be acquired without intervention; and
• what goals are appropriate for therapy (Tyler & Tolbert, 2002).
speech perception test
Speech perception is the ability to perceive differences between speech sounds. In children with speech sound
disorders, speech perception is the child's ability to perceive the difference between the standard production of a
sound and his or her own error production, or to perceive the contrast between two phonetically similar sounds
(e.g., r/w, s/sh, f/th).
Speech perception skills can be tested using the following paradigms:

• Auditory discrimination: Pairs containing a single phoneme are presented, and the child is instructed to say
“same” if the paired items sound the same and “different” if they sound different.
• Picture Identification: The child is shown two to four pictures representing words with minimal phonetic
differences. The doctor says one of these words and the child is asked to point to the correct picture.
• Pronunciation accuracy/inaccuracy
o Speech production: perception task: When using sounds that the child is suspected of having difficulty
perceiving, visual targets containing these sounds are used as visual cues. The child is asked to judge
whether the speaker says the article correctly (e.g., a picture of a ship is shown; the speaker says “ship” or
“yep”; Locke, 1980).
o Mispronunciation detection task : Using computer-presented picture stimuli and recorded stimulus names
(either correct or with a single phoneme error), the child is asked to detect a mispronunciation by pointing
to a mark green for “correct” or a red cross for “incorrect” (McNeill & Hesketh, 2010).
o Lexical decision/judgment task: Using target pictures and single-word recordings, this task assesses the
child's ability to identify words that are pronounced correctly or incorrectly. A picture of the target word
(e.g., “lake”) is displayed, along with a recorded word, either “lake” or a word with a contrasting phoneme
(e.g., “wake”). The child points to the picture of the target word if it was pronounced correctly or to an
“X” if it was pronounced incorrectly (Rvachew, Nowak, & Cloutier, 2004).

Considerations for evaluating toddlers and/or children who are reluctant or have less intelligible speech
Young children may not be able to follow directions for standardized tests, have limited expressive vocabulary,
and produce unintelligible words. Other children, regardless of age, may produce less intelligible speech or be
reluctant to speak in a testing setting.
Strategies for collecting an adequate speech sample with these populations include

• obtain a speech sample during the assessment session using game activities;
• use pictures or toys to elicit a variety of consonant sounds;
• involve parents/carers in the session to encourage talking;
• asking parents/caregivers to supplement data from the assessment session by recording the child's speech at home
during spontaneous conversation; and
• asking parents/caregivers to keep a record of the child's intended words and how these words are pronounced.

Sometimes the speech sound disorder is so severe that the child's intended message cannot be understood.
However, even when a child's speech is unintelligible, it is usually possible to obtain information about his or
her speech sound production.
For example:

• A single-word articulation test provides opportunities for the production of identifiable sound units, and these
productions can usually be transcribed.
• It may be possible to understand and transcribe a spontaneous speech sample by (a) using a structured situation to
provide context when obtaining the sample and (b) annotating the recorded sample by repeating the child's
utterances, when possible, to facilitate transcription. later.

Considerations for evaluating bilingual/multilingual populations

Assessment of a bilingual individual requires an understanding of both language systems because the sound
system of one language can influence the sound system of another language. The evaluation process should
identify whether the differences are truly related to a speech sound disorder or are normal speech variations
caused by the first language.
When evaluating a bilingual or multilingual person, clinicians generally

• collect information, including

o language history and language use to determine which language(s) should be assessed, o phonological
inventory, phonological structure and syllable structure of the non-English language, and o individual's
dialect;
• assess phonological skills in both languages in individual words as well as connected speech;
• take into account dialect differences, when they are present; and
• identify and evaluate the child
either common substitution patterns (those seen in typically developing children),
either unusual substitution patterns (those often seen in people with a sound disorder
of speech), and
o Cross-linguistic effects (the phonological system of the native language influences the production of sounds
 in English, resulting in an accent, that is, phonetic features of a person's original language (L1) that are
transferred to a second language (L2 ; Fabiano-Smith & Goldstein, 2010).

View phonemic inventories and cultural and linguistic information in all languages and ASHA's practice portal
page on providing bilingual services . See the Resources section for information related to assessing the
intelligibility and participation in life of monolingual children who speak English and monolingual children who
speak languages other than English.

Phonological Processing Assessment

Phonological processing is the use of the sounds of one's language (i.e., phonemes) to process spoken and
written language (Wagner & Torgesen, 1987). The broad category of phonological processing includes
phonological awareness , phonological working memory , and phonological retrieval .
The three components of phonological processing (see definitions below) are important for speech production
and for the development of spoken and written language skills. Therefore, it is important to assess phonological
processing skills and monitor the spoken and written language development of children with phonological
processing difficulties.

• Phonological awareness is the awareness of the sound structure of a language and the ability to consciously
analyze and manipulate this structure through a variety of tasks, such as speech sound segmentation and word
blending, onset, syllable and phonemic levels.

• Phonological working memory consists of storing phoneme information in a temporary short-term memory store
(Wagner and Torgesen, 1987). This phonemic information is then readily available for manipulation during
phonological awareness tasks. Repetition without words (p. E.g., repeating "/pæg/") is an example of a
phonological working memory task.
• Phonological retrieval is the ability to retrieve phonological information from long-term memory. It is usually
assessed using rapid naming tasks (e.g., rapid naming of objects, colors, letters, or numbers). This ability to
retrieve phonological information from your language is an integral part of phonological awareness.

Language assessments
Language testing is included in a comprehensive speech sound evaluation because of the high incidence of co-
occurring language problems in children with speech sound disorders (Shriberg & Austin, 1998).

Spoken language assessment (listening and speaking)

Typically, spoken language assessment begins with an assessment of expressive and receptive skills; A full
battery is performed if indicated by the exam results. See the ASHA Practice Portal page on Spoken Language
Disorders for more details.

Assessment of written language (reading and writing)

Difficulties with the speech processing system (e.g., listening, discriminating speech sounds, remembering
speech sounds, producing speech sounds) can lead to difficulties in speech production and phonological
awareness. These difficulties can have a negative impact on the development of reading and writing skills
(Anthony et al., 2011; Catts, McIlraith, Bridges, & Nielsen, 2017; Leitão & Fletcher, 2004; Lewis et al., 2011).
For typically developing children, speech production and phonological awareness develop in ways that are
mutually supportive (Carroll, Snowling, Stevenson, & Hulme, 2003; National Institute for Literacy, 2009). As
children engage in sound games, they learn to segment words into separate sounds and "map" the sounds onto
printed letters.
Understanding that sounds are represented by a symbolic code (e.g., letters and letter combinations) is essential
for reading and spelling. When reading, children need to be able to segment a written word into individual
sounds, based on their knowledge of the code, and then combine those sounds to form a word. When spelling,
children should be able to segment a spoken word into individual sounds and then choose the correct code to
represent these sounds (National Institute of Child Health and Human Development, 2000; Pascoe, Stackhouse,
& Wells, 2006).
Components of written language assessment include the following, depending on the child's age and expected
stage of written language development:

• Print awareness : Recognize that books have a front and a back, recognize that the direction of words is from left
to right, and recognize where words start and stop on the page.
• Alphabet Knowledge: Includes naming/printing letters of the alphabet from A to Z.
• Sound – Symbol Matching: Knowing that letters have sounds and knowing the corresponding letter sounds and
letter combinations.
• Reading Decoding : Using knowledge of sound symbols to segment and blend sounds in grade level words.
• Spelling: Use knowledge of sound symbols to spell grade level words.
• Reading fluency: reading fluently without frequent or significant pauses.
• Reading Comprehension : Understanding grade-level text, including the ability to make inferences.
The broad term "speech sound disorder(s)" is used on this Portal page to refer to functional speech sound
disorders, including those related to the motor production of speech sounds (articulation) and those related to the
linguistic aspects of speech production (phonology). ).
It is often difficult to cleanly differentiate between articulation and phonological errors or to differentially
diagnose these two separate disorders. However, we often talk about types of articulation error and types of
phonological error within the broad diagnostic category of speech disorder(s). A single child can show both
types of errors, and those specific errors may need different treatment approaches.
Historically, treatments that focus on the motor production of speech sounds are called articulation
approaches; Treatments that focus on the linguistic aspects of speech production are called
phonological/language-based approaches.
Articulation approaches target each sound deviation and are often selected by the clinician when the child's
errors are assumed to be motor-based; The goal is the correct production of the target sounds.
Phonological/language-based approaches target a group of sounds with similar error patterns, although the
actual treatment of error pattern exemplars may target individual sounds. Phonological approaches are often
selected in an effort to help the child internalize phonological rules and generalize these rules to other sounds
within the pattern (e.g., final consonant deletion, cluster reduction).
Articulation and language- and phonology-based approaches can be used in therapy with the same individual at
different times or for different reasons.
Both approaches to treating speech sound disorders generally involve the following sequence of steps:

• Establishment: selection of target sounds and stabilization of production at a voluntary level.

• Generalization: Facilitate the transfer of sound productions to increasingly challenging levels (e.g., syllables,
words, phrases/sentences, conversational speech).
• Maintenance: stabilize the target sound production and make it more automatic; Encourage self-control of speech
and self-correction of errors.

Target selection
Approaches to selecting initial therapy targets for children with articulation and/or phonological disorders
include the following:

• Developmental sounds : targets are selected according to the order of acquisition in children with a
typical development.
• Non-developmentally/theoretically motivated, which includes the following:
o Complexity: focuses on more complex and linguistically marked phonological elements that are not in the
child's phonological system to promote cascading and generalized learning of sounds (Gierut, 2007;
Storkel, 2018).
o Dynamic systems: focuses on teaching and stabilizing simple target phonemes that do not introduce new
feature contrasts into the child's phonological system to assist in the acquisition of target sounds and more
complex targets and features (Rvachew & Bernhardt, 2010).
o Systemic: focuses on the role of sound in the child's phonological organization to achieve maximum
phonological reorganization with the least amount of intervention. Target selection is based on a distance
metric. Targets can be maximally different from the child's error in terms of place, voice, and manner, and
they can also be maximally different in terms of manner, place of production, and expression (Williams,
2003b). See the Places, Manners, and Voices Chart for English Consonants (Roth & Worthington, 2015) .
• Client-Specific: Select targets based on factors such as relevance to the child and family (e.g., the sound is in the
child's name), stimulation, and/or visibility when it occurs (e.g., / f/vs. /k/).
• Degree of deviation and impact on intelligibility: Select targets based on errors (e.g., errors of omission; error
patterns such as deletion of initial consonants) that most affect intelligibility.

See ASHA's Person -Centered Approach to Function: Speech Sound Disorder [PDF] for an example of goal
setting consistent with ICF.

Treatment strategies
In addition to selecting appropriate goals for therapy, SLPs select treatment strategies based on the number of
intervention goals that need to be addressed in each session and the manner in which these goals are
implemented. A particular strategy may not be appropriate for all children and strategies may change throughout
the course of intervention as the child's needs change.
"Target attack" strategies include the following:

• Vertical : Intense practice on one or two targets until the child reaches a specific criterion level (usually at the
conversational level) before moving on to the next target or targets (see, for example, Fey, 1986).
• Horizontal, intense practice on a few objectives; Multiple targets are addressed individually or interactively in the
same session, providing exposure to more aspects of the sound system (see, for example, Fey, 1986).
• Cyclic: elements incorporating horizontal and vertical structures; the child is given practice on a given goal or
 goals for a predetermined period of time before moving on to another goal or goals for a predetermined period of
time. Then, practice cycling through all the objectives again (see, for example, Hodson, 2010).

Treatment options
The following are brief descriptions of both general and specific treatments for children with speech sound
disorders. These approaches can be used to treat speech sound problems in a variety of populations. See Speech
Characteristics: Selected Populations [PDF] for a brief summary of selected populations and characteristic
speech problems.
Treatment selection will depend on several factors, including the age of the child, the type of speech sound
errors, the severity of the disorder, and the degree to which the disorder affects general intelligibility (Williams,
McLeod, & McCauley, 2010). This list is not exhaustive, and inclusion does not imply endorsement by ASHA.

Contextual utilization approaches

Contextual utilization approaches recognize that speech sounds are produced in syllable-based contexts in
connected speech and that some contexts (phonemic/phonetic) can facilitate the correct production of a
particular sound.
Contextual utilization approaches may be useful for children who use a sound inconsistently and need a method
to facilitate consistent production of that sound in other contexts. Instruction for a particular sound begins in the
syllable context(s) where the sound can be produced correctly (McDonald, 1974). The syllable is used as the
building block for practice at more complex levels.
For example, the production of a “t” can be facilitated in the context of a high front vowel, as in “tea” (Bernthal
et al., 2017). Facilitative contexts or “best possible options” for production can be identified for voiced, velar,
alveolar, and nasal consonants. For example, a “best bet” for nasal consonants is before a low vowel, as in
“angry” (Bleile, 2002).

Contrast Phonological Approaches

Phonological contrast approaches are frequently used to address phonological error patterns. They focus on
improving phonemic contrasts in the child's speech by emphasizing the sound contrasts necessary to differentiate
one word from another. Contrast approaches use pairs of contrasting words as targets rather than individual
sounds.
There are four different contrastive approaches: minimal oppositions, maximum oppositions , empty set
treatment , and multiple oppositions.

• Minimal Oppositions (also known as “minimal pairs” therapy): Use pairs of words that differ by a single
phoneme or unique feature that indicates a change in meaning. Minimal pairs are used to help establish contrasts
that are not present in the child's phonological system (e.g., “door” vs. “pain,” “pot” vs. “dot,” “key” vs. “tea”;
Blache, Parsons, & Humphreys, 1981;
• Maximal Oppositions: Uses word pairs containing a contrasting sound that is as distinct as possible and varies
along multiple dimensions (e.g., voice, place, and manner) to teach an unfamiliar sound. For example, "mall" and
"call" are maximal pairs because /m/ and /k/ vary in more than one dimension: /m/ is a nasally voiced bilabial
voice, while /k/ is a voiceless stop without voice (Gierut, 1989, 1990, 1992). See the Places, Manners, and Voices
Chart for English Consonants (Roth & Worthington, 2018) .
• Empty set treatment: Similar to the maximal oppositions approach, but uses word pairs containing two
maximally opposite sounds (e.g., /r/ and /d/) that are unknown to the child (e.g., "row" vs. to "doe") or "ray" vs.
"day"; Gierut, 1992).
• Multiple Oppositions: A variation of the minimal oppositions approach, but uses word pairs that contrast a child's
error sound with three or four strategically selected sounds that reflect both maximal classification and maximal
distinctiveness (e.g., "door," "four", "task") and "store", to reduce the fallback from /d/ to /g/; Williams, 2000a,
2000b).

Complexity approach
The complexity approach is a speech production approach based on data supporting the view that the use of
more complex linguistic stimuli helps promote generalization to untreated but related targets.
The complexity approach grew mainly from the maximum oppositions approach. However, it differs from the
maximum oppositions approach in several ways. Instead of selecting targets based on characteristics such as
voice, place, and manner, target complexity is determined in other ways. These include hierarchies of
complexity (e.g., clusters, fricatives, and affricates are more complex than other sound classes) and stimulability
(i.e., sounds with the lowest levels of stimulation are the most complex). Furthermore, although the maximal
oppositions approach trains targets on contrasting word pairs, the complexity approach does not. See Baker and
Williams (2010) and Peña-Brooks and Hegde (2015) for detailed descriptions of the complexity approach.

Basic Vocabulary Focus

A core vocabulary approach focuses on whole word production and is used for children with inconsistent
production of speech sounds who may be resistant to more traditional therapy approaches.
The words selected for practice are those that are frequently used in the child's functional communication. A list
of high frequency words is developed (e.g., based on observation, parent report, and/or teacher report), and
several words are selected from this list each week for treatment. The child is taught his or her “best” word
production, and the words are practiced until they are produced consistently (Dodd, Holm, Crosbie, & McIntosh,
2006).

Cycles approach
The cycles approach focuses on phonological pattern errors and is designed for children with highly
unintelligible speech who have extensive omissions, some substitutions, and restricted consonant use.
Treatment is scheduled in cycles of 5 to 16 weeks. During each cycle, one or more phonological patterns are
targeted. After each cycle is completed, another cycle begins, which addresses one or more different
phonological patterns. Recycling of phonological patterns continues until specific patterns are present in the
child's spontaneous speech (Hodson, 2010; Prezas & Hodson, 2010).
The objective is to approximate the process of gradual typical phonological development. There is no
predetermined level of phoneme mastery or phoneme patterns within each cycle; Cycles are used to stimulate the
appearance of a specific sound or pattern, not to produce its mastery.

Distinctive features therapy

Distinctive feature therapy focuses on phoneme elements that are missing from a child's repertoire (e.g. e.g.,
friction, nasality, voice, and place of articulation) and is generally used for children who primarily substitute one
sound for another. See the Table of Places, Manners, and Voices for English Consonants (Roth & Worthington,
2018) .
Distinctive feature therapy uses targets (e.g., minimal pairs) that compare the phonetic elements/features of the
target sound to those of its substitution or some other sound contrast. Feature patterns can be identified and
targeted; The production of a target sound often generalizes to other sounds that share the specific feature
(Blache & Parsons, 1980; Blache et al., 1981; Elbert & McReynolds, 1978; McReynolds & Bennett, 1972;
Ruder & Bunce, 1981) .

metaphon therapy
Metaphonological therapy is designed to teach metaphonological awareness , that is, awareness of the
phonological structure of language. This approach assumes that children with phonological disorders have failed
to acquire the rules of the phonological system.
The focus is on the sound properties that need to be contrasted. For example, for voice problems, the concept of
"loud" (voice) versus "quiet" (voiceless) is taught. Targets generally include processes that affect intelligibility,
can be imitated, or are not seen in typically developing children of the same age (Dean, Howell, Waters, & Reid,
1995; Howell & Dean, 1994).

Naturalistic Speech Intelligibility Intervention

The naturalistic speech intelligibility intervention addresses the specific sound in naturalistic activities that
provide the child with frequent opportunities for the sound to be produced. For example, using a McDonald's
menu, signs at the grocery store, or favorite books, the child can be asked questions about the words that contain
the specific sounds. The child's error productions are recast without the use of imitative cues or direct motor
training. This approach is used with children who can use recasts effectively (Camarata, 2010).

Non-spoken oral and motor therapy

Non-speech oral-motor therapy involves the use of oral-motor training prior to teaching sounds or as a
supplement to speech sound instruction. The reason behind this approach is that (a) immature or poor oral
control or strength may be causing poor articulation and (b) articulator control needs to be taught before working
on correct production of sounds. Consult systematic reviews of this treatment to help guide clinical decision
making (see, for example, Lee & Gibbon, 2015 [PDF]; McCauley, Strand, Lof, Schooling, & Frymark, 2009 ) .
See also the Treatment section of the Speech Sound Disorders Evidence Map filtered for Oral-Motor Exercises .

Speech sound perception training

Speech sound perception training is used to help a child acquire a stable perceptual representation for the
target phoneme or phonological structure. The goal is to ensure that the child attends to appropriate acoustic cues
and evaluates them according to a language-specific strategy (i.e., one that ensures reliable perception of the
target in a variety of listening contexts).
Recommended procedures include (a) auditory bombardment in which many and varied target exemplars are
presented to the child, sometimes in a meaningful context such as a story and often with amplification, and (b)
identification tasks in which the child identifies correct and incorrect versions of the target (e.g., “rat” is a
correct example of the word corresponding to a rodent, while “wat” is not).
Tasks generally progress from the child judging the speech produced by others to the child judging the accuracy
of his or her own speech. Speech sound perception training is often used before and/or in conjunction with
speech production training approaches. See Rvachew, 1994; Rvachew et al., 2004; Rvachew, Rafaat, & Martin,
1999; Wolfe, Presley and Mesaris, 2003.
Traditionally, the speech stimuli used in these tasks are presented via live speech by the SLP. More recently,
computer technology has been used; An advantage of this approach is that it allows the presentation of more
varied stimuli representing, for example, multiple voices and a variety of error types.

Treatment techniques and technologies

Techniques used in therapy to increase awareness of the target sound and/or provide feedback on the placement
and movement of the articulators include the following:

• Use of a mirror for visual feedback of the place and movement of the articulators.
• Use of gestural cues for the place or form of production (for example, using a long gesture
broad hand gesture for fricatives instead of a short gesture for "cut")
• Using ultrasound imaging (placing an ultrasound transducer under the chin) as a biofeedback technique to
visualize the position and configuration of the tongue (Adler-Bock, Bernhardt, Gick, & Bacsfalvi, 2007; Lee,
Wrench, & Sancibrian , 2015; Preston, Brick, & Landi, 2013;
• Use of palatography (various coloring agents or a palatal device with electrodes) to record and visualize tongue
contact on the palate as the child makes different speech sounds (Dagenais, 1995; Gibbon, Stewart, Hardcastle, &
Crampin, 1999; Hitchcock, McAllister Byun, Swartz and Lázaro, 2017)
• Amplification of target sounds to improve attention, reduce distraction, and increase sound awareness and
discrimination; For example, auditory bombardment with low-level amplification is used with the loop approach at
the beginning and end of each session to help children perceive differences between errors and the target. sounds
(Hodson, 2010)
• Provide spectral biofeedback through a visual representation of the acoustic signal of the
speaks (McAllister Byun & Hitchcock, 2012)
• Provide tactile biofeedback using tools, devices, or substances placed inside the mouth (e.g., tongue depressors,
peanut butter) to provide information about correct tongue placement and coordination (Altshuler, 1961; Leonti,
Blakeley, & Louis, 1975 ; Shriberg, 1980)

Considerations for the treatment of bilingual/multilingual populations

When treating a bilingual or multilingual individual with a speech sound disorder, the clinician is working with
two or more different sound systems. While there may be some overlap in the phonemic inventories of each
language, there will be some sounds unique to each language and different phonological rules for each language.
One linguistic sound system can influence the production of the other sound system. The role of the SLP is to
determine whether the observed differences are due to a true communication disorder or whether these
differences represent speech variations associated with another language a child speaks.
Strategies used when designing a treatment protocol include

• determine whether a bilingual or multilingual approach should be used (see ASHA's Practice Portal page on
providing bilingual services );
• determine the language in which services will be provided, based on factors such as language history, language
use, and communication needs;
• identify alternative means of providing accurate models for specific phonemes that are unique to the child's
language, when the clinician is unable to do so; and
• noting whether success generalizes across languages throughout the treatment process (Goldstein & Fabiano,
2007).

Considerations for treatment in schools

Criteria for determining eligibility for services in a school setting are detailed in the Individuals with Disabilities
Education Improvement Act of 2004 (IDEA). Based on these criteria, the SLP must determine

• if the child has a speech sound disorder;

• whether there is an adverse effect on educational performance resulting from the disability; and
• if specially designed instruction and/or related services and supports are needed to help the student progress in the
general education curriculum.

Examples of adverse effects on educational performance include the following:

• Speech sound disorder affects a child's ability or willingness to communicate in the classroom (for example, when
responding to teachers' questions; during classroom discussions or oral presentations) and in social settings with
peers (for example (for example, interactions during lunch, recess, physical education, and extracurricular
activities).
• Speech sound disorder signals problems with phonological skills that affect spelling, reading, and writing. For
example, the way a child spells a word reflects the errors made when pronouncing the word. See the ASHA
Resource Language in Brief and the ASHA Practice Portal pages on Spoken Language Disorders and Written
Language Disorders for more information on the relationship between spoken and written language.
Eligibility for speech-language pathology services is documented in the child's individualized education
program, and the goals and dismissal process are explained to parents and teachers. For more information about
eligibility for services in schools, see ASHA's resources on eligibility and dismissal in schools , the IDEA Part B
Summary: Individualized Education Programs and Eligibility for Services , and the Final Rule. of Part C of the
2011 IDEA.
If a child is not eligible to receive services under IDEA, he or she may still be eligible to receive services under
the Rehabilitation Act of 1973, Section 504. 29 USC § 701 (1973) . See ASHA's Practice Portal page on
Documentation in Schools for more information on Section 504 of the Rehabilitation Act of 1973.
Exit from speech-language pathology services occurs once eligibility criteria are no longer met, that is, when the
child's communication problem no longer negatively affects academic performance and functional performance.

Children with persistent speech difficulties

Speech difficulties sometimes persist throughout the school years and into adulthood. Pascoe et al. (2006) define
persistent speech difficulties as "difficulties in normal speech development that do not resolve as the child
matures or even after they receive specific help for these problems" (p. 2). The population of children with
persistent speech difficulties is heterogeneous, varying in etiology, severity, and nature of the speech difficulties
(Dodd, 2005; Shriberg et al., 2010; Stackhouse, 2006; Wren, Roulstone, & Miller, 2012).
A child with persistent speech difficulties (functional speech sound disorders) may be at risk for

• Difficulty communicating effectively when speaking;

• difficulty acquiring reading and writing skills; and
• psychosocial problems (eg. e.g., low self-esteem, increased risk of bullying; see, p. e.g., McCormack, McAllister,
McLeod, & Harrison, 2012).

Intervention approaches vary and may depend on the child's area(s) of difficulty (e.g., spoken language, written
language, and/or psychosocial problems).
When designing an effective treatment protocol, the SLP considers

• teach and encourage the use of self-control strategies to facilitate the consistent use of learned skills;
• collaborate with teachers and other school staff to support the child and facilitate his or her access to the academic
curriculum; and
• the management of psychosocial factors, including self-esteem problems and bullying (Pascoe et al., 2006).

Transition planning
Children with persistent speech difficulties may continue to have problems with oral communication, reading
and writing, and social aspects of life during the transition to postsecondary education and vocational settings
(see, for example, Carrigg, Baker , Parry and Ballard, 2015). The potential impact of persistent speech
difficulties highlights the need for ongoing support to facilitate a successful transition to young adulthood. These
supports include the following:

• Transition Planning: The development of a formal transition plan in middle or high school that includes a
discussion of the need for ongoing therapy, if appropriate, and supports that may be needed in postsecondary
educational or vocational settings (IDEA, 2004).
• Disability Support Services : Individualized supports for postsecondary students that may include additional
time for exams, accommodations for oral speaking tasks, the use of assistive technology (for example, to assist
with reading and writing tasks), and the use of methods and devices to increase oral comprehension.
Communication, if necessary.