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SPEECH SOUND DISORDER · BIRTH THROUGH HIGH SCHOOL
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Everything you want to know about treatment approaches for speech sound disorders
From Van Riper to Cycles, Complexity to Core Vocabulary, and everything in between: this high-speed review of evidence-based intervention for speech sound disorders is like squeezing a semester into a half-hour. Spoiler alert—we may be thinking about articulation vs. phonological disorders all wrong.
August 13, 2022
This review was updated from the original version in August 2022. We made a correction to the research linked under the complexity approach.
Speech sound disorders. It’s one of those things our relatives who don’t really understand what we do assume is the only thing we do. It’s one of the areas of practice our field was founded on, and one where we’re fortunate to have an array of treatment approaches (like, dozens) backed up by decades of research. All these evidence-based options can be a challenge to navigate, though, and choosing the right approach could mean the difference between a child meeting their goals and “graduating” from speech and that same child staying on the caseload for years. That’s exactly why we’ve put together this Ask TISLP: to give you a starting point for making informed treatment decisions. To narrow things down, we’ll be focusing only on idiopathic (traditionally called “functional”) SSDs—those rooted in articulation and/or phonology and without a known cause. That means that we’re not talking CAS, dysarthria, or speech disorders related to cleft/craniofacial conditions or to hearing differences. But never fear! You can search all of those topics using the filters here to find reviews on supporting speech for those kiddos.
Here’s what to expect:
Before you ask—yes, there’s a cheat sheet. Grab our downloadable chart of treatment approaches here, but don’t skip the discussion, ok? Context matters. Let’s get this party started!
We make a distinction between articulation and phonologically based errors because we need to address them differently and because the phonology side of things has had a tendency to get overlooked.
Articulation errors are motor-based—there’s a breakdown in the movement of the articulators, so our therapy for articulation errors focuses on accurate placement and movement of the tongue, lips, teeth, etc.
Phonological errors, on the other hand, are language-based, meaning that the child has incorrect or fuzzy mental representations of the speech sounds. Let’s break that one down a bit. When we learn the phonology of a language, our brains learn the rules for which qualities of sounds are phonemic and important for meaning (like the final voicing difference in /bæk/ vs /bæg/), and which aren’t. For example, the aspirated /p/ in “pin” and the unaspirated one in “spin” both fit in our same mental category of English /p/—although the same wouldn’t be true for every language! A child with phonological errors may have internalized the “wrong” rules—like disregarding the manner difference between /s/ and /t/ and storing them in the same mental category. This might surface as a consistent stopping error. Fuzzy phonological representations happen when kids are still learning to make sense of the rules, like the fact that fricatives are long and noisy and stops are short, so they aren’t able to clearly and consistently distinguish fricatives from stops. This might show up as inconsistent errors. When you start looking, phonology is everywhere: even single-sound errors might show up phonologically in a child’s decoding and spelling. Therefore, phonological therapy needs to help the child internalize the correct phonological rules.
Of course, in a lot of cases, articulation and phonological issues are both in the mix. Kids that have both types of errors have incorrect/fuzzy representations stored in their brains AND make motor mistakes. For example, a child who glides liquids might not have /l/ and /w/ clearly stored as different phonemes in their brain—a phonological error—AND might also not be able to move the tongue tip to the alveolar ridge to produce /l/—the articulation error.
This all means that we need to collect sufficient data in a comprehensive assessment process to find these phonological issues when they exist. You can use formal assessments (like the HAPP-3, the DEAP, or the KLPA-3), speech sampling, and/or speech perception and phonological processing tasks like those described here to help you figure out if a child's errors are articulation-based, phonological, or both, and to identify any phonological patterns in the child’s errors. For an overview of comprehensive evaluations of children’s speech production, check out this open-access tutorial, this one for multilingual children, or this one for single speech sound errors.
After collecting all that excellent assessment data, you’ll choose the best match of a treatment approach and go from there, keeping in mind that you sometimes might have to start therapy before totally “figuring out” the child’s working speech sound system and exactly where all the breakdowns are. That’s where clinical data collection comes in!
At a certain point, the artic/phono dichotomy outstays its welcome. We’ll let Dr. Kelly Farquharson explain:
“Fey (1992) noted that articulation and phonology are “inextricable constructs.” That is—it’s REALLY hard to separate them into black and white, stand-alone categories. Pennington (2006) actually refers to the terms “articulation disorder” and “phonological disorder” as what speech sound disorders were formerly called. As in, he assumed that we’ve moved beyond that dichotomy a long time ago. His point, also, is that if we dichotomize it, we are making assumptions about the underlying issue that we simply can’t prove—said differently, how do we prove that phonological representations are “fuzzy”? In this paper I share a few case examples of children whose speech sound production might make you assume one diagnosis, but further data suggests otherwise. One child has a single sound error—which might make one assume an articulation disorder. However, his single sound error appeared in his spelling, which speaks to fuzzy representations. The inverse was true for the child with multiple sound patterns—he might appear phonological on the surface, but his phonological skills were intact otherwise.”
Let’s think of articulation and phonology as two different lenses for looking at a child’s speech sound errors—and for assessment and treatment, we need to be wearing bifocals.
We’ve sectioned our discussion of treatment approaches by which lens they’re based on, but don’t let that trick you into seeing your clinical decisions as an either/or situation (more on that later).
As we take you through the different approaches, we’ll briefly address the size and quality of the evidence base for each. We got a lot of this information from this 2021 textbook edited by Williams, McLeod, & McCauley, which is an excellent resource—nerd-out kind of reading—if you want to dive deeper. Overall, most of the evidence base for idiopathic SSD treatment is based on case studies or controlled case/cohort studies (level 2 or 3 evidence, if you use the SIGNS evidence grading system). There are some level 1 randomized controlled trials (RCTs), but they’re few and far in between. This makes sense, since even though RCTs are the “gold standard,” they’re difficult, time-consuming, and expensive to carry out. So while the evidence base here is much larger and more informative than in some other areas of SLP practice, it’s certainly not perfect. As always, it's important that we use our knowledge and experience to integrate the existing evidence, keeping in mind the needs of our clients/students and their families.
We’ll start with an old friend: the Traditional Articulation approach, with credit to Van Riper all the way back in 1939. It was developed for children with mild articulation errors and later adapted for children with moderate-to-severe errors.
Now chances are, this is one approach you’ve got down cold. Brumbaugh and Smit (we reviewed it here) found that SLPs supporting preschoolers with SSDs use the Traditional approach most frequently (and were less familiar with phonological approaches), and Cabbage and colleagues found it made the top three approaches among school-based SLPs, too. Remember, though, that the Traditional Articulation approach is unlikely to be efficient or effective for children with phonological errors, so don’t stop here!
Though we’ve seen some variations in the last 80-odd years, the key components of Traditional articulation therapy remain the same. It may have a bit of auditory perception tied in—like asking if the sounds /g/ and /d/ or the words “gate” and “date” are the same or different—but it always mostly targets motor production. Research on motor learning principles tells us that distributed, variable practice on a large number of complex targets is more advantageous compared to mass practice on a smaller number of simple targets (to refresh your memory on motor learning principles, see Tables 1 and 2 of this paper). You can also use a horizontal approach to target attack to improve efficiency. Some modern spins to articulation therapy include using a computer program (like SATPAC, discussed in this review) or biofeedback (see here, here, and here to learn more), both of which are especially useful options for older children who have residual distortions on sounds like /ɹ/.
The Stimulability Approach from Dr. Adele Miccio is another (short-term) option for addressing articulation in very young children (2–4 years old) who have extremely small phonetic inventories and are not yet stimulable for most consonant sounds. After stimulability improves, you can reassess and transition to a different approach as needed.
We have a few more choices under this lens, and it’s critical to choose carefully based on the number, type(s), and consistency of phonological errors. Remember that we’re not focusing only on the movement of the articulators here. Phonological approaches also need to address the fact that errors like producing “toe” for “so” result in differences in meaning. We put these approaches in bullet points for readability, but remember we also have the printable chart version here for easy scanning.
For more details and a comparison of minimal pairs, maximal oppositions, and multiple oppositions (AKA the contrastive approaches), see this tutorial. For all contrastive approaches, the SCIP app from Dr. A. Lynn Williams is an excellent resource for target selection and therapy.
We know children with SSDs may be at additional risk for literacy disorders—see our reviews on the relationship between SSDs and literacy here, here, and here. For kids where you suspect (or have confirmed) a literacy disorder, you can consider incorporating metaphonology in your treatment plan. This can look like targeting children’s explicit awareness of sounds’ distinctive features—place, manner, and voicing—using kid-friendly language. Some metaphonological approaches you may be familiar with include Metaphon (described by the creators here, or see the ASHA Practice Portal for a summary) and LiPS, although the evidence base for these programs is pretty limited.
Integrated Phonological Awareness Intervention takes things a step further by focusing on letter-sound knowledge and phonemic awareness. Rather than indirectly support literacy skills while you’re targeting speech, this approach embeds speech production practice in literacy activities, like syllable and rhyme awareness, segmenting, blending, and manipulating individual phonemes. We know of 9 studies (1 RCT) supporting IPAI for improving phonological awareness skills (many used the rules from the Cycles approach to select targets), although two studies (1 RCT), suggest that it may not be sufficient (at least not in realistic dosages) to correct speech sound errors. If you’re interested, check out these free phonological awareness resources from Dr. Gail Gillon, who led much of the research on IPAI.
Is your brain full? Has the word “approach” ceased to have any meaning? Approach… approach… aPPROach. Anyway. While these… intervention methods look nice and clear-cut on paper (like here, in our printable chart), there’s a lot of clinical judgment involved in carrying them out, so let’s chat about some lingering questions you may have:
Not necessarily. Let’s actually put “just artic” to bed, shall we? According to Farquharson, “this phrase makes the assumption that this type of communication disorder is less important and less complex than others” and may cause clinicians unintentionally to restrict their treatment options. She suggests SLPs “consider approaches such as minimal pairs, even if the child has a single sound error.”
If you’re wearing your cool artic-phono bifocals (3D glasses? Is that a cooler image?), you’ll NEED to mix and match to some extent to support both of those needs. The critical piece, which has sometimes slipped through the cracks, is this: if the child has (or may have) phonological errors, we need to clean up their phonological rules, so we need to choose a treatment approach that can do this. At the same time, we can’t forget to support accurate placement of the articulators. You’ll be pulling therapy components and concepts (like principles of motor learning, elicitation strategies, etc.) from articulation approaches to support this need.
But what if you have a child with a severe phonological SSD and literacy disorder on your caseload. Do you use Cycles, Maximal Oppositions, or a metaphonological approach? Unfortunately, friends, there isn’t a “right” answer here. Trust your clinical experiences and judgment to choose what you think will work for this particular child. Then, use regular data collection and feedback from the child and their family to monitor the effectiveness of the therapy approach. Don’t throw in the towel if it’s “not working” right away. Where we have the evidence to support it, we included details above about how long it may take to see results for a given approach. For Integrated Phonological Awareness Intervention, research suggests it may take 17–20 hours to see results, as compared to more like 30–40 hours of therapy for Cycles. If the child is not feeling the therapy, like say intense drill or even drill play = zero motivation, you may need to readjust. The child is making no progress—like really, no progress—you may need to readjust. We know you know therapy is a delicate balance of keeping the child motivated and making progress. Have confidence in your clinical expertise to back up your decisions!
Also, know that we’ve laid out the approaches for you as researchers originally designed and studied them. That said, there are a variety of reasons your clinical judgment might lead you to modify an approach for a specific child. Session length and frequency is one factor in particular that may be constrained by forces beyond your control. Again, you use your clinical judgment to modify the approach, but rely even more heavily on data and client perspectives to determine whether it’s working.
Finally, this list is not exhaustive. We've included the most common/popular approaches, but there are others out there!
There are other options! Naturalistic approaches are an evidence-based choice for young children with co-occurring speech and language disorders, such as autistic kids and those with Down syndrome or cleft lip/palate. These approaches capitalize on children’s interaction and engagement during play to facilitate speech production—and they’re more easily implemented by parents and caregivers than the other approaches we’ve talked about. You can start with naturalistic recasting during play, which is just what it sounds like—repeating the child’s utterance back to them (but without the errored sound/s) in natural play activities. And if you’re already doing Enhanced Milieu Teaching (EMT) or a similar approach including strategies like arranging the environment, following the child’s lead, modeling, and expanding productions, you can add a phonological emphasis (EMT+PE) to simultaneously support speech and language in naturally-occurring conversations during play. Our review of a study of children with cleft palate who participated in EMT+PE lays out the core strategies for you, or you can get more detail in this article.
Check out the research and resources linked above under each approach and in our downloadable chart. You can also consider:
Allen, M. M. (2013). Intervention efficacy and intensity for children with speech sound disorder. Journal of Speech, Language, and Hearing Research. https://doi.org/10.1044/1092-4388(2012/11-0076) [available to ASHA members]
Almost, D., & Rosenbaum, P. (1998). Effectiveness of speech intervention for phonological disorders: A randomized controlled trial. Developmental Medicine & Child Neurology. https://doi.org/10.1111/j.1469-8749.1998.tb15383.x [open access]
American Speech-Language Hearing Association. Selected Phonological Processes (Patterns)*. ASHA Practice Portal. https://www.asha.org/practice-portal/clinical-topics/articulation-and-phonology/selected-phonological-processes/
Bernthal, J., Bankson, N., & Flipsen, P. (2017). Articulation and phonological disorders: Speech sound disorders in children (8th ed.). Pearson.
Brumbaugh, K. M., & Smit, A. B. (2013). Treating children ages 3–6 who have speech sound disorder: A survey. Language, Speech, and Hearing Services in Schools. https://doi.org/10.1044/0161-1461(2013/12-0029) [available to ASHA members]
Cabbage, K. L., & DeVeney, S. L. (2020). Treatment approach considerations for children with speech sound disorders in school-based settings. Topics in Language Disorders. https://doi.org/10.1097/tld.0000000000000229
Cabbage, K., Farquharson, K., & DeVeney, S. (2022). Speech sound disorder treatment approaches used by school-based clinicians: An application of the experience sampling method. Language, Speech, and Hearing Services in Schools. https://doi.org/10.1044/2022_lshss-21-00167 [available to ASHA members]
Dean, E. C., Howell, J., Waters, D., & Reid, J. (1995). Metaphon: A metalinguistic approach to the treatment of phonological disorder in children. Clinical Linguistics & Phonetics. https://doi.org/10.3109/02699209508985318
Denne, M., Langdown, N., Pring, T., & Roy, P. (2005). Treating children with expressive phonological disorders: does phonological awareness therapy work in the clinic? International Journal of Language & Communication Disorders. https://doi.org/10.1080/13682820500142582
Dodd, B. (2013). Differential diagnosis and treatment of children with speech disorder (2nd ed.). John Wiley & Sons.
Dodd, B., Crosbie, S., McIntosh, B., Holm, A., Harvey, C., Liddy, M., .Fontyne, K., Pinchin, B, & Rigby, H. (2009). The impact of selecting different contrasts in phonological therapy. International Journal of Speech-Language Pathology. https://doi.org/10.1080/14417040701732590 [open access]
Dodd, B., Holm, A., Crosbie, S., & McIntosh, B. (2006). A core vocabulary approach for management of inconsistent speech disorder. Advances in Speech Language Pathology. https://doi.org/10.1080/14417040600738177
Fabiano-Smith, L. (2019). Standardized tests and the diagnosis of speech sound disorders. Perspectives of the ASHA Special Interest Groups. https://doi.org/10.1044/2018_PERS-SIG1-2018-0018 [open access]
Fey, M. E. (1992). Articulation and phonology: Inextricable constructs in speech pathology. Language, Speech, and Hearing Services in Schools. https://doi.org/10.1044/0161-1461.2303.225 [available to ASHA members]
Farquharson, K. (2019). It might not be “just artic”: The case for the single sound error. Perspectives of the ASHA Special Interest Groups. https://pubs.asha.org/doi/10.1044/2018_PERS-SIG1-2018-0019 [open access]
Hesketh, A., Dima, E., & Nelson, V. (2007). Teaching phoneme awareness to preliterate children with speech disorder: a randomized controlled trial. International Journal of Language & Communication Disorders. https://doi.org/10.1080/13682820600940141
Kaiser, A. P., Scherer, N. J., Frey, J. R., & Roberts, M. Y. (2017). The effects of enhanced milieu teaching with phonological emphasis on the speech and language skills of young children with cleft palate: A pilot study. American Journal of Speech-Language Pathology. https://doi.org/10.1044/2016_AJSLP-16-0008
[available to ASHA members]
Maas, E., Robin, D. A., Hula, S. N. A., Freedman, S. E., Wulf, G., Ballard, K. J., & Schmidt, R. A. (2008). Principles of motor learning in treatment of motor speech disorders. American Journal of Speech-Language Pathology. https://doi.org/10.1044/2022_LSHSS-21-00167
[available to ASHA members]
McLeod, S., & Baker, E. (2017). Children's speech: An evidence-based approach to assessment and intervention. Pearson.
McLeod, S., Verdon, S., Baker, E., Ball, M. J., Ballard, E., David, A. B., Bernhardt, B. M., Bérubé, D., Blumenthal, M., Bowen, C., Brosseau-Lapré, F., Bunta, F., Crowe, K., Cruz-Ferreira, M., Davis, B., Fox-Boyer, A., Gildersleeve-Neumann, C., Grech, H., Goldstein, B., Hesketh, A., Hopf, S., Kim, M., Kunnari, S., MacLeod, A., McCormack, J., Másdóttir, P., Mason, G., Masso, S., Neumann, S., Ozbič, M., Pascoe, M., Pham, G., Román, R., Rose, Y., Rvachew, S., Savinainen-Makkonen, T., Topbaş, S., Scherer, N., Speake, J., Stemberger, J. P., Ueda, I., Washington, K. N., Westby. C., Williams, A. L., Wren, Y., Zajdó, K., & Zharkova, N. (2017). Tutorial: Speech assessment for multilingual children who do not speak the same language (s) as the speech-language pathologist. American Journal of Speech-Language Pathology. https://doi.org/10.1044/2017_AJSLP-15-0161 [open access]
Ruscello, D. M., Cartwright, L. R., Haines, K. B., & Shuster, L. I. (1993). The use of different service delivery models for children with phonological disorders. Journal of Communication Disorders. https://doi.org/10.1016/0021-9924(93)90008-X
Rvachew, S., & Nowak, M. (2001). The effect of target-selection strategy on phonological learning. Journal of Speech, Language, and Hearing Research. https://doi.org/10.1044/1092-4388(2001/050)
[available to ASHA members]
Storkel, H. L. (2018). The complexity approach to phonological treatment: How to select treatment targets. Language, Speech, and Hearing Services in Schools. https://doi.org/10.1044/2017_LSHSS-17-0082 [open access]
Storkel, H. L. (2022). Minimal, maximal, or multiple: Which contrastive intervention approach to use with children with speech sound disorders? Language, Speech, and Hearing Services in Schools. http://doi.org/10.1044/2021_lshss-21-00105 [open access]
Van Riper, C. (1939). Speech correction: Principles and methods. Prentice-Hall.
Williams, A. L., McLeod, S., McCauley, R. J. (2021). Interventions for speech sound disorders in children (2nd ed.). Paul H. Brookes.
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