Articulation Disorders (Speech Sound Disorders)

- Recommendations

The following statements and flowchart were adapted from the Guidelines of University of North Carolina and Clinical guidance speech therapy which received the highest scores as regards the currency, contents, and quality.

Recommendations statements

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Definition

Presentation

Speech sound disorders (SSD) include sound substitutions, omissions, distortions and additions. In addition, there can be errors that affect the word level and/or the rhythm and intonation characteristics of running speech.

Speech sound disorders result from difficulties with speech, motor production and coordination of speech movements, as well as the lack of phonological knowledge or misapplication of the phonological rules associated with the child’s native language. All languages are governed by phonological rules which determine the appropriate speech sounds (or phonemes) and phoneme sequences that characterize a particular language.

The cause of speech sound disorders in most children is unknown.

The cause of some speech sound problems is known and can be the result of motor speech disorders (e.g., Apraxia and Dysarthria), structural differences (e.g., cleft-palate), syndromes (e.g., Down Syndrome) or sensory deficiencies (e.g., hearing loss).

Low

High

Strong recommendation

Conditional recommendation

Cross sectional study

Systematic review

Presentation

Apart from short term memory disorders, the exact cause of speech sound disorders in most children is unknown.

The cause of other articulation disorders is known and can be the result of motor speech disorders (e.g., Apraxia and Dysarthria), structural differences (e.g., cleft-palate), syndromes (e.g., Down Syndrome) or sensory deficiencies (e.g., hearing loss).

SSD have to be clearly differentiated from other organic articulation disorders as early as possible during preliminary diagnosis in order to direct the patient to the suitable diagnostic procedure

High

Strong recommendation

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Risk factors.

Symptomatology

Assessment

• Gender-males being higher risk.

• Ear, nose and throat problems.

• Family history of speech and language problems.

• Limited parental education/ learning support at home.

• Omissions/deletions: Specific sounds are omitted or deleted (e.g., boo for book and geen for green).

• Substitutions: One or more sounds are substituted (e.g., wed for red and dut for duck, widuh for rider).

• Additions: One or more extra sounds are added into a word (e.g., bulack for black).

• Distortions: Sounds are modified or altered (e.g., a slushy

/s/).

• Whole-word/syllable-level errors: Weak syllables are deleted (e.g., boon for balloon); a syllable is repeated or deleted (e.g., nana for candy).

• Prosody errors: Errors that occur in stress, rhythm and intonation.

Case history

• Family history of speech/language difficulties.

• Recurrent middle ear infections.

• Child’s primary language used in the home.

• Family and teacher concerns.

• Age developmental milestones were met.

• Medical history.

High

Low

Strong recommendation

Systematic review

Cohort study

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Assessment

Oral mechanism examination includes:

• Assessment of dentition and alignment of teeth

• Muscle movement as well as development of the jaw, lips and tongue and the integrity of the oral structures (hard and soft palate, jaw, maxilla, lips and tongue)

• Oral motor reflexes as well as purposeful movement through imitation of non- speech actions

• Diadokokinetic rate: muscle movement for coordination and sequencing

• Assessment of tongue and mouth resting posture to determine existence of tongue thrust

low

High

Strong recommendation

strong recommendation

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Assessment

Audiological assessment

Speech Sound Assessment

Assessment

Stimulability

Will be provided to children during the initial Speech and Language Evaluation unless results of a comprehensive audiological assessment has already been completed. Follow up audiological assessment is indicated when progress in speech development has not been achieved or is mini- mal and evidence suggests risk for hearing im- pairment.

The evaluation process may include the selec- tion of administration of standardized tests, lan- guage/speech samples, or a descriptive analysis of informal findings.

Assess articulation at the word, phrase and con- versational levels.

Establish a phonetic inventory for the child (i.e., what sounds can the child produce?).

Identify the error patterns the child uses and look for phonological process use in children who are less intelligible.

Identify speech sound production inconsisten- cies. The child does not always misarticulate the error sound the same way in all words.

Evaluate stimulability of error sounds.

Evaluate intelligibility.

Child’s ability to produce target sounds with cues

• Used to select treatment targets based on the child’s ability to utilize these cues

• Assists in determining prognosis.

High

Low

low

Strong recommendation

Systematic review

Cohort study

Clinical questions	Action recommendation	Evidence quality	Strength of recommendation	Study type	References
Intelligibility	Intelligibility refers to the listener’s ability to understand the child’s speech. A guideline for expected conversational intelligibility levels of typically developing children talking to unfamiliar listeners is summarized below • 1 year- 25% intelligible • 2 year- 50% intelligible • 3 year- 75% intelligible • 4 year- 100% intelligible Intelligibility can be impacted by several factors including: • Length of utterance • Familiarity with child’s speech. • Child’s speech rate, intonation, loudness level, vocal quality and fluency • Contextual cues • Presence of ambient noise during conversation.	Low	Strong recommendation	Comparative study	11
Onset of intervention	If SSD is not attributed to any other communication disorder, intervention should be started at the age of 5-6 years. Therapy should be postponed to give chance for completing the phonemic inventory and disappearance of all phonological processes including devoicing	low	Conditional recommendation	Cohort study	12
Intervention Contextual utilization Contrast therapy	Treatment starts with practicing syllable based contexts in which the sound is produced correctly. That syllable is used to train more difficult productions. For example, a /s/ may be more easily produced in the syllable with a high front vowel. Targets focus on a specific phoneme feature using contrasting word pairs. Minimal pairs are different by one feature or phoneme that changes the word meaning (tip vs. ship). Maximal pairs use a sound target differing by several distinctive features which affect phoneme placement and manner to introduce sounds that the child cannot produce ( beat vs. cheat)	Low High	Conditional recommendation Strong recommendation	Cohort study Systematic review	13 14

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Core vocabulary approach

Cycles approach

Distinctive features approach

Used with children who are highly unintelligible due to inconsistent misarticulations and may not respond well to traditional therapy. This is a word-based approach as opposed to a phoneme-based technique. Words the child commonly uses are selected for practice and feedback is provided to reinforce the most accurate production of each word.

Focuses on improving phonological patterns with a strategy similar to normal sound acquisition. It is used with children who have poor intelligibility, characterized by numerous omissions and limited phonemic inventories. Each cycle targets all phonological patterns in error until they emerge in spontaneous speech.

Focuses on sound features the child cannot produce (nasals, fricative, voicing, placement) and is usually used with children who substitute.

sounds. Error patterns are targeted using tasks such as minimal pair contrasts; usually once a contrast pattern emerges, it can be generalized.

to other sounds that share the same feature.

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Metaphone therapy

Naturalistic Speech Intelligibility Intervention

Speech sound Perception Training

Used with children who appear to have not mastered phonological system rules. Examples are descriptive and provide information about how a sound is produced, e.g., voiced (noisy) vs. voiceless (quiet). Sounds most impacting intelligibility are selected first.

Uses everyday activities to elicit the target sound frequently during the session. For example, the child is asked about a toy that involves responses using the targeted sound. (i.e., “What color is the car?” “Red.”) Appropriate productions are recast (i.e., casually modeled by the clinician or parent).

Speech perception tasks are used to help the child gain a consistent perception of the target sound. Tasks may include auditory bombardment and sound identification tasks. Usually used prior to or at the same time as speech production intervention.

Low

High

Conditional recommendation

Strong recommendation

Cohort study

Systematic review