Complexity Therapy for Children with Severe Speech Sound Disorders
“But… but … that’s not at all how I learned to do therapy!”
What if someone gave you solid evidence for doing therapy in a manner that appeared to be the exact inverse of what you had always done? That’s how I felt in the 1990s when I first heard about the research in speech sound disorders done by Judith Gierut, John Dinnsen and others, which became CATE - the Complexity Approach to Treatment Effectiveness. CATE advocates selecting later developing, more complex sounds as initial targets for speech sound intervention, rather than the traditional practice of treating early developing, inconsistent sounds first.
When I first heard about complexity theory, I was working with preschoolers who were unintelligible and making limited progress, so I decided to try targeting later developing targets with them, and had great results! It was truly surprising how the children were able to imitate later developing sounds, even when they didn’t have early developing sounds in their spontaneous speech. This counter-intuitive approach turned my SLP world upside-down, but in the best way possible: my preschool students were making very rapid progress, with some able to be dismissed from therapy within a year! In the years since, I have used this approach with a wide variety of students up through early elementary school age, with the same dramatic results - highly intelligible speech with just a few remaining inconsistent errors, all in the space of one school year.
The research behind CATE examined and tested traditional assumptions about speech sound therapy targets: should they be early or later developing sounds, stimulable sounds or nonstimulable sounds, sounds that are inconsistently used or those that are absent from the child’s system, or sounds that are more complex or less complex. To implement effective therapy, the CATE research directs us to choose targets that are the most challenging for our students:
Such phonemes, for a given child, are considered the most “learnable” because the child has the most to learn about them. Learning about unknown phonemes actually facilitates learning of the entire speech sound system. By targeting more complex, unknown sounds, the child is provided with a more complete picture of the speech sound system, and begins to derive specific phonologic knowledge from that picture of “the whole,” much as children developing speech sounds typically do.
Gierut’s research also looked closely at how to teach new phonemes via contrast pairs. We have all worked on reducing error processes by using contrast pairs, usually minimal pairs which contrast the child’s error with the target sound, such as tap/cap for fronting or tame/same for stopping. The complexity model research, on the other hand, indicates that the use of maximal contrasts results in the greatest system-wide change. In fact, Gierut suggests contrasting 2 unknown phonemes to provide the child with as much information as possible about the sound system, thus promoting system-wide change. Ideally the target phonemes differ in all four aspects of phonetic production: place, voice, manner and major sound class (sonorant/obstruent). Examples of maximal phonetic contrast include: / Ɵ/r, k/l, s/r, ʧ/l /
By selecting maximally different, later-developing, unknown targets, the children are exposed to new and comprehensive knowledge about the sound system. They are exposed about all aspects of speech sounds: place, manner, voicing and sonorance/obstruence, rather than a single feature such as manner (e.g. stopping v. frication). They independently apply this new knowledge to less complex phonemes without direct intervention. In fact, untreated sounds often emerge before the therapy targets emerge, resulting in a generalized rising tide of improved intelligibility.
My greatest hesitation in getting started with complexity centered around whether therapy would be so hard that it would cease to be fun, and kids wouldn’t want to participate. I found that the hesitation was all on my side - the kids simply didn’t know that what I was asking was “hard”! I’ve come to realize that everything preschoolers have to learn is “hard” and would indeed be daunting if children weren’t born to learn. If you’ve ever watched an infant learning to walk, you know that they love the challenge: falls do not deter them from getting up again; in fact, they are simply delighted by their progress even when they are still hanging on to the furniture. I have found the same to be true for children learning sounds that are the most difficult for them to produce - they just keep trying! Complexity therapy leverages that learning hunger to help them become intelligible quickly!
When I first started implementing complexity theory, I was hesitant to tackle sounds such as /r/, which had traditionally been deferred until a much later age. I eased my angst by selecting less daunting targets, frequently /sh/ and /g/, as most of my students did not have later-developing /ʃ/, and also had no knowledge or stimulability for velars. /sh/ and /g/ are maximally different in place, voice and manner, but not major sound class. In addition, even though /g/ is an early-developing sound, it was a learnable target because the child had no knowledge of the sound. Treatment still resulted in system-wide change. Interestingly, teaching maximal contrasts as targets tends to also eliminate or significantly reduce the chances of the child over-generalizing the target to the substitution: no need to “unlearn” a lot of newly-learned, but misplaced sounds! For fronting, in particular, I had found over-generalization to be a significant problem, but the introduction of maximal contrasts eliminated it: the children readily incorporate /k, g/ into spontaneous speech without also replacing their substituted sound everywhere.
It turns out that “difficult” therapy isn’t actually that difficult and can be a lot of fun, full of rewards for the clinician and the child. Since these children are at significant risk for academic difficulties, particularly in reading, I also try to build student success in language and early literacy skills by using phonologic and phonemic awareness tasks to teach the target sounds, developing letter-sound correspondence while increasing the child’s stimulability for unknown sounds, and practicing target sounds in high frequency words in sentences as a part of each therapy session.
The results of using complexity have been dramatic - nearly all the children I have worked with using this approach have finished or been nearly finished with speech sound therapy within one school year. No more working on 1 or 2 new sounds each year clear through elementary school: the child’s rapidly becomes intelligible while they develop early literacy skills. School success in other areas follows!
Getting started on something so radically different from how we were trained can be intimidating, and I felt the need to find a way to ease my initial hesitation. I found that even if I didn’t pick those really hard sounds (such as /r/), the children made rapid progress when I selected as targets unknown sounds that were maximally different from each other. After more than a decade of using complexity, all the while gaining confidence that I can teach, for example, /r/ or /Ɵ/ as initial targets, and even start with fricative-liquid clusters such as /sl/, I am no longer hesitant to stretch my therapeutic wings and target sounds that once seemed impossible. As a result, children are making rapid progress, so it’s a win for everyone!
I am often asked whether this approach is appropriate for children with intellectual disabilities. The answer is an emphatic “Yes!” Throughout my career, I have worked with individuals with severe intellectual disabilities, and have had more success in eliciting and generalizing speech sounds with this approach than I have with any other method I have tried. It appears that the use of maximal contrasts may actually be easier for all children, but particularly those with learning challenges, because the maximal differences don’t require the fine-grained discrimination of minimal contrasts such as dough/go, in which we are asking the child to make the one change they don’t know how to do or discriminate - raising the back of the tongue instead of the tip. With a contrast such as think/rink, the child can just approximate the target and still be successful at making the two words sound different.
The Complexity Approach to Treatment Effectiveness is a powerful tool to add to your therapy toolkit for children with multiple speech sound errors and severely impaired intelligibility.
References:
Baker, E., and McLeod, S. (2011). Evidence-Based Practice for Children with Speech Sound Disorders: Part 2 Application to Clinical Practice. Language, Speech and Hearing Services in Schools, 42; 140-151.
Baker, E., Williams A.L, McLeod, S., & McCauley, R. (2018) Elements of phonological interventions for children with speech sound disorders: the development of a taxonomy. American Journal of Speech-Language Pathology, 27, 906-935.
Blachman B.A., Ball E.W., Black R., Tangel D.M. Road to the Code: A Phonological Awareness Program for Young Children. Baltimore, MD: Paul H. Brookes Publishing Company; 2000.
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, 44 (3): 306-319.
Creaghead, N., and Farnham, T. (2013) Accelerating Progress for Young Children with Speech Sound Disorders. Short Course, American Speech-Language-Hearing Association Convention.
Crowe, K, and McLeod, S. (2020) Children’s English consonant acquisition in the United States: a review. American Journal of Speech-Language Pathology, 29, 2155 -2169.
Elbert, M., Dinnsen, D. A., & Powell, T. W. (1984). On the Prediction of Phonologic Generalization Learning Patterns. Journal of Speech and Hearing Disorders, 49(3), 309-317.
Farnham T. (2014) Articulation and Phonology Guidelines. http://omnie.ocali.org/mod_view.php?nav_id=268.
Fey M.L. (1992) Articulation and phonology: inextricable constructs in speech-language pathology. Language, Speech and Hearing Services in Schools. 23:225-232.
Gierut, J. A. (1989). Maximal Opposition Approach to Phonological Treatment. Journal of Speech and Hearing Disorders, 54(1), 9-19.
Gierut, J. A. (1990). Differential Learning of Phonological Oppositions. Journal of Speech and Hearing Research, 33(3), 540-549.
Gierut J.A. (1992) The conditions and course of clinically induced phonological change. Journal of Speech and Hearing Research. 5(5):1049-1063.
Gierut J.A. (1998). Treatment efficacy: functional phonological disorders in children. Journal of Speech and Hearing Research. 41(1):S85-S100.
Gierut, J.A. (2001). Complexity in Phonological Treatment: Clinical Factors. Language, Speech and Hearing Services in Schools, 32, 229 – 241.
Gierut, J.A. (2004) The Learnability Project. The ASHA Leader, 9(22): 28.
Gierut, J. (2005) Ohio Speech-Language-Hearing Association Convention presentation. March, 2005.
Gierut, J.A.(2007). Phonological Complexity and Language Learnability. American Journal of Speech-Language Pathology, 16, 6-17.
Gierut J.A. (2007).Clinical forum: phonological complexity and language learnability. American Journal of Speech-Language Pathology. 16:6-17.
Gierut, J.A. (2015). Phonological protocols. Learnability Project Working Papers. Bloomington, IN: Indiana University. (First appeared in the Learnability Project Lab Manual, version 1, 1986)
Gierut, J.A., & Champion A.H. (2001) Syllable onsets II: Three-element clusters in phonological treatment. Journal of Speech Language and Hearing Research 44(4), 886-904.
Gierut J.A., Elbert M., Dinnsen D. (1987) A functional analysis of phonological knowledge and generalization learning in misarticulating children. Journal of Speech Language and Hearing Research. 30(4):462-479.
Gierut J.A,. Morrisette M.L., Hughes M.T., Rowland S.(1996) Phonological treatment efficacy and developmental norms. Language, Speech and Hearing Services in Schools. 27:215-230.
Gierut, J.A., Morrisette, M.L., Hughes, M.T., & Rowland, S. (1996) Phonological treatment efficacy and developmental norms. Language, Speech and Hearing Services in Schools 27;215-230.
Gierut, J.A,. Morrisette ,M.L., Ziemer, S.M. (2010) Nonwords and generalization in children with phonological disorders. American Journal of Speech-Language Pathology. 19:167-177.
Gillam, R. & Frome-Loeb, D. (2010). Principles for school-age language intervention: Insights from a randomized controlled trial. ASHA Leader 15:10-13.
McLeod, S., & Crow, C. (2018). Children’s consonant acquisition in 27 languages: a cross-linguistic review. American Journal of Speech-Language Pathology, 27, 1-26.
Morrisette M.L., & Gierut, J.A (2002) Lexical organization and phonological change in treatment. Journal of Speech Language and Hearing Research, 45(1):143-159.
Powell, T. W. & Elbert, M. (1984). Generalization Following the Remediation of Early- and Later-Developing Consonant Clusters. Journal of Speech and Hearing Disorders, 49(2), 211-218.
Powell T.W., Elbert M., & Dinnsen, D.A. (1991) Stimulability as a factor in the phonological generalization of misarticulating preschool children. Journal of Speech and Hearing Research, 34(6):1318-1328.
Rvachew, S., & Nowak, M. (2001) The effect of target selection strategy on phonological learning. Journal of Speech Language and Hearing Research, 44(3):610-623.
Storkel, H. (2018) Tutorial: implementing evidence-based practice: selecting treatment words to boost phonological learning. Language, Speech and Hearing Services in Schools, 49, 482-496.
Storkel, H. (2019) The complexity approach to phonological treatment: how to select treatment targets. Language, Speech and Hearing Services in Schools, 49, 463-481.
Sosa, A. (2016) Lexical considerations in the treatment of speech sound disorders in children. Perspectives of the ASHA Special Interest Groups, SIG 1, 1 (part 2) 57-65.
Williams A.L. (1991) Generalization patterns associated with training least phonological knowledge. Journal of Speech and Hearing Research, 34:722-733.
Williams A.L. (2000) Multiple oppositions: theoretical framework for an alternative contrastive intervention approach. American Journal of Speech-Language Pathology, 9:282-288.
Williams A.L. (2005). Assessment, target selection and intervention: dynamic interactions within a systemic perspective. Topics in Language Disorders, 25(3):231-242.
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