The Wonder of Cycles Created by Barbara Hodson Shared by Anne Hasting 2013 Where credit is due • Created by Barbara Hodson • Evaluating and Enhancing Children’s Phonological Systems • www.phonocomp.com This approach • Created for severe-profound intelligibility problems • More closely matches natural acquisition • Evidence-based – Ages 2-14 – Variety of disorders • Refined over 35 years • Works Poorly intelligible kids… • • • • • Not auditory self-monitoring Rely on inaccurate kinesthetic self-monitoring Order in disorder More likely to evidence certain processes Lag behind in basic literacy and spelling later What’s important? • Intelligibility! • Not number of errors – Child with /s/ lisp and /s/ omission have same number of errors on GFTA-2 • Intelligibility in connected speech – how to estimate? – Sentence imitation – HAPP-3 Identify errors • Tests are for identifying disability – Avoid teaching to the test – Not very helpful anyway • Play and listen, take notes • Put parents to work if kid doesn’t cooperate – Video recording, audio recording, notes • Full analysis not necessary – First look for absence of primary patterns (slide 11) What do you want? • Cycles terminology focuses not on the deficits, but on what you want the child to do – Syllable reduction? Syllableness – Initial/final consonant deletion? Singleton consonants, initial and final – Fronting/backing? Anterior-posterior contrasts – Cluster reduction? /s/ clusters – Liquid gliding? Liquids – Processes? Patterns Cycles has cycles • Cycle: series of target patterns • Work on each target pattern in succession – 5-20 weeks, depending on number of deficiencies and on stimulability • Then start over, add phonemes to patterns if possible • First you cycle primary patterns • When primary patterns reach accuracy criteria (3-5 cycles), begin cycling secondary patterns Priorities • Omissions and additions are top – Substitutions are next critical after o & a – Distortions have much less impact on intelligibility • Structural changes – Syllable deletion – Singleton consonant deletions (initial and/or final) – Cluster reduction – Epenthesis – Syllable addition What are we working on again? • Patterns NOT sounds • Need to use sounds to work on patterns • Catch-22? Just keep in mind that the sounds are a means to an end. • Do NOT work on every sound in error • Choose a few *stimulable* sounds to teach patterns • One clinical hour per target sound – Number of target sounds depends on stimulability Primary Patterns • Primary patterns: – Syllableness – Singleton consonants • Initial • Final – /s/ clusters – Anterior-posterior contrasts – Liquids • Target what the child needs Syllableness • Spondees (equal-stress words) – Targeting non-spondee two-syllable words results in inappropriate prosody or encourages syllable deletion • Target is producing multiple syllables • How’s he doing? – ice cream -> cream – ice cream -> eye ee – ice cream -> ha ha Singleton consonants • Initial singleton consonants (if in error) • Choose 2-6 target phonemes – Stops /b, p/ possibly /d, t, g, k/ – Nasals /m, n/ – Glide /w/ • Always use real words, not made-up syllables • Always use words the child can say – If CVC is not stimulable, try CV Singleton Consonants • Final singleton consonants • Choose 2-6 target phonemes – Voiceless stops /p, t, k/ – Nasals /m, n/ • Always use real words, not made-up syllables • Always use words the child can say – If CVC is not stimulable, try VC /s/ clusters • /s/ clusters • Initial – /st, sp, sk, sm, sn/ (careful fronting/backing) – Video 1, s clusters M • Final – /ts, ps, ks/ (careful fronting/backing) – Yay for morphology: plurals, 3p singular verbs • ONLY if singleton consonants are present • If fluent words: “It’s a spoon.” “It’s a snail.” – Video 2, it’s a sk I Anterior-posterior contrasts • If not stimulable, target as a secondary pattern • Most kids are fronters or velar deleters; you want velars – Final /k/ – Initial /k/, /g/ • Some kids are backers; you want alveolars – Initial /t/, /d/ – Final /t/ • Avoid words that have both front and back sounds: dog, coat, take, kiss, knock Liquids • 3 y/o vs. 7 y/o working on /r/ for first time – Developmentally appropriate acquisition – Hodson’s data • “Not a glide” – Derhotacized/lax /r/ and vowels are acceptable • Data collection: – Run -> wun – Run -> oowun – Run -> oo uuuun – Run -> r)un – Video 3, liquids I Liquids • Target initial /l/ – Stable jaw tongue clicking for a week at home before targeting • Target initial /r/ (“er”) – Needs to be “er a:k” – Jaw wide open for onset, keep it open during pause and rime (no /w/ insertion) • Target /r/ blends if stimulable for velars – /k, g/ are facilitative • Target velar and alveolar /l/ blends when /l/ is solid • /p, b, m, f, v/ encourage gliding, so rope, roof, rabbit, lamp, and leaf would be out Nitty gritty, part 1 • One clinical hour per target phoneme (2-6 hours per target pattern) – Hodson recommends one hour per week total: three 20minute, two 30-minute, one 60-minute – Double time if child has intellectual disability • MUST be stimulable – Use sounds the child can say (maybe not easily) to work on patterns the child has not mastered – Stimulable doesn’t mean easy • Focused auditory input cycle for nons (nonstimulable, nonverbal, or noncompliant) – One cycle of primary patterns: only input, no production requirements – Usually needed for children younger than 3 years – 2 weeks on each primary pattern except liquids (10 weeks) Primary Pattern Graduation • Move from primary to secondary patterns when: – Initial /m, n, w/ and stops 60% correct in conversation – Final /m, n, p, t, k/ 60% correct in conversation – A-p contrasts 60% in conv. in one word position – /s/ clusters emerging in conversation – Liquid approximations at the word level • Listen during liquids – Not reached criteria? Cycle error patterns again • Severe intelligibility = 3-4 primary cycles Secondary Patterns • Begin after criteria have been reached for primary pattern “graduation” • Do NOT kill yourself analyzing all patterns early • Listen during liquids Possible Secondary Patterns • Some common ones: – – – – – – – Voicing contrasts Vowel contrasts *Anterior-posterior contrasts Stridency Palatals Other consonant clusters Context-related processes • Assimilations • Metathesis • Idiosyncratic rules Voicing Contrasts • Errors with voiced/voiceless cognates – p/b, t/d, s/z, etc. • Prevocalic voicing • Use minimal pair words and some amplification Vowel Contrasts • Usually get the vowels sorted out during the primary cycles • Use minimal pairs and some amplification Anterior-Posterior Contrasts • Target in secondary cycles if not stimulable during primary cycles • See slide 16 Stridency • Stridents: f, v, s, z, sh, zh, ch, j • Stridency deletion: substituting non-stridents or deleting the strident altogether – Fan->pan, Sue->new, peach->pea, fishing->fitting – Stridents are often stopped but not always • Usually working on /s/ clusters generalizes but if not: • Target /f/ and /s/ first, usually in final position Palatals • Palatals: y, sh, ch, j • Target y first • Then insert y after other palatals – Chyair (child will probably say tsyair) – Shyoe (syoe) – Jyump (dzyump) • Usually ch is more stimulable than sh or j Other Consonant Clusters • • • • Examples: kw, tw, sw, by, hy, fy, ky, my /s/+stop final clusters (e.g. toast) Medial /s/ clusters (boxes, sister) Three consonant sequences (straw, square) Context-related Processes • Assimilations: – Labial, e.g. pin -> pim – Alveolar, e.g. take -> tate – Velar, e.g. green -> gring – Nasal, e.g. mat -> man • Assimilations multiply with other errors – Pin -> im (adding initial consonant deletion) – Take -> date (adding prevocalic voicing) – Green -> wing (adding cluster reduction & gliding) – Mat -> many (adding diminutization) Context-related Processes • Metathesis (switching positions) – Ask->aks, take->kate • Reduplication – Bottle->baba, TV->beebee • Idiosyncratic rules - some fun ones: – Alveolar and velar stops, and all stridents = /h/ – All fricatives, affricates, and clusters = /d/ • (except /h/ ) • Minimal pairs Advanced Patterns • Upper elementary, middle (~age 9 and up) – Look fine on artic tests but have intelligibility issues in the real world – Usually have language/learning disabilities • Complex consonant sequences (extra, excuse) – Video 4, complex sequences I • Multisyllabicity (apostrophe, aluminum) – Segment phonemes syllable by syllable – Teach “phonics writing” – Once you’ve broken it up, put it all back together Example: Morgan, age 4:10 • Morgan is poorly intelligible in conversation but between the GFTA and mom you get: – House -> how – Stop -> top – Big -> bid – Carson -> tawtuh – Make -> nay – Like -> wipe – Play -> pay • What will you do with her? Example: Morgan • Primary patterns – Singleton consonants (final) – /s/ clusters – Anterior-posterior contrasts – Liquids Example: Adam, age 6:1 • Adam’s intelligibility in conversation varies • Errors include: – Stop -> chop – Likes -> wite – Chair -> tayoh – Tree -> tee – Susannah -> Chuchannah – Skates -> chate – Christmas -> Kimuch – Shoes -> chooch – Zero -> jeewo Example: Adam • Primary patterns: – /s/ clusters (avoid sk) – Anterior-posterior contrasts – Liquids Example: Hannah, age 3:3 • Hannah doesn’t say much. Mom understands very little of what Hannah does say. Imitated single words include: – Drum -> uh – Mommy -> um – Me = correct – Green -> nee – Blue -> woh – Chair = refused to attempt – Baby -> bee Example: Hannah • Auditory input cycle? • Primary patterns – Syllableness – Singleton consonants (initial) – Singleton consonants (final) – /s/ blends when singleton consonants emerging – Anterior-posterior contrasts – Liquids Example: Nathan, age 10:6 • Nathan has had 7 years of remediation but remains unintelligible at times. You hear: – – – – – – – – – – Skinny -> sinny Color -> coloh Electricity -> elekitsy Christina -> wikseeta Lightning = correct Germany = Johmany Mixture -> mistoh Hopping = correct Sneeze -> seeze Huge = correct Nathan • Primary Patterns – /s/ clusters – Liquids (/r/) • Secondary Patterns – Metathesis and migration best addressed in: • Advanced Patterns – Complex consonant sequences – Multisyllabicity Whew • Enough framework for you? – It’s the most important part! – Organization of overall treatment • What does a session look like? Sessions • • • • • • Review Listening words Practice patterns Metaphonological skills Listening words Stimulability Session Structure • Review last week’s targets IF same pattern – 2 minutes • Listening words (amplified auditory stimulation) – 15 seconds – 12-15 words at slight amplification (6-12 dB) – Clinician reads, child listens – Speak normally – Child can attempt a few production practice words (see next slide) while wearing amplification – Try PVC piping or Whisperphone Duet – Evidence-based Session Structure • Production practice – main bulk of session – Choose 2-5 target words (no nonsense syllables) – Ages 1-too immature to sit and attend: • Opportunities for targets to be produced naturally in context – Ages 3ish and up: • Create practice cards • Draw, write, color targets on index cards • Can “play and say” or produce in context or a little of both • Metaphonological skills—see next slide – Able to read: • Short oral reading period focusing on target pattern Metaphonological Skills • Struggle with basic literacy and spelling • A few minutes each session targeting: – Rhyming – Segmentation and blending of: • Syllables, Video 5, syllable blending M • Onset and rime, Videos 6 & 7, blending I, seg E • Phonemes, Videos 8, 9, & 10, blending D, seg D & J – Manipulation – Send home short rhymes like Jack and Jill • Video 11 nursery thyme cloze s • Increase the time in final cycles Session Structure • Listening words – 15 seconds – Same list, same amplification • Stimulability – 2 minutes – Select next session’s practice words Nitty gritty, part 2 • Evidence-based but may not work if you do not follow the protocol • Quality over quantity • STIMULABLE • No data collection – measures are provided at the end of each cycle not each session – Interferes with naturalistic interactions – Mixing errors with correct leads to fuzzy phonological representation • Don’t say “good job” when you mean “good try” – Give accurate feedback and immediately try to correct the error Nitty gritty, part 3 • Group therapy – FAPE, individualization – Progress is known to be slower – Listening to several targets in one session may lead to fuzzy phonological representation • Choosing targets – Listening list: anything with target pattern – Practice words: stimulable, phonetic environment, can teach semantics – Metaphonological words: child must already know • Fine if production is imperfect Homework • Homework – 2 minutes per day – School age: para/aide or educator can do this – Parent reads listening words, child says each practice word once, read rhyme if applicable – Good luck – I train parents/teachers on ear training Ear training • Supports Cycles • Important: limited to current target pattern • Five types: – Modeling – Auditory awareness – **Feedback** – Praise – Corrections Ear training • Modeling (auditory bombardment) – Focused play, say targets often without requiring the child to imitate • Auditory awareness – “Johnny, want to go—hey, go has your /g/ sound! Want to go outside and play?” • Feedback – “Ditzy dame routine” – “The tea? Hm, I don’t see any tea out there to drink… Oh, you mean tree! Sorry, I heard tea. I do see the snow on the tree.” – “Nack? I don’t know what a nack is… Oh, snack! Sure, you can have a snack.” Ear training • Praise – “Nice /s/ in sit!” – “I heard that good /k/ sound when you said keys.” • Corrections – “No? Try again: snow. … That’s right!” – I require an equal number of praise and corrections, max 5 corrections per day • Impossible until child is generalizing • No praise = no corrections IEP objectives • (Auditory input cycle) Will participate in activities targeting correct speech patterns • Will produce words beginning or ending with /k/ • Will produce at least two of the following at the word level: /sp, st, sk, sm, sn/ • Will produce at least two of the following at the end of words: /p, t, k, m, n/ • Will produce words with two syllables • Will attempt words beginning with /l/ sound • Will produce an approximation of /r/ • Will produce words ending with /s/ Evidence • Randomized, single-blind clinical trials • Comparisons with other treatments • Hundreds of kids – Less than a year for most preschoolers to become intelligible (30-40 clinical hours) – Closer to two years for extremely disordered phonological systems but normal cognitive – Cleft palate, recurrent otitis media, apraxia, mildsevere hearing impairment, cochlear implant, cognitive delays My Evidence • All names are changed • Progress in a single school year Evidence: Hugh • Began Cycles age 3:10 • No previous tx • Embarrassed, avoided speaking – Data game • • • • • Otitis media history, resolved Poor stimulability Fantastic follow through on ear training Intelligibility jump after 3 months >80% intelligible at end of school year Hugh’s progress in conversation Target Pattern Occurrence Target Pattern Occurrence Final consonants 0% Final consonants 100% A-P contrast 60% A-P contrast 100% Stridents 0% Stridents 100% /s/ clusters 0% /s/ clusters 100% Other clusters 0% Other clusters 100% Liquid /l/ 0% Liquid /l/ 0% Liquid /r/ 0% Liquid /r/ 20% Evidence: Bella • • • • Began Cycles age 3:3 Otitis media history Good stimulability Resistant to practice – Bribery • Intelligibility jump age 3:6, again age 3:9 • Dx mild-mod conductive hearing loss, got hearing aids age 3:10 • Discontinued artic age 4:1 Bella’s progress in conversation Target Pattern Occurrence Target Pattern Occurrence Final consonants 100% Final consonants 100% A-P contrast 0% A-P contrast 100% Stridents 0% Stridents 100% /s/ clusters 0% /s/ clusters 100% Other clusters 0% Other clusters 100% Liquid /l/ 0% Liquid /l/ 100% Liquids /r/ 0% Liquids /r/ 0% Palatals 0% Palatals 100% Evidence: David • Age 4:10 • 1.5 years previous tx: worked final consonants to sentences, /k/ in isolation • Poorly intelligible, glottal stops for nearly all medial phonemes • Poor stimulability • Very active! • Intelligibility jump age 5:3 David’s progress in conversation Target Pattern Occurrence Target Pattern Occurrence Final consonants 80% Final consonants 100% A-P contrast 0% A-P contrast 100% Stridents 40% Stridents 100% /s/ clusters 0% /s/ clusters 100% Other clusters 0% Other clusters 80% Liquid /l/ 0% Liquid /l/ 20% Liquid /r/ 0% Liquid /r/ 0% Voicing contrast 0% Voicing contrast 100% Palatals 0% Palatals 80% Evidence: Carly • • • • Began Cycles age 4:4 No previous tx Selective mutism Mom does all treatment with my guidance – Home visits to teach mom, email – Small sessions throughout the week • Pals services for personal/social Carly’s progress in conversation Target Pattern Occurrence Target Pattern Occurrence Final consonants 100% Final consonants 100% A-P contrast 0% A-P contrast 60% Stridents 40% Stridents 60% /s/ clusters 0% /s/ clusters 40% Other clusters 0% Other clusters 60% Liquid /l/ 0% Liquid /l/ 0% Liquid /r/ 0% Liquid /r/ 0% Voicing contrast 0% Voicing contrast 40% Data from 5 months into tx All at 100% except liquids after 8 months tx Evidence: Michael • • • • • • Began Cycles age 3:2 No previous tx Recurrent otitis media through age 3:8 Behavior, attention difficulties Language processing Mom sat in on sessions, good follow through at home Michael’s progress in conversation Target Pattern Occurrence Target Pattern Occurrence Final consonants 100% Final consonants 100% A-P contrast 40% A-P contrast 60% Stridents 40% Stridents 60% /s/ clusters 0% /s/ clusters 0% Other clusters 0% Other clusters 0% Liquid /l/ 0% Liquid /l/ 0% Liquid /r/ 100% Liquid /r/ 100% Voicing contrast 0% Voicing contrast 60% Data from 4 months into tx All at 100% except other clusters after 10 months tx Every speech sound correct including complex consonant sequences after 14 months tx Dismissal • All deviation percentages of occurrence (except liquids) below 40% • TOMPD (total occurrences of major phonological deviations) on HAPP-3 below 50 • Probably need to continue phonological skills training • Follow-up after 6 months The last word • 3-6 months to generalize to conversation after fluent productions at word level • Key is to KEEP MOVING ON • Don’t get stuck on something they haven’t generalized • Don’t expect Cycles to work if you modify it • myspeechteacher.wikispaces.com • Listenandtalk@me.com Appendix A History of Therapy Approaches from Hodson 2010 (see note) Overview • Early Approaches – Phoneme-Oriented Intervention – Phonetic Placement – Moto-Kinesthetic – Stimulus Approach – Sensory-Motor Approach – Discrimination Approach • Behavioristic Approaches • Linguistic-Based Approaches Early: Phonetic Placement • • • • • Circa 1927 Emphasis on articulators: tongue and lips Modification of placement and airflow Use of diagrams and demonstrations Assumption (incorrect) that phonemes are always articulated with the same placement – Neglects coarticulatory changes • Poor efficacy • May still be useful in early phases of articulation intervention to demonstrate how a phoneme is produced Early: Moto-Kinesthetic Approach • • • • Circa 1938 Speech is a dynamic event Involved external manipulation of the articulators Articulatory movement must be “felt” and developed as a muscle sense of kinesthetic image • Sounds are taught in syllables with schwa, reduplicated syllables, multisyllabic words, phrases, then sentences • Tactile cuing, such as pressing under chin to stimulate /k/ • Poor efficacy Early: Stimulus Approach • Van Riper 1939-1978 • Aka Traditional Approach • Misarticulations are more than placement or production errors • Poor auditory sensory perception contributes • Auditory training prior to production practice • Only one sound targeted at a time • Five steps: sensory-perceptual training, sound elicitation, sound production stabilization (isolation to sentences), transfer, maintenance • Useful for one or two phoneme errors • Problems: insufficient for multiple errors, limited emphasis on generalization to untargeted phonemes Early: Sensory-Motor Approach • McDonald 1964 • Attention to position in words (init, med, fin) • Speech is a sequence of syllables rather than sounds in individual words • Recommended deep assessment to examine coarticulatory effects • Use 2- to 3-syllable words • Correct production in varied phonetic contexts • No ear training or production in isolation • Poor efficacy, though better than previous three • Useful for determining facilitative phonetic environments Early: Discrimination Approach • Winitz and Bellerose 1962 • Teach auditory discrimination of error sound from target sound • Begin with gross contrasts then finer contrasts – Ship/lock before ship/chip • Controversy about whether discrimination tasks are necessary • Requires metalinguistic skills, discussion of word structures as opposed to word meaning – Not developmentally appropriate for younger children Behavioristic Approaches 1 • 1970s • Articulation hierarchy – Isolation, nonsense syllables (CV, VC, CVC) – All word positions, then phrases, sentences • Must meet specific criterion (ex. /k/ 90% in phrases) before moving up a level • More prompting if productions are consistently incorrect • Test transfer or generalization to nontreated words to determine progress Behavioristic Approaches 2 • Response to needs for efficiency and documentation • Two popular behavioristic phoneme-oriented approaches: Programmed Instruction (1977) and Multiple Phonemic Approach (1975) • Behavioral objectives have become required for IEPs Behavioristic: Programmed Instruction • • • • Mowrer, Baker, & Schutz 1968 Reinforcement schedules: stickers, tokens Penalties for incorrect production Many responses required--tedious, boring (for clinician and child) Behavioristic: Multiple Phonemic • McCabe & Bradley 1975 • Establishment phase: all phonemes in isolation – Even correct phonemes – Every phonemes produced at least once each session • Transfer phase: similar to Stimulus Approach – Articulation hierarchy – Whole word accuracy is calculated • Maintenance phase: Conversation outside the session and over time • Working on so many targets at the same time is confusing for children with many errors • Data collection and organization cab be difficult • SLPs often modify this program—several not all phonemes Linguistic: Distinctive Features • Blache 1978 • Distinctive features: classification system to distinguish phonemes across languages – Place, manner, voice, etc. • Experimental, limited clinical application • Target features rather than phonemes • Subsequent substitutions that include desired features are reinforced and viewed as progression toward correct production • No isolated phonemes; use minimal pairs • Distinctive features are helpful for classifying sounds, but this approach does not account for omissions • Distinctive feature analysis has been subsumed under phonological analysis Linguistic: Phonological Approaches • Hodson & Paden 1983, 1991; Stoel-Gammon & Dunn 1985 • Goals: intelligibility, reorganized phon. System, enhanced strategies for phon. Processing • Early approaches focused on suppression of processes through intervention of sounds affected by the processes • Cycles, Metaphon, Phonological Awareness Cycles • Um.. Go back to the beginning Linguistic: Metaphon • Howell & Dean 1994 • Cognitive-linguistic approach • Premise is children can change sound productions by developing awareness of place, manner, voice similarities & differences • Emphasis on classification rather than production • Phase one: phonological production concepts and terms are targeted through sorting of nonspeech sounds • Phase two: judgment of minimal pair words • 1995 study showed that preschoolers improved expressive phonological productions Linguistic: Phonological Awareness • Not a separate approach • Expressive phonology impacts literacy • Phonological awareness ability is highly correlated with literacy success – Awareness of sound structure, ability to manipulate sounds in words, etc. • Phonological awareness can be taught • Intervention can change both phonological awareness and expressive phonology Linguistic: Whole Language • Children with expressive phon. Problems often have other language impairments • Interactive story-telling can improve phonological development, as well as semantic, and syntactic skills • Child describes picture, SLP scaffolds – Encourage child to clarify sounds, sentence structure, semantic relationships – Encourage to add information – Encourage to increase complexity by including relationships (ex. cause-effect) and motivation (ex. feelings) • SLP models enhanced language, children restate • Efficient and effective for children with mild impairment • Children with more severe deficits need more direct phonological intervention Appendix B Target Selection from Hodson 2010 Phoneme-Oriented Approaches • Chronological or developmental age – Early-developing phonemes are considered a prerequisite for later-developing phonemes • • • • Phoneme frequency—ex. /s/ Stimulability—stimulable before non Visibility—ex. labial consonants Variability inconsistency—sounds produced sometimes are chosen • Utility—ex. sound in the child’s name Phoneme-Oriented Approaches • Elbert 1992; Gierut, Morrisette, Hughes, & Rowland 1996 suggest selection of phonemes with least productive phonological knowledge – Nonstimulable, later developing – A series of single-subject design studies suggested some benefit • Rvachew and Nowak 2001 challenged this based on results of a randomized-control study – Results were poorer for children working on least phonological knowledge targets first