Stuck on First No Longer Resistant speech-sound disorders can put treatment into extra innings. Here are some tips to help young clients hit a home run. Make It Work
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Make It Work  |   October 01, 2016
Stuck on First No Longer
Author Notes
  • Sue B. Hume, PhD, CCC-SLP, is a clinical associate professor in the Department of Audiology and Speech Pathology at the University of Tennessee Health Science Center. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders. shume@uthsc.edu
    Sue B. Hume, PhD, CCC-SLP, is a clinical associate professor in the Department of Audiology and Speech Pathology at the University of Tennessee Health Science Center. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders. shume@uthsc.edu×
Article Information
Speech, Voice & Prosodic Disorders / Normal Language Processing / Make It Work
Make It Work   |   October 01, 2016
Stuck on First No Longer
The ASHA Leader, October 2016, Vol. 21, 32-33. doi:10.1044/leader.MIW.21102016.32
The ASHA Leader, October 2016, Vol. 21, 32-33. doi:10.1044/leader.MIW.21102016.32
Most of us know him: He’s the child who’s been lingering on your caseload for too long, the one who just can’t reach criteria for dismissal, despite your best efforts. He’s a good student with no known cause for his speech problem. And although he can produce his target sounds in some contexts during treatment sessions, there has been little—or maybe even no—carryover beyond the therapy room.
None of your strategies seems to make a difference, and his speech is noticeably different from his peers. His parents are growing more concerned as he is approaching his preteen years. No one wants to give up, but carryover into conversation is looking less realistic. He’s the kid stuck on first, and it’s our job to help him get to the next base.
Fortunately, the majority of children with speech sound disorders achieve normalization by third grade (approximately 8.5 years), as indicated in 1994 research by Lawrence Shriberg, Frederic Gruber and Joan Kwiatkowski, published in the Journal of Speech and Hearing Research. And most children who receive speech treatment achieve carryover as part of the treatment process. However, for those children who continue to have persistent speech-sound errors (commonly referred to as “intractable” or “resistant”), there is potential for a negative impact on education and social experiences, especially if errors continue into adolescence and adulthood. As ominous as this scenario sounds, there are strategies that may help improve and possibly even help resolve resistant speech disorders.
Context: Analyze the swing
Most children with conversational breakdown have difficulty coordinating articulatory movement related to the precision, timing and varying contexts required of connected speech. Listening to a sample of conversation should provide clues: Does speech degrade with rate changes or in more complex phonetic or linguistic environments? If any of these factors appear to affect accuracy, try addressing them directly.
Targeting oral agility in increasingly complex phonetic/linguistic utterances may be one key to improving connected speech. A child who continues to use excessive assimilation, such as “pit” for “pig” in conversation, may benefit from stimuli loaded with front/back, back/front articulatory movements, as well as voicing shifts. Although training may begin at sentence level (“Gabe got a ticket driving his pickup truck”), quickly transition into scripts, narratives and conversations with emphasis on variations in rate, prosody and utterance diversity that mimic everyday speech.
Co-articulation patterning: Batting practice
For children who have particular difficulty with movement shifts, try using co-articulated syllable strings with vowels and consonants that vary in manner and placement features (for example, “tah dah nah lah rah chah kah”) as a short warm-up activity at the beginning of your session. Removing the linguistic content allows the child to focus on proprioceptive awareness of articulatory movements. You might even want to give this exercise a fun name, such as “linguistic gymnastics,” but don’t stay at this level too long—your goal is to move into the more natural rate and flow of conversation.
Conversation: Running the bases
Another factor to consider is the communication environment. Speech is not an isolated skill that has to be practiced at a certain time or place, as with learning to play piano. Look at all the different opportunities to infuse speech targets into conversations relevant to the child’s everyday life.
For example, if he plays baseball and is working on carryover of /s/, incorporate names of teammates and coaches, and weekly games and events. You can reinforce correct productions or provide instructive feedback, but more important, the child can repair errors when they are occurring in the conversation. Children can be taught to use this strategy in various situations, beginning with scripts and advancing to narratives, exchanges and even arguments. Parents and teachers can also use this type of conversational correction if the child is comfortable with it.

Speech is not an isolated skill that has to be practiced at a certain time or place, as with learning to play piano. Look at all the different opportunities to infuse speech targets into conversations relevant to the child’s everyday life.

Motivation: Team spirit
Let’s face it: A child who has been in treatment for a considerable amount of time has a different mindset by now. He’s outgrown the tangible reinforcers used with younger children. He may be discouraged by his lack of progress and embarrassed by his speech and that he is still in therapy. However, this is where age and maturity can be a plus.
Help the child increase his motivation and success by letting him take more ownership of his treatment. Start by making him a more active participant both in and outside of treatment sessions. Let him choose an objective (for example, /s/) and situations where it will be targeted.
Awareness of the target is a good place to start. Have the child listen for his target in his own and others’ speech. Next have him incorporate his target during a specific activity using the self-repair tactics you have worked on. This strategy is crucial for successful carryover, as it increases self-monitoring and decreases reliance on external correction. Having him chart and keep track of his targets and experiences encourages accountability. As his accuracy increases, so will his motivation.
Take a break: Seventh inning stretch
If truly nothing is working or motivation just isn’t there, maybe it’s time to take a break. A break isn’t a failure. You can always resume treatment when the child is ready. You can teach strategies to use in high-stakes communication situations, such as using the correct sound when meeting someone new or when called on in class.
Conversation: Cross home plate
Speech treatment generally entails dissecting the natural act of speaking into its components, and eventually reinserting them into conversation. This process often results in a disconnect between treatment activities and real-world communication. So why not make conversation an ongoing objective at the initiation of treatment? Even a brief and limited verbal exchange while playing with toy cars is a good way to encourage awareness of /k/ in one target word. So let’s hit it out of the park by incorporating conversation in every session for natural carryover and a successful treatment outcome.
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October 2016
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