Traditional Approach to Articulation Treatment

One of the options for speech therapy for articulation is the traditional approach.  Back in the dark ages ( or when I was being trained as a speech and language therapist), the researchers prescribed a sequence of treatment for children that had difficulty saying sounds.

“The hallmark of traditional therapy lies in its sequence of activities for: (1) identifying the standard sound, (2) discriminating it from its error through scanning and comparing, (3) varying and correcting the various productions until it is produced correctly, and finally, (4) strengthening and stabilizing it in all contexts and speaking situations.” Van Riper, 1978 p. 179

The traditional approach works well with students with a few articulation errors especially if they are developmental in nature.

The guiding principles of the treatment is that

• One sound is worked on at a time.
• The is a progression of the sound from the syllable level, to the single syllable words, to phrases, sentences and then conversation. One position is worked on at a time.

How do you know where to begin; BASELINE TESTING AND STIMULABILITY TESTING.  I have that in bold because this is a very necessary step. Any lapse in treatment may cause there to be changes in articulation both positively and negatively. There may be some sounds that are in error but not stimulable. You always start with the error that it appears the student is most stimulable for.

There are five steps in Van Riper traditional method:

1. Discrimination Training
2. Stimulability
3. Sound Stabilization
4. Generalization
5. Maintenance

Discrimination Training: The child will be able to discriminate between correct and incorrect production.

• First, the student discriminates between the clinician’s correct and incorrect production.
• Then, the student discriminates between their correct and incorrect production

I like to have a visual to go along with this so that the child does not need to say anything but rather raises the paddle ( visual) to indicate if the sound is correct or incorrect. Try to use something that the student likes the below example was a child that loved tennis and notice the green stick on the new way or the correct production and then the red stick on the old tennis ball or the incorrect or old production.

 

Stimulability: this is also known as sound elicitation and it teaches the correct placement and production for the sound. Sometimes this is the hardest part of treatment having the child know how to produce the sound. You want to work with the sound that the student is most stimulable for as you will have the most success with this.

A mirror is an essential tool for this part of the treatment.

 

You can also video or audio tape for the student. There are some great apps that allow you to practice and record the words. I like the Little Bee Articulation App for this and for keeping data easily.

There are some great devices that increase the volume for the student to hear the sound louder than they are producing it.

You can help the child get the proper placement with a tongue depressor or a lollipop to assist them. I can’t use them in schools anymore but I loved the dum dum lollipops as they were small and were perfect for directing the location of the tongue while giving the student a taste sensation.

There are four approaches you can make for stimulability:

• Auditory stimulability/ imitation
• Use of context
• Motor kinesthetic
• Sound Approximations

Auditory stimulability: this is the easiest, listen, watch, do what I do.

Use of context: pair the sound with sounds that are easier to produce the sound with. This is why I like to do the syllable drill before going to words as it gives me an idea as to which vowel sounds might be easiest for the student to produce.

Motor Kinesthetic:  I use two different methods on this, either using tongue depressors, lollipops etc.  to indicate the spot or I use a motor tactile cue to help the child remember the placement.

Sound Approximations:  there are some sounds that can be formed easier if the child moves from a sound they can produce to a sound they are working on.  This is shaping the sound.

Sound Stabilization: Expand the contexts that the student can produce the words.

The linguistic levels of this are:

• Isolation: (imitation/spontaneous)
• Syllable: Note I like to do the isolation and the syllable level at each of my sessions so that I know I am starting with good production. (imitation/spontaneous)
• Words (imitation/spontaneous)
• Phrases (imitation/spontaneous)
• Sentences: Note the jump from phrases to sentences is usually not a problem. (imitation/spontaneous)
• Conversation: This is often a problem as the student usually becomes less focused when in conversation and will forget to use their good sound.

Generalization: This occurs when the child can produce the sound regardless of the sound environment or situation. It is important that the student is able to produce the sound at home, school, and community and not just in the therapy room.  These are the one clients that I consistently give homework to.  The ASHA NOMS (National Outcome Measurement System) noted that mass practice is essential to progress (Skelton, 2004a) and home practice leads to significantly faster progress and generalization (ASHA, 2010). 

I typically have this homework come back to school/clinic and encourage the parent to write on it to tell me how it went. I do make sure that the homework given to the parent is something that I know the child is very accurate with.  I give a sticker for homework to encourage the child to do it.

Generalization is not an easy step but can be facilitated by using a variety of environments in which people ( therapist, teacher, parent) are helping to monitor and provide support to the student to go from studied focus use of the sound to more natural production.

In the schools, I have a step-down program for students in which I may give intensive treatment to get the sounds and once it appears to have generalized I transfer to a consult increasing the time that I might to a speech sample to make sure that the student maintains the sound.

How do you choose the sounds that you will work on?

The first thing that you want to do is take baselines either through a formal test or an informal sampling. The sound that you choose to work on must be:
1. Functional for the child. It should have a socially significant difference in the communicative skills of the client. This is individualized so for example, a child having difficulty saying their name because of a sound this might be the sound you begin with. You would also then have created an environment that will naturally have many repetitions.
2. Stimulable
3. Occur in Key Words or Contextual Testing
4. Visible * usually easier but be careful with the th sound
5. Occur more frequently (r,s,t,n,l,e)
6. Affect intelligibility most
7. Are acquired earlier
8. Part of child’s phonemic inventory (has /k/ in final position, but missing in other positions
9. Generalize to others (cognates)- sounds produced the same, but differ in voicing ( /t/, /d/)

This methodology is thought of training deep as you train one sound intensely until proficient.

I hope this summary is helpful as the process in treatment in the clinic is

• Get baseline data
• Match needs of students to the evidenced-based practice giving a rationale for why you chose the treatment that you did.
• Follow the treatment approach the way it was designed as the evidenced-based practice was designed with certain protocols and sequence of tasks.
• Take data to evaluate the student’s ability
• Note there may be times that the treatment approach is not giving you the results that you are expecting. Then examine your practice make sure that you are following the approach with fidelity. If this is true, determine if there is a need to trial a different approach with the client.