The Wonder of Cycles

Created by Barbara Hodson Shared by Anne Hasting 2013

Where credit is due

Created by Barbara Hodson Evaluating and Enhancing Childrens 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

Whats 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 doesnt 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 Hows 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: Its a spoon. Its a snail.
Video 2, its 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 Hodsons 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 doesnt 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 youve 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

Adams 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 doesnt 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?
Its 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 weeks 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 skillssee 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 sessions 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

Dont 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 gohey, go has your /g/ sound! Want to go outside and play?

Feedback Ditzy dame routine

The tea? Hm, I dont 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 dont 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. Thats 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

Hughs progress in conversation

Target Pattern Final consonants A-P contrast Stridents /s/ clusters Other clusters Liquid /l/ Liquid /r/ Occurrence 0% 60% 0% 0% 0% 0% 0% Target Pattern Final consonants A-P contrast Stridents /s/ clusters Other clusters Liquid /l/ Liquid /r/ Occurrence 100% 100% 100% 100% 100% 0% 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

Bellas progress in conversation

Target Pattern Final consonants A-P contrast Stridents /s/ clusters Other clusters Liquid /l/ Liquids /r/ Palatals Occurrence 100% 0% 0% 0% 0% 0% 0% 0% Target Pattern Final consonants A-P contrast Stridents /s/ clusters Other clusters Liquid /l/ Liquids /r/ Palatals Occurrence 100% 100% 100% 100% 100% 100% 0% 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

Davids progress in conversation

Target Pattern Final consonants A-P contrast Stridents /s/ clusters Other clusters Liquid /l/ Liquid /r/ Voicing contrast Occurrence 80% 0% 40% 0% 0% 0% 0% 0% Target Pattern Final consonants A-P contrast Stridents /s/ clusters Other clusters Liquid /l/ Liquid /r/ Voicing contrast Occurrence 100% 100% 100% 100% 80% 20% 0% 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

Carlys progress in conversation

Target Pattern Final consonants A-P contrast Stridents /s/ clusters Other clusters Liquid /l/ Liquid /r/ Voicing contrast Occurrence 100% 0% 40% 0% 0% 0% 0% 0% Target Pattern Final consonants A-P contrast Stridents /s/ clusters Other clusters Liquid /l/ Liquid /r/ Voicing contrast Occurrence 100% 60% 60% 40% 60% 0% 0% 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

Michaels progress in conversation

Target Pattern Final consonants A-P contrast Stridents /s/ clusters Other clusters Liquid /l/ Liquid /r/ Voicing contrast Occurrence 100% 40% 40% 0% 0% 0% 100% 0% Target Pattern Final consonants A-P contrast Stridents /s/ clusters Other clusters Liquid /l/ Liquid /r/ Voicing contrast Occurrence 100% 60% 60% 0% 0% 0% 100% 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 Dont get stuck on something they havent generalized Dont 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 programseveral 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 frequencyex. /s/ Stimulabilitystimulable before non Visibilityex. labial consonants Variability inconsistencysounds produced sometimes are chosen Utilityex. sound in the childs 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