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Over five years of running phonology groups, Gwen Lancaster, Shelagh Benford, Gerry Buckley, Alison Langshaw and Emma McCormack have found that a high level of fun motivates and supports children to change their speech.
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ur primary aim as speech and language therapists who work with children with phonological impairments is to increase intelligibility. In most cases our objective is to help the child become aware of the need to change their speech output in order to be understood - and for that change to become part of their phonological system so that they become more intelligible to everyone they know. It is common practice for children with phonological impairments to be treated in groups as it is efficient and can be enjoyable for clinicians and clients. These groups are sometimes referred to as ‘sound awareness’ groups (eg. Allen et al., 2008). This implies that phonological awareness tasks such as sorting words by sound are explicity included in the therapy. This makes sense in the light of research such as Gillon (2000; 2002), who found that children with phonological impairments and also problems with attaining literacy benefited more when given explicit phonological awareness training than those given a ‘traditional’ approach to therapy. This finding, however, was not replicated by Hesketh et al. (2000) when they studied children with phonological impairments in which the control group was given a more eclectic approach. Here we are going to present a way of working with children with speech impairments that is theoretically grounded but entails a quite direct approach to helping children change their speech output in order to be more easily understood. We will describe our treatment of children referred to phonological therapy groups in North Bristol over a five year period. These could be termed ‘sound unawareness groups’ – or, put more positively, ‘meaning and motivation groups’. We did not explicitly include phonological awareness tasks except at times with older children who also had literacy difficulties. However, many of the activities we included such as auditory discrimination and minimal pairs are also used to help children develop phonological awareness.
Stackhouse and Wells (1997) provide a useful psycholinguistic assessment framework but, in our dynamic work of helping children to overcome
their speech impairments, Hewlett (1990) has been more influential as an explanatory model. The Hewlett model includes four boxes. The first, ‘Auditory input’, is essential and begins to form in infants aged 6 to 12 months. ‘Phonological output’ is where the child (or adult aquiring a new phonological system for a new language) stores auditory information. ‘Motor programming’ links the two. The other box is ‘motor processing’, or praxis. We view the links he describes between the boxes as crucial to providing therapy that helps our clients change. Hewlett describes a ‘slow’ and ‘fast’ route between the boxes. The fast route is the direct link from the auditory input store to the already stored form of a word in phonological output. A child with a phonological impairment might therefore access his outdated phonological representation for the word he wants to say. The slow route means the child needs to revisit the link between the auditory input store and motor programming. This can then influence the phonological store so the child can access their updated phonological representation. Even when this happens the child still has to work on praxis. It is like any new physical skill such as learning to play tennis. The child needs opportunities to try out and practise his new speech sound frequently for it to become automatised and part of his motor praxis. Children were referred to our groups from all clinics in North Bristol. Two clinicians (or one clinician and a speech and language therapy assistant) ran groups intensively. These were for three hours in a week during most school holidays for all age groups and from 4-5pm weekly for a term for the 6+ age range. When practicable groups were also run in schools or nurseries. The groups included up to 8 children (although we once had 15!) Many children attended for more than one goup. We included parents in some of the groups with younger children. Teaching assistants also attended some of the after school groups and saw a different side to the children they worked with. We gave all children homework tasks tailored to their needs and level and also varied the amount of support and challenge provided to each child. When carrying out the intensive three times a week groups, we found
that many children were already beginning to attempt to make changes in their speech output in the second session. Here we will describe the main approach used in group work with children aged 5 and above. With younger children we carried out auditory input work, and then discrimination of sets of words. However, as soon as they were able, we encouraged children to say the words. Rates of progress are different in all groups, so clinicians modified their input accordingly.
Referring clinicans provided information about the phonological error patterns of the children. The clinicians who ran the groups were able to include children with any degree of severity and any types of error patterns. This is because we focused on selected sets of words that included target and non target speech sounds for all the children referred. The idea of using both ‘minimal’ (such as ‘sea’ and ‘tea’) and ‘maximal’ (such as ‘me’ and ‘ tea’) pairs has been discussed in the literature (Gierut,1990; Williams, 2003) as effective for children with moderate / severe phonological impairments. It has the additional advantage that a group of children with a range of error patterns can benefit from being in a single group. Using this approach we could sometimes work in schools and nurseries with all the children in the setting who were on our caseload. This brought the additional advantage that school staff were able to participate in sessions and acquire skills to help the child improve intelligibility in daily interactions. When planning the sessions we aimed to include both maximal and minimal pairs for each child in the group. A word set such as ‘/ee/, key, tea, sea, seat, ski, tea, teak’ could address the patterns of fronting, backing, final consonant deletion and /s/ cluster reduction as well as the unusual pattern of initial consonant deletion. Meanwhile, a set such as ‘air, bear, care, fair, pear, prayer, tear, scare, spare, stare’ (see p.9) could address fronting, stopping, voicing, approximant cluster reduction and /s/ cluster reduction and the unusual patterns of glottalisation and initial consonant deletion.
SPEECH & LANGUAGE THERAPY IN PRACTICE summer 2009
Picture set (clockwise): spare, fair, scare, air, bear, stare, care, pear.
Children with speech disorders are often confronted with their difficulty when they realise “they don’t understand me!” In the groups we confronted children often and deliberately with their difficulty to help them begin to become aware of how to change their speech output and to give them a very good reason to do so. This strategy requires a therapeutic and supportive atmosphere that includes a good deal of fun, energy, and a high level of participation. The child might have to take a risk, make an effort and then perhaps fail but still needs to feel supported and motivated enough to try again. An additional benefit was that the children could express their problems with peers and we were able to contain these in the atmosphere of fun. We always had a theme for the session. This included topics like the fair, going on holiday, the zoo, cafés, motor racing, pirates, magic land, kings and queens and bees. We also included topical or seasonal themes like the Olympics, the World Cup, ‘Crufts’, Easter, Halloween and bonfire night. At the end of the session we would tell the parents and children what the theme for the next session would be. This worked very well particularly for the children attending after school, who might prefer to go to football practice instead. However if they remembered we were doing ‘pirates’ or ‘magic land’ they were immediately enthused, and also reminded that the groups were actually nearly as much fun as football. Most sessions included making something to take home on which the children would glue pictures of the items in the word set. For example they might make a ferris wheel where the pictures were revealed one by one, a magic wand with pictures stuck on streamers, a pirate hat, steering wheel, or a suitcase. This creative activity was often the first task and provided clinicians with many occasions to name the target words. We encouraged discussion of the topic and used the opportunity to transcribe the spontaneous speech of the children and note any changes. We found the discussions about the theme helped children develop relationships with their peers and become more confident. In addition we learnt a lot from them. For example we found out that one boy knew a lot more than we did
about dog obedience training during a ‘Crufts’ topic. Similarly one quite shy little girl gave us a lot more information about bees because they were also a topic in school. In every session we introduced the words through the creative craft activity and then played a game that involved further familiarisation and discrimination of the word set. When possible we included a set of objects to represent the words as well as pictures. Pictures were made using Boardmaker and were coloured and laminated. We also used black and white pictures in varying sizes for the craft activities. We then encouraged articulation of single target consonants with the aim of familiarising the children with non-verbal cues to each sound (Passy, 1993). In later sessions we no longer needed to include this. We then carried out three or four activities that required the children to say the words. In these tasks we responded to what we heard the child say, not what they might have meant. Even quite early on in treatment we gave the child time to work out his or her own solution to the problem of being misunderstood. Feedback might be something like ‘I heard you say car, you’ve got a car’ but more usually we would provide a model by adding, ‘You need a scar and scarf’. We might provide a lengthening of the target sound depending on the needs of the child. In any case we would give the child time to work out what changes were needed before we provided verbal and nonverbal cues. The way we responded to the child who was searching for a solution was important and obviously depended on their level of impairment. We aimed to keep verbal cues to a minimum so the child had to access his own phonological representation of the word he wanted to say. We encouraged a high level of participation. The best activities were those in which all the children were talking at once (figure 1). Some activities involved turn taking, but we aimed to have at least two or three children actively involved in each turn (figure 2).
Figure 1 Activities for participation • Collect a set. Objects representing a word set were placed in a bag, with one item for each child (for example, accents allowing, the set could be scarves, toy cars, toy calves, plastic tarts, tar (bits from the car park!), star stickers and a red face paint stick with which we could draw a ‘scar’ on the child). The children had to collect a set of these items as fast as possible, by asking us for the items. This was obviously frenetic but all children were motivated to be the first to get the set. We supported the children by giving cues if they were having difficulty naming an item. • The therapist might hide one of the set of objects and pictures. Objects could be hidden in a sock, so the children could see or feel the shape , or in a tin that the therapist shook. All the children said what they thought the item was. We made a note of what each child said, and gave points if they were right. In groups with older children we indicated that often the hidden object would be one of the ‘difficult’ words in order to encourage them to have a go at revising their speech patterns and get more points. • Another way to make sure all children participated was to provide them with a prop. For example in ‘magic land’ they would wave their magic wands during activities and in ‘Crufts’ they all had a toy dog who took part in all the games.
Thanks to Black Sheep Press for providing the illustrations. The company is publishing a number of new phonological packs – see www.blacksheeppress.co.uk for details (Avril Nicoll, Editor). Figure 2 Turn-taking activities • A shopping game could include one child in the shop with the set of objects or pictures, one child ‘phoning’ the shop on behalf of a puppet, and requesting an item and one child ‘driving’ the item to the puppet. In larger groups we also incorporated a ‘lift’ (box on string) in which the item was placed and one child would send the lift up and down to the puppet in his top floor flat. Each role was rotated around the group. • A throwing game such as knocking items off a table by throwing a beanbag could include two children throwing at a time (or even all of them!) The children named the items they wanted to hit before they threw.
SPEECH & LANGUAGE THERAPY IN PRACTICE summer 2009
We included movement and motor skills during the sessions. This is one way to motivate children and keep energy levels high. In addition clinicians would make mistakes, pretend to be upset, make funny faces, and be overly dramatic so that children and clinicans would often be laughing or waiting in anticipation for what could happen next. With older children we might include gentle teasing - ‘do you wear a tap on your head?’ - to encourage reflection on the meaning of what they were heard to say, and cause general amusement. Most games and toys can be adapted for use in activities to address speech disorders. Similarly, many of our stock of activiites
Figure 3 Adapating to the theme 1. Magic land • Magic castle scene board, general discussion. • Make a magic sock (older children) or magic wand. • Magic Sock game - the sock has three compartments to make pictures ‘disappear’ (Lancaster & Pope, 1989). The children call out for the picture to return which it ‘magically’ does if they say the target word. • Brewing a potion - the children all suggest which items from the set go into the brew. The potion then turns into a prince by the clinician’s sleight of hand. • Rescuing a princess - a ‘ladder’ leads to the princess locked in the tower. The children name pictures as they go up the ladder and rescue the princess if they get to the top. • Kim’s game - the children wave their wands as the object or picture disappears and then say which one has gone. • Magic show- older children present a magic trick. 2. Crufts • Discussion about dogs and dog shows with pictures of Crufts. • Each child chooses a plastic toy dog which takes part in the ‘show’. • Make a kennel from a box. • ‘Find the scent’. Pictures are screwed up, and the children try to remember which is which. The clinician names the one the dog must find. If wrong it is screwed up again. • Agility. Two teams. One member from each team either names the set of words, or tries to get their dog round the agility course as many times as possible before the other team have named all the words in the set. • Best in show. Under the set of pictures are rosettes. The children name a picture and the one who finds ‘best in show’ is the winning dog. 3. Pirates • Toy pirates and boat for discussion about pirates. • Make a pirate hat on which the children stick pictures of the word set. • Find the treasure/ avoid the poison. Under a set of pictures are hidden one ‘treasure’ and one ‘poison’. On top of each picture are raisins. The children name a picture and can eat the raisin if it is not ‘poisonous’. If they get the treasure they have extra raisins. If they get poison they can’t eat the raisin and we start the game again. • Stepping stones across the crocodile infested river. The word set is glued onto stepping stones. One or two children at a time name the picture they want to get to next. The other children act as scary crocodiles snapping at their feet. If they make a mistake they get ‘eaten’ by the crocodiles. • Cannon practice. A toy cannon that shoots plastic balls is used to try and hit a picture that the child has named. • Stick / tick / kick / sick. Four chairs, one covered in sticky tape with sticky side up so that children ‘stick’ to it, one with a toy crocodile who ‘ticks’, one with a soft ball to kick and one with a sick bag. Children say which one they want to sit on, and direct each other and the clinicians. 4. Motor sport • Make a steering wheel with a set of pictures stuck to it. • Discuss cars and motor racing. • Car racing. Pictures are stuck on toy cars and are raced off a sloping board. Children ‘guess’ which car will win. • Car stunt course (see ‘agility’ above). • Car race track. Children name pictures as they go round the track. 5. Bees • The bee family (Lancaster, 2007) are introduced and bees are discussed. • Make a house for the ‘masonry’ bees by sticking each bee into a window on the house. • Find the nectar (similar to ‘find the scent’ above). • Guess the bee. The clinician describes a bee and children suggest its name. • Beehive. Different bees need to go to different homes. The children suggest the bee that would be most happy in the home described by the clinician. • Bees find nectar or a predator. (See ‘treasure/ poison’ above in ‘pirates’.)
could be adapted to comply with the theme. Some examples are in figure 3. Although the activities are similar, using themes encouraged our creativity and we think was a motivating factor for the children we worked with. We hope other speech and language therapists are doing the same – and, if not, we recommend it. Gwen Lancaster is a speech and language therapist with Merton Local Authority, Shelagh Benford with Salisbury Foundation NHS Trust, Gerry Buckley with The Mater Child and Adolescent Mental Health Service in Dublin, Alison Langshaw with North Bristol NHS Trust and Emma McCormack with Tower Hamlets NHS Trust.
Allen, S., Hirst, E. & Jones, R. (2008) ‘Better by redesign’, Bulletin of the Royal College of Speech & Language Therapists, 676 (August), pp.2223. Gierut, J. (1990) ‘Differential learning of phonological oppositions’, Journal of Speech and Hearing Research, 33, pp.540-549. Gillon, G.T. ( 2000) ‘The efficacy of phonological awareness intervention for children with spoken language impairment’, Language, Speech and Hearing Services in Schools, 31, pp.126-141. Gillon, G.T. (2002) ‘Follow-up study investigating the benefits of phonological awareness intervention for children with spoken language impairment’, International Journal of Language and Communication Disorders, 37, pp.381-400. Hesketh, A., Adams, C., Nightingale, C. & Hall, R. (2000) ‘Phonological awareness therapy and articulatory training approaches for children with phonological disorders: a comparative outcome study’, International Journal of Language and Communication Disorders, 35, pp.337-354. Hewlett, N (1990) ‘Processes of development and production’ in Grunwell, P. (ed.) Developmental Speech Disorders. Edinburgh: Churchill Livingstone, pp.15-38. Lancaster, G. & Pope, L. (1989) Working with children’s phonology. Milton Keynes: Speechmark. Lancaster, G. (2007) Developing speech and language skills: Phoneme Factory. London: David Fulton. Passy, J. (1993) Cued Articulation. Ponteland: STASS Publications. Stackhouse, J. & Wells, B. (1997) Children’s speech and literacy difficulties: a psycholinguistic framework. London: WileyBlackwell. Williams, A.L. (2003) Speech Disorders Resource Guide for Preschool Children. NY: Thomson Delmar Learning.
• Boardmaker – see www.mayer-johnson.com
REFLECTIONS • DO I OFFER THERAPY THAT IS DYNAMIC, ENERGETIC, PARTICIPATIVE AND FUN? • DO I RELATE PRACTICE TO THEORETICAL FRAMEWORKS? • DO I LOOK FOR INNOVATIVE WAYS TO GROUP CLIENTS?
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SPEECH & LANGUAGE THERAPY IN PRACTICE summer 2009
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