Original Paper
Folia Phoniatr Logop 2011;63:237–241
DOI: 10.1159/000323183
Speech Inconsistency Index in Brazilian
Portuguese-Speaking Children
Márcia Mathias de Castro Haydée Fiszbein Wertzner
Department of Speech-Language Pathology and Occupational Therapy, University of São Paulo School of
Medicine, São Paulo, Brazil
Key Words
Speech inconsistency index ⴢ Phonological disorders ⴢ
Brazilian Portuguese
Abstract
Objective: Speech inconsistency is characterised by variable
productions of the same lexical items within the same con-
text. This study aimed to describe inconsistencies among
Brazilian Portuguese (BP)-speaking children with and with-
out phonological disorder (PD) as well as the effectiveness
of a speech inconsistency test (SIT). Methods: The study
sample included children between 5 years 0 months (5; 0
years) and 10;10 years of age, both genders, 51 children with
PD and 50 without speech-language disorders. The SIT in-
cludes 25 pictures, each named 3 times in different sequenc-
es within the same session. Results: The inconsistency aver-
age of children with PD (27.4%) was higher than that of typi-
cally developing children (9.8%). Linear regression showed
age and gender effects, receiver operating characteristic
curves were built for speech inconsistency with combined
gender and age cutoff values. Inconsistent subjects among
typically developing children included 2 younger boys and
2 older girls. Inconsistencies were found among children
with PD, including 10 boys up to 7; 6 years and 11 over this
age, and 7 girls up to 7;6 years and 6 over this age. Conclu-
sion: Speech inconsistency in BP-speaking children seems to
be an effective measure for differentiating children with PD
from those with typically developing phonology.
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Published online: January 26, 2011
Introduction
Phonological disorders (PD) are frequently observed
in Brazilian Portuguese (BP) children and in speakers of
other languages. In BP, there are many studies including
typical phonological development from 2 year 0 month
(2;0)- to 8-year-old children [1], PD assessment, phono-
logical processes presented by PD children [1], causal fac-
tors [2], stimulability [3], speech rate [4], severity [5] and
others.
PD children are heterogeneous in terms of severity,
types of errors, causal factors, auditory perception, sound
production and cognitive linguistic processing. In order
to clarify the most important underlying deficits respon-
sible for speech impairment, some procedures have been
designed to identify specific deficits in perceptual, cogni-
tive, structural, affective or motor areas [6–8]. Proce-
dures designed to assess PD must be specific to each lan-
guage, but for BP there is a need for a speech inconsis-
tency assessment tool. Speech inconsistency may be a
helpful tool to identify markers for subgroups of children
with PD, which may help to indicate what skills the child
needs to work on to resolve the problem.
Speech inconsistency is an important aspect of evalua-
tion in PD. PD children may be classified as consistent if
the production of a word is always the same, and as incon-
sistent if there are multiple types of production of the same
word either in the same context or different contexts [9].
Children whose speech is characterised by inconsistent
errors may have difficulty in selecting and sequencing
Márcia Mathias de Castro
Rua Ana de Proença, 49 Tatuapé
São Paulo, SP 03409-040 (Brazil)
Tel. +55 11 2942 9134, Fax +55 11 3091 7714
E-Mail mamcastro @ usp.br
phonemes for the production of phonological structure, Table 1. SIT words
which indicates a deficit in phonological planning with
effects on phonetic planning [10]. Moreover, inconsisten- BP English BP English
cy is associated with highly unintelligible speech [11]. árvore tree zebra zebra
In typically developing children, the multiple types of futebol soccer flor flower
production of the same word are sometimes referred to escola school ioiô yo-yo
as inconsistency, and sometimes as variability, in speech. trem train xale shawl
Variability in speech is defined as different productions placa plate vela candle
menino boy nó node
of words attributed to factors observed in normal acquisi- livro book remédio medicine
tion (e.g. phonetic context, maturation or cognitive-lin- bola ball computador computer
guistic influences) [10, 12]. passarinho bird bicicleta cycling
In order to identify speech inconsistency, there are palhaço clown papagaio parrot
some different procedures that can be used in speech as- azul blue bandeira flag
cachorro dog índio indian
sessment. Researchers agree that the best way to assess tigela bowl
inconsistency is to compare multiple productions of the
same word in the same context. A child is considered to
present inconsistent speech if the production of the same
word differs over 3 naming trials [8, 10, 13]. The BP SIT was administered to both groups. Twenty-five pic-
The aim of the current study was to describe a speech tures were named 3 times in different sequences during the same
inconsistency index (SII) for BP-speaking children with session. The children’s productions were audio and video record-
and without PD as well as the effectiveness of the index ed, and were auditorily categorised by the first author based on
for BP. Considering BP-speaking children with PD, ques- perceptual analysis of the live voice (when the child produced the
words) and confirmed from the audiovisual recording.
tions that guided this study were whether inconsistency The SIT was based on the criteria adopted in English studies
affects the speech of children according to age and gen- [13]. Thus, the test is composed of words ranging in length from
der, and whether the speech inconsistency test (SIT) is an 1 to 4 syllables, with syllabic structures of BP involving vowels (V)
efficient tool for use during the assessment of children and consonants (C; i.e. V, VV, CV, VC, CCV, CVC, CVV and
with suspected PD. CCVC) forming words of high and low frequency in the sample
analysed, and composed of a variable number of phonemes (from
2 to 9). We included all singletons and consonantal clusters of PB
as well as oral and nasal vowels.
Subjects and Methods During the SIT application, if the child did not name the target
word, prepared statements were provided with clues for each pic-
The study design was approved by the ethics committee of the ture. If the child still did not name the target word, the stimulus
Clinics Hospital, University of São Paulo School of Medicine (pro- was presented and named, and it was explained to the child that
tocol No. 988/06). Parents or legal guardians signed the informed the question would be asked again. After 5 stimuli, the picture was
consent. presented. In case the word was not named, this target was dis-
A total of 101 children between 5;0 and 10;10 years of age took considered for the analysis.
part in the study, 51 of them with PD, designated as the PD group The 3 namings of each word were analysed and classified as
(PDG), and 50 without any speech-language disorders, constitut- consistent when the child named the same word equally all 3
ing a control group (CG). PD children were diagnosed as phono- times. Conversely, when at least 1 of the 3 word productions of a
logically disordered after the application of a protocol that in- certain word target was different for any sound it was classified as
cludes the following tests: BP phonology tests (imitation and pic- inconsistent. Next, the SII was calculated, and the number of in-
ture naming ABFW, a language test for children [1], as well as consistent words was divided by the total number of words (n =
continuous speech), phonological awareness tests, reading and 25) (table 1), giving a result in percent.
writing tasks and vocabulary tests, among others. Phonological
tests allow for the observation of the inventory, phonological pro-
cesses and Percentage of Consonants Correct-Revised analysis
[14]. The inclusion criteria in this group were: the presence of pho- Results
nological processes not expected for the child’s age; no previous
speech pathology treatment, and hearing thresholds no greater The Percentage of Consonants Correct-Revised index
than 20 dBHL from 250 Hz to 8.0 kHz. The criterion for inclusion
in the Brazilian Phonology test ABFW [1] showed higher
in the CG was the absence of language, speech or hearing prob-
lems, as stated on the questionnaire completed by the parents and average values in the CG (mean = 98.8%, SD = 1.8%) com-
confirmed by the phonological evaluation. pared to the PDG (mean = 81.1%, SD = 16.1%). This differ-
ence was significant by the Kruskal-Wallis test (p = 0.000).

238 Folia Phoniatr Logop 2011;63:237–241 de Castro/Wertzner


Sensitivity
a 1 – specificity
Fig. 1. ROC curves for age and gender.
a Females from 5; 0 to 7; 6 years old. Area
under the curve = 0.92; sensitivity = 0.78;
Sensitivity
specificity = 1.00. b Males from 5; 0 to 7;6
years old. Area under the curve = 0.81; sen-
sitivity = 0.60; specificity = 0.88. c Females
over 7;6 years old. Area under the curve =
0.80; sensitivity = 0.56; specificity = 0.89.
d Males over 7; 6 years old. Area under the
curve = 0.94; sensitivity = 0.69; specific- c 1 – specificity
ity = 1.00.
Speech Inconsistency Index
The SII average of the PDG (mean = 27.4%, SD = 14.6%)
was higher than that of the CG (mean = 9.8%, SD = 9.9%).
In the PDG, the minimum SII value was 4%, indicating
that none of the subjects produced all words in a consis-
tent manner, while in the CG the minimum value was
(0%), demonstrating that some children produced all
words consistently. The maximum value was 40% in the
CG and 63% in the PDG; the median was 8% in the CG
and 28% in the PDG. The linear regression analysis dem-
onstrated a group effect, in which the average percentage
of the SII of the PDG was higher than that of the CG (p =
0.001). Regarding gender, the averages were higher for
boys (CG: mean = 12%, SD = 11.3%; PDG: mean = 30.3%,
SD = 15.3%) than for girls (CG: mean = 8.4%, SD = 8.7%;
PDG: mean = 22.5%, SD = 12.2%), and this gender effect
was observed in both groups (p = 0.016). There was also
an age effect, in that the SII decreased with age (p = 0.001).
Thus, the SII depended on gender and decreased, on av-
erage, by 2.6% with each additional year in both groups
(p = 0.425).
Effectiveness of BP SIT
Receiver operating characteristic (ROC) curves were
built to verify the effectiveness of the SIT and to deter-
mine the cutoff values for inconsistency, simultaneously
providing the highest sensitivity and specificity. The val-
ues of the areas under the curves were 60.80, indicating
SII in BP-Speaking Children
1.0 1.0
0.8 0.8
Sensitivity
0.6 0.6
0.4 0.4
0.2 0.2
0 0
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
b 1 – specificity
1.0 1.0
0.8 0.8
Sensitivity
0.6 0.6
0.4 0.4
0.2 0.2
0 0
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
d 1 – specificity
good discriminatory powers of the test. The diagnosis of
typical speech or PD was used as a criterion in the con-
struction of the ROC curves. All subjects were included
in this analysis.
As the linear regression showed age and gender effects,
4 ROC curves were built for the SII with combined gender
and age cutoff values. Thus, children were grouped by age
from 5;0 to 7;6 years (younger) and above 7;6 years (older)
(fig. 1).
In figure 2, we can observe that the cutoff values for
the SII were 21.5% for younger girls and 31.9% for young-
er boys; the value for the older girls was 14.5%, and for the
older boys it was 17.6%. Out of the 101 children evaluated,
38 (38%) were above the SII cutoff values, including 4
children of the CG and 34 of the PDG. The inconsistent
subjects among the CG (8%) included 2 younger boys and
2 older girls. In the PDG (67%), inconsistency was found
in 10 younger boys and 11 older boys as well as in 7 young-
er girls and 6 older girls (fig. 2).
Discussion
Speech inconsistency testing is commonly applied for
diagnostic use to identify subgroups of PD children and for
planning intervention in English-speaking children. The
tool presented in this study was designed to check incon-
sistency in children with PD whose native language is BP.
Folia Phoniatr Logop 2011;63:237–241 239
 duction (larynx, pharynx, velum, lips, tongue, jaw), and
60 60
the coordination of this system requires a synergy be-
tween the articulators to produce the target sound. This
synchrony may also be compromised in children with in-
45 45 consistent speech [16].
Inconsistency (%)

Inconsistency (%)
The inconsistency may also result from different neu-
30 30 ral control strategies at various levels of the linguistic sys-
tem that reflect different activation patterns; speech in-
21.5
volves an extensive cortical and subcortical network. A
15 15 14.5
preverbal message is formed in semantic-syntactic ar-
eas, producing the grammatical encoding integrated with
0 0 the morphophonological and phonetic encoding which
a CG PDG b CG PDG
forms the sequence of the phonological selection, the
phonetic encoding, the articulation selection and, finally,
articulation and speech expression [16].
60 60

Speech Inconsistency Index

45 45 In this study, we found that CG children were more
Inconsistency (%)

Inconsistency (%)

consistent than PDG children. In English language stud-

30
31.9
30
15 15
0 0
c CG PDG d CG
Fig. 2. Individual values of SII in CG and PDG in each combi-
nation of gender and age with cutoff values. a Females from 5;0
to 7;6 years old. b Females over 7;6 years old. c Males from 5;0 to
7;6 years old. d Males over 7;6 years old.
In this study, we focused on inconsistency assessment
in order to verify its applicability as a diagnostic marker
for PD. We intended to relate speech inconsistency with
phonological planning, as suggested in some recent re-
search. Inconsistency refers to the sequence of sounds in-
volved in the phonological structure of a word and to the
selection of this structure in variable ways for the same
word [9, 10, 15].
Phonological planning also occurs simultaneously
with the synchronised production planning of the articu-
lators, which generates a great linguistic demand to be
managed and sent to the motor system, involving rapid
sequence timing and strength control of a large number
of articulators. The coordinated activity of many muscle
groups and articulators is directly involved in sound pro-
ies [12], an average of 13% variability was found in chil-
dren with typical development, whereas in the present
17.6
study, the variability was 9.8 8 9.9%. If we consider that
variability in speech production in typically developing
children is related to factors such as phonetic accuracy,
the position of the sound in the word, the surrounding
consonants, new word acquisition as well as the demands
PDG
regarding one language component (syntactic and se-
mantic) can influence the ability to produce another
component [12].
In the CG, 4 children had SII values above the cutoff
values established, despite presenting phonological pro-
cesses inappropriate to their ages. We observed that in-
consistency occurred in words of low frequency with
multiple and phonetically complex syllables, which may
explain this variability.
In contrast, 34 (67%) of the PDG children presented
speech inconsistency, and these results suggest a diffi-
culty in underlying phonological planning for most PDG
children, corroborating the results of a previous study
with English-speaking children [15]. The varying pro-
ductions of a single word suggest a lack of stability of the
phonological system and indicate a delayed acquisition
[13]. Many studies have interpreted varying productions
as evidence that inconsistent PD children demonstrate
difficulty in planning [10, 15].
Two interesting aspects were highlighted in this study,
one of which concerns gender. The higher SII values ob-
served among the boys in the PDG suggest that their pho-
nological maturation was slower than that of the girls [8].
The other interesting finding was the influence of age,

240 Folia Phoniatr Logop 2011;63:237–241 de Castro/Wertzner

revealing that the SII decreased with age, namely 2.6%
per year on average. The constant use of language and
maturation improve phonological planning in PD chil-
dren [13]. The number of phonological features that chil-
dren may include in phonological planning is limited and
develops gradually [12].
In the present study, the SII showed gender and age ef-
fects as well as differences between the CG and PDG. For
example, younger boys in the PDG were more inconsis-
tent. This finding might indicate delayed maturation in
phonological planning in boys, which could explain the
increased incidence of PD in boys.
Effectiveness of BP SIT
Analysis of the BP SIT showed gender and age effects
and indicated 4 cutoff values in the ROC curves. These
cutoff values differed from the ones determined for Eng-
lish-speaking children, which consider that inconsisten-
cy of 40% or greater characterises meaningful inconsis-
tency in PD [13]. However, the authors do not discuss how
the criteria were set in their study, making it difficult to
compare their results to those of the present study. With
that caution in mind, in the present study the cutoff val-
ues were lower than those in the study by Crosbie et al.
[13], and most children with PD were considered incon-
sistent.
The sensitivity and specificity obtained for the SIT
demonstrate that, in diagnosis, children below the estab-
lished cutoff values for gender and age have high proba-
bilities of developing typically, whereas children above
the cutoff values show a high possibility of presenting PD
and should be referred for diagnosis to specialised ser-
vices.
In conclusion, the present results show that the SIT is
consistent with the diagnosis of PD and indicate that the
test was effective in separating the true positives, i.e. the
subjects who really presented with PD, from the true neg-
atives, i.e. those children with a typical phonological de-
velopment expected for their age. This study suggests that
phonological planning develops during each year of a
child’s development and differs between genders. The rel-
evance of this measure is related to an accurate diagnosis,
in which practice can be used as evidence to guide clini-
cal decisions.
Acknowledgement
Grants: FAPESP (Fundação de Amparo à Pesquisa do Estado
de São Paulo) 06/56997-0, 2008/57145-2; CNPq (Conselho Na-
cional de Desenvolvimento Científico e Tecnológico) 475468/
2006-6.

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