Complex SSD revisited

Dr S Geertsema 2017
INTRODUCTION

 Speech production involves myriad processes in typically developing

child.
 These processes gradually progress over time.
 Progress occurs in speech clarity or intelligibility, child’s organisation
of speech sounds in language and ability to physically produce speech
sounds.
 Later on production of sounds develops into production of syllables or
words containing these sounds (Bowen, 2011).
 Considering that children have to apply processes and regulate word
stress, speech timing, and prosody, it’s clear that any error in speech
production may have implications for child’s communication.
INTRODUCTION CONT.
 Speech Sound Disorder (SSD) is described as developmental disorder
with articulatory and/or phonological difficulties where no
additional cognitive sensory, motor, structural, or affective issues
are present (McGrath et al., 2007; Shriberg et al., 2010).
 Even before the adoption of term, estimated prevalence of 3.8% in 6-
year-old US children and a 1.5 times greater prevalence in boys than
in girls has been reported for one sub-type of SSDs (Shriberg,
Tomblin, & McSweeny, 1999)
 Since 1970s SSD has been classified from a phonological perspective,
which refers to both motor-based- and phonological rule-based
speech-sound errors (Bernthal, Bankson, & Flipsen, 2013).
 No single classification system that is employed uniformly by speech-
language pathologists (Lewis, Avrich, & Stein, 2011)
INTRODUCTION CONT.

 Linguistic Profiling and Speech Subtypes Model

(Dodd, 2005), for example, is based primarily on
linguistic profiles and speech subtypes.
 This classification system embraces five subtypes
of SSD: phonological delay, consistent deviant
phonological disorder, inconsistent speech
disorder, childhood apraxia of speech (CAS), and
articulation disorder.
INTRODUCTION CONT.
 With inconsistent speech disorder, children have delayed and non-
developmental error types and variability in production of single
words.
 Finally, children presenting with articulation disorder (the result of
an incorrectly learnt motor plan/programme according to Fey (1992)
and Crosbie et al. (2005)) are consistently unable to produce
particular phonemes.
 Consistently produce the same type of distortion or substitution
error for the target sound in all phonetic contexts and in all
elicitation conditions (for example, lateral lisp in imitation, picture
naming, conversational speech (Dodd, 2005).
 The nature of the disorder is therefore motor-based, which accounts
for the term “motor-based speech sound disorders (SSDs).”
EBP in SSD
 Traditionally, both phonological processes and articulation disorders
(SSD), have been effectively treated by applying motor-based
approaches - also referred to as phonetic or traditional approaches
(Bauman-Waengler, 2014).
 Motor-based treatment approaches were suggested for both these
disorders because of their inaccurate motor production and
inadequate motor learning of a specific speech sound (Van Riper,
1996; Klein, 1996).
 Traditional phonetic-placement approach (PPA) of Van Riper (1978),
the programmed instruction articulation treatments (Baker & Ryan,
1971), and the Motoric Automization Program (Hoffman et al., 1989)
are examples of motor-based approaches.
EBP in SSD
 More recent literature has waived this traditional treatment stance and has
focused mostly on treatment methods associated only with phonological disorder,
motivated by the understanding that the problem lies at a linguistic level (i.e.
phonemic level).
 For this reason, a motor-based approach to treatment does not make sense
(Bowen, 2011). Research into phonological approaches has escalated, neglecting
motor-based treatment approaches to motor-based SSD.
 A wide variety of phonological intervention approaches has emerged, including
core-vocabulary- and phonological-contrast therapy (Crosbie et al., 2005), minimal
and maximal oppositions target selection (Topbas & Unal, 2010), multiple
oppositions treatment (Allen, 2013), and concurrent task sequencing (Skelton,
2004).
 A shift in research focus also led to investigation of the effects of these linguistic-
based approaches on motor-based SSD. Powell et al. (1998) indicated a greater
overall effect for traditional treatment as opposed to phonological treatment in a
group of children presenting with a single /s/-articulation impairment.
EBP in SSD
 Few recent authors have reported comparative studies in regard to
the traditional bearing that motor-based treatment may benefit
phonological disorders.
 Even fewer detailed efficacy studies have reported on the traditional
approaches to motor-based SSD.
 Lousada et al. (2012) upheld the historic notion, but still favoured
phonological treatment for phonological disorders specifically.
 Rvachew (1994) highlighted the benefit of speech perception training
as part of traditional treatment methods for children with
phonological disorder.
 Hesketh, Adams, Nightingale, and Hall (2000) found no significant
difference in the improvement of phonological awareness between
phonological and traditional articulation therapy in children with
phonological disorder.
EBP in SSD
 Baker and McLeod (2011) reviewed evidence-based practice for
children with SSD.
 Failed to provide further evidence on the specific treatment effects
of traditional motor-based approaches to motor-based SSD.
 They excluded traditional treatment aimed at children with motor-
based SSD, as they proposed that the majority of children with SSD
are considered to have primarily phonological disorder.
 Skelton and Funk (2004) added investigations into certain principles
of traditional treatment and proposed the application of randomised
variable practice conditions through concurrent treatment for
articulation disorders.
 They concluded that an easy-to-hard task sequence, as described in
traditional approaches, may be unnecessary for successful
articulation treatment outcomes where a single target sound is in
error.
EBP in SSD
 The few examples of recent research seem to support the
notion that the PPA’s historical effectiveness still stands
firm for motor-based SSD.
 Traditional approaches to treatment may be effective to a
certain extent in the treatment of phonological disorder
(albeit unpopular), and also have merit at the phonetic
level.
 However, these approaches were neglected in recent
research, and this dearth warrants further investigation
into specific details such as the treatment principles,
hierarchy, and conditions underlying the nature of the
approaches and the steps embedded in them.
EBP in SSD
 Furthermore, as these motor-based
articulation errors are presumed to be the
result of an incorrectly learnt motor
plan/programme, investigation should
focus on the principles of motor learning
that underlie the nature of the motor-
based approaches, such as the longstanding
effective PPA.
Motor learning and EBP in SSD

 Several principles underlie the teaching of motor skills in motor-based SSD.

 Based on the review by Hegde (1998b), it appears that traditionally (in the
eighties and earlier) the amount of practice was the focus of speech learning.
 When the treatment of SSD is discussed, reference is made to general
principles of learning, programmed instruction, and behaviour modification
(Bernthal et al., 2013; Van Riper, 1996; Pena-Brooks & Hegde, 2000).
 However, no treatments for SSD make specific reference to motor learning
principles (MLPs) (Magill, 2007; Schmidt & Lee, 2011).
 These MLPs are embedded in different theories of how the motor system
learns and subsequently retains skilled actions (Magill, 2007; Schmidt & Lee,
2011) and have not yet been directly applied to the treatment of SSD (Adams
& Page, 2000). (Therefore currently under investigation).
Motor learning and EBP in SSD
 Motor learning (ML) entails the study of the acquisition of
motor skills, the performance enhancement of learned
motor skills, or the reacquisition of skills that are
difficult to perform or cannot be performed because of
injury, disease, or any other reason (Magill, 2007).
 Knock, Ballard, Robin, and Schmidt (2000) provided
preliminary evidence that the application of MLPs may
have a similar effect on the learning of speech motor acts
as they do on limb movements.
 More recently a systematic review by Bislick et al. (2012)
has indicated that the current level of evidence for the
application of MLPs to healthy adults and individuals with
motor speech disorders is promising and warrants
continued investigation.
Motor learning and EBP in SSD
 Various conditions of practice underlie some of these MLPs and should be
taken into consideration during treatment (Magill, 2007; Schmidt & Lee,
2011).
 Some conditions such as practice variability, practice schedule and feedback
in practice have been demonstrated to be important in limb motor learning.
 Practice variability refers to “the variety of movement and context
characteristics the learner experiences while practicing a skill” (Magill, 2007,
p.434).
 Practice schedules include random, blocked, and serial practice.
 Random practice is defined as utilising different targets in random order and
is the opposite of blocked practice.
 Blocked practice is the repeated production of a target skill without
involving other targets before switching to another target.
 Serial practice involves the production of several discrete actions
simultaneously during a set sequence or order (Schmidt & Wrisberg, 2008).
Motor learning and EBP in SSD
 The SML approach (Van der Merwe, 2011) to treating apraxia of speech (AOS)
is primarily based on a four-level model of speech sensorimotor control as
described by Van der Merwe, Schmulian, and Groenewald (1997) and Van der
Merwe (2011).
 The four-level model consists of one pre-motor stage (linguistic-symbolic
planning) and the remaining motor stages: motor planning, motor
programming, and motor execution (Van der Merwe, 2011).
 Each target sound is rehearsed in systematically changing phonetic contexts
in series of nonwords.
 The adaptation of spatial specifications of each speech sound to the phonetic
context and rate of production, as well as the adaptation of temporal
specifications to segmental duration, coarticulation potential, rate, and
interarticulatory synchronisation happens at the second level of motor
planning
Motor learning and EBP in SSD
 Certain MLPs are thought to positively influence both the
SML and PPA into the classification of specific guidelines,
strategies, and techniques utilised.
 Applying the MLPs addresses the ever-present problem of
generalisation of the correct production of treated sounds
(SMT) to different phonetic contexts and connected
speech in natural communication (Wambaugh & Nessler,
2004).
 As such, the application of MLPs may facilitate
performance, generalisation, and maintenance of skills
(Magill, 2007; Schmidt & Lee, 2011). Both the PPA (Van
Riper, 1996) and the SML approach (Van der Merwe, 2011)
instruct generalisation of acquired skills.