The Wonder of Cycles Created by Barbara Hodson

slide1. The Wonder of Cycles Created by Barbara Hodson
Shared by Anne Hasting
2014<br>
slide2. Where credit is due Created by Barbara Hodson
Evaluating and Enhancing Children’s Phonological Systems
www.phonocomp.com<br>
slide3. 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<br>
slide4. 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<br>
slide5. What’s 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<br>
slide6. 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 doesn’t cooperate
Video recording, audio recording, notes
Full analysis not necessary
First look for absence of primary patterns (slide 11)<br>
slide7. 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<br>
slide8. 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<br>
slide9. 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<br>
slide10. 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<br>
slide11. Primary Patterns Primary patterns:
Syllableness
Singleton consonants
Initial
Final
/s/ clusters
Anterior-posterior contrasts
Liquids
Target what the child needs<br>
slide12. Syllableness Spondees (equal-stress words)
Targeting non-spondee two-syllable words results in inappropriate prosody or encourages syllable deletion
Target is producing multiple syllables
How’s he doing?
ice cream -> cream 
ice cream -> eye ee 
ice cream -> ha ha <br>
slide13. 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<br>
slide14. 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<br>
slide15. /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: “It’s a spoon.” “It’s a snail.”
Video 2, it’s a sk I<br>
slide16. 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<br>
slide17. Liquids 3 y/o vs. 7 y/o working on /r/ for first time
Developmentally appropriate acquisition
Hodson’s 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<br>
slide18. 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<br>
slide19. Nitty gritty, part 1 One clinical hour per target phoneme (2-6 hours per target pattern)
Hodson recommends one hour per week total: three 20-minute, 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 doesn’t 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)<br>
slide20. 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<br>
slide21. Secondary Patterns Begin after criteria have been reached for primary pattern “graduation”
Do NOT kill yourself analyzing all patterns early
Listen during liquids<br>
slide22. 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<br>
slide23. Voicing Contrasts Errors with voiced/voiceless cognates
p/b, t/d, s/z, etc.
Prevocalic voicing
Use minimal pair words and some amplification<br>
slide24. Vowel Contrasts Usually get the vowels sorted out during the primary cycles
Use minimal pairs and some amplification<br>
slide25. Anterior-Posterior Contrasts Target in secondary cycles if not stimulable during primary cycles
See slide 16<br>
slide26. 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<br>
slide27. 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<br>
slide28. 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)<br>
slide29. 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)<br>
slide30. 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<br>
slide31. 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 you’ve broken it up, put it all back together<br>
slide32. 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?<br>
slide33. Example: Morgan Primary patterns
Singleton consonants (final)
/s/ clusters
Anterior-posterior contrasts
Liquids<br>
slide34. Example: Adam, age 6:1 Adam’s intelligibility in conversation varies
Errors include:
Stop -> chop
Likes -> wite
Chair -> tayoh
Tree -> tee
Susannah -> Chuchannah
Skates -> chate
Christmas -> Kimuch
Shoes -> chooch
Zero -> jeewo<br>
slide35. Example: Adam Primary patterns:
/s/ clusters (avoid sk)
Anterior-posterior contrasts
Liquids<br>
slide36. Example: Hannah, age 3:3 Hannah doesn’t 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<br>
slide37. Example: Hannah Auditory input cycle?
Primary patterns
Syllableness
Singleton consonants (initial)
Singleton consonants (final)
/s/ blends when singleton consonants emerging
Anterior-posterior contrasts
Liquids<br>
slide38. 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<br>
slide39. Nathan Primary Patterns
/s/ clusters
Liquids (/r/)
Secondary Patterns
Metathesis and migration best addressed in:
Advanced Patterns
Complex consonant sequences
Multisyllabicity<br>
slide40. Whew Enough framework for you?
It’s the most important part!
Organization of overall treatment
What does a session look like?<br>
slide41. Sessions Review
Listening words
Practice patterns
Metaphonological skills
Listening words
Stimulability<br>
slide42. Session Structure Review last week’s 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<br>
slide43. 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 skills—see next slide
Able to read:
Short oral reading period focusing on target pattern<br>
slide44. 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<br>
slide45. Session Structure Listening words – 15 seconds
Same list, same amplification
Stimulability – 2 minutes
Select next session’s practice words<br>
slide46. 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
Don’t say “good job” when you mean “good try”
Give accurate feedback and immediately try to correct the error<br>
slide47. 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<br>
slide48. 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<br>
slide49. Ear training Supports Cycles
Important: limited to current target pattern
Five types:
Modeling
Auditory awareness
**Feedback**
Praise
Corrections<br>
slide50. Ear training Modeling (auditory bombardment)
Focused play, say targets often without requiring the child to imitate
Auditory awareness
“Johnny, want to go—hey, go has your /g/ sound! Want to go outside and play?”
Feedback – “Ditzy dame routine”
“The tea? Hm, I don’t 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 don’t know what a nack is… Oh, snack! Sure, you can have a snack.”<br>
slide51. Ear training Praise
“Nice /s/ in sit!”
“I heard that good /k/ sound when you said keys.”
Corrections
“No? Try again: snow. … That’s right!”
I require an equal number of praise and corrections, max 5 corrections per day
Impossible until child is generalizing
No praise = no corrections<br>
slide52. 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/<br>
slide53. 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, mild-severe hearing impairment, cochlear implant, cognitive delays<br>
slide54. My Evidence All names are changed
Progress in a single school year<br>
slide55. 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<br>
slide56. Hugh’s progress in conversation<br>
slide57. 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<br>
slide58. Bella’s progress in conversation<br>
slide59. 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<br>
slide60. David’s progress in conversation<br>
slide61. 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<br>
slide62. Carly’s progress in conversation Data from 5 months into tx
All at 100% except liquids after 8 months tx<br>
slide63. 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<br>
slide64. Michael’s progress in conversation 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<br>
slide65. 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<br>
slide66. The last word 3-6 months to generalize to conversation after fluent productions at word level
Key is to KEEP MOVING ON
Don’t get stuck on something they haven’t generalized
Don’t expect Cycles to work if you modify it
myspeechteacher.wikispaces.com
Listenandtalk@me.com<br>
slide67. Appendix A History of Therapy Approaches
from Hodson 2010 (see note)<br>
slide68. Overview Early Approaches
Phoneme-Oriented Intervention
Phonetic Placement
Moto-Kinesthetic
Stimulus Approach
Sensory-Motor Approach
Discrimination Approach
Behavioristic Approaches
Linguistic-Based Approaches<br>
slide69. 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<br>
slide70. 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<br>
slide71. 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<br>
slide72. 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<br>
slide73. 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<br>
slide74. 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<br>
slide75. 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<br>
slide76. Behavioristic: Programmed Instruction Mowrer, Baker, & Schutz 1968
Reinforcement schedules: stickers, tokens
Penalties for incorrect production
Many responses required--tedious, boring (for clinician and child)<br>
slide77. 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 program—several not all phonemes<br>
slide78. 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<br>
slide79. 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<br>
slide80. Cycles Um.. Go back to the beginning<br>
slide81. 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<br>
slide82. 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<br>
slide83. 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<br>
slide84. Appendix B Target Selection
from Hodson 2010<br>
slide85. Phoneme-Oriented Approaches Chronological or developmental age
Early-developing phonemes are considered a prerequisite for later-developing phonemes
Phoneme frequency—ex. /s/
Stimulability—stimulable before non
Visibility—ex. labial consonants
Variability inconsistency—sounds produced sometimes are chosen
Utility—ex. sound in the child’s name<br>
slide86. 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<br>