Using Orthographic Representations in Speech and Language Therapy

Word learning, and in particular, productive word learning is associated with three important processes in the phonological domain: first, the child must encode the acoustic-phonetic form of the word in the language input; second the child must transform this representation into a lexical representation, generally considered to take on a more abstract phonological form; finally the child must retrieve the representation to reproduce it. The first process is reliant on speech processing abilities that have been shown to be impaired in many children with speech, language and reading deficits, as shown by for example by Ben Munson and colleages (@benjyraymunson) and Nina Kraus and colleages. Phonological encoding is enhanced by access to repeated high-quality but variable inputs as shown by Richtmeier et al for normally developing children and by Rice et al for children with SLI. The majority of children with SSD have difficulties with encoding: we have a paper in press with the American Journal of Speech-Language Pathology showing that speech accuracy in these children can be improved with an approach that focuses largely on the provision of intense high quality input – I will have more to say on this subject when it (finally) emerges in print.

The second process, forming a phonological representation and storing it in the lexicon, involves articulatory recoding which can be a serious problem for children with severe SSD, accounting for deficits in speech accuracy (especially in association with inconsistency), nonword repetition, word learning, productive vocabulary, word finding, rapid automatic naming, and other phonological processing skills. These children are often diagnosed with motor planning disorders but I have pointed out previously that the problem is actually at the level of phonological planning. I have further pointed out the very close relationship between speech planning and memory. Children who are having difficulty with phonological planning may not show the same benefit from a therapy approach that is focused on the provision of high quality inputs. Therefore a new paper on the use of orthographic inputs to teach new words caught my eye.  Ricketts et al taught children with SLI and ASD as well as younger and age-matched children with typical language to label nonsense objects with new names, using a computer program. For some words, the children were exposed only to the object–auditory word pairing; for others they saw the object, heard the word and saw a printed version (orthographic representation) as well. All children found it easier to learn the new words when they were exposed to the orthographic representation along with the auditory word.

This study reminded me of the research we are doing with children who are referred to our clinic with an apraxia diagnosis due to inconsistent speech errors. So far, 40% of those children have difficulty with phonological planning rather than motor planning as revealed by the syllable repetition test, as I have explained in a previous blog. We have been using a single subject randomization design to compare the relative efficacy of two treatment approaches with these children. The Phonological Memory & Planning (PMP) intervention pairs the phonemes in the target words with visual referents that include letters as shown here. Imitative models are avoided and the child is encouraged to create their own phonological plan and produce the word using the visual symbols when necessary. An alternative treatment, the Auditory-Motor Integration (AMI) Treatment is quite different with a heavy emphasis on prior auditory stimulation and self-judgments of the match between auditory inputs and outputs. A third condition is a usual care CONtrol condition focusing on high intensity practice. In all cases we teach nonsense words paired with real objects, with the words structured to target the children’s phonological needs in the segmental and prosodic domains.

The results are assessed by applying a resampling test to probe scores and then combining p-values across the children. These are the statistical results (F and t tests by resampling test) for the Same Day Probe Scores, with p-values combined across the 5 children who have proven to have phonological planning problems in concert with a severe inconsistent speech disorder:

TASC PMP results Aug 2015

The results in the third column show that all of the children obtained a significant treatment effect. The findings in the remaining columns pertain to planned comparisons with positive t values being in the expected direction. The combined p values indicate that all treatments are significantly different from each other and inspection of the mean scores across children show that the pattern of results is PMP > CON > AMI. The result is made more interesting by the fact that the pattern of results is the exact opposite for children with a motor planning disorder. Tanya Matthews and I will compare these two subgroups with data and video during our presentation at ASHA 2016 in Denver this coming fall.

Session Number: 1429
Session Title: Differential Diagnosis of Severe Phonological Disorder & Childhood Apraxia of Speech
Day: Friday, November 13, 2015
Time: 1:00 PM – 3:00 PM
Session Format: Seminar 2-hours

For now, the take away message is that learning new words involves (at least) three important processes: encoding the sound of the new word, memory processes for storing and retrieving the phonological representation and motor planning processes for planning and programming articulatory movements prior to production of the new word. There are published studies showing that intervention procedures targeting each of these processes help children with speech, language and reading difficulties. Increasing frequency of high quality input improves quality of the acoustic-phonetic representation. Pairing phonological segments with visual symbols helps with storage and retrieval of the phonological representation. High intensity speech practice with appropriate stimulation and feedback improves motor planning and motor programming. The trick is to figure out which children require which procedures at which time.

Phonological Memory and Phonological Planning

I have been writing about the children in our intervention study for children with Childhood Apraxia of Speech (CAS). So far about half of the children referred to us appear to have difficulties in the domain of phonological memory with their overt phenotype corresponding to the subtype described by Dorothy Bishop Dodd as Inconsistent Deviant Disorder. Shriberg et al. (2012) have developed the Syllable Repetition Task as one means of identifying deficits in “memory processes that store and retrieve [phonemic, sublexical, and lexical] representations. We have been using this SRT test to differentiate children who have deficits in phonological planning versus motor planning. I described the profile that corresponds to difficulties with motor planning (transcoding) in a previous post. Today I will discuss the phonological memory or phonological planning profile that we see in approximately half of the children that are referred to us with suspected CAS.

These children can be identified by a qualitative analysis of their SRT performance and by their performance on the Inconsistency Test of the DEAP. Starting with the SRT, one child in our study for example was able to achieve 12/18 consonants correct when imitating 2-syllable items but only 5/18 consonants correct when imitating 3-syllable items, thus exemplifying the classic profile of a child with phonological memory difficulties – better nonword repetition performance for short versus long items. Qualitatively he tended toward consonant harmony errors even with some 2-syllable items, /bama/=[mama],  /maba/=[mama],  and then more frequently with the 3-syllable items, /nabada/=[mamada]. Addition of syllables and vowel errors also occurred, /manaba/ = [mamadada],  /manabada/=[mimadama]. Poor maintenance of phonotactic structure and vowel errors were also observed on the Inconsistency Test, “helicopter” = [hokopapɚ], “elephant”= [ɛmpɩnt], which yielded an overall inconsistency score of 78% as many words were produced with multiple variants, e.g., “butterfly”= [bʌtfaɩ], [bʌtwaɩ], [bʌtətwaɩ].

The most striking illustration of the difficulties these children have with the storage and retrieval of phonological representations comes during our treatment sessions however. In this research program we are teaching the children nonsense words in meaningful contexts. For example in one scenario we teach the children the names of “alien flowers” and in one of the treatment conditions we use graphic stimuli, paired with gestural cues if necessary, to represent the syllables and phonemes in the words and phrases that we are teaching. Many of the children in our study learn all of the nonsense words without difficulty (5 words per goal/condition introduced over 6 45-minute sessions). However children with the phonological memory difficulties have great difficulty learning the words (SLP: This is a speet. Say speet. Child: speet. That’s right, speet. What is it? Child: I don’t know. SLP: Yes, you do it’s speet, the purple one, the purple one is speet, remember, say speet. Child: ‘speet’. SLP, you’ve got it, the purple flower is speet, it’s a speet, what is it, it’s a … Child: um, I don’t know, and so on).

Image

The most effective intervention to use with these children closely mirrors the procedures described by Barbara Dodd as the “core vocabulary” approach and demonstrated by Sharon Crosbie in the video that accompanies their chapter in the Williams, McLeod and McCauley (2010) book. The video is lovely and shows how to use graphic stimuli and a chaining procedure to teach the child to produce a word consistently – the idea is to encourage the child to develop and implement their own phonological/motor plan rather than relying on an imitative model. The children respond to this technique really well and will learn to say the new words such as “speet” and “stoon” quickly and accurately. The trouble begins when our student SLPs want the children to use the new words spontaneously in phrases (e.g., “water the speet”). They have great difficulty remembering the word or even the carrier phrase without the imitative model and I have to work really hard to teach the student clinicians to withhold the imitative model in favour of using other cues to stimulate spontaneous production of the target words and phrases (SLP: What is it? Let’s start with the snake sound here…).

We have wonderful video of student SLPs learning these techniques as well as children achieving their goals. Tanya Matthews and I will be presenting them at ASHA 2014. The difference in the way that you implement therapy with these children is subtle but important. I am pretty sure that Case Study 8-4 in our book had a phonological planning deficit rather than the motor planning disorder that he was treated for. I can’t help but think that if he was treated with these techniques he might have made some progress in the three years that we followed his case (whereas he made literally no progress at all until he was treated with a synthetic phonics approach in second grade). I’d love to hear from you if you have any other ideas about how best to treat children with phonological memory problems and inconsistent deviant disorder.