Clinical Linguistics & Phonetics

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A shift of treatment approach in speech language

pathology services for children with speech sound
disorders – a single case study of an intense
intervention based on non-linear phonology and
motor-learning principles

Inger Lundeborg Hammarström, Rose-Marie Svensson & Karin Myrberg

To cite this article: Inger Lundeborg Hammarström, Rose-Marie Svensson & Karin Myrberg
(2019) A shift of treatment approach in speech language pathology services for children with
speech sound disorders – a single case study of an intense intervention based on non-linear
phonology and motor-learning principles, Clinical Linguistics & Phonetics, 33:6, 518-531, DOI:
10.1080/02699206.2018.1552990

To link to this article: https://doi.org/10.1080/02699206.2018.1552990

© 2018 The Author(s). Published with

license by Taylor & Francis Group, LLC.

Published online: 20 Dec 2018.

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CLINICAL LINGUISTICS & PHONETICS
2019, VOL. 33, NO. 6, 518–531
https://doi.org/10.1080/02699206.2018.1552990

A shift of treatment approach in speech language pathology

services for children with speech sound disorders – a single
case study of an intense intervention based on non-linear
phonology and motor-learning principles
Inger Lundeborg Hammarströma, Rose-Marie Svenssonb, and Karin Myrberga,b
a
Division of Speech Language Pathology, Audiology and Oto Rhino Laryngology Department of Clinical and
Experimental Medicine, Linköping University, Linköping, Sweden; bCentre for Research and Development
(CFUG), Uppsala University, County Council of Gävleborg, Gävle, Sweden

ABSTRACT ARTICLE HISTORY

Even though there are documented benefits of direct intensive interven- Received 1 June 2018
tion for children with speech sound disorders (SSDs), the intensity given at Revised 20 November 2018
Swedish Speech Language Pathology services rarely exceeds once a week. Accepted 23 November 2018
Also, indirect therapy approaches are commonly employed. KEYWORDS
The purpose of the present case study was to investigate the effects of Children with speech sound
an intensive specialist therapy, based on non-linear phonological analysis disorders; non-linear
and motor learning principles. The participant was a boy aged 4:10 years phonology; motor learning
with severe SSD, who previously had received indirect therapy from age 3 principles; treatment
with, very limited results.
A single subject ABA design was used. At baseline, whole word match
was 0%, Word shape CV match was 39% and PCC was 22, 7%. He had no
multisyllabic words, no consonant clusters and no established coronals.
Intervention was given 4 days weekly for 3 weeks in two periods with
a 7-week intervening break and a post therapy assessments. Therapy was
focused on establishing multisyllabic words, iambic stress pattern, clusters
and coronals with the principle of using already established elements for
targeting new elements.
At post therapy assessment, whole word match was 39%, word shape
CV match was 71% and PCC 69.1%. Multisyllabic words (86%), coronals
(82%) and word initial clusters (80%) were established. Without being
targeted, back vowels were also present and segment timing improved.
The strong treatment effects of this study demonstrate that at least
severe cases of SSD require the clinical knowledge and skills that only
a SLP can provide and that frequent direct therapy is both beneficial and
needed.

Introduction
Children with speech sound disorders (SSDs) form a large part of Speech and Language
Pathologist’s (SLP’s) caseloads (Joffe & Pring, 2008). SSD is an umbrella term covering both
articulatory and phonological deficits. In some definitions the symptomatology is considered to
be primary (idiopathic) and distinct from language impairment (Eadie et al., 2015), in others, the

CONTACT Inger Lundeborg Hammarström [email protected] Division of Speech Language

Pathology, Audiology and Oto Rhino Laryngology Department of Clinical and Experimental Medicine, Linköping University,
Linköping SE 581 83, Sweden
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iclp.
© 2018 The Author(s). Published with license by Taylor & Francis Group, LLC.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License
(http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium,
provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
 CLINICAL LINGUISTICS & PHONETICS 519

full range of speech difficulties, both primary and secondary (of known origin) is included
(multilingual-speech/position paper, www.csu.au/research/multilingual-speech/position-paper).
The clinician has an array of approaches to choose from when planning intervention for
children with SSD. Some approaches are theoretically linked to the hypothesis that the child’s
underlying system needs reorganization to improve phoneme use. Therapy is therefore focused
on highlighting the contrastive function of speech elements and the child’s ability to reflect on it
(Baker, 2010). Others are related to beliefs that the child’s disorder is a disorder of motor planning
and/or programming with focus on speech movements (Maas & Farinella, 2012) and therapy
based on motor learning principles. When applying motor learning principles in speech inter-
vention, the emphasis is on modelling speech gestures, speech rate and a large amount of practice
trials (Maas et al., 2008) In a study by Strand, Stoeckel, and Baas (2006), the outcome of an
intensive treatment for four children with severe childhood apraxia of speech (CAS) was
reported. The treatment approach used, dynamic temporal and tactile cueing (DTTC), which
is emphasizing the shaping of movement gestures for speech production and continued practice,
proved to be successful for three of the participating children. In a review study of treatments for
CAS by Elisabeth Murray and co-workers (Murray, McCabe, & Ballard, 2014). The DTTC was
judged to have convincing evidence to support its efficacy.
In a systematic review of intervention studies for children with SSD published 1979–2009,
Elise Baker and Sharynne McLeod (2011) identified 134 studies. In 46 of them, distinct inter-
vention approaches were found and 24 had no approach-specific teaching procedures. The 46
distinct approaches were each associated with varying levels of evidence. A majority (74%) of the
134 studies had relatively low levels of evidence. Thus, the choice of therapy approach is not
entirely obvious and also, many children are not clear cut cases and can have a mixture of
phonological problems and speech problems with motor involvement (McCauley & Strand,
1999). Perhaps this is the reason why eclectic approaches including both perceptually and
linguistically based activities alongside oral motor activities are widely used. In a survey of
clinical practice in the UK, a majority of the respondents used a variety of treatment approaches,
whereof auditory discrimination, minimal contrast therapy and phonological awareness were
widely used, often in combination. A large majority also involved caretakers in the process. (Joffe
& Pring, 2008). In a review study on the effectiveness of different treatments, it is concluded that
several different therapy methods are effective in modifying children’s phonology (Kamhi, 2006).
This has led to researchers claiming that a careful target selection might be the relevant trigger of
change (Gierut, 2005). Before determining the most appropriate intervention plan, a detailed
analysis of the child’s speech sound repertoire must be made. In order to be able to make
a comprehensive analysis, the full range of adult target speech must be sampled including
prosody and stress, word and syllable shape and articulation. By using a nonlinear phonological
analysis, all aspects of phonological form including different word structures, stress patterns,
syllable shapes and segments in speakers off all ages and with different etiologies of speech
difficulties can be captured (Bernhardt, Bopp, Daudlin, Edwards, & Wastie, 2010). Among the
features of an analysis that Ball, Müller, and Rutter (2010) list as important to the clinician, is
guidance in planning the intervention. This is further elaborated by Ball (2016). Nonlinear
phonology is a theoretical framework, which provides not only a methodology for analysis, but
also guides the clinician in goal selection and treatment strategies (Bernhardt et al., 2010;
Bernhardt & Stemberger, 1998).
Even though underlying theoretical framework lays basis for overall intervention decision,
preferably evidence-based, other factors such as target selection and service delivery in terms of
520 I. L. HAMMARSTRÖM ET AL.

both techniques and the length and number of sessions and the number of teaching episodes
per session must also be set. Studies have shown that more intensive interventions have better
outcome. In a study of efficacy and intensity of intervention for children with SSD, the outcome
of a therapy given three times per week for 8 weeks was significantly better than a therapy given
once a week for 24 weeks (Allen, 2013).
Even if high-quality research help the overall intervention decision, other factors such
as client values, service delivery considerations and clinical expertise also play an impor-
tant role (Kamhi, 2006). Motivation is one key to the success of speech therapy and a way
of maximizing motivation is by choosing target words that are functionally powerful, i.e.
are frequently used by the child and its environment. One approach which emphasizes this
is the core vocabulary approach (Dodd, Holm, Crosbie, & McIntosh, 2006, 2010) which
focuses primarily on consistent word production rather than accuracy in children with
inconsistent phonology. An inconsistent phonological disorder is characterized by at least
40% variability in three separately repeated picture naming tasks within one session and
absence of other signs of CAS. It is hypothesized that children with inconsistent errors
have difficulties in assembling a fully specified phonological template for the production of
an utterance (Holm, Crosbie, & Dodd, 2005). In the core vocabulary approach, the focus is
on teaching the child how to assemble word phonology first in single words and then in
connected speech. The selection of target words is guided by how often the child uses the
words in its functional communication and contributes to the use of consistent produc-
tion (Dodd et al., 2006).
The social and economic costs that affect individuals with SSD and society at large
emphasize the need for identifying the most effective and efficient treatment. A very
important criterion is whether the treatment outcome is generalized in terms of transfer
to untrained words, structures or sounds (Barbena, Keske-Soares, Cervi, & Brandão,
2014). Another criterion, linked to the former is whether intelligibility is improved by
the treatment. However, only a few studies have used intelligibility measures to evaluate
the effectiveness of phonological intervention (Lousada, Jesus, Hall, & Joffe, 2014).
Due to frequently reported shortage of SLPs (Joffe & Pring, 2008; Lee, 2018), there is
limited time and resources to assess and treat children. Therefore, indirect approaches are
adopted where the SLP provides treatment through proxies such as caregivers or teachers.
Caregivers tend to be actively engaged if the child is younger, but become less involved as
the child grows older (Law, Dennis, & Charlton, 2017). There is evidence that even though
parents are generally positive towards the games and activities carried out by the SLPs,
they are rarely informed of the aim and the SLPs rationale for the intervention (Roulstone
et al., 2015). If indirect approaches are to be adopted, an experienced SLP who gives
thorough instructions is required and that the caregivers and/or teachers have both the
time and the dedication and experience needed to follow the instructions.
In Sweden, indirect approaches have been increasingly employed and direct intervention is
often restricted to more severe cases of SSD. When direct intervention is offered, the intensity in
terms of dose frequency rarely exceeds once a week (Krögerström, Liljebäck, & Wuotila Isaksson,
2013).
 CLINICAL LINGUISTICS & PHONETICS 521

The Swedish language

The typical word in Swedish consists of a stem of one or two syllables, often with additional
inflectional affixes. (Hedlund, Pirkola, & Järvelin, 2001). The domain for stress in Swedish is the
prosodic word and only one stress is permitted within the prosodic word. Stress in Swedish varies
and there are minimal pairs where the placement of stress is distinctive for example in/ˈjɑːpan/
(Japan) and/jaˈpɑːn/(Japanese). However, the trochaic stress pattern is more frequent. Swedish
has also a tonal word accent system with a phonological distinction between two tonal config-
urations of words, referred to as accent 1 (rising tone) in for example/ṕoːlɛn/(Poland) and accent
2 (falling tone) in for example/p̀ oːlɛn/(the pile).
Consonant clusters occur in a fairly large number with 32 two-consonant clusters and 6 tri-
consonantal in word-initial position and innumerable word-final consonant sequences, in both
monosyllabic and multisyllabic words (Eliasson, 2014).
Relevant to word structure is the length distinction for vowels. Swedish has nine distinctive
vowel qualities, which contrast for length (long versus short) in stressed syllables (Table 1). Long
vowels only appear in stressed syllables but short vowels are found both in stressed and
unstressed syllables. Consonants following long vowels are short.
The consonant inventory consists of 18 phonemes (Table 2), which all, with the exception of/
h/, can be realized as long or short, although this difference is not contrastive (McAllister, 1998).
The purpose of this study to evaluate the outcome (both retention of trained targets and
possible generalization to other items) of an intensive SLP intervention for a monolingual
Swedish speaking boy aged 4;10 with a severe SSD. The therapy was based on a nonlinear
phonological analysis and aspects of motor learning principles were used.

Table 1. The Swedish vowel inventory.

Front Central Back
High iː yː uː uː
ʏɪ ʊ
Mid-high eː øː ɵ
o:

Mid ɛœ ɔ
ɛː
Low a ɑː

Table 2. The Swedish consonants.

Place of articulation
Labial Coronal Dorsal Laryngeal
Labial Labiodental Dental Post- alveolar* Palatal Velar Glottal
Manner of articulation Stops pb td ʈɖ kɡ
Nasals m n ɳ ŋ
Trill r
Fricatives fv s ʂ ɕj ɧ h
Laterals l ɭ
* the retroflexes, ʈ ɖ ɳ ʂ and ɭ are often the result of assimilations between/r/and a coronal in Central Swedish, but are
often regarded as separate consonant phonemes since they are used contrastively in word medial and word final
position.
522 I. L. HAMMARSTRÖM ET AL.

Method1
Design
A multiple baseline single-participant design was used with two baseline assessments, two
3-week intensive therapy blocks, with a 7-week intervening break, and a post-therapy
assessments, 1 week after therapy block II was completed. An overview of the procedure is
given in Table 3.

Participant and case history

Alex, a boy, a monolingual Swedish speaking boy, was enrolled in the study when he was
4 years and 10 months. He lived together with his mother, father and a 4-year older sister
in a middle socio-economic class area. He had no family history of SSD, but the older
sister had recently been diagnosed with attention deficit hyperactivity disorder (ADHD),
and the parents expressed some concern regarding suspected hyperactivity also in Alex.
He had attended pre-school from 1;5 years of age. Alex was first referred to the Speech-
Language pathology service from a child health care centre for a speech and language
assessment when he was 3 years and 3 months.
He was found to have fairly good receptive language, but had great expressive difficulties.
He mostly used gestures accompanied by onomatopoeia. The few words he expressed were
very restricted in terms of word- and syllable structure and he mastered only a few places and
manners of articulation. His syntax was very restricted and he used mainly single-word
utterances. He was very frustrated by not being understood by others and he had begun to
withdraw from the other children at pre-school. His parents also told how the neighbouring
children occasionally made fun of his speech Language comprehension assessment was
administrated with the receptive subtest of the Reynell Developmental Language Scales, III
(Edwards et al., 1997). The new SIT test (Hellqvist, 2011) and the TROG-2 Test for Reception
of Grammar (Bishop, 2003). Alex’s results on SIT and TROG-2 not differ significantly from
the Swedish standardization samples. The Swedish translation of the Reynell Developmental
Language Scales III has not been standardized, however, the Swedish version of fourth version,
the NRDLS has been standardized and the psychometric properties of the Swedish version are
very similar to the original British test (Lundeborg Hammarström, Kjellmer, & Hansson,
2017). Aspects of expressive language other than phonology were not assessed.
Alex met other developmental milestones within the expected time frames. His medical
history only included pneumonia at 2 months of age; he was a healthy boy with no
concerns with hearing or vision. At 3:6 years of age, he was tested with the third edition of
theWechsler Preschool and Primary Scale of Intelligence, WPPSI-IV (2005) and found to
be typically developed in all other respects than language. A magnetic resonance tomo-

Table 3. Time table of the study.

December-January February March-April May June
Base-line assessments Therapy block I Intervening break Therapy block II Post therapy assessment

1
The study was carried out in accordance with the ethical principles for medical research of the Helsinki
Declaration as revised in 2008.
 CLINICAL LINGUISTICS & PHONETICS 523

graphy of the brain was also carried out and he was also examined by a paediatric neurologist.
However, nothing atypical was noted.
In the period between the first visit at 3:3 years and the starting point for the present
study at 4:10 years, SLP intervention was not given on a regular basis and very little
progress was noted. The numbers of appointments at the clinic were summed up to 10, of
which six were intervention sessions. Based on a hypothesis that Alex’s difficulties, to
a large extent could be due to motor speech problems, the SLP worked with non-verbal
oral motor exercises and speech sound and syllable production using pictures from the
Nuffield Centre Dyspraxia Programme, NDP3. In the remaining four sessions, follow-up
assessments were made. Moreover, the SLP was engaged in consultative activities such as
advice to the family, collaboration with a communication aid center, introduction of
Augmentative and Alternative Communication, AAC (simple signs) and advice to the pre-
school teachers. Alex quickly adopted new simple signs that were used in the pre-school
and used them alongside his limited expressive vocabulary and onomatopoeia words both
at home and with friends. Consultative services were also given to a local language
therapist (LT), a teacher with 1 year of additional training in speech disorders in children,
who visited Alex’s pre-school and worked with him for a few sessions, mainly focusing on
speech sound production.

Procedure
Baseline and post-therapy assessment
Two baseline assessments were made with 5 weeks in between, using the Swedish
phonology test, Linus (Blumenthal & Lundeborg Hammarström, 2014), which samples
across the full range of consonants, vowels, consonant clusters, stress patterns and word
length of the adult Swedish language.
The post-therapy assessment was based on 45 words; a mixture of words practiced in
the second therapy block and words elicited during story retelling (Bus Story Test). The
full phonology test was not conducted in the post-therapy assessment, mainly due to
a desire to check the target words, the matched probes and words in connected speech.

Pre-intervention assessment
Before the start of each intervention block, two assessments of the target words were made
as a baseline for therapy with 1 week interval. Respectively, two separate post-treatment
measures were made with 1 week interval after each therapy block was finished. The
measures of the training words were then combined with assessments of matched probes,
i.e. words used as a measure of generalization to untreated words.
All assessments were audio-recorded with Olympus Digital Sound Recorder.

Intervention
The overall aim of the therapy was to expand Alex’s phonology and thereby improveed his
intelligibility. He was treated for four sessions per week, twice by a specialist SLP (the third
author) at the SLP clinic and twice by the LT in a separate quiet room at the pre-school.
524 I. L. HAMMARSTRÖM ET AL.

The LT was introduced to the intervention by attending one training session at the SLP
clinic and observed when the specialist SLP was working with Alex. She also received
a written step-by-step instruction to the method and all the materials she used during her
sessions. The therapy was divided into two 3-week blocks with a 7-week intervening break
(Table 3).
Target words were chosen with inspiration from the Core Vocabulary approach (Dodd
et al., 2006) with a list of words that both covered the targets and were functionally
appropriate for Alex. Another source of inspiration was nonlinear phonological interven-
tion with the principle of using established elements for targeting new elements
(Bernhardt et al., 2010). The chosen approach was informed by integral stimulation,
DTTC, (Strand et al., 2006). Therapy targets were multisyllabic words, words with iambic
stress, and consonant clusters and words with coronals (Table 4).
The selected words, each symbolized by a picture, were delivered 30 times per session. Each
word was trained in two blocks per sessions, thus delivered 15 times per block. The word order
was not the same in the two blocks. The therapy technique used was imitation with emphasis
on Alex being focused on the task by a “watch me-listen” strategy. This visual guidance was
gradually reduced until Alex managed to say a target word correctly with no assistance. When
Alex managed to say a word correctly in >90% of the trials in in two successive sessions, the
target word was replaced by a new word and thereafter just practiced occasionally during the
sessions. This occurred with two of the target words during the first therapy block and with
four of the target words/short phrases during the second therapy block. In addition to the
training sessions during therapy block II, Alex’s caretakers were instructed to ask Alex to
repeat the target words from the first therapy block on a daily basis.
After the first therapy block Alex managed to say 5 of 7 target words correctly and 3 of 7
probes correctly at final evaluation. After the second therapy block, 7 of 10 targets were
produced correctly alongside with 4 of 6 probes. It should be noted, that even if 100% correct
production was not achieved for all target words and probes, production of all words improved.
Overall, Alex was happy and positive during treatment and managed to stay reasonably
focused. Occasionally, he had some difficulties with maintaining attention, and there was an
obvious connection between his performances and his ability to concentrate. His motivation
improved when the SLP let Alex help out with ticking the last production of each block in the
production sheet and thereby helped him to keep track of the course of the session. Alex was
also very keen on choosing a sticker in the end of each session.

Analysis
The materials from the base-line and post-therapy assessment were transcribed narrowly
by the first author using the transcription conventions of the International Phonetic
Association (IPA, 1999). Percentage of correctly pronounced words (Whole Word
Match, WWM), word shape CV match, and correct consonants (PCC) (Shriberg,
Austin, Lewis, McSweeny, & Wilson, 1997; Shriberg & Kwiatokowski, 1982) Also propor-
tion of word initial clusters and elicited coronals were calculated.
Table 4. Chosen target words and phrases and matched probes, with target pronunciations used in the two blocks of therapy
Therapy block I Therapy block II
Target words Probes Target words Probes
tupp* [tɵp] (rooster) topp [tɔp] (top) Klocka [ˈklɔka] (watch) plocka [ˈplɔka] (pick)
napp [nap] (pacifier) nål [noːl] (needle) Blomma [ˈblʊma] (flower) blöda [ˈbløːda] (bleed)
tåg* [toɡ] (train) tak [tɑːk] (roof) Pannkaka [ˈpaŋˌkɑːka] (pancake) badanka [ˈbɑːdˌaŋka] (rubber duck)
docka [ˈdɔka] (doll) data [ˈdɑːta] (data) Sommarlov** [ˈsɔma(ɾ)ˌloːv] (summer holiday)
ballong* [baˈlɔŋ] (balloon) giraffe [ɧɪˈraf] (giraffe) iIpad [ˈajpæd] Adam [ˈɑːdam] (Adam)
delfin [dɛlˈfiːn] (dolphin) gitarr [jɪˈtar] (guitar) Igelkott** [ˈiːɡɛ(l)kɔt] (hedgehog)
kanin [kaˈniːn] (rabbit) orange [ʊˈraɳʂ] (orange) jag vill ha [jɑː vɪl hɑː] (I want) han är fin [han ɛ: fiːn] (he is nice)
polis [pʊˈliːs] (police) fåtölj [fɔˈtølj] (armchair) jag vill sova**[jɑː vɪl ˈsoːva] (I want to sleep)
jag är fem år [jɑː ɛː fɛm oːr] (I’m 5 years) hon är ett år [hɵn ɛː ɛt oːr] (she is 1 years)
jag ska bada** [jɑː skɑː ˈbɑːda] (I’m going for
a swim)
*were replaced by three words with iambic stress pattern (polis, ballong and kanin) **replaced the word/phrase immediate above. Replacements were done when the participant managed
to say the target correctly in 90% of the trials.
CLINICAL LINGUISTICS & PHONETICS
525
526 I. L. HAMMARSTRÖM ET AL.

Reliability
Reliability of the transcriptions were measured point-by-point as percentage exact agree-
ment between the first author and an experienced colleague based on 10% of the record-
ings from one of the base-line assessments. The agreement was 87.5%

Results
Pre-therapy
Alex’s production at the two baseline assessments varied both in terms of which word he agreed
to produce and how the words were elicited. Many words were elicited by repetition, but the
words that were elicited by repetition were not the same at both assessments. He did not perform
more accurately on repeated words in comparison with the spontaneously elicited words. No
major change in his production was noted during the base-line period. Based on the total
number of elicited words at the base-line assessments Whole Word Match (WWM) was 0%,
Word Shape CV match (WSM) 39.5% and PCC 22.7%. Regarding word shapes Alex mastered
CV-, CVC, CVCV and CVCVC words, but he had no words with iambic stress and no
consonant clusters. Regarding the segments he had all manners of articulation except trills, but
substituted almost all coronals with dorsals. He also had some problems with segment timing
and back vowels, which tended to be centralized and some central vowels, which were substituted
by front vowels. His pre-therapy phonological strengths and needs are displayed in Table 5.

Post-therapy
After therapy, 1 week after treatment block two was finished, WWM was 38%, and WSM
69%. The proportion of established multisyllabic words, was 86% and the proportion
words with initial clusters was 80%. PCC was 69.1% with 68% coronals established.
Without being targeted, back vowels were present and segment timing improved, see
Figure 1 and Table 6.

Table 5. The participating boy’s phonological strengths and needs before therapy divided by word
structure, single consonants by word positions* and features.
Word positions, single
Word structure consonants Features & segments
Strenghts 2 syllabic words, trochaic stress pattern and WI:/p b m f l j k ɡ h/ Manner: Plosive,
the following CV word shapes: CV, CVC, nasal, fricative
CVCV, CVCVC, (VC) WM:/b ŋ/ Place: labial
(labiodental), palatal,
dorsal
WF:/f/ Laryngeal often
matches
Inconsistent or often WI:/d/ Manner: lateral
used as substitution WM:/p b f n l ɕ j k g/ Place
or in assimilation WF:/p t n l ɕ j k g/ laryngeal
Needs ≥3 syllables, iambic stress pattern and all WI:/t d s (n l)/ Manner: Trill
with CC WM:/p f t d r s l ɳ ʂ j/ Place: Coronal:
dental
WF:/v t d r n s l ɳ ʈ/ Laryngeal: Voicing
precision need
*Word-initial:WI, Word-medial: WM, Word-final:WF
 CLINICAL LINGUISTICS & PHONETICS 527

% Results, pre and post-therapy

100
90
80
70
60
50
40
30
20
10
0
Whole Word Word Shape CV CCV-match PCC Coronal match
Match Match

Base line After therapy

Figure 1. Percentage of whole word match, word shape match, CCV-match, PCC and coronal match at
baseline and one week after therapy.

Table 6. The participating boy’s phonological strengths* and remaining needs** after therapy divided
by word structure, single consonants by word positions.
Word positions, single
Word structure consonants Features & segments
Strenghts 3 syllabic words, both WI:/ p b m t d n f v l j k ɡ h ɕ / Manner: Plosive, nasal, fricative
trochaic and iambic stress WM: / p b v k g ŋ/ Place: labial labiodental, palatal,
pattern and the following CV dorsal, Coronal: dental
word shapes: CV, CVC, CVCV, WF: /p f t n l s g / Laryngeal often matches
CVCVC, VC, CCV
Inconsistent or WI: /s/ Manner: lateral
not elicited WM: / d l / Place (coronal:dental)
WF: /d l / Laryngeal: Voicing precision
Remaining /s/+C, C+/v/ and CCC WI: / r ɧ / Manner: Trill
needs WM: / r ʂ ʈ ɖ ɳ / Place: retroflex
WF: / r ʂ ʈ ɖ ɳ / Laryngeal
*gains in bold ** not all sounds in all positions were elicited

Discussion
The results of this study show that the motor-based high-intensity intervention delivered
to the studied boy was successful both in terms of better performance on targeted
structures and transfers to other structures, such as the vowels. One way of measuring
performance after intervention is by the assessment of the production of probes. The
percentage of whole word match was higher in the targets than in the probes for both
therapy blocks. This could perhaps be an effect of the probes not being trained, but also
that the choice of probes was only based on phonological resemblance with not as much
consideration to whether the words were functionally appropriate to the boy. The overall
aim was to expand the participant’s phonology and thereby make him more intelligible.
However, intelligibility was not formally assessed. The perceptions of the parents and pre-
528 I. L. HAMMARSTRÖM ET AL.

school teachers regarding intelligibility were obtained by asking them. According to both
caretakers and pre-school teachers, Alex’s intelligibility improved considerably, and as
a consequence, Alex opened up for more verbal interaction with peers.
The chosen treatment approach directly addressing speech movement patterns was not
solely motivated by the hypothesis that the Alex’s SSD was due to CAS. He had some
characteristics of CAS, although not confirmed and, thus, was not a clear candidate for
a phonological diagnosis either. Also, the therapy used prior to this study had failed to help
him. However, it could be argued that the amount of previous therapy was very limited.
There could be several reasons as to why the intervention in this study worked well. The
DTTC is a highly structured approach with concentrated drill and a “watch me-listen” strategy
(Strand & Skinder, 1999). This perhaps suited Alex, who had some difficulties concentrating.
Another explanation could be the very careful choice of targets. Functionally powerful
words with targeted sounds and syllable shapes were chosen for two reasons. Firstly, single
phonemes and syllable shapes seldom appear as separate communicative units. They appear in
words, however in a more subtle sense than the words in a dictionary (Gussman, 2002).
Secondly, the idea was that Alex’s self-esteem would benefit from becoming more intelligible
and as a consequence of this made him more motivated. The positive outcome was perhaps
also enhanced by the use of established elements for targeting new elements inspired by
nonlinear phonological intervention (Bernhardt et al., 2010). Another important explanatory
factor could be the high intensity in terms of both dose frequency and the high frequency of
target word trials per session (dose). Intensive dose frequency has been shown to be more
effective than lower treatment intensity for children with SSD (Allen, 2013; Kaipa & Petterson,
2016). Alex’s caretakers were highly supportive and wanted to help out. A home training
program was therefore added in therapy block II. This could possibly have contributed to the
outcome. Rvachev and Brosseau-Lapré (2012) showed in a study that an inclusion of home
training was effective when being aligned to what was being done at the clinic.
Half of the therapy sessions were conducted by the LT at the pre-school. Thus, it could
be argued that the boy didn’t have SLP therapy strictly. However, the LT worked according
to the step-by-step instruction made by the specialist SLP and also got all training material
from her.
In SLP education in Sweden, it has been emphasized for several years that the choice of
therapy for children with SSD should be linked to diagnosis. Students have been taught
that motor-based intervention approaches should be restricted to children diagnosed with
a motor speech disorder and phonemic perception and awareness training should be
offered to those assumed to have a deficit in the underlying phonological system. However,
for many children the diagnosis is not crystal clear. These children may have symptoms
that appear to be a mixture of a phonological disorders and CAS. For these children and
perhaps for all children with SSD, other factors could guide the choice of treatment
approach. Beside a comprehensive analysis of the child’s speech and a careful target
selection, other characteristics of the child should also be taken into consideration.
A clinical observation among SLPs is that many children with SSD have signs of other
issues such as attention and concentration problems. Perhaps these children benefit more
from structured training procedure with relatively high dose and dose frequency, regard-
less of assumption of underlying cause of the speech impairment.
The study was conducted in the clinical setting and there are several concerns about the
methodology. At the post-therapy assessment, a check-up of all target words and their
 CLINICAL LINGUISTICS & PHONETICS 529

corresponding probes and an assessment of connected speech was conducted. It was desired
to also make a formal phonological assessment with the phonology test. However, for practical
reasons Alex could not be scheduled for more than one visit and content had to be adjusted to
his limited attention. Another concern could be the use of PCC as a measure of outcome of
production of test words. The measure as originally proposed by Shriberg and Kwiatokowski
(1982) was based on phonetic transcriptions of conversational speech. However, in a later
publication (1997) Shriberg and co-workers stated that single-word material may be used
provided that results are not to be related to severity of involvement.

Conclusion
This study only included one single case, which makes definitive conclusions premature.
However, the results indicate that a highly structured and high-intensity DTTC therapy based
on a careful target selection guided by the principle of using established elements for targeting
new elements from Nonlinear phonology and the choice of functionally powerful words
inspired by the core vocabulary approach could be cost effective in comparison to the indirect
or low-intensity training given over longer stretches of time for children with SSD currently
used in Sweden. Home exercises can be added, preferably clearly incorporated/aligned to the
work done in the clinic. The positive outcome of the treatment argues for research on larger
numbers of children.

Acknowledgments
The authors firstly wish to acknowledge the hard work both Alex and his caretakers made. Thanks
also to Alex’s local LT and his teachers for their assistance.

Disclosure statement
The authors report no conflicts of interest. The authors alone are responsible for the content and
writing of the paper.

Funding
This research received no specific grant from any funding agency.

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