The Wonder of Cycles

Created by Barbara HodsonShared by Anne Hasting

2013

Where credit is due

• Created by Barbara Hodson

• Evaluating and Enhancing Children’s Phonological Systems

• www.phonocomp.com

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

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

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

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)

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

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

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

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

Primary Patterns

• Primary patterns:– Syllableness – Singleton consonants• Initial • Final

– /s/ clusters – Anterior-posterior contrasts – Liquids

• Target what the child needs

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

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

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

/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

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

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

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

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)

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

Secondary Patterns• Begin after criteria have been reached for

primary pattern “graduation”• Do NOT kill yourself analyzing all patterns early• Listen during liquids

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

Voicing Contrasts

• Errors with voiced/voiceless cognates– p/b, t/d, s/z, etc.

• Prevocalic voicing• Use minimal pair words and some

amplification

Vowel Contrasts

• Usually get the vowels sorted out during the primary cycles

• Use minimal pairs and some amplification

Anterior-Posterior Contrasts

• Target in secondary cycles if not stimulable during primary cycles

• See slide 16

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

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

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)

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)

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

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

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?

Example: Morgan

• Primary patterns– Singleton consonants (final)– /s/ clusters– Anterior-posterior contrasts– Liquids

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

Example: Adam

• Primary patterns:– /s/ clusters (avoid sk)– Anterior-posterior contrasts– Liquids

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

Example: Hannah

• Auditory input cycle?• Primary patterns– Syllableness– Singleton consonants (initial)– Singleton consonants (final)– /s/ blends when singleton consonants emerging– Anterior-posterior contrasts– Liquids

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

Nathan

• Primary Patterns– /s/ clusters– Liquids (/r/)

• Secondary Patterns– Metathesis and migration best addressed in:

• Advanced Patterns– Complex consonant sequences– Multisyllabicity

Whew

• Enough framework for you?– It’s the most important part!– Organization of overall treatment

• What does a session look like?

Sessions

• Review• Listening words• Practice patterns• Metaphonological skills• Listening words• Stimulability

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

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

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

Session Structure

• Listening words – 15 seconds– Same list, same amplification

• Stimulability – 2 minutes– Select next session’s practice words

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

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

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

Ear training

• Supports Cycles• Important: limited to current target pattern• Five types:– Modeling– Auditory awareness– **Feedback**– Praise– Corrections

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.”

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

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/

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

My Evidence

• All names are changed• Progress in a single school year

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

Hugh’s progress in conversationTarget Pattern Occurrence

Final consonants 100%

A-P contrast 100%

Stridents 100%

/s/ clusters 100%

Other clusters 100%

Liquid /l/ 0%

Liquid /r/ 20%

Target Pattern Occurrence

Final consonants 0%

A-P contrast 60%

Stridents 0%

/s/ clusters 0%

Other clusters 0%

Liquid /l/ 0%

Liquid /r/ 0%

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

Bella’s progress in conversationTarget Pattern Occurrence

Final consonants 100%

A-P contrast 0%

Stridents 0%

/s/ clusters 0%

Other clusters 0%

Liquid /l/ 0%

Liquids /r/ 0%

Palatals 0%

Target Pattern Occurrence

Final consonants 100%

A-P contrast 100%

Stridents 100%

/s/ clusters 100%

Other clusters 100%

Liquid /l/ 100%

Liquids /r/ 0%

Palatals 100%

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

David’s progress in conversationTarget Pattern Occurrence

Final consonants 80%

A-P contrast 0%

Stridents 40%

/s/ clusters 0%

Other clusters 0%

Liquid /l/ 0%

Liquid /r/ 0%

Voicing contrast 0%

Palatals 0%

Target Pattern Occurrence

Final consonants 100%

A-P contrast 100%

Stridents 100%

/s/ clusters 100%

Other clusters 80%

Liquid /l/ 20%

Liquid /r/ 0%

Voicing contrast 100%

Palatals 80%

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

Carly’s progress in conversationTarget Pattern Occurrence

Final consonants 100%

A-P contrast 0%

Stridents 40%

/s/ clusters 0%

Other clusters 0%

Liquid /l/ 0%

Liquid /r/ 0%

Voicing contrast 0%

Target Pattern Occurrence

Final consonants 100%

A-P contrast 60%

Stridents 60%

/s/ clusters 40%

Other clusters 60%

Liquid /l/ 0%

Liquid /r/ 0%

Voicing contrast 40%

Data from 5 months into txAll at 100% except liquids after 8 months tx

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

Michael’s progress in conversationTarget Pattern Occurrence

Final consonants 100%

A-P contrast 40%

Stridents 40%

/s/ clusters 0%

Other clusters 0%

Liquid /l/ 0%

Liquid /r/ 100%

Voicing contrast 0%

Target Pattern Occurrence

Final consonants 100%

A-P contrast 60%

Stridents 60%

/s/ clusters 0%

Other clusters 0%

Liquid /l/ 0%

Liquid /r/ 100%

Voicing contrast 60%

Data from 4 months into txAll at 100% except other clusters after 10 months txEvery speech sound correct including complex consonant sequences after 14 months tx

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

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

Appendix A

History of Therapy Approachesfrom Hodson 2010 (see note)

Overview

• Early Approaches– Phoneme-Oriented Intervention– Phonetic Placement– Moto-Kinesthetic– Stimulus Approach– Sensory-Motor Approach– Discrimination Approach

• Behavioristic Approaches• Linguistic-Based Approaches

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

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

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

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

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

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

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

Behavioristic: Programmed Instruction

• Mowrer, Baker, & Schutz 1968• Reinforcement schedules: stickers, tokens• Penalties for incorrect production• Many responses required--tedious, boring (for

clinician and child)

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

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

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

Cycles

• Um.. Go back to the beginning

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

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

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

Appendix B

Target Selectionfrom Hodson 2010

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

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