Question
Is there a typical age to begin phonology treatment in young children? I just started working with a birth-to-three program and have been seeing a 30 month old child for phonology treatment of fronting, cluster reduction, stopping, and some voicing errors
Answer
There is no such thing as "too early", in principle, because prelinguistic speech perception and speech production (vocalization) experience lay the foundation for early words, which lay the foundation for later speech, language, and literacy. (See, for example, Stoel-Gammon 1992, Vihman 1996, or the Vihman chapter in the Bernthal & Bankson textbook.) Your real questions are different, I think:
- Under what circumstances is phonological therapy warranted?
- What does phonological treatment consist of with a very young child?
- Phonological therapy is warranted when:
a.the child's phonological development is interfering with her/his communication in key contexts, especially if frustration is evident (in child and/or in parents/caregivers)
b.development of perceptual, vocal, or social prerequisites is lagging enough to raise concerns about later development
c.there are important risk factors (Down syndrome, hearing loss, perinatal stroke, prematurity, family history, etc.)
The latter two situations may be present even in an infant. In that sense, it's sometimes appropriate for an SLP to have "phonological" (vocalization and speech perception) goals even from birth.
What we would usually expect for a three-year-old would be CV, CVC-based words of up to three syllables, with at least a few consonant clusters showing up in either final or initial position. Consonants should typically include all stops, glides, and nasals, and at least one fricative or liquid. These sounds should appear in both initial and medial position, with 5-6 or more of them appearing in final position. The vowel repertoire should be pretty complete, with the exception of rhotic diphthongs ("ar, or, eer, air" etc.). Weak syllable deletion should be waning. A child who does not fit this description (e.g., has no velars) but does have a good variety of sounds from different places and manners of production (e.g., has more liquids and/or fricatives) may be still developing normally - just on a slightly idiosyncratic path.
The child's intelligibility among familiar listeners is of much more concern than intelligibility among unfamiliar listeners at this age - and these two may be very different. A high level of frustration on the part of either the child or the parents can be a reason to work on phonology with a young child whose phonology is not really very delayed for her/his age. The bottom line is that communication should be a very positive experience for a toddler. If it is not, something needs to change.
In some cases, it's not the child's phonology that needs to be repaired, but the parents'/caregivers' interaction styles or expectations. That's "a whole nother" essay! (Go to www.hanen.org for some resources.) - Assuming phonological therapy is warranted, what should intervention look like for an infant or toddler?
Phonological treatment with an infant consists of stimulation and reinforcement:
a.providing, and teaching caregivers to provide, input consisting of:- speech presented in "motherese" (child-directed speech) - with higher, exaggerated pitch patterns, simple sentence structures, repetitive usage of contextually-appropriate words (see below)
- modeling vocalizations that are age-appropriate for that child
b.providing, and teaching caregivers to provide, reinforcement consisting of:- "babbling back": repeating, in a turn-taking format, the sounds that the infant makes
- labeling and describing the actions the child is doing, the objects the child is looking at, etc. (in child-directed speech)
- speech presented in "motherese" (child-directed speech) - with higher, exaggerated pitch patterns, simple sentence structures, repetitive usage of contextually-appropriate words (see below)
For the SLP, the "babbling back", the modeling of age-appropriate vocalizations, and labeling/describing the child's focus of attention are components of the same activity. Repetitions of the child's vocalizations are used first to ensure that the infant has turn-taking skills. Then, in each interactive session the SLP's utterances alternate between repeating the infants' vocalizations in order to maintain attention and focus, modeling vocalizations at the next level of development in an attempt to shape the infants' vocalizations, and labeling the child's focus of attention or activity in order to foster receptive language development.
In all cases, it is very helpful to consult with OT and/or PT to determine the best positioning, type of physical contact, etc. to ensure that the child is best able to process and respond to the input. Those who work in early intervention have the wonderful advantage of having such colleagues easily available for consultation.
For toddlers, phonological intervention will still be very child-focused. It is not feasible to use flash cards, etc. with such young children. Rather, choose a set of toys that share the phonological target(s) - e.g., toys whose names or actions include clusters or fricatives. The session will appear to be simply play to the non-SLP, but the SLP will repeatedly model those names, action words, descriptive words, etc. that include the targeted sound class or structure, in the context of the play activity. The child will be indirectly encouraged to say the words in very communicative contexts that are integral to the play (e.g., saying "go!" before pushing a car if velars are the target).
If the child misproduces the target, "correction" should not take the form of a negative comment, but rather of additional models. It is usually helpful to try to draw the child's attention to the SLP's face while modeling these targets. For example, I often give the child a choice between two toys, holding each one against one of my cheeks. This draws the child's eyes to my mouth as I say, "Do you want the ____ or the ____?" Or I might hold a new toy up to my cheek and say, "Look what I found! It's a ____!" Some children I've worked with have even picked up this strategy themselves, holding objects up to their cheeks when they label them; it's very cute.
Giving choices relates to another important principle: It's better for the child to believe that you are stupid (i.e., you did not understand the request) than that you are mean (i.e., that you know what she is trying to say but you refuse to give her the toy until she says it better). At the same time, giving the message that you did not understand communicates to the child that correct articulation matters - that communication will not succeed unless the word is produced more accurately. However, frustration is not a positive outcome. I usually use the "rule of three": I fake confusion until the child's production is improved somewhat (though not necessarily perfect) up to a maximum of three times, repeating the choices to the child slowly and clearly. If she still cannot improve her production after the third time, I pretend that I now understand (assuming that I do) regardless of whether the production is more accurate. Again, I hold the object near my mouth as I say, "Oh, you want the ____. Okay, here you go. Here's the ____. That's a (descriptive word) ___, isn't it?"
Also, in my opinion, it is not appropriate to choose overly-specific goals for children at this age. If the child is stopping, then presumably she is not producing fricatives. The goal, then, will not be correct production of a specific fricative in a specific position, but emergence of some fricatives in some positions. Therefore, fricative-heavy words ("shoes, fluffy, hush, feather", etc.) will be chosen for the play sessions, and the child will get positive social reinforcement (i.e., communicative success) for producing anything that is more fricative-like than before. I often find that children's earliest fricative is [x] - a voiceless velar fricative - which is not a fricative of English, but gives the child lots of tactile as well as auditory feedback. That's progress! Once the child has some sensory-motor experience of producing a fricative and having it recognized as such, she is well on her way. Then, more specific fricative classes (e.g., the labials f and v, or any others that seem to be stimulable) can be modeled. (Note: Of course, I never model the wrong sound or misproduce a word myself - the child needs to know what the correct target is - but I always reward closer approximations.)
Similarly, I would not target a specific final consonant, but rather model lots of words with final consonants and celebrate the closure of the word with anything that is consonant-like. Note that these two goals are a good pair: many (though certainly not all) children produce fricatives (and nasals and velars) in final position first.
Do not worry if the first productions of a new sound class involve "regression" of some other sort - e.g., when the child first produces final consonants, it may be with consonant harmony. Trade-offs of this kind are very common in child phonological development.
Very young children with motor speech disorders (or suspected motor speech disorders) - childhood apraxia of speech, dysarthria, etc. - require additional strategies and techniques. (For CAS, see www.apraxia-kids.org and/or Davis & Velleman, 2000.) But the bottom line remains the same: the young child's learning environment and style is very social and very play-based. Whatever your goals are, and regardless of how hard you yourself are actually working to fit the goals to the activity and vice versa, to the young client it should seem literally like child's play.
Davis, B. L., & Velleman, S. L. (2000). Differential diagnosis and treatment of Developmental Apraxia of Speech in infants and toddlers. Infant-Toddler Intervention, 10(3), 177-192.
Stoel-Gammon, C. (1992). Prelinguistic vocal development: Measurement and predictions. In C. A. Ferguson, L. Menn & C. Stoel-Gammon (Eds.), Phonological development: Models, research, and implications (pp. 439-456). Monkton, MD: York Press.
Vihman, M. M. (2004). Early phonological development. In J. E. Bernthal & N. W. Bankson (Eds.), Articulation and phonological disorders (5th ed., pp. 63-104). Boston: Allyn and Bacon.
Vihman, M. M. (1996). Phonological development: The origins of language in the child. Cambridge, MA: Blackwell Publishers Inc.
Shelley L. Velleman is an associate professor of Communication Disorders at the University of Massachusetts at Amherst. She is the author of many articles about normal and disordered phonological development (including childhood apraxia of speech), and also of "Making phonology functional" (Butterworth-Heinemann,1998) and the "Childhood apraxia of speech resource guide" (Delmar/Thomson, 2003).
