Phonology

We talked in the previous chapter about how to decide when and how to assess phonological production. In general, children at developing levels of language are not candidates for speech sound intervention unless their intelligibility is significantly impaired. Because so much phonological growth is going on in the DL period, intervention for particular sounds can usually be deferred until school age, since many speech sound problems resolve on their own by then (Shriberg & Kwiatkowski, 1994). However, if a child is seriously unintelligible, intervention is warranted. Social disvalue and even social isolation, as well as frustration and behavioral and emotional reactions, can occur in children who have difficulty in getting messages across, even if they would eventually outgrow the unintelligibility. Although the specific targets of the intervention in this area will be the acquisition of particular sounds or the suppression of particular simplification processes, we need to remember that the important long-term goal is to increase the client’s overall intelligibility. All the issues we discussed in Chapter 3 about being careful to ensure that behaviors learned in intervention generalize to real conversation must be addressed to ensure that phonological production improvement leads to real gains in intelligibility. Kent, Miolo, and Bloedel (1994); Gordon-Brannan and Hodson (2000); and Morris, Wilcox, and Schooling (1995); discussed a variety of instruments that can be used to evaluate changes in intelligibility in the course of an intervention program.

Although the range of approaches to speech sound intervention is beyond the scope of this text, Williams, McLeod, and McCauley (2010) provide a comprehensive description and evaluation of the bases in evidence of a large number of interventions in this area, categorizing them into three major groups: interventions that focus specifically on speech sound production but assume that errors stem from phonological, rather than motoric sources; interventions that place speech sound production in the broader context of speech perception, language, literacy, and communication; or those that focus primarily on the motor acts involved in speech production.

We need to remember, too, that speech sound and language disorders often co-exist in the same child (Pennington & Bishop, 2009). So assessing syntactic and semantic skills in unintelligible children is always important in order to avoid missing deficits in these areas that are masked by the difficulty in understanding what the client says. When assessment of an unintelligible child indicates that syntactic and semantic deficits are present, it makes sense to address those targets early in the intervention program, rather than waiting until the child is fully intelligible. One way to address them is through input, providing indirect language stimulation, focused stimulation, or auditory bombardment (see Comprehension versus Production Targets, later in the chapter) of the forms we want the child to begin learning. These activities can be supplemented with more direct production activities that control for pronounceability of target words. In general, in accordance with our principle of requiring the client to do only one new thing at a time, we will want to address phonological and semantic/syntactic targets separately, not within the same activity. However, Tyler, Lewis, Haskill, and Tolbert (2002, 2003) showed that, when children have both phonological and morphosyntactic deficits, working on morphosyntax leads to changes in both areas. This research suggests that, for children with both speech and language problems, morphosyntactic deficits should be addressed first, followed by work on whatever phonological targets have not resolved in the course of the first segment of intervention.

One further consideration in planning phonological intervention at the preschool level concerns the connection between phonology and metaphonology. Metaphonology, or phonological awareness (PA), is the ability to detect rhyme and alliteration; to segment words into smaller units, such as syllables and phonemes; to synthesize separated phonemes into words; and to understand that words are made up of sounds that can be represented by written symbols or letters. These PA skills develop sequentially through the late preschool period (Hodson, 1994; Swank, 1999; Schuele & Boudreau, 2008). Several of these abilities have been shown to be closely related to success in learning to read (Hogan, Catts, & Little, 2005; Scarborough, 2003; Swank, 1994, 1999) and spell (Bourassa & Treiman, 2001; Clarke-Klein & Hodson, 1995; Gillon, 2002; Kirk & Gillon, 2007). Bird et al. (1995), Larrivee and Catts (1999), Pennington and Bishop (2009), and Rvachew et al. (2003) have shown that children with productive phonological problems during the DL period sometimes have trouble acquiring PA and are at risk for developing reading problems. This information suggests that when working with preschoolers who have phonological production problems, incorporating PA activities within the speech therapy may be helpful in preventing literacy difficulties. A few studies have shown that doing so does improve both speech and PA in children with speech delays (e.g., Hesketh, Adams, Nightingale, & Hall, 2000; Kirk & Gillon, 2007; Van Kleeck, Gillam, & McFadden, 1998). Hesketh (2010) summarizes this literature, concluding that children as young as 4 can be taught PA, that PA instruction improves literacy performance especially when alphabet letters are taught as well, and that including PA in a speech program leads to as much improvement in speech as is seen when the focus is speech only. Since incorporating PA activities in speech therapy may help shore up preliteracy weakness in children with speech sound disorders, clinicians can consider including PA activities in speech intervention for preschool children with reduced intelligibility. Some suggestions for doing this appear in Box 9-1. Kiewel and Claeys (1999) and Noble-Sanderson (1993) also provided phonology programs built around storybook activities that integrate speech sound remediation with the development of PA for children at the DL level.

Semantics

Children with developmental language disorders (DLD) appear to acquire words in comprehension much the way typically developing children do, but may need to hear a new word twice as many times as other children before comprehending and independently using the new word (Gray, 2003; Rice, Buhr, & Oetting, 1992). Children with language impairments also have particular difficulty in the acquisition of words to talk about cognitive states, like thinking (Lee & Rescorla, 2008), with verb vocabulary (Loeb, Pye, Redmond, & Richardson, 1996) as well as the use of verb particles (pick up, put down, etc.) (Watkins, 1994). In addition, children with DLD are less able to identify semantic features than their peers with normal language. These findings suggest that children with DLD have broader difficulties with receptive vocabulary than simply a reduced ability to acquire labels; they may need enriched input with repeated opportunities to see connections between words and their referents in order to learn new lexical items. Gray (2005) found that providing both semantic and phonological cues aided learning new words by preschoolers with DLD. This suggests that as we introduce new vocabulary, it makes sense to highlight both semantic (“triangle is the name of this shape; it’s a shape that has three sides; a piece of pizza is shaped like a triangle”) and phonological (“triangles have three sides and tri an gle has three parts; triangle starts with the same sound as toy) aspects of the word.

Owens (2004) provided a list of likely vocabulary targets for the DL period. These appear in Appendix 9-1. But Neuman and Dwyer (2009) point out that, because of the known relationship between complexity of vocabulary in preschool and reading achievement as much as 2 years later, it is important not only to teach basic words, but to expose students to rare words, as well. Ruston & Schwanenflugel (2010) showed that conversational input from an adult emphasizing use of rare words, linguistic recasts,and open-ended questions increased expressive vocabulary in children with low levels of vocabulary development. Paul (2011) gives guidelines for providing this kind of enriched input. These techniques can be important not only for preschoolers with DLD, but also for children who have impoverished vocabularies for other reasons, such as limited English proficiency, as well.

You’ll notice from the list in Table 9-1 that this area contains targets not only in vocabulary, which is, of course, important, but also in the kinds of semantic relations conveyed within and between clauses of sentences. In the early DL phase, an important goal of intervention is helping children broaden the range of ideas they can talk about. Toward the end of this phase, we want to help clients make their sentences more efficient by combining ideas, or propositions, within a sentence to convey specific semantic relations between clauses. Assessment information collected during the standardized and informal portions of the evaluation should guide us toward the level of semantic complexity to target within the client’s language.

Remember that, when we’re planning targets and methods of intervention for language, we artificially segment language into components such as semantics and syntax. But really, when we target a particular sentence type, that sentence is, of course, conveying a meaning. Similarly, when we target a particular meaning for expression, that expression takes a syntactic form. So in practice it is hard to separate the semantic and syntactic components of sentences. When we plan intervention targets and activities involving semantic and syntactic expression in sentences, the main thing to remember is the principle we talked about in Chapter 3: only one new thing at a time. When asking a child to produce a more complex sentence form, we want to be sure it encodes a meaning that the child has already expressed in a simpler way. When asking the child to talk about a new meaning or combine new meanings in sentences, we need to control for syntactic complexity, making sure that the form we want the client to use in producing this new meaning is already within the production repertoire.

Syntax and morphology

Syntactic and morphological targets of intervention are perhaps the most obvious goals of the DL period. Working on production of grammatical forms is among the most traditional aims of language intervention and one most speech-language pathologists feel comfortable targeting. We ought to be aware of two points in selecting our grammatical intervention goals for children in the DL period, though. First, although grammatical goals are virtually always appropriate for children in this period, the need to improve syntax should not lead us to ignore the other areas of intervention that also are important. Many children with grammatical deficits also have unintelligible speech, small vocabularies, word-finding problems, limited preliteracy skills, or difficulties in using language in the service of play, thinking, and conceptual development. These needs ought to be addressed, too.

A second thing we need to bear in mind is that there are some typical patterns of grammatical deficits in children with language impairments (that is, some aspects of syntax and morphology are more likely to show deficits than others). Knowing what these are can help us to zero in on these areas in the assessment process. Let’s look at what these typical grammatical problems are for children in the DL period.

Bound morphemes are particularly difficult for children with language problems of a variety of etiologies (Goffman & Leonard, 2000; Leonard, 1997; Rice, Warren, & Betz, 2005; Rice & Wexler, 1996). Auxiliary verbs and small, closed-class morphemes, such as articles (a, an, the) and pronouns (e.g., I, you, he, she, we they), also seem to cause particular difficulties for children with language impairments (Bates, 2003; Beverly & Williams, 2004; Eisenberg, 2005; Rice, Warren, & Betz, 2005). Irregular past morphemes and use of –ing endings seem to be a relative strength (Redmond & Rice, 2001; Rice, Warren, & Betz, 2005). Studies of children with slow expressive-language development as toddlers who show chronic delays through the preschool years (Paul & Riback, 1993; Rescorla & Roberts, 2002) substantiate this pattern. Difficulties with the elaboration of sentences through complex sentence production have also been reported (Eisenberg, 2005; Thordardottir & Weismer, 2001). It would appear, then, that verb marking with auxiliaries and inflections, closed-class morphemes, pronoun use, and the acquisition of complex sentences are areas in which children with language disorders can be expected to show particular difficulties during the DL period. These areas would be especially appropriate targets for intervention, when, of course, these deficits are documented by the assessment process. Fey, Long, and Finestack (2003) discuss some guiding principles for selecting goals for syntax and morphology during the DL phase. These are summarized in Table 9-2.

Comprehension versus production targets

We talked in Chapter 3 about the issue of targeting comprehension as opposed to production in the intervention program. There we said that, when assessment indicates a form or meaning is comprehended but not produced, production training is indicated. Lahey (1988) emphasized the fact that equivalent comprehension and production responses are often not present in normal language learners. She argued that a child should be exposed, through multiple meaningful exemplars in the input language, to forms and meanings that are not in the comprehension repertoire. But she concluded that comprehension responses, such as pointing to contrastive stimuli, do not need to be trained before production of the forms is targeted. Guided production activities appear to facilitate both comprehension and production of new meanings and forms in children.

Recall, too, that Chapter 3 included some suggestions about targeting comprehension versus production performance in the intervention program. Production training should be a high priority for forms and meanings for which the child demonstrates comprehension. For forms and meanings that the child does not yet appear to comprehend but that are chosen as intervention targets on the basis of other considerations we’ve discussed, an input component should be part of the intervention plan. This might include focused stimulation or indirect language stimulation activities that provide multiple opportunities for the clinician to demonstrate use of the structure in context.

Auditory bombardment is another viable input option. Hodson and Paden (1991) advocated using this approach to facilitate phonological development. They argued that phonological skills are acquired, at least in part, by listening. This implies that children need to listen carefully and often to the sounds they are being asked to produce. Kouri (2005) showed that, in a vocabulary training program, auditory bombardment had effects comparable to an elicited imitation program on the use of target words in real communication. Hodson and Paden suggested having children listen to a list of target words. It is worth noting that Flexer and Savage (1993) showed that both children with language impairments and those with normal hearing showed improved attention when assistive listening devices were used to improve signal-to-noise ratios during a testing situation. There is, then, some evidence that these devices might be useful in auditory bombardment activities for children with language needs. In auditory bombardment activities, the child simply sits and plays quietly with nondistracting material such as Play-Doh as the clinician reads the list of words. Although traditional auditory bombardment uses simply a list, it might, alternatively, consist of listening to a story that contains numerous examples of target forms. Hoffman, Schuckers, and Daniloff (1989) provided poems and stories that are weighted with examples of phonological targets. Cleave and Fey (1997) discussed the development of “syntax stories” created to provide auditory bombardment of particular target forms within a story context. Box 9-2 gives an example of an excerpt from one of their “syntax stories.” Regardless of whether a list or a story is read, the auditory bombardment segment generally makes up about 5 minutes of the intervention session. The child is not required to perform any discrimination activities, only to listen. Such activities also make excellent “homework” assignments for families interested in working on targets at home. They can easily be substituted for the child’s usual bedtime story and don’t require the parents to judge or correct the child’s communication. If follow-up activities, such as illustrating the clinician’s “syntax story” and rereading it with cloze procedures, are added, as Cleave and Fey suggest, even more benefit can be derived from the auditory bombardment.

Approaches that facilitate comprehension, such as focused stimulation, indirect language stimulation, and auditory bombardment, should be presented along with activities that elicit production of target forms and meanings. Such a combination of approaches can help to ensure that clients can both understand and use the forms and meanings being taught. It is not necessary, though, to wait until the child demonstrates comprehension in pointing or discrimination activities before trying to solicit the use of target forms and meanings.

Pragmatics

Before we discuss intervention approaches for pragmatics, we want to clarify our view of the role of pragmatics in the intervention program for children with DL. Contemporary thought about language acquisition emphasizes the central place of pragmatic functions. That’s because we see language not as a set of rules to be learned, but as a tool for communication. Learning language is not just learning sounds, words, and sentence structures; it’s also learning how to get things done in the real world with those sounds, words, and sentences. The study of how language is used in the context of communication is what is meant by pragmatics.

Pragmatics is just as important for thinking about language intervention as it is for acquisition. There are two ways to add pragmatics to our practice. The first is to generate a set of pragmatic targets or objectives for intervention. We could categorize children according to their pragmatic skills, identify their pragmatic deficits, and teach them to use whatever pragmatic behaviors they are lacking. Targets might include skills such as turn-taking, topic maintenance, and register variation. The problem with this approach is that we can’t really isolate these pragmatic skills from the syntax and semantics on which they rely. Unless we are teaching the earliest preverbal communication skills to a nonspeaking child, a client must use sounds, words, and sentences to achieve pragmatic targets.

A better way to incorporate pragmatics in the intervention program, in our view, is the method advocated by Craig (1983) and Marton (2005). They argued that, rather than defining pragmatics as an additional set of rules that the child needs to learn, we are wiser to see pragmatics as the context in which intervention takes place, and to make sure that each new form learned is practiced in a variety of pragmatic contexts. That is, rather than teaching turn-taking as a separate skill, we would develop activities in which the client could take turns with the clinician using a linguistic form that was a target of intervention. Or, instead of teaching topic maintenance as a separate skill, we would give the client an opportunity to talk about a topic of interest for an extended number of turns, using newly acquired forms. We could, for example, ask a client who is working on past-tense forms to describe each step used to, make the pudding now being shared with a parent who was not present during its preparation. If the child strays from the topic, the clinician could provide a prompt to return to describing the sequence, such as, “Wait a minute, weren’t you saying how we made the pudding? ‘We stirred the milk,’ you said. Then what happened?”

Must these pragmatic contexts be present in every intervention activity? We don’t think so. In fact, in our view they should not be, because that would lead us to violate Slobin’s (1973) principle of one new thing at a time. If past-tense forms are just being elicited, we won’t want to ask the child to use these new forms to fulfill a new function such as maintaining a topic—not until the new form has been somewhat stabilized. A more reasonable approach, to our way of thinking, is to incorporate pragmatic contexts into the intervention plan for every objective, but not for every activity. Some activities should be devoid of pragmatic context, to allow the child to focus attention on the linguistic objectives. Other activities can be designed to help clients use the new structures in real pragmatic contexts.

The real communicative contexts chosen should be based on the pragmatic assessment data. Suppose Rachel, for example, had been evaluated with Prutting and Kirchner’s (1983) Pragmatic Protocol and had been found to have deficits in conversational repair. Once appropriate question forms had been added to her repertoire by means of semantic and syntactic intervention, these forms might be put to use in the context of conversational repair. The clinician might feign misunderstanding of something Rachel said, model asking a clarification question, and encourage Rachel to answer it to repair the breakdown. The clinician might then give a mumbled or otherwise unclear message and encourage Rachel to ask a question to get clarification. In this way the client can be helped to use new semantic and syntactic forms in pragmatic contexts identified as problem areas as a result of the pragmatic assessment. Brinton and Fujiki (1989, 1995) provided detailed procedures for this aspect of intervention.

Play and thinking

A variety of studies (summarized by DeKroon, Kyte, & Johnson, 2002; Johnston, 1994; Leonard, 1997; Mainela-Arnold, Evans, & Alibali, 2006; Rescorla & Goossens, 1992) have shown that children with language problems perform less well than normally speaking peers on a variety of cognitive tasks, including symbolic play, even when they score within the normal range on nonverbal intelligence tests. During the preschool period in normal development, as Vygotsky (1962) pointed out, language begins to help to structure thought, and thought is carried out primarily in the modality of language. One of the major accomplishments of normally developing children in the preschool period is the beginning of the integration of language and cognitive processes, each feeding off and growing out of the accomplishments of the other. Much learning about concepts, categories, and the physical world during the preschool years goes on through the medium of language, instead of through direct perception and experience, as it did in the sensorimotor period. Children structure symbolic play through language both when they play alone (often talking out loud to pretend playthings) and when they play with peers (often negotiating the roles and rules of the play by talking about them: “I’ll be the baby and you be the mommy, but be a nice mommy and don’t scold me when I spill my bottle.”). It should not be surprising, then, that children with language problems would begin to lag behind in some of these skills that are so intertwined with language.

When working with children at DL levels, we want to incorporate activities that encourage the child to use the language being learned to structure pretend play, solve problems, and explore new ideas. Moreover, play is an important context in which such problem solving and exploration can take place. As children develop more elaborated and flexible forms of language, these can be used for more mature and imaginative play. Again, play and thinking may not be direct targets of the intervention. Like the social skills in the pragmatics area, we can use play and problem solving as contexts in which the child can practice using new forms and meanings. By providing contexts in which the child can use recently acquired forms for new purposes, we accomplish two things. First, we help the child to generalize the intervention targets to meaningful situations. Second, we move the child into the zone of proximal development, providing a scaffold that helps the child to use language to achieve new levels of symbolic and conceptual development with our models and support. Play and problem-solving are important contexts for extending the child’s use of newly emerging forms and meanings. As we proceed through the intervention program, we will want to build in some of these rich contexts, in addition to the more constrained settings in which forms and meanings may be elicited initially.

Preliteracy

Many preschoolers with language delays develop problems in learning to read and write, even when their oral language problems appear to resolve (Skibbe et al., 2008; Stothard, Snowling, Bishop, Chipchase, & Kaplan, 1998). Research reviewed in the National Joint Committee on Learning Disabilities (2007) Technical Report 12, Learning Disabilities and Young Children: Identification and Intervention, has shown that deficits in phonological processing can be a major obstacle in learning to read. This research suggests that strong oral language, phonological awareness, understanding about print, alphabet knowledge, invented spelling, rapid naming, and a child’s ability to write his or her own name prior to kindergarten are all indicators of literacy success in school (National Early Literacy Panel, 2005). And research has shown that the most effective interventions for children at risk for later reading problems focus on oral language instruction in preschool and kindergarten, and include explicit teaching of phonemic awareness, letter-sound relationships, vocabulary, and language comprehension (Dickinson, McCabe, & Essex, 2006; Lyon, 1999).

Increasingly, and for good reason, speech-language pathologists are being expected to address these areas of instruction in preschool programs for children at risk, and to promote preliteracy development in these children (American Speech-Language-Hearing Association [ASHA], 2000b; Justice & Ezell, 2004; National Joint Committee on Learning Disabilities, 2007; Wallach, Charlton, & Christie, 2009). That’s because SLPs are usually the professionals with the deepest understanding of phonological processing and the broadest knowledge about the connections between reading and oral language (Spencer, Schuele, Guillot, & Lee, 2008) and have much to offer others who work with young children when designing pre-literacy programs not only for those at risk, but for all children in the preschool classroom. When working with children in the DL phase, incorporating pre-literacy goals and contexts is an important part of our direct work with clients, and can also serve as a fruitful basis for collaboration with classroom teachers and care-providers. Kaderavek and Justice (2004) outlined the major goals of pre-literacy development during the DL period. These appear in Table 9-3. The goals can be divided into three major categories: phonological awareness, print and alphabet knowledge, and literate language.

Phonological awareness goals should be familiar by now: they include the ability to count syllables and sounds, to identify rhymes and words that start/end with the same sounds, and to manipulate sounds in words (“What’s fun without the /f/?”). We talked already about ways to build emerging literacy skills by incorporating PA activities within the speech sound program for children at the DL level. But PA is important for children with other language delays, as well as for children at risk for reading failure due to vulnerabilities such as limited English proficiency, cultural differences, or poverty. SLPs have important roles to play in getting preschoolers ready to read, both as clinicians for children with documented language disorders, and as consultants for improving pre-literacy instruction for all children in the preschool classroom.

In addition to PA, however, Kaderavek and Justice (2004) argue that skills related to print and alphabet knowledge are also crucial to emergent literacy development. These skills are sometimes called literacy socialization (Serpell, Sonnenschein, Baker, & Ganapathy, 2002; Snow, 1999), and involve understanding how books work and how print represents speech through written language units like letters, words, and punctuation. Activities that provide instruction and practice in literacy socialization are also important aspects of a pre-literacy program.

Finally, the third aspect of pre-literacy instruction has to do with the development of literate language. Literate language is the style used in written communication and is typically more complex and less related to the physical context than the language of ordinary conversation. We’ll say a lot more about literate language in Chapter 10, but for now, we need to be aware that the ability to understand literate language is the “third leg” of a comprehensive pre-literacy program. As we work with children in clinical sessions, with teachers as consultants, or in classrooms as collaborative interventionists, we can introduce literate language forms to preschool children by exposing them to stories, poems, plays, and other texts that exemplify this more elaborate language style, and giving them the opportunity to interact with these texts by hearing them, acting them out, retelling them, and relating them to personal experiences.

Kaderavek and Justice (2004) review research that demonstrates that both for children with language impairments, and for those at risk for reading problems due to poverty or language differences, explicit pre-literacy instruction in these areas, which is embedded in preschool classroom routines and activities, has positive effects on children’s readiness for learning to read. Preschool programs that provide direct instruction and practice in name recognition and writing, alphabet recitation and recognition, awareness of book and print conventions, and PA games have been shown to lead to significantly greater growth in emergent literacy skills than programs that merely expose children to books and print (Justice, Chow, Capellini, Flanigan, & Colton, 2003; Justice & Ezell, 2004). In addition to incorporating PA within speech intervention for children with speech delays, SLPs can also consult with teachers on how to address emergent literacy for all children in the preschool classroom. SLPs can identify the relevant areas of pre-literacy to address, using guidelines like those in Table 9-3; assist in designing lessons to provide instruction and practice of these skills in high interest activities tied to classroom themes; work alongside the classroom teacher to present the instruction and provide extra support to children who are having difficulty; and carefully monitor children’s participation and progress in the classroom activities to identify those who might need more intensive intervention in these areas (Gillam & Justice, 2010; Kaderavek & Justice, 2004).

Clinician-directed methods

In Chapter 3, we looked at a variety of clinician-directed approaches geared for the DL period. These included drill; drill play; Leonard’s (1975a) CD modeling; and Lee, Koenigsknecht, and Mulhern’s (1975) Interactive Language Development Teaching. There also are a variety of commercially available intervention packages, including some computer software, that use a CD approach to intervention for targets within the DL phase. Remember that CD approaches are highly effective in eliciting forms in production that the child has not used before or has used very infrequently. When initial elicitation of new forms is the goal, CD approaches make good sense for clients who can tolerate them. The weakness of CD approaches is their failure to generalize to real communication and their tendency to place the child in a passive respondent role. There are two ways to address these problems. One is to follow Fey’s (1986) advice and use the techniques outlined in Chapter 3 to increase the naturalness of CD activities. The second is to supplement CD approaches with other methods that give the client an opportunity to practice newly acquired forms in assertive roles and in the service of genuine communication. Let’s look at some examples of CD approaches that might be used for several of the typical goals of intervention at the level of DL.

Phonology

Speech sounds

One issue that often arises in phonological training is the question of whether to provide discrimination drills in which the child must identify pictures of words containing contrasting sounds (toe/sew) before production practice begins. This practice has been controversial, but recent research (Rvachew & Grawburg, 2006; Wolfe et al., 2003) suggests that discrimination training is helpful only if the child fails to discriminate sounds on which production errors appear, prior to therapy. For these sounds, active discrimination drills worked better than auditory bombardment in increasing discrimination ability. But for sounds the child could discriminate at the beginning of training, additional discrimination training showed no positive effects. These findings suggest that assessing discrimination of sounds in error should be part of the assessment for speech delays and the use of discrimination drills should be reserved for only those sounds the child has been shown to have difficulty differentiating.

Articulation drills are a standard part of traditional intervention for speech disorders. Shriberg and Kwiatkowski (1982a) showed that drill was effective for improving phonological production in children in the DL period (even though neither clinicians nor preschool children liked it very much). Contrastive drills are one particular kind of drill often used in phonological intervention for children with DL. Contrastive drills involve developing lists of pairs of words in which the two words in each pair differ in specific ways. In a minimal pairs approach, two words that differ by only one feature of the target phoneme are presented for contrast (Baker, 2010; Saben & Ingham, 1991; Weiner, 1981). For example, if stopping of fricatives is a pattern being targeted, a list of pairs of words would be developed in which one word contained a fricative and a contrasting word contained the corresponding stop. Examples would be sew/toe, zoo/do, fat/pat, and nice/night. The client is asked to say each pair of words. The hope is that having the contrasting words in the same context will encourage the client to differentiate between them, preferably by suppressing the phonological pattern that would make them homonymous. The maximal opposition (Gierut, 1990) or multiple oppositions (Williams, 2010) approach also opposes pairs of words, but this approach contrasts words that differ maximally on the target phoneme, so that the contrasting words differ not just on one feature of the target phoneme but on several. Using stopping of fricatives as our example target pattern again, a maximal opposition approach would contrast pairs such as sew/no, zoo/moo, fat/cat, and nice/nine. Lists of words for use in contrastive drills for various phonological process targets have been published by Elbert, Rockman, and Saltzman (1980) and Godar, Fields, and Schreiber (2004). Kuster (2010) provides additional internet resources for finding these lists. Additional CD approaches for speech sound treatment can be found in Williams et al. (2010).

Drill play is often a preferred form of CD intervention at this level. The production practice segment of the Cycles approach, discussed by Prezas and Hodson (2010), uses a drill play format. These authors offered several possible drill play activities that can be incorporated into the production practice phase of phonological intervention. All the activities involve the use of small cards, each with a picture drawn by the client that represents one of the words containing the target phoneme or sequence that is used in the practice session. Some example activities from Hodson & Paden (1991) include the following:

1. Hide and seek. The clinician hides the cards in obvious places around the room; the client says each word as he or she finds the card.

2. Safari. Each card is clipped to a picture of an animal. The client uses binoculars (which may be made from two toilet-paper tubes taped together) to find each animal and says each word on the card attached to it.

3. Sack ball. Large, open shopping bags, each with one of the client’s cards taped to it, are placed around the room. The client throws a softball into a bag and then names the card on that bag. The game is continued until the client has thrown at least once into each bag.

4. Buried. The client’s cards are buried in sand or foam peanuts. The client names each card as it is unearthed.

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