Carly had selective mutism. Her receptive language was strong (SS 118), but she did not speak to people outside her immediate family, so expressive language testing was not possible at the time of her Birth-3 transition. She did not speak to the Birth-3 providers. I handled her transition and began working with her at age 3:3, in October 2010.

After a few weeks of visiting her at home, she began to speak to me, but I could not understand her. After a few months, she was speaking enough for me to identify some error patterns. I obtained data from our interactions and from her mother. Carly was not willing to work on her articulation--she would speak only on her own terms, and her terms did not include speaking on command. I worked with her at her preschool on using language with the teachers and children there. However, I was not able target her speech clarity.

By January I was able to get the HAPP-3 done with her. Her score was 154, and her severity rating was low profound. Multiple process errors were interacting to bring down intelligibility. The profound range is 150-200 major phonological deviations on the 50 stimulus words, so 154 is at the bottom of the profound range--low profound is 150-160.


Kellie Jan 2011.png
Jan 2011 - age 3:6 - no previous treatment

Examples:
- basket -> badi
- boat -> boat
- candle -> dano
- flower -> bowoh
- fork -> bo
- ice cubes -> i doob
- jumping -> dubin
- plane -> bane
- queen -> ween
- rock -> wa
- screwdriver -> dudaioh
- shoe -> doo
- smoke -> mote
- soap -> doap
- square -> daoh
- television -> debibi
- toothbrush -> doobu
- three -> wee
- nose -> node

Carly's first year of preschool was November 2010-May 2011. She spoke to the teachers by December, and she began speaking to a few other children in April. She continued to be uncomfortable with speaking on command. If an adult said, "Say no thank you," or "Tell him not to do that," Carly would stare at the adult.

Carly's second year of preschool began September 2011. She began the school year speaking to everyone that she had spoken to in the spring: two teachers and three children. That was wonderful--no summer backsliding. However, she remained unwilling to speak on command, at least for me.

I obtained HAPP-3 data again in October 2011. Carly had been receiving speech services for one year through IEP and six months previously through IFSP. Speech clarity had not yet been targeted. Carly was making spontaneous progress in that area, but her progress was slow. She had moved from low profound to the middle of the severe range, with 24 less errors than she had made nine months before, in January 2011. She had begun including final consonants.


Kellie Oct 2011.png
October 2011 - age 4:3 - nine months had passed but no treatment for intelligibility

Examples:
- basket -> badit
- boats -> boat
- candle -> dano
- flower -> bowoh
- fork -> bote
- ice cubes -> i doob
- jumping -> dupin
- plane -> bane
- queen -> deen
- rock -> wat
- screwdriver -> dudaiboh
- shoe -> doo
- smoke -> mote
- soap -> doap
- square -> waoh
- television -> debiden
- toothbrush -> doobut
- three -> wee
- nose -> node

Knowing that Carly was already 4:3 and had one school year left until kindergarten, I was anxious to work on her speech clarity and metaphonological (sound organization and manipulation) skills. Because Carly still would not speak on command for me, I enlisted her mother's help.

Mom was willing to do anything to help Carly develop and succeed. I met with her and taught her the foundational concepts of phonology and the Cycles Approach. I had her practice for a week with a sound Carly could already say, initial /b/, and we met one week later to continue instruction. We met weekly for four weeks, and we emailed as needed. After four weeks, mom was comfortable continuing on her own. I emailed her weekly to see how things were going and give the week's assignment, attaching practice words in PDF format. We met in person as needed--three or four more times between December and May.

Mom reported that she worked on Carly's speech several times per week, in short sessions.

Under my direction, Mom also targeted metaphonological skills. She worked through blending and segmentation of syllables, onset-rime, and phonemes. Carly picked up those skills quickly, learning to blend phonemes by April 2012.

I obtained HAPP-3 data again in May 2012. At this time, Carly was intelligible to unfamiliar listeners. She gained confidence. Her major phonological deviations on the 50 HAPP-3 stimulus words was under 40, which is part of the dismissal criteria. Carly was 4:10. Her errors at that time were with liquids (/l/ and /r/) and palatals (sh, ch, j).


Kellie May 2012.png
May 2012 - age 4:10 - after seven months of treatment

Examples:
- basket -> baskek
- boats -> boats
- candle -> cando
- flower -> fower
- fork -> fohk
- ice cubes -> ice cubes
- jumping -> dumpin
- plane -> pwane
- queen -> queen
- rock -> wock
- screwdriver -> stewdiver
- shoe -> soo
- smoke -> smoke
- soap -> soap
- square -> squao
- television -> tevizen
- toothbrush -> toofbus
- three -> fwee
- nose -> nose

I gave her summer homework of phoneme manipulation tasks for continued metaphonological practice. Carly entered kindergarten in August 2012 with a minimal IEP targeting liquids and palatals.

Here are Carly's cycles, with one week on each target. As always with the Cycles Approach, patterns were targeted at the word level, except for the phrase "It's a ___" for /s/ blends.

Cycle 1
(Anterior-Posterior Contrast)
-final /k/
-/g/ initial
(S Blends)
-/st/ initial
-/sp/ initial
-/sn/ initial
-/sm/ initial
(Liquids)
-/l/ initial
-/r/ initial

Carly struggled with every target in Cycle 1. Velars were fronted much of the time. Singleton /s/ was interdental (sounding similar to "th"), but she nasally emitted it when first trying to put it in a blend--sounded like a snort from her nose. Teaching it as a quiet "smile sound" helped. She had trouble suppressing gliding /w/ for liquids.

Cycle 2
(Anterior-Posterior Contrast)
-final /k/
-/g/ initial
(S Blends)
-/st/ initial
-/sp/ initial
-/sn, sm/ initial
-final /ts/
-final /ps/
-final /ks/
(Liquids)
-/l/ initial
-/r/ initial
(Voicing Contrasts)
-/p/ initial
-/t/ initial
-/k/ initial
(Palatals)
-"ch" initial

Cycle 2 went better than the first cycle. Velars were fluent in final position and hit or miss in initial position. /s/ blends were fluent with just a few cues. Glides were able to be suppressed with heavy cueing. By the end of the cycle, Carly was producing velars nearly all the time in connected speech, and /s/ blends were emerging in conversation. She met the criteria for starting secondary patterns. By this time, she had sorted out the few vowel errors she had made, as well as much of her assimilation errors. Her secondary patterns were voicing contrasts and palatals. Voicing contrast was easy--she produced the words fluently after a few tries. Palatals were tough, and she only got one here and there.

Cycle 3
(S Blends)
-/st/ initial in the phrase "It's a..."
-/sp/ initial in the phrase "It's a..."
-/sn, sm/ initial in the phrase "It's a..."
-/sk/ initial (word level)
-final /ts, ps, ks/
(Liquids)
-/l/ initial
-/r/ initial
(Palatals)
-"ch" initial
-"j" initial

Cycle 3 was even better. /s/ blends were initially tough in the phrase, but she got the hang of it by the second week. Final /s/ blends were so fluent that all three were targeted in a single week. Liquids were the toughest part of this cycle; Carly continued to need a model before each attempt at a target. She was producing voiceless initial consonants nearly all the time in conversation, so we did not target /p, t, k/ again. Palatals continued to be difficult, with few successful productions given a high level of cues and models.

Cycle 4
(Liquids)
-/l/ initial
-/r/ initial
(Palatals)
-"ch" initial
-"j" initial
-"sh" initial

Cycle 4... I would not even call it a cycle, really. By this time it was May, and she was highly intelligible. Liquids and palatals were all that was left to target, because everything else had generalized to conversation in 100% of occurrences--yes, in connected speech. After seven months of SLP-led but Mom-implemented treatment, Carly went from severe intelligibility to mild.