A friend asked me to listen to her son, Michael. My friend was unsure whether to refer him to the local school for an IEP (note that they did not live in the district where I worked). Michael was a bright child with a lot to say, but he was very hard to understand. I began working with him privately, and after going through the evaluation process with the county, Michael qualified for an IEP.

Michael received treatment 30 minutes weekly. Progress was difficult the first few months, and Michael demonstrated many oppositional and sometimes aggressive behaviors. He did everything he could to avoid attempting the practice targets. Michael has the distinction of being the first child to head-butt me. Many tears were shed during the first two months of therapy--and not only by me. ;-) However, as he made some progress and was more successful during therapy, his compliance increased and the maladaptive behaviors decreased. Michael's mother was vigilant about doing the homework (production practice, metaphonological skills training, and ear training), which was apparent based on Michael's increased accuracy when I did the review at the beginning of each session. Michael became proud of his abilities and energetically bounded into the room to tell me his best word from the week's practice.

Initial HAPP-3 data were collected October 20, 2011, when he was 3 years, 2 months old. Michael was an unusual child in that he could say /r/ but not /h/. Error examples included:
- clouds -> doud
- fish ->bit
- flower -> bower
- horse -> ort
- page -> bade
- queen -> deen
- rock -> rock (perfect!)
- screwdriver -> doo-dye-er
- smoke -> moke
- truck -> bruck
- yoyo -> nono
- green -> breen
- three -> bree
- crayons -> bran
- toothbrush -> doobrut
- soap -> doap
- leaf -> weap


Screen shot 2012-05-26 at 11.59.15 AM.png
October 2011

In late January 2012, Michael's IEP began. They wanted to focus on the /h/ sound almost exclusively, but that was not going to get Michael intelligible. They used a developmental perspective regarding speech sounds and became rather agitated when /s/ blends were brought up. Michael's mother fought for the school therapist to align her therapy with what I was doing; after bringing an educational consultant on board, the school agreed to try the IEP objectives I suggested.
1. Michael will produce at least two initial /s/ blends (/st, sp, sn, sm, sk/) with 80% accuracy at the word level.
2. Michael will produce a final /s/ blend (/ps, ts, ks/) with 80% accuracy at the word level.
3. Michael will suppress gliding of /l/ initial with 80% accuracy at the word level, separating the liquid approximation from the word as needed.

I specified that the following objectives would be targeted after Michael had mastered objectives 1-3.
4. Michael will produce /g/ in initial word position.
5. Michael will produce initial /s/ blend words in the phrase "It's a ."
6. Michael will produce at least one of the following in initial word position: /p, t, k/.
7. Michael will produce at least one of the following in initial word position: ch, sh, j.

After the parent assured that she would not complain about lack of progress, the IEP team agreed to those objectives. I emailed his school therapist after each session to let her know how Michael had done and which words were most facilitative, as well as what target to plan on for the following week. The school therapist was great about working on the same targets I did, and she came up with creative activities for the little guy to work on generalization. Michael received 30 minutes of treatment weekly in general education, at the parent's request.

Not only did Michael achieve his IEP objectives within the IEP year, he achieved them within four months. In May 2012, Michael was nearly 100% intelligible. He was much more successful when flirting with the secretaries. His only errors at that point were /l/ and "th." In seven months of treatment, he had gone from severe to mild.


Screen shot 2012-05-26 at 11.59.53 AM.png
May 2012

Here are Michael's May 2012 productions of the words above.
- clouds -> cwouds
- fish -> fish
- flower -> fwower
- horse -> horse
- page -> page
- queen -> queen
- rock -> rock
- screwdriver -> soojiver
- smoke -> smoke
- truck -> truck
- yoyo -> yoyo
- green -> green
- three -> free
- crayons -> crayons
- toothbrush -> toobrush
- soap -> soap
- leaf -> leaf

***

Here are Michael's Cycles. As always with Cycles, patterns are targeted at the word level, with the exception of the "It's a ___" phrase for /s/ blends.

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

Cycle 1 was so hard! Michael's behaviors were difficult, and his mother had him in time out for about half of each session. Each target was difficult in its own way. The /s/ blends were mostly separated, although he did say a few words with a more fluent /s/ in the last target. We got absolutely no /l/ out of him but did try. Trying at least showed him that what he was saying what not what everyone else was saying.

Cycle 2
(Anterior-Posterior Contrast)
-/g/ initial
(S blends)
-/st/ initial
-/sp/ initial
-/sn/ initial
-/sm/ initial
-/ts, ps, ks/ final
Liquids
-/l/ initial

By the end of Cycle 2, Michael had resolved his prevocalic voicing independently. He was able to say the /s/ blends with more facility at the word level. However, he was saying final /s/ with close to 100% accuracy in conversation--again, that was final /s/ only. He said final /s/ blends now in conversation. He said the /g/ sound at the word level but still had not generalized initial velars to conversation. He did say final velars, but he had come in with some final velars. Still no /l/.

Cycle 3
(Anterior-Posterior Contrast)
-/k/ initial
-/g/ initial
(S Blends)
-It's a /st/
-It's a /sp/
-It's a /sk/
-It's a /sn/
(Liquids)
-/gr/ initial
-/kr/ initial
-/l/ initial

Michael blazed through the targets in Cycle 3. His behavior dramatically improved. He had some trouble with the /s/ blend phrases, but with home practice, he was able to say them by the third or fourth blend. By the end of this Cycle, Michael had generalized initial velars in conversation, as well as singleton fricatives in initial and final position (note that this was not targeted--/s/ blends stimulated singleton fricatives). He also developed palatal sounds in final position (in conversation), and he sometimes produced them correctly in initial position. I had been hopeful that Michael would resolve his somewhat atypical /br/ substitution for /kr, kl, gr, gl, thr/ etc. independently, but that did not happen. Therefore, these blends were targeted during Cycle 3. Michael learned to say /l/ in a few highly facilitative words, and he was incredibly proud of this skill. It was a pleasure watching his growth during Cycle 3. This Cycle ended May 2012, which is when the second HAPP-3 data were collected. He said everything perfectly (except for /l/ and th, as mentioned), but he still was not producing /s/ blends enough in conversation, so we continued treatment.

Cycle 4
(Palatals)
-ch initial
-sh initial
(S Blends)
-It's a /sn/
-It's a /st/
(Liquids)
-/kl/ initial
-/kr/ initial
-/gr/ initial

In Cycle 4, Michael finished generalizing /s/ blends to conversation. He also finished generalizing palatals. During this cycle, he began saying /l/ correctly, so /kl/ was targeted. /kr, gr/ were targeted to finish cleaning up that /br/ error. This cycle was during the summer, so therapy sessions occurred sporadically. At the end of this cycle, October 2, 2012, Michael was saying every sound and blend correctly, including /l/ and th. Michael's age was 4 years, 2 months, and he had been in therapy for just under a year.

Michael continued to struggle with metaphonological skills and language processing, so therapy shifted to focus on those skills after May 2012. Michael maintained intelligibility. He had worked through syllable blending, syllable segmentation, and onset-rime blending but was unable to segment onset-rime or blend phonemes.

Due to reasons unrelated to therapy, Michael had to discontinue services October 2, 2012-September 19, 2013. When he resumed therapy, his /s/ was slightly backed and his palatals were slightly fronted, which he was able to correct with an auditory cue. Michael had difficulty hearing the difference between the /s/ and "sh" sounds in minimal pairs. His mother reported that he had had three ear infections since Spring 2013. Michael's therapy includes a few minutes of production practice, but most of his sessions focus on metaphonological and phonemic awareness skills. Although he is five, he was retained from entering kindergarten for the 2013-2014 school year.