Unbabbled: Speech Sound Disorders

Speech Sound Disorders with Jessica Carter

When a child’s speech is difficult to understand, there can be many underlying causes. Their difficulty could be due to an articulation disorder, childhood apraxia of speech, a phonological processing disorder or something else entirely.

This episode, we discuss speech sound disorders with speech-language pathologist, Jessica Carter. Jessica defines what phonological processing disorders and articulation disorders are and explains how they differ from childhood apraxia of speech. We then discuss common warning signs that parents and educators can look for, as well as therapy recommendations for each diagnosis. She also lets us know what parents can expect when they go in for an assessment.

About Jessica

Jessica Carter, MS, CCC-SLP, is a bilingual speech-language pathologist and clinical faculty member at the University of Texas at Dallas’s School of Behavior and Brain Sciences, where she teaches a variety of pediatric courses including Preschool Assessment and Intervention Methods, Pediatric Motor Speech Disorders, and Bilingual Speech Assessment and Treatment. Jessica also coordinates a joint initiative between UT Dallas and the Dallas Independent School District. Prior to joining the faculty at UT Dallas, she worked in public schools, private practice and home health.


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Stephanie (00:05):

Hello and welcome to Unbabbled, a podcast that navigates the world of special education, communication delays and learning differences. We are your hosts, Stephanie Landis and Meredith Krimmel and we're certified speech language pathologist who spend our days at the parish school in Houston, helping children find their voices and connect with the world around them. When a child is difficult to understand, there can be many underlying causes. Their difficulty could be due to an articulation disorder, apraxia of speech, a fun logical processing disorder or something else. In this episode, we discuss speech sound disorders with speech language pathologist, Jessica Carter. Jessica Carter is a bilingual speech language pathologists and clinical faculty member at the University of Texas at Dallas' school of behavioral and brain science where she teaches a variety of courses including pediatric motor speech disorders and supervises graduate students during their pediatric practicum. During the episode, we focus on the speech sound disorders of phonological processing and articulation. Jessica defines a phonological processing disorder and articulation disorder and explains how they both differ from childhood apraxia of speech. We also discussed the differences in assessment and therapy for each diagnosis. Jessica also gives tips for parents to use at home. Hello and welcome. We're here talking with Jessica Carter at the TSHA convention. Welcome.

Jessica (01:26):

Hi, thanks so much for having me.

Stephanie (01:28):

And we're here chatting with you today specifically about phonological processes and a little bit of articulation. We have spoken with people on the podcast in the past about apraxia, and one of the things they say is that, yeah, it's different from phonological processing. And now we're so excited to delve into, well, what is phonological processing?

Jessica (01:46):

So when we think about phonological process disorders, what we're thinking about is there's a pattern and a child's speech, and it's really normal for little kiddos to have these patterns. Like for example, they may leave off a syllable of a word. So instead of saying computer, they might say pewter, or instead of, you know, banana, they might say Nana, or they might leave the ends off of words. So instead of cat, you get cat. And it's really normal for kids to do that as they're growing up. But as they get older, we expect those processes to disappear. And when they keep persisting, then we call that a disorder. So they're the pet, these patterns in their speech that are happening that at a certain point it makes them really hard to understand. And so we want to intervene.

Stephanie (02:32):

Most children go through the phase where every kitty cat is a titty tat bite and I want to eat a tootie and it's really cute for a while. And then it's not so cute once they get older because nobody can understand them.

Meredith (02:47):

Yeah. So what is the difference between a funnel logical processing disorder and an articulation disorder?

Jessica (02:51):

So when we typically think of a phonological process disorder, we're thinking of patterns of errors. So your of a titty tat. So those are sounds that you make in the back of your mouth, like, um, with the back of your tongue. And so every sound that's in the front ends up happening in the back. So that's a pattern that doesn't just happen to k but it also happens to g as well. And all of those sounds happen in the front. And articulation disorder might just be on one sound. So it might be you don't say the S just fine and it comes out as th with the tongue coming forward or it might just be distorted and you might say, and the air comes out the side of your mouth, but it's typically on one sound. Whereas those phonological processes are going to happen on multiple sounds that are part of that pattern.

Meredith (03:41):

And I imagine these funnel logical processes all come in and leave at different stages of development and age. When should a parent start to be concerned about phonological processes?

Jessica (03:49):

It's a really good question because it's really normal for some of them to occur. Up until a kid is getting close to about three years old and around three you start to see a lot of these disappear. By the time that a child is four, they should be 90% intelligible, meaning 90% of the time you're able to hear that you're able to understand them. So if you're three and mom is still not understanding you very well, that's definitely a concern. Um, and if you're four, and an unfamiliar listener doesn't have any idea what you're saying, that's a concern. So it takes a little bit of delving into to figure out exactly what's going on because we do, again know that a lot of these processes are normal up to a certain point. But one of the things we think about is how well do you understand your child? How well is your child understood? And that's what we want to be able to talk about when your child is three and you should be able to answer pretty darn well.

Meredith (04:44):

Yeah. In treatment for articulation disorders, you might focus on the sound or the error, but what does treatment for a phonological processing disorder look like?

Jessica (04:53):

Well, treatment for a phonological process disorder means you're going to look at that whole pattern. So for example, there are a lot of sounds in the English language that have airflow, so like S, S and an F and sh all of these have air flow. So when we have a child, for example, who has trouble with all of those sounds, with airflow, we might call that stopping. So instead of just working on that S we're also, we're working on airflow on all of those sounds. We may just work on S for a little bit and then add an F and then add an sh, et cetera. But you're working on all of this whole class of sounds or this whole pattern as opposed to just targeting one particular sound. And there are a couple of different approaches. One that I really find to be had, it's very efficacious in the literature but also super child-friendly, very child-friendly is the Hudson cycles approach. And you are addressing those phonological processes in an order and a cyclical order. And it involves play, which is really, really important for our preschoolers. So you're going to work on a whole class of sounds, in a very, um, in a very structured way, but the kids going to think that they're playing.

Meredith (06:04):

Sounds excellent.

Jessica (06:05):

It's really great for preschoolers.

Meredith (06:06):

Yeah. Does it have a home component as well?

Jessica (06:08):

It does. It has a really nice home practice program and the creator of this whole system has published a little book that has pictures and you send it home to the parents and they're part of this process is what we call auditory bombardment. And it's that comes into with traditional articulation therapy as well, where the whole idea is that when we learn how to talk, we learn by listening. And so we want our kids to be able to listen to the sounds be produced correctly. So we have that auditory bombardment component so parents can do that at home. So they might get a word list that has all of the words that have SNM. And so you're going to say soup seeing and et cetera, et cetera. And you're going to say all of these for your kids to listen and then you're going to have them practice as well. But it may be just really short. And the whole idea is we don't want kids just thinking about their speech when they're with the speech pathologist. We want them to be thinking about speech when they're at home too. So this is an early bridge to generalizing those skills right away into a home environment and a place that's not with the SLP.

Stephanie (07:14):

And it gives parents that nice jumping point so they know exactly what to do and exactly what to target instead of the pressure on them of like, Ooh, now how am I supposed to do therapy when I'm at home?

Jessica (07:23):

Exactly. And you want to be a parent. You don't want to be therapizing your child all the time. Cause that's a lot of stress. So this isn't designed to just be a, you know, five minutes a day, something really short. We make it fun by giving the parents a hairbrush to use as a microphone. And so they're going to say the words into their microphone and then pass the microphone over to their kid for their kids to talk and practice saying the words. And we provide, um, in a home program, there's a lot of scaffolding that goes into it for the parents. So we say, Hey, you're not going to worry about correcting your kid's speech right now. You're just going to say it. You're going to let them say it. The whole idea is for them to be thinking about this outside of therapy and as the kids get better than we can help parents with specific strategies for their kids. But it's real low pressure at first and yeah, it gives them a really nice specific easy thing they can do at home.

Meredith (08:11):

Or like something they can do like in the bathtub?

Jessica (08:14):

So easier in the carpool line or in the grocery store. It's so easy.

Stephanie (08:19):

Yeah. That's nice. Do you find that many of the kids can hear the errors that they're making?

Jessica (08:23):

It's a really good question. That's one of the things you want to check pretty early because some kids are very aware and they know that what they're saying is not correct. But some kids really don't. And so one of the things you want to check is one, do they understand when I, when I as their SLP is making the error or if I'm making the error and do you understand if you're making the arrow. So I've had kids say, Hey, it's the tat, and I say the tat, and they're like, yeah, no, the tat, it's the tat and they're trying to say cat and they know that I'm saying it wrong, but they still don't hear that they're saying it wrong. So then we start to scaffold for that self awareness because we want to build that really early because that helps generalization really fast too.

Stephanie (09:08):

We have mentioned that we spoke a little bit about araxia. If listeners haven't, with any of those great episodes, can you briefly talk about how phonological processes might present differently than apraxia?

Jessica (09:20):

It can be kind of hard because we have some children with severe phonological process disorders that might look like they have symptoms or signs of childhood, apraxia of speech, but childhood apraxia of speech is a motor speech disorder and a phonological process disorder is really the manifestation of language through speech. So there really are two different things, but some of the things that you might see that we look at in terms of differential diagnosis is are the errors consistent in phonological processing? Typically they are. You may have a few inconsistent errors, but typically you're going to have patterns of errors. Whereas in childhood, apraxia of speech you aren't. Those errors are going to look a lot more varied. You're going to have more difficulty with onset and voicing. A lot of times with childhood apraxia of speech. When a child is saying a word like cat and you're not really sure and they may say cat and you think, was that a G at the beginning or was that a C at the beginning? I'm not really sure what that was. You also have some issues with what we call core articulatory effects, where sounds from one word as you transitioned to another word may affect those next sounds, and you see that a lot in childhood apraxia of speech. So when we're thinking phonological process disorders, you may have a kid that's really unintelligible, super, super unintelligible, but they're typically going to show patterns of errors. Whereas in CAS they're not.

Meredith (10:42):

If a parent is listening with a child who might have a phonological processing disorder, what can they expect in terms of prognosis and treatment?

Jessica (10:49):

It's a really good prognosis, especially if you work on things like discrimination skills really early to help build in that generalization early. The phonological process disorders typically have a really good prognosis.

Meredith (10:59):

And if you have a child with the phonological processing disorder, is there any connection to that and dyslexia or any sort of reading disorders? There is definitely a link to trouble with reading later as you're thinking about decoding some of those sound like sound symbol association or when you're thinking about spelling out words. If a kid is saying tat for cat and they're trying to write it down and they're sounding it out at, they're probably going to write tat. So there are definite links to that. So we, one of the things in therapy, a lot of times your SLP may do is pull in some of those sound symbol association, um, strategies early so that we can prevent trouble later with reading.

Stephanie (11:41):

Right. One of the things you mentioned when talking about phonological processing is that it's language based. Is there a link then also with children who may have phonological processing and then language disorders also?

Jessica (11:52):

They often you see them as co-occurring, but there's some really actually interesting research that's in process right now that's looking at the motors speech system or motor system and language and how those crossover and um, one of our colleagues that UT Dallas is doing a lot of research in that. And so that's kind of extrapolated a little bit out from your question, but it's, it's very interesting. There's a lot of comorbidity, you see a lot of co-occurrence of those sorts of things and she's looking at the link and overlap between language and that motor and articulation piece because frankly a lot of my kids that were referred to me that I've seen for articulation or phonological process disorders end up having something with language as well.

Stephanie (12:39):

Yeah, yeah. We find that often as we're going through and we see since our program spans from early childhood through elementary when they were younger, they were working on a lot of these phonological processes and they may not have been. Some of our kids come in at like three and so they have so much low language anyway as they're building their language we're finding yet, Oh there's also some language things and they get older and we're like, Ooh. Some of those phonological things are now impacting and it's a little more, we have reading and the writing also and so it feels probably very hard as parents discouraging cause you're like, we got over the hurdle of the phonological processes, but we are also noticing that it all seems to be a little bit of linked there.

Jessica (13:18):

Oh absolutely. It's going to be really interesting as we learn more about the brain as we learn more about how systems work together. You can't separate things out for kids. Things really work together. You have to look at the child as a whole and take things, um, as a holistic approach for your kids.

Stephanie (13:33):

Yeah, I know. I wish there was, they have those, the maps of the areas of the brain and be like, well that's just the one part of the brain and maybe like isolated, but children are so complex that it all fires together right. It becomes muddled.

Jessica (13:48):

Yeah, it can be and it can be really hard for parents too. One of the questions I get a lot from parents is why, especially when we're starting out therapy is, Hey, it seemed like he was getting better, but all of a sudden right now I don't understand him anymore. How did that happen? What's happening? And I see that a lot with my kiddos that have, you know, those co-occurring language disorders where they weren't talking a whole lot, what they said was really hard to understand. But now as their language is growing, they're talking about things that happened yesterday or they're talking about things that happened on the playground. And so parents no longer have a context for their kids. So it sounds to them like their kid's getting worse. Really, their kid's getting better, their language is getting better. They just don't have the context that they had before to help them understand and figure out what their kid's trying to say. Because now you know the kids talking about the slide, which is not in front of them anymore. So mom can't figure it out.

Meredith (14:42):

That's a really great point. That is a great point because so often I think we as parents know what our kids mean, or we have so much context around our children that we ourselves might not be aware that there's an issue.

Stephanie (14:55):

So context is so important and as they get off and go to school or preschool, they're opening themselves to these whole new experiences that we're not there with. Right? So when they start in the middle of a conversation and you're like, I don't know what you're talking about can be great, because now they're starting to relate to you about experiences that you're not there with them as a language side of it. But as a parent, you're like, what?

Jessica (15:15):

And it makes it so much more challenging because you think, Oh my gosh, we're now, I have, we're having all these communication breakdowns. But it's because there's growth. So there's always more to say and there's always another hurdle to get past.

Meredith (15:27):

It's interesting as the parent, because you usually have the context and how you don't. So now you're the, almost like the unfamiliar listener.

Jessica (15:33):

You're exactly right. And there's a lot of research out there about how an unfamiliar listener, you know, when you're gathering information, Hey, who understands your kid, that if it's an unfamiliar listener that doesn't understand them, that's a nice big red flag because, um, they typically can tell.

Stephanie (15:49):

Also as parents, especially with phonological processes, we pick up on their patterns and we know their patterns. You're sorting it out of, you're sorting it out already. And so we have the context and we know their patterns. So we know that two D is always a cookie or if they have a special stuffed animal that they talk about a lot, that they're mispronouncing the name of, we know what they're meaning. Yes, the neighbor has no idea.

Jessica (16:13):

Right? And you want your child to be able to communicate with whomever they're speaking. And it's really hard when that neighbor doesn't know that touchy is cookie.

Meredith (16:24):

It could be really frustrating for the child.

Jessica (16:26):

Very frustrating for kids. And that's one of the things that really gets to me is when the children are saying it's a touchy and you're desperately trying to figure it out and you just, you don't know. Right.

Stephanie (16:36):

When parents are coming to a speech language pathologist for an evaluation, what are some things that they would expect from the evaluation?

Jessica (16:42):

Well, a couple of things that are going to happen, especially with your little bitty people, you're going to expect them to, your SLP to get a speech sample of their kid talking just you know about play or about a book, but we want to hear what they sound like in connected speech when they have a whole lot to say to us. You might also expect, depending on a kid's age and depending on their language level, for them to maybe do a standardized test where they're going to sit down and say isolated words and that helps the SLP figure out what some of those patterns are. Because a lot of our kids, when they just start talking about whatever it is they're interested in, it's really hard to understand them. So hearing those single words can help us figure out those patterns. But you would definitely want to hear, you would definitely expect for your child to be able to play and talk. Um, just in case like they'd have, they were having a conversation with you cause we want to hear what they sound like in everyday life.

Stephanie (17:41):

For children who are coming in, even with speech, will you do a language evaluation with that or do you focus just on the speech side?

Jessica (17:49):

It's a good question. It's always a consideration or should always be a consideration. Whether or not you actually formally evaluate for language is really going to be based on what that child is doing. So if the concern is, Hey, it's a phonological process disorder, Hey, it's articulation. That may be the lens that you're looking through as a speech pathologist, but you're going to look at that whole kiddo when they come in. So when they start talking, you're going to immediately be thinking, Hmm, what does their language look like? What is their articulation look like? What is their voice voice quality sound like? Are there any stuttering issues you're going to be going through this whole laundry list of things because you don't want to miss something. So language is always going to be something that you're going to at least take a cursory look at and maybe deeper depending on the particular child.

Stephanie (18:35):

Do you have any resources that you tend to um, give to parents as things that they can look up or things that they can do at home outside of just that one program?

Jessica (18:45):

That's a good question. Most of the things that I tend to give parents are things that I have developed with some of my colleagues over the years that work for us in the clinical setting. So nothing in particular that I can think of outside of maybe recommending some specific books for auditory bombardments. So if your child is working on um, final final consonants, making sure they put their tail on the end of their word. I might pick a book that has a really strong final sound, like some of the Pete, the cat books are really great because Pete, the cat has a lot ts at the end. And so something like that, um, is usually an easy way to kind of work that into a routine at home. Cause you know, it's nice to read bedtime stories and it's easy way to work in speech. Yeah.

Stephanie (19:34):

At the end of every podcast we put our guests in the hot seat and we asked them if they had one piece of advice to give our listeners. It can be related to speech, language pathology and phonological processes or it can just be life in general. If you had a piece of advice, what would you give?

Jessica (19:51):

Oh gosh. I think if I had a piece of advice for parents, I would say if you have any concerns at all about your kiddo, if you've got that feeling that, you know, I'm just not quite sure if this is right, ask now, ask when they're, when they're young. Don't wait. Because the worst that you can hear is they're fine. Right. And then you think, okay, well I just, you know, got some peace of mind. But at the, you know, if there's something that's really going on, then you caught it as early as you possibly can. So that's what I would tell parents.

Stephanie (20:26):

That's fantastic advice. Yes. Well, thank you so much for taking time out of the convention to chat with us. It was such a joy.

Jessica (20:31):

Thank you so much for having me.

Stephanie (20:33):

Thank you.

Meredith (20:40):

Thank you for listening to the Unbbabled podcast. For more information on today's episode, please see our episode description for more on The Parish School , visit parishschool.org and if you're not already, don't forget to subscribe to the Unbabbled podcast on your app of choice. And if you like what you're hearing, be sure to leave a rating and review a special thank you to Stig Daniels, Amy Tanner, Amanda Arnold, and Stella Limuel for their hard work behind the scenes. Thanks again for listening.