Selecting Speech Treatment Targets that Optimize Gains
This is a transcript from our podcast episode published May 30th, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime.
A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible.
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Kate Grandbois: Welcome everybody today. We are so excited for our guests. We've had multiple conversations leading up to today's episode and she's been incredibly flexible and she has so much to share. Welcome Kelly Vess.
Welcome Kelly.
Kelly Vess: Hi, I'm so excited to be here. This will be an amazing talk. Thanks for having.
Amy Wonkka: [00:02:00] We're so happy to have you. And you're here today to discuss selecting treatment target, to achieve optimal gain in treating phonological disorders. But before we get started, can you please tell us a little bit about yourself?
Kelly Vess: Okay. Yes. I have close to 20 years of experience as a preschool speech language pathologist, and all along the way, I've been a researcher as well. So I researched every detail of my practice to be as efficient as possible. So you can always find me at ASHA every year, showing the latest research and what really makes a difference in your practice if you really want to get optimal outcomes.
So that's something I'm extremely passionate about, which is why I'm so excited to be here today. Because what we're going to talk about today is what I found to make, to have the greatest impact on outcomes in treating speech sound disorders. So I'm so excited to share this. It's going to be [00:03:00] such a game changer for your listeners.
Kate Grandbois: That sounds like a, like something I can't wait to get into and a little over my head already, which is great because it means I'm going to learn something. Um, tell us a little bit about your background and, and what you do.
Kelly Vess: Um, aside from being a speech pathologist, I'm also an author. I've written a book on, uh, speech sound disorders and how to treat the whole child with speech sound disorders, because we know that if a child has a speech sound disorder, the child is at greater risk for literacy impairment at greater risk for behavioral issues at greater risk for language issues and at greater risk for academic failure.
So the book and treating speech sound disorders is not about treating a speech sound disorder. I'm passionate about treating the whole child and creating lifelong change. So that is my passion. I'm also a clinical supervisor. So year round, I do research with graduate students [00:04:00] and I teach graduate students how to treat speech sound disorders with preschoolers.
Kate Grandbois: That sounds so interesting. I love working with graduate students. It's such a fulfilling experience. I'm sure you feel the same way.
Kelly Vess: What I love about it is we always ask, how can we do this better? So we're always saying, okay, this is good. This is great practice. This is best practice event. Can we make it better?
And I think that that's, what's so neat about when you get a mastermind together, you get graduate students, you get yourself together and then you come together and you create this third mind. That's bigger than either of you combined. You create another mind, that's even greater. So I love working with graduate school students.
We're always innovating and we're always creating better. And that's why I'm so excited to be here because your listeners bring this unique skillset, this unique talent, this new unique secret sauce to the table. And when they have new techniques that they add to that, they're going to innovate [00:05:00] whatever I share with you today and make it even better.
Kate Grandbois: You've already complimented so many people and you've only been here for just a few minutes. So this is already, I'm feeling very positive and excited and energized. So that's awesome. Well, before we get into all the good stuff, the powers that be,i.e. ASHA makes me read all of our learning objectives and financial and nonfinancial disclosure.
So I'm going to go ahead and read through those and get them out of the way so that we can get onto the good stuff. So first and foremost learning objectives, learning objective number one, participants will be able to select cluster treatment targets based on multiple phonological processes present to improve efficiency of treatment
Learning objective number two, participants will be able to assess how stimulus treatment targets are to accurate production provided multimodal cueing and learning objective number three, participants will be able to make informed clinical judgments in selecting treatment targets based on phonological processes, variability of production, stimulability for [00:06:00] accuracy and developmental complexity, disclosures Kelly Vess financial disclosures. Kelly is the author of speech sound disorders, comprehensive evaluation and treatment for which she receives royalties. Kelly Vess, nonfinancial disclosure as Kelly is a member of ASHA, special interest group 1 language learning and education.
Kate Grandbois financial disclosures. That's me. I am the owner and founder of GrandBois therapy and consulting LLC. And co-founder of SLP nerd cast. My nonfinancial disclosure is I'm a member of ASHA, SIG 12, and serve on the AAC advisory group from Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy mass ABA, the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis, special interest groups.
Amy Wonkka: Amy that's me. I have financial disclosures are that I am an employee of a public school system and a receive compensation as co-founder of SLP nerd cast. And my non-financial disclosures are that I am a member of ASHA's special interest group 12, and I serve on the AAC advisory group from Massachusetts advocates for [00:07:00] children.
All right, we've done it. We've gotten through the boring bits and now onto the good stuff. Kelly, why don't you start off by giving us and our listeners just a little refresher. Can you tell us a little bit about phonological disorders specifically?
Kelly Vess: Okay. Excellent. The final logical disorders are when we're looking at immature speaking patterns that are persisting beyond developmental age.
So for instance, maybe the child is still deleting the final consonant of sounds. So that's fine. When the child is two years old and the child points to a dog and says, duh, but when the child is three years old and the child continues to delete the final consonant still has that immature speaking pattern.
Then it becomes a phonological processing disorder. It's persisting beyond the age as expected. So the child is still saying duh for dog. And when we see that we know that this child is not, that there's [00:08:00] something about the linguistic system that's not well-developed, they don't seem to understand that a word has a beginning, middle and end, another example of a final logical processing that, that disorder example that you're going to see very commonly is a child fronting a sound. So if the child looks at the cat, instead of saying cat, the child's going to say Tat because pulling the tongue back and retracting the tongue is difficult for the child. So now the child's four years old and at four years old, that's persisting beyond age expectation.
So for that reason, we're going to say this child has, is likely has a phonological processing disorder, these simplified speaking patterns, which were okay to do when you're younger are not being suppressed and they're not developing into more mature speech. So that's what we're looking at when we're looking at in preschool is phonological processing disorder.
They're doing [00:09:00] things beyond age expectation that they should have suppressed and they should have developed a more mature speaking form.
Kate Grandbois: So, thank you so much for that refresher, because as our listeners know, I don't know very much about these kinds of things. I've been working in the world of AAC for entirely too long.
And as a matter of fact, this is Amy's area. She, you know, so much more about this than me, Amy, but with, with so many other things too, but I really appreciate sort of setting the groundwork and setting the stage for what we're going to talk about today and, and giving us that refresher. And I have to assume then that everything we're going to be talking about today from a treatment perspective is very much related to these linguistic foundations and as, and differs from a different kind of speech intervention approach.
For example, for something that's motor related, is that an accurate assumption?
Kelly Vess: Well, we're going to focus on today is classes of sounds, for instance, and phonological processing [00:10:00] disorder for child is stopping fricatives. The child is producing the P for F P and B for F and V, the child's boozing T and D for S and Z.
The child is preserved producing probably T and D for “sh” and “juh”. So we have a lot, or for th the child is producing, uh, I'm sorry, P or B perhaps. So we have a whole class of sounds that are impacted. And what we're going to want to do is we're going to. Focused on the rule. We're not going to want to focus on six different sounds and take a chisel to that rock.
What we're going to learn today is we're going to learn how to treat that phonoprocessing disorder. Treat that rule and take fireworks to that rock and explode that rock. And that's how Len Williams, the president of ASHA describes it. When we use the complexity approach, which we're talking about today, we're not taking a chisel to that rock to those six sounds.
We're going to take a fireworks in that rock, [00:11:00] explode that rock and change the child's linguistic system by using the most complex sounds and sound combinations. That's what's so exciting about it. This is not. I think of Charlie and the chocolate factory oompah oompah oompadeedo approach in which you're doing one sound at a time, one by one, slow, so slow and said, it's an explosion that will literally change a child's linguistic system very, very quickly and impact all sounds simultaneously.
Kate Grandbois: Can I ask a question? Just so to say it back to you or make sure I've understood it. So the complexity approach is a specific approach that where you're treating a rule or a cluster or a group of phonological presentations, instead of treating one thing at a time, is that an [00:12:00] accurate description of the complexity, the approach, because I've never heard of it before. Just straight up.
Kelly Vess: Yeah. The complexity approach. Exactly. The complexity approach says, okay, the speech speech develops like a waterfall. And if we go in and if we go into those clusters, which are the last things to develop in our language and SKR, it develops at seven years of age. That's the very last cluster in our language.
Let's go to the top of our mountain, the most complex sound and work at that level. And then we're going to improve that level and there's going to be a waterfall effect in which all of the sounds below it are going to spontaneously improve. That's what's neat about it. That's how speech develops. It doesn't work like a Geyser if I work on the earliest developing sounds.
So I work on the, the simplest sounds, the P the B the M I only help P B and M. [00:13:00] If I don't improve the later developing sounds, its speech doesn't work like a Geyser in which it shoots up. It works like a waterfall in which it cascades down. So I care less about PBMTD and the earliest developing sounds because they're not going to impact the later ones.
I care about the later developing sounds because if I work on these sounds, the earlier developing sounds are going to spontaneously develop. And that's what Lynn Williams was talking about. When she said you're bringing, putting a firecracker to the rock, you're blowing the rock up and improving all of these sounds underneath by working on the most difficult sounds.
So that's what we're going to talk about today. For instance, if I work on the SKR blend, I'm going to work on stopping the fricatives. I'm going to work on fronting of velar sounds K and G to T and D. I'm going to work on [00:14:00] gliding of L and R. So I'm going to get three phonological processes that are very common to preschoolers all at the same time, three for the price of one.
And what matters, why that matters so much is because we only have 30 to 60 minutes a week to make a difference. So we have to challenge creates change. Status quo does not. So I look at the brain like the body. If you only have 30 to 60 minutes a week to work out, you can make a difference. But you're going to have to be challenged in order to make a difference.
You're not going to do it. Taking a walk 30 to 60 minutes a week. You're going to do it by doing something challenging. Let's say burpees, a full body anaerobic activity that tests your strength and all your muscles as. Well, you get three for the price of one you'll wear might make you cry afterwards.
Kate Grandbois: Everybody hates burpees. Yeah.
Kelly Vess: Yeah, [00:15:00] exactly. But what are you doing? You're working multiple sounds at once. You're working multiple muscle groups at once. You're using your time efficiently and you're challenging. Cause challenge creates change. Status quo. Doesn't the children I work with when they come to me, they're at the one percentile they're at the standard score.
50, they have severe speech impairment due to find a logical processes by the end of the school year on average, during the normal range, they're in the 50 percentile, they have a hundred standard score and that's because I'm challenged creates change. I'm at the top of the mountain. I'm working on SKR with these kiddos and that's what we're going to talk about today in the waterfall.
All that other stuff is spontaneously developing the ends of the words that they're dropping. I don't focus my time on that. That's going to spontaneously develop. So that, that's what we're going to talk about today and why it's so [00:16:00] exciting is that you're going to create your, these children are going to take a 180 because we're going to work smarter and not harder.
And it's in the treatment target. The treatment target matters a lot.
Kate Grandbois: Oh, I was. So I was just going to say, tell us more, tell us what to do. How do you do this?
Kelly Vess: Okay. This is great. So the first thing we're going to do, step one, we're going to do the speech sound disorder test, the single word test. And we know there isn't a lot of reliability that, but we need to find out what are we going to work on?
So what are we going to focus on those phonological processes? We don't care about the sounds. We care about the rules. What is this child doing? Okay. This child is stopping. They're stopping all fricatives. Okay. We need to pick what sound are we going to pick an S blend, what? because S is complex. So we and S is also highly frequent.
So let's work on something high and complex S oh, they're also fronting. Okay. They're fronting the sounds. Are we going to [00:17:00] work on K G and Ang? No, let's go on for K. So we'll go. S K. Oh, they're gliding L and R. Okay. Let's go R in there. S K R will be the blend that we work on three for the price of one. Am I going to work on syllable deletion? No. Am I going to work on final consonant deletion? No, because that is going to naturally develop. I'm going to work on the top of the mountain, not in the bottom of the mountain. That's how it's going to roll, but let's so that's the starting point. The starting point is go to the top of the mountain. And you're probably wondering what if the child can’t do SKR blends.
What if the child says, you know, you say, okay, so scrape and the child says tape, then what do you do? What we're going to do is we are going to empty out our tool box. We're going to give them every cue at once because we don't care what the child can do. That's status [00:18:00] quo. We care about what the child could do.
That's dynamic assessment. So we're going to, what kind of cues are we going to give them everything, everything under the sun fits in your toolbox, give them everything and see what they're capable of. So for instance, when it comes to the queuing, here are the cues. I'm going to give them to check and see what are you capable of?
Cause that's what I care about. I don't care what you can do on your own we're agents of change. Okay. We were not testers. We're changers. We're changing these children. So I'm going to say, all right, what would happen if I give you, you slow unison speech and I give you, what's called a temporal cue, which means I show it to you spatially.
So if I'm making a snake sound, I'm going to make a snake with my finger and I'm going to do it really, really slowly and hold it out so you can hear it and you can join me. And why don't I, maybe you have to even meet a, you're going to hold this a touch cue [00:19:00] your face, your mouth back, recheck, retract your lips.
Maybe you have the whole, just your lips in a smile form to make that, that as sound. And maybe I have to say a little visual imagery. Okay. Let's make the snake sound. I'm going to give you every cue in my toolbox and see if you can do it. And suppose friends, since the child says with everything, you'd give them with angry dog sound.
You say, okay, let's make the anger dog sound. They say scrape. Now you're asking a good question. What are you going to do? Then we don't want to reinforce w for R we don't want to cement that because practice makes perfect, but practice also makes imperfect. So what are we going to do? We're going to still go for three clusters.
We're going to say let's do S Q U blends. How about I squash it to you instead, we'll talk about that later, because three clusters where you put three sounds together is more [00:20:00] powerful than two. You're going to get bigger gains with three. That's what our research has found. So we'll talk a little bit about that later.
So the second thing we're going to do is we're going to first, we're going to pick the top of the mountain sound that the child can produce if we give them every cue imaginable, and that's our starting point. So then what do we do after that? Right. So the child is like, can't produce the R. So you say, they say rake, they say, wake, you give them angry dog sound.
And they still say, wait, what can we do then we're going to say location, location, location, just like real estate. We need better neighbors. So we're going to find neighboring sounds that can help them produce the R. So what sounds can we put before the letter R that gets some retracting that li those lips.
[00:21:00] So if we would want a sound where they're going to retract the lips So they're going, it's going to make R easier
Kate Grandbois: I feel like I should know the answer. I don't know the answer and you need, you know, the answer,
Kelly Vess: I think of a consonant that will retract the lips.
Kate Grandbois: Amy, what's your answer? Would I think anything thinking about like ger?
Oh, there you go.
Kelly Vess: Yeah, that makes sense. Yeah. So, what are we going to do? This really, really works is we're going to say I okay. You can't, you're doing w for R let's give you the G or the K blend. So let's say the word instead of we're going to say like meds, for instance, let's grind to me, please. If you're going to see that in Gerber, or maybe we're going to say a con let's, can you clean it?
I mean, we're doing crank it to me please. So when you do the K and the G [00:22:00] are location, location, location,
Kate Grandbois: I love that acronym. That's very easy to remember. Yeah.
Amy Wonkka: I want to say all of this back to you to make sure that I understand what you're saying. And I think that what you're saying, it's okay to say I'm wrong.
I think that what you're saying is that the first thing a clinician wants to do when they're thinking about the target, because the target is so important, the first thing the clinician needs to do is get a feel for what the child is already producing. So identify those processes that might be in place, whether they're stopping final consonant, deletion, whatever, and then you're really doing, like you just described in so many really nice ways.
You're doing this dynamic assessment. And so you're giving all of your clinician cues and seeing what is the child stimulable for. If I use dynamic assessment and try all of these different types of cues, what cues work and are there things that still the, the child isn't stimulable for? Even if I give all of my clinician [00:23:00] cues, so then if those cues don't work, then we need to, as clinicians put on our speech pathology hats, and think about what we know about place manner and voicing, and think about what are some other like sound friends that we can put next to the target to help facilitate that production. Is that, is that a fair restatement?
Kelly Vess: Awesome. Awesome. I love it. I love it. Exactly. I love it is the first, what are the rules? Let's crash those rules, second you said, okay, I'm going to empty my toolbox on you. And then third, if that's not working okay, I need some help. I need some neighbors. What would be good neighbors to help me to get that sound?
I love it. So for R, because ours is so difficult, some other sounds that are really good are tr or dr blends because tr blend is actually the affricate ch. So once again, you can't round your lips when you do cha [00:24:00] you protrude them. Sure. drain. So, and then you have the word drop. So those are great blends to break the w for R I like to work on the w for our early, because that's a sound that persist into adulthood.
Many of us know adults where it's habituated and the, and by kindergarten, I must find it to be too late where it's habituated often too much. And it's very difficult to change because they've said w for R a million times before. But yes. Thank you. That is awesome. Amy. I love
Kate Grandbois: good job, Amy.
Amy Wonkka: Good examples. No, that was great. All right, thumbs up. I got it right.
Kelly Vess: It's great. Because what happens during these evaluations is the parent not only does, does the child believe in you. Like, whoa, I can do these things. It's very empowering when you, when you're, when you bring out and show them what they're capable of the parent bias, then as well, this is what makes [00:25:00] us different than Joe Schmo off the street.
When they say tat and the person says, say cat, and they say tat, okay, game over. That's not like us. We're like game on. So yeah. Thank you so much for that wonderful summarization of 1, 2, 3. This is as simple as that.
Kate Grandbois: I have a question that's related to something you said a few minutes ago, so you'll have to forgive me if this is slightly tangential, but you said something about what the research says.
And I wondered if for those, um, SLPs who are listening, who maybe aren't as familiar with this approach or interested in applying this approach, does the research say anything about what profile of client this is best matched for? In other words, who is represented, what students or clients are represented in this research?
Kelly Vess: Well, the research shows that the children that with severe severe impairment really benefit from this approach. So children that have like don't have hardly any sounds developed [00:26:00] because by working on these more complex sounds, you're going to develop a lot of sounds. And I think it's a really important question that you ask, because when you're using this approach, when these kids come to me in the one percentile, they make huge gains initially, because they're getting puh P B T D N K.
They're getting those F B those really simple sounds. And then it's like mountain biking. And you get to the top when you get to the R and the L and the blends you get off the bike, and those are more complex sounds. They're more difficult, whatever approach you're using. And you're walking really, really slowly.
I do use this approach personally, with all of the preschoolers on my caseload and even the children that just have problems with R distortions, because I found in my work that you have to work over what your goal is when you're in speech therapy, you have to [00:27:00] overtrain, you have to work at a higher level for it to generalize outside of that room.
So I've done research on R, I work on the word scrape SKR. And then they make benefit on are that way and the singleton position. Cause I work on at a harder level. And it's funny because all of these elementary speech pathologists are like, they email me, I've been working on R for like three years with the child.
And then I started working on an SKR with them and they're getting it in like two months. And that's because you're working at a higher level and that's the way it works. It cascades down what you do in speech doesn't Geyser up and what you do in speech I find doesn't even move to the side. You've got to work at a higher level than the real world that you expect to happen.
Kate Grandbois: This makes a lot of sense. I mean, even though it's slightly above my pay grade, but I, I really appreciate the visuals that you're using and the, the acronyms and things. I think that that makes, that makes it feel doable and applicable.
Kelly Vess: And I'll [00:28:00] tell you what my, what my research has also found, which is like, if I want to improve two element blends, like S blends two element, the word, like slide, I need to work at a higher level in speech therapy.
I need to work on a word like splash, a three element word, and speech therapy for the child to be able to do it on testing. And for the child to be able to do it in the real world. So that that's what I've found and that's the way it works. You've got to go over it, whatever your goals are for the child to accomplish with no cues, you need to work over it with cues and speech and then fade them out.
Amy Wonkka: So when we think about, sorry, jumping in, I'm just looking at our learning objectives in that second learning objective, and thinking about stimulability, we talked a little bit about stimulability and if you try, you know, using your intervention approaches in that and the child still isn't stimulable, just like you said, we don't want to keep having this repeated practice of an error pattern and that's not what we want.
We don't want to be learning an [00:29:00] incorrect production. Um, so we've talked about stimulability in the context of clinician cues and also, you know, kind of setting up those, I don't know, I'm going to call them sound friends, but sort of facilitate context for your target production. Can you talk to us a little bit just about some more of that multimodal cueing that you're using and just, you already gave us some really nice examples of that, but maybe helping our listeners think a little bit more about what, how you might sort through that stimulability piece a little bit.
If you have a student who's maybe not stimulable with your cues, maybe they're not stimulable with the facilitative cues and how you change your cueing a little bit, um, for those kiddos.
Kelly Vess: Awesome. Like there's some that, like, for instance, I work with three-year-olds, there's some, some three-year-olds that can't produce K and G they cannot do it.
And the reason for that is protracting and retracting the tongue [00:30:00] is really, really hard and they simply don't have that neuromuscular developed yet. And I'm not going to, there was a child. I'm going to tell you a story just to cement what we're saying, which the only word she could say G in, she could not front-end is saying the word ugly.
I tried every key word out there. And why is that? Because I had uh I had lee. So she would say, that's not ugly. I want it please in the month, that was bizarre. But the next week we were working on, can you scrape it to me please? Because I have a cool girl teeth, but you have to start somewhere. Okay. But what about the child that can't do K and G what do we do then?
Because they just can't. We work on L and R and that's because L and R our neighbors right next store there, that palatal sound right there. And do you know what happens when I work on L and R? When the child turns four and a half, typically K and G will naturally develop. [00:31:00] That's what I'm finding. I have found one child in the last 10 years where it persisted.
The K and G and it was a lot of elbow grease at four and a half years too, but only one out of probably a hundred, but that's a great question. Some children, it's just, it's not there yet and you're going to have to shelf it and you're going to, but what I did when we work on L and R that's more complex and it's nice when K and G naturally develops, cause K and J could bring children to tears, holding their tongue down the tongue depressor, putting a cherry on their teeth, all of this, lying on their back and writing on a table and looking in a mirror, just stop.
It just stopped. They're not ready for it yet. So, but thank you. That's a really great question. And I think another thing is we're going to get into it in a moment, which is really important is, is all of the cues and how do you remove those cues? Because that's super, super important. You give them everything in the toolbox.
Now, how do you [00:32:00] take tools away? So I think we can go to that and this is very important. What should we go to that? So we're going to go, we're giving, I'm going to give you an example, the word scrape, which is the hardest to use and the language and language in our language. And I'm going to, you're going to hear it auditorily, but I want to give you an example of what it sounds like you, unison speech, really slowly going every sound.
And then I'm going to show you what I'm going to take away, and we're going to go through the steps. So I'm going to be using my body. And when I use my body and fingers, these are cues. Sure. I've been trained in prompt. I know Kaufman. I know easy does it for Praxia. I know all of these cues out there.
I create my own and so do my graduate students, based on what makes sense to me. And it's been highly effective. So what, what I think my rattlesnake looks different than someone else's Cobra. Everyone has a different [00:33:00] cue that they use depending on what feels right to them. So I'm just going to show you the SKR.
I'm just going to show you how I do that would be like this and I'll yell out. I'm sorry. Snake sound. Let me hear you snakes so loud. What a loud snake sound.
Kate Grandbois: And for people who can't see Kelly is doing these beautiful hand motions with like a Viper fingers and like swirly snake movements. So this is definitely a, a very, uh, immersed experience.
Kelly Vess: Yes. Thank you. And I liked it. I learned this from Lynn Williams back in 2008, when she came to Misha, she was like, this is a snake and the snake was going all over her body. Now the child can perceive this snake sound. So I always tell my graduate students pretend you’re at a Taylor swift concert and you're in the back row balcony seat.
So you needed to use those gestures. So big, bigger is better and so loud. So they [00:34:00] really break in through this, the static. Okay. So we're doing this next time and then I'm going to take my finger. I'm not putting it in my mouth. Kind of make it a compat about CA so they're going to do the two and then with the angry, angry dog noise errr, once again, I'm holding onto it until they can join me.
I'm giving them time to perceive it and I'm not going to take woo. I'm like, oh no, that's weak no that's a fish waiting for it to come out. Right. Okay. So that's maximum prompt. It's unison dadada. First thing to take out is auditory remove the auditory as soon as possible. So you're saying, so I'm not going to start.
I'm going to stop talking as soon as possible. Why is that? Because auditory prompts are the hardest to fade, children become dependent on auditory prompts. And there was, besides that I want the child to be the teacher. I want to develop an internal locus of control. So I'm going to [00:35:00] use the word scrape and no other word.
I'm not going to say screws, screen scrapes, scratch. No screech. Cause if I'm doing that, then I'm in control. And not only am I in control, the child's focusing on what to say and not how to speak. So I'm only going to say the word scrape. That's the only word I'm going to say all year. And there's research behind that.
That says one exemplar, just one is better than many. And this is the why is because the child can master it. And the child can say, I don't care about the word I care about how I talk. Am I making a snake sound? Is the tongue in the back of my mouth? Do I have angry dog teeth? That's what's going on in the child's head.
So we're doing toolbox. The first tool I take away is speech and I'm only miming, I’m miming with the child with my mouth. Will I jump in with an [00:36:00] angry dog teeth if to help out with the hard sounds? Yeah. So maybe the word is great or because I know the child has a little bit of problems with the w for R, but the first step is get rid of the auditory cue and give everything else to the child.
Kate Grandbois: Since this is an auditory modality. Just again, for the sake of saying it for our listeners, you are gesturing so emphatically. So when you're saying angry dog teeth, your, your lips are retracted. Your teeth are bared. Your you've got your hands up. Like little paws. I mean, this is. This is a very immersed experience.
So as you're describing, removing different environmental cues and removing the speech, there are still a lot else. There's a lot going on for the child sitting across from you because you are really immersed in this multimodal queuing system.
Kelly Vess: And that's extremely important. Thank you for bringing it up because I tell the interns, you really have to be like a [00:37:00] cheerleader, cause you're like, give me an S, you know, and if you're just like, you know, that really helps.
No, it's a big, it's just like you have, you're giving letters to a sound and you're doing a cheer except the child's right next to you. But it really works because all of the energy that you're expelling too is really motivating to the child. And you know, what is the most motivating of the child? You're the teacher now I'm the student.
I didn't even say a word I that, and I think that is the ultimate goal of therapy is internal locus of control. The child is in charge of the learning. The child has taken ownership. And that to me is the golden apple. If we've taught children, children learned that my efforts matter. That what I can be successful if I work hard, that's the best thing we can teach children with communication impairments.
And it's interesting because the research James Lawn did meta and analytical research. Uh, he is an amazing [00:38:00] researcher of these children, that communication impairments in kindergarten. And when they're 32 years old, they're more likely to have an external locus of control, meaning they don't think they have control over their lives.
They don't think they have control over their professional lives. They're less likely to think they have control over their personal lives, their personal success. They think it's outside of their country. Well, we can change their lives early on by letting them know you're the teacher you're in control.
I'm the student. Wow. So in that hard work matters.
Kate Grandbois: So once you remove the auditory cue, what's next or you're, you're still your cheerleader. You're making big movements. You're really having a good time. It's party time central, but you're no longer providing an auditory cue.
Kelly Vess:Yes. I love, I love you're asking all the important questions.
Don't drop the baby because the child needs to be [00:39:00] 80%. And if we pull away too many tools in my toolbox and the child goes below 80%, we have two things that are going to happen. One we're going to habituate errors or two, we're going to frustrate the child. We don't want that to happen. So we're always going to give enough tools and support.
We might have to add more like, whoa, I pulled back too much, sorry. Or we might have to pull back. Okay. You're 90% accurate. This is too easy for you. I got to stay at 80% of all times. That's a magic number. So we're there at 80%. The next thing I might pull up is tactile. I don't touch the children. I have the children touch themselves because they’re the teacher.
So for instance, if we're doing the B sound, they put their hands over their mouth. Like, because there's something like that, they will touch their own mouth and I'll touch my own mouth. So the next cue is to get away from them touching themselves. And I think that's important because of the COVID and because of [00:40:00] illness.
So they might hold their cheeks for the ch ch sound. They might hold their cheeks down for the choo choo sound that we're going to get away with now. And we're going to make it visual on the air. So I may choo choo with my hands. So we're going to get away from the child, touching the child's own phase to help produce the child sounds.
So we took away the auditory first auditory. We always want to get rid of that as soon as possible, then we're going to get away from the child, touching the child's own face and using instead that what I call temporal cuing, which is what you're showing with your body and space, how to produce the sound like the snake that it's continuous, the snake keeps going and going with the SM that's known as a temporal cue.
I'm going to hold on to those. I'm going to hold on to my visual cue. So I might just make a snake. I'm not giving the temporal the show, how to do it. I'm just putting a cobra so that they remember their snake sound and where I [00:41:00] might give an imagery cue, which I'm like, Ooh, I hear the snake sound snake sound.
I might yell out snake sound. So I'm going to first take out auditory, then take out touching, and then, um, but, and then we're going to keep the temporal showing with our body, how to cue. We're going to keep a visual and we're going to keep the imagery.
Kate Grandbois: And just for the sake of again, describing what you're doing, you're making these hand motions that are animal like.
So you're still providing, when you're talking about a temporal cure, you're talking about moving your body continually to show time when you're talking about a visual cue, you're still making bear paws, or you're still making a little viper signal, which is, I've never really thought of making a little Viper motion with my hand, your two little fingers up like fangs.
I love the way that you're making this. So multi-dimensional, that's it. I, it makes a lot of sense to remove the cueing in that order.
Kelly Vess: Yeah. And that's the thing like learning, we've learned best when [00:42:00] it's multimodal. When both, I believe when the children too, when I show you the cues, I'm doing the children's, child's doing the cues with me.
The child's also making a snake with their body. The child's also, so this is very important. We learn best when we're using all of, when we're multi expression, when the children are expressing themselves through their body and through their entire bodies. And when we're teaching, using our entire bodies. Song as well.
I didn't mention song, but, but we do the songs too. So afterwards after we're done, I heard the snake sound, the snake sound, the snake sound. I heard the snake sound. I heard a loud, you know, I'll tell
Kate Grandbois: Therapy with you sounds fun. Yeah. A lot of exciting things happening in your treatment.
Kelly Vess: Yeah, and fun is so important. I'm glad you brought that up.
We don't talk enough about that. I think in therapy and speech pathology realm, there's tons of research for emergent learning. And that just shows that if children love learning, they're going to go on to learn [00:43:00] more and become better at it. It's just like emergent reading. So I always, when I evaluate an activity with a graduate student or I always ask when the number one question is, how fun is this
Kate Grandbois: Oh, right. And I also think there's something to be said for the intersection of communication and joy and, and making sure that not only is it fun, but the individual that we're working with is experiencing some sort of joy while they are learning to communicate, or they are experiencing joy through, you know, as a result of their communication and, and, and especially that's.
So it's so important for even us as adults, but especially for, for young young children who are struggling with the communication impairment of some sort,
Kelly Vess: oh yeah. How many children? And so sad, I've seen so many three-year-olds three-year-olds would be like, I bring out a children's book and they're like, I'm not a good reader.
And it's like, whoa, but that's what, that's exactly what you're saying it already, [00:44:00] you know, or they close their mouth. Cause they know, I can't say that word. Like they already have like, almost shame associated with their speech or their literacy or their language skills at three years of age. So if we can change that, like you said, it makes speech something joyful now that's huge.
Kate Grandbois: Absolutely. Okay. So you've walked us through this complexity approach and, you know, getting our biggest bang for our buck by targeting more complex sounds at the top of the mountain, as you said, and you've walked us through multimodal queuing and how to provide multimodal queuing and then fade multimodal queuing.
I wonder if you could tell us a little bit more about learning objective number three, um, specifically around selecting the treatment targets that you're working with based on the phonological patterns that you see
Kelly Vess:. Yeah, I love that. So what you're talking about right now is really, really [00:45:00] important. Oh, before I go into that, I want to talk a little bit, I'm going to go right back to that.
Cause that's really important. Yeah. Go for it about how progress is going to be made, because I think a lot of people are going to do the complexity approach and they're going to say I've been working at SKR blends. Okay. Kelly, I've been, we're going to ask, Hey Kelly I’ve working on skr blends and they're 0%. Okay. I been working all year.
I've been working on the word scrape and there's 0%. This does not work. That's what I think they're going to say. And I, and I, and I'm going to get back to that. I want you to know that speech develops like teeth. Okay. So if we can't change how speech develops, we're not going to make the molars, the molars come at right.
First of all, how, how do teeth develop first? You have the front teeth, and then you have the lateral incisors teeth. And then after that, then the canines, and then you're going to have the molars. And I don't care what your dentist does. That's what everyone's teeth are going to develop. Okay. All around the [00:46:00] world and all the languages around the world.
Speech always develops the same way. So first you're going to have vowels. Then you're going to have stops. Then you're going to have fricatives. Then you're going to have affricates. Then you're going to have to them clusters three element clusters and liquids. Those really hard liquids like L and R, okay.
Coming up there at the top. So when you're working on three element blends, which are the top of the mountain, they're going to develop last. Okay. So when you do testing, what's going to happen. I've been working on SKR blends. When I show a parent the test results, we're going to say, oh, okay, I'm working at SKR.
And they've developed P B T D N F V K G SH J, that none of these sounds that even touched, I didn't touch these sounds in any of these words, but those are going to spontaneously develop because of the waterfall effect. What are they going to struggle with? They're going to do multi-syllabic words.
[00:47:00] They're going to do final consonants. What's going to be left for us to work on. Do you want to guess what, what is going to be still hard for the child that I'm working on SKR with? And what's left now that the child is struggling with.
Kate Grandbois: I have no idea, Amy, Amy's going to, Amy's going to, Amy's going to guess. I can't
Amy Wonkka: guess it's going to be those later developing sounds and clusters
Kelly Vess: that I'm working on.
So what is your child? Okay. Your child, where they were at the top of the mountain. We're walking right now. We're walking that bike in the mountain biking and the child is going to have problems with clusters. The child is going to have problems with L and R. These late developing sounds are going to be left, but that's what I've been working on all year.
Well, yeah, but we don't change how speech develops the earlier sounds will always develop before the later sounds, but they're just going to develop faster. And I just explained to the parents, we're just [00:48:00] running up these stairs.
Kate Grandbois: So my question is related to, you know, in terms of thinking or talking to that SLP, who's been working on these later developing sounds all year and hasn't seen any progress.
How would you recommend measuring progress in that scenario? Are you continually monitoring the development or probing for earlier development sounds to make sure that there is some. Some progress monitoring happening instead of just saying, well, we worked on this one blend all year. It didn't happen.
Oh, well, like how do you, how do you measure progress along the way?
Kelly Vess: I love what you're asking because every eight weeks I, I give a speech test, single word, speech tasks, and I see progress that way. So, okay. The child starts with 80 errors on the test. Now this is not uncommon. And three months later, there's 40 errors.
And then three months later, now we only have 20 errors, but [00:49:00] guess what those 20 errors are, that are the L cause we're at the top of the hill now. But I explained to the parent how this is going to work. We're going to run up these stairs. Look at all of these early developing sounds that naturally develop.
Look your child's saying the ends of words now. your child's saying all the syllables now, you know, this is working, but I explained to them also, okay, this is where we're now elbow grease time at the end that things are going to slow down. But that's what I do is you write, if I said, well, let's assess skr.
Oh, we're still 0%. We're still 0%. Now I will tell you a population that doesn’t, that does not test while I've found is children with ADHD, uh, children with attentional deficits when I put speech tests in front of them.
But I want to tell you just rest assured with these children, because if you're doing in therapy, the 80% rule, they're [00:50:00] 80% accuracy in accurate therapy. The parents are 80% accurate at home. I find it takes them a year and then a year later it's like fireworks. They're going from one percentile to the 50 percentile, normal as well.
It just takes them a whole year. For it to generalize, to testing. They do not. I find a lot of them don't test well.
Kate Grandbois: Um, but from an ethical standpoint, you're monitoring progress of your treatment throughout the course of your treatment through data collection and goal modification. If you're in a, you know, if you're not writing IEP goals, right.
I mean, you're not just hanging your hat on the, well, we'll see what happens in a year peg because we can't do that as SLPs. I appreciate. And I think it's important to note the importance of, uh, important to know the importance of, I think it's, I think it's valuable to make note that it's critical for us to be probing for some of the, for the impacts of some of our treatment, even if it's not directly [00:51:00] obvious for us in our treatment space.
Kelly Vess: Yeah. And that's what, what I care about is the level of cueing. They're always going to be ADP. 80%, maximum level of prompt, 80% visual, only level of prompt, 80% imagery, only level 80%, no prompting. So I really I'm, my goal when I write goals. Cause then I'll be like, what is your goal? My goal will look like this.
The child would produce S K R with given a maximum level of prompting at 80% accuracy. The next goal. The child will produce essay, K R blends with 80% accuracy, given a moderate level of prompting, the next goal, a minimum level of prompting, the next goal, no prompting. So, um, or maybe even just minimal would be where we left off.
Kate Grandbois: Do you ever write goals for earlier developing sounds even though you're treating a more complex target. So for example, you [00:52:00] are hoping to address improvements in an earlier developing phonological process like stopping, but you're working on these much higher developing blends. Do you ever write goals for something that you're not directly working on and then measure or probe for progress towards those earlier developing skills?
Kelly Vess: Oh, I like that. I don't. But I realize that
Kate Grandbois:says the woman who knows nothing about phonological disorders as a full disclosure
Kelly Vess:, no, I love it because I hear it. My goals from earlier intervention and they write goals, like the child was suppressed, stopping the child was depressed, fronting. The child was depressed, cluster reduction and they write, those are milestone goals for me.
So I'm able to say achieve achieved and usually cluster reduction they're gliding it. Typically hasn't been achieved as, at the end. Those are the molars that come in last, even though I've been working on that the whole time. But yeah, that's, I like those. [00:53:00] You can definitely write your goals that way.
Write your goals. I like to do SKR because it's clear on what I'm doing every day in practice, but if I did stopping gliding and fronting, those are great. Those are great goals to write. That equally assess them and maybe assess more the class that we're working on, the rule we're working on. If someone else were to pick it up and say, Hey, I, what am I doing?
SKR? What? Yeah. So I love that.
Kate Grandbois: Amy, did you have a question?
Amy Wonkka: I was just thinking back about kind of this complexity approach and how it, you know, kind of dress these different types of funnel, logical processes that we might see. And I guess I was wondering, are there ever times when you wouldn't look at a cluster.
At, at producing a consonant cluster kind of as your treatment activity, would that change if you had a student who presented with a [00:54:00] specific profile of phonological processes or, you know, kind of, what, what does that thought process look like back sort of thinking about those target selections?
Kelly Vess: Yeah, I think that's a great question.
I'm going to be, this is what I do, and it really, really works for me. A lot of the children I work with are vowelizers. So they, ah, ah, and I show this to my book. Our step one is SW blends. And the reason for that is because S is long. So it gives them time to perceive it. An S is 150 milliseconds long. Where if you look at PB TD, those stop sounds are only 30 milliseconds.
So I want a sound that's long enough for them to perceive and join in on, and then the w is easy to produce. So it'd be like, I can draw it out. So I like to say the word sweep. So I'll say, so it sounds like that's [00:55:00] so.
I can hold, Ooh, forever. I can hold “s” forever. So that gives the child time to join in with me in unison speech. And then, like I said, what happens when I work on SW blend is all of those earlier developing sounds naturally develop. I'm not wasting time working on P B T D and those early sounds. And they always naturally develop.
I've never gone below S w ever. Uh, and that's what you're going to see in the book. You're going to see a lot of children that can't talk. And if we show SW as a step one and that's because we can use our body and give them more to proceed and more to join in on.
Amy Wonkka: And that's making me think just back to way, way back at the time machine, but back to my grad school days and, and all of the, when we [00:56:00] first learned transcription and thinking about placement or in voicing and how important that is, you know, and, and just sometimes we have been trained to do sort of that more systematic approach and say like, okay, I'm going to work on things within this one class of, you know, manner.
Right. So thinking about stops as a class, or thinking about continuants as a class. And so this complexity approach, if I, if I'm getting it correctly and it might not be, but, um, would be kind of integrating what we already know as speech pathologists about place manner voicing. And just thinking about these more complex combinations of things that really aren't in the student system at the moment.
And we're trying to work on that in hopes that it's going to result in. Learning of other things, rather than going sort of methodically through like, okay, I'm doing stops. Okay. I'm doing affricates. Okay. I'm doing transitions [00:57:00] between, you know, a stop it or something like that. Is that, I mean, that's, that's sort of the big contrast, right?
Kelly Vess: You brought up such an important topic to end on, which was maximally distinct sounds. How do we, yes. How do we do acrobats in the mouth? How do we do Cirque de Solei in the mouth? Okay. We know that complex is better and let’s talk coordination. Okay. I love it. All right. So part of the complexity approach, that's super important.
I'm glad you're bringing this up, but this is ending on a bang is that we need, what's known as maximally distinct sounds. So we have consonants, two types of consonants that are language. We have obstonants which the air flow is obstructed and we have sonorants where the airflow is glided along the tongue, like [00:58:00] sonorous.
Okay. What we want to do when we do clusters is we want to make an abstract with a sonorant and that is creating Cirque de Solei in the mouth. You're going from zero to a hundred and you're improving motor coordination. And in doing that, you're going to improve syllable production. You're going to improve final consonants.
You're going to improve blends. All of those things are going to be improved. Those coordination improves assimilation errors are going to be improved. So what are we going to do? We're going to take a sound like an S land. Are we going to say the word spoon? No, because then we have a fricative and a stop, and that's an obstrant with an obstrant.
They're two alike. That's not Cirque de Solei in the mouth. We want to take that s blend “s”. And we want to put it, like I said, with the w which is a [00:59:00] glide. So we're going abstract to a sonorant sound Cirque de Solei in the mouth, major coordination, difficulty maximally distinct, and like Lynn Williams would say that's when you take fireworks to the rack, you're challenging motor coordination.
So why would we take S L why is S L such a great blwns slide? Because you're taking an obstruent, which is the S sound, and you're combining it with a lateral liquid in which the air flows sonorous so obstruent, but the sonorant sounds so what is better SW or S L S. 'cause SL is more complex. So the higher up the mountain you go, the more sounds you're going to improve.
Yeah.
Amy Wonkka: But all of this you're overlaying on top of it, all the stuff you talked about at the beginning in terms of stimulus ability. Right? So if you have a [01:00:00] child who's not stimulus for the “l”, no matter what you do and how you structure your cues, you might go with SW.
Kelly Vess: Yes, exactly. That's exactly what I'd go for.
Yeah, exactly. So if they can't do SL like do SW do I do S T no, cause that's a fricative stop. Do I do S P S K? No, no, no, no, no. So I'm glad you brought up this extremely important, uh, point, which is mix your obstruents with the glides and th the, the glide even better would be that liquids L and R. But if you can't do that L and R.
Go right to the w and like you said, cause practice makes perfect practice also makes imperfect. We do not want to reward W's for LNR. I love it. I love it. That thank you for bringing up that really super important, uh, concept in the complexity [01:01:00] approach.
Amy Wonkka: This is fun. Thank you. I'm like getting my like grad school forgot all about sonorants and obstruents.
So this is lovely.
Kate Grandbois: And so this is all slightly above my head, but I'm, I'm learning a lot and I'm enjoying and appreciating a lot of this. And I wonder if in our last couple of minutes, there's anything else you'd like to tell us about selecting those treatment targets based on phonological processes.
Kelly Vess: Oh, well, first of all, I want to thank you so much for having me.
This has been a blast. I have drool coming down my mouth. We're talking about such an important topic that changes children's brains. It is awesome. So what we're going to leave with is when it comes to selecting treatment targets, it's like playing poker at the end of the day. It's just like playing poker.
And what is poker? Three of a kind beats two. So three element clusters such as SPL [01:02:00] is better than two element clusters, such as SL, higher cards, later developing sounds are better than earlier developing sounds. So the king beats the two, you don't want to work on the P you want to work on the R and said, because like I said, speech doesn't develop like a Geyser.
It always develops like a waterfall. And when I'm doing my own research, I find it doesn't even develop like a hose. If I'm working on something in speech, it's not laterally producing it produces downward. So I always want to go higher than what my goal is in speech always go higher than your goal because they always have the waterfall effect.
And then I think in the last area, I want to tell you about that we didn't really discuss, but T H sound, I found T H to be a dud, even though it's a late developing sound. T H R blends are really late. And T [01:03:00] H is really late because it's outside of the mouth. I find that it doesn't have the impact the S blends do.
So I know we didn't discuss that today, but put that in your pocket. T H R blends are outsiders. So if we're in Las Vegas, I always think they're the street musician. They're very talented, but they just don't have influence on others. They're outsiders. They're not the Celine Dion's or the Britney Spears.
Those are the s blends.
Kate Grandbois: It's such a great analogy. I was like, where's she going Las Vegas, but then that makes so much sense.
Kelly Vess: It's all poker. Okay. And you've got your Britney Spears and you have your street, musicians are equally talented. The thr is very complex, but it's an outsider. It has, I've done research on this.
It doesn't have the impact on the other sounds that nice waterfall effect that s blends do.
Kate Grandbois: [01:04:00]This was really, really interesting. And I appreciate, we both appreciate. All of your time. Thank you so much for joining us today. Amy, do you have any other final questions?
Amy Wonkka: No, I wanted to thank you so much. This was really, this was really fun and it, it just makes me think of needing to go up and just go back to my college texts and look up the place manner voicing chart and just refresh my memory about all the relationships with the sounds to one another.
Kelly Vess: Okay, well, thank you. Your podcast is awesome. Um, I just love it and I'm so happy to be here. Thank you.
Kate Grandbois: Well, no, thank you. Thank you. That was a very nice compliment that you just paid us and we're happy to have you for anyone who's listening. Thank you so much for joining us today. We hope you learned something.
All of the references and resources that we mentioned throughout the episode will be listed in the show notes, and they're also listed on our website. So if you're listening while you're running or jogging or folding your laundry, no need to worry about having not taken notes. We've got it, all that written [01:05:00] down for you, Kelly.
Thank you again so much for joining us today. Thank you so much. Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count for professional development in your area of study, please check in with your governing bodies or you can go to our website, www.SLPNerdcast.com.
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