case study speech sound disorder

Word-final complexity in speech sound intervention: two case studies

Affiliations.

• 1 School of Speech, Language and Hearing Sciences, San Diego State University, San Diego, California, USA.
• 2 Communication Sciences and Disorders, University of Iowa, Iowa City, Iowa, USA.
• 3 Department of Geography, San Diego State University, San Diego, California, USA.
• PMID: 36121007
• PMCID: PMC10024642 (available on 2024-06-03 )
• DOI: 10.1080/02699206.2022.2122082

In speech sound intervention, consonant clusters promote generalisation (i.e. improvement in untreated sounds and words), ostensibly due to their relative complexity compared to other phonological targets. However, our understanding of clusters as intervention targets is largely restricted to those in word-initial position (e.g. [fl-], flip ). The present study extends available work to consider the effects of word-final consonant cluster targets (e.g. [-ks]). Phonologically complex word-final clusters may be morphologically simple (e.g. mix ) or morphologically complex (e.g. packs , inflected with third-person singular) - yet this cross-domain complexity remains an understudied phenomenon. Presently, two case studies provide an initial investigation of word-final cluster intervention targets for children with phonologically based speech sound disorders. Intervention targets for both Anna (3;7 [years;months]) and David (4;1) featured the phonologically complex word-final cluster [-ks], with Anna's target being morphologically simple and David's being morphologically complex. Intervention was provided in 45-minute, individual sessions three times per week for a maximum of 18 sessions. Both children demonstrated high target accuracy by intervention's end. Following intervention, both children demonstrated progress in intelligibility and ability to produce word-final consonant clusters; David further demonstrated generalisation across multiple measures. Results are interpreted with consideration of individual differences and existing research on complexity in phonological intervention. Overall, present findings motivate continued research, as manipulation of word-final complexity allows for emphasis on a context that is relevant for children with speech sound disorders, for peers with difficulties in morphology (including word-final grammatical morphemes) and for the substantial proportion of children demonstrating weaknesses in both domains.

Keywords: Speech sound disorder; complexity; consonant cluster; intervention; phonological disorder.

Publication types

• Research Support, N.I.H., Extramural
• Research Support, Non-U.S. Gov't
• Speech Production Measurement
• Speech Sound Disorder* / therapy
• Speech Therapy / methods

Grants and funding

• F31 DC017697/DC/NIDCD NIH HHS/United States
• R21 DC017201/DC/NIDCD NIH HHS/United States

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The Developmental Approach to Articulation Therapy: A Case Study

Last week, we shared a review of articulation approaches . Now, we’re diving into a case study for the Traditional Approach.

A Case Study for the Traditional Approach

Casey, an eleven-year-old fifth-grade girl, had difficulty producing the “r” and “th” sounds (/r, ɚ, ɝ, ɪr, ɜr, ɑr, ɔr, θ, ð/). Results of a speech-language evaluation reveal a speech sound disorder characterized by sound substitutions (e.g., /ə/ for /ɚ/, /w/ for /r/, /s/ for /θ/, and /d/ for /ð/). When given verbal and visual cues, Casey is stimulable for these sounds; however she has more difficulty with vocalic /r/ than the others. Although her speech is reportedly about 90% intelligible to most listeners, Casey’s peers are starting to comment on her speech as “baby talk” Casey’s teacher says that she is a hard worker and performs average to above average in most subjects. The teacher has noticed that Casey is reluctant to participate in class and worries about her self-confidence as she approaches the sixth grade.

Sample Target Selection for the Traditional Approach

We’ll start with earlier developing sounds and move towards the sounds that are developed later.

1. Initial /r/ in isolation until benchmark level is met (e.g., 80% accuracy)

• Progress to trials in syllables, words, phrases, sentences.

• Continue trials at each level until benchmark is met (e.g., 80% accuracy over ___ consecutive sessions).

2. Voiced “th” in isolation until benchmark level is met (e.g., 80% accuracy)

3. Voiceless “th” in isolation until benchmark level is met (e.g., 80% accuracy)

Sample Goals for the Traditional Approach

Long-Term Goal (Example)

Casey will produce /r/ in 4-5 word sentences with 80% accuracy during structured language activities given verbal and/or visual cues by ____.

Short-Term Goal (Example)

Casey will produce /r/ in 2-3 word phrases with 80% accuracy during structured language activities given verbal and/or visual cues by ____.

Sample Strategies for the Traditional Approach

Provide verbal and visual cues (e.g., providing a mirror for feedback) as needed, explaining and demonstrating placement.

Sample Activities for the Traditional Approach

I love using the SLP Now Articulation Stickers! This blog post shows how you can use them to create perfectly tailored activities for your students.

Home Speech Home offers free targeted word lists for easy practice.

Mommy Speech Therapy also offers free worksheets !

Tags: Articulation , Therapy Plans

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Functional Speech and Voice Disorders: Case Series and Literature Review

David s. chung.

1 Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD

Chelsea Wettroth

Mark hallett, carine w. maurer.

2 Department of Neurology, Stony Brook University School of Medicine, Stony Brook, NY

Associated Data

A video accompanying this article is available in the supporting information here.

Functional disorders of speech and voice, subtypes of functional movement disorders, represent abnormalities in speech and voice that are thought to have an underlying psychological cause. These disorders exhibit several positive and negative features that distinguish them from organic disorders.

Methods and Results

We describe the clinical manifestations of functional disorders of speech and voice, and illustrate these features using six clinical cases.

Conclusions

Functional disorders of speech and voice may manifest in a variety of ways, including dysphonia, stuttering, or prosodic abnormalities. Given that these disorders have been understudied and may resemble organic disorders, diagnosis may be challenging. Appropriate treatment may be quite effective, highlighting the importance of prompt and accurate diagnosis.

Introduction

Functional (or psychogenic) disorders of speech and voice (FSVDs) are common among patients with functional movement disorders (FMDs), with prior studies reporting that between 16.5% and 53% of FMD patients exhibit a comorbid functional abnormality in speech or voice. 1 , 2 , 3 , 4 Like other functional neurologic disorders, FSVDs can be challenging to diagnose, as symptoms may resemble those of organic motor speech disorders (MSDs), and both disorders may coexist. Patients are often reluctant to accept the diagnosis, and many physicians hesitate to make a diagnosis of functional neurologic disorder out of fear of overlooking an underlying organic disorder. 5 FSVDs have often been underemphasized or ignored, and their incidence and prevalence have yet to be clearly established. 6 Early identification of these disturbances as functional is critical, as it can lead to appropriate behavioral management and avoid unnecessary additional testing. Here, we discuss the general characteristics of FSVDs and explore their clinical manifestations with clinical cases. Treatment strategies for these disorders have been discussed elsewhere. 7 , 8 , 9

Clinical Manifestation of FSVDs

FSVDs can exhibit several red flags that can help distinguish them from organic MSDs (Table ​ (Table1). 1 ). In contrast with MSDs, patients with FSVD often exhibit inconsistencies and considerable variability in their speech or phonation, 10 and their symptoms may alter considerably with distraction or suggestibility. Patients with FSVDs may also exhibit struggle behavior resulting in exaggerated facial movements, including marked facial grimacing, lip pursing, eye blinking or contraction of the periorbital, lower facial muscles or platysma during attempted speech. Patients complaining of weakness may paradoxically exhibit speech with a strained quality or exaggerated facial posturing that is inconsistent with their complaint of weakness. 6 Deficits in patients with FSVDs also have a greater potential for reversibility than those in MSD patients. While speech therapy rarely provides dramatic improvement for patients with MSDs, several studies have documented that a short course of speech therapy can be quite effective for a substantial portion of patients with FSVDs. 11 , 12 One study demonstrated that 77% of patients with acquired functional stuttering were able to achieve nearly normal, if not normal, speech within two therapy sessions. 13

Red Flags for Functional Speech and Voice Disorders

FSVDs can manifest in a variety of different ways (Table ​ (Table2). 2 ). A small number of studies have provided detailed phenomenological characterization of these patients (Table ​ (Table3). 3 ). Different phenomenologies present with varying frequencies across these studies; this variance is likely due (in part) to small sample sizes and the lack of a standardized classification system for FSVDs. These studies have demonstrated that FMD patients with a comorbid FSVD closely resemble those without FSVD in terms of sex, age of onset, and underlying psychiatric comorbidities (Table ​ (Table3 3 ).

Clinical Features and Characterization of Functional Speech and Voice Disorders

Overview of Studies Detailing Characterization of FSVDs

Abbreviations: F, female; FMD; functional movement disorders; FSVD, functional speech and voice disorders; M, male; N/A, not applicable.

Functional voice disorders present as non‐organic abnormalities affecting phonation. There are two main types of functional voice disorder: psychogenic voice disorder (PVD) and muscle tension voice disorder (MTVD). PVD manifests as a sudden onset of aphonia or dysphonia with a loss of voluntary control of the voice. Aphonia can present with a whisper, and dysphonia may feature breathy falsetto, hoarseness, or vocal production of two separate tones. 14 MTVD presents with the gradual onset of dysphonia, and is secondary to excessive tension in the para‐laryngeal musculature. 14 MTVD is often mistaken for spasmodic dysphonia; however, spasmodic dysphonia and MTVD differ in terms of task‐dependency, with spasmodic dysphonia more likely to show differential performance across different phonetic contexts. 15 MTVD has also been shown to more readily improve with speech therapy. The classification of MTVD as functional remains controversial. 16 , 17 As a result, the concepts of primary MTVD, dysphonia occurring in the absence of concurrent organic vocal cord pathology, and secondary MTVD, dysphonia in the presence of an underlying organic condition, have arisen. 16 Primary MTVD, although it may exhibit similar clinical manifestations to other organic voice disorders, lacks the pathology, such as structural changes to the vocal folds or cartilages, to sufficiently account for its symptomatology, 14 and is most consistent with a functional etiology.

Functional speech disorders present as non‐organic disorders affecting speech and articulation, including functional stuttering, functional prosody, and functional abnormalities in articulation.

Generally defined as involuntary dysfluency in speech, stuttering manifests as repetitions of syllables or words, speech blocks, or extended pauses between sounds, and can be organic or functional in nature. Functional stuttering (FS) may be differentiated by indifference towards abnormal speech, or presentation of an accent on the wrong syllable. Importantly, acquired organic stuttering often presents with dysarthria, aphasia, or apraxia of speech; the absence of these features is a red flag for a functional etiology. An individual with FS may exhibit variable moments of fluent speech interspersed among periods of significant stuttering, or vice versa. Stuttering on every sound, syllable, or word may also point to an excessive consistency that can suggest FS. Epidemiologically, FS is equally prevalent among males and females, contrasting with the 3:1 male: female ratio observed in patients with organic stuttering. 13 , 18 , 19 , 20

Disturbances in prosody, the rhythmic and intonational aspect of language, can suggest the presence of an FSVD. While organic neurologic disease can also cause prosodic disturbances, variability of prosody and the absence of dysarthria, aphasia, or speech apraxia are suggestive of a functional etiology. 21 , 22 Foreign accent syndrome (FAS) is a type of prosodic disturbance causing patients to speak in a non‐native accent; FAS can have either an organic etiology, often linked to dominant hemisphere vascular or traumatic lesions, or a functional one. 23 , 24 Patients with organic FAS exhibit a fixed speech deficit and cannot produce additional accents without considerable effort. In contrast, patients with functional FAS can exhibit variability of their accent, and are often able to imitate other accents with relative ease. They may also exhibit stereotyped behavioral mannerisms that would not be present in cases of organic FAS. 23 In addition to FAS, functional prosodic disturbances may manifest as infantile or childlike prosody, sometimes referred to as “babytalk”; this childlike prosody may be accompanied by infantile facial expressions and gestures. 6

While articulation distortions associated with organic causes can range in severity, functional articulation problems are usually not subtle. Functional distortions in articulation can be associated with inconsistent lingual, jaw, or facial weakness on tasks unrelated to speech. If hemiparesis is present, a wrong‐way tongue deviating away from the hemiparetic side is consistent with an underlying functional disorder, and can be suggestive of a functional articulation abnormality. 6 , 25

Here, we present six cases that illustrate different clinical manifestations of FSVDs.

This 29‐year‐old female with an eight‐year history of abnormal involuntary movements displayed highly variable speech abnormalities, including childlike prosody and intervals of slow, deliberate speech with long pauses prior to speech initiation. She manifested struggle behavior in the form of intermittent facial grimacing and functional lower face dystonia that profoundly impacted her speech. Speech findings were distractible, and worsened noticeably during explicit examination of speech (Video 1, Segment A).

Three years prior, this 59‐year‐old female presented with sudden onset of facial pain, involuntary tongue movements, and severely impaired speech. Several weeks later, she developed gait and balance difficulty and her speech deteriorated to the point where she was unable to talk for several months. At the time this video was taken, her gait had normalized, and her speech had significantly improved, although she continued to exhibit several characteristics of FSVD, including functional prosodic disturbance, with intermittent childlike speech prosody, resulting in part from forward pursing of the lips and forward positioning of the tongue. Her unusually high‐pitched voice also contributed to the childlike impression of her verbal output. In addition to childlike speech prosody, the patient also exhibited downward retraction of her lower face during speech, simulating a central facial droop (Video 1, Segment B).

This previously healthy 46‐year‐old male presented with sudden onset of involuntary facial spasms, and posturing of the trunk and extremities five weeks prior to presentation. His speech was characterized by frequent pauses and intermittent stuttering. The struggle behavior exhibited during his dysfluent speech, including distractible facial grimacing and excessive platysmal contraction is consistent with a diagnosis of FSVD (Video 1, Segment C).

This 38‐year‐old female acutely developed changes in her voice while speaking on the telephone with her boyfriend. Voice abnormalities were reported to be episodic, with occasional normal voice. Clinical examination showed dysphonic speech accompanied by distractible struggle behavior with facial grimacing and repeated pauses scattered throughout her spontaneous speech (Video 2, Segment A).

This 67‐year‐old female experienced the sudden onset of stuttering speech and aphonia. While her stuttering improved with Prozac and a brief course of speech therapy, she continued to exhibit whispering quality of her speech. Despite this inability to generate normal volume of voice during spontaneous speech, she is able to generate normal volume during an episode of abnormal involuntary movements (Video 2, Segment B).

This 57‐year‐old female reported paroxysms of abnormal speech lasting up to one month in duration; the patient and her family noted normal speech in between episodes. At the time of our encounter, the patient exhibited slow, deliberate speech with articulation and grammatical errors, and spoke with childlike prosody. When repeating simple sounds, she perseverated and exhibited inconsistent speech abnormalities (Video 2, Segment C).

We have described the general characteristics and common phenotypic manifestations of FSVDs, and illustrated these using clinical cases. FSVDs exhibit a broad spectrum of clinical manifestations, some of which resemble organic disease. Although strategies used to identify FSVDs have been established, diagnosis of FSVDs remains complicated, underscoring the need for further study. Moreover, while dysphonia, stuttering, and prosodic abnormalities are common among FSVDs, it is important to realize that any aspect of speech or phonation may be affected. There is a greater need for attention toward FSVDs to improve the reliability of diagnoses and guide patients to proper treatment.

Author Roles

1. Research Project: A. Conception, B. Organization, C. Execution; 2. Statistical Analysis: A. Design, B. Execution, C. Review and Critique; 3. Manuscript Preparation: A. Writing the First Draft, B. Review and Critique.

D.C.: 1B, 1C, 3A, 3B

C.W.: 1B, 3B

M.H.: 1A, 1B, 3B

C.W.M.: 1A, 1B, 1C, 3A, 3B

Disclosures

Ethical Compliance Statement : The authors confirm that the approval of an institutional review board was not required for this work. All persons gave their informed consent prior to their inclusion in the study. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines.

Funding Sources and Conflicts of Interest : This study was supported by the NINDS Intramural Research Program. The authors declare that there are no conflicts of interest relevant to this work.

Financial Disclosures for the previous 12 months : DC, CW, and CWM have nothing to disclose. Dr. Hallett serves as Chair of the Medical Advisory Board for and may receive honoraria and funding for travel from the Neurotoxin Institute. He may accrue revenue on US Patent #6,780,413 B2 (Issued: August 24, 2004): Immunotoxin (MAB‐Ricin) for the treatment of focal movement disorders, and US Patent #7,407,478 (Issued: August 5, 2008): Coil for Magnetic stimulation and methods for using the same (H‐coil); in relation to the latter, he has received license fee payments from the NIH (from Brainsway) for licensing of this patent. He is on the Editorial Board of approximately 20 journals, and received royalties and/or honoraria from publishing from Cambridge University Press, Oxford University Press, and Elsevier. Dr. Hallett's research at the NIH is largely supported by the NIH Intramural Program. Supplemental research funds have been granted by Merz for treatment studies of focal hand dystonia, Allergan for studies of methods to inject botulinum toxins, and Medtronic, Inc. for a study of DBS for dystonia.

Case Study: Speech Sound Disorder Impacting Mental Health

In the interest of safeguarding, this child has been referred to as ‘Sophie’ throughout the case study.

Background 

Sophie had faced challenges pronouncing certain words, so had encountered difficulties in effectively communicating with others, leading to frustration and a sense of isolation. These challenges not only hindered her social interactions but also took a toll on her overall mental wellbeing.

How did Chatterbug help?

Sophie was diagnosed with Speech Sound Disorder. Her journey towards improved communication and enhanced mental health began with the intervention of one of our dedicated speech and language therapists (SLT), Olivia. Through engaging and enjoyable therapy sessions conducted weekly over a period of time, Sophie received tailored support to address her speech sound disorder. The consistency and frequency of these sessions proved instrumental in facilitating significant progress within a concise timeframe.

During these therapy sessions, Sophie received targeted guidance and practice exercises aimed at improving her speech sounds and pronunciation. Olivia, employed a variety of techniques and strategies tailored to Sophie’s individual needs, ensuring a holistic approach to her speech therapy.

Sophie’s progress to date

Following the intervention provided by Chatterbug , Sophie demonstrated remarkable progress in various aspects of her communication skills. Her speech became clearer and more intelligible, with noticeable improvements in pronunciation and articulation. Moreover, Sophie’s newfound confidence in her ability to communicate effectively positively impacted her overall mental wellbeing.

As a result of her dedication and the support received from Chatterbug, Sophie has successfully overcome many of the challenges associated with her speech sound disorder. She has now completed her block of therapy sessions and has achieved significant generalisation of her improved speech sounds across different contexts.

Sophie’s journey serves as a testament to the transformative power of targeted speech therapy in addressing speech sound disorders and enhancing mental health outcomes.

Get in touch

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