Articulation Delays and Disorders
Articulation delays and disorders are one category of speech sound disorder. When a child has an articulation delay/disorder, they have difficulty positioning their articulators (tongue, lips, teeth, jaw) to make a specific sound or group of sounds. Types of articulation delays/disorders include:
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sibilant distortions (more commonly known as 'lisps')
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derhoticization (articulation difficulties with the 'r' sound)
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tongue protrusion (tongue protrudes between the teeth for sounds such as /t/ and /d/)
Assessment
During assessment, the SLP systematically samples and analyzes a child's speech to determine if their speech sound system is developing as expected. If there are sounds they haven't mastered yet, the SLP determines if the child's speech is:
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developmentally appropriate - their overall intelligibility and specific errors are as expected at their age,
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delayed - the rate of development is not as expected, but follows the typical pattern (e.g., their speech is like that of a younger child), or
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disordered - the child is exhibiting atypical errors which are not expected at any age.
Assessment will include:
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differential diagnosis - what type of speech sound delay/disorder does the child have (e.g., related to hearing impairment, articulation, phonological, motor speech)?
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identification of difficulties in other communication domains - does the child also have difficulties with language, voice, resonance, and/or fluency?
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stimulability testing - is the child responsive to cueing by the SLP?
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judgment of severity
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referral recommendations - does the child need to see another professional (e.g., audiologist) for further testing?
Treatment
When we help children with articulation delays and disorders learn to produce specific speech sounds, we teach them how to position and move their articulators (e.g., jaw, lips, tongue) and what the sound should sound like. We help them to identify when they are and are not producing the sound right so they can correct themselves. We also provide structured practice opportunities in which we systematically build their ability to produce the sound in increasingly difficult phonetic and linguistic contexts with decreasing levels of adult support. Over time, the child is able to spontaneously produce the sound automatically and effortless in everyday speech.
There are different models of treatment which are briefly described below. Which model is most appropriate will depend on:
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How severe your child's articulation delay/disorder is: This is based on many factors including how many sounds they require help with, how intelligible they are overall, their age, and the type of sound errors they make. For example, if your child has a severe articulation disorder, a home program will likely not be appropriate.
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How responsive they are to treatment / how persistent their errors are: Rate of progress is influenced by many factors within a client's control (e.g., how consistently they complete home practice) and outside of their control (e.g., severity of the articulation disorder, other demands on the child such as ADHD or anxiety). There are also other factors which are completely unpredictable - some children will just require more time to make progress regardless of all other factors.
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The parent's comfort with doing home practice: Home programming, for example, requires that the guardian doing the practice with the child be very confident in administering treatment protocols and advancing their child's goals between sessions because they will see the SLP less often.
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How consistent home practice is: Home practice is required to see progress regardless of how frequently your child sees their SLP. It becomes even more important, however, when you see the SLP less frequently (e.g., direct work with SLP only every 2 weeks; home programming).
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The family's resources and distance from clinic: In most cases, it is our preference to work directly with the child every one or two weeks in person. However, a family may desire home programming due to financial constraints or telepractice to avoid travel.
Treatment Models
Frequent direct sessions with SLP one-on-one:
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appropriate for all types and severities of articulation delays/disorders
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30- to 45-minute sessions with the SLP delivering treatment every one or two weeks
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daily home practice (5-10 minutes a day) must take place to ensure the child gets the minimum dosage
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treatment sessions take place at the Dartmouth or Kentville clinic
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if you would like your child's therapy session to take place during the school day but you are at work, ask your child's school if they would be eligible for transportation to and from the clinic through the Schools Plus program
Frequent direct sessions with the SLP in a small group:
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sometimes siblings can do work together with the SLP if they are of a similar age, have similar goals, and are able to work together productively
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sessions are typically 45 or 60 minutes to allow enough practice opportunities for each child
Telepractice:
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the initial assessment would still be in person
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appropriate for most types of articulation delays/disorders
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30- to 45-minute sessions with the SLP delivering treatment every one or two weeks plus daily home practice (5-10 minutes a day) must take place to ensure the child gets the minimum dosage
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appropriate for children who are able to sit relatively still in front of the computer - frequent significant movement blurs the image and impairs the SLP's ability to view the child's speech mechanism
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can be completed from home or school - when the child connects from school, this is usually facilitated by a staff member at their school's Learning Centre or Resource Room
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requires a stable internet connection and use of a headset (headphones AND microphone)
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requires use of an iPad or computer
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we use the Zoom Healthcare platform or Jane Telehealth platform, depending on the child
Home program:
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appropriate for mild or moderate articulation delays (pending assessment with the SLP)
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the child's guardian does treatment with them at home every day
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example: one 30-minute practice session once a week with 5-10 minutes of practice on all other days
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example: two 20-minute practice sessions a week plus 5-10 minutes of practice on other days
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45-minute sessions once every month or other month with the SLP in which the SLP:
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checks progress
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advances goals
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coaches parent in treatment techniques
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provides new treatment and practice materials
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home practice must be very consistent and the guardian must feel confident in their ability to apply their coaching from the SLP between sessions
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appointments with the SLP take place during the day Monday to Friday - they are not eligible for scheduling in the evening or on the weekend as these times are reserved for clients receiving regular weekly or biweekly treatment sessions who are in school during the day and/or their guardian works during the day
When a child has an articulation delay or disorder, the earlier treatment is started the better. This will prevent further practice of incorrect speech movements, build confidence in their community skills and ability to achieve their goals, and minimize potential social impact (e.g., how to respond to teasing).
When considering whether or not to pursue treatment, a child's guardians should consider the following:
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Children do not 'grow out of' articulation delays/disorders - they will need treatment to acquire these skills.
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Although the child's speech errors may not have a functional or social impact on their lives now, it may in the future when they are older. To quote an adult client who had an untreated articulation disorder and was having difficulty being understood by clients on the telephone, "My parents thought it was 'cute' when I was a kid. Well, I'm no longer a kid and it's no longer cute."
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Avoid calling the child's errors 'cute' - depending on the child's age, they may be very aware that they don't speak like their peers do and may be being teased. Referring to it as 'cute' may unintentionally minimize what the child is feeling about their speech. There are other ways of talking with a child about their speech that are more effective at building their confidence.
Sibilant Distortions (aka 'Lisps')
Sibilant distortions affect 'sibilant' sounds as in Sue, zoo, shoe, measure. They also affect other sounds as in choo and jump. They result from incorrect tongue and/or jaw placement that distorts the sound.
Sibilant distortions are commonly referred to as 'lisps' by the public. SLPs often avoid use of this older term, however, as it is associated with negative and inaccurate portrayals in the media.
The /s/ sound is produced by placing the tip of the tongue very close to the hard palate behind the upper front teeth. You can feel the location in your mouth - feel for the bumpy ridge of the hard palate behind your teeth. This is called the 'alveolar ridge'. At the same time, the sides of the tongue raise up and touch the hard palate and inner sides of the molars. This tongue position creates a narrow groove or channel along the middle of the tongue. Air then comes up from the lungs and passes through this narrow constriction. The air flow becomes turbulent, creating a 'hissing' quality.
Dental and Interdental Sibilant Distortions
Sometimes a sibilant distortion is a normal part of speech development. Children may produce a dental or interdental sibilant distortion (aka frontal lisp) while learning to say 's', 'z', and 'sh'. When a child continues to produce these kinds of distortions after age 4 1/2, however, it may be considered a speech sound delay.
With a dentalized distortion, the tongue tip is too far forward. Instead of being close to the alveolar ridge, it rests behind the upper front teeth.
With an interdentalized distortion, the tongue tip is even farther forward and is too low. It rests between the front teeth and the jaw is open a little too much (which allows the tongue to protrude through). This type of distortion may sound similar to 'th'.
Hear and see a frontal sibilant distortion produced by an SLP here.
Lateral and Palatal Sibilant Distortions
Other sibilant distortions are not part of normal speech development at any age. 'Lateral sibilant distortions' (bilateral and unilateral) and a 'palatal sibilant distortion' are considered speech sounds disorders and will not fade on their own.
With a lateral distortion, the tongue is incorrectly placed along its middle and sides. The jaw may also slide to one side. There are different types of lateral sibilant distortions. With a unilateral distortion, the tongue moves away from the centre and off to one side of the mouth. Air escapes along the side of the tongue, creating a 'slushy' quality.
Hear and see a lateral distortion produced by an SLP here.
Hear a unilateral distortion produced by a 4-year old child here:
With a palatal sibilant distortion, the tongue is too far back in the mouth. The mid-section raises up and touches the back of the hard palate or even the front of the soft palate. Air escapes around the sides of the tongue. This is the least common type of lisp.
Hear and see a palatal distortion produced by an SLP here.
Treatment
All types of sibilant distortions are treatable by a speech-language pathologist. Treatment should be started as early as possible to avoid continued practice with an incorrect movement pattern.
If your child is exhibiting a sibilant distortion and you would like to speak with one of our speech-language pathologists, contact us.
Typical Speech Sound Development
Click on the images below to view as a pdf.
Tongue Tie
Tongue tie ('ankloglossia') describes a condition present at birth in which the piece of tissue that runs from the floor of the mouth to the underside of the tongue ('lingual frenulum') is larger than usual. The lingual frenulum typically attaches to the underside of the tongue about halfway down its length. In the case of ankloglossia, this excess tissue means that the attachment extends too far forward, closer to the tongue tip. This can restrict the movement of the tongue (e.g., forward protrusion, elevation to the hard palate). Although there can be difficulties with breastfeeding and clearing food from the mouth, it typically does not affect speech except for in severe cases. Parents should speak with their doctor if they have questions about ankloglossia. A speech-language pathologist can evaluate implications for speech production.
Ankloglossia. Image from "Netter's Head and Neck Anatomy for Dentistry" p. 420.