Phonological Disorders

Speech-language pathologists (SLPs) are qualified to treat all types of speech sound disorders, but phonological disorders are among the most common. 

Unlike an articulation disorder, which involves difficulty with the physical movements required of speech production, a phonological disorder is closely tied to the linguistic underpinnings of words. 

Also known as a phonological processing disorder, this type of speech sound disorder is characterized by predictable, rule-based errors that deviate from the mistakes typical of early  speech development. 

Children may make the same types of errors on a variety of sound combinations. They may pronounce words by dropping the first sound or substituting a preferred sound in place of other sounds. 

These error patterns are called phonological processes—and it’s important that SLPs know how to identify them and treat them. 

What is phonological processing disorder? 

It’s easy to spot a phonological disorder once you understand what differentiates it from other speech sound disorders. 

A client with a phonological disorder struggles to form accurate representations of speech sounds and patterns in the brain. Instead, these linguistic patterns may be disorganized or mapped incorrectly. The result is that the wrong sounds are produced, even when a child can physically make them. 

Typically, this disorder  impacts more than one sound. 

Sometimes, patterns are consistent, involving the same errors across words. Other times, a client’s errors may be inconsistent, with multiple, inaccurate attempts of the same word—each one different from the last. 

By age five, children can typically produce most sounds (with the exception of some later-acquired ones like l, s, r, v, z, ch, sh, and th). 

As children learn to speak, they may make errors known as phonological processes. These processes simplify words by removing sounds or substituting harder sounds for easier ones. 

A child with a phonological disorder will use phonological processes that are not typical of developing speech—and they will continue to use them beyond the age when the target sound should have been acquired. 

Some speech error patterns that point toward a phonological disorder include: 

• Backing: Sounds made toward the front of the mouth are moved to the back. For example, a client may say “goo” instead of “do.” 
• Initial or medial consonant deletion: This is when clients leave out the first or middle consonant in a word. For example, saying “ee” for “Bee” or “spier” for “spider.”
• Sound preference substitution: Repeatedly substituting one sound for many others. For example, using /b/ in place of clusters, fricatives, and glides. 
• Atypical cluster reduction: Dropping a consonant sound that is typically maintained. For example, saying “loo” instead of “glue.”

Phonological delay vs disorder

There is often confusion around phonological delays and disorders—so what’s the difference? 

It all comes down to typical versus atypical phonological processes. 

When young children acquire speech sounds, there is a common progression from simple to increasingly complex phonemes.

A child with a phonological delay will follow the expected pattern of acquisition, but may have trouble producing some sound combinations after the expected age of acquisition. 

Children with phonological delays make sound pattern errors and substitutions that are common in early speech development. 

These are considered typical phonological processes, and they differ from the atypical phonological processes that characterize phonological disorders. 

Some typical phonological processes characteristic of a phonological delay include:

• Stopping: Substituting short, stop consonants like /t/ and /d/ for longer, continuous sounds like /s/ and /f/. For example, saying “dee” instead of “see.” 
• Fronting: Sounds made further back in the mouth are moved toward the front, as in “tat” for “cat.” 
• Cluster reduction: Dropping a more complex sound in a cluster of two to three phonemes at the start of a word. For example, saying “tar” instead of “star” or “bed” for “bread.”

Again, it’s important to remember that these typical phonological processes are a natural part of speech development. They represent a phonological delay when used beyond the age they would be expected to disappear (which varies from about 3 to 6 years of age, depending on the process). 

Speech sound disorders aren’t always clear-cut. Some clients may present with both a phonological delay and disorder. Listen closely for phonological patterns that are delayed and those that are disordered, or –atypical at any age. 

Keep in mind that other speech sound disorders, like articulation disorder and childhood apraxia of speech, can coexist alongside phonological processing disorders and delay, too. 

Every case is different, so SLPs should meet each client where they are and tailor treatment to meet their unique needs. 

Phonological disorder treatments

There are many schools of thought when it comes to speech therapy for phonological disorders. 

The good news? That means there are plenty of treatment approaches for SLPs to choose from. 

A comprehensive understanding of each approach makes it easier for therapists to select the best method for their individual clients’ circumstances. 

Before we dive into treatment approaches, it’s important to identify and select therapy targets. 

When a child presents with multiple speech sound substitutions and phonological processes, it can be tricky to decide what to focus on first. 

Target selection requires an evaluation of the following factors: 

• Complexity: First, target the most complex phonological patterns that are not part of the child’s repertoire. By targeting more challenging elements first, the therapeutic effects will ultimately trickle down to correct, or address, errors in simpler sound patterns. 
• Impact on intelligibility: Focus on the speech errors that have the greatest effect on a client’s ability to be understood by others. 
• Dynamic systems: Start with simple phonemes without adding new feature contrasts. This may ultimately support the acquisition of more complex phonemes and patterns. 

SLPs will also need to decide whether to focus treatment on one or two targets (known as a vertical target attack), or broaden therapy to encompass multiple targets that are practiced less intensively (known as horizontal strategy). 

Consider the big picture context of your client’s speech sound inventory and communication needs when deciding the targets and target attack strategies that fit best.

Similarly, landing on the right phonological disorder treatment approach demands a broad understanding of evidence-based practice and your client’s unique speech characteristics.

Phonological/language-based approaches are the gold standard for speech therapists who treat phonological disorders or delay. These therapeutic techniques support clients in generalizing phonological rules that can carry over to other sounds and patterns. 

Phonological contrast approaches 

These therapy techniques emphasize differences and similarities between phonemes. 

There are four possible approaches: 

• Multiple oppositions
• Minimal oppositions
• Maximal oppositions
• Treatment of the empty set 

Each one involves contrasting target phonemes against other sounds that differ based on one or multiple features. 

SLPs present pairs of words side-by-side to highlight differences in voice, place, and manner. This can help expand a child’s underlying phonological network and establish important contrasts between sounds and sound patterns. 

Cycles approach

For clients with highly unintelligible speech, the cycles approach works by focusing on select phonological patterns for a period of 5 to 16 weeks. 

SLPs target one or several phonological patterns for a cycle, then move on to the next set of treatment targets until they eventually land back on the original one. 

Each cycle focuses on supporting the acquisition, rather than mastery, of a phonological pattern. The idea is to mimic typical phonological development through therapy. 

Complexity approach 

Sometimes, focusing on the most challenging phonemes and sound patterns first yields the best results. 

The complexity approach involves targeting sounds and sound patterns based on their difficulty. For example, SLPs may address affricates before stops, and less stimulable sounds before highly stimulable ones. 

Treating more complex sounds can lead to carryover on related, and simpler targets, even when clients don’t receive direct intervention.  

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