4. Treatment as guidance
Discovery by the child
The natural focus in helping the child with a developmental disorder is to guide the process of discovery of whatever is for him or her the missing or not well-enough defined section of the pathway.
The child is given a sequence of nonsense words to repeat, each different enough from the last to avoid confusion, but similar enough to make the sequence logical. The degree of difference will of course, vary from child to child. But in a very significant way, children with any sort of difficulty in the formation of words and sentences tend to have a very marked difficulty in detecting any sort of relations between the sound patterns of words – between, say, hippopotamus and HEPPOPUTAMUS, both with the obvious stress contour, with primary stress on the third syllable and a secondary stress on the first syllable.
For a child with a difficulty, such a sequence might be anything from 30 to 100 items long. The clinical aim is to minimise any stress for the child by ensuring that as far as possible every item is said correctly. Obviously this means starting somewhere ‘below’ the point at which it is thought that the difficulty may be kicking in. Obviously, this requires some informed guess work.
Many children have a small difficulty saying cardigan, typically replacing the G by a D, in way that is easily understood. Interestingly, many children who say cardigan this way have no difficulty with crocodile, where the K sound in the middle and the D differ with respect to what is known as the ‘voicing’. That small difference seems to be critical, making crocodile easier to say. But now suppose the child says cardigan not with a D at the beginning of the last syllable but with a sound vaguely like an L and the final sound vaguely like the final sound in ring. Here the G is clearly influencing the sound at the which is itself influencing the sound at the beginning. Even though the syllable is unstressed, such a pronunciation can be hard or impossible to understand unless the hearer happens to know in advance or be able to guess what the word is supposed to be.
Taking the difficulty a long way down, It might be possible to pronounce the sequence K _ N _ K at the beginnings of the syllables, with stress on the second, with no final N at the end of the last – as something like KENOKER, follow that with KELARKY, make vaious similar substitutions and then try a variety of forms with the stress on the first syllable, and only then start adding a final N, as CORDERKIN, perhaps. Then after maybe 30 or 40 trials we might have a go at cardigan. Sometimes this is then completely correct – presumably for the first time. Sometimes this becomes correct only a few days or a week later – with no effort at a follow-up or home practise. Typically as soon as such a criterion has been achieved, it is maintained. Very occasionally the child is aware of the change, sometimes commenting something to the effect of “Gosh, I can say that now”.
Then the process is repeated with other words, all the while varying stress pattern and the sound structure in controlled steps.
It might seem that this promises only one, two or perhaps three newly correct pronunciations per clinical session. Not very satisfactory progress with a child of four, five or six whose speech is mostly incomprehensible, with thousands of mispronunciations needing to be corrected. But the progress goes beyond the work that is done in the clinic. By working around a constellation of what are known as ‘featural’ and ‘prosodic’ structures, the child explores for him or herself the freedoms which exist. The newly resulting skills are highly transferable. And the speech increases exponentially – faster than by working on the ‘processes’ like the exchange of features between the G and the N in that child’s pronunciation of cardigan.
Unbeknownst to me, Shulamith Chiat (1983) was looking at the relation between word stress and the replacement of T by K at the same that I was starting to develop the approach to treatment described here – what I call ‘Possible words treatment’. Brett, Chiat and Pilcher (1987) compare the realisation of common words and nonsense words with various stress patterns, concluding that the unfamiliarity of the unfamiliar words does not seem to bear on the pronunciation. Chiat (1987) identifies the key variable is the ‘foot’ in the first two syllables of accident and hospital.
This is quite different from the dogmatic approach by ReST, also using nonsense, polysyllabic forms, but with the focus on feedback and correction, rather than discovery by the child. (See Ballard, et al (2010), Murray et al (2012), Thomas et al (2014), claiming that the discovery and invention was made entirely within their department with no reference to any previous work.