Lexical Considerations in the Treatment of Speech Sound Disorders in Children The interaction between lexical and phonological development has been the focus of a growing body of research. Findings suggest that phonological ability influences word learning and that certain characteristics of words influence how words are produced by children. This article summarizes research findings regarding the effects of word frequency, phonological ... Article
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Article  |   June 14, 2016
Lexical Considerations in the Treatment of Speech Sound Disorders in Children
Author Affiliations & Notes
  • Anna Sosa
    Department of Communication Sciences and Disorders, Northern Arizona University, Flagstaff, AZ
  • Disclosures
    Disclosures ×
  • Financial: The author has no relevant financial interests to disclose.
    Financial: The author has no relevant financial interests to disclose.×
  • Nonfinancial: The author has no relevant nonfinancial interests to disclose.
    Nonfinancial: The author has no relevant nonfinancial interests to disclose.×
Article Information
Speech, Voice & Prosodic Disorders / Speech, Voice & Prosody / Part 2
Article   |   June 14, 2016
Lexical Considerations in the Treatment of Speech Sound Disorders in Children
Perspectives of the ASHA Special Interest Groups, June 2016, Vol. 1, 57-65. doi:10.1044/persp1.SIG1.57
History: Received October 15, 2015 , Revised December 19, 2015 , Accepted February 12, 2016
Perspectives of the ASHA Special Interest Groups, June 2016, Vol. 1, 57-65. doi:10.1044/persp1.SIG1.57
History: Received October 15, 2015; Revised December 19, 2015; Accepted February 12, 2016

The interaction between lexical and phonological development has been the focus of a growing body of research. Findings suggest that phonological ability influences word learning and that certain characteristics of words influence how words are produced by children. This article summarizes research findings regarding the effects of word frequency, phonological neighborhood density (PND), and phonotactic probability (PP) on phonological development, and describes how these factors have been manipulated to influence phonological learning in the treatment of speech sound disorder in children. Clinical applications and ideas for considering lexical factors in the selection of target words for treatment are provided.

In working with children diagnosed with speech sound disorder, a typical clinical goal would include a statement of the target behavior that is being practiced. The target behavior will generally specify the targeted sound (e.g., /s/), the position in the word where the sound occurs (e.g., in initial position), and detail about the linguistic context that is being used to practice the target sound (e.g., words in phrases). Thus, a familiar goal for a client working on speech sound production might read, “Child X will accurately produce /s/ in initial position of words in phrases.” The goal would then go on to specify the criterion level of performance and perhaps additional details about number of sessions or environment where the goal must be met. Noticeably absent from this goal is any indication of what the target words should actually be. Does it matter, for example, if initial /s/ is targeted in the word sun or sorry or if final /k/ is targeted in the word fishhook or bake? The fact that this is rarely specified in clinical goals raises at least two important questions. First, how do clinicians actually go about selecting which words they will use in treatment? And, second, does it matter?
By ignoring “the word” in treatment targeting speech sound production, we are, in essence, implying that it doesn't matter which words are used. While this sentiment may be consistent with the belief that articulation/phonology is somehow outside of, or separate from the actual language system, a belief that has prevailed in the history of our field (Hoff & Parra, 2011), it is not consistent with our current understanding of the important interactions that occur between sounds and words during language acquisition (Stoel-Gammon, 2011). In order to make the case that the answer to the second question above, “does it matter,” is yes, that consideration of the “the word” is an important component in planning treatment for children with speech sound disorder, we will start by summarizing what is currently known about the general relationship between lexical and phonological development. Next we will discuss how certain properties of words influence learning of sounds and sound patterns. Finally, we will consider how deliberate manipulation of the lexical characteristics of the words used may improve upon current practice and, potentially, improve clinical outcomes.
Lexical-Phonological Interactions in Language Development
The study of child language, and by extension clinical evaluation and treatment of language disorders, is often compartmentalized into discrete areas reflecting the different components of language. That is, in evaluating a child with suspected communication disorder, we may assess vocabulary, morphology, phonology, and syntax, among other things, but we often don't consider the relationships between these different areas. Recently, there has been increased emphasis on the important interactions that take place between these different language components. Specifically, there has been considerable attention paid to the relationship between lexical and phonological development in children. One finding from this line of research is that phonological and lexical development tend to be commensurate (Stoel-Gammon, 2011); children with larger vocabularies have more advanced phonological systems than children with smaller vocabularies (Paul & Jennings, 1992; Smith, McGregor, & Demille, 2006; Stoel-Gammon, 1991). Thus, children with small vocabularies for their age typically exhibit phonological ability that is similar to younger children with the same vocabulary size rather than same-aged peers with larger vocabularies. A number of studies have found that vocabulary size is a better predictor of phonological ability than chronological age (Macrae, 2013; Macrae & Sosa, 2015; Munson, Edwards, & Beckman, 2005; Sosa & Stoel-Gammon, 2012). Phonological ability in these studies was measured by a variety of different metrics, including consonant inventory (Paul & Jennings, 1992; Rescorla & Ratner, 1996), production variability (Macrae, 2013; Macrae & Sosa, 2015; Sosa & Stoel-Gammon, 2012), and nonword repetition accuracy (Hoff, Core, & Bridges, 2008; Munson et al., 2005). These findings are consistent with current theories of phonological development that propose that phonological knowledge emerges gradually as children extract regular patterns from similarities among words in their vocabulary (e.g., usage-based phonology; Bybee, 2003; Sosa & Bybee, 2008). A more thorough discussion of theories and models that predict a relationship between phonological and lexical development, however, is beyond the scope of this paper.
Evidence suggests that the relationship between lexical and phonological development is bidirectional (Stoel-Gammon, 2011). That is, phonological factors influence word learning (Schwartz & Leonard, 1982; Storkel, Maekawa, & Hoover, 2010) and lexical factors influence phonological learning (Ota, 2006; Ota & Green, 2013; Sosa & Stoel-Gammon, 2012). Furthermore, there is some indication that the predominant direction of influence may change throughout development. Stoel-Gammon (1998)  suggests that the influence of phonology on vocabulary learning may dominate in early stages of acquisition with the influence of lexical characteristics on phonological ability emerging later in development. The focus in the following sections will be on how lexical factors impact phonological development. More specifically, we will highlight what is known about how different lexical characteristics affect speech production and how these characteristics might be manipulated advantageously during treatment for children with speech sound disorder.
Lexical Factors that Influence Speech Production
A variety of lexical factors are known to influence how adults process language and we are beginning to understand how these same factors influence child speech perception and production. Specifically, word frequency and phonological neighborhood density (PND) are properties that have been found to influence speed and accuracy of both perception and production in adults (summary in Ellis, 2002). Word frequency refers to the frequency with which a given word occurs in a language and is often determined from analysis of written corpora. Phonological neighborhood density is a measure that emerges from the idea that words in an individual's lexicon are organized based on phonological similarities. Specifically, words that differ from one another by only one phoneme are considered phonological neighbors (Luce & Pisoni, 1998). For example, the words heat, hats, hot, mat, and half are all phonological neighbors of the word “hat.” Words with many neighbors are described as belonging to dense neighborhoods while words with few neighbors reside in sparse neighborhoods. Another property of sounds and words that is related to PND is phonotactic probability (PP). Phonotactic probability (PP) refers to the frequency with which individual sounds and sound sequences occur in a language (Jusczyk & Luce, 2002). Not surprisingly, PND and PP tend to be highly correlated; words with many neighbors are usually composed of sounds and sound sequences that occur frequently in the language. While PP is typically considered a phonological characteristic rather than a lexical characteristic because it describes properties of sounds and sound sequences rather than characteristics of the whole word, PP can be manipulated by careful selection of individual words. That is, one could choose words that have either high or low PP sound sequences (e.g., onset consonant clusters that occur either frequently or infrequently in the language) when selecting words for treatment.
In the following section, we will discuss what is known about the influence of each of these lexical characteristics on speech production in children with and without speech sound disorder. Next, we will provide a summary of existing research findings on how manipulation of these characteristics may impact treatment outcomes.
Lexical Effects in Phonological Development
Word Frequency
One of the earliest accounts of the role of word frequency in phonological development comes from Velten (1943)  who observed that the words his daughter used most frequently were the last to change when she acquired a new sound; the frequent words seemed to be resistant to change. Since that early observation, however, several studies have found that high word frequency sometimes facilitates accurate production of individual sounds and sound sequences. Leonard and Ritterman (1971), for example, found that 7-year-old children produced initial and final /s/ clusters more accurately in high vs. low frequency words. Tyler and Edwards (1993), in a longitudinal investigation of the acquisition of aspirated voiceless stops, found evidence to suggest that stable, correct production seemed to appear first in words that were produced more frequently by the children.
More recently, two studies by Ota (2006; Ota & Green, 2013) report facilitative effects of word frequency on the acquisition of different phonological structures. Specifically, Ota (2006)  found that at some age periods, Japanese speaking children between 1.5–2 years of age were less likely to exhibit syllable deletion in high frequency words vs. low frequency words. Similarly, Ota and Green (2013)  found that initial consonant clusters were produced more accurately by typically developing toddlers in words that were more frequent in the maternal input. Sosa and Stoel-Gammon (2012), in a study of spontaneous real word production by typically developing 2-year-olds, did not find a direct relationship between word frequency and whole-word accuracy. They did, however, find that high frequency words were produced more consistently upon repeated production than low frequency words, suggesting that word frequency does influence phonological learning. Taken together, the results of these studies provide evidence that word frequency is an important factor in phonological acquisition. In some cases, words that are produced by the child very frequently may be resistant to change; but in other cases, word frequency may facilitate the acquisition of certain sounds and sound patterns and may contribute to general stability of production. Likely, the influence of word frequency will depend on the stage of development as well as the nature of the phonological structure being acquired.
Phonological Neighborhood Density (PND) and Phonotactic Probability (PP)
Phonological Neighborhood Density (PND) and PP are distinct constructs that represent different properties of words and sounds; PND reflects the overall phonological similarity of a word to other words in the language while PP describes properties of a word at the level of the individual sound and sound sequence. In spite of these important differences, there is considerable overlap in these properties and many studies have not disentangled the relative influence of each in phonological learning. Therefore, we will integrate the summary of what is known about the effect of each factor on phonological production into one discussion.
In general, PND and PP seem to facilitate accurate production of sounds and words by young children; words that have more phonological neighbors and words that have more frequent sounds and sound sequences tend to be produced more accurately than words with few neighbors and words with less common sounds and sound sequences. This has been a remarkably consistent finding in the phonological development literature. Here, we will summarize some of those findings.
Leonard and Ritterman (1971), mentioned above, found that high frequency /s/ clusters (e.g., /sp/) were produced more accurately by the 7-year-olds in their study than low frequency /s/ clusters (e.g., /sf/). They concluded that high frequency clusters are more “available” for children to discriminate and produce, resulting in increased accuracy during production. This is consistent with results from a series of studies showing that phoneme frequency and phoneme sequence frequency impact the order of acquisition of sounds in a variety of different languages (Edwards, Beckman, & Munson, 2015). In general, acquisition of phonological structures is facilitated by frequency of occurrence of those structures.
Other studies have used nonword repetition tasks to investigate the role of PP and PND on production accuracy. Munson et al. (2005)  and Zamuner, Gerken, and Hammond (2004), for example, both found that nonwords with high probability sounds and sound sequences were produced more accurately than words with low probability sounds. The children in these studies ranged in age from 1.5–5 years of age and had both typical and disordered phonological development. While the variable they manipulated was PP, PND could not be ruled out as a potential source of the effect. Sosa and Stoel-Gammon (2012)  looked specifically at the impact of both PND and PP on whole word accuracy and variability during the production of real words by typically developing 2-year-olds. They found that PND was the primary factor influencing production at this age, with words from high density neighborhoods produced more accurately and less variably than words with fewer neighbors.
Manipulation of PND/PP and Word Frequency in Treatment
Given the abundant evidence that lexical characteristics such as word frequency and PND/PP play an important role in phonological development, it is reasonable to speculate that the same factors may influence the process of phonological learning as a result of intervention for children with speech sound disorder. Gierut and colleagues, in a number of studies, have tested exactly this hypothesis. They have looked at the impact of these lexical characteristics on treatment outcomes from two perspectives. First, they have investigated whether manipulation of the frequency of the words used in treatment has an effect on phonological learning (as measured by accuracy of target sounds or overall gains in the phonological system). Second, they have investigated whether words that are the recipients of change (i.e., the words in which the target sound is produced accurately after treatment) differ according to these lexical factors. In this discussion, we will focus on the first perspective: whether manipulation of word frequency and phonological neighborhood density influences phonological learning during treatment.
Results from these studies have been mixed, particularly in identifying a consistent effect of PND. Two studies have found a relative disadvantage associated with the use of words from high-density neighborhoods in treatment (Gierut, Morrisette, & Hust Champion, 1999; Morrisette & Gierut, 2002). In these studies, involving 20 children in total, targeting sounds in words from high-density neighborhoods failed to produce generalization to either treated or untreated sounds (Morrisette & Gierut, 2002). In a more recent study, however, Gierut and Morrisette (2012)  found a relative advantage for using words from high density neighborhoods in treatment; use of words with many neighbors induced greater phonological generalization than use of words from sparse neighborhoods. Gierut and Morrisette (2012)  attribute the discrepancy between this result and those of earlier studies to methodological differences. Specifically, they point out that there appears to be an interaction between word frequency and PND and that the design of the most recent study allowed for observation and interpretation of this interaction.
The observed effect of word frequency on phonological learning during treatment for speech sound disorder has been more consistent across studies. In general, teaching sounds in high frequency words leads to greater phonological learning than treating sounds in low frequency words (Gierut et al., 1999; Gierut & Morrisette, 2012; Morrisette & Gierut, 2002). As mentioned above, however, Gierut and Morrisette (2012)  identified an interaction between word frequency and PND such that the use of words that were simultaneously high frequency and from high density neighborhoods was the optimal condition for promoting phonological generalization in treatment.
One additional consideration in thinking about whether to use high vs. low frequency words in treatment is the use of real vs. nonwords to teach sound production. On a frequency continuum, nonwords represent the extreme low frequency end. That is, because they are not words, their frequency in the language is, by definition, zero. They differ in other important ways from real words as well. For instance, they lack semantic, lexical, and phonological representations in the speaker's mental lexicon. The use of nonwords in the treatment of speech sound disorder has long been an integral part of articulation/phonology treatment. Van Riper's traditional approach (Van Riper, 1939), for example, stipulates that treatment should begin with establishing accurate production in phonotactically legal nonsense syllables (Pena-Brooks & Hegde, 2007). A few studies have looked at the relative efficacy and efficiency of using real words vs. nonwords to promote phonological learning through treatment (Gierut, Morrisette, & Ziemer, 2010; Gierut & Morrisette, 2010). Both studies report results that suggest there may be a short-term (i.e., efficiency) advantage of using nonwords to practice targeted sounds during treatment. Target sounds treated in nonwords reached accuracy levels equal to or greater than the same sounds treated in real words (Gierut & Morrisette, 2010). The use of nonwords (vs. real words) to teach production of target sounds also resulted in greater generalization to both treated and untreated sounds immediately after treatment (Gierut et al., 2010). While these results provide evidence for the efficacy of using nonwords in treatment, additional research is needed to better understand under what circumstances the use of nonwords, as opposed to real words, would be advantageous.
Clinical Applications
The preceding discussion offers compelling evidence that word-specific factors such as word frequency, PND, PP, and lexicality (i.e., real word vs. nonword) do impact phonological learning both in typical development and in treatment-induced learning. Given this, it seems that careful consideration of which words to use to treat target sounds should be an integral part of treatment planning for children with speech sound disorder. It is evident that sounds do not develop in isolation; they are learned in conjunction with the words in which they occur (Ferguson & Farwell, 1975; Stoel-Gammon, 2011). It follows that this interaction in learning should be taken into account in treatment aimed at teaching children to accurately produce sounds that are produced in error.
We now return to the first question posed in the introduction to this article: how do clinicians actually go about selecting words to use in treatment? The answer to this question surely varies from individual to individual and from case to case. One possibility is that clinicians actually pay very little attention to the words used and may rely on published materials that provide lists or “decks” of words targeting specific sounds. Under these circumstances, the rationale for the inclusion of the words in the list is unknown. Alternatively, clinicians may consider a number of different factors in the selection of words to use with a particular child.
Consideration of phonetic environment or overall word complexity is a factor that is likely considered by many clinicians. For example, one might select words in which the target sound occurs in an environment that is considered easier for accurate production of the sound. This is often referred to as contextual facilitation of correct sound production (Kent, 1982) and has been discussed extensively in the literature, particularly in the earlier days of clinical research in speech-language pathology. Some contextual factors that have been considered include syllable stress, word or syllable position, and adjacent sounds (Kent, 1982). Kent (1982)  points out, however, that contextual facilitation is complex and that the judged adequacy of a production may be due as much to perceptual factors on the part of the listener as it is to improved articulation in certain contexts. He also notes that contextual facilitation is just one consideration and should not be the basis for management of all errors with all children.
Another factor that clinicians may consider in selection of treatment words is the functionality of a word. For example, for a child whose name is Lily but who cannot produce /l/, Lily may be selected for treatment in order to improve her functional communication (i.e., her ability to be understood when giving her name). Other examples include selecting a word for treatment that a child is particularly motivated to say. For example, a clinician may choose to use the word jet to target the voiced palatal affricate because the child particularly loves jets and talks about them regularly. Overall, however, lexical properties such as word frequency or PND/PP are probably rarely considered in word selection. The following section will provide examples of how consideration of these factors may be integrated into the treatment planning process for children with speech sound disorder.
From a developmental perspective, high word frequency, high phonological neighborhood density, and high phonotactic probability all facilitate accurate and stable production in young children. Treatment for speech sound disorder is often planned using a developmental approach; that is, earlier developing sounds in easier phonetic environments are targeted first. It follows then, that if treatment is implemented following a developmental sequence, starting by working on sounds or sound patterns in high frequency, high PND/PP words would be advantageous. This may be particularly important for children who exhibit considerable variability or token-to-token inconsistency in production. If the goal of intervention is to establish consistent production (e.g., Core Vocabulary Intervention; Dodd, Holm, Crosbie, & McIntosh, 2009), then selection of high frequency and high density words may facilitate production stability.
Beyond general developmental considerations, the evidence suggests that the use of high frequency words should be prioritized. In several studies, Gierut and colleagues have found that using high frequency words facilitates accurate production of the target sounds as well as generalization to untreated words and sounds. Additionally, high frequency words may be more resistant to change, so these words may need to be targeted directly in order for change to occur. Although the evidence regarding PND has been somewhat mixed, the most recent evidence suggests that the use of high density words should also be prioritized. More specifically, the use of words from high density neighborhoods that are also high frequency may represent the most advantageous condition.
Finally, available evidence suggests that the use of nonwords to target specific sounds and sound structures may be a viable option. While early approaches to the treatment of articulation and phonological disorders often included a stage in which nonwords were used to establish sound production, some clinicians may be reluctant to use nonwords in treatment. This reluctance likely stems from a trend in the field to emphasize treatment goals and procedures that target functional communication; that is, behaviors that may immediately expand the communicative skills of clients (Pena-Brooks & Hegde, 2007). Using nonwords may be seen as having little functional value because the child is not engaging in production practice of words that they will actually use in their everyday communication. The same may be true, however, of words taken from a word list or word deck that may be unusual words that the child doesn't say very often and may not even know. One hypothesized advantage of using nonwords to target individual sounds is that producing nonwords (as opposed to real words) reduces interference from other linguistic levels (e.g., semantic, lexical, etc.), allowing the child to direct more processing effort toward the physical production of the sound (Gierut et al., 2010). In this author's personal clinical experience, there have been times when a child is unable to produce a specific sound in a real word in spite of multiple levels of cuing and modeling, but when the sound is introduced in a nonsense word, the child is able to produce it accurately. In this case, it appears that putting the sound in a nonsense word allows the child to concentrate on the actual physical production of the sound without interference from their own semantic, lexical, or phonological representations. After production of the sound is established in nonwords, treatment would then progress to using real words, preferably high frequency words from dense phonological neighborhoods.
There are a variety of publicly accessible resources that can be used to establish the lexical characteristics of words. For example, the Washington University Speech Lab Neighborhood Database developed by Mitchell Sommers (Washington University, n.d.) provides word frequency and phonological neighborhood density values of words. It can also generate lists of words that are phonological neighbors, which may be useful in selecting sets of words that target similar phonological structures. Another resource is the on-line calculator developed by Holly Storkel at the University of Kansas (Storkel & Hoover, 2010). This calculator provides PND, PP, and word frequency information for words based on corpora of child speech. While there are no strict cutoffs for what is considered high or low frequency or high or low neighborhood density, these values can be compared for potential target words and determination of which words to use can be based on these values. For example, using the University Speech Lab Neighborhood Database, the frequency of the word light is 333 while the frequency of the word leaf is only 12. If the goal is to target high frequency words with initial /l/, then light would likely be included, while leaf may be excluded. Beyond the publicly available databases, general information about word frequency for an individual child could be obtained directly from parents via questionnaire or frequency rating scales for potential target words.
Conclusion
In this article, we have made the case that treatment planning for children with speech sound disorder should include a careful consideration of which words will be used to work on target sounds and sound patterns. Evidence shows that there are important interactions between sounds and words in development and that a variety of different lexical characteristics influence how sounds are produced by children. There is also evidence to suggest that selecting certain types of words (e.g., high frequency words) may facilitate learning during treatment for children with speech sound disorder. The word properties that were discussed include word status (i.e., real word vs. nonword), word frequency, phonological neighborhood density, and phonotactic probability. While additional research is needed to enhance our knowledge of how manipulation of these variables impacts treatment outcomes, it is our hope that this discussion will encourage clinicians to continue to think carefully about which words they choose for treatment and perhaps expand upon the set of factors and considerations they are currently using to make this decision.
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