speech impediment vs delay

Speech Delay or Speech Disorder?

What’s the difference between speech delay and a speech disorder.

Parents often ask, “Is my child a late bloomer with a speech delay or should I be concerned about a speech disorder?”

Before I answer that question, let’s take a step back and clarify some important terms.

Speech Disorder : when a child is unable to produce speech sounds correctly or fluently or has problems with his/her voice.

Language Disorder : when a child has trouble understanding others ( receptive language disorder ) or sharing thoughts, ideas and feelings completely ( expressive language disorder )

Language or Speech Delay : when a child’s speech and/or language is developing in the right sequence, but at a slower rate than norms.

Please note that kids develop at different rates and there is a developmental progression to speech development. A sound substitution at 2 years old may be developmentally appropriate but the same error at 4-5 years old would need remediation. We have put together some milestones and red flags for you to investigate. After reading this post, if you have any concerns talk to your pediatrician or a speech pathologist.

Click here for details on the Causes, Diagnosis, Signs / Symptoms, Treatment and Prognosis Speech, and Language Disorders .

Here is a nice article on American Speech and Hearing Association’s website called Late blooming or Language problem?

Language Milestones and Red Flags

Receptive Language Milestones

Receptive language.

• Understanding comes before expression
• It is important to assess other contributing factors such as attention span to distinguish between motivation, inability to follow direction, and / or lack of vocabulary/concept knowledge

• Should be consistently responding to name (by 9 months)
• Follows simple commands
• Understands simple questions
• Listens to simple stories, songs, and rhymes
• Points to pictures in a book when named
• Points to a few body parts when asked
• Understands 50-100  words
• Follows two step directions
• Follows directions containing adjectives , adverbs, and pronouns
• Can point to pictured actions
• Listens to and enjoys hearing stories for longer periods of time
• Understands 500-900 words
• Recognizes words even when the object is not present
• Hears you when you call from another room
• Understands more complex questions
• Follows three step directions
• Follows longer directions
• Follows classroom directions
• Attends to a short story and answers questions about it
• Hears and understands most of what is said at home and at school
• Begins to learn from listening
• Big / Little
• Together / Away
• Same / Different
• Empty / Full
• In front / In back
• Clean / Dirty
• Night / Day
• Comparatives
• Superlatives
• Time concepts
• Order concepts
• Whole / Half

Expressive Language

Expressive language milestones, how a child communicates (expresses himself).

• Semantics: vocabulary
• Phonology: speech sounds
• Morphology: grammar
• Syntax: sentence structure
• Pragmatics: social language
• First words are spoken around one year
• Vocabulary depends on what is most meaningful to the child
• Building a rich representation of new words is important
• By age two, should be using words more often than gestures
• Common objects, actions people
• Animal sounds
• Consistently imitates new words
• Common verbs, adjectives and pronouns
• Uses words to relate ideas and observations
• Uses words to deliver a message
• Retells stories
• Relates longer stories
• Present progressive – ing (Example crying)
• Regular plural – s (Socks)
• Negation (No + ____)
• Possessive- ‘s (Girl’s hat)
• Irregular Past Tense (Fell down)
• Uncontractible Copula (It is)
• Articles (the, a)
• Regular Past Tense (She jumped)
• 3rd Person Regular (Puppy chews it)
• 3rd Person Irregular (She does)
• Uncontractible Auxiliary (She was laughing)
• Contractible Copula (She’s ready)
• Contractible Auxiliary (We’re hiding)
• Future tense (We will go)
• Around two years old, vocabulary will be large enough to start combining words into short phrases
• action + agent (daddy kiss)
• action + object (push truck)
• agent + object (man hat)
• action + locative (in bath)
• entity + locative (doll bed)
• possessor + possession (mommy shoe)
• entity + attribute (water hot)
• Uses two and three word phrases
• Uses keywords and sentence starters such as “I want”
• My, me, mine, you (2 to 2,5)
• Your, she, he, your, we (2.5 to 3)
• Whats (blank) doing?
• Points to a described object
• Answers simple questions logically
• What’s that?
• What (blank) doing?
• Uses three and four word sentences
• Uses conjunctions (and)
• They, them, us, her, his (3 to 3.5)
• Its, our, him, myself, yourself, ours, their, theirs (3.5 to 4)
•  Who or Whose?
• Answers more complex questions logically
• Answers “if (blank) then
• Uses minimum of five to six words per sentence
• Asks questions with proper sentence structure
• Uses compound sentences combined by: and, but, so, because
• Uses grammatically correct sentences by age five
• Event relation sequences: when, while, after, before, might
• Increased variety of sentence types
• Herself, himself, itself, ourselves, yourselves, themselves
• Uses correct grammar when asking questions
• Asks about future and past
• Uses infinitive (Do you want to (blank)?
•  Uses can and may
• Follow simple directions
• Waves “bye”
• Repeats actions to make others laugh
• Engages in parallel play
• Pairs gestures with words
• Refers to self by name
• Exhibits verbal turn taking
• Protests by vocalizing “no”
• Engages in pretend play
• Says social words: hi, bye, please thank you
• Talks to self during play
• Practices intonation, imitating adults
• Makes eye contact during interactions
• Watches other children and briefly joins their play
• Begins to use language for fantasies, jokes, and teasing
• Makes conversational repairs when listener does not understand
• Engages in longer dialogues
• Participates in simple group activities
• Defends possessions
• Carries on conversation with self and toys
• Engages in simple make-believe activities
• Begins to control behavior verbally, not just physically
• Takes turns and plays cooperatively
• Relates personal experience through verbalization
• Begins dramatic play, acting out whole scenes
• Expresses ideas and feelings
• Maintains topic
• Conveys emotions
• Enjoys speaking
• Takes turns in conversation
• Uses direct requests with justification
• Uses words to invite others to play
• Uses language to resolve disputes with peers
• Has good control of elements of conversation
• Speaks of imaginary conditions (what if…)
• Understands simple rules of conversation
• Modifies speech to age of listener
• Asking Questions

Language Red Flags

• Does not use six to ten words consistently
• Does not follow simple directions
• Cannot point to body parts
• Does not respond to name (by 9 months)
• Has a vocabulary of less than 50 words
• Has a decreased interest in social interactions
• Is not combining words into phrases
• Does not imitate words or actions
• Does not use simple sentences
• Strangers have a difficult time understanding what they are saying
• Does not play with or talk to other children
• Does not ask or answer simple questions
• Is not able to tell simple stories
• Talks only about the here and now
• Puts words in the wrong order in a sentences
• Leaves out words or grammar structures in a sentence
• Does not follow multiple step directions
• Uses only short phrases to communicate
• Does not engage in reciprocal conversation
• Cannot answer questions
• Regression in skills
• Difficulty with transitions
• Repetitive behaviors
• No interest in communicating with others
• Lack of interest in toys/games
• Lack of eye contact

Speech Milestones and Red Flags

Speech Milestones

• Distortions – a phoneme that does not sound quite right. For example Go Shlow down for  Go Slow.
• Substitutions – when one sound is replaced with another sound. For example, Weady to go for Ready to go.

Note that some errors are developmentally appropriate depending on the child’s age, and thus do not indicate an articulation disorder. We use the Goldman-Fristoe to test articulation. It’s the method we use to determine if a child has a speech delay or a speech disorder.

• 25 – 50%
• 50 – 75%
• 75 – 90%
• 90 – 100%
• Tongue protrudes through the front teeth
• The /s/ and/or /z/ sounds like a “th”
• Developmentally appropriate until age 4 ½
• Tongue is in a position close to that of an /l/
• The air flows over the sides of the tongue
• Sounds “slushy”
• Not developmentally appropriate at any age
• Mastered around age 7
• Many children are able to work on this sound earlier
• Pre-vocalic: the /r/ starts the word (red, read, etc.)
• Vocalic /r/: -er, -ar, -or, -air, -ear, -ire
• Blends: /r/ plus another consonant

Speech Red Flags

Speech articulation red flags.

• Cannot produce vowels or the consonant sounds /p/, /b/, /m/, /w/ by age three
• Cannot produce /t/, /d/, /k/, /g/, /f/ by age four
• Inconsistent errors (“cup” could be: cup, pup, up, cuh)
• Is not understood by familiar listeners
• You feel like you are consonantly “translating” for your child
• Your child becomes frustrated when not understood

Concerned? Ask for help.

If you have concerns about a language or speech delay or concerned about language or speech disorder, don’t be afraid to ask for help. It has been proven time and time again that early intervention is key. Talk to your pediatrician first, but if you have real concerns contact a speech pathologist who has been specifically trained in diagnosing speech and language issues.

Don’t be overly worried.

But, do not be overly worried. In a study by Dale et. al.: ( Illusory Recovery: Are Recovered Children With Early Language Delay at Continuing Elevated Risk? ) up to 50% of children with language or speech delay will catch up by age 4. Children who “recover” from their language or speech delay by age four showed that they were not at a significantly higher risk of future language problems.

Speech Delay or Speech Disorder?

How Do I Know if My Child Has a Speech Disorder, or if it’s a Simple Language Delay?

So you think your child’s speech and language development may be coming in a little slow?  Those cute babbles have yet to turn into clear words, as she is about to enter pre-school. But, how do you know it’s a speech disorder, rather than a simple speech delay? And, if indeed it is a speech disorder, what does that mean? Will my child be able to communicate effectively, will she be able to read, participate in class and most importantly, gain self-confidence?  These are just some of the questions parents face as their child begins to learn speech patterns and language skills as a toddler.

Starting the research process of what to do if your child has a speech disorder can be overwhelming and frustrating. There are many ways to help you identify specific speech issues and provide you with tools and information on how and where to get help.

What is a speech disorder?

Speech disorders can affect the way a person creates sounds. These sounds help us to form words and are necessary for communication with other people. Speech disorders can affect both adults and children. While toddlers learn language skills at different rates, most follow a general timeline of development. If your child doesn’t seem to be meeting communication milestones, you will want to bring it up with your pediatrician. While it may be a simple speech delay, recognizing and treating the problem early is crucial for developing language and other cognitive skills in the long run. The general timetable for speech development is broad, and your child may run into small roadblocks along the way. The important thing to remember is if something seems wrong, trust your instincts. Nobody knows your child as well as you, so don’t be afraid to ask your doctor if you think your child’s speech and language skills are not developing normally.

Language Building Milestones

Here are the general speech and  language-building milestones to be aware of, up to the age of 2. Talk to your child’s doctor if your child exhibits any of the symptoms below:

By 12 months:

• Doesn’t say “mama” or “dada”
• Doesn’t use gestures such as waving, shaking her head, or pointing
• Doesn’t understand and respond to words such as “no” and “bye-bye”
• Isn’t pointing out things of interest such as a bird or airplane overhead
• Doesn’t say single words between 12 and 15 months

By 18 months:

• Doesn’t point to at least one body part when asked
• Isn’t somehow communicating to you when she needs help with something or pointing to what she wants
• Doesn’t say at least 6 words

Between 19 and 24 months:

• Doesn’t have a rapidly growing vocabulary (about one new word a week)

By 24 months:

• Doesn’t respond to simple directions
• Doesn’t pretend with her dolls or herself (like brushing her hair or feeding her doll)
• Can’t point to named pictures in a book
• Can’t join two words together
• Doesn’t know the function of common household objects (like a toothbrush or fork)

For Additional Information:

Books and Games to Promote Language and Speech Development

Recognizing Developmental Delays in Children – Web MD

Typical Speech and Language Development – ASHA, the American Speech-Language- Hearing Association

Symptoms and Characteristics of Speech Delay

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Overcoming Speech Impediment: Symptoms to Treatment

There are many causes and solutions for impaired speech

• Types and Symptoms
• Speech Therapy
• Building Confidence

Speech impediments are conditions that can cause a variety of symptoms, such as an inability to understand language or speak with a stable sense of tone, speed, or fluidity. There are many different types of speech impediments, and they can begin during childhood or develop during adulthood.

Common causes include physical trauma, neurological disorders, or anxiety. If you or your child is experiencing signs of a speech impediment, you need to know that these conditions can be diagnosed and treated with professional speech therapy.

This article will discuss what you can do if you are concerned about a speech impediment and what you can expect during your diagnostic process and therapy.

FG Trade / Getty Images

Types and Symptoms of Speech Impediment

People can have speech problems due to developmental conditions that begin to show symptoms during early childhood or as a result of conditions that may occur during adulthood. 

The main classifications of speech impairment are aphasia (difficulty understanding or producing the correct words or phrases) or dysarthria (difficulty enunciating words).

Often, speech problems can be part of neurological or neurodevelopmental disorders that also cause other symptoms, such as multiple sclerosis (MS) or autism spectrum disorder .

There are several different symptoms of speech impediments, and you may experience one or more.

Can Symptoms Worsen?

Most speech disorders cause persistent symptoms and can temporarily get worse when you are tired, anxious, or sick.

Symptoms of dysarthria can include:

• Slurred speech
• Slow speech
• Choppy speech
• Hesitant speech
• Inability to control the volume of your speech
• Shaking or tremulous speech pattern
• Inability to pronounce certain sounds

Symptoms of aphasia may involve:

• Speech apraxia (difficulty coordinating speech)
• Difficulty understanding the meaning of what other people are saying
• Inability to use the correct words
• Inability to repeat words or phases
• Speech that has an irregular rhythm

You can have one or more of these speech patterns as part of your speech impediment, and their combination and frequency will help determine the type and cause of your speech problem.

Causes of Speech Impediment

The conditions that cause speech impediments can include developmental problems that are present from birth, neurological diseases such as Parkinson’s disease , or sudden neurological events, such as a stroke .

Some people can also experience temporary speech impairment due to anxiety, intoxication, medication side effects, postictal state (the time immediately after a seizure), or a change of consciousness.

Speech Impairment in Children

Children can have speech disorders associated with neurodevelopmental problems, which can interfere with speech development. Some childhood neurological or neurodevelopmental disorders may cause a regression (backsliding) of speech skills.

Common causes of childhood speech impediments include:

• Autism spectrum disorder : A neurodevelopmental disorder that affects social and interactive development
• Cerebral palsy :  A congenital (from birth) disorder that affects learning and control of physical movement
• Hearing loss : Can affect the way children hear and imitate speech
• Rett syndrome : A genetic neurodevelopmental condition that causes regression of physical and social skills beginning during the early school-age years.
• Adrenoleukodystrophy : A genetic disorder that causes a decline in motor and cognitive skills beginning during early childhood
• Childhood metabolic disorders : A group of conditions that affects the way children break down nutrients, often resulting in toxic damage to organs
• Brain tumor : A growth that may damage areas of the brain, including those that control speech or language
• Encephalitis : Brain inflammation or infection that may affect the way regions in the brain function
• Hydrocephalus : Excess fluid within the skull, which may develop after brain surgery and can cause brain damage

Do Childhood Speech Disorders Persist?

Speech disorders during childhood can have persistent effects throughout life. Therapy can often help improve speech skills.

Speech Impairment in Adulthood

Adult speech disorders develop due to conditions that damage the speech areas of the brain.

Common causes of adult speech impairment include:

• Head trauma 
• Nerve injury
• Throat tumor
• Stroke 
• Parkinson’s disease 
• Essential tremor
• Brain tumor
• Brain infection

Additionally, people may develop changes in speech with advancing age, even without a specific neurological cause. This can happen due to presbyphonia , which is a change in the volume and control of speech due to declining hormone levels and reduced elasticity and movement of the vocal cords.

Do Speech Disorders Resolve on Their Own?

Children and adults who have persistent speech disorders are unlikely to experience spontaneous improvement without therapy and should seek professional attention.

Steps to Treating Speech Impediment 

If you or your child has a speech impediment, your healthcare providers will work to diagnose the type of speech impediment as well as the underlying condition that caused it. Defining the cause and type of speech impediment will help determine your prognosis and treatment plan.

Sometimes the cause is known before symptoms begin, as is the case with trauma or MS. Impaired speech may first be a symptom of a condition, such as a stroke that causes aphasia as the primary symptom.

The diagnosis will include a comprehensive medical history, physical examination, and a thorough evaluation of speech and language. Diagnostic testing is directed by the medical history and clinical evaluation.

Diagnostic testing may include:

• Brain imaging , such as brain computerized tomography (CT) or magnetic residence imaging (MRI), if there’s concern about a disease process in the brain
• Swallowing evaluation if there’s concern about dysfunction of the muscles in the throat
• Electromyography (EMG) and nerve conduction studies (aka nerve conduction velocity, or NCV) if there’s concern about nerve and muscle damage
• Blood tests, which can help in diagnosing inflammatory disorders or infections

Your diagnostic tests will help pinpoint the cause of your speech problem. Your treatment will include specific therapy to help improve your speech, as well as medication or other interventions to treat the underlying disorder.

For example, if you are diagnosed with MS, you would likely receive disease-modifying therapy to help prevent MS progression. And if you are diagnosed with a brain tumor, you may need surgery, chemotherapy, or radiation to treat the tumor.

Therapy to Address Speech Impediment

Therapy for speech impairment is interactive and directed by a specialist who is experienced in treating speech problems . Sometimes, children receive speech therapy as part of a specialized learning program at school.

The duration and frequency of your speech therapy program depend on the underlying cause of your impediment, your improvement, and approval from your health insurance.

If you or your child has a serious speech problem, you may qualify for speech therapy. Working with your therapist can help you build confidence, particularly as you begin to see improvement.

Exercises during speech therapy may include:

• Pronouncing individual sounds, such as la la la or da da da
• Practicing pronunciation of words that you have trouble pronouncing
• Adjusting the rate or volume of your speech
• Mouth exercises
• Practicing language skills by naming objects or repeating what the therapist is saying

These therapies are meant to help achieve more fluent and understandable speech as well as an increased comfort level with speech and language.

Building Confidence With Speech Problems 

Some types of speech impairment might not qualify for therapy. If you have speech difficulties due to anxiety or a social phobia or if you don’t have access to therapy, you might benefit from activities that can help you practice your speech. 

You might consider one or more of the following for you or your child:

• Joining a local theater group
• Volunteering in a school or community activity that involves interaction with the public
• Signing up for a class that requires a significant amount of class participation
• Joining a support group for people who have problems with speech

Activities that you do on your own to improve your confidence with speaking can be most beneficial when you are in a non-judgmental and safe space.

Many different types of speech problems can affect children and adults. Some of these are congenital (present from birth), while others are acquired due to health conditions, medication side effects, substances, or mood and anxiety disorders. Because there are so many different types of speech problems, seeking a medical diagnosis so you can get the right therapy for your specific disorder is crucial.

Centers for Disease Control and Prevention. Language and speech disorders in children .

Han C, Tang J, Tang B, et al. The effectiveness and safety of noninvasive brain stimulation technology combined with speech training on aphasia after stroke: a systematic review and meta-analysis . Medicine (Baltimore). 2024;103(2):e36880. doi:10.1097/MD.0000000000036880

National Institute on Deafness and Other Communication Disorders. Quick statistics about voice, speech, language .

Mackey J, McCulloch H, Scheiner G, et al. Speech pathologists' perspectives on the use of augmentative and alternative communication devices with people with acquired brain injury and reflections from lived experience . Brain Impair. 2023;24(2):168-184. doi:10.1017/BrImp.2023.9

Allison KM, Doherty KM. Relation of speech-language profile and communication modality to participation of children with cerebral palsy . Am J Speech Lang Pathol . 2024:1-11. doi:10.1044/2023_AJSLP-23-00267

Saccente-Kennedy B, Gillies F, Desjardins M, et al. A systematic review of speech-language pathology interventions for presbyphonia using the rehabilitation treatment specification system . J Voice. 2024:S0892-1997(23)00396-X. doi:10.1016/j.jvoice.2023.12.010

By Heidi Moawad, MD Dr. Moawad is a neurologist and expert in brain health. She regularly writes and edits health content for medical books and publications.

Language Delay vs Disorder: What Are Their Differences?

Understanding the difference between language delay vs disorder helps parents ensure that their children are reaching developmental milestones.

As untrained professionals, parents often worry that their children are dealing with language disorders with delayed language.

With that said, there’s a significant difference between the two, one of which requires more in-depth treatment than the other.

What Is a Language Delay?

What is a language disorder, difficulty understanding language, difficulty using gestures, challenges with expanding vocabulary, inability to understand children’s speech, using a speech-language pathologist, improving parent education, language delay vs disorder.

As its name suggests, a language delay simply means that a child develops language slower than others their age.

A language delay does not mean that a child has a specific issue with auditory comprehension or receiving language.

Instead, it’s an indicator that a child is developing slowly compared to milestones for their age.

As time goes on, you’ll begin to notice an improvement in language development and use in children with language delays.

Although they will learn slower, they will still acquire the fundamentals to form and understand speech over time.

If these fundamental skills do not develop, it’s time to consider that your child might have a language disorder.

Language disorders can be incredibly challenging for children and their families to live with because they can cause frustration.

Sometimes, these disorders manifest themselves as children not learning a language or having an impediment that prevents them from using language.

You’ll notice their language use is significantly disrupted, whether by atypical acquisition or speech impediments like slowed speech.

Working with a language disorder is something that requires the assistance of a trained professional.

Typically, parents seek counsel from their pediatrician, who can then refer them to a specialist, such as a speech-language pathologist.

Using professional techniques, children can begin to acquire the fundamentals for language development and use.

When Does a Language Delay Become a Disorder?

One of the most challenging parts of having children with language delay is determining whether it’s a disorder or not.

You’ll want to talk to your pediatrician if you begin to notice any significant signs of language delay.

This process can ensure that your child gets the help they need to alleviate the frustration from a lack of language acquisition.

In most cases, when children don’t develop any language skills or have difficulty acquiring basic language skills, a delay could become a disorder.

There are a few critical markers to consider to know if it’s time to seek professional help.

Also known as receptive language, children who can understand language will often be able to:

• Point to pictures when directed
• Respond when their name is called
• Follow basic instructions
• Identify clothing and body parts

If your child isn’t showing any signs of understanding the language used when spoken to, it could point to a language disorder.

The majority of children use non-verbal speech to communicate during their early months of life .

You’ll notice they use gestures to communicate their intents and needs before learning the words for items and actions.

Not only are gestures themselves important to watch for, but their context as well.

Children should be using gestures appropriately in social and functional situations.

For example, if a parent says, “ Wave bye-bye! ” waving would be appropriate.

If no gestures are used, it could signify that the child hasn’t acquired receptive language.

As children age, they begin to develop a broad vocabulary consisting of things in their immediate environment.

For example, children with pets will often learn “Dog” or “Cat” before others.

They will also differentiate between “Dad” and “Mom” and even identify themselves.

With a regular regimen of learning new vocabulary, children should be learning several new words per week, even on their own.

If this isn’t the case, a language disorder could be a concern for parents to consider.

Communication frustration is one of the most common issues encountered with a language disorder.

Children who cannot express their wants and needs via gestures or verbal communication often find themselves frustrated.

They should convey messages and tell stories in a relatively clear manner to which the listener can understand them.

It’s essential to pay close attention to how your child communicates with you as well as others.

If they show difficulty playing with other children with no communication, it could be time to seek help.

How Are Language Disorders Treated?

There are numerous ways that language disorders can be treated, and they usually take a multi-step approach.

Treatment can occur in clinical settings, but children will also require reinforcement at home , school, and the neighborhood.

By implementing speech therapy across all environments, their learning potential can drastically improve.

Let’s take a look at some of the most common treatment options used by professionals to alleviate language disorders.

The most common method for dealing with language disorders is with the help of a speech-language pathologist (SLP).

SLPs are highly trained professionals who know age-appropriate ways for assisting children to acquire language and use communication.

By combining education with play, children will work in a comfortable environment to improve their language acquisition and use.

Speech-language pathologists often encourage language use through questions and answers and provide engaging activities for children.

It’s also common for them to use toys, objects, and pictures for language development.

As mentioned, language development is a team effort, especially when it comes to raising a child.

You must have a good understanding of your child’s potential difficulties to assist with their development.

Three fantastic resources you should consider purchasing to begin your family’s language learning journey are:

1. Language Disorders from Infancy through Adolescence: Listening, Speaking, Reading, Writing, and Communicating – Rhea Paul, Courtenay Norbury, Carolyn Gosse

The Language Disorders from Infancy Through Adolescence covers language development and disorders across your child’s entire developmental period.

Parents can learn how to accurately assess language disorders as well as the top-recommended treatments for each.

This text looks at critical issues, communicative difficulties, and the basic concepts of vocabulary building using a developmental approach.

2. Children’s Speech: An Evidence-Based Approach to Assessment and Intervention – Sharynne McLeod and Elise Baker

As another fabulous resource, the Children’s Speech: An Evidence-Based Approach to Assessment and Intervention is a great starting point for parents to gather a comprehensive understanding of speech sound disorders.

Written by student clinicians, you’ll have a complete overview of SSDs, an excellent reference for learning parents.

With that said, it takes a more scientific approach to study speech sound disorders with photographs, electro-palatograms, and more.

3. Introduction to Children with Language Disorders – Vicki A. Reed

Do you need a guide to assist you with better understanding different speech disorders and their treatments?

Reed’s Introduction to Children with Language Disorders is a good read.

It reviews the most common speech disorders that SLPs encounter in their career.

It also provides in-depth reviews of assessment and intervention for conditions to help you better understand what your child is dealing with.

Understanding how language delay vs disorder differ is something that requires a lot of time and patience.

As a family, using the help of a speech-language pathologist is a phenomenal way to assist your child with overcoming these issues.

Also, by reviewing top-recommended guides, you can better understand the challenges that need to be addressed for proper language acquisition and use.

What’s the Difference Between Speech Disorders and Language-Based Learning Disabilities?

By Ellen Koslo, AuD

Question: What’s the difference between a speech disorder or impairment and a language-based learning disability?

A speech disorder or impairment usually means a child has difficulty producing certain sounds. This makes it difficult for people to understand what he says. Talking involves precise movements of the tongue, lips, jaw and vocal tract. There are a few different kinds of speech impairments:

Articulation disorder is difficulty producing sounds correctly. A child with this type of speech impairment may substitute one speech sound for another, such as saying wabbit instead of rabbit .

Voice disorder is difficulty controlling the volume, pitch and quality of the voice. A child with this type of speech impairment may sound hoarse or breathy or lose his voice.

Fluency disorder is disruption in the flow of speech, often by repeating, prolonging or avoiding certain sounds or words. A child with this type of speech impairment may hesitate or stutter or have blocks of silence when speaking.

Language-based learning disabilities (LBLD) are very different from speech impairments. LBLD refers to a whole spectrum of difficulties associated with young children’s understanding and use of spoken and written language.

LBLD can affect a wide variety of communication and academic skills. These include listening, speaking, reading, writing and doing math calculations. Some children with LBLD can’t learn the alphabet in the correct order or can’t “sound out” a spelling word. They may be able to read through a story but can’t tell you what it was about. Children with LBLD find it hard to express ideas well even though most kids with this diagnosis have average to superior intelligence.

One place where parents are likely to encounter the term LBLD is in their child’s IEP . But school professionals may refer instead to “ dyslexia ” or “ dysgraphia .” These are more specific and easier to describe to parents.

Unlike speech impairments, LBLD are caused by a difference in brain structure. This difference is present at birth and is often hereditary. LBLD can affect some children more severely than others. For example, one student may have difficulty sounding out words for reading or spelling, but no difficulty with oral expression or listening comprehension . Another child may struggle in all of those areas.

LBLD isn’t usually identified until a child reaches school age. Typically it takes a team of professionals—a speech-language pathologist (SLP), psychologist, and a special educator—to find the proper diagnosis for children with LBLD. The team evaluates speaking, listening, reading and written language.

Learning problems should be addressed as early as possible. If left untreated, they can lead to a decrease in confidence, lack of motivation and sometimes even depression. Seeking treatment for your child can help significantly. Most kids with LBLD can succeed with the right services and supports.

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Language Delays and Disorders

A language delay occurs when a child’s language skills are acquired in a typical sequence, but lag behind peers their own age. A language disorder is characterized by atypical language acquisition significantly disrupting communication across settings. If a child’s development of speech and language appears slower than normal, an appointment with a pediatrician is recommended in order to to ask about the child’s communication development and to learn whether a referral to a speech language pathologist is appropriate. For children with possible concerns with language the following questions are important to consider:

Does the child understand language? The ability to understand language, also referred to as receptive language, usually precedes expression and use. Skills can include following simple directions, responding to their name when called, pointing to pictures when named, and identifying body parts and clothing items.

How does the child use gestures? All children initially use gestures but generally outgrow them as they develop language.  Children may use gestures instead of words to communicate their intents. Take note of the different gestures a child uses and how they are used in functional and social situations. Gestures may include pointing to request, pointing to “show” others, waving hello and goodbye or giving a “high five.”

How many new words is the child adding to his vocabulary each month? Even though he or she may appear to be slow in language development, new words should still be added frequently at least several words a week and even when not directly taught.

Can you understand what your child says? Even very young children should be able to convey a message, tell a story and describe events or pictures.  Children should not experience extended communication frustration.

Does your child have difficulty in daycare/school? Some academic and/or behavioral issues may be related to language difficulties.

How does the child use non-verbal communication and socialize with others? Make note of social games that your child plays, as well as their interest in other children and adults. It is important make note of use of eye contact and overall social interest with other children and adults. Children with delayed or disordered language abilities have interest in play with other children, but may struggle to do so due to language deficits.

Remember, no two children are alike. Concerned parents should seek the counsel of a certified speech-language pathologist who can conduct an evaluation to assess any delays in communication and make recommendations for intervention. Children under three years of age can receive an evaluation through the Early Intervention program through the state of Illinois. For children over three years of age, evaluations can be conducted through the public school and/or in our center.

The Northwestern University Center for Audiology, Speech, Language, and Learning provides comprehensive evaluation and therapy services on the Evanston campus. Diagnostic evaluations determine the course of treatment, including frequency and appropriateness of individual and/or group therapy.

The Northwestern University Center for Audiology, Speech, Language, and Learning is a unique community resource that merges university research and innovative teaching with clinical services. Experts in the field – faculty who are nationally certified and state licensed speech-language pathologists – direct provision of clinical services, bringing exceptional knowledge and experience to our clients.

For more information, contact us at 847-491-3165 or [email protected] .

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Types of Speech Impediments

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Articulation Errors

Ankyloglossia, treating speech disorders.

A speech impediment, also known as a speech disorder , is a condition that can affect a person’s ability to form sounds and words, making their speech difficult to understand.

Speech disorders generally become evident in early childhood, as children start speaking and learning language. While many children initially have trouble with certain sounds and words, most are able to speak easily by the time they are five years old. However, some speech disorders persist. Approximately 5% of children aged three to 17 in the United States experience speech disorders.

There are many different types of speech impediments, including:

• Articulation errors

This article explores the causes, symptoms, and treatment of the different types of speech disorders.

Speech impediments that break the flow of speech are known as disfluencies. Stuttering is the most common form of disfluency, however there are other types as well.

Symptoms and Characteristics of Disfluencies

These are some of the characteristics of disfluencies:

• Repeating certain phrases, words, or sounds after the age of 4 (For example: “O…orange,” “I like…like orange juice,” “I want…I want orange juice”)
• Adding in extra sounds or words into sentences (For example: “We…uh…went to buy…um…orange juice”)
• Elongating words (For example: Saying “orange joooose” instead of "orange juice")
• Replacing words (For example: “What…Where is the orange juice?”)
• Hesitating while speaking (For example: A long pause while thinking)
• Pausing mid-speech (For example: Stopping abruptly mid-speech, due to lack of airflow, causing no sounds to come out, leading to a tense pause)

In addition, someone with disfluencies may also experience the following symptoms while speaking:

• Vocal tension and strain
• Head jerking
• Eye blinking
• Lip trembling

Causes of Disfluencies

People with disfluencies tend to have neurological differences in areas of the brain that control language processing and coordinate speech, which may be caused by:

• Genetic factors
• Trauma or infection to the brain
• Environmental stressors that cause anxiety or emotional distress
• Neurodevelopmental conditions like attention-deficit hyperactivity disorder (ADHD)

Articulation disorders occur when a person has trouble placing their tongue in the correct position to form certain speech sounds. Lisping is the most common type of articulation disorder.

Symptoms and Characteristics of Articulation Errors

These are some of the characteristics of articulation disorders:

• Substituting one sound for another . People typically have trouble with ‘r’ and ‘l’ sounds. (For example: Being unable to say “rabbit” and saying “wabbit” instead)
• Lisping , which refers specifically to difficulty with ‘s’ and ‘z’ sounds. (For example: Saying “thugar” instead of “sugar” or producing a whistling sound while trying to pronounce these letters)
• Omitting sounds (For example: Saying “coo” instead of “school”)
• Adding sounds (For example: Saying “pinanio” instead of “piano”)
• Making other speech errors that can make it difficult to decipher what the person is saying. For instance, only family members may be able to understand what they’re trying to say.

Causes of Articulation Errors

Articulation errors may be caused by:

• Genetic factors, as it can run in families
• Hearing loss , as mishearing sounds can affect the person’s ability to reproduce the sound
• Changes in the bones or muscles that are needed for speech, including a cleft palate (a hole in the roof of the mouth) and tooth problems
• Damage to the nerves or parts of the brain that coordinate speech, caused by conditions such as cerebral palsy , for instance

Ankyloglossia, also known as tongue-tie, is a condition where the person’s tongue is attached to the bottom of their mouth. This can restrict the tongue’s movement and make it hard for the person to move their tongue.

Symptoms and Characteristics of Ankyloglossia

Ankyloglossia is characterized by difficulty pronouncing ‘d,’ ‘n,’ ‘s,’ ‘t,’ ‘th,’ and ‘z’ sounds that require the person’s tongue to touch the roof of their mouth or their upper teeth, as their tongue may not be able to reach there.

Apart from speech impediments, people with ankyloglossia may also experience other symptoms as a result of their tongue-tie. These symptoms include:

• Difficulty breastfeeding in newborns
• Trouble swallowing
• Limited ability to move the tongue from side to side or stick it out
• Difficulty with activities like playing wind instruments, licking ice cream, or kissing
• Mouth breathing

Causes of Ankyloglossia

Ankyloglossia is a congenital condition, which means it is present from birth. A tissue known as the lingual frenulum attaches the tongue to the base of the mouth. People with ankyloglossia have a shorter lingual frenulum, or it is attached further along their tongue than most people’s.

Dysarthria is a condition where people slur their words because they cannot control the muscles that are required for speech, due to brain, nerve, or organ damage.

Symptoms and Characteristics of Dysarthria

Dysarthria is characterized by:

• Slurred, choppy, or robotic speech
• Rapid, slow, or soft speech
• Breathy, hoarse, or nasal voice

Additionally, someone with dysarthria may also have other symptoms such as difficulty swallowing and inability to move their tongue, lips, or jaw easily.

Causes of Dysarthria

Dysarthria is caused by paralysis or weakness of the speech muscles. The causes of the weakness can vary depending on the type of dysarthria the person has:

• Central dysarthria is caused by brain damage. It may be the result of neuromuscular diseases, such as cerebral palsy, Huntington’s disease, multiple sclerosis, muscular dystrophy, Huntington’s disease, Parkinson’s disease, or Lou Gehrig’s disease. Central dysarthria may also be caused by injuries or illnesses that damage the brain, such as dementia, stroke, brain tumor, or traumatic brain injury .
• Peripheral dysarthria is caused by damage to the organs involved in speech. It may be caused by congenital structural problems, trauma to the mouth or face, or surgery to the tongue, mouth, head, neck, or voice box.

Apraxia, also known as dyspraxia, verbal apraxia, or apraxia of speech, is a neurological condition that can cause a person to have trouble moving the muscles they need to create sounds or words. The person’s brain knows what they want to say, but is unable to plan and sequence the words accordingly.

Symptoms and Characteristics of Apraxia

These are some of the characteristics of apraxia:

• Distorting sounds: The person may have trouble pronouncing certain sounds, particularly vowels, because they may be unable to move their tongue or jaw in the manner required to produce the right sound. Longer or more complex words may be especially harder to manage.
• Being inconsistent in their speech: For instance, the person may be able to pronounce a word correctly once, but may not be able to repeat it. Or, they may pronounce it correctly today and differently on another day.
• Grasping for words: The person may appear to be searching for the right word or sound, or attempt the pronunciation several times before getting it right.
• Making errors with the rhythm or tone of speech: The person may struggle with using tone and inflection to communicate meaning. For instance, they may not stress any of the words in a sentence, have trouble going from one syllable in a word to another, or pause at an inappropriate part of a sentence.

Causes of Apraxia

Apraxia occurs when nerve pathways in the brain are interrupted, which can make it difficult for the brain to send messages to the organs involved in speaking. The causes of these neurological disturbances can vary depending on the type of apraxia the person has:

• Childhood apraxia of speech (CAS): This condition is present from birth and is often hereditary. A person may be more likely to have it if a biological relative has a learning disability or communication disorder.
• Acquired apraxia of speech (AOS): This condition can occur in adults, due to brain damage as a result of a tumor, head injury , stroke, or other illness that affects the parts of the brain involved in speech.

If you have a speech impediment, or suspect your child might have one, it can be helpful to visit your healthcare provider. Your primary care physician can refer you to a speech-language pathologist, who can evaluate speech, diagnose speech disorders, and recommend treatment options.

The diagnostic process may involve a physical examination as well as psychological, neurological, or hearing tests, in order to confirm the diagnosis and rule out other causes.

Treatment for speech disorders often involves speech therapy, which can help you learn how to move your muscles and position your tongue correctly in order to create specific sounds. It can be quite effective in improving your speech.

Children often grow out of milder speech disorders; however, special education and speech therapy can help with more serious ones.

For ankyloglossia, or tongue-tie, a minor surgery known as a frenectomy can help detach the tongue from the bottom of the mouth.

A Word From Verywell

A speech impediment can make it difficult to pronounce certain sounds, speak clearly, or communicate fluently. 

Living with a speech disorder can be frustrating because people may cut you off while you’re speaking, try to finish your sentences, or treat you differently. It can be helpful to talk to your healthcare providers about how to cope with these situations.

You may also benefit from joining a support group, where you can connect with others living with speech disorders.

National Library of Medicine. Speech disorders . Medline Plus.

Centers for Disease Control and Prevention. Language and speech disorders .

Cincinnati Children's Hospital. Stuttering .

National Institute on Deafness and Other Communication Disorders. Quick statistics about voice, speech, and language .

Cleveland Clinic. Speech impediment .

Lee H, Sim H, Lee E, Choi D. Disfluency characteristics of children with attention-deficit/hyperactivity disorder symptoms . J Commun Disord . 2017;65:54-64. doi:10.1016/j.jcomdis.2016.12.001

Nemours Foundation. Speech problems .

Penn Medicine. Speech and language disorders .

Cleveland Clinic. Tongue-tie .

University of Rochester Medical Center. Ankyloglossia .

Cleveland Clinic. Dysarthria .

National Institute on Deafness and Other Communication Disorders. Apraxia of speech .

Cleveland Clinic. Childhood apraxia of speech .

Stanford Children’s Hospital. Speech sound disorders in children .

Abbastabar H, Alizadeh A, Darparesh M, Mohseni S, Roozbeh N. Spatial distribution and the prevalence of speech disorders in the provinces of Iran . J Med Life . 2015;8(Spec Iss 2):99-104.

By Sanjana Gupta Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

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• Childhood apraxia of speech

Childhood apraxia of speech (CAS) is a rare speech disorder. Children with this disorder have trouble controlling their lips, jaws and tongues when speaking.

In CAS , the brain has trouble planning for speech movement. The brain isn't able to properly direct the movements needed for speech. The speech muscles aren't weak, but the muscles don't form words the right way.

To speak correctly, the brain has to make plans that tell the speech muscles how to move the lips, jaw and tongue. The movements usually result in accurate sounds and words spoken at the proper speed and rhythm. CAS affects this process.

CAS is often treated with speech therapy. During speech therapy, a speech-language pathologist teaches the child to practice the correct way to say words, syllables and phrases.

Children with childhood apraxia of speech (CAS) may have a variety of speech symptoms. Symptoms vary depending on a child's age and the severity of the speech problems.

CAS can result in:

• Babbling less or making fewer vocal sounds than is typical between the ages of 7 to 12 months.
• Speaking first words late, typically after ages 12 to 18 months old.
• Using a limited number of consonants and vowels.
• Often leaving out sounds when speaking.
• Using speech that is hard to understand.

These symptoms are usually noticed between ages 18 months and 2 years. Symptoms at this age may indicate suspected CAS . Suspected CAS means a child may potentially have this speech disorder. The child's speech development should be watched to determine if therapy should begin.

Children usually produce more speech between ages 2 and 4. Signs that may indicate CAS include:

• Vowel and consonant distortions.
• Pauses between syllables or words.
• Voicing errors, such as "pie" sounding like "bye."

Many children with CAS have trouble getting their jaws, lips and tongues to the correct positions to make a sound. They also may have a hard time moving smoothly to the next sound.

Many children with CAS also have language problems, such as reduced vocabulary or trouble with word order.

Some symptoms may be unique to children with CAS , which helps to make a diagnosis. However, some symptoms of CAS are also symptoms of other types of speech or language disorders. It's hard to diagnose CAS if a child has only symptoms that are found both in CAS and in other disorders.

Some characteristics, sometimes called markers, help distinguish CAS from other types of speech disorders. Those associated with CAS include:

• Trouble moving smoothly from one sound, syllable or word to another.
• Groping movements with the jaw, lips or tongue to try to make the correct movement for speech sounds.
• Vowel distortions, such as trying to use the correct vowel but saying it incorrectly.
• Using the wrong stress in a word, such as pronouncing "banana" as "BUH-nan-uh" instead of "buh-NAN-uh."
• Using equal emphasis on all syllables, such as saying "BUH-NAN-UH."
• Separation of syllables, such as putting a pause or gap between syllables.
• Inconsistency, such as making different errors when trying to say the same word a second time.
• Having a hard time imitating simple words.
• Voicing errors, such as saying "down" instead of "town."

Other speech disorders sometimes confused with CAS

Some speech sound disorders often get confused with CAS because some of the symptoms may overlap. These speech sound disorders include articulation disorders, phonological disorders and dysarthria.

A child with an articulation or phonological disorder has trouble learning how to make and use specific sounds. Unlike in CAS , the child doesn't have trouble planning or coordinating the movements to speak. Articulation and phonological disorders are more common than CAS .

Articulation or phonological speech errors may include:

• Substituting sounds. The child might say "fum" instead of "thumb," "wabbit" instead of "rabbit" or "tup" instead of "cup."
• Leaving out final consonants. A child with CAS might say "duh" instead of "duck" or "uh" instead of "up."
• Stopping the airstream. The child might say "tun" instead of "sun" or "doo" instead of "zoo."
• Simplifying sound combinations. The child might say "ting" instead of "string" or "fog" instead of "frog."

Dysarthria is a speech disorder that occurs because the speech muscles are weak. Making speech sounds is hard because the speech muscles can't move as far, as quickly or as strongly as they do during typical speech. People with dysarthria may also have a hoarse, soft or even strained voice. Or they may have slurred or slow speech.

Dysarthria is often easier to identify than CAS . However, when dysarthria is caused by damage to areas of the brain that affect coordination, it can be hard to determine the differences between CAS and dysarthria.

Childhood apraxia of speech (CAS) has a number of possible causes. But often a cause can't be determined. There usually isn't an observable problem in the brain of a child with CAS .

However, CAS can be the result of brain conditions or injury. These may include a stroke, infections or traumatic brain injury.

CAS also may occur as a symptom of a genetic disorder, syndrome or metabolic condition.

CAS is sometimes referred to as developmental apraxia. But children with CAS don't make typical developmental sound errors and they don't grow out of CAS . This is unlike children with delayed speech or developmental disorders who typically follow patterns in speech and sounds development but at a slower pace than usual.

Risk factors

Changes in the FOXP2 gene appear to increase the risk of childhood apraxia of speech (CAS) and other speech and language disorders. The FOXP2 gene may be involved in how certain nerves and pathways in the brain develop. Researchers continue to study how changes in the FOXP2 gene may affect motor coordination and speech and language processing in the brain. Other genes also may impact motor speech development.

Complications

Many children with childhood apraxia of speech (CAS) have other problems that affect their ability to communicate. These problems aren't due to CAS , but they may be seen along with CAS .

Symptoms or problems that are often present along with CAS include:

• Delayed language. This may include trouble understanding speech, reduced vocabulary, or not using correct grammar when putting words together in a phrase or sentence.
• Delays in intellectual and motor development and problems with reading, spelling and writing.
• Trouble with gross and fine motor movement skills or coordination.
• Trouble using communication in social interactions.

Diagnosing and treating childhood apraxia of speech at an early stage may reduce the risk of long-term persistence of the problem. If your child experiences speech problems, have a speech-language pathologist evaluate your child as soon as you notice any speech problems.

Childhood apraxia of speech care at Mayo Clinic

• Jankovic J, et al., eds. Dysarthria and apraxia of speech. In: Bradley and Daroff's Neurology in Clinical Practice. 8th ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed April 6, 2023.
• Carter J, et al. Etiology of speech and language disorders in children. https://www.uptodate.com/contents/search. Accessed April 6, 2023.
• Childhood apraxia of speech. American Speech-Language-Hearing Association. https://www.asha.org/public/speech/disorders/childhood-apraxia-of-speech/. Accessed April 6, 2023.
• Apraxia of speech. National Institute on Deafness and Other Communication Disorders. http://www.nidcd.nih.gov/health/voice/pages/apraxia.aspx. Accessed April 6, 2023.
• Ng WL, et al. Predicting treatment of outcomes in rapid syllable transition treatment: An individual participant data meta-analysis. Journal of Speech, Language and Hearing Research. 2022; doi:10.1044/2022_JSLHR-21-00617.
• Speech sound disorders. American Speech-Language-Hearing Association. http://www.asha.org/public/speech/disorders/SpeechSoundDisorders/. Accessed April 6, 2023.
• Iuzzini-Seigel J. Prologue to the forum: Care of the whole child — Key considerations when working with children with childhood apraxia of speech. Language, Speech and Hearing Services in Schools. 2022; doi:10.1044/2022_LSHSS-22-00119.
• Namasivayam AK, et al. Speech sound disorders in children: An articulatory phonology perspective. 2020; doi:10.3389/fpsyg.2019.02998.
• Strand EA. Dynamic temporal and tactile cueing: A treatment strategy for childhood apraxia of speech. American Journal of Speech-Language Pathology. 2020; doi:10.1044/2019_AJSLP-19-0005.
• Ami TR. Allscripts EPSi. Mayo Clinic. March 13, 2023.
• Kliegman RM, et al. Language development and communication disorders. In: Nelson Textbook of Pediatrics. 21st ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed April 6, 2023.
• Adam MP, et al., eds. FOXP2-related speech and language disorder. In: GeneReviews. University of Washington, Seattle; 1993-2023. https://www.ncbi.nlm.nih.gov/books/NBK1116. Accessed April 6, 2023.
• How is CAS diagnosed? Childhood Apraxia of Speech Association of North America. https://www.apraxia-kids.org/apraxia_kids_library/how-is-cas-diagnosed/. Accessed April 13, 2023.
• Chenausky KV, et al. The importance of deep speech phenotyping for neurodevelopmental and genetic disorders: A conceptual review. Journal of Neurodevelopmental Disorders. 2022; doi:10.1186/s11689-022-09443-z.
• Strand EA. Dynamic temporal and tactile cueing: A treatment strategy for childhood apraxia of speech. American Journal of Speech Language Pathology. 2020; doi:10.1044/2019_AJSLP-19-0005.
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Home » Programs and Services » Rehabilitation Services » Receptive and Expressive Language Delays

Receptive and Expressive Language Delays

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To Schedule an Evaluation, Call 714-509-4220

What is a language disorder?

An expressive language disorder is one in which the child struggles to get their meaning or messages across to other people. A receptive language disorder is one in which a child struggles to understand and process the messages and information they receive from others. Some children have a mixed receptive-expressive language disorder in which they have symptoms of both types of disorders.

Types of language delays

There are two major types of language disorders: receptive language disorders and expressive language disorders.

A receptive language delay happens when your child has difficulty understanding language. An expressive language disorder happens when your child has difficulty communicating verbally.

What causes language disorders or delays?

Frequently, a cause for a child’s developmental language disorder cannot be identified. Other times, it can be a symptom of an underlying developmental delay or disorder.

What are the symptoms of a language delay or disorder?

Children with language delays and disorders can struggle in social and academic situations. Those struggles can result in problems with behavior and acting out. It is important for caregivers to discuss any concerns regarding a child’s language development with the pediatrician. Caregivers who suspect a child has a language delay should refer to the speech and language milestones development chart by clicking here. While not all children will develop at the same rate, it serves as a good guide as to the development caregivers should see in children as they grow. Additionally, children with a receptive language disorder may have some or all of the following symptoms:

• Difficulty understanding what people have said to them.
• Struggle to follow directions that are spoken to them.
• Problems organizing their thoughts for speaking or writing.

Children with an expressive language disorder may have some or all of the following symptoms:

• Struggle to put words together into a sentence or may not string together words correctly in their sentences.
• Have difficulties finding the right words while speaking and use placeholder words like “um.”
• Have a low vocabulary level compared to other children the same age.
• Leave words out of sentences when talking.
• Use tenses (past, present, future) incorrectly.

These are some signs of language delay by age:

• 12 months: isn’t using gestures, such as pointing or waving bye-bye
• 18 months: prefers gestures over vocalizations to communicate, has trouble imitating sounds, has trouble understanding simple verbal requests
• by 2 years: can only imitate speech or actions and doesn’t produce words or phrases spontaneously, says only some sounds or words repeatedly and can’t use oral language to communicate more than their immediate needs, can’t follow simple directions, has an unusual tone of voice (such as raspy or nasal sounding)

How is a language disorder diagnosed?

Children with a suspected language disorder undergo a comprehensive assessment to identify the specific delay and disorder. The assessments may include an interview with the parent or caregiver regarding the child’s medical history, unstructured play with the child to see how the child uses and understands language in a natural environment, and several standardized tests. These tests help the child’s treatment team determine the presence or severity of a child’s language disorder.

How is a receptive or expressive language delay treated?

Specific treatment for dysphagia will be determined by the child’s health care team based on the following:

• The child’s age, overall health, and medical history.
• The extent of the swallowing disorder.
• The child’s tolerance for specific medications, procedures, or therapies.
• Expectations for the course of the swallowing disorder.
• The family’s opinion or preference.

The child’s therapist will put together an individualized treatment plan based upon the results of the child’s assessments. Through books, games and play, components of language are taught and practiced. A therapist will continue to work with a child until the child is able to produce and understand language naturally in a conversation without cues or until the child reaches their best potential for language.

How can I help if my child has a language disorder?

• Parents are an important part of helping kids who have a speech or language problem. Here are a few ways to encourage speech development at home:
• Focus on communication. Talk with your baby, sing, and encourage imitation of sounds and gestures.
• Read to your child. Start reading when your child is a baby. Look for age-appropriate soft or board books or picture books that encourage kids to look while you name the pictures.
• Use everyday situations. To build on your child’s speech and language, talk your way through the day. Name foods at the grocery store, explain what you’re doing as you cook a meal or clean a room, and point out objects around the house. Keep things simple, but avoid “baby talk.”

Recognizing and treating speech and language delays early on is the best approach. Call your doctor if you have any concerns about your child’s speech or language development.

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• Speech and language therapy
• Clinical information
• Speech sound disorders – overview​

Speech sound disorders - overview​

Last updated : 2024

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Introduction, typical speech development, speech development in languages other than english, what is speech sound disorder, long term impact of ssd, what to expect at the first appointment, phonological or speech sound awareness, ask your slt, how to talk to children with ssd, dummy/soother use, ‘growing out of it’.

• Screen time and Apps
• Non-speech oro-motor exercises (NSOMEs)
• RCSLT Position Paper on Childhood Apraxia of Speech

Sources of support for families of children with SSD

Contributors.

This guidance is for everyone who is concerned about a child’s speech sound development or who has responsibility for looking after or providing services for children in the UK. This includes:

• parents/caregivers and other family members
• health care professionals e.g. health visitors, children’s nurses, school nurses, Allied Health Professionals (AHPs), doctors
• educational practitioners e.g. teachers, teaching assistants*, early years practitioners, educational psychologists
• educational leaders and managers e.g. head teachers, special/additional educational needs coordinators, leadership team members, school governors
• those responsible for commissioning speech and language therapy services.

Please also see the sections on Sources of Support and References .

If you’re a speech and language therapist (SLT), please sign up  or  log in  to access  the full version of this guidance aimed at SLTs .  

*In this guidance the term ‘teaching assistant’ will be used to refer to individuals who provide additional support to children in classrooms, acknowledging that in different educational settings these jobs have different titles.

When people talk they are using two complex systems:

• Language – which puts words into sentences to make meaning
• S peech – which puts the individual sounds (vowels and consonants) into words so that we can hear and understand what people are saying.

Children develop speech and language from soon after they are born from the languages they hear around them. Children usually grow up sounding like the other people in their family and local community when they talk. Most speech and language develops in early to mid-childhood. People continue to develop language knowledge all their lives, e.g. learning new words related to their interests or work.

In every language there is a typical pattern of speech sound development (see Speech development in languages other than English) . Children vary in their speech sound development. Some children develop speech sounds earlier than other children. For English, the typical pattern of speech development in the UK is shown in the table below. Most sounds are established when children are about three years old. Some sounds develop later and children may be about 6-7 years old before they use all sounds correctly.

This table is based on the most up to date information on UK English sound development. Development of speech sounds in other countries where English is the majority language (e.g. Australia, America) may differ slightly from the UK but will be similar.

Table showing development of English speech sounds

Before children are about 3 years old they sometimes make predictable errors in their speech sounds. These errors typically resolve as the child starts to use the correct sound. Examples of these are:

• Before they start using ‘k’ properly, they typically say ‘t’ instead, e.g. ‘cat’ sounds like ‘tat’.
• They may miss out a part of the word e.g. ‘tomato’ sounds like ‘mato’, ‘banana’ sounds like ‘nana’
• They miss off the last sound in a word e.g. ‘bus’ sounds like ‘bu’, truck sounds like ‘tru’.

These are of concern if they persist beyond 3 years and if it is difficult to understand the child in everyday situations (the child is unintelligible). Most children have intelligible speech and good language skills when they start school between the age of 4 and 5. If there are concerns about a child’s speech, it is important to seek help sooner rather than later.

Referrals to speech and language therapy services can be considered at any age but criteria may vary across speech and language therapy services. If the child is not cooing, babbling or using many sounds from 0 to 2 years, then contact a Health Visitor for advice. If parents/caregivers are very concerned about their child’s speech they can often contact their local NHS speech and language therapy service directly and refer their child (search online for ‘NHS Speech and Language Therapy near me’ and choose your local NHS Trust/Board). Some services only accept referrals from health visitors or schools. Speech sound development is complete when the child sounds like the adults in their family or the other children in their school. This can differ across local accents. For example, people in some areas of the UK usually pronounce ‘th’ in words such as ‘teeth’ or ‘that’ as ‘f’ (‘ teef ’ and ‘ fat ’ ) .

Children who grow up in families where English is not spoken at home will develop speech sounds in a way typical for the language they are learning. Each language has its own set of sounds, although some sounds are the same across different languages. If you are concerned that a child is not developing speech sounds in line with other children of the same age who speak the same language, please refer them to speech and language therapy. Do not refer them if speech sounds in their home language are developing as expected.

Children who grow up speaking two or more languages together will develop speech sounds in all of their languages at about the same time. This depends on how much of each language they hear around them. The language they hear most will usually develop earlier. This may be different from children who just speak one language. This is not a problem as the benefits of being bilingual /multilingual far outweigh this. If there are concerns that the child’s speech sound development in any of their languages is slow or sounds different to other children speaking that language, refer them to speech and language therapy. If an interpreter is needed, the speech and language therapy service will arrange for one to be present at appointments.

More information about

• the benefits of growing up bilingual
• what to expect from speech and language therapy services
• assessment in home languages

can be found in the RCSLT Bilingualism Guidance (2018) .

When a child’s speech is very difficult to understand compared to other children of the same age speaking the same language, the cause may be a speech sound disorder (SSD). Speech sound disorders are diagnosed by speech and language therapists (SLTs) after detailed assessment of all aspects of speech production. There are several different types of SSD which can be diagnosed and treated by SLTs. About 12 children in every 100 will have SSD and about half of them will also have language difficulties.

Articulation disorders

Articulation disorders are due to difficulty making the correct movements for speech. It usually affects only a small number of sounds. Common examples in English are where the ‘s’ sound is said like a ‘th’ sound e.g. sing sounds like thing (a lisp) and ‘r’ sounds like ‘w’ e.g. ‘ rabbit’ sounds like ‘wabbit ’. The child finds it difficult to say the sound on its own and in words.  Some children find this impacts on their wellbeing and mental health. Referral to speech and language therapy can help. Some articulation disorders make speech very hard to understand. These children should be referred to speech and language therapy.

Phonological disorders

Phonological disorders are when the child has difficulty using sounds in the correct place in a word or is using the wrong sounds in words. The child can say the sound on its own but has difficulty saying it in words or misses out sounds e.g. the child can say ‘k’ and ‘g’ on their own, but says ‘ teep’ instead of ‘keep ’ or ‘ pid’ instead of ‘pig ’. These can make the child very difficult to understand to people outside their family and sometimes to close family members. These children should be referred to speech and language therapy.

There are also SSD related to deafness , cleft palate , Down Syndrome , 22q11 deletion syndrome, cerebral palsy and other childhood conditions. It is important to seek the help of an SLT for these children. You may hear the terms ‘dysarthria’ or ‘childhood apraxia of speech’ (CAS) , both of these are rare speech disorders which are diagnosed and treated by SLTs. Please see the section on Sources of Support.

Speech sound disorders can have a long lasting impact if not treated at the right time. Children with SSD are at risk of literacy difficulties that impact their access to education. SLTs work closely with teachers to reduce this risk and support children’s progress. Early support is crucial so that the child is ready to learn phonics which links letters and letter combinations to speech sounds when  children learn to read. There are things that parents/caregivers can do to help. Please see the section on Sources for Support.

SSD can also last into adulthood with impact on employment opportunities and mental health. Adults with SSD may be able to access speech and language therapy through the NHS or if they wish to access support privately they can contact the Association of Speech and Language Therapists in Independent Practice (ASLTIP).

Children with SSD often have difficulty with language too. This means they have difficulty expressing themselves to others. They may not know as many words (vocabulary) as other children; they may have difficulty making correct or long sentences or have difficulty understanding what others say to them. This has an impact on their educational achievement, relationships with others, mental health and future employment. You can find out more on the RCSLT pages about developmental language disorders.

What happens after a child has been referred to speech and language therapy service will vary depending upon where they live. Each speech and language therapy service will tell parents/caregivers what to expect. Some speech and language therapy services make first contact by telephone to listen to parents’/caregivers’ concerns and provide initial advice. Assessment appointments may take place in the child’s home or school, in an NHS health centre or clinic or online.

The parent/caregiver will be asked about the child’s development from birth. For school age children they will be asked how the child is getting on at school. The child’s school will also be asked for information.

For very young children, the SLT or an SLT Assistant (SLTA) will play with the child and observe how they play. They will use play and pictures to encourage the child to talk. They may use assessments that are designed to prompt the child to say a standard set of words or phrases. The aim of this is to get information that can be compared with typically developing children. SLTs will usually assess speech and language in this first assessment. Parents/caregivers are asked not to help their child during this assessment so that the SLT can see what the child can do on their own.

For school aged children, the SLT will use more formal assessments to assess specific aspects of speech and language. These may still look like the SLT is playing games as it is important for the child to be at ease.

At the end of the appointment the SLT will discuss their observations and the next steps with the parent/caregiver. The SLT will take some time to analyse the information they have collected so may not be able to give a diagnosis immediately. Children with complex SSD will need more assessment time.

Possible next steps include more assessment, some activities for the parent/caregiver to do at home, some group or individual therapy (there will be a waiting list for this) or discharge. Some children need speech and language therapy but are not ready to benefit from it, for example because they have difficulty paying attention or listening. In these cases, parents/caregivers may be given a programme of activities to do at home before therapy starts. These activities play an important role in helping the child benefit from therapy. It is important for the child that they are carried out as suggested.

What to expect from therapy for SSD

Speech and language therapists are the only professionals who have the knowledge and expertise to work with children who have SSD. Speech and language therapy for children with SSD will always be planned by an SLT. Evidence indicates that the SLT should deliver therapy for SSD. Specially trained SLT Assistants (SLTAs) may deliver some sessions under close supervision of the SLT. Extra practice may be given for parents/caregivers or teaching assistants to carry out on a daily basis as appropriate. The SLT will discuss therapy goals and intended outcomes with parents/caregivers and often with teachers. Some areas may experience a shortage of SLTs reducing access to appropriate levels of speech and language therapy. The RCSLT continues to advocate with governments and agencies for adequate speech and language therapy resources and support.

The type of therapy will depend upon the type of SSD diagnosed by the SLT. Sometimes more than one type of therapy at the same time or in sequence is needed. Some therapy focuses on saying sounds accurately (articulation); some is more about listening to the correct sounds and hearing the difference between two or more sounds before saying those sounds in words (phonology); some is about the way sounds fit together in words (phonological awareness).

The SLT will choose the therapy that is best for your child based on the assessment information and on the evidence base. There are many effective therapies that have been shown by research to help children develop intelligible speech. Some of the therapy will involve the child practicing saying sounds and words, but it will often also involve listening to sounds and words.

Therapy is usually delivered in fun activities/games so that the child is kept engaged and motivated. To be effective, therapy may need to be delivered for many weeks or months depending on the needs of the child. Therapy sessions typically last 30 minutes to an hour, depending on the child’s needs. The type of therapy chosen will influence the number, length and spacing of sessions. The frequency of sessions will take into account the amount and type of extra practice outside the therapy sessions. Extra practice makes a valuable contribution to the child’s progress (Sugden et al., 2018) and is often one of the activities from therapy.

After a period or block of therapy (also called an episode of care) it is usual to have several weeks with no therapy to see how the therapy has worked. Sometimes during this period children make lots of extra progress but some children make little or none. This is important information to help the SLT plan the next steps.

Children with complex or persistent SSD, including those with childhood apraxia of speech (CAS), will need more therapy for longer. The number of sessions a week and the amount of practice needed will vary according to the child, the severity of their SSD and the way they respond to therapy. There will be more than one period of therapy (or episode of care) with a break of a few weeks in between. Sometimes further assessment will lead to a different diagnosis as they respond to therapy or new information is discovered. This is nothing to worry about but will ensure the child continues to get the best therapy for their type of SSD.

Children with severe SSD, including those with CAS, may be supported to use Augmentative and Alternative Communication (AAC). This can take the form of signing (e.g. Makaton), symbol based communication mats or books or a voice output device. The aim of AAC in this context is to support the child’s participation in education and social and family life, while therapy to improve intelligibility is ongoing. More information about AAC can be found on the RCSLT AAC guidance pages .

If a child has language disorder as well as SSD, they will be given therapy for their language disorder too. This can be at the same time as the therapy for SSD or it may start after the child’s speech is easier to understand. The SLT will advise on the most effective way of delivering this therapy.

Following each block of therapy, the next steps will be discussed with parents/caregivers. When the child’s speech is intelligible to different people and specific goals of therapy have been met it is time for the child to be discharged. This will be discussed with parent/caregivers and often with teachers if the school have been involved in supporting the therapy. Sometimes activities are suggested for a short time to help maintain new skills. Children with complex needs in addition to SSD may have increased intelligibility but some people may still find them difficult to understand. Some of these children may use AAC to support their intelligibility. Sometimes family or personal circumstances may make it difficult to provide extra practice at home or to attend therapy. Parents/caregivers should discuss these issues with the SLT so the next steps can be agreed. Children can be re-referred to speech and language therapy at any time until they are 18 if there are further concerns about their speech and/or language. Speech and language therapy services for young people aged over 18 vary across the UK. If you require speech and language therapy during these years, please ask your local children’s speech and language therapy service for advice.

Phonological awareness (sometimes called Speech Sound Awareness or Sound Awareness) is an essential skill for

• learning new words (vocabulary)
• learning to read and spell (phonics)
• using speech sounds in words.

Most children develop all their phonological awareness skills from hearing language around them. Children with SSD or language difficulties often have delayed phonological awareness development. Early Years settings usually do phonological awareness activities with small groups of children to prepare them for learning phonics when they start learning to read. SLTs may give phonological awareness activities to parents/caregivers to do at home when children have SSD or language difficulties.

Phonological awareness is an auditory skill, developed through hearing and listening to people speaking around us. It is our knowledge of how sounds fit together to make words. It develops in two stages.

Stage one must be learnt before stage two. Stage one is the knowledge of large segments which are words and syllables e.g. ‘The girl runs’ has three words; ‘greenhouse’ and ‘picnic’ both have two syllables; ‘hippopotamus’ has five syllables.

Stage two is the knowledge of small segments which are the sounds (or phonemes) in words e.g. ‘on’ has two sounds (phonemes) o-n; ‘cat’ has three sounds (phonemes) c-a-t, ‘rabbit’ has five sounds (phonemes) r-a-bb-i-t.

Letters and sounds (phonemes) are not always the same, for example in ‘rabbit’ the single sound ‘b’ is represented by two letters, which is why it is important to hear words and not read them when learning phonological awareness.

Children who speak languages other than English (LOTE) develop phonological awareness in the same way, from large to small segments. Because different languages are structured differently, phonological awareness skills vary slightly from language to language. Phonological awareness skills in a child’s home language can support its development in other languages.

During assessment and therapy if you don’t understand what is happening or why, it is OK to ask the SLT. It is OK to:

• ask for an explanation of the diagnosis you are given if you are not sure what it means
• ask about how long and how often the SLT thinks your child will need therapy
• say you are keen to be a part of the child’s therapy
• talk to your therapist if you are having difficulty supporting therapy at home e.g. if you are overly busy, if it’s not the right time for your family or you are worried that your child won’t do therapy activities with you at home
• ask “Why are you doing that?” if the point of an activity is not clear
• ask “What does that assess?” if it is not obvious
• ask “Why are you saying things and not my child?” if your child is not saying much in the therapy
• say that you are worried about your child
• ask if your child’s nursery or school will be involved with speech and language therapy.

Parents/caregivers and schools should get written reports from SLTs after assessment and intervention. If there is anything in the report that you don’t understand you can ask the SLT for clarification.

When talking with children with SSDs, it is helpful if you support their speech by giving them a good clear model of speech to listen to. Explain to the child that sometimes you don’t understand what they say so sometimes will ask them questions to help you understand. If you have not understood what they said you could try the following:

• Ask them to show you what they mean/want, then you say the words to them e.g. if they point to the Lego you say “OK you want to play with the Lego?”
• Give them two words that you think might be what they are saying e.g. “Do you want the rabbit or the elephant?”
• Instead of saying “What did you do at school today?”, ask a question that gives them a choice e.g. “Did you play football or rounders at school today?”
• You can guess at what they said, “Is it in the garden or the kitchen?” to draw their attention to the word you didn’t understand.

Do not ask the child to repeat what you said (no matter how tempting it is). This is not helpful to them and may lead them to avoid talking or saying certain words.

Parents/caregivers know that using a dummy or soother can be helpful in getting their child off to sleep and calming them when they are upset. The use of dummies for this purpose does not affect speech development. However, we all know how hard it is to talk when we have something in our mouth. When a child is talking, remember to remove the dummy from their mouth. Excessive use of a dummy during the day can interfere with speech sound development. It is advised that dummies are not used for long periods during the day when the child is starting to talk alongside their play.

Children born with a tongue tie (the medical term is ankyloglossia) may have restricted movement in the tip of their tongue. If this interferes with suckling it will take longer to feed the child in the early days and weeks. If there is a severe impact on feeding in the first few weeks of life, there may be a medical recommendation for the tongue tie to be cut. At this stage it can be done without general anaesthetic. There is no evidence that tongue tie affects speech development, so this is not a reason to cut a tongue tie at any age.

A small number of children with SSD will “grow out of it”, that is they will catch up with children the same age without any help. For young children, it is not always clear which children will need speech and language therapy and which will not. SLTs will advise on the best course of action. For school age children it is unlikely they will progress without therapy. If there is concern about a child’s speech development, it is always advised to refer to speech and language therapy.

Screen time

Using the TV, computer, tablet or phone together with a child to watch programmes, play games, read or listen to stories can all be good opportunities to share good language and speech models. You can talk about things you have seen and new words you have heard, giving the child a chance to learn new words. If no one is actively watching the screen it is best to turn off the device and not have it on in the background. Some children with SSD will find it hard to hear speech over background noise. If the TV or music are on when they are playing or talking it will be harder for them to hear good speech models and will slow their progress.

There are lots of Apps available that claim they help children’s speech development. Some of these will be helpful but most will not be. Some can be harmful. Before getting an app to help a child with SSD it is important to talk to an SLT to check it will be helpful and not do harm.

Non-speech oro -motor exercises ( NSOMEs )  

There are several types of therapy for SSD offered on the internet or in Apps that say they will strengthen a child’s tongue and mouth and help their speech development e.g. chewing on tubes or doing mouth exercises. Often these cost money and appear to offer cures for SSD. There is no research that supports the effectiveness of this type of therapy. In some cases they can be harmful. It is advised to check with an SLT before starting any type of alternative treatment for SSD. If you are waiting for therapy for a child, ask the SLT what you can do to help while you are waiting, it could be as simple as reading or listening to books together. It will never be doing mouth, lip or tongue physical exercises.

Good hearing helps speech sound development. All babies born in the UK are offered a hearing test within a few weeks of birth. For babies born in hospital, hearing can be checked before they go home. This is to rule out permanent deafness. It is an important test for all babies. Discovering deafness at this early age will help their speech, language and communication development.

Children are offered hearing tests at several times in the preschool years. If your child is offered hearing tests it is important to go along, even if you have no concerns about their hearing.

Children can have periods when their hearing is reduced due to infections or blockages in their ears e.g. bad colds, otitis media (glue ear) . It is important to go to all hearing tests offered to children. If you have concerns about your child’s hearing talk to your GP or Health Visitor.

RCSLT Position Paper on Childhood Apraxia of Speech 2024

The RCSLT Position Paper on Childhood Apraxia of Speech (CAS) has been developed primarily for the speech and language therapy workforce. Other professional groups and organisations together with parents, families and carers will find this to be a useful, relevant and informative resource. Speech and language therapy specific terminology has been used in this document and if further explanation or guidance is needed, please discuss this with a speech and language therapist.

Some of the resources linked in this document are only accessible to RCSLT members. For further information on the purpose of RCSLT guidance, please see: how we develop our guidance .

The aim of this document is to offer guidance regarding children with CAS for:

• SLTs and managers of SLT services in order to influence commissioning arrangements and plan service delivery
• Higher Education Institutions (HEIs) for the purposes of pre-registration and postgraduate education and academic research
• Organisations committed to providing or determining appropriate provision and support for individuals with CAS

This paper, published in 2024, replaces the 2011 Policy Statement on Developmental Verbal Dyspraxia.

Some of these link to activities that are good for all children to support their speech and language development. They include information for bilingual children.

• ASLTIP Therapy for children
• BBC Tiny Happy People
• Better Health Start for Life. Learning to Talk 1-2 years
• Better Health Start for Life. Learning to Talk 2-3 years
• Better Health Start for Life. Learning to talk 3-5
• Welsh Government’s Talk with Me

These links are for organisations that offer information and support for families of children with SSD, including CAS.

• Apraxia Kids
• Dyspraxia Foundation
• Mikey’s Wish
• Speech and Language UK

Lead author  

Dr Helen Stringer  

Supporting authors  

Meriem Amer-El-Khedoud  

Sarah Atkinson  

Lorraine Bamblett  

Dr Joanne Cleland  

Alex Jones  

Elizabeth Marks  

Caroline Rendle  

Dr Lucy Southby  

Dr Pam Williams  

Dr Sara Wood  

We are grateful to the project reference group, the Child Speech Disorder Research Network, and all the RCSLT members and other stakeholders who contributed to the development of this guidance through the consultation.  

The evidence base for the information about speech sound disorders (SSD) is in the following research papers.

Typical speech development in UK, English

Dodd, B., Holm, A., Hua, Z., and Crosbie, S., 2003, Phonological development: a normative study of British English‐speaking children. Clinical Linguistics and Phonetics , 17 , 617–643. https://doi.org/10.1080/0269920031000111348 .

Typical speech development in languages other than English (LOTE)

http://www.csu.edu.au/research/multilingual-speech/speech-acq-studies This website is curated by Professor Sharynne McLeod at Sturt University, Australia (2024)

Anthony, J.L. and Francis, D.J., 2005, Development of phonological awareness. Current Directions in Psychological Science , 14 , 255–259. https://doi.org/10.1111/j.0963-7214.2005.00376.x .

Anthony, J.L., Lonigan, C.J., Burgess, S.R., Driscoll, K., Phillips, B.M., and Cantor, B.G., 2002, Structure of Preschool Phonological Sensitivity: Overlapping Sensitivity to Rhyme, Words, Syllables, and Phonemes. Journal of Experimental Child Psychology , 82 , 65–92. http://dx.doi.org/10.1006/jecp.2002.2677 .

Carroll, J.M., Snowling, M., Hulme, C., and Stevenson, J., 2003, The Development of Phonological Awareness in Preschool Children. Developmental Psychology , 39 , 913–923. https://doi.org/10.1037/0012-1649.39.5.913 .

Bialystok, E., Majumder, S., and Martin, M.M., 2003, Developing phonological awareness: Is there a bilingual advantage? Applied Psycholinguistics . https://doi.org/10.1017/S014271640300002X .

What is speech sound disorder (SSD)?  

Broomfield, J. and Dodd, B. , 2004, The nature of referred subtypes of primary speech disability. Child Language Teaching and Therapy , 20 , 135–151. https://doi.org/10.1191/0265659004ct267oa .   

Dodd, B. , 2014, Differential Diagnosis of Pediatric Speech Sound Disorder. Current Developmental Disorders Reports , 1–8. https://doi.org/10.1007/s40474-014-0017-3 .  

Shriberg, L.D. , Kwiatkowski, J. , Best, S. , Hengst, J. , and Terselic-Weber, B. , 1986, Characteristics of children with phonologic disorders of unknown origin. Journal of Speech and Hearing Disorders , 51 , 140–161. https://doi.org/10.1044/jshd.5102.140 .  

S tringer, H., Cleland, J., Wren, Y., Rees, R., & Williams, P . (2023). Speech sound disorder or DLD (phonology)? Towards a consensus agreement on terminology. International Journal of Language and Communication Disorders . https://doi.org/10.1111/1460-6984.12989    

Waring, R. and Knight, R. , 2013, How should children with speech sound disorders be classified? A review and critical evaluation of current classification systems. International Journal of Language and Communication Disorders , 48 , 25–40. https://doi.org/10.1111/j.1460-6984.2012.00195.x

Long term impact of SSD  

Benway, N.R. , Garcia, K. , Hitchcock, E. , McAllister, T. , Leece, M.C. , Wang, Q. , and Preston, J.L. , 2021, Associations Between Speech Perception, Vocabulary, and Phonological Awareness Skill in School-Aged Children With Speech Sound Disorders. Journal of Speech, Language, and Hearing Research , 64 , 452–463. https://doi.org/10.1044/2020_JSLHR-20-00356 .   

Clegg, J. , Hollis, C. , Mawhood, L. , and Rutter, M. , 2005, Developmental language disorders – A follow-up in later adult life. Cognitive, language and psychosocial outcomes. Journal of Child Psychology and Psychiatry and Allied Disciplines , 46 , 128–149. https://doi.org/10.1111/j.1469-7610.2004.00342.x .   

Harris, J. , Botting, N. , Myers, L. , and Dodd, B. , 2011, The relationship between speech impairment, phonological awareness and early literacy development. Australian Journal of Learning Difficulties, 16 , 111–125. https://doi.org/10.1080/19404158.2010.515379 .   

Wren, Y. , Pagnamenta, E. , Orchard, F. , Peters, T.J. , Emond, A. , Northstone, K. , Miller, L.L. , and Roulstone, S. , 2023, Social, emotional and behavioural difficulties associated with persistent speech disorder in children: A prospective population study. JCPP Advances . https://doi.org/10.1002/JCV2.12126 .   

Wren, Y. , Pagnamenta, E. , Peters, T.J. , Emond, A. , Northstone, K. , Miller, L.L. , and Roulstone, S. , 2021, Educational outcomes associated with persistent speech disorder. International Journal of Language & Communication Disorders , 56 , 299–312. https://doi.org/10.1111/1460-6984.12599 .   

Speech and language therapy for SSD  

Byers, B.A. , Bellon-Harn, M.L. , Manchaiah, V. , Allen, M. , Saar, K.W. , and Rodrigo, H. , 2021, A Comparison of Intervention Intensity and Service Delivery Models With School-Age Children With Speech Sound Disorders in a School Setting. Language, Speech, and Hearing Services in Schools , 52 , 529–541. https://doi.org/10.1044/2020_LSHSS-20-00057 .   

Hegarty, N. , Titterington, J. , and Taggart, L. , 2020, A qualitative exploration of speech-language pathologists’ intervention and intensity provision for children with phonological impairment. https://doi-org.libproxy.ncl.ac.uk/10.1080/17549507.2020.1769728 , 23 , 213–224. https://doi.org/10.1080/17549507.2020.1769728 .   

Kaipa, R. and Peterson, A.M. , 2016, A systematic review of treatment intensity in speech disorders. International Journal of Speech-Language Pathology , 18 , 507–520. https://doi.org/10.3109/17549507.2015.1126640 .   

Law, J., Garrett, Z., & Nye, C. (2004). The Efficacy of Treatment for Children With Developmental Speech and Language Delay/Disorder: A meta-analysis. Journal of Speech, Language, and Hearing Research , 47 (4), 924–943. https://doi.org/10.1044/1092-4388(2004/069)  

Sugden, E., Baker, E., Munro, N., Williams, A. L., & Trivette, C. M. (2018). Service delivery and intervention intensity for phonology-based speech sound disorders. International Journal of Language and Communication Disorders , 53 (4), 718–734. https://doi.org/https://doi.org/10.1111/1460-6984.12399 .   

Dummy/soother use  

Baker, E. , Masso, S. , McLeod, S. , and Wren, Y. , 2018, Pacifiers, Thumb Sucking, Breastfeeding, and Bottle Use: Oral Sucking Habits of Children with and without Phonological Impairment. Folia Phoniatrica et Logopaedica , 70 , 165–173. https://doi.org/10.1159/000492469 .   

Burr, S. , Harding, S. , Wren, Y. , and Deave, T. , 2021, The Relationship between Feeding and Non-Nutritive Sucking Behaviours and Speech Sound Development: A Systematic Review. Folia phoniatrica et logopaedica   : official organ of the International Association of Logopedics and Phoniatrics (IALP) , 73 , 75–88. https://doi.org/10.1159/000505266 .   

Strutt, C. , Khattab, G. , and Willoughby, J. , 2021, Does the duration and frequency of dummy (pacifier) use affect the development of speech? International Journal of Language & Communication Disorders , 56 , 512–527. https://doi.org/10.1111/1460-6984.12605 .   

Tongue tie  

Wang, J. , Yang, X. , Hao, S. , and Wang, Y. , 2022, The effect of ankyloglossia and tongue-tie division on speech articulation: A systematic review. International Journal of Paediatric Dentistry , 32 , 144–156. https://doi.org/https://doi-org.libproxy.ncl.ac.uk/10.1111/ipd.12802 .   

Screen time  

Karani, N. F., Sher, J., & Mophosho, M. (2022). The influence of screen time on children’s language development: A scoping review. South African Journal of Communication Disorders , 69 (1), 825-. https://doi.org/10.4102/sjcd.v69i1.85    

Non-speech oro-motor exercises (NSOMEs)  

Lee, A. S.-Y., & Gibbon, F. E. (2015). Non-speech oral motor treatment for children with developmental speech sound disorders.  (Publication no. DOI: 10.1002/14651858.CD009383.pub2).  Retrieved 15/03/2017, from Cochrane Database of Systematic Reviews 2015, Issue 3. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009383.pub2/abstract;jsessionid=98F1A86EC7CBD1F7E23BB7BF97270373.f04t02#footer-article-info  

Parra-López, P. , Olmos-Soria, M. , and Valero-García, A. V. , 2022, Nonverbal Oro-Motor Exercises: Do They Really Work for Phonoarticulatory Difficulties? International Journal of Environmental Research and Public Health 2022, Vol. 19, Page 5459 , 19 , 5459. https://doi.org/10.3390/IJERPH19095459 .   

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10 Most Common Speech-Language Disorders & Impediments

As you get to know more about the field of speech-language pathology you’ll increasingly realize why SLPs are required to earn at least a master’s degree . This stuff is serious – and there’s nothing easy about it.

In 2016 the National Institute on Deafness and Other Communication Disorders reported that 7.7% of American children have been diagnosed with a speech or swallowing disorder. That comes out to nearly one in 12 children, and gets even bigger if you factor in adults.

Whether rooted in psycho-speech behavioral issues, muscular disorders, or brain damage, nearly all the diagnoses SLPs make fall within just 10 common categories…

Types of Speech Disorders & Impediments

Apraxia of speech (aos).

Apraxia of Speech (AOS) happens when the neural pathway between the brain and a person’s speech function (speech muscles) is lost or obscured. The person knows what they want to say – they can even write what they want to say on paper – however the brain is unable to send the correct messages so that speech muscles can articulate what they want to say, even though the speech muscles themselves work just fine. Many SLPs specialize in the treatment of Apraxia .

There are different levels of severity of AOS, ranging from mostly functional, to speech that is incoherent. And right now we know for certain it can be caused by brain damage, such as in an adult who has a stroke. This is called Acquired AOS.

However the scientific and medical community has been unable to detect brain damage – or even differences – in children who are born with this disorder, making the causes of Childhood AOS somewhat of a mystery. There is often a correlation present, with close family members suffering from learning or communication disorders, suggesting there may be a genetic link.

Mild cases might be harder to diagnose, especially in children where multiple unknown speech disorders may be present. Symptoms of mild forms of AOS are shared by a range of different speech disorders, and include mispronunciation of words and irregularities in tone, rhythm, or emphasis (prosody).

Stuttering – Stammering

Stuttering, also referred to as stammering, is so common that everyone knows what it sounds like and can easily recognize it. Everyone has probably had moments of stuttering at least once in their life. The National Institute on Deafness and Other Communication Disorders estimates that three million Americans stutter, and reports that of the up-to-10-percent of children who do stutter, three-quarters of them will outgrow it. It should not be confused with cluttering.

Most people don’t know that stuttering can also include non-verbal involuntary or semi-voluntary actions like blinking or abdominal tensing (tics). Speech language pathologists are trained to look for all the symptoms of stuttering , especially the non-verbal ones, and that is why an SLP is qualified to make a stuttering diagnosis.

The earliest this fluency disorder can become apparent is when a child is learning to talk. It may also surface later during childhood. Rarely if ever has it developed in adults, although many adults have kept a stutter from childhood.

Stuttering only becomes a problem when it has an impact on daily activities, or when it causes concern to parents or the child suffering from it. In some people, a stutter is triggered by certain events like talking on the phone. When people start to avoid specific activities so as not to trigger their stutter, this is a sure sign that the stutter has reached the level of a speech disorder.

The causes of stuttering are mostly a mystery. There is a correlation with family history indicating a genetic link. Another theory is that a stutter is a form of involuntary or semi-voluntary tic. Most studies of stuttering agree there are many factors involved.

Dysarthria is a symptom of nerve or muscle damage. It manifests itself as slurred speech, slowed speech, limited tongue, jaw, or lip movement, abnormal rhythm and pitch when speaking, changes in voice quality, difficulty articulating, labored speech, and other related symptoms.

It is caused by muscle damage, or nerve damage to the muscles involved in the process of speaking such as the diaphragm, lips, tongue, and vocal chords.

Because it is a symptom of nerve and/or muscle damage it can be caused by a wide range of phenomena that affect people of all ages. This can start during development in the womb or shortly after birth as a result of conditions like muscular dystrophy and cerebral palsy. In adults some of the most common causes of dysarthria are stroke, tumors, and MS.

A lay term, lisping can be recognized by anyone and is very common.

Speech language pathologists provide an extra level of expertise when treating patients with lisping disorders . They can make sure that a lisp is not being confused with another type of disorder such as apraxia, aphasia, impaired development of expressive language, or a speech impediment caused by hearing loss.

SLPs are also important in distinguishing between the five different types of lisps. Most laypersons can usually pick out the most common type, the interdental/dentalised lisp. This is when a speaker makes a “th” sound when trying to make the “s” sound. It is caused by the tongue reaching past or touching the front teeth.

Because lisps are functional speech disorders, SLPs can play a huge role in correcting these with results often being a complete elimination of the lisp. Treatment is particularly effective when implemented early, although adults can also benefit.

Experts recommend professional SLP intervention if a child has reached the age of four and still has an interdental/dentalised lisp. SLP intervention is recommended as soon as possible for all other types of lisps. Treatment includes pronunciation and annunciation coaching, re-teaching how a sound or word is supposed to be pronounced, practice in front of a mirror, and speech-muscle strengthening that can be as simple as drinking out of a straw.

Spasmodic Dysphonia

Spasmodic Dysphonia (SD) is a chronic long-term disorder that affects the voice. It is characterized by a spasming of the vocal chords when a person attempts to speak and results in a voice that can be described as shaky, hoarse, groaning, tight, or jittery. It can cause the emphasis of speech to vary considerably. Many SLPs specialize in the treatment of Spasmodic Dysphonia .

SLPs will most often encounter this disorder in adults, with the first symptoms usually occurring between the ages of 30 and 50. It can be caused by a range of things mostly related to aging, such as nervous system changes and muscle tone disorders.

It’s difficult to isolate vocal chord spasms as being responsible for a shaky or trembly voice, so diagnosing SD is a team effort for SLPs that also involves an ear, nose, and throat doctor (otolaryngologist) and a neurologist.

Have you ever heard people talking about how they are smart but also nervous in large groups of people, and then self-diagnose themselves as having Asperger’s? You might have heard a similar lay diagnosis for cluttering. This is an indication of how common this disorder is as well as how crucial SLPs are in making a proper cluttering diagnosis .

A fluency disorder, cluttering is characterized by a person’s speech being too rapid, too jerky, or both. To qualify as cluttering, the person’s speech must also have excessive amounts of “well,” “um,” “like,” “hmm,” or “so,” (speech disfluencies), an excessive exclusion or collapsing of syllables, or abnormal syllable stresses or rhythms.

The first symptoms of this disorder appear in childhood. Like other fluency disorders, SLPs can have a huge impact on improving or eliminating cluttering. Intervention is most effective early on in life, however adults can also benefit from working with an SLP.

Muteness – Selective Mutism

There are different kinds of mutism, and here we are talking about selective mutism. This used to be called elective mutism to emphasize its difference from disorders that caused mutism through damage to, or irregularities in, the speech process.

Selective mutism is when a person does not speak in some or most situations, however that person is physically capable of speaking. It most often occurs in children, and is commonly exemplified by a child speaking at home but not at school.

Selective mutism is related to psychology. It appears in children who are very shy, who have an anxiety disorder, or who are going through a period of social withdrawal or isolation. These psychological factors have their own origins and should be dealt with through counseling or another type of psychological intervention.

Diagnosing selective mutism involves a team of professionals including SLPs, pediatricians, psychologists, and psychiatrists. SLPs play an important role in this process because there are speech language disorders that can have the same effect as selective muteness – stuttering, aphasia, apraxia of speech, or dysarthria – and it’s important to eliminate these as possibilities.

And just because selective mutism is primarily a psychological phenomenon, that doesn’t mean SLPs can’t do anything. Quite the contrary.

The National Institute on Neurological Disorders and Stroke estimates that one million Americans have some form of aphasia.

Aphasia is a communication disorder caused by damage to the brain’s language capabilities. Aphasia differs from apraxia of speech and dysarthria in that it solely pertains to the brain’s speech and language center.

As such anyone can suffer from aphasia because brain damage can be caused by a number of factors. However SLPs are most likely to encounter aphasia in adults, especially those who have had a stroke. Other common causes of aphasia are brain tumors, traumatic brain injuries, and degenerative brain diseases.

In addition to neurologists, speech language pathologists have an important role in diagnosing aphasia. As an SLP you’ll assess factors such as a person’s reading and writing, functional communication, auditory comprehension, and verbal expression.

Speech Delay – Alalia

A speech delay, known to professionals as alalia, refers to the phenomenon when a child is not making normal attempts to verbally communicate. There can be a number of factors causing this to happen, and that’s why it’s critical for a speech language pathologist to be involved.

The are many potential reasons why a child would not be using age-appropriate communication. These can range anywhere from the child being a “late bloomer” – the child just takes a bit longer than average to speak – to the child having brain damage. It is the role of an SLP to go through a process of elimination, evaluating each possibility that could cause a speech delay, until an explanation is found.

Approaching a child with a speech delay starts by distinguishing among the two main categories an SLP will evaluate: speech and language.

Speech has a lot to do with the organs of speech – the tongue, mouth, and vocal chords – as well as the muscles and nerves that connect them with the brain. Disorders like apraxia of speech and dysarthria are two examples that affect the nerve connections and organs of speech. Other examples in this category could include a cleft palette or even hearing loss.

The other major category SLPs will evaluate is language. This relates more to the brain and can be affected by brain damage or developmental disorders like autism. There are many different types of brain damage that each manifest themselves differently, as well as developmental disorders, and the SLP will make evaluations for everything.

Issues Related to Autism

While the autism spectrum itself isn’t a speech disorder, it makes this list because the two go hand-in-hand more often than not.

The Centers for Disease Control and Prevention (CDC) reports that one out of every 68 children in our country have an autism spectrum disorder. And by definition, all children who have autism also have social communication problems.

Speech-language pathologists are often a critical voice on a team of professionals – also including pediatricians, occupational therapists, neurologists, developmental specialists, and physical therapists – who make an autism spectrum diagnosis .

In fact, the American Speech-Language Hearing Association reports that problems with communication are the first detectable signs of autism. That is why language disorders – specifically disordered verbal and nonverbal communication – are one of the primary diagnostic criteria for autism.

So what kinds of SLP disorders are you likely to encounter with someone on the autism spectrum?

A big one is apraxia of speech. A study that came out of Penn State in 2015 found that 64 percent of children who were diagnosed with autism also had childhood apraxia of speech.

This basic primer on the most common speech disorders offers little more than an interesting glimpse into the kind of issues that SLPs work with patients to resolve. But even knowing everything there is to know about communication science and speech disorders doesn’t tell the whole story of what this profession is all about. With every client in every therapy session, the goal is always to have the folks that come to you for help leave with a little more confidence than when they walked in the door that day. As a trusted SLP, you will build on those gains with every session, helping clients experience the joy and freedom that comes with the ability to express themselves freely. At the end of the day, this is what being an SLP is all about.

Ready to make a difference in speech pathology? Learn how to become a Speech-Language Pathologist today

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• Arizona State University - Online - Online Bachelor of Science in Speech and Hearing Science - Designed to prepare graduates to work in behavioral health settings or transition to graduate programs in speech-language pathology and audiology.
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Healthcare Technology Featured Article

• 8 Causes Of Speech Difficulties In Children

There are lots of different reasons for this, from the physical to the mental, there are a number of key reasons that these children may have difficulty speaking or communicating.

If your child or a child that you care for is experiencing speech difficulties, it’s important to address the issue as soon as possible. But in order to do so, you need to understand what is causing the problem. This is crucial for effective diagnosis and treatment.

To give you a better understanding of common speech difficulties and what your child might be going through, we’re going to share some of the most common causes. These include:

1. Developmental delays

It’s first worth noting that some children will develop speech and language skills more slowly than their peers without any underlying condition. This is not something to be concerned about, we are all different and everyone learns at a different speed. 

Not only this but some may suffer with cognitive development delays that can impact their speech and language acquisition. Again, this can be minor and nothing to worry about but in some cases, it can be more severe and can impact their speech, as well as their social skills and ability to take care of themselves in the future. 

2. Hearing impairment

Children with partial or complete hearing loss may struggle with their speech. This is because they cannot hear the sounds they need to replicate and it is much harder for them to have conversations and interact with their peers in the same way. 

It also makes it harder to teach them in traditional ways such as through reading, song and games, techniques that are often recommended by speech and language therapists. 

Similarly, those who suffer from recurrent ear infections as a young child may find they have temporary hearing loss. This can also affect their speech development, but often this is a short-term issue. 

3. Neurological disorders

There are also several neurological reasons that your child may be suffering from a speech difficulty.

Many children with Autism Spectrum Disorder (ASD) have speech and language difficulties because this can impact their auditory processing and motor skills.

Similarly, Developmental Apraxia of Speech (DAS) is a motor speech disorder where children have trouble planning and coordinating the movements they need to speak. Some children with Autism can also suffer from DAS.

Another neurological disorder is Cerebral Palsy. Though the severity of this can vary, this disorder affects the movement and muscle tone of children and can impact the key muscles needed for speech.

4. Physical impairments

It’s not just neurological conditions that cause problems, physical impairments like cleft lip or palate can make speech articulation much harder for sufferers. As can conditions like dysarthria. This is weakness in the muscles required for speech and can hinder the child’s ability to speak clearly.

5. Genetic syndromes

There are two key genetic syndromes that can impact a child’s ability to speak and again, this can differ in severity.

Children with Down syndrome often have speech and language delays because of differences in their oral structure and function. For example, they may have weaker oral muscles, less muscle tone and a smaller upper jaw which can all affect their speech.

Similarly, Fragile X Syndrome is a genetic condition that affects a person's development and ability to learn. This can result in speech delays and language difficulties.

6. Psychological and emotional factors

Deep-routed psychological issues can stop a child from speaking, for example, selective mutism. This is a complex anxiety disorder where a child is unable to speak in certain situations.

Psychological trauma or extreme stress can also have the same impact on speech, either stunting a child’s development or pushing them towards selective mutism anyway. 

7. Environmental factors

It is an unfortunate reality that children who are not exposed to enough language stimulation at home may experience delays. Those who are not given stimulation by way of toys, role play, reading, music and even TV can take longer to learn how to speak and communicate.

Interestingly, bilingualism, while not a disorder, can also cause problems in the early stages. Children who are learning multiple languages simultaneously might experience temporary speech delays as they navigate both languages.

In this case, although this may be potentially alarming at first, it can leave your child with more specialist linguistic skills later in life and obviously the ability to communicate in multiple languages, which is great.

8. Illness and injury

Finally, there are some other medical conditions that can affect speech. Infections and illnesses can temporarily or even permanently impact speech, though these are less common in young children.

Traumatic brain injuries can also stunt or stop their speech development. This can happen if the trauma or injury affects the areas of the brain responsible for speech and language.

Diagnosis and intervention

Early diagnosis and intervention are the key to managing speech delays or difficulties in children. If you're worried about a child in your care, speech and language therapists can conduct comprehensive assessments to determine the cause of the issues and develop an individualised treatment plan to tackle this.

Some of these interventions or treatment plans might include:

• Speech therapy using tailored exercises and activities to improve their speaking skills
• Hearing aids or cochlear implants may be given to children with hearing impairments
• Other medical treatment can be given to address underlying conditions or infections or counselling may be offered to those stunted by psychological and emotional factors like anxiety or trauma
• Family education and support may be given to help parents or caregivers understand and support their child's learning and speech development

But in order to ensure that the correct course of treatment is given, you first need to first identify which of these causes is affecting your child. That way, the appropriate strategies can be implemented to help them overcome their speech difficulties and improve their communication skills for the future. 

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What is Angelman syndrome? Genetic disorder inspires Colin Farrell to start foundation

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Colin Farrell says his personal life has inspired him to launch a new foundation aimed at helping people with intellectual disabilities.

The actor, 48, recently launched the Colin Farrell Foundation, which "committed to transforming the lives of individuals and families living with intellectual disability through education, awareness, advocacy, and innovative programs,"  according to its website .

Farrell has personal experience with family members who have an intellectual disability. His 20-year-old son, James, whom he shares with his ex-partner Kim Bordenave, was diagnosed with Angelman syndrome as a child.

In a recent interview with People, Farrell, who had not publicly spoken much about the diagnosis before, said James will turn 21 in September and will age out of the support systems that are provided to families with children who have special needs.

Farrell said his foundation will provide support for those adult children with intellectual disabilities through "advocacy, education and innovative programs," People reported. He will serve as president of the organization.

Here's what to know about Angelman syndrome.

'He's magic': Colin Farrell opens up on son's Angelman syndrome

What is Angelman syndrome?

Angelman syndrome is a rare neuro-genetic disorder caused by a loss of function of the UBE3A gene that happens during fetal development, and causes developmental delays, intellectual disability, movement issues and speech impairments, according to the Cleveland Clinic. There is no cure for the disorder.

It is named after Dr. Harry Angelman, and English physician who first described the condition in 1965.

The disorder is rare , affecting around one in 12,000 to 20,000 people, the Cleveland Clinic says.

Is Angelman syndrome passed down from parents?

The majority of Angelman syndrome cases are the result of a spontaneous gene mutation, which means it is not passed down from the biological parents to a child.

Angelman syndrome equally affects males and females.

What are the symptoms of Angelman syndrome?

People with Angelman syndrome will show developmental delays that are noticeable between 6-12 months, and seizures often begin around 2-3 years of age.

Features that can point to the disorder include developmental delays, speech impediments, intellectual delays, problems with movement and balance and recurrent seizures, according to the National Institute of Neurological Disorders and Stroke.

Gastrointestinal, orthopedic and eye problems are also common, as well as hyperactivity and a short attention span.

In addition to the neurological symptoms, people with Angelman Syndrome may have distinct facial characteristics , the Cleveland Clinic says, including a small head, wide mouth, large tongue, widely-spaced teeth and a large lower jaw.

Children with Angelman syndrome typically have a "happy, excitable attitude," according to the Cleveland Clinic, and can frequently, laugh, smile and make hand-flapping motions.

How is Angelman syndrome treated?

As there is no cure for the genetic disorder. Treatment for Angelman syndrome often focuses on managing medical problems and developmental delays, according to Boston Children's Hospital.

Treatment can include medication for seizures, physical therapy, speech therapy, occupational therapy and behavioral therapy.

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Speech Sound Disorders-Articulation and Phonology

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See the Speech Sound Disorders Evidence Map for summaries of the available research on this topic.

The scope of this page is speech sound disorders with no known cause—historically called articulation and phonological disorders —in preschool and school-age children (ages 3–21).

Information about speech sound problems related to motor/neurological disorders, structural abnormalities, and sensory/perceptual disorders (e.g., hearing loss) is not addressed in this page.

See ASHA's Practice Portal pages on Childhood Apraxia of Speech and Cleft Lip and Palate for information about speech sound problems associated with these two disorders. A Practice Portal page on dysarthria in children will be developed in the future.

Speech Sound Disorders

Speech sound disorders is an umbrella term referring to any difficulty or combination of difficulties with perception, motor production, or phonological representation of speech sounds and speech segments—including phonotactic rules governing permissible speech sound sequences in a language.

Speech sound disorders can be organic or functional in nature. Organic speech sound disorders result from an underlying motor/neurological, structural, or sensory/perceptual cause. Functional speech sound disorders are idiopathic—they have no known cause. See figure below.

Organic Speech Sound Disorders

Organic speech sound disorders include those resulting from motor/neurological disorders (e.g., childhood apraxia of speech and dysarthria), structural abnormalities (e.g., cleft lip/palate and other structural deficits or anomalies), and sensory/perceptual disorders (e.g., hearing loss).

Functional Speech Sound Disorders

Functional speech sound disorders include those related to the motor production of speech sounds and those related to the linguistic aspects of speech production. Historically, these disorders are referred to as articulation disorders and phonological disorders , respectively. Articulation disorders focus on errors (e.g., distortions and substitutions) in production of individual speech sounds. Phonological disorders focus on predictable, rule-based errors (e.g., fronting, stopping, and final consonant deletion) that affect more than one sound. It is often difficult to cleanly differentiate between articulation and phonological disorders; therefore, many researchers and clinicians prefer to use the broader term, "speech sound disorder," when referring to speech errors of unknown cause. See Bernthal, Bankson, and Flipsen (2017) and Peña-Brooks and Hegde (2015) for relevant discussions.

This Practice Portal page focuses on functional speech sound disorders. The broad term, "speech sound disorder(s)," is used throughout; articulation error types and phonological error patterns within this diagnostic category are described as needed for clarity.

Procedures and approaches detailed in this page may also be appropriate for assessing and treating organic speech sound disorders. See Speech Characteristics: Selected Populations [PDF] for a brief summary of selected populations and characteristic speech problems.

Incidence and Prevalence

The incidence of speech sound disorders refers to the number of new cases identified in a specified period. The prevalence of speech sound disorders refers to the number of children who are living with speech problems in a given time period.

Estimated prevalence rates of speech sound disorders vary greatly due to the inconsistent classifications of the disorders and the variance of ages studied. The following data reflect the variability:

• Overall, 2.3% to 24.6% of school-aged children were estimated to have speech delay or speech sound disorders (Black, Vahratian, & Hoffman, 2015; Law, Boyle, Harris, Harkness, & Nye, 2000; Shriberg, Tomblin, & McSweeny, 1999; Wren, Miller, Peters, Emond, & Roulstone, 2016).
• A 2012 survey from the National Center for Health Statistics estimated that, among children with a communication disorder, 48.1% of 3- to 10-year old children and 24.4% of 11- to 17-year old children had speech sound problems only. Parents reported that 67.6% of children with speech problems received speech intervention services (Black et al., 2015).
• Residual or persistent speech errors were estimated to occur in 1% to 2% of older children and adults (Flipsen, 2015).
• Reports estimated that speech sound disorders are more prevalent in boys than in girls, with a ratio ranging from 1.5:1.0 to 1.8:1.0 (Shriberg et al., 1999; Wren et al., 2016).
• Prevalence rates were estimated to be 5.3% in African American children and 3.8% in White children (Shriberg et al., 1999).
• Reports estimated that 11% to 40% of children with speech sound disorders had concomitant language impairment (Eadie et al., 2015; Shriberg et al., 1999).
• Poor speech sound production skills in kindergarten children have been associated with lower literacy outcomes (Overby, Trainin, Smit, Bernthal, & Nelson, 2012). Estimates reported a greater likelihood of reading disorders (relative risk: 2.5) in children with a preschool history of speech sound disorders (Peterson, Pennington, Shriberg, & Boada, 2009).

Signs and Symptoms

Signs and symptoms of functional speech sound disorders include the following:

• omissions/deletions —certain sounds are omitted or deleted (e.g., "cu" for "cup" and "poon" for "spoon")
• substitutions —one or more sounds are substituted, which may result in loss of phonemic contrast (e.g., "thing" for "sing" and "wabbit" for "rabbit")
• additions —one or more extra sounds are added or inserted into a word (e.g., "buhlack" for "black")
• distortions —sounds are altered or changed (e.g., a lateral "s")
• syllable-level errors —weak syllables are deleted (e.g., "tephone" for "telephone")

Signs and symptoms may occur as independent articulation errors or as phonological rule-based error patterns (see ASHA's resource on selected phonological processes [patterns] for examples). In addition to these common rule-based error patterns, idiosyncratic error patterns can also occur. For example, a child might substitute many sounds with a favorite or default sound, resulting in a considerable number of homonyms (e.g., shore, sore, chore, and tore might all be pronounced as door ; Grunwell, 1987; Williams, 2003a).

Influence of Accent

An accent is the unique way that speech is pronounced by a group of people speaking the same language and is a natural part of spoken language. Accents may be regional; for example, someone from New York may sound different than someone from South Carolina. Foreign accents occur when a set of phonetic traits of one language are carried over when a person learns a new language. The first language acquired by a bilingual or multilingual individual can influence the pronunciation of speech sounds and the acquisition of phonotactic rules in subsequently acquired languages. No accent is "better" than another. Accents, like dialects, are not speech or language disorders but, rather, only reflect differences. See ASHA's Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology and Cultural Responsiveness .

Influence of Dialect

Not all sound substitutions and omissions are speech errors. Instead, they may be related to a feature of a speaker's dialect (a rule-governed language system that reflects the regional and social background of its speakers). Dialectal variations of a language may cross all linguistic parameters, including phonology, morphology, syntax, semantics, and pragmatics. An example of a dialectal variation in phonology occurs with speakers of African American English (AAE) when a "d" sound is used for a "th" sound (e.g., "dis" for "this"). This variation is not evidence of a speech sound disorder but, rather, one of the phonological features of AAE.

Speech-language pathologists (SLPs) must distinguish between dialectal differences and communicative disorders and must

• recognize all dialects as being rule-governed linguistic systems;
• understand the rules and linguistic features of dialects represented by their clientele; and
• be familiar with nondiscriminatory testing and dynamic assessment procedures, such as identifying potential sources of test bias, administering and scoring standardized tests using alternative methods, and analyzing test results in light of existing information regarding dialect use (see, e.g., McLeod, Verdon, & The International Expert Panel on Multilingual Children's Speech, 2017).

See ASHA's Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology and Cultural Responsiveness .

The cause of functional speech sound disorders is not known; however, some risk factors have been investigated.

Frequently reported risk factors include the following:

• Gender —the incidence of speech sound disorders is higher in males than in females (e.g., Everhart, 1960; Morley, 1952; Shriberg et al., 1999).
• Pre- and perinatal problems —factors such as maternal stress or infections during pregnancy, complications during delivery, preterm delivery, and low birthweight were found to be associated with delay in speech sound acquisition and with speech sound disorders (e.g., Byers Brown, Bendersky, & Chapman, 1986; Fox, Dodd, & Howard, 2002).
• Family history —children who have family members (parents or siblings) with speech and/or language difficulties were more likely to have a speech disorder (e.g., Campbell et al., 2003; Felsenfeld, McGue, & Broen, 1995; Fox et al., 2002; Shriberg & Kwiatkowski, 1994).
• Persistent otitis media with effusion —persistent otitis media with effusion (often associated with hearing loss) has been associated with impaired speech development (Fox et al., 2002; Silva, Chalmers, & Stewart, 1986; Teele, Klein, Chase, Menyuk, & Rosner, 1990).

Roles and Responsibilities

Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of persons with speech sound disorders. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016).

Appropriate roles for SLPs include the following:

• Providing prevention information to individuals and groups known to be at risk for speech sound disorders, as well as to individuals working with those at risk
• Educating other professionals on the needs of persons with speech sound disorders and the role of SLPs in diagnosing and managing speech sound disorders
• Screening individuals who present with speech sound difficulties and determining the need for further assessment and/or referral for other services
• Recognizing that students with speech sound disorders have heightened risks for later language and literacy problems
• Conducting a culturally and linguistically relevant comprehensive assessment of speech, language, and communication
• Taking into consideration the rules of a spoken accent or dialect, typical dual-language acquisition from birth, and sequential second-language acquisition to distinguish difference from disorder
• Diagnosing the presence or absence of a speech sound disorder
• Referring to and collaborating with other professionals to rule out other conditions, determine etiology, and facilitate access to comprehensive services
• Making decisions about the management of speech sound disorders
• Making decisions about eligibility for services, based on the presence of a speech sound disorder
• Developing treatment plans, providing intervention and support services, documenting progress, and determining appropriate service delivery approaches and dismissal criteria
• Counseling persons with speech sound disorders and their families/caregivers regarding communication-related issues and providing education aimed at preventing further complications related to speech sound disorders
• Serving as an integral member of an interdisciplinary team working with individuals with speech sound disorders and their families/caregivers (see ASHA's resource on interprofessional education/interprofessional practice [IPE/IPP] )
• Consulting and collaborating with professionals, family members, caregivers, and others to facilitate program development and to provide supervision, evaluation, and/or expert testimony (see ASHA's resource on person- and family-centered care )
• Remaining informed of research in the area of speech sound disorders, helping advance the knowledge base related to the nature and treatment of these disorders, and using evidence-based research to guide intervention
• Advocating for individuals with speech sound disorders and their families at the local, state, and national levels

As indicated in the Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so.

See the Assessment section of the Speech Sound Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Screening is conducted whenever a speech sound disorder is suspected or as part of a comprehensive speech and language evaluation for a child with communication concerns. The purpose of the screening is to identify individuals who require further speech-language assessment and/or referral for other professional services.

Screening typically includes

• screening of individual speech sounds in single words and in connected speech (using formal and or informal screening measures);
• screening of oral motor functioning (e.g., strength and range of motion of oral musculature);
• orofacial examination to assess facial symmetry and identify possible structural bases for speech sound disorders (e.g., submucous cleft palate, malocclusion, ankyloglossia); and
• informal assessment of language comprehension and production.

See ASHA's resource on assessment tools, techniques, and data sources .

Screening may result in

• recommendation to monitor speech and rescreen;
• referral for multi-tiered systems of support such as response to intervention (RTI) ;
• referral for a comprehensive speech sound assessment;
• recommendation for a comprehensive language assessment, if language delay or disorder is suspected;
• referral to an audiologist for a hearing evaluation, if hearing loss is suspected; and
• referral for medical or other professional services, as appropriate.

Comprehensive Assessment

The acquisition of speech sounds is a developmental process, and children often demonstrate "typical" errors and phonological patterns during this acquisition period. Developmentally appropriate errors and patterns are taken into consideration during assessment for speech sound disorders in order to differentiate typical errors from those that are unusual or not age appropriate.

The comprehensive assessment protocol for speech sound disorders may include an evaluation of spoken and written language skills, if indicated. See ASHA's Practice Portal pages on Spoken Language Disorders and Written Language Disorders .

Assessment is accomplished using a variety of measures and activities, including both standardized and nonstandardized measures, as well as formal and informal assessment tools. See ASHA's resource on assessment tools, techniques, and data sources .

SLPs select assessments that are culturally and linguistically sensitive, taking into consideration current research and best practice in assessing speech sound disorders in the languages and/or dialect used by the individual (see, e.g., McLeod et al., 2017). Standard scores cannot be reported for assessments that are not normed on a group that is representative of the individual being assessed.

SLPs take into account cultural and linguistic speech differences across communities, including

• phonemic and allophonic variations of the language(s) and/or dialect(s) used in the community and how those variations affect determination of a disorder or a difference and
• differences among speech sound disorders, accents, dialects, and patterns of transfer from one language to another. See phonemic inventories and cultural and linguistic information across languages .

Consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016a; WHO, 2001), a comprehensive assessment is conducted to identify and describe

• impairments in body structure and function, including underlying strengths and weaknesses in speech sound production and verbal/nonverbal communication;
• co-morbid deficits or conditions, such as developmental disabilities, medical conditions, or syndromes;
• limitations in activity and participation, including functional communication, interpersonal interactions with family and peers, and learning;
• contextual (environmental and personal) factors that serve as barriers to or facilitators of successful communication and life participation; and
• the impact of communication impairments on quality of life of the child and family.

See ASHA's Person-Centered Focus on Function: Speech Sound Disorder [PDF] for an example of assessment data consistent with ICF.

Assessment may result in

• diagnosis of a speech sound disorder;
• description of the characteristics and severity of the disorder;
• recommendations for intervention targets;
• identification of factors that might contribute to the speech sound disorder;
• diagnosis of a spoken language (listening and speaking) disorder;
• identification of written language (reading and writing) problems;
• recommendation to monitor reading and writing progress in students with identified speech sound disorders by SLPs and other professionals in the school setting;
• referral for multi-tiered systems of support such as response to intervention (RTI) to support speech and language development; and
• referral to other professionals as needed.

Case History

The case history typically includes gathering information about

• the family's concerns about the child's speech;
• history of middle ear infections;
• family history of speech and language difficulties (including reading and writing);
• languages used in the home;
• primary language spoken by the child;
• the family's and other communication partners' perceptions of intelligibility; and
• the teacher's perception of the child's intelligibility and participation in the school setting and how the child's speech compares with that of peers in the classroom.

See ASHA's Practice Portal page on Cultural Responsiveness for guidance on taking a case history with all clients.

Oral Mechanism Examination

The oral mechanism examination evaluates the structure and function of the speech mechanism to assess whether the system is adequate for speech production. This examination typically includes assessment of

• dental occlusion and specific tooth deviations;
• structure of hard and soft palate (clefts, fistulas, bifid uvula); and
• function (strength and range of motion) of the lips, jaw, tongue, and velum.

Hearing Screening

A hearing screening is conducted during the comprehensive speech sound assessment, if one was not completed during the screening.

Hearing screening typically includes

• otoscopic inspection of the ear canal and tympanic membrane;
• pure-tone audiometry; and
• immittance testing to assess middle ear function.

Speech Sound Assessment

The speech sound assessment uses both standardized assessment instruments and other sampling procedures to evaluate production in single words and connected speech.

Single-word testing provides identifiable units of production and allows most consonants in the language to be elicited in a number of phonetic contexts; however, it may or may not accurately reflect production of the same sounds in connected speech.

Connected speech sampling provides information about production of sounds in connected speech using a variety of talking tasks (e.g., storytelling or retelling, describing pictures, normal conversation about a topic of interest) and with a variety of communication partners (e.g., peers, siblings, parents, and clinician).

Assessment of speech includes evaluation of the following:

• Accurate productions
• sounds in various word positions (e.g., initial, within word, and final word position) and in different phonetic contexts;
• sound combinations such as vowel combinations, consonant clusters, and blends; and
• syllable shapes —simple CV to complex CCVCC.
• Speech sound errors
• consistent sound errors;
• error types (e.g., deletions, omissions, substitutions, distortions, additions); and
• error distribution (e.g., position of sound in word).
• Error patterns (i.e., phonological patterns)—systematic sound changes or simplifications that affect a class of sounds (e.g., fricatives), sound combinations (e.g., consonant clusters), or syllable structures (e.g., complex syllables or multisyllabic words).

See Age of Acquisition of English Consonants (Crowe & McLeaod, 2020) [PDF] and ASHA's resource on selected phonological processes (patterns) .

Severity Assessment

Severity is a qualitative judgment made by the clinician indicating the impact of the child's speech sound disorder on functional communication. It is typically defined along a continuum from mild to severe or profound. There is no clear consensus regarding the best way to determine severity of a speech sound disorder—rating scales and quantitative measures have been used.

A numerical scale or continuum of disability is often used because it is time-efficient. Prezas and Hodson (2010) use a continuum of severity from mild (omissions are rare; few substitutions) to profound (extensive omissions and many substitutions; extremely limited phonemic and phonotactic repertoires). Distortions and assimilations occur in varying degrees at all levels of the continuum.

A quantitative approach (Shriberg & Kwiatkowski, 1982a, 1982b) uses the percentage of consonants correct (PCC) to determine severity on a continuum from mild to severe.

To determine PCC, collect and phonetically transcribe a speech sample. Then count the total number of consonants in the sample and the total number of correct consonants. Use the following formula:

PCC = (correct consonants/total consonants) × 100

A PCC of 85–100 is considered mild, whereas a PCC of less than 50 is considered severe. This approach has been modified to include a total of 10 such indices, including percent vowels correct (PVC; Shriberg, Austin, Lewis, McSweeny, & Wilson, 1997).

Intelligibility Assessment

Intelligibility is a perceptual judgment that is based on how much of the child's spontaneous speech the listener understands. Intelligibility can vary along a continuum ranging from intelligible (message is completely understood) to unintelligible (message is not understood; Bernthal et al., 2017). Intelligibility is frequently used when judging the severity of the child's speech problem (Kent, Miolo, & Bloedel, 1994; Shriberg & Kwiatkowski, 1982b) and can be used to determine the need for intervention.

Intelligibility can vary depending on a number of factors, including

• the number, type, and frequency of speech sound errors (when present);
• the speaker's rate, inflection, stress patterns, pauses, voice quality, loudness, and fluency;
• linguistic factors (e.g., word choice and grammar);
• complexity of utterance (e.g., single words vs. conversational or connected speech);
• the listener's familiarity with the speaker's speech pattern;
• communication environment (e.g., familiar vs. unfamiliar communication partners, one-on-one vs. group conversation);
• communication cues for listener (e.g., nonverbal cues from the speaker, including gestures and facial expressions); and
• signal-to-noise ratio (i.e., amount of background noise).

Rating scales and other estimates that are based on perceptual judgments are commonly used to assess intelligibility. For example, rating scales sometimes use numerical ratings like 1 for totally intelligible and 10 for unintelligible, or they use descriptors like not at all, seldom, sometimes, most of the time, or always to indicated how well speech is understood (Ertmer, 2010).

A number of quantitative measures also have been proposed, including calculating the percentage of words understood in conversational speech (e.g., Flipsen, 2006; Shriberg & Kwiatkowski, 1980). See also Kent et al. (1994) for a comprehensive review of procedures for assessing intelligibility.

Coplan and Gleason (1988) developed a standardized intelligibility screener using parent estimates of how intelligible their child sounded to others. On the basis of the data, expected intelligibility cutoff values for typically developing children were as follows:

22 months—50%

37 months—75%

47 months—100%

See the Resources section for resources related to assessing intelligibility and life participation in monolingual children who speak English and in monolingual children who speak languages other than English.

Stimulability Testing

Stimulability is the child's ability to accurately imitate a misarticulated sound when the clinician provides a model. There are few standardized procedures for testing stimulability (Glaspey & Stoel-Gammon, 2007; Powell & Miccio, 1996), although some test batteries include stimulability subtests.

Stimulability testing helps determine

• how well the child imitates the sound in one or more contexts (e.g., isolation, syllable, word, phrase);
• the level of cueing necessary to achieve the best production (e.g., auditory model; auditory and visual model; auditory, visual, and verbal model; tactile cues);
• whether the sound is likely to be acquired without intervention; and
• which targets are appropriate for therapy (Tyler & Tolbert, 2002).

Speech Perception Testing

Speech perception is the ability to perceive differences between speech sounds. In children with speech sound disorders, speech perception is the child's ability to perceive the difference between the standard production of a sound and his or her own error production—or to perceive the contrast between two phonetically similar sounds (e.g., r/w, s/ʃ, f/θ).

Speech perception abilities can be tested using the following paradigms:

• Auditory Discrimination —syllable pairs containing a single phoneme contrast are presented, and the child is instructed to say "same" if the paired items sound the same and "different" if they sound different.
• Picture Identification —the child is shown two to four pictures representing words with minimal phonetic differences. The clinician says one of these words, and the child is asked to point to the correct picture.
• Speech production–perception task —using sounds that the child is suspected of having difficulty perceiving, picture targets containing these sounds are used as visual cues. The child is asked to judge whether the speaker says the item correctly (e.g., picture of a ship is shown; speaker says, "ship" or "sip"; Locke, 1980).
• Mispronunciation detection task —using computer-presented picture stimuli and recorded stimulus names (either correct or with a single phoneme error), the child is asked to detect mispronunciations by pointing to a green tick for "correct" or a red cross for "incorrect" (McNeill & Hesketh, 2010).
• Lexical decision/judgment task —using target pictures and single-word recordings, this task assesses the child's ability to identify words that are pronounced correctly or incorrectly. A picture of the target word (e.g., "lake") is shown, along with a recorded word—either "lake" or a word with a contrasting phoneme (e.g., "wake"). The child points to the picture of the target word if it was pronounced correctly or to an "X" if it was pronounced incorrectly (Rvachew, Nowak, & Cloutier, 2004).

Considerations For Assessing Young Children and/or Children Who Are Reluctant or Have Less Intelligible Speech

Young children might not be able to follow directions for standardized tests, might have limited expressive vocabulary, and might produce words that are unintelligible. Other children, regardless of age, may produce less intelligible speech or be reluctant to speak in an assessment setting.

Strategies for collecting an adequate speech sample with these populations include

• obtaining a speech sample during the assessment session using play activities;
• using pictures or toys to elicit a range of consonant sounds;
• involving parents/caregivers in the session to encourage talking;
• asking parents/caregivers to supplement data from the assessment session by recording the child's speech at home during spontaneous conversation; and
• asking parents/caregivers to keep a log of the child's intended words and how these words are pronounced.

Sometimes, the speech sound disorder is so severe that the child's intended message cannot be understood. However, even when a child's speech is unintelligible, it is usually possible to obtain information about his or her speech sound production.

For example:

• A single-word articulation test provides opportunities for production of identifiable units of sound, and these productions can usually be transcribed.
• It may be possible to understand and transcribe a spontaneous speech sample by (a) using a structured situation to provide context when obtaining the sample and (b) annotating the recorded sample by repeating the child's utterances, when possible, to facilitate later transcription.

Considerations For Assessing Bilingual/Multilingual Populations

Assessment of a bilingual individual requires an understanding of both linguistic systems because the sound system of one language can influence the sound system of another language. The assessment process must identify whether differences are truly related to a speech sound disorder or are normal variations of speech caused by the first language.

When assessing a bilingual or multilingual individual, clinicians typically

• gather information, including
• language history and language use to determine which language(s) should be assessed,
• phonemic inventory, phonological structure, and syllable structure of the non-English language, and
• dialect of the individual;
• assess phonological skills in both languages in single words as well as in connected speech;
• account for dialectal differences, when present; and
• identify and assess the child's
• common substitution patterns (those seen in typically developing children),
• uncommon substitution patterns (those often seen in individuals with a speech sound disorder), and
• cross-linguistic effects (the phonological system of one's native language influencing the production of sounds in English, resulting in an accent—that is, phonetic traits from a person's original language (L1) that are carried over to a second language (L2; Fabiano-Smith & Goldstein, 2010).

See phonemic inventories and cultural and linguistic information across languages and ASHA's Practice Portal page on Multilingual Service Delivery in Audiology and Speech-Language Pathology . See the Resources section for information related to assessing intelligibility and life participation in monolingual children who speak English and in monolingual children who speak languages other than English.

Phonological Processing Assessment

Phonological processing is the use of the sounds of one's language (i.e., phonemes) to process spoken and written language (Wagner & Torgesen, 1987). The broad category of phonological processing includes phonological awareness , phonological working memory , and phonological retrieval .

All three components of phonological processing (see definitions below) are important for speech production and for the development of spoken and written language skills. Therefore, it is important to assess phonological processing skills and to monitor the spoken and written language development of children with phonological processing difficulties.

• Phonological Awareness is the awareness of the sound structure of a language and the ability to consciously analyze and manipulate this structure via a range of tasks, such as speech sound segmentation and blending at the word, onset-rime, syllable, and phonemic levels.
• Phonological Working Memory involves storing phoneme information in a temporary, short-term memory store (Wagner & Torgesen, 1987). This phonemic information is then readily available for manipulation during phonological awareness tasks. Nonword repetition (e.g., repeat "/pæɡ/") is one example of a phonological working memory task.
• Phonological Retrieval is the ability to retrieve phonological information from long-term memory. It is typically assessed using rapid naming tasks (e.g., rapid naming of objects, colors, letters, or numbers). This ability to retrieve the phonological information of one's language is integral to phonological awareness.

Language Assessments

Language testing is included in a comprehensive speech sound assessment because of the high incidence of co-occurring language problems in children with speech sound disorders (Shriberg & Austin, 1998).

Spoken Language Assessment (Listening and Speaking)

Typically, the assessment of spoken language begins with a screening of expressive and receptive skills; a full battery is performed if indicated by screening results. See ASHA's Practice Portal page on Spoken Language Disorders for more details.

Written Language Assessment (Reading and Writing)

Difficulties with the speech processing system (e.g., listening, discriminating speech sounds, remembering speech sounds, producing speech sounds) can lead to speech production and phonological awareness difficulties. These difficulties can have a negative impact on the development of reading and writing skills (Anthony et al., 2011; Catts, McIlraith, Bridges, & Nielsen, 2017; Leitão & Fletcher, 2004; Lewis et al., 2011).

For typically developing children, speech production and phonological awareness develop in a mutually supportive way (Carroll, Snowling, Stevenson, & Hulme, 2003; National Institute for Literacy, 2009). As children playfully engage in sound play, they eventually learn to segment words into separate sounds and to "map" sounds onto printed letters.

The understanding that sounds are represented by symbolic code (e.g., letters and letter combinations) is essential for reading and spelling. When reading, children have to be able to segment a written word into individual sounds, based on their knowledge of the code and then blend those sounds together to form a word. When spelling, children have to be able to segment a spoken word into individual sounds and then choose the correct code to represent these sounds (National Institute of Child Health and Human Development, 2000; Pascoe, Stackhouse, & Wells, 2006).

Components of the written language assessment include the following, depending on the child's age and expected stage of written language development:

• Print Awareness —recognizing that books have a front and back, recognizing that the direction of words is from left to right, and recognizing where words on the page start and stop.
• Alphabet Knowledge —including naming/printing alphabet letters from A to Z.
• Sound–Symbol Correspondence —knowing that letters have sounds and knowing the sounds for corresponding letters and letter combinations.
• Reading Decoding —using sound–symbol knowledge to segment and blend sounds in grade-level words.
• Spelling —using sound–symbol knowledge to spell grade-level words.
• Reading Fluency —reading smoothly without frequent or significant pausing.
• Reading Comprehension —understanding grade-level text, including the ability to make inferences.

See ASHA's Practice Portal page on Written Language Disorders for more details.

See the Treatment section of the Speech Sound Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

The broad term "speech sound disorder(s)" is used in this Portal page to refer to functional speech sound disorders, including those related to the motor production of speech sounds (articulation) and those related to the linguistic aspects of speech production (phonological).

It is often difficult to cleanly differentiate between articulation and phonological errors or to differentially diagnose these two separate disorders. Nevertheless, we often talk about articulation error types and phonological error types within the broad diagnostic category of speech sound disorder(s). A single child might show both error types, and those specific errors might need different treatment approaches.

Historically, treatments that focus on motor production of speech sounds are called articulation approaches; treatments that focus on the linguistic aspects of speech production are called phonological/language-based approaches.

Articulation approaches target each sound deviation and are often selected by the clinician when the child's errors are assumed to be motor based; the aim is correct production of the target sound(s).

Phonological/language-based approaches target a group of sounds with similar error patterns, although the actual treatment of exemplars of the error pattern may target individual sounds. Phonological approaches are often selected in an effort to help the child internalize phonological rules and generalize these rules to other sounds within the pattern (e.g., final consonant deletion, cluster reduction).

Articulation and phonological/language-based approaches might both be used in therapy with the same individual at different times or for different reasons.

Both approaches for the treatment of speech sound disorders typically involve the following sequence of steps:

• Establishment —eliciting target sounds and stabilizing production on a voluntary level.
• Generalization —facilitating carry-over of sound productions at increasingly challenging levels (e.g., syllables, words, phrases/sentences, conversational speaking).
• Maintenance —stabilizing target sound production and making it more automatic; encouraging self-monitoring of speech and self-correction of errors.

Target Selection

Approaches for selecting initial therapy targets for children with articulation and/or phonological disorders include the following:

• Developmental —target sounds are selected on the basis of order of acquisition in typically developing children.
• Complexity —focuses on more complex, linguistically marked phonological elements not in the child's phonological system to encourage cascading, generalized learning of sounds (Gierut, 2007; Storkel, 2018).
• Dynamic systems —focuses on teaching and stabilizing simple target phonemes that do not introduce new feature contrasts in the child's phonological system to assist in the acquisition of target sounds and more complex targets and features (Rvachew & Bernhardt, 2010).
• Systemic —focuses on the function of the sound in the child's phonological organization to achieve maximum phonological reorganization with the least amount of intervention. Target selection is based on a distance metric. Targets can be maximally distinct from the child's error in terms of place, voice, and manner and can also be maximally different in terms of manner, place of production, and voicing (Williams, 2003b). See Place, Manner and Voicing Chart for English Consonants (Roth & Worthington, 2018) .
• Client-specific —selects targets based on factors such as relevance to the child and his or her family (e.g., sound is in child's name), stimulability, and/or visibility when produced (e.g., /f/ vs. /k/).
• Degree of deviance and impact on intelligibility —selects targets on the basis of errors (e.g., errors of omission; error patterns such as initial consonant deletion) that most effect intelligibility.

See ASHA's Person-Centered Focus on Function: Speech Sound Disorder [PDF] for an example of goal setting consistent with ICF.

Treatment Strategies

In addition to selecting appropriate targets for therapy, SLPs select treatment strategies based on the number of intervention goals to be addressed in each session and the manner in which these goals are implemented. A particular strategy may not be appropriate for all children, and strategies may change throughout the course of intervention as the child's needs change.

"Target attack" strategies include the following:

• Vertical —intense practice on one or two targets until the child reaches a specific criterion level (usually conversational level) before proceeding to the next target or targets (see, e.g., Fey, 1986).
• Horizontal —less intense practice on a few targets; multiple targets are addressed individually or interactively in the same session, thus providing exposure to more aspects of the sounds system (see, e.g., Fey, 1986).
• Cyclical —incorporating elements of both horizontal and vertical structures; the child is provided with practice on a given target or targets for some predetermined period of time before moving on to another target or targets for a predetermined period of time. Practice then cycles through all targets again (see, e.g., Hodson, 2010).

Treatment Options

The following are brief descriptions of both general and specific treatments for children with speech sound disorders. These approaches can be used to treat speech sound problems in a variety of populations. See Speech Characteristics: Selected Populations [PDF] for a brief summary of selected populations and characteristic speech problems.

Treatment selection will depend on a number of factors, including the child's age, the type of speech sound errors, the severity of the disorder, and the degree to which the disorder affects overall intelligibility (Williams, McLeod, & McCauley, 2010). This list is not exhaustive, and inclusion does not imply an endorsement from ASHA.

Contextual Utilization Approaches

Contextual utilization approaches recognize that speech sounds are produced in syllable-based contexts in connected speech and that some (phonemic/phonetic) contexts can facilitate correct production of a particular sound.

Contextual utilization approaches may be helpful for children who use a sound inconsistently and need a method to facilitate consistent production of that sound in other contexts. Instruction for a particular sound is initiated in the syllable context(s) where the sound can be produced correctly (McDonald, 1974). The syllable is used as the building block for practice at more complex levels.

For example, production of a "t" may be facilitated in the context of a high front vowel, as in "tea" (Bernthal et al., 2017). Facilitative contexts or "likely best bets" for production can be identified for voiced, velar, alveolar, and nasal consonants. For example, a "best bet" for nasal consonants is before a low vowel, as in "mad" (Bleile, 2002).

Phonological Contrast Approaches

Phonological contrast approaches are frequently used to address phonological error patterns. They focus on improving phonemic contrasts in the child's speech by emphasizing sound contrasts necessary to differentiate one word from another. Contrast approaches use contrasting word pairs as targets instead of individual sounds.

There are four different contrastive approaches— minimal oppositions, maximal oppositions , treatment of the empty set, and multiple oppositions.

• Minimal Oppositions (also known as "minimal pairs" therapy)—uses pairs of words that differ by only one phoneme or single feature signaling a change in meaning. Minimal pairs are used to help establish contrasts not present in the child's phonological system (e.g., "door" vs. "sore," "pot" vs. "spot," "key" vs. "tea"; Blache, Parsons, & Humphreys, 1981; Weiner, 1981).
• Maximal Oppositions —uses pairs of words containing a contrastive sound that is maximally distinct and varies on multiple dimensions (e.g., voice, place, and manner) to teach an unknown sound. For example, "mall" and "call" are maximal pairs because /m/ and /k/ vary on more than one dimension—/m/ is a bilabial voiced nasal, whereas /k/ is a velar voiceless stop (Gierut, 1989, 1990, 1992). See Place, Manner and Voicing Chart for English Consonants (Roth & Worthington, 2018) .
• Treatment of the Empty Set —similar to the maximal oppositions approach but uses pairs of words containing two maximally opposing sounds (e.g., /r/ and /d/) that are unknown to the child (e.g., "row" vs. "doe" or "ray" vs. "day"; Gierut, 1992).
• Multiple Oppositions —a variation of the minimal oppositions approach but uses pairs of words contrasting a child's error sound with three or four strategically selected sounds that reflect both maximal classification and maximal distinction (e.g., "door," "four," "chore," and "store," to reduce backing of /d/ to /g/; Williams, 2000a, 2000b).

Complexity Approach

The complexity approach is a speech production approach based on data supporting the view that the use of more complex linguistic stimuli helps promote generalization to untreated but related targets.

The complexity approach grew primarily from the maximal oppositions approach. However, it differs from the maximal oppositions approach in a number of ways. Rather than selecting targets on the basis of features such as voice, place, and manner, the complexity of targets is determined in other ways. These include hierarchies of complexity (e.g., clusters, fricatives, and affricates are more complex than other sound classes) and stimulability (i.e., sounds with the lowest levels of stimulability are most complex). In addition, although the maximal oppositions approach trains targets in contrasting word pairs, the complexity approach does not. See Baker and Williams (2010) and Peña-Brooks and Hegde (2015) for detailed descriptions of the complexity approach.

Core Vocabulary Approach

A core vocabulary approach focuses on whole-word production and is used for children with inconsistent speech sound production who may be resistant to more traditional therapy approaches.

Words selected for practice are those used frequently in the child's functional communication. A list of frequently used words is developed (e.g., based on observation, parent report, and/or teacher report), and a number of words from this list are selected each week for treatment. The child is taught his or her "best" word production, and the words are practiced until consistently produced (Dodd, Holm, Crosbie, & McIntosh, 2006).

Cycles Approach

The cycles approach targets phonological pattern errors and is designed for children with highly unintelligible speech who have extensive omissions, some substitutions, and a restricted use of consonants.

Treatment is scheduled in cycles ranging from 5 to 16 weeks. During each cycle, one or more phonological patterns are targeted. After each cycle has been completed, another cycle begins, targeting one or more different phonological patterns. Recycling of phonological patterns continues until the targeted patterns are present in the child's spontaneous speech (Hodson, 2010; Prezas & Hodson, 2010).

The goal is to approximate the gradual typical phonological development process. There is no predetermined level of mastery of phonemes or phoneme patterns within each cycle; cycles are used to stimulate the emergence of a specific sound or pattern—not to produce mastery of it.

Distinctive Feature Therapy

Distinctive feature therapy focuses on elements of phonemes that are lacking in a child's repertoire (e.g., frication, nasality, voicing, and place of articulation) and is typically used for children who primarily substitute one sound for another. See Place, Manner and Voicing Chart for English Consonants (Roth & Worthington, 2018) .

Distinctive feature therapy uses targets (e.g., minimal pairs) that compare the phonetic elements/features of the target sound with those of its substitution or some other sound contrast. Patterns of features can be identified and targeted; producing one target sound often generalizes to other sounds that share the targeted feature (Blache & Parsons, 1980; Blache et al., 1981; Elbert & McReynolds, 1978; McReynolds & Bennett, 1972; Ruder & Bunce, 1981).

Metaphon Therapy

Metaphon therapy is designed to teach metaphonological awareness —that is, the awareness of the phonological structure of language. This approach assumes that children with phonological disorders have failed to acquire the rules of the phonological system.

The focus is on sound properties that need to be contrasted. For example, for problems with voicing, the concept of "noisy" (voiced) versus "quiet" (voiceless) is taught. Targets typically include processes that affect intelligibility, can be imitated, or are not seen in typically developing children of the same age (Dean, Howell, Waters, & Reid, 1995; Howell & Dean, 1994).

Naturalistic Speech Intelligibility Intervention

Naturalist speech intelligibility intervention addresses the targeted sound in naturalistic activities that provide the child with frequent opportunities for the sound to occur. For example, using a McDonald's menu, signs at the grocery store, or favorite books, the child can be asked questions about words that contain the targeted sound(s). The child's error productions are recast without the use of imitative prompts or direct motor training. This approach is used with children who are able to use the recasts effectively (Camarata, 2010).

Nonspeech Oral–Motor Therapy

Nonspeech oral–motor therapy involves the use of oral-motor training prior to teaching sounds or as a supplement to speech sound instruction. The rationale behind this approach is that (a) immature or deficient oral-motor control or strength may be causing poor articulation and (b) it is necessary to teach control of the articulators before working on correct production of sounds. Consult systematic reviews of this treatment to help guide clinical decision making (see, e.g., Lee & Gibbon, 2015 [PDF]; McCauley, Strand, Lof, Schooling, & Frymark, 2009 ). See also the Treatment section of the Speech Sound Disorders Evidence Map filtered for Oral–Motor Exercises .

Speech Sound Perception Training

Speech sound perception training is used to help a child acquire a stable perceptual representation for the target phoneme or phonological structure. The goal is to ensure that the child is attending to the appropriate acoustic cues and weighting them according to a language-specific strategy (i.e., one that ensures reliable perception of the target in a variety of listening contexts).

Recommended procedures include (a) auditory bombardment in which many and varied target exemplars are presented to the child, sometimes in a meaningful context such as a story and often with amplification, and (b) identification tasks in which the child identifies correct and incorrect versions of the target (e.g., "rat" is a correct exemplar of the word corresponding to a rodent, whereas "wat" is not).

Tasks typically progress from the child judging speech produced by others to the child judging the accuracy of his or her own speech. Speech sound perception training is often used before and/or in conjunction with speech production training approaches. See Rvachew, 1994; Rvachew et al., 2004; Rvachew, Rafaat, & Martin, 1999; Wolfe, Presley, & Mesaris, 2003.

Traditionally, the speech stimuli used in these tasks are presented via live voice by the SLP. More recently, computer technology has been used—an advantage of this approach is that it allows for the presentation of more varied stimuli representing, for example, multiple voices and a range of error types.

Treatment Techniques and Technologies

Techniques used in therapy to increase awareness of the target sound and/or provide feedback about placement and movement of the articulators include the following:

• Using a mirror for visual feedback of place and movement of articulators
• Using gestural cueing for place or manner of production (e.g., using a long, sweeping hand gesture for fricatives vs. a short, "chopping" gesture for stops)
• Using ultrasound imaging (placement of an ultrasound transducer under the chin) as a biofeedback technique to visualize tongue position and configuration (Adler-Bock, Bernhardt, Gick, & Bacsfalvi, 2007; Lee, Wrench, & Sancibrian, 2015; Preston, Brick, & Landi, 2013; Preston et al., 2014)
• Using palatography (various coloring agents or a palatal device with electrodes) to record and visualize contact of the tongue on the palate while the child makes different speech sounds (Dagenais, 1995; Gibbon, Stewart, Hardcastle, & Crampin, 1999; Hitchcock, McAllister Byun, Swartz, & Lazarus, 2017)
• Amplifying target sounds to improve attention, reduce distractibility, and increase sound awareness and discrimination—for example, auditory bombardment with low-level amplification is used with the cycles approach at the beginning and end of each session to help children perceive differences between errors and target sounds (Hodson, 2010)
• Providing spectral biofeedback through a visual representation of the acoustic signal of speech (McAllister Byun & Hitchcock, 2012)
• Providing tactile biofeedback using tools, devices, or substances placed within the mouth (e.g., tongue depressors, peanut butter) to provide feedback on correct tongue placement and coordination (Altshuler, 1961; Leonti, Blakeley, & Louis, 1975; Shriberg, 1980)

Considerations for Treating Bilingual/Multilingual Populations

When treating a bilingual or multilingual individual with a speech sound disorder, the clinician is working with two or more different sound systems. Although there may be some overlap in the phonemic inventories of each language, there will be some sounds unique to each language and different phonemic rules for each language.

One linguistic sound system may influence production of the other sound system. It is the role of the SLP to determine whether any observed differences are due to a true communication disorder or whether these differences represent variations of speech associated with another language that a child speaks.

Strategies used when designing a treatment protocol include

• determining whether to use a bilingual or cross-linguistic approach (see ASHA's Practice Portal page on Multilingual Service Delivery in Audiology and Speech-Language Pathology );
• determining the language in which to provide services, on the basis of factors such as language history, language use, and communicative needs;
• identifying alternative means of providing accurate models for target phonemes that are unique to the child's language, when the clinician is unable to do so; and
• noting if success generalizes across languages throughout the treatment process (Goldstein & Fabiano, 2007).

Considerations for Treatment in Schools

Criteria for determining eligibility for services in a school setting are detailed in the Individuals with Disabilities Education Improvement Act of 2004 (IDEA). In accordance with these criteria, the SLP needs to determine

• if the child has a speech sound disorder;
• if there is an adverse effect on educational performance resulting from the disability; and
• if specially designed instruction and/or related services and supports are needed to help the student make progress in the general education curriculum.

Examples of the adverse effect on educational performance include the following:

• The speech sound disorder affects the child's ability or willingness to communicate in the classroom (e.g., when responding to teachers' questions; during classroom discussions or oral presentations) and in social settings with peers (e.g., interactions during lunch, recess, physical education, and extracurricular activities).
• The speech sound disorder signals problems with phonological skills that affect spelling, reading, and writing. For example, the way a child spells a word reflects the errors made when the word is spoken. See ASHA's resource language in brief and ASHA's Practice Portal pages on Spoken Language Disorders and Written Language Disorders for more information about the relationship between spoken and written language

Eligibility for speech-language pathology services is documented in the child's individualized education program, and the child's goals and the dismissal process are explained to parents and teachers. For more information about eligibility for services in the schools, see ASHA's resources on eligibility and dismissal in schools , IDEA Part B Issue Brief: Individualized Education Programs and Eligibility for Services , and 2011 IDEA Part C Final Regulations .

If a child is not eligible for services under IDEA, they may still be eligible to receive services under the Rehabilitation Act of 1973, Section 504. 29 U.S.C. § 701 (1973) . See ASHA's Practice Portal page on Documentation in Schools for more information about Section 504 of the Rehabilitation Act of 1973.

Dismissal from speech-language pathology services occurs once eligibility criteria are no longer met—that is, when the child's communication problem no longer adversely affects academic achievement and functional performance.

Children With Persisting Speech Difficulties

Speech difficulties sometimes persist throughout the school years and into adulthood. Pascoe et al. (2006) define persisting speech difficulties as "difficulties in the normal development of speech that do not resolve as the child matures or even after they receive specific help for these problems" (p. 2). The population of children with persistent speech difficulties is heterogeneous, varying in etiology, severity, and nature of speech difficulties (Dodd, 2005; Shriberg et al., 2010; Stackhouse, 2006; Wren, Roulstone, & Miller, 2012).

A child with persisting speech difficulties (functional speech sound disorders) may be at risk for

• difficulty communicating effectively when speaking;
• difficulty acquiring reading and writing skills; and
• psychosocial problems (e.g., low self-esteem, increased risk of bullying; see, e.g., McCormack, McAllister, McLeod, & Harrison, 2012).

Intervention approaches vary and may depend on the child's area(s) of difficulty (e.g., spoken language, written language, and/or psychosocial issues).

In designing an effective treatment protocol, the SLP considers

• teaching and encouraging the use of self-monitoring strategies to facilitate consistent use of learned skills;
• collaborating with teachers and other school personnel to support the child and to facilitate his or her access to the academic curriculum; and
• managing psychosocial factors, including self-esteem issues and bullying (Pascoe et al., 2006).

Transition Planning

Children with persisting speech difficulties may continue to have problems with oral communication, reading and writing, and social aspects of life as they transition to post-secondary education and vocational settings (see, e.g., Carrigg, Baker, Parry, & Ballard, 2015). The potential impact of persisting speech difficulties highlights the need for continued support to facilitate a successful transition to young adulthood. These supports include the following:

• Transition Planning —the development of a formal transition plan in middle or high school that includes discussion of the need for continued therapy, if appropriate, and supports that might be needed in postsecondary educational and/or vocational settings (IDEA, 2004).
• Disability Support Services —individualized support for postsecondary students that may include extended time for tests, accommodations for oral speaking assignments, the use of assistive technology (e.g., to help with reading and writing tasks), and the use of methods and devices to augment oral communication, if necessary.

The Americans with Disabilities Act of 1990 (ADA) and Section 504 of the Rehabilitation Act of 1973 provide protections for students with disabilities who are transitioning to postsecondary education. The protections provided by these acts (a) ensure that programs are accessible to these students and (b) provide aids and services necessary for effective communication (U.S. Department of Education, Office for Civil Rights, 2011).

For more information about transition planning, see ASHA's resource on Postsecondary Transition Planning .

Service Delivery

See the Service Delivery section of the Speech Sound Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

In addition to determining the type of speech and language treatment that is optimal for children with speech sound disorders, SLPs consider the following other service delivery variables that may have an impact on treatment outcomes:

• Dosage —the frequency, intensity, and duration of service
• Format —whether a person is seen for treatment one-on-one (i.e., individual) or as part of a group
• Provider —the person administering the treatment (e.g., SLP, trained volunteer, caregiver)
• Setting —the location of treatment (e.g. home, community-based, school [pull-out or within the classroom])
• Timing —when intervention occurs relative to the diagnosis.

Technology can be incorporated into the delivery of services for speech sound disorders, including the use of telepractice as a format for delivering face-to-face services remotely. See ASHA's Practice Portal page on Telepractice .

The combination of service delivery factors is important to consider so that children receive optimal intervention intensity to ensure that efficient, effective change occurs (Baker, 2012; Williams, 2012).

ASHA Resources

• Consumer Information: Speech Sound Disorders
• Interprofessional Education/Interprofessional Practice (IPE/IPP)
• Let's Talk: For People With Special Communication Needs
• Person- and Family-Centered Care
• Person-Centered Focus on Function: Speech Sound Disorder [PDF]
• Phonemic Inventories and Cultural and Linguistic Information Across Languages
• Postsecondary Transition Planning
• Selected Phonological Processes (Patterns)

Other Resources

• Age of Acquisition of English Consonants (Crowe & McLeod, 2020) [PDF]
• American Cleft Palate–Craniofacial Association
• English Consonant and Vowel Charts (University of Arizona)
• Everyone Has an Accent
• Free Resources for the Multiple Oppositions approach - Adventures in Speech Pathology
• Multilingual Children's Speech: Overview
• Multilingual Children's Speech: Intelligibility in Context Scale
• Multilingual Children's Speech: Speech Participation and Activity Assessment of Children (SPAA-C)
• Phonetics: The Sounds of American English (University of Iowa)
• Phonological and Phonemic Awareness
• Place, Manner and Voicing Chart for English Consonants (Roth & Worthington, 2018)
• RCSLT: New Long COVID Guidance and Patient Handbook
• The Development of Phonological Skills (WETA Educational Website)
• The Speech Accent Archive (George Mason University)

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About This Content

Acknowledgements .

Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Speech Sound Disorders:  Articulation and Phonology page:

• Elise M. Baker, PhD
• John E. Bernthal, PhD, CCC-A/SLP
• Caroline Bowen, PhD
• Cynthia W. Core, PhD, CCC-SLP
• Sharon B. Hart, PhD, CCC-SLP
• Barbara W. Hodson, PhD, CCC-SLP
• Sharynne McLeod, PhD
• Susan Rvachew, PhD, S-LP(C)
• Cheryl C. Sancibrian, MS, CCC-SLP
• Holly L. Storkel, PhD, CCC-SLP
• Judith E. Trost-Cardamone, PhD, CCC-SLP
• Lynn Williams, PhD, CCC-SLP

Citing Practice Portal Pages 

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association (n.d.) Speech Sound Disorders: Articulation and Phonology. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Articulation-and-Phonology/ .

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