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Speech-Language-Reading Connections, and a Case Study of a Child with CAS whose Speech, Language and Reading Disabilities were Successfully Treated - featured April 29, 2011

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Speech-Language-Reading Connections, and a Case Study of a Child with CAS whose Speech, Language and Reading Disabilities were Successfully Treated

By: Sandra McKinnis, M.A., CCCSLP

Research conducted over the past 38 years has established that reading is not just the visual memory task it was once thought to be. As early as 1972, Kavanaugh and Mattingly in “Language by Ear and by Eye: The relationship between speech and reading” argued that a connection exists between spoken and written language.
This connection is not surprising as word recognition and reading comprehension share “many of the same processes and sources of knowledge involved in talking and understanding oral language (Butler, 1999; Catts, 1993; Kahmi & Catts, 1991). Knowledge of phonetics, phonology, morphology, syntax, semantics, and pragmatics is involved in understanding both spoken and written language.”

Word recognition, also called decoding, is a complex skill built upon a number of language and visual processing capabilities. Mature readers recognize most words by sight and have words stored in memory in multiple ways. They have established connections between how the word looks in print, how it sounds when spoken, its relationship to other words through rhyming and alliteration, its semantic meanings, and its possible syntactic place within sentences.

Multisyllabic words are stored according to their morphological structure, and understanding of base words, and, prefixes and suffixes facilitates decoding. Nagy and Anderson (1984) estimated that about 70% of English words have meanings that can be predicted to some degree from the meaning of their parts (Roth & Troia, 2006). Understanding of morphological structure also facilitates spelling (Wolter, Wood, D’zatco, 2009; Green 2009).

Particularly important for word decoding is the development of phonemic awareness skills. Phonemic awareness involves being able to mentally separate words into their smallest spoken units. It is a critical skill needed for both sounding out written words as well as for learning phonics. The development of phonemic awareness is dependent upon words being accurately encoded into memory. In turn, as children store the correct phonemic patterns for words in their mental lexicon, gains in language comprehension, including vocabulary growth, and speech production occur.

Solid word knowledge also contributes to both decoding competency and reading comprehension. Between 18 months of age and age three, typically developing children learn nearly 8-9 words a day and by age three can verbally produce over 1,000 words. By age 6, when they are first introduced to reading instruction, most children know over 14,000 words. A good oral vocabulary has been linked to both better single word decoding and reading comprehension (Roth & Troia, 2006).

Scarborough (1998) found that the size of a child’s receptive and expressive vocabulary at age three predicted decoding ability in second grade. Walker, Greenwood, Hart and Carta (1994) also found that overall reading and spelling achievement in kindergarten through third grade could be predicted by vocabulary development by age three. Children with vocabulary deficits have trouble learning to decode and understand written texts and then miss important opportunities to learn new words. From about third grade on most new words children learn are acquired through their reading. (Wagovich & Newhoff, 2004).

While reading, speech and language links exist, there are differences between oral and written language. Reading requires an “explicit knowledge of the phonological aspects of speech” and its connection to the corresponding graphemes (Catts, 1996, page 4). Reading is a relatively new skill for which biological adaptations in humans do not exist. Whereas all humans have developed speech and language ability, nearly 40% of the world population cannot read or write and an additional 25% cannot write well enough for it to be a functional skill.

Reading and Visual Processing
Children must also achieve certain visual abilities to be successful at learning to read. Readers must be able to discriminate between visual symbols, visually track symbol sequences in a left to right progression and mentally store visual symbol sequences (words) in working memory during the decoding process. Good visual closure skills enhance the ability to mentally retrieve words quickly without visually decoding every letter in a word. Readers also must be able to retrieve the sounds and/or words for written symbols at the rate at which they visually track across a line of print.

Being able to store words into long term visual memory as they are encountered in print is a critical reading skill. By 4th grade, average readers have at least 8,000 sight words stored in memory and are able to easily decode and remember most new words they encounter. Accuracy in decoding increases reading speed and fluency as well. Comprehension skills progress in tandem with increased skill in visual tracking and word recognition/decoding.

Reading Disabilities
The reading process is mastered effortlessly by only 5% of all children. An additional 60% eventually achieve proficiency with regular classroom instruction. Unfortunately, for 20 to 35% of all children this progression breaks down and more intensive instruction is required5. At least 10 to 15% of all readers struggle with learning to read throughout their school years and beyond. Most of the children in this last group will be enrolled in special education classes and their main educational challenge will be in learning to read.

It is estimated that at least 70% of children in special education classrooms have speech and/or language disabilities13 that impact their reading achievement. Deficits in speech sound production, phonological processing, memory, and word retrieval hamper their ability to learn to unblend and blend sounds into words, and to learn the relationship between letters and their speech sound referents for reading decoding. Language deficits in the understanding and use of grammar, syntax, and pragmatics contribute to their problems with text comprehension. These speech and language deficits have been causally linked to reading disabilities in a large body of research4-9,14-18,23-25,27 conducted over the past 30 years.

Visual processing deficits also are seen in these children. It is common for Struggling Readers (SRs) to be visually overwhelmed by the amount of print on a page, to have trouble with eye tracking smoothly from left to right, perceiving word boundaries to visually isolate one word from another, and/or with perceiving each letter within a word. Visual memory problems are common. These visual difficulties, coupled with their language difficulties, make learning to decode words, and, developing an adequate sight word vocabulary problematic for these children.

In addition, many SRs develop inefficient decoding strategies and habits. These children are often so eager to read in the quick and effortless manner they observe in good readers, that they resist the sound by sound practice in unblending and blending needed for building decoding accuracy.

Intervention: What Works and What Doesn’t
The 1999 National Reading Panel (NRP) found with respect to reading fluency, that “guided, repeated, oral reading procedures that included guidance from teachers, peers, or parents had a significant and positive impact on word recognition, fluency, and comprehension across a range of grade levels”. Conversely they reported that “silent reading was not an effective practice” especially for students who had not developed critical phonemic awareness and word reading skills.

A number of studies have documented that some of the underlying language deficits experienced by poor readers, particularly impairments in phonological processing, can be ameliorated with training1-3,10-12,21,22. In addition to sound based interventions that improve phonemic awareness, explicit instruction in word decoding (phonics) has been found to be particularly helpful for these children21. The NRP states that phonics instruction should occur in tandem with many opportunities to identify words in meaningful contexts. Recent research studies indicate that phonemic awareness training without explicit instruction in linking speech sounds to letters is not helpful for these children.

Many children with reading disabilities can be taught to read through the use of traditional phonics instruction programs. Unfortunately, for children who experience cognitive, speech, language, and/or language processing problems these instructional strategies are sometimes not sufficient. These struggling readers are notoriously poor at remembering, and retrieving phonics rules. They also have a more difficult time than other poor readers in appropriately applying the rules.

The nature of the phonics rules themselves is problematic for these children as many grapheme patterns taught occur inconsistently across words. For example the commonly taught phonics rule that the final “e” in a word “Makes the vowel say its own name” only applies to 63% of words in English20. The rule that “When two vowels go walking the first does the talking” does not apply in words like “head”, or the past tense of “read”. When trying to use these rules, SRs may over generalize the rule; apply it inconsistently, or not at all.

In addition, SRs often have trouble quickly remembering and retrieving which speech sound “goes with” which letter(s) when unblending and blending words. They may correctly sound out a word and then have trouble retrieving the spoken word that matches this sound sequence. Learning traditional phonics rules does not solve the decoding problems these children experience.

The following case study describes an approach the author has developed over the past 34 years to help children with communication problems learn to listen effectively, speak clearly, understand and use language, read and spell. In this approach, the child’s speech and language intervention is interwoven with instruction in phonemic awareness, and embedded within intensive oral reading practice.

Case Study
CS was seen as a 4 year old at our clinic and at that time had severely disordered speech and language skills. He was diagnosed with severe apraxia of speech. His Arizona Articulation Proficiency Score was 49 which placed his speech in the severest range of impairment. Due to scheduling conflicts he was not seen for treatment following his initial evaluation and was referred to his local school district for services. He subsequently returned to our clinic at 6 years, 11 months.

At the time of his reassessment he continued to have severely disordered speech and language skills (AAPS score of 64.5), was severely dysfluent with multiple dysfluent episodes on nearly every utterance, and, was a non-reader. He experienced severe word retrieval problems.

His program at our clinic included work to improve his speech clarity using drill work and intensive oral reading in which his target sounds were practiced and correct productions reinforced. His mother followed up with daily home oral reading practice.

A two piece page cover in which the upper piece could be rotated across a line of print while exposing one letter/groups of letters at a time was used during oral reading to help him learn to match his rate of eye tracking to his rate of sound and word retrieval. This device facilitated acquisition of the decoding skills of segmentation, alphabetics, and blending and helped to ensure that his decoding attempts were accurate.

Instead of teaching him the traditional phonics rules for decoding and spelling, a vowel chart was created using words from his oral reading. This chart organized vowel spellings by their sound rather than their grapheme. Vowels were targeted in this activity because they were more problematic for him than consonants. This chart was used as a reference tool during his oral reading when decoding difficulties arose.

Multi-syllabic word production and decoding was taught by writing multisyllabic words on strips of paper, cutting them at the phoneme boundaries, then having him reassemble and verbally produce/decode the words. This was extended into a game wherein 30-40 syllable “pieces” were scrambled and dumped on the table. He then sorted these by first, middle, and last syllables and reassembled the pieces to form the original words. These were then read/said verbally. The “syllable pieces” were sent home for additional practice.

Colton is now 9 years, 8 months old and has no errors in his speech. His receptive and expressive language skills are above age level expectations (Oral and Written Language Scales: Listening Comprehension: 11 years, 3 months; SS: 107, %tile rank of 68; Oral Expression: 9 years, 6 months, SS: 97, %tile rank of 42). He is reading at grade level. Dysfluencies have decreased and now occur in approximately 20 to 25% of his utterances. Word retrieval problems persist but are much improved from the time of his re-assessment. The following standardized measures document his earlier progress.

Speech Clarity: Arizona Articulation Proficiency Score increased from 64.5 to 93 in just 9 months. (C.A. 6 years, 11 months to 7 years, 8 months). A score of 100 on this measure indicates no errors were heard on the test items.

Language Comprehension/Vocabulary
(TAE = Test Age Equivalent)

1. Pre-Test: C.A: 6 years, 11 months, Oral and Written Language Scale (OWLS); TAE: 5 years, 7 mos.; 16th %tile; SS: 85

Post-Test: OWLS: C.A. 8 yrs.,2 mos.; TAE: 8 years, 3 mos.; 50th %tile; SS: 100

2. Pre-Test: Receptive One Word Picture Vocabulary Test (ROWPVT); C.A: 6 years, 11 months; TAE: 6 yrs.,5 mos.; 37th %tile; SS:95

Post-Test: ROWPVT: C.A: 8 yrs.,5 mos.; TAE: 10 yrs.,6 mos.; 87th %tile; SS:117

Expressive Language

1. Pre-Test: OWLS; C.A.: 6 years, 11 months; TAE: 4 years, 10 mos.; 6th %tile; SS: 77
Post-Test: OWLS: C.A. 8-2; TAE: 6 years, 6 mos.; 12th %tile; SS: 82

2. Pre-Test: Expressive One Word Picture Vocabulary Test (EOWPVT): C.A: 6 years, 11 months; TAE: 6 yrs.,11 mos.; 50th %tile; SS:100

Post-Test: EOWPVT: C.A.8-5; TAE: 9 yrs.,0 mos.; 63rd %tile; SS:105


Reading Comprehension; Letter and Word Recognition

1. Pre-Test: Kaufman Test of Education Achievement-II(KTEA, C.A: 8-2
a. Letter and Word Recognition: 1.4 g.e; 9th %tile; SS: 80
b. Reading Comprehension: <1.0 g.e.; 3rd %tile; SS: 71

2. Post-Test: 1-11-11; KTEA-II; C.A: 9 yrs.,8 mos.
a. Letter and Word Recognition: 2.5 g.e.; 14th %tile; SS: 84
b. Reading Comprehension: 3.9 g.e.; 45th %tile; SS: 99


References:(Numbers following citations in the text correspond to those in the references. The complete reference list can be obtained by e-mailing the author at: [email protected])

1. Collins, J., (1997). How Johnny should read. Time Magazine, October 27th, 1997.

2. Apel, K. and Swank, L.K. (1999). Second chances: Improving decoding skills in the older student. Language, Speech, and Hearing Services in Schools, 30 (2), 231-241.

3. Bahr, R.H., Velleman, S.L., Ziegler, M.A., (1999). Meeting the Challenge of Suspected Developmental Apraxia of Speech through Inclusion. Topics in Language Disorders, 19, (3), 19-35.

4. Ball, E.W., (1997). Phonological awareness: Implications for whole language and emergent literacy program. Topics in Language Disorders, 17 (3), 14-26.

5. Berninger, V.W., Abbott, R.D., Swanson, H.L., Lovitt, D., Triveldi, P., Lin, Shin-Ju, Gould, L, Youngstrom, M., Shimada, S., Antmann, D. Language, Speech, and Hearing Services in Schools, 41, 179-193.

Study Questions:
  1. 1. Why do you think oral reading was an effective speech and language intervention strategy for Colton?
  2. How do you think his speech-language program complemented his classroom reading instruction?
  3. What part do you think home practice played in his progress?
  4. How do you think his word retrieval issues affected his fluency?
  5. Is his progress typical of children with severe apraxia of speech?





This Months Featured Author:Sandra McKinnis, CCC-SLP

Sandra McKinnis, M.A., CCC is an SLP in private practice in Anchorage Alaska. She has over 34 years of experience serving children and adults with all types of communication disorders. She is the author of the Processing Program (SuperDuper Publications), and the creator of the Easy Eye Tracker Reading Tool (patent pending). Her newest therapy materials include: Every Word Counts: Multi-Modality Speech-Language-Reading Instructional Materials for Children with Apraxia and Other Communication Disorders. She can be reached at: [email protected].

Tags: Article SLP Childhood Apraxia of Speech SLP Language Literacy Newsletter 29 April 2011 Case Study Questions