Intervention Software for Children With Speech Sound Disorders
Phase: NA
Conditions: Speech Disorders
Sponsor: Aveiro University

Table to Tablet (T2T): A Novel Intervention Framework for 
Children With Speech Sound Disorders 
1st of January 2017 
University of Aveiro 
Aveiro, Portugal 
 
This study is a randomised control trial. The first step was the creation of partnerships 
between the University of Aveiro and schools in the Aveiro region (Jesus, Martinez, 
Valente, & Costa, 2017). Teachers were asked to identify children that they thought had 
immature or poor speech. All identified children were then assessed (T1). Due to the 
fact that the project was only selecting children with SSD, most other children (with 
different diagnoses) were referred to external (to the project) SLPs. The children who 
fitted the inclusion criteria were then randomly allocated to one of two groups (tabletop 
or tablet) and were assessed again after a waiting period of 3 months (T2). After this 
second assessment, the children had intervention and were assessed at post-intervention 
(T3). 
Participants 
Twenty-two Portuguese children (four girls and eighteen boys) with phonologically-
based SSD, with a mean age of 57 months were selected. This disproportionate number 
of males-females is a typical distribution (70-80% boys) in the Portuguese population, 
and has been reported in previous studies (Jesus, Lousada, Domingues, Hall, & Tomé, 
2015). Children were assessed and diagnosed as having phonologically-based SSD after 
an extensive assessment by a Speech and Language Pathologist (SLP), an audiologist 
and a psychologist.  
Participant inclusion criteria were:  

• Age range from 3;6 to 6;6;  
• European Portuguese as first and only language;  
• No impairments on oro-motor structure and function (assessed with the 
Protocolo de Avaliação Oro Facial – PAOF (Guimarães, 1995);  
• No symptoms of verbal dyspraxia;  
• Age appropriate receptive language (assessed with the Teste de Linguagem 
ALPE – TL-ALPE (Mendes, Afonso, Lousada, & Andrade, 2014));  
• Audition of 20 dB or lower in the frequencies 500, 1000, 2000 and 4000 Hz;  
• Age appropriate non-verbal IQ  assessed with the Wechsler Preschool and 
Primary Scale of Intelligence-Revised – WPPSI-R (Wechsler, 2003); 
• Presenting at least two phonological processes at pre-intervention time (Crosbie, 
Holm, & Dodd, 2005; Dodd, Zhu, Crosbie, Holm, & Ozanne, 2002).  
The children’s phonological abilities were assessed by a SLP with a single-word 
naming (67 words) task (Mendes, Afonso, Lousada, & Andrade, 2013).  All the children 
were also assessed for consistency of production. All participants scored below 40% in 
the Inconsistency Assessment of the Teste Fonético-Fonologico ALPE (Mendes et al., 
2013), and were considered to be consistent (Dodd et al., 2002).  
Ethical permission was obtained from an independent ethics committee (Comissão 
de Ética da Unidade Investigação em Ciências da Saúde – Enfermagem da Escola 
Superior de Enfermagem de Coimbra, Coimbra, Portugal) and informed consent was 
collected from all carers prior to any data collection. The study was also registered at 
ClinicalTrials.gov.  
Intervention  
In order to build an intervention  that mirrored existing evidence-based and well defined 
speech and language therapy practice for working with children with SSD  (Lousada, 

Jesus, Hall, & Joffe, 2014; Lousada et al., 2013), tabletop and digital SSD intervention 
programes were developed which incorporated key target areas that have been shown to 
be effective. These included: (1) Auditory Bombardment (focusing on the target 
phoneme or phoneme combination) (Hodson & Paden, 1991); (2) Hearing and 
Discriminating (to incorporate sounds into the phonological system) (Lancaster, 2008); 
(3) Grapheme-phoneme correspondence (knowledge of phoneme-grapheme 
relationships) (Gillon & McNeill, 2007); (4) Phoneme identity (to identify phonemes in 
words) (Gillon & McNeill, 2007); (5) Segmentation (to analyse words at the phonemic 
level) (Gillon & McNeill, 2007); (6) Blending (to blend isolated sounds together to 
form words) (Gillon & McNeill, 2007); (7) Rhyme (to identify phonological similarities 
in spoken word pairs) (Gillon & McNeill, 2007); and, (8) Phoneme manipulation (to 
analyse and manipulate sounds) (Gillon & McNeill, 2007). The intervention was 
identical across the two delivery modes: Tabletop and tablet.  
There are a total of eighteen different activities grouped by target area (mean number 
of activities per area of two). As a companion to the activities, homework in the form of 
a set of games and worksheets were specifically developed for the project. Regular 
homework is recommended for maximising progress (Gunther & Hautvast, 2010).  
Parents/caregivers were invited to be present in therapy sessions either at their 
child’s school or at the clinic, and short homework tasks were given at the end of each 
session to complete for the following session.  
In the tabletop group the homework activities were work sheets focusing on the 
targeted phonological processes, and   in the tablet group,  homework was based on four 
different computerised games. 

Each child allocated to the tablet group received a tablet with the games installed at 
the beginning of the intervention. In each session an information sheet about the game 
that should be played that week was given to the caregiver. 
Furthermore, generalisation tasks for each phonological process were created. These 
tasks are included to allow SLPs to test if changes in a child’s phonological system go 
beyond the treatment words and targets (Bowen, 2015). 
The allocation to one of the interventions (with same content but different delivery 
method – tabletop or tablet) took place during the waiting period, after the selection 
process and before the pre-intervention assessment. Each child was given a number 
from 1 to 22 and randomly allocated to one of the two groups. The numbers were 
randomised using an online tool (True random integer sequence generator based on 
atmospheric noise data https://www.random.org/sequences/; RANDOM.ORG; 
Randomness and Integrity Services Ltd). 
The phonologically based intervention consisted of a combination of phonological 
awareness activities (Lousada et al., 2013) adapted from Gillon and McNeill’s (2007) 
phonological awareness programme,  Hodson and Paden’s (1991) auditory 
bombardment, and discrimination and listening tasks from Lancaster (2008). 
The criteria taken into account to choose the target phonological processes were: 
Frequency – occurring at least at a 40% rate in the child’s speech (Hodson & Paden, 
1991); intelligibility (Dodd & Bradford, 2000; Lousada et al., 2014) – less than 2/3 
(66%) of the utterances of a child can be understood by unfamiliar listeners (Gordon-
Brannan & Hodson, 2000, p. 146); stimulability – including  stimulable sounds (Dodd 
& Bradford, 2000); developmental – earlier acquiring sounds  (Dodd & Bradford, 2000; 
Mendes et al., 2013). 

Each session had a total of three activities, one from each of the eight target areas  
with the exception of the first two sessions, where the focus was on auditory 
bombardment, listening and discrimination (Gillon & McNeill, 2007), and some advice 
on  tongue placement, using the materials developed by Pedro et al. (2018), to help 
elicit the target sound. The organisation of the activities per session was based on 
Lousada et al. (2013), with sessions divided into two blocks.  
One group was treated with the tabletop materials and the other group with an app 
running on a tablet. The intervention approach was identical across both groups, the 
only difference being the method of presenting the materials (tabletop versus tablet -
based). The tabletop materials consisted of printed cards, board games, stuffed animals, 
cardboard boxes, a large dice, fishing rods, and other similar materials used in therapy.  
In the tablet group all the activities were run in an eight inch screen ASUS MEMO Pad 
8, with 1 GB of RAM and Android 4.4.2 KitKat (Jesus, Santos, & Martinez, 2018). 
The intervention for both groups consisted of 12 weekly individual sessions of 45 
minutes, across a three-month duration.  
The intervention was divided into two six-session blocks with no breaks (there was 
an assessment between them and a change of focus – a different phonological process). 
A duration of six sessions is enough to significantly impact phonological skills, but a 
greater total intervention duration is needed to demonstrate an intensity effect (Allen, 
2013). For each child, one phonological rule was chosen as an intervention target for 
each block. Both groups were treated by the same SLP trained in both methods. 
Parents/caregivers were invited to be present in therapy sessions either at their child’s 
school or at the clinic, and short homework tasks were given at the end of each session 
to complete for the following session. 
Targets 

The activities included were based on a phonological therapy approach. The selection of 
words used in therapy was based on:  Syllabic structure (CV, CVC or CCV) (Brooks & 
Kempe, 2014); number of syllables (one or two) (Flipsen, 2006); being age appropriate 
(Fenson et al., 1993); being easily illustrated; and being different from words used for 
assessment (Lousada et al., 2013; Mendes, Afonso, Lousada, & Andrade, 2013). Words 
used in therapy were those with which children had difficulty, a criteria used in previous 
research (Gillon, 2008), and included initial, medial and final word (where applicable) 
position of the target sound. A list of minimal pair words were selected for Hearing and 
Discriminating and Phoneme Manipulation. For the Rhyme activity, a list of 
monosyllabic rhyming words were identified. The criteria used to select these words 
were: They are all phonologically simple and high frequency, well known by most 
Portuguese children; two syllable (Hearing and Discriminating and Phoneme 
Manipulation) or one syllable (Rhyme) words that would rhyme and could be 
represented by an illustration. Nineteen short stories (one for each phonological process) 
that used at least twenty words with the target sound were also created, as used by 
Bowen (2015).  
Each target word was illustrated by a professional designer resulting in more than 
350 illustrations. A set of three background images was also created (by the same 
designer) for each short story. 
Testing 
Assessments of the children with SSD took place at three time points: 
• T1 – Baseline and pre-randomisation; 
• T2 – Pre-intervention and after a waiting period of 3 months; 
• T3 – Post-intervention.  

The baseline assessments (T1), pre and post-intervention assessments (T2 and T3), 
were carried out by the same SLP blind to the study’s aims, children allocation and 
intervention. 
In all the assessments (T1, T2 and T3), children’s productions were recorded to 
allow a careful offline analysis (Lancaster, Keusch, Levin, Pring, & Martin, 2010). The 
recordings were made with a Behringer ECM8000 electret microphone, held by a table 
support at approximately 1 meter and aligned with the mouth of the children. The 
microphone was connected to an Olympus LS-100 multi-track linear PCM recorder. 
The data was recorded in mono format .wav (Windows PCM) without compression at a 
sample rate of 48000 Hz, with 16 bits per sample. The assessments were made in one of 
two places: University of Aveiro’s Speech, Language and Hearing Laboratory (SLHlab) 
clinic or the child’s school in a quiet room. 
To ensure the accuracy of the annotation of the children’s phonological abilities, 
their productions were transcribed phonetically based on perceptual and acoustic 
analysis using Praat Version 6.0.17. These transcriptions were annotated on two levels: 
The child’s actual production, transcribed phonetically using the SAMPA (Wells, 1997) 
machine-readable phonetic alphabet; and the child’s syllabic structure, using the code C 
for consonants, V for vowels and G for glides. 
The Speech and Language Therapy assessments used were: University of Aveiro’s 
Case History Form for Child Language (Jesus & Lousada, 2010); TFF-ALPE phonetic-
phonological test (Mendes et al., 2013); TL-ALPE language test (Mendes et al., 2014); 
PAOF oro-motor abilities test (Guimarães, 1995); an adaptation to Portuguese of the 
Speech Participation and Activity of Children - SPAA-C children’s questions (McLeod, 
2003). Images from the Test of Childhood Stuttering (TOCS) (Gillam, Loga, & 

Pearson, 2009) were used to engage the children in conversation and  generate 
spontaneous speech (Limbrick, McCormack, & McLeod, 2013). 
Children’s transcribed productions were entered into the Automatic Phonological 
Analysis Tools (APAT) (Saraiva, Lousada, Hall, & Jesus, 2017) by a SLP blind to the 
study’s aims and group allocation using SAMPA (Wells, 1997). The APAT is a valid 
and reliable tool (Saraiva et al., 2017) to analyse phonological parameters in an 
automatic way.  
The baseline period occurred between the first assessment at baseline (T1) and the 
pre-intervention assessment (T2). This period was used to organise all the logistics, 
schedules and places to deliver therapy (clinic and schools). It was also used to assess 
the children’s non-verbal IQ and hearing. The children did not receive any intervention 
in this time period. All the children waited three months (the same duration as  the 
intervention) before treatment and therefore acted as their own control (Sadlier, 
Stephens, & Kennedy, 2008). This period allowed us to see the impact of natural 
maturation on the children’s speech and to compare it to performance after intervention. 
The mean PCC scores (Shriberg & McLeod, 1982) were used to compare 
performance of  the two groups. The PCC index is one of the most commonly used 
indexes to quantify the severity of speech impairment in children with SSD during both 
evaluation and intervention (Wren, McLeod, White, Miller, & Roulstone, 2013). This 
quantitative measure is highly sensitive to differences in phonological deficits because it 
provides information pertaining to the two main error types: Omissions and 
substitutions (Shriberg, Austin, Lewis, McSweeny, et al., 1997; Shriberg, Austin, 
Lewis, & McSweeny, 1997). 
Although there is evidence that only a small number of children have difficulties 
producing vowels, Watts (2004) recommends doing a more detailed analysis at this 

level using the percentage of vowels correct (PVC) in addition to percentage of 
phonemes correct (PPC). 
Generalisation 
After each block of intervention,  non-intervention words, which included the process 
targeted in intervention, were given as generalisation words, in order to assess  
generalisation to non-targeted words (Palle, Berntsson, Miniscalco, & Persson, 2012). 
The words were selected based on the phonological process trained. They were different 
from those used during intervention but targeted the same phonological processes and 
were a close match in terms of production difficulty, frequency in the Portuguese 
language and syllable structure. 
Each child had five opportunities to produce the correct target. These words were 
used to determine if the child generalised the targeted speech skill and provide 
important insight into the impact of intervention on a child’s phonological system 
(Baker & McLeod, 2004). 
Reliability 
The production of all isolated words of two randomly selected children from the three 
assessment periods (baseline, pre- and post-treatment) were annotated and transcribed 
by a trained SLP not involved in the study and blind to its aims. Point-to-point 
reliability was 95.52% (baseline assessment – T1), 94.74% (pre-treatment assessment – 
T2) and 96.46% (post-treatment assessment – T3). These values are comparable with 
those reported in other studies in disordered child phonology  (Shriberg, Tomblin, & 
McSweeny, 1999; Shriberg & Lof, 1991) and were considered adequate for the 
objective of this study. Two children (for each assessment point) represents 9% of 
speech samples and this percentage is equivalent to what is reported when checking 

reliability in other effectiveness  studies (Crosbie et al., 2005; Dodd & Bradford, 2000; 
Lousada et al., 2014; Lousada, Jesus, Capelas, et al., 2013). 
Data analysis / statistics 
Non-parametric Wilcoxon and Mann-Whitney tests were used to compare data between 
groups and time periods and multi-comparisons corrections for type-one errors have 
been made using Bonferroni’s correction for every pair of comparisons involving both 
tabletop and tablet groups. Effect sizes were calculated using Cohen’s d with the bias 
correction given by Hedges’s g for the independent samples case (Lakens, 2013). For 
the purpose of interpreting the effect sizes, the following commonly used benchmarks 
were used (Field, 2017): Small (d=0.2), medium (d= 0.5), and large (d=0.8). The 
statistical analysis was made using IBM SPSS Statistics version 22. The level of 
significance used was 0.05. 
 
 

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