Speech sound disorder interventions approach in Brazil: A scoping reviewABSTRACT
Purpose: to identify the most frequently published therapeutic approaches for phonological disorder in monolingual Brazilian Portuguese-speaking children in the past 10 years (2014-2024) in the leading Brazilian speech-language pathology journals.
Methods: a search conducted for scientific articles in English and/or Portuguese, published between 2014 and 2024, in the four main Brazilian speech-language pathology journals: CoDAS, CEFAC, ACR, and Distúrbios da Comunicação. The search terms used were: desvio fonológico/phonological disorder/distúrbio fonológico AND therapy OR intervention.
Literature Review: twenty articles were selected from a total of 78. Of these, 50% were published in CEFAC; 80% were published more than six years ago, and 75% originated from research conducted at the Federal University of Santa Maria, RS, Brazil. On average, the studies included six participants, with a mean age of 5 years and 7 months.
Conclusion: the most frequently published therapeutic approaches in the journals reviewed were: minimal pairs, ABAB-withdrawal and multiple probes, phonological awareness, and modified cycles. All phonological therapeutic approaches reported were effective in remediating phonological disorder, according to the authors of the respective studies.
Keywords:
Speech-Language Pathology; Speech Sound Disorders; Therapeutics; Child
RESUMO
Objetivo: verificar quais são as abordagens terapêuticas para o transtorno fonológico mais publicadas nas principais revistas de Fonoaudiologia brasileiras em crianças falantes monolíngues do português brasileiro nos últimos 10 anos (2014-2024).
Métodos: pesquisa de artigos científicos em língua inglesa e/ou portuguesa, publicados entre os anos de 2014 a 2024, nas quatro principais revistas de Fonoaudiologia brasileira: CoDAS, CEFAC, ACR e Distúrbios da Comunicação. Os termos pesquisados foram: desvio fonológico/transtorno fonológico/distúrbio fonológico AND terapia OR intervenção.
Revisão da Literatura: foram selecionados 20 artigos dos 78 rastreados. Destes, 50% foram publicados na Rev. CEFAC; 80% publicados há mais de seis anos, 75% são artigos de pesquisas realizadas na Universidade Federal de Santa Maria. As pesquisas tiveram em média seis participantes, com idade média de 5:7.
Conclusão: as abordagens terapêuticas mais publicadas nas revistas pesquisadas foram: pares mínimos, ABAB-Retirada e provas múltiplas, consciência fonológica e ciclos modificado. Todas as abordagens terapêuticas fonológicas utilizadas foram eficazes na superação do transtorno fonológico, conforme os autores que as estudaram.
Descritores:
Fonoaudiologia; Transtorno Fonológico; Terapêutica; Criança
INTRODUCTION
In the acquisition of the phonological system of Brazilian Portuguese, children with typical phonological development acquire the inventory of contrastive phones necessary to produce speech, similar to that of adults in their social group between the ages of four and seven years. This acquisition timeline considers mastery of sounds and syllable structures that emerge later, such as medial and final codas and complex onsets1,2.
Studies conducted in Brazil1,2 have examined the order of acquisition of Brazilian Portuguese consonantal segments in children with typical phonological development, identifying mastery of the articulatory manners of plosive and nasal consonants, as well as the fricatives /f/, /v/, /s/, and /z/ in simple onset position by three years of age1. The fricatives /ʃ/ and /ʒ/ in simple onset position are mastered by four years of age. The liquid consonants in simple onset position /l/ and /R/ are mastered by three years and six months; /r/ is mastered by four years and six months; and /ʎ/ is mastered by six years of age. The coda containing the archiphoneme |S| is mastered by four years, and with |R| by four years and six months. Complex onsets with /r/ are mastered by six years, and with /l/ by six years and six months1. These parameters of typical phonological acquisition in Brazilian Portuguese are essential for understanding children’s speech development.
When phonological acquisition and development do not occur within the expected age ranges, due to difficulties in learning the phonological system of the language - linked to the perception and organization of speech sounds - a speech-language pathology diagnosis of phonological impairment is established3,4. Phonological impairment falls under the umbrella term speech sound disorders4,5.
Speech sound disorders encompass different types of speech disorders, subdivided into three clinical domains5. The first is the motor speech domain, which includes two levels: the execution level, with childhood dysarthria as its primary example, and the planning level, exemplified by childhood apraxia of speech. The second domain is the speech articulation domain, which addresses the phonetic level, such as speech sound errors involving /s/ and /r/. These errors may or may not be residual and may occur in children aged nine years or older. The third domain is the cognitive-linguistic and phonological domain, which includes phonological impairment4,5.
Phonological impairment is a cognitive-linguistic speech impairment that affects a child’s speech sound production, due to difficulties in organizing the mental representation of these sounds within the domain of internalized linguistic knowledge. It occurs when there is a breakdown in the mental representation of speech sounds - a phonemic disorder - because the sound information stored and represented in the mental lexicon is impaired6.
Brazilian studies report an average prevalence of 31%7-12 in speech-language pathology clinics. Among Brazilian children attending preschool and elementary school, the average prevalence is 19.5%13-16.
In English-speaking contexts, the therapeutic approaches most frequently used by American speech-language pathologists have been compiled in the phonological intervention taxonomy for pediatric speech sound disorders17. The aim of this taxonomy was to identify the most frequently studied elements within 15 pediatric phonological intervention approaches and to demonstrate how the taxonomy can enhance transparency in therapeutic approaches, thereby assisting in selecting the most appropriate intervention for teaching (SLP training and continuing education) and research.
In Brazilian Portuguese, no review study has been found that compiles the most frequently used phonological therapeutic approaches by Brazilian speech-language pathologists, particularly in scientific journals in the field of speech-language pathology.
Therefore, the primary objective of this study is to identify the therapeutic approaches for phonological impairment most frequently published in the leading Brazilian speech-language pathology journals for monolingual Brazilian Portuguese-speaking children over the past 10 years (2014-2024).
METHODS
This literature review was conducted following the methodological criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR)18.
The guiding question was: Which therapeutic approaches for phonological impairment are most frequently published in the leading Brazilian speech-language pathology journals over the past 10 years (2014-2024)?
The PCC framework (Population, Concept, Context) was used to structure the research question. The population consisted of children with phonological impairment, monolingual Brazilian Portuguese speakers, aged four to eight years and eleven months - within the age range for diagnosis of phonological impairment1,14,19 - and without other comorbidities. The concept investigated was therapeutic approaches for phonological impairments. The context was the treatment of children with phonological impairment conducted and studied in Brazil’s official language, Brazilian Portuguese.
Scientific articles reporting speech-language pathology interventions for phonological impairments were selected from the four main Brazilian speech-language pathology journals: CoDAS, Audiology-Communication Research (ACR), CEFAC, and Distúrbios da Comunicação (DIC). Articles from CoDAS, ACR, and CEFAC were searched in the SCIELO database, while articles from DIC were retrieved from its own website, linked to the Pontifical Catholic University of São Paulo (PUC-SP). Studies were required to be published in Portuguese and/or English.
The search terms used were: transtorno fonológico/phonological impairment/desvio fonológico/phonological deviation/distúrbio fonológico/phonological disorder/speech sound disorder AND terapia/therapy; speech AND therapy; phonology AND therapy OR intervention. Intervention studies involving children with phonological impairment published in the last ten years (2014-2024) and available in the consulted databases were included. The database searches were conducted between May and July 2024.
The most current term, phonological impairment2,20, was used as a synonym for older terms, such as phonological deviation and phonological disorder. Additionally, phonological impairment was used as a synonym for the umbrella terms speech sound disorders and speech sound disorders, when referring specifically to phonological impairment.
The inclusion criteria were original scientific articles reporting speech-language pathology intervention studies for phonological impairment in children aged four to eight years and eleven months, monolingual Brazilian Portuguese speakers. The exclusion criteria were: literature review articles; studies addressing other speech-language disorders, such as childhood apraxia of speech, residual speech errors, hearing loss/auditory impairment, or other neurodevelopmental disorders or syndromes (e.g., Down syndrome, autism spectrum disorder); studies focusing solely on speech-language assessment; and studies including bilingual children.
The data extracted from the selected articles included the year of publication, the journal in which the study was published, the therapeutic approach used, the university where the research was conducted, the sample size, and the mean age of the participants.
In the body of the literature review, the objectives of each study, relevant methodological data and results, and the conclusions of each included article were presented.
LITERATURE REVIEW
A total of 75 articles were retrieved. In the SCIELO online library, 63 articles were identified, while the DIC journal database yielded 12 articles. Only 20 articles met the eligibility criteria, according to the article selection diagram18 (Figure 1).
Chart 1 presents the selected articles with the extracted data, ordered in descending order by year of publication, from 202320 to 201436.
Most of the articles (n = 16) were published between 201824-27 and 201419,32-36. The most recent publications appeared in CoDAS20,21 (n = 2) and DIC22,23 (n = 2). The journal with the highest percentage of publications on this topic was CEFAC (50%, n = 10), followed by DIC (30%, n = 6) and CoDAS (20%, n = 4). No articles within the scope of this review were found in Audiology-Communication Research (ACR).
The Federal University of Santa Maria (UFSM) was responsible for 75% (n = 15) of the included articles3,6,22,24-26,29-36. Although phonological impairment has high prevalence, reported in various regions of Brazil7-9,11-13, publications were concentrated in one higher education institution in the South of Brazil. In this review, 25% (n = 5) of the articles on therapeutic approaches for phonological impairment were developed at UNESP Marília20, USP São Paulo21, PUC-SP23, USP Bauru27, and UNICENTRO19 (State University in Irati-PR).
Most of the articles (n = 4) published by other universities were published from 2018 onward20,21,23,27. A trend was observed for universities in the Southeast region of Brazil to publish studies on this topic, particularly from 2020 onward20,21,23. No studies were found from other regions of Brazil.
All analyzed articles were case studies conducted with children with phonological impairment, with an average sample size of six participants (ranging from one27 to 1421 children).
The mean age of participants was five years and seven months, with the youngest being four years3 and the oldest six years and five months6,22,26,30.
The most investigated therapeutic approaches in the reviewed articles were: minimal pairs/minimal or maximal oppositions, reported in seven articles19,20,22,30,32,34,35, including one study25 that used the minimal pairs/maximal oppositions model as a purely phonological therapy, compared and combined with phonological awareness skill stimulation; ABAB-withdrawal and multiple probes, studied in four articles29,31,35,36; phonological awareness6,25,26; modified cycles27,33; and one article21 that presented a phonological stimulation program based on the cycles approach. Other approaches identified included pseudowords24, the strata approach based on stimulability and segment complex, discussed in the article presenting the SIFALA software28, and multiple oppositions3.
One study23 did not employ any specific therapeutic approach, aiming instead to describe the use of interactive technological tools on tablets in speech-language pathology intervention for children with phonological impairment. The authors justified the use of different therapeutic techniques, including some approaches to orofacial motor skills, to expand the patients’ phonetic inventory according to the particularities of each clinical case. Four children, with a mean age of 5 years and 4 months, participated in eight to nine weekly 30-minute sessions using the tablet as part of therapy. The authors concluded that the tablet facilitated therapeutic processes by enhancing the dialogic interaction between therapist and patient. The study23 did not provide any objective parameters regarding the speech therapy performed.
The minimal pairs approach was found to be associated with gamification20, with computer-based auditory training22, compared to the phonetic-articulatory therapy30, to praxis activities involving lips, and lips and tongue32,34, and with therapy25 and assessment35 of phonological awareness skills following phonological therapy.
The minimal pairs therapeutic approach operates at the word level, with its basic treatment procedure involving the contrast between two words that differ by only one phoneme22,25. The words may present minimal oppositions, such as “Vera” and “vela”20, differing in only one distinctive feature [±continuant], or maximal oppositions, such as “mala” and “rala,” differing in two or more distinctive features [±approximant], [±continuant], [±anterior], [±labial]. The contrast between phonemes used in therapy may differ in at least three dimensions: in the number of distinctive oppositions, in the nature of the distinctive feature differences, and in their relation to the child’s grammar prior to treatment22. The selection of phonemes is based on the type of generalization to be promoted in the phonological system and in the learning of the target sounds22.
Among the studies that employed minimal pairs, the most recent20 aimed to compare the effectiveness of traditional phonological therapy with phonological therapy combined with a gamification strategy using a computer game. The study included 10 children with a mean age of 5 years and 6 months and a diagnosis of phonological impairment. Participants were randomized into two groups: traditional phonological therapy (control group) and phonological therapy combined with a computer-mediated gamification strategy (gamification group). They underwent 16 individual speech-language therapy sessions, twice a week, each lasting 50 minutes. The targeted phonological process was liquid substitution. The authors found no differences in outcomes between the two groups. However, in analyzing the number of sessions required to achieve 85% correct production of the target phoneme, the performance of the control group was superior to that of the gamification group.
The aforementioned study20 used minimal pairs without explicitly mentioning it, as all the target words differed in only one phoneme - /r/ [+continuant] and /l/ [−continuant] - totaling 15 target-word pairs, with the probe words including 11 minimal pairs. In this study20, some pseudowords24 were also used to form minimal pairs, such as “caruso” and “caluso.”
Aiming to analyze the effectiveness of a therapeutic process for phonological impairment based on the PROMPT and contrastive approaches, one study19 worked with minimal pairs, referring to it as the contrastive approach, which “selects target sounds from their minimal pairs, based on those that are also negatively affecting the child’s speech intelligibility” (p. 321). This approach was combined with PROMPT (Prompts for Restructuring Oral Muscular Phonetic Targets Phonological Contrast). Twelve children, with a mean age of 5 years and 7 months, underwent 32 sessions divided into four modules of eight sessions each, once a week, lasting approximately 40 minutes. Some children were discharged before completing the 32 therapy sessions. At the end of the therapeutic process, there were five discharges, two terminations, and one withdrawal. Four children remained in therapy. Over the course of the evaluations, the children reduced the number of altered phonemes and persistent phonological processes. The authors concluded that individualized speech-language intervention with children, based on the PROMPT and Contrastive approaches, led to significant progress regarding phonological impairment19.
Auditory training using the software was the focus of a study22 that employed the minimal pairs therapeutic approach. The aim of the study22 was to verify the effectiveness of central auditory processing stimulation in the rehabilitation of phonological impairment. Six children with a speech-language pathology diagnosis of phonological impairment, with a mean age of 6 years and 5 months, were divided into two groups: purely phonological therapy (GE1) and phonological therapy combined with auditory training (GE2). A total of 25 therapy sessions were conducted twice a week, each lasting one hour. The therapy session was divided into 30 minutes of phonological therapy and 30 minutes of non-auditory activities for GE1, and 30 minutes of auditory training plus 30 minutes of phonological therapy for GE2. Auditory training did not affect measures assessing phonological improvement - percentage of consonants correct-revised (PCC-R) or number of phonemes acquired - but it did improve participants’ performance on temporal processing tests.
Aiming to present relevant variables in the therapeutic process of acquiring complex onset (CO) in children who simplified CO, one study30 analyzed the results obtained by four children with a mean age of 6 years and 5 months and phonological impairment, who used the compensatory lengthening strategy. These children had [r] and [l] in their phonetic inventory and simplified complex onset. This study compared the minimal pairs approach with the phonetic/articulatory therapy approach for CO acquisition. In the cases studied, the phonetic/articulatory approach proved to be more effective, as the children showed evidence of underlying phonological knowledge.
Two studies32,34 used the minimal pairs/maximal oppositions approach as the method of choice for phonological therapy, associating this approach with stimulation of orofacial praxis skills and tongue praxis exercises. Six children (three boys and three girls) with phonological impairment, with a mean age of 6 years and 2 months, participated in both studies. One group received phonological therapy with minimal pairs (GFo), another group received minimal pairs therapy combined with orofacial praxis exercises involving the face and tongue (GFoLFa), and another group received minimal pairs therapy with tongue praxis exercises (GFoL).
The first study32 aimed to verify which group (with or without orofacial praxis skill stimulation) demonstrated greater structural generalization, considering the following types: items not used in treatment; to another position in the word; within a sound class; and to another sound class. The authors found that GFoLFa demonstrated greater generalization to other positions in the word, to items not used in treatment, within a sound class, and to another sound class compared with the other groups studied. Study32 concluded that groups receiving praxis intervention achieved greater generalization; however, further studies applying this model to different samples are necessary. The results of these studies32,34 suggest that tongue and facial praxis skills, when combined with the minimal pairs/maximum oppositions therapeutic approach, promote faster therapy progress and greater phonological gains.
Another study35 aimed to analyze the phonological awareness skills and speech progress (phonetic and phonological inventory and generalizations) of five children (one girl and four boys), aged between 5:0 and 6:11 years, with phonological impairment who underwent phonological therapy using minimal pairs and the ABAB-Withdrawal and Multiple Probes (ABAB) therapeutic approach. One child was discharged after nine sessions with the ABAB approach; two children required 18 sessions with ABAB; and two children, who had several sounds missing from their phonetic inventory, received 25 therapy sessions using the minimal pairs and minimal pairs/maximum oppositions approach. All children improved with regard to phonological impairment; however, phonological awareness skills did not show a relationship with progress in phonological therapy.
The ABAB-Withdrawal and Multiple Probes (ABAB) therapeutic approach is based on the implicational hierarchy of distinctive features for selecting treatment target sounds. In other words, treatment using more difficult sounds with more complex distinctive features facilitates broad changes in the phonological system31. The approach begins with speech data collection (A1), through assessments involving spontaneous speech samples and a phonological assessment instrument29,31. From this evaluation, the target sound to be addressed in therapy is determined. The first therapy cycle (B1) lasts nine sessions, twice a week, each lasting 45 minutes. The withdrawal period (A2) consists of a reassessment phase to verify the generalizations the child has made29,31. During this period, the child does not engage in speech activities29,31. After reassessment, another therapy cycle (B2) of nine sessions is conducted, followed by a new withdrawal period (A3)29,31. Therapy cycles and withdrawal periods are repeated until discharge.
The most recent study29 using the ABAB approach aimed to verify its effectiveness in restructuring the phonological system of children with devoicing and the influence of target sound selection in this process. Seven children with a mean age of 5:9 participated. The children were treated with the liquid phonemes /ʎ/, /R/, /r/ and the fricative /ʒ/. All participants increased the number of phonemes in their phonological system and their PCC-R. Correct production of plosive phonemes was minimally affected by the approach, whereas correct production of fricative phonemes improved. The study29 concluded that the ABAB approach was effective in some aspects of treating children with devoicing. However, target sound selection did not influence the process, as all children showed therapeutic progress to the same extent.
Another study31 using the ABAB approach aimed to analyze the phonological changes obtained (phonological system, phonetic inventory, and distinctive feature changes) before and after treatment with the approach in different severities of phonological impairment. Eight children with phonological impairment, with a mean age of 5:5 at therapy onset, underwent phonological therapy using the approach for four months. The children were divided into groups according to the severity of phonological impairment: severe (SG), moderate-severe (MSG), mild-moderate (MMG), and mild (MG). The authors concluded that the ABAB-Withdrawal approach was effective for children with phonological impairment in terms of phonological system, distinctive features, and phonetic inventory. The SG group showed the greatest progress.
The last study36 using the ABAB approach aimed to analyze the effectiveness of therapy with facilitating target words containing the fricative /ʒ/, the therapeutic progress, and possible structural generalizations obtained after treatment. Four children with phonological impairment, with a mean age of five years, completed a therapy cycle: A1-B1-A2, focusing on the fricative /ʒ/. The authors concluded that facilitating words positively influence therapeutic progress, promote generalization, and accelerate positive outcomes36.
Phonological awareness is the child’s ability to manipulate the sounds of speech, both at the syllable level and at the phoneme level. This is an important skill in the literacy process, as it helps the child understand the phoneme-grapheme relationship, thereby facilitating reading and writing25. Children with phonological impairment are either in the preschool stage or already attending the first years of elementary school, undergoing literacy instruction. The studies6,25,26 addressing the stimulation of phonological awareness skills as a therapeutic approach for phonological impairment are presented below.
One study25 aimed to present and analyze the effects of phonological awareness stimulation in the therapy of phonological impairment, comparing three different therapeutic approaches in seven children, with a mean age of six years, attending preschool or the 1st year of elementary school. Two children received purely phonological therapy, with the minimal pairs/maximal oppositions approach (PMT), two children received the minimal pairs/maximal oppositions approach combined with the stimulation of phonological awareness skills (PMPA), and three children underwent therapy based solely on the stimulation of phonological awareness skills (PA). The study25 concluded that the therapeutic approaches presented and analyzed promoted reorganization of the phonological system in most of the treated participants. Approaches involving the stimulation of phonological awareness skills led to greater development of this skill. The PMT group did not develop phonological awareness skills.
By the same authors of the aforementioned study25, another study6 aimed to propose and apply a therapeutic approach for phonological impairment based on the stimulation of phonological awareness skills and the use of words with controlled phonological structure. In this study, the results of the PA group6,25 were presented. Three children, with a mean age of 6 years and 5 months, attending the first year of elementary school, underwent 25 phonological awareness therapy sessions: the first 10 sessions involved syllabic awareness tasks, and the final 15 sessions involved segmental (phoneme-level) tasks. All children increased their PCC-R, with one child being discharged from speech therapy after 20 therapy sessions. Study6 concluded that the applied therapeutic approach promoted reorganization of the phonological system in all three cases studied. The phonological structure of the words comprising the phonological awareness tasks appeared to impact the children’s performance in the proposed phonological awareness activities. The therapeutic approach for phonological impairment involving phonological awareness skills was effective in overcoming phonological impairment and improved the participants’ phonological awareness.
Aiming to verify the effects of speech therapy focusing on phonological and articulatory awareness on speech skills and the literacy process of children with phonological impairment, one study26 enrolled seven children, with an estimated mean age of 6 years and 5 months, in therapy using the software ‘Pedro em uma noite assustadora’, which targets phonological awareness skills at the phoneme level, articulatory awareness, and the sound-letter relationship. Participants attended eight weekly therapy sessions lasting 30 minutes each. The sessions addressed identification and comparison of initial and final phonemes in words, phonemic synthesis in two sessions, phoneme segmentation and counting, phoneme identification, association of sound and letter with the articulatory image, and phoneme-grapheme conversion. The authors concluded that this approach improved participants’ phonological and articulatory awareness, advanced their writing hypotheses, and helped overcome phonological impairment, with increased PCC-R and reduced phonological processes in speech. These findings suggest that therapeutic approaches incorporating phonological awareness are more appropriate for children in the literacy phase, as they also improve written language skills.
The cycles approach is widely used in Brazil, with modifications, and is referred to as the modified cycles approach27,33. It consists of targeting the phonological processes of the child with phonological impairment in chronological order of suppression of these processes27. Each therapeutic cycle lasts three weeks. During this period, one phonological process is addressed per week, focusing on the awareness of the characteristics of the phoneme involved in the phonological process, through stimulation and sound production33, always at the word level.
One study27 described the case of a 5-year-old boy with phonological impairment and ankyloglossia who underwent therapy using the modified cycles approach and frenectomy. The participant attended 12 sessions of phonological therapy while awaiting the frenectomy and 23 additional sessions after surgery. The authors concluded that the patient’s speech intelligibility severity decreased during phonological therapy; however, the frenectomy was essential for improving articulatory distortions. In this study27, there was a significant overlap between phonetic and phonological aspects, as the participant was unable to produce [r] and [l] and distorted the phones [s], [z], [n], [t], and [d], due to the short lingual frenulum.
The cycles approach was also employed in another study33 aimed at analyzing and comparing the occurrence and types of generalization observed following the treatment of the fricatives /z/, /ʃ/, and /ʒ/ in words with favorable phonological contexts and in words with less favorable or neutral contexts. Six children with phonological impairment, with a mean age of 6 years and 4 months, were divided by age range, educational level, severity of phonological impairment, and alteration of distinctive features into three treatment groups, ensuring that one participant was treated with target words in a favorable phonological context and the other in a less favorable or neutral context. Two treatment cycles were conducted, twice a week, each lasting 50 minutes. The following generalizations were analyzed after therapy: to untreated items, to a different position within the word, within the same sound class (other acquired fricatives), and to other sound classes (plosives, liquids, nasals, and affricates). Participants who worked with target words in favorable contexts showed greater percentage gains in generalization to untreated items and to different word positions compared to those who worked with target words in less favorable or neutral contexts.
Based on the cycles approach, the Phonological Stimulation Program (PEF) was presented in a study21 aimed at evaluating long-latency auditory evoked potentials (LLAEP) in 14 children with phonological impairment, with a mean age of 6 years, after speech-language therapy. The PEF consists of a total of 12 weekly sessions, each lasting 50 minutes. Every two weeks, the participant was exposed to the phonemes of a sound class in simple onset syllables: plosives, fricatives, liquids, and nasals; followed by syllable structures in coda and complex onset. Regardless of the participant’s phonological process, the entire therapeutic program was implemented: two weeks targeting words with simple onset plosives; two weeks with simple onset fricatives; two weeks with simple onset liquids; two weeks with simple onset nasals; two weeks with words in coda position; two weeks with complex onset containing /r/; and two weeks with complex onset containing /l/. The study concluded that the central auditory pathway was modified after phonological therapy, due to the increase in the number of components present in the LLAEP, demonstrating neural plasticity in the auditory pathway following the 12 therapy sessions.
A treatment approach using pseudowords was reported in a study24 aimed at verifying the therapeutic progress of children with phonological impairment treated using a new therapeutic approach that considered the facilitating linguistic environment in pseudowords and meaningful words. Three children with phonological impairment, with a mean age of 6 years and 2 months, underwent seven therapy sessions, three times per week, each lasting 50 minutes. The authors selected the target phoneme /r/ for being more complex, according to the principles of the implicational hierarchy of distinctive features, and for being acquired later in phonological development. The approach targeted perception and production of three pseudowords and three real words in a facilitating environment; six real words in a facilitating environment; and three pseudowords and three real words in a neutral environment. The authors concluded that this therapeutic approach was effective for the treatment of phonological impairment. Pseudowords are a sequence of phonemes that follow the phonological rules of the language but have no meaning24. The production of pseudowords is a complex task involving several cognitive functions24.
Aiming to verify the effect of the strata-by-stimulability-and-complexity approach and the use of the Speech Intervention Software (SIFALA) in the treatment of phonological impairment, one article28 analyzed the speech data of four children with a mean age of 5:2. Two children with mild and mild-moderate phonological impairment underwent six therapy sessions, and two children with severe phonological impairment underwent 28 and 32 sessions. The sessions were individual, three times a week, lasting 30 minutes. SIFALA collected, recorded, and generated accuracy percentages for each segment in different positions. The purpose of using SIFALA was to stimulate the child’s motivation for therapy. The session structure included auditory bombardment, imitation of the target segment, placement of the target segment, auditory discrimination, and stimulation of the target segment at the word or sentence level. Parents were instructed to carry out the activities at home. Participants underwent phonological therapies with: low production of the segment targeted at greater complexity of the Implicational Model of Feature Complexity (IMFC); low production targeted at lower complexity of the IMFC; high production targeted at greater complexity of the IMFC, and high production targeted at lower complexity of the IMFC. The article concluded that all participants presented statistically significant improvements in their phonological systems. The participant treated with high production targeted at greater complexity of the IMFC presented more correct segments in the pre- and post-therapy comparison.
The multiple oppositions approach was developed to treat children with more severe phonological impairments, as it uses several sounds simultaneously, considering the child’s capacity for generalization3. One article3 analyzed and compared the therapeutic progress of two children with phonological impairment, aged 4:2 and 4:11, submitted to the multiple oppositions approach with the same target sounds. In this study, the authors worked with the fricative target sounds /s/ /z/ /ʃ/ /ʒ/ in four words [‘kasa] [‘kaza] [‘kaʃa] [‘kaʒa]. The word [‘kaʒa] was used to mean a nickname for "cajado" (staff). The children underwent 25 therapy sessions, lasting 45 minutes, twice a week. The authors found that the child with severe phonological impairment acquired far more phonemes (from 3 phonemes acquired to 11) than the child with moderate-severe phonological impairment (from 11 phonemes to 12). It was also noted that the family of the child who made greater progress was more engaged in therapy compared to the family of the child with less progress, who missed some sessions and did not complete the proposed activities at home.
The phonological therapy taxonomy for the English language17 was used as a basis for comparison between the approaches found in this research and those published internationally. Of the 15 therapeutic approaches listed by the taxonomy, this study found four: complexity, cycles, minimal pairs, and multiple oppositions. We separated the minimal pairs approach from the multiple oppositions approach, as the taxonomy treats them as distinct.
The complexity approach17,37-39 was addressed through the ABAB approach29,31,35,36 and the strata-by-stimulability-and-complexity approach with SIFALA28. This approach involves selecting more complex target sounds to promote generalization of learning to less complex sounds. It is based on the theoretical assumption of implicational relationships. For example, a phonological system with fricative sounds implies that plosive sounds are also present39. In English, it is the most researched approach but the least used, with only 8% of Speech-Language Pathologists (SLPs) employing it37.
One article37 found that SLPs tend to use approaches they are most familiar with. Seventy percent of SLPs had no experience with the complexity approach and therefore did not use it. In Brazil, there are no studies assessing such parameters.
This literature review aimed to present the therapeutic approaches for phonological impairment found in the main Brazilian Speech-Language Pathology journals in the last 10 years (2014-2024). It presented the results reported by the authors of the analyzed articles and, in some cases, offered brief discussions of the approaches, when relevant. It is believed that speech-language pathologists should choose the approach according to the patient’s needs, considering the severity of the phonological impairment and their own familiarity with the approach.
It is important to consider possible limitations of the studies, such as the absence of control groups and low statistical power. Nevertheless, there is no justification for not using a therapeutic approach for the treatment of phonological impairment, as most of the articles reviewed described the therapy sessions in sufficient detail to allow the approaches to be replicated in both clinical and research contexts.
The association between the use of orofacial praxes and interventions in orofacial motricity, such as frenectomy, with phonological approaches, showed effectiveness in treating phonological impairment.
This study found a concentration of articles on therapeutic approaches for phonological impairment in Southern Brazil, with notable contributions from UFSM. More recent studies have been published by universities in Southeastern Brazil. Therefore, it would be of interest for other regions of Brazil, beyond the South and Southeast, to conduct studies on this topic, investigating social, environmental, and cultural effects on speech-language therapy for phonological impairment.
Sample size remains a challenge for such studies, as recruiting a large number of participants is difficult. A suggestion for future research is to use statistical analyses suited to small samples.
CONCLUSION
Therapeutic approaches for phonological impairment in monolingual-speaking children, published in leading Brazilian journals of Speech-Language Pathology and Audiology in Brazilian Portuguese over the past 10 years, included minimal pairs, the ABAB-Withdrawal and multiple-probe design, approaches involving phonological awareness skills, and the cycles approach.
All phonological therapy approaches reported in the reviewed articles were found to be effective in remediating phonological impairment, according to the authors who investigated them.
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*Articles that conducted only speech-language assessment, without therapeutic intervention.**Articles categorized as “other” were systematic review articles, studies assessing other pathologies, or those outside the scope of this research.***All research in the articles was conducted by humans, without the use of software or artificial intelligence.