Multiple oppositions

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"Unlike other contrastive approaches, multiple oppositions therapy targets several errors that are part of a phoneme collapse in a child’s phonological system"

Williams 2000b

Suitable children

Consistent phonological impairment
Moderate to profound phoneme collapse
Age: 3 → 6 years
Have at least 6 sounds missing across 3 manner categories
No concomitant hearing or oromotor problems

Unsuitable children

Children with a severe or profound phonological impairment dominated by syllable structure or prosodic difficulties (McLeod and Baker 2017, p.449).

(Bowen 2010, Williams et al. 2010, McLeod and Baker 2017)

Note: This population may have a co-morbid expressive language delay (Williams et al. 2010).

Multiple Oppositions procedure

Adapted from McLeod and Baker 2017: 447-450, Williams et al. 2010: 85-88)

Treatment set and stimuli

Target the largest phoneme collapse and choose 2-4 target phonemes to contrast with the substitution (i.e., the set). Recent research (Sugden et al. 2019) implies that a higher dose for targets within sessions may be more effective than a lower dose for this approach (achievable by capping the number of target phonemes to 3).
Choose 5 words for each phoneme in the set, which is a total of 25 words if targeting 4 phonemes in contrast to their substitution or 20 words if targeting 3 phonemes in contrast to their substitution.
The dose per training set is focused on the number of target words i.e., 20 if targeting 4 phonemes or 15 if targeting 3 phonemes.
Each set should consist of a minimum of 20 target words and a dose of 60-100 words.
If you don't have enough stimuli you can double-up pictures to make the dose up to 20.
An example of a training set targeting 3 phonemes would be: [d] ~ /s, ʃ, sl/ → dip ~ sip, ship, slip
Each training set is reviewed in one game (which can be themed).

Familiarisation and production of contrasts (feedback uses modelling and recasts and is immediate):
- The SLT introduces the target sounds and intervention vocabulary via a storytelling procedure. Ideally, the intervention vocabulary is familiar to the child and frequently occurring.
- Based on the SLT’s model, the child is given the chance to imitate the target sounds. Cues and prompts are used as necessary.
- This stage often takes 1 session.
Production and play (feedback uses modelling and recasts and is immediate):
- Imitation: The SLT asks the child to imitate the target sounds from their model. It is necessary for the child to attain 70% correct imitation across two successive sets before they can move on to the next stage.
- Spontaneous Production: The SLT asks the child to produce the target sound without modelling. It is necessary for the child to attain 90% correct production across two successive sessions before they can move on to the next stage.
- Within this stage, a naturalistic play activity takes place at the end of each intervention session. This may consist of block building, board games etc. but should provide the child with multiple occasions to use the therapy targets.
Production of contrasts within communicative contexts (development of self-monitoring is encouraged through the use of delayed feedback, semantic confusion and inaccurate productions by the SLT):
- The sound contrasts targeted are used with the child in naturalistic play activities (i.e., child directed activities using a selection of toys/materials which include the target phonemes in words). It is necessary for the child to attain 90% accuracy using the treatment words in a natural communicative environment before they can progress.
- To monitor the progress of intervention, probes are administered regularly (see below).
- If a child meets their personal pre-determined criteria for Stage 3, but does not show generalisation or present at discharge level, then they progress to Stage 4.
Conversational recasts (development of self-monitoring is encouraged through the use of delayed feedback, semantic confusion and inaccurate productions by the SLT):
- The SLT corrects the child's errors or adds to the conversation, in a natural way during naturalistic play activities (i.e., conversational recasts). This gives the child the chance to self-correct, without directly receiving any imitative prompts from the SLT.

Note: Clinical judgement should be used alongside the child's assessment data when choosing and implementing an intervention protocol.

Generalisation

A probe containing 10 untrained probe words of each target sound (i.e., up to 40 words) in the word position targeted.
Probes are used at the start of intervention (i.e., to measure baseline performance) and then at the onset of every 3rd intervention session (approximately) to monitor the child's progress (see Sugden et al. 2019). See multiple oppositions resources page (LINK) for an example probe.
If 90% accuracy on a probe target sound is attained, then a conversational speech sample should be gathered. This sample should include numerous occasions for the child to produce the target sound.
Therapy on the target is terminated when the child reaches 50% accuracy in conversational speech.

Monitoring progress

If the child is not progressing to the accuracy levels expected (as identified in the above procedure), then a review may be necessary. SLTs must use their clinical judgement here, as well as the pre-determined criteria set for each individual child.

Supporting literature

The available evidence base indicates that multiple oppositions is a promising intervention with probable efficacy for creating system-wide change that increases speech intelligibility in children with multiple sound errors

(Williams et al. 2010, p.82)

Some of the supporting literature includes: