the unintelligible preschooler:
DESCRIPTION
The Unintelligible Preschooler:. Assessment and Treatment Feb. 11-12, 2000. Peter Flipsen Jr., Ph.D. Assistant Professor of Communication Disorders Minnesota State University, Mankato ASHA Certified (CCC-SLP) Minnesota Title Registered (SLP) Canadian Certified (S-LP(C)). - PowerPoint PPT PresentationTRANSCRIPT
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The Unintelligible Preschooler:
Assessment and Treatment
Feb. 11-12, 2000
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Peter Flipsen Jr., Ph.D.
Assistant Professor of Communication Disorders Minnesota State University, Mankato
ASHA Certified (CCC-SLP) Minnesota Title Registered (SLP) Canadian Certified (S-LP(C))
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Course Objectives:
Identify factors that contribute to the intelligibility of speech
Select appropriate test materials for unintelligible preschoolers
Identify the nature of intelligibility deficits in unintelligible preschoolers
Select appropriate treatment strategies Incorporate parents into treatment
programs
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Overview
Part 1 - Assessment Review intelligibility as a concept Review factors contributing to
intelligibility Review assessment of intelligibility Discuss possible factors
contributing to intelligibility deficits Review procedures for evaluating
each of the factors
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Overview
Part 2 – Intervention Dealing with short-term issues Dealing with structural problems Dealing with motor problems Dealing with resonance problems Dealing with linguistic problems Incorporating parents
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Pretest
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Who Are We Talking About? Preschool children who are
otherwise typically-developing but who present with speech that is unusually difficult to understand
One or both parents may be good “translators” but most unfamiliar listeners have difficulty communicating with these children.
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Some examples:
Faustin – age 6;0 Dylan – age 5;1 Aaron – age 4;1
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Who these children are not. Not hearing impaired No obvious structural problems No frank neurological impairments No major cognitive deficits No problems with receptive
language
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Consequences of Being Unintelligible Communication is not effective May reduce attempts to speak Limits practice time for learning
language Increasing frustration May lead to behavior problems Reduced message complexity Shorter utterances more easily
understood
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Consequences of Being Unintelligible Limited practice time may account
for why many of these children also have expressive language delays (Miller & Leddy, 1998)
Some emerging evidence that significant delays in speech acquisition lead to later problems with reading acquisition
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Historical Pattern
Up until the early 70s these children were seen as having “functional articulation disorders”
Implied that it was a problem learning how to say the sounds
1970s -sudden shift to saying they had “phonological impairments”
Implied that it was a problem knowing where to use the sounds
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The Clinical Puzzle
Difficult to define the specific nature of the problem these children are having
Also difficult to know what the best treatment approach might be
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The Clinical Solution?
Both of the historical labels assumed that this was a single group
No single approach to treatment seems to work for all of them
Very likely the problems are based in a variety of causes
Need to identify the likely cause for each child if possible
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Part I - Assessment
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The Concept of Intelligibility Understandability How effectively a person can get
their message across The goal of every communication
event “… the functional common
denominator of verbal behavior.” - Kent et al. (1994)
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Factors Affecting Intelligibility The listener The listening environment The speaking context
(pragmatic and linguistic) The speaker
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Listener Factors
Hearing acuity For most clinical purposes, we
select listeners with normal hearing Receptive language skills For most clinical purposes, we
select listeners with normal skills
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Listener Factors
Familiarity with speaker personally Parents (and anyone who spends
much time with these children) quickly become “biased” listeners
Learn to ‘translate’ the abnormal patterns
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Flipsen (1995)
Study of parents as “familiar” listeners
Four children tested longitudinally while in therapy
Made recordings of children speaking single words (Y-B test)
Mothers, fathers and unfamiliar listeners tried to identify words
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Flipsen (1995)
Mothers understood significantly more of the words than any of the other listeners
Fathers were not significantly better than the unfamiliar listeners
Appeared that mothers were spending much more time with the children (not formally measured)
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Listener Factors
Familiarity with the material being produced
If you’ve heard the “Rainbow passage” 50 times you come to know what to expect
If you chose the sentences to be read you know what to expect
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Listener Factors
Familiarity with the speaker’s population
Particular disorder groups do tend to have similar overall speech patterns
The more time you’ve spent with those groups the more easily you are able to understand them
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Listener Factors
Familiarity with disordered speech in general
Experienced SLPs better at understanding disordered speech than non-SLPs
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Environmental Factors
Affect both speaker and listener Noise levels Presence / absence of visual
distractions Comfort level THESE CAN USUALLY BE
CONTROLLED FOR MOST CLINICAL PURPOSES
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Contextual Factors
Speaking Task Conversation Monologue Reading
Material being produced Connected Text Sentences Single words
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Contextual Factors
Usually see an interaction between level of intelligibility and the type of material being produced
Speakers with milder intelligibility deficits tend to do better with connected contexts
Speakers with more severe intelligibility deficits tend to do better with single-word context
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Fig. 1
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Fig. 1a
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Speaker Factors
Cognitive skills Usually doesn’t impact intelligibility
except at very low levels Poor presuppositional skills – may
not provide all the necessary info May also see speech motor skills
deficits in those with more severe cognitive deficits
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Speaker Factors
Expressive language skills Vague vocabulary may be a
problem Missing morphological markers
may also interfere Force the listener to have to work
harder to process the information
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Speaker Factors
Phonological skills Includes knowledge of: phonemes allophones morpheme structure rules and
sequential constraints morphophonemic rules
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Speaker Factors
Speech Motor Skills Ability to formulate and transmit
the neuromotor instructions Frank dysarthria and dyspraxia
readily reduce intelligibility Affect both accuracy and timing of
segment production
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Speaker Factors
Hearing Acuity Clearly if you can’t hear what
you’re producing, you will have difficulty producing it accurately
Not a factor in the group we’re discussing
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Speaker Factors
Auditory Perceptual Skills Not a major issue for all these
children Some may have problems with
perceiving the difference between sounds they have difficulty producing and what substitute
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Speaker Factors
Status of the physical mechanism Most minor structural problems are
not a problem by themselves It is possible however for several of
these to combine with each other to make the task of producing speech more difficult
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Speaker Factors
Voice Quality Harsh or hoarse voice adds noise
to the signal making it harder to understand
Higher pitched voices in children are by definition ‘thinner’ (fewer harmonics) making them more susceptible to effects of other factors
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Speaker Factors
Resonance Status Hyponasal (denasal) speech can
be harder to understand because of the loss of oral-nasal contrasts
Nasal consonants account for about 10% of all speech sounds
Rarely a major factor however
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Speaker Factors
Hypernasal speech has a more serious impact on intelligibility
Nasal cavity resonances are low intensity (hard to hear)
Nasal cavity has anti-resonances that cancel out some acoustic energy making the output even harder to hear
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Articulation Skills The ability to produce the
individual speech sounds Speakers with few errors may still
be unintelligible Speakers with many errors may be
quite intelligible
Speaker Factors
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Fig. 2
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Fig 2a
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Fig 2b
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Speaker Factors
Speech sound production skill only accounts for 20-50% of the variance in intelligibility
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Speaker Factors
Prosodic Skills Excessively fast or slow rate may
reduce intelligibility Clutterers use extreme rate – hard
to process what they are saying Classic strategy in adult dysarthria
is to have them slow down If speech is too slow, listener may
lose track of the whole message
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Speaker Factors
Atypical stress patterns may also reduce intelligibility
e.g., stress on wrong word in sentence or on the wrong syllable in a word or too little stress
Listeners rely on stress to assist with sorting out the words
e.g., many N-V pairs differ only on stress
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Speaker Factors
Motivation and effort We all know people who appear to
“mumble” at times but can make themselves understood if they choose to
And when we ask some speakers to repeat, they may change what they do and the result is an improved signal
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Speaker Factors
Nonverbal communication skills (i.e., gestures) may play a role
Recent study by Garcia & Cobb (1998) showed that gestures also contribute to message understanding in adult dysarthria (only 2 speakers studied however)
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Intelligibility and Severity NOT the same thing though often
highly correlated. A child producing many speech
sound distortions may be quite intelligible but may be rated as moderately impaired.
A child with a harsh voice may be quite intelligible but listeners have to work harder to understand him.
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Intelligibility
Clearly a very complex phenomenon
It is not surprising that it is not well understood by clinicians
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Intelligibility
Probably not meaningful to speak of a single value.
Each individual probably has a range of “intelligibility potentials” (Kent et al., 1994).
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Reporting Intelligibility
To be meaningful, the following need to be reported:
Some value The material being produced The listener (s).
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Examples
X was 68% intelligible when producing single words recorded on audiotape as judged by an unfamiliar SLP
82% of the words produced by X when reading 5-8 word sentences on a video recording were intelligible as judged by his parents.
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Developmental Aspects of Intelligibility Children are not fully intelligible
even with first real words Usually only approximations of
adult forms Not a great deal of data on how
intelligibility develops
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Developmental Aspects
Weiss, Gordon & Lillywhite (1987) present some data (from conversational speech): 18 months 25% 24 months 50% 30 months 64% 36 months 80% 42 months 92% 48 months 100%
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Developmental Aspects
Despite being fully intelligible, the average 4 year-old child is still has not mastered all the speech sounds.
Enough of the sounds are correct that listeners can sort out what is actually intended.
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Developmental Aspects
Good “rough” index is that % intelligible in conversation for an unfamiliar listener should =
age in years divided by 4.
e.g., 3 year old = ¾ (75%). e.g., 4 year old = 4/4 (100%)
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Measuring Intelligibility
Despite the importance of intelligibility, we don’t do a very good job of measuring it
We tend to rely on informal ratings that have poor reliability
We have tended to assume that speech sound production accounts for most of it (clearly not true)
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Measuring Intelligibility (general guidelines) Clinician working with the child
should NOT act as the judge if at all possible.
Record all measurement events and SAVE them!
Try to use unfamiliar, untrained listeners each time
Parents, older siblings OK if you use them each time (socially valid)
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General Guidelines
If you have to be the judge, listen to the “after” tape first, then the “before” .
Do the judging all in one sitting.
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General Guidelines
Record the same type of material each time
Use the same tape recorder each time for recording
Record in the same place each time
Listen in the same place each time
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Measuring Intelligibility (specific procedures) Informal ratings Very widely used After a diagnostic session, clinician
makes a decision about ‘how intelligible’ the child was
Often a % estimate May be a general statement
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Exercise #1
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Specific Procedures
Labeled rating scales Many available Usually make judgments based on
a connected speech sample (conversation or reading)
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Labeled Scales
A typical 3-point scale 1 = readily intelligible 2 = intelligible if topic known 3 = unintelligible, even with careful
listening
Source: Bleile (1997)
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Labeled Scales
A typical 5-point scale 1 = completely intelligible 2 = mostly intelligible 3 = somewhat intelligible 4 = mostly unintelligible 5 = completely unintelligible
Source: Bleile (1997)
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Labeled Scales
A typical 7-point scale 1 = intelligible 2 = listener attention needed 3 = occasional repetition of words
needed 4 = repetitions/rephrasing necessary 5 = isolated words understood 6 = occasionally understood by adult 7 = unintelligible Source: Shprintzen & Bardach (1995)
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Exercise #2
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Specific Procedures
Formal procedures Involve either preset stimuli or
transcription of connected speech
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Specific Procedures
Yorkston-Beukelman test Actual title: Assessment of the
Intelligibility of Dysarthric Speech Acronym = A.I.D.S. Prefer to call it the Y-B test
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Y-B Test
Has both single word and sentence stimuli
Single words = choose 1 randomly from each of 50 sets of 12 words
Children repeat the words; adults read them
Listener’s task can be either transcription or multiple choice
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Figure 10
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Figure 11
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Exercise #3
Items 26-50 on Y-B test
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Y-B Test
22 Sentences = choose 2 from each of 11 sets of 100
Range from 5 - 15 words long Speaker must be able to read Listener’s task = transcribe Reporting for both versions =
% words correct
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Preschool Speech Intelligibility Measure Morris, Wilcox & Schooling (1995) Modified the single word version of
the Y-B test (no sentences) Changed some of the words that
were not appropriate for young children
Recently published through Communication Skill Builders (name changed to “Children’s …”)
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Weiss Test
Included in the Weiss Articulation Test (Weiss, 1980)
Transcribe a sample of 200 words Report % words understood
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Shriberg’s Intelligibility Index (II) Transcribe a conversational
sample of at least 90 different words
This size of sample ensures that your sample should include all of the phonemes of English
Report % words understood
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Word Counting Problem
With connected speech that is hard to understand, we have a counting problem.
How do we count the words if we don’t know what the words are?
In longer stretches of unintelligible speech, how do we know where one word ends and the next one begins?
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Word Counting Problem
Solution = listeners can reliably detect syllable pulses
Put X for each syllable you hear Group syllables into words Typically-developing preschool
speech is approximately: 70% 1 syllable words 20% 2 syllable words 10% 3+ syllable words
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Word Counting Problem
Assume sequences of 4 syllables or fewer are all single words
With sequences of 5 syllables, assume first 3 are single words and last 2 make up a 2-syllable word
E.g., X X X (XX) Etc
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Exercise #4a-4c
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So why are these children Unintelligible? There are many reasons why a
preschool child’s speech might be unintelligible.
No one-size-fits-all solution Need to identify the source for
each particular child Should greatly improve our
chances for intervention success.
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Possible Sources
Prosodic problems Structural problems Resonance problems Speech Motor problems Linguistic problems
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Prosodic Problems
By themselves likely insufficient to account for reduced intelligibility
May contribute to the problem however
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Assessing Prosody
No well established procedures available
General impressions insufficient Need some type of structured
approach
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Assessing Prosody
Most straightforward way is to listen to a sample of about 30 utterances
Assess rate, stress, loudness, and phrasing on each utterance
Rate each as “normal” or “non-normal” on each variable
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Assessing Prosody
No well established criteria for normal
Shriberg’s system: Problem = any non-normal rating
occurring on at least 20% of utterances
Borderline = any non-normal rating occurring on 10-20% of utterances
Probably too liberal
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Assessing Prosody
Recommend: Problem = any variable that is
rated as ‘non-normal’ on at least 30% of the utterances rated
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Structural Problems
NOT talking about major issues like a cleft palate or other craniofacial anomalies
May see a series of small problems that by themselves are not a problem
Combinations of small problems sometimes create difficulties
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Oral-Facial Exam Review
Principles from Mason (1982) Examine structure and function Examine form and symmetry Relationships as important as the
parts themselves Abnormalities on the outside may
indicate problems on the inside Not all parts of the oral-facial
complex grow at the same rate
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Oral-Facial Growth
Maxillary arch and tongue grow at about the same pace
Reach adult size by age 11-13 Tongue growing most rapidly
between 5 ½ and 7 ½ years Mandible grows slower Reaches adult size by age 18-20
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External Structure
See form Front view Normal face = 5 “eyes” wide
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Fig. 3
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Fig. 3a
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External Structure
Face has 3 vertical divisions Upper face = hairline to eyebrows Midface = eyebrows to base of
nose Lower face = base of nose to chin Upper face = lower face in height
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Fig. 4
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Front View of Face
Intercanthal width = Width between the eyes
Alar base width = width of base of nose
Normally: intercanthal width = alar base width
Lips corners should line up with medial edges of the irises
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Fig. 5
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Front View of Face
Nasal ala should be of equal size and shape
Columella (division between nostrils) should be complete
Philtrum (trough between nose and lips) should be well-defined
Cupid’s bow (upper edge of lips) should be well-defined
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Lip Incompetence
At rest, the lips of a normal adult should be together
Called lip “competence” Expected in adults For 80% of children under age 12,
the lips are apart at rest Called lip “incompetence” This is NORMAL in children
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Lip Incompetence
Recall that the mandible is slower growing than the maxilla
Result = in children the mandible is smaller than maxilla
Tends to draw the lower lip back away from the upper lip
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Mouth Breathing
Unknown how common this is NOT indicated by “lips apart” at
rest Could be (quite normal) lip
incompetence Requires airflow studies to confirm
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Front View of Face
Lower lip should cover up a small portion of the upper incisor teeth
Look for surgical scars and document if present
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Lateral View of Face
Auditory meatus should line up with zygomatic arch (cheekbone)
A single lowset ear is not uncommon
Embryologically the ears start out in the neck and migrate up the side of the face to their final position
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Lateral View of Face
Both pinnas should be complete Profile line runs from bridge of
nose down through base of nose to tip of chin
Should be straight or slightly convex (curved outward)
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Lateral View of Face
Esthetic line runs from tip of nose to tip of chin
The lips should be at the line or slightly behind
More likely at the line for children The lower lip should be slightly
closer than the upper lip
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Lateral View of Face
Angle where upper lip joins with the base of the nose = Naso-labial angle
Normally = 90-110 degrees Smaller = maxilla protruding Larger = maxilla retracted
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Exercise #5
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Internal Structure
Are all the teeth present? Make note of any missing ones Gaps between teeth (diastemas)
common in children
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Occlusion
Relationship between upper and lower molars (NOT front teeth)
Normal = upper 1st molar ½ a tooth ahead of lower 1st molar
Class II = reversed situation Class III = upper 1st molar more
than ½ a tooth forward of lower
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Teeth
Entire upper dental arch slightly wider than lower dental arch
All upper teeth should be positioned slightly outside of lower teeth when they meet
If any upper tooth is inside of a lower tooth, this = crossbite
Crossbite can occur anywhere
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Teeth
Upper central incisors should be slightly ahead of lower
If too far ahead, this = overjet If behind, this = underjet When teeth are together, all upper
should contact lower If not, this = openbite Openbite can occur anywhere
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Teeth
Upper central incisors, should cover 1/3 to ½ of lower incisors
If more than ½, this = closed bite
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Tongue
At rest, tongue should sit behind the lower central incisors
The sides of the tongue should rest on the lower back teeth
The lingual frenum should allow the tongue tip to easily touch the alveolar ridge
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Tongue
Macroglossia (enlgarged tongue) = rare. Usually signals some active disease process
Down syndrome – actually have normal tongue in small oral cavity
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Palate
Two possible shapes to palate: 1. High and narrow 2. Shallow and wide Midline should be pinkish or white
(not purple) Torus palatinus = overgrowth of
tissue where primary palate meets main palate
Seen in about 1/7 of population
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Fig. 6
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Velum
Soft palate + uvula Should hang symmetrically Bifid uvula may signal submucous
cleft but often doesn’t
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Tonsils
Note if present Normally not visible in older
children and adults Atrophy (get smaller) after puberty
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Tonsils
If really large they can displace the posterior fauces
May result in widening of the pharyngeal space (situation is called “cryptic” tonsils)
If long-standing, fauces may remain in pushed-back position even after tonsils atrophy
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Cryptic Tonsils
Uvula should be the last thing you see before the posterior pharyngeal wall
If posterior fauces are pushed back, the upper edge may be visible between the uvula and the pharyngeal wall
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Fig. 7
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Exercise #6
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Consequences of Structural Problems Some differences observed may
have consequences for speech Many children adapt to the
differences and we don’t see any problems with speech
Our concern is with the children who fail to adapt
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Dental Problems
Class II malocclusion (upper teeth retracted) – results in less front-back space for tongue to move in
Class III malocclusion (upper teeth protruded) – results in alveolar ridge being further forward than usual; tongue has farther to move than usual
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Dental Problems
Openbite – tongue has a tendency to want to fill in the open space
May create abnormal resting position for tongue possibly leading to abnormal movement patterns
Anterior closed bite – alveolar ridge is lower than usual
Ridge harder to reach especially in connected speech
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Ankyloglossia
Tongue-tie Doesn’t always create a problem If present and speech is a problem,
might be worth considering having it “clipped”
Not usually the main cause but may be contributing
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Palatal Shape
Really narrow or really shallow palate may restrict tongue movement
May make it difficult to efficiently move between positions
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Tonsils
Very large tonsils may restrict movement of the back of tongue
May also make it difficult to get palatal closure
Cryptic tonsils may account for some cases of mild hypernasality
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Case studies
1. Overjet and shallow palate 2. Anterior openbite &
fingersucking 3. Large tonsils and /r/
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Developmental Problems In very rare cases, reduced
intelligibility may reflect an overall immature vocal tract
Oral cavity needs to be large enough for tongue to move rapidly between positions
Unclear if this will have a major impact on intelligibility
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Developmental Problems Case study – 4 year-old Aaron All sounds in words age-
appropriate (P.A.T.) Cluster reduction = delayed Connected speech 65-70%
intelligible 15th percentile for height / weight Very small oral cavity may be
restricting rapid tongue movement
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Developmental Problems Useful to obtain (or have access
to) percentile rank charts for height and weight for children
Could also get this info on a particular child from the family physician
See Kent (1994) “Reference Manual” published by Pro-Ed
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Oral-Facial Function
Oral-facial exam form includes “external function” checks – looking at nonspeech movements to assess integrity of cranial nerves and nerve-muscle connections
Looking for muscle weakness (dysarthria)
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Internal Function
All tasks include speech sounds No need to measure “fast”
productions – probably doesn’t represent speech abilities
Diadochokinetic rate measures of doubtful usefulness
Accuracy and sequencing problems almost always seen at normal rates
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Internal Function
Make sure head is level For some children opening mouth
completely make cause them to “lock up”
May need to have them close mouth slightly to get out of this
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Resonance Evaluation
Having child say /a/ and watching for elevation only tells you if the velum can elevate
Can’t see VP closure (which includes movement of pharyngeal walls)
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Resonance Evaluation
Need sample of connected speech to judge hyper- or hyponasality
Probably worth having other listeners to make judgments as well
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Resonance Evaluation
Remember that mild nasality is expected on vowels that occur next to nasal consonants (assimilative nasality).
Nasality that only occurs on specific sounds may represent an articulatory problem
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Structured Stimuli
If hypernasality suspected, ask child to imitate you saying two types of sentences (lots of nasals or no nasals)
Compare productions on the two types.
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Pittsburgh Sentences
1. Mama made lemon jam 2. Put the baby in the buggy 3. Kindly give Kate the cake 4. Go get the wagon for the girl 5. Sissy sees the sun in the sky 6. The ship goes in shallow water 7. Jim and Charlie chew gum 8. Please tie the stamps with string
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Resonance Evaluation
Ignore “stopping” in #5 - 8 if child has not acquired the later fricatives or affricates
Ignore “velar fronting” in #3 and #4 if child has not acquired velars
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Resonance Evaluation
If you suspect a problem with the velum, need to have a formal instrumental assessment
Best = direct exam with either nasopharyngoscope or videoflouroscopy
Next best = indirect exam with oral-nasal airflow measurements
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Respiratory Function
Record maximum prolongation of /a/
Preschoolers should be able to prolong for at least 5 seconds
Children above grade 2 = at least 9 seconds
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Developmental Apraxia of Speech (DAS) Other than the dysarthrias
associated with cerebral palsy, this is the classic childhood motor speech problem
Need specific positive signs (NOT enough to say progress in therapy has been slow)
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DAS Formal Tests
Screening Test for Developmental Apraxia of Speech (STDAS)
Available from Pro-Ed Kaufman Speech Praxis Test for
Children (KSPT) Available from Wayne State
University Press
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DAS Clinical Criteria
Significant problems with consonant production
May see vowel errors Errors increase as length of unit
increases Errors often include more than 2
features Errors often inconsistent
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DAS Clinical Criteria
Difficulty with producing sequences involving changing place of artic.
May see groping movements May see oral apraxia (problems
with nonspeech movements) May have history of ‘neurological
event’ May have problems with timing
and control of nasality and prosody
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DAS Clinical Criteria
Usually have normal nonverbal IQ Usually have normal receptive
language skills Usually have normal hearing Usually don’t have muscle
weakness
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DAS – Specific Procedures Pay attention to phonetic inventory
(often very limited) Note syllable shape inventory (may
also be limited)
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Inventories
Phonetic inventory – all the sounds child is capable of producing (not necessarily used where they should be)
Includes sounds that occur accidentally; suggests child is capable of producing it
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Inventories
Phonemic inventories – sounds produced correctly and used where they should be
List of correct sounds on a traditional articulation test = the phonemic inventory
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Inventories
Syllable shape inventories – range of different syllable forms used
Often restricted in DAS Most common shapes in children =
CV, CVC, VC, V, CCV, VCC, CVCC, and CCVC.
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DAS – Specific Procedures Stimulability usually quite poor Sequencing (p-t-k etc.) tasks
frequently a problem Note awareness – often very
aware that speech is difficult Compare imitated to spontaneous
(often better at imitation)
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Linguistic Problems
Also called “phonological” problems
In recent years, we’ve tended to lump all unintelligible children without obvious organic problems into this group
Need to rule out prosodic, structural, resonance or speech motor problems first
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Linguistic Assessment Essential problem = loss of
contrasts in speech Often quite unaware of their
problem (though some are; especially as they get older)
“fis” phenomenon May be more concerned with
social aspects of speech than the details
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Linguistic Assessment
Multiple errors present when given conventional articulation tests
More efficient to describe errors in terms of “patterns” or “processes”
Provide an organizational framework for intervention
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Linguistic Assessment
Major emphasis on sound errors Ideally we should base our
analysis on conversational speech Problematic for children with very
unintelligible speech Problem is not knowing what the
intended words are so we don’t know what the target sounds are supposed to be
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Linguistic Assessment
Need to use a structured single-word procedure for most of these children
Several published ones available
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Khan-Lewis Procedure
Do a reanalysis of the productions from the Goldman-Fristoe to yield a process analysis
Advantage = don’t need to get another sample
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Hodson’s APP-R
See handout
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Exercise #7
APP-R practice analysis
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Auditory Discrimination
For some children, their “linguistic” problem may be based in trouble discriminating particular sounds they are having trouble with
No reason to expect a generalized problem with speech discrimination
Pay particular attention here if child has a history of lots of OME
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Auditory Discrimination
Check to see if they can discriminate between the sound they use and the intended target
Provide several opportunities Could use picture pointing tasks Could use ‘same-not the same’
tasks but be sure they understand the concept of “same”
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Part II - Intervention
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Short-Term Problems
Unintelligibility = primary concern Not always the listener’s fault Scudder et al. (1993) suggest we
can train these children to engage in “conversational repair”
They tend to just repeat Try teaching them to revise (use
different words) Train to add information
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Structural Problems
Dental problems – make referral for orthodontic assessment
Ankyloglossia – if obvious and child is unintelligible, recommend that it be clipped
Be sure parents understand that the procedure by itself will not “cure” the problem but will likely help the therapeutic process
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Palatal Shape Problems
Usually not correctable. Surgery usually only done in cases of severe craniofacial problems.
Impact may be reduced somewhat on its own with craniofacial growth
May want to try rate control (teach them to slow down) though this is often difficult with preschoolers
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Tonsils
May affect hearing indirectly (i.e., contribute to otitis media)
If they also restrict speech movements, it might be worth recommending removal
Remember that this is a medical decision. ENT may have other reasons for not removing them
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Developmental Problems with Structure Recall previous case study May be a case of “watch and see” For case study - worked on
production of consonant clusters (which were delayed) as an indirect way to get him to slow down. Proved somewhat helpful.
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Resonance Problems
Speech therapy alone will NOT solve a velopharyngeal problem (except in rare cases of phoneme specific nasality)
Little or no good evidence that nonspeech activities (e.g., blowing, sucking) make any difference
Almost always requires surgical or prosthetic management
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DAS Intervention
Two important principles: 1. Need to teach new behaviors 2. Need lots of practice BUT want
to be sure to avoid excessive repetition of the same things (want to teach flexibility)
3. Watch frustration if steps in progression are too hard
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DAS Intervention
Nonsense material often too abstract for very young children
Better to associate real-world syllables with meaning
e.g., “go” in some active game Make activities sequential (focus
on completing tasks)
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DAS Intervention
Want to expand both phonetic and syllable shape inventories
Begin with sounds already in the phonetic inventory
Teach new sounds using syllable shapes they already use
Teach new syllable shapes using sounds already in inventory
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DAS Intervention
Visual stimuli often helpful Create picture stimuli for each
sound and practice in games Combine stimuli to help create
sound sequence practice Aim for both accuracy and
flexibility LOTS of production practice
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Nuffield Dyspraxia Programme British program Package of stimuli for treatment
Nuffield Hearing and Speech Centre - London
Phone 071 278 8527 Fax 071 833 5518
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Linguistic Problems
Intervention arising from APP-R See handout
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More on Hodson
Hodson spends most of her time talking about single words
These children are very stimulable Single words less of an issue
Need to move up to connected speech level fairly quickly
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Connected Speech
Can take the single word targets being used and put them into sentences
Yes even with preschoolers! Production focus is on the target
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Connected Speech
Use pictures previously used for single word practice
Have child choose 4-6 pictures Have them make up short
sentences for each word Practice several times and send as
homework
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Fig. 8
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Hodson’s Limitations
Hodson provides a good basis for assessment and selection of targets
Is not very specific on how to teach the child where to use the new sounds
Relies on games and assumes child will do it on their own
Doesn’t always work
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Bowen’s Additions
Includes several elements that fill in the gaps left by Hodson
Bowen prefers other assessment protocols but Hodson is more accessible here
Recommend: Use Hodson for assessment and selecting targets and Bowen for specific intervention procedures
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Bowen’s Additions
Outlined in recommended reading 1. Parent involvement 2. Use of metalinguistic tasks 3. Specific production activities 4. Multiple exemplar techniques 5. Homework
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Parent Involvement
As much as possible parents should be involved right from the beginning
Parents should see initial assessment (video?)
Should know the entire management plan (see the big picture)
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Parent Involvement
Information and activities outlined in her book: “Developmental Phonological Disorders: A Practical Guide for Families and Teachers”
Available from Amazon.com or bn.com ($18.95 US)
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Parent Involvement
See also Caroline Bowen’s website:
http://members.tripod.com/Caroline_Bowen/home.html
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Metalinguistic Tasks
Intended to focus child’s attention on the sounds being produced
Teaching self-monitoring Several ways to do this
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Metalinguistic Tasks
Traditional associations between pictures and sounds (sometimes called metaphonetics)
Segmentation – teach sorting of words that begin or end with the same sound
Rhyming – read rhyming books such as Dr Suess and talk about “words that rhyme”
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Metalinguistic Tasks
Judgment activities – you produce correct and incorrect versions and ask child to judge
Revision and repair – talk about what would happen if you make a mistake and how you would correct it
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Production Activities
Here Bowen recognizes that sometimes you have to directly teach production of a sound
Even children whose main problem is a linguistic one may need this
Traditional articulation therapy activities
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Multiple Exemplar Techniques Minimal pairs production activities 1. Point to picture of word
produced – focuses listening 2. Find rhyming pairs 3. Say one of a pair and child finds
the one that rhymes
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Multiple Exemplar Techniques 4. Child produces both members of
the pair one after the other 5. Child as teacher – judgment
tasks (produce pair and ask if same or different)
6. Silly sentences – produce both members of pair sentences and child identifies the “silly” one
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Homework
Should reinforce what is being done in the therapy sessions
Activities can be more naturalistic however
Parent needs to see the activities directly (observe or video)
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Homework
Doesn’t have to be major time commitment
5-7 minutes per day 5-6 days per week Suggests no practice the morning
of therapy sessions (OK after)
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Homework Activities
Naturalistic activities – usual interactions
Modeling of correct productions of the current target
Corrective feedback Encouraging self-monitoring Encouraging self-correction Reinforce revisions and repairs
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Typical Bowen Session
Focused auditory stimulation Minimal contrasts task Judgment of correctness task Phonetic production activities (if
needed) Focused auditory stimulation Parent instruction (if present but
could also do it on a video)
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Homework Books
Include space at front for communications if parent is not attending sessions
Include pages constructed for sentence practice (my addition)
Add new pages as new targets are worked on
Probably don’t want more than 8-10 pages in book at any one time
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An Alternate View
So far we’ve been assuming that a single problem accounts for all the errors for each child
For some children, some errors may be motor problems, some audit. discrim. and some linguistic
Need to check each sound (could group by error source for treatment) – see handout
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Figure 9
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Summary
Unintelligible Preschoolers are not a single group
Assessment crucial to identifying the source of the problem
Intervention should be focused As far as possible parents should
be included in intervention
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Posttest
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Workshop Evaluations
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The End