Exam 2 Flashcards
__________________, ______________, and ______________can cause speech deficits
Muscular weakness, deficient neural control, and growth deficiencies
Oral mechanism exam- need to know the degree of
abnormality, not just presence or absence of abnormality
Lips:
only gross structural abnormalities of the lips actually cause speech disorders, like cleft lip (once they get cleft lip surgically repaired they still may not have a completely normal structure but they can still produce speech sounds)
Teeth: f, v, th
Sometimes it can affect speech production but it doesn’t necessarily affect speech production (studies of preschoolers)
3 types of malocclusions:
- Class 1: small variations in alignment of teeth or a • few missing teeth
- Class 2: overbite or overjet, the lower jaw is receding (upper jaw protrudes over the lower jaw)
- Class 3: low jaw protrudes while the upper jaw recedes
Dental arch malocclusions don’t necessarily cause speech deficits;
can be a contributing factor but not necessarily
Tongue:
very adaptable organ, can compensate very well when there is an extensive amount missing. A lot of the tongue can be missing and the person will still have good speech intelligibility.
Ankyloglossia:
a short lingual frenulum, must be at least moderate to severe to cause speech disorder (some believe it can cause trouble with infant feeding)
Glossectomy:
total or partial surgical removal of the tongue
Hard Palate
quite a variation of palate height and width, normal variations don’t affect speech production. Must be a gross deficit, like cleft palate, cancer of the
palate and removal (can get palatal prosthesis and have normal speech)
Soft Palate: velum
- Part of the velopharyngeal mechanism so very important for resonation
- Used to produce pressure consonants
- Can be affected by cleft palate of the soft palate
- Can have paresis or paralysis of the velum after a stroke
- Results in hypernasality of sounds, specifically on vowels, nasals, liquids and glides
- Nasal emission during pressure consonants (weak pressure consonant production)
- Palate developed in utero around time of Eustachian tubes so can occur with middle ear dysfunction (check for this)
- Substitution of glottal stops for stops (glottal click)
- Pharyngeal fricatives (contact between the base of the tongue and the posterior pharyngeal wall) for the sibilants
- Enlarged adenoids can also cause velopharyngeal inadequacy- enlarged can affect nasopharynx and result in hypo-nasal speech and can also affect the Eustachian tubes by obstruction
Results of velopharyngeal inadequacy
- Results in hypernasality of sounds, specifically on vowels, nasals, liquids and glides
- Nasal emission during pressure consonants (weak pressure consonant production)
Motor skills
-diadochokinetic rates
• Adult normal between the ages 9-15
• Children will be quite a bit slower
o The slower rate doesn’t mean there will be a motor speech disorder
• It is helpful in identifying childhood/adult apraxia
Oral Sensation
- Has nothing to do with speech production
* Studied through anesthesia in mouth and assessing speech, no decrease in intelligibility found
Language skills
- Strong relationship between language disorders and phonological disorders because they are bot rule based
- In preschool children they co-exist in up to 50% of children
- 40-80% of children with phonological disorders also had a language disorder and vice versa
- Those children who have a severe phonological disorder are more likely to also have a language disorder
- The best clinical practice it to treat both of them
- Errors increase as you increase complexity of utterance and syllables in a word
Personal Characteristics
• Age: younger children have more speech disorders than older children but by 1st grade they should match the adult model
Gender
- Girls master sounds earlier as a whole than boys do.
- Standardized test separate gender, but there is not a significant difference.
- Articulation and phonological disorders are more prevalent in boys than girls
Intelligence
- Normal variations in intelligence do not affect presence or absence of SSD.
- If a person has an IQ below 70, higher prevalence of artic disorders
Socioeconomic status
• No significant difference in speech disorders
Familial prevalence
• Family by family basis, not always hereditary but can be
Tongue Thrust
- The way your tongue is in a protruded manner at rest or during swallowing, common in children up to age 5
- May be functional (habitual) and has nothing to do with structural anomaly
- Also could be due to enlarged tonsils and adenoids
Tongue Thrust
Characterized by: forward gesture of the tongue during swallowing
- Tongue placement is between the anterior teeth with the tongue tip contacting • the upper lip
- Can also be characterized by forward carriage of the tongue in the oral cavity of the tongue at rest
- Characterized by fronting of the tongue during speech, tongue between or against the anterior teeth
This can cause
• Interdentalization of t, d, n, l
• Frontal lisp of s and z
• Anterior placement of the palatals
- A child can have one or all of these characteristics to be considered tongue thrust
- Study- thought to be due to low muscle tone of the tongue and also jaw instability, tongue instability, poor oral awareness, and may be due to allergies •
- In school, only target tongue thrust that affects speech
Use tongue and jaw _________techniques to target
r, l, s
stability
Speech screening
• Pass or fail procedure that can be conducted on a large amount of individuals in a relatively short period time
• Helps identify children who potentially have a speech or phonological disorder
• Does no mean that child has disorder- let parents know that
o Does mean they should be sent for more in depth testing
• Conducted in schools: pre-K-1st grade (beginning of the year)
• In hospital: altered mental status, stroke, brain injury (injury- may be called in to look at cognitive, speech, language, etc (mini mental state examination)
• Mini Mental State Examination: orientation to person, time, and place, memory recall, writing, and counting tasks
Non-standardized screening
- Clinician tailors their own screening, more prevalent with children of a different ethnical background or if it needs to be specified to a specific population.
- Include: open -ended questions, brief conversation, objects, pictures, note any abnormalities
- Problem: can take a lot longer to give, have to make sure you are getting the information that you need. Also, you have to have rapport with the child so it can be a downfall (they may not talk enough)
- It is the clinicians call so you must know norms about processes, ages, speech sounds, etc
- Older child or client: grandfather/rainbow passage reading
- If there is every a question, always send for more in-depth testing to make sure a child isn’t over-looked
Assessment
- The process and procedures used to attain a clear description of articulatory and phonological skills of a child with a view to determining the presence or absence of a disorder
- Maintain an open mind, don’t try to diagnose as you assess b/c you may overlook areas of impairment or strength
Diagnosis:
the goal or outcome you are trying to achieve
General Steps of Assessment:
• Reviewing client’s background
- Case history form, ask them to do a thorough job filling it out
- Gather reports from other professionals that have seen the child
- Consent form (HIPAA) by client to obtain those reports
- Ask about client interests to bring toys, activities, snacks the child likes (helps with rapport during assessment)
- Hospital: case background information from History & Physical (H&P) part of the client’s file
General Steps of Assessment:
• Planning the diagnostic session
o Plan standardized test
o Appropriate for age and ethno cultural background of the child
o Plan testing sequence- have flexibility
o Take all information from case history form
• If child has a tongue thrust, has trouble eating meat (may want to do bedside swallow exam)
General Steps of Assessment:
• Selecting appropriate tests
• Prepare test room
o Keep distractions to a minimum o Hide objects, tests, and toys o Back to mirror o Adequate light o Video/audio recordings
General Steps of Assessment:
• Conduct an opening interview
o Seek additional information or clarification on the various sections of the case history
o With client or caregiver
o Don’t use too much technical jargon, but don’t talk down
o Ask your additional questions you may have had based on case history form
o Ask if problem has changed since they first noticed it
o Is the child aware of speech impairment? How/does the impairment affect them daily or at school? Ask how the caregiver responds to the child
o Consistent or inconsistent errors?
o What is your goal for speech therapy?
o Anything else you want me to know about your child?
o Let them know what to expect in the assessment
General Steps of Assessment:
• Administering the tests
o Hearing screening (can include parents)
o Language sample/play- Good to do 1st to build rapport
o Level of stimulability
o Speech rate
o Intelligibility
o At least screen for language (or full assessment)
General Steps of Assessment:
- Reviewing client’s background
- Planning the diagnostic session
- Selecting appropriate tests
- Prepare test room
- Conduct an opening interview
- Administering the tests
- Assessing related areas
- Conduct closing interview
- Make recommendations
- Writing diagnostic report
Assessing Related Areas
- Oral-Mechanism Exam (Diadochokinetic rates)
- Level of stimulability
- Speech Rate
- Speech Intelligibility (#1 goal- gives you baseline)
- Language (at least screen)
- Hearing
Orofacial Exam
- Helpful to look at overall structure and muscles to determine neurological involvement
- Note abnormalities and refer for proper services (dentist- teeth, ENT- tonsils)
- Observe facial symmetry and look at all subsystems of speech
- Respiration
- Phonation
- Articulation
- Resonation
Tools for Oral Mech Exam
- Flashlight (pen light)
- Tongue depressors
- Gloves
- Stop watch
- Small mirror (nasal emission- fog when producing non-nasal sounds) and used for motor imitation
- Cotton gauze pad (gag reflex)
Diadochokinetic Rates
- Sequential or alternate motor rates (SMR, AMR) looking for apraxia or dysarthria
- Looking at speech and irregularity
- Count number of syllables client produces over a duration of time
- Or produce 20 repetitions of a sound and time how long that takes them /p/ /t/ /k/ then /ptk/
- Norms in book on page 303
- Normal adults 5-7 repetitions per second for AMRs and 2.6-7.5 repetitions per second for SMRs (children slower)
- Assess the functional and structural integrity of the lips, jaw, and tongue through the rapid repetition
Conducting a Hearing Screening
- If you don’t have an audiometer refer to the health department (may be free)
- Need to know hearing to know proper adjustments that need to be made in seating or use of an FM system
- If middle ear fluid is present- may need to post-pone assessment until it is cleared
- Fail- not necessarily a hearing impairment but do need further evaluation (a lot of times need pediatrician or doctor referral for insurance to cover it)
- 500, 1000, 2000, 4000 Hz at 20 or 25 dB
Administering the Tests
- Standardized: always adhere to administration procedures
- Always note any deviation from standard procedures in diagnostic report
- Generally look at single words and do traditional analysis (substitutions, omissions, additions, and distortions, in word initial, medial, and final position)
- Do provide norm based information for standard score, percentile rank, severity, age equivalence
- Usually takes 15-20 minutes (fast)
- Phonological assessment takes a little longer because you look at whole-word influences- used if they have multiple misarticulations
- Evoking procedures: a lot prove the procedures and carriers phrases, know what is ok for guidelines (some allow repetition, imitation, and modeling and some do not. Delayed imitation is also something a lot of tests allow)
3 types of response recording
- Correct/incorrect: + or - (generally used in screenings, doesn’t provide info about what the child actually produced)
- Types of errors: note omissions (- or ), substitutions (k/t means k for t), additions (transcribe entire word), and distortions (diacritic markings- (easier to remember later) or number severity)
- Whole word transcription: used more for phonological analysis- advantage you can actually see not just the sound the test is looking at but breakdowns in other errors of the word so errors don’t get overlooked
Advantages of Standardized Tests
helps in qualification
• comprehensive and hits all targets you need
• you have the target (adult model)
Disadvantages of Standardized Tests
Generally looking at single words, there will be a greater breakdown in conversation than their will be at the single word level
• May not be normed for dialect, ethnic background, etc
• You only get to hear a sound 1 time, may get it right in that word but in conversation it is unintelligible
• You can both under and over diagnose
• Inadequate sampling of vowels
Non-standardized Assessment/speech sample analysis
Can provide a lot of information that you can’t get from a standardized test
- Preparing to obtain a speech sample
* Obtaining the speech sample
o Build rapport
o Start with parallel play
o Sometimes a good idea to bring parents in sometimes not (if can’t get child to talk in first 5-10 min) talk to parents first
o Have parents and child play at end if you didn’t get enough to get normal conversation between child and parent
o Ask open-ended questions
o Arrange objects around the room (things they like) to give them reason to communicate (request)
o Record (video and/or audio)
o Re-state things (gloss over things) that are not clear or unintelligible for self-reminders when re-listening
o 50-150 utterances (usually takes 20-30 minutes depending on child)
o Avoid loud noise-making toys
o Note gestures, abnormal articulator placement during speech production, facial grimacing
2 Types of speech sound analysis
Independent analysis
Relational analysis
**Best practice is to do both unless the child is highly unintelligible
Independent analysis
-looking at child’s utterances without relation to the adult model (focusing on what the child can produce)
o Mostly used with children who are highly unintelligible or very young children
Relational analysis
analysis where you do compare to the adult target looking at specific types of errors, patterns, and phonological processes
Traditional analysis
looking at the position in which the sounds are misarticulated (initial, medial, final) and the types of errors (omissions, substitution, additions, and distortions) really great for children with just a few misarticulations and it is relatively quick to do
Pattern analysis:
can look at place, manner, voice, distinctive features, or phonological process (can do with articulation or non-standardized test)
Place-Manner-Voice analysis
Look at place, manner and voice
Distinctive Feature Analysis
Presence or absence of a distinctive feature (pretty overshadowed by phonological analysis)
Phonological process analysis
more popular- used for those highly unintelligible with multiple misarticulations. Standardized tests are an easy way to do this because you can get percentages more easily than from a speech sample. o Using the phonological process 40% of the time or greater it should be targeted in therapy, and it must affect more than one sound in a given class o Less than 40% -monitor
Developmental analysis
comparing the sounds that a child has compared to normal age of mastery of sounds (standardized tests are nice for this b/c they give you norm-based guidelines) or use developmental charts in book for non-standardized tests
• Speech intelligibility analysis
#1 goal is to increase speech intelligibility, assess at conversation level subjective analysis scale of intelligibility from 1-3 or 1-5 o Number of intelligible words/ total words (or utterances)
Severity Analysis
most standardized tests derive severity but could be under or over diagnosed
o Severity from slight to severe
o Option: percentage of consonants correct (PCC) # of consonants they can produce/total # of consonants x 100 (all positions of consonants)
o 85-100% mild to normal
o 65-85% mild to moderate
o 50-65% moderate to severe
o Below 50% severe to profound
Things to consider:
• Number of sounds in error or processes in error
• Consistency of errors
• Child’s age
Contextual testing analysis
looking for a context in which they can produce the sound accurately
o Helpful for baseline (where to start in treatment)
o Not used for assessment but for where to start with treatment
Phonetic inventory
look at all phonemes they can produce (all word positions)
o Good visual analysis
o Helpful to show parents
Syllable structure analysis
look at different syllables they can produce (open syllables - final consonant deletion)
Consistency analysis
consistently producing an error 40% of the time or more you will want to target
o Inconsistent <40% means they can produce correct production- monitor
Advantages of Speech Sample
- Allows for multiple occurrences of the same sound ( to get better idea of consistency)
- Looks at more representative conversational speech
- Looks at syllable shapes
- Looks a utterance length
- Looks at speaking rate
- Can look at language
Disadvantages of Speech Sample
Time consuming • Don't have easy to find norms • Don't have adult target • May not get representative sample of every sound • Child may not talk
Conducting Stimulability Testing
- Some standardized tests do allow for this, good thing to do before treatment (verbal cue, visual cue, tactile cue) to see if there are things that will help them produce the target correctly.
- Done informally early in treatment or can be done in evaluation
Contextual Testing:
Facilitative Phonetic Context: to help identify a facilitative phonetic context for correct production of a sound
• DEET
• Clinical Probes of Articulation Consistency
Testing Speech Discrimination
to see if they can hear difference in target and error (minimal pairs), include discrimination with treatment
Analyzing & Interpreting the Assessment Data
Determine:
- if disorder exists
- nature of the problem
- severity
- any related factors (hearing, oral mech, case history)
- determine if treatment if going to be appropriate
- determine prognosis
Making a diagnosis (goal in assessment)
Determine the severity and nature of the problem
consider speech intelligibility
Normal
- Normal: If errors are related to 2nd language or dialect
- Normal: age appropriate speech
- Normal: errors are slight and not perceived by the average person
- take into account the client and parent wishes
- Ethical to treat if client or parent want treatment, just may not be covered by insurance
Articulation Disorder
- Few errors
* More motor based
Phonological Disorder
- Phonological errors if underlying rule or pattern that can be identified
- There is multiple articulation errors and poor speech intelligibility
- Various processes
- Limited syllable shapes
- Limited phonetic inventory
- Collapse in phonemic contrast
- Have difficulty with rule and suppression of processes
Prognosis:
Prognostic statement
- An estimated course of a disorder under specified conditions
- Initial prognosis make at the time of assessment after you have gathered assessment information
3 major components to a prognostic statement
- Goal statement
o What the target is (e.g. /s/ /z/ processes etc) reference to the skill the child is expected to learn or achieve - Judgment of success
o fair, poor, excellent (how well you expect the child to do in therapy) - Prognostic variables
o Help decide fair, poor, excellent prognosis
o Severity - more severe- poorer prognosis
o Chronological age- younger the better prognosis
o Motivation- motivation to improve
o Inconsistency- more inconsistent with incorrect production the greater prognosis (already can produce some of the time)
o Associated conditions (other diagnoses, (Down syndrome, poorer prognosis)
o Treatment history (history of limited progress over time, therapy for years, poorer prognosis
o Family support (more support better prognosis)
*Poor prognosis doesn’t mean you don’t treat.
ASHA: prognosis is just a reasonable statement or judgment
Prognostic statement:
Jamie’s prognosis for improved production of /s/ with therapy was judged excellent based on the following variables: the mild nature of her articulation disorder, her stimulability for correct production of the erred sound, her cooperative behavior during the assessment, and the absence of any structural problems
(Make sure it has all 3 components)
Making Treatment Recommendations
• Take all info gathered and decide if treatment is warranted or not and design treatment plan
Conducting the Final interview
- Review all gathered information, explain test scores, show deficits, visual illustrations, norms, phonetic inventory
- Ask questions
- Don’t talk down
- Don’t use technical jargon they will not understand
Writing a diagnostic report
• Compile all information into diagnostic report • Identifying information • Background information • History • Assessment information o Speech o Language o Hearing o Oral mechanism exam • Diagnostic statement • Prognostic statement • Treatment recommendations
Childhood Apraxia of Speech (CAS)
a neurological childhood speech sound disorder in which the precision and the inconsistency of movements underlying speech are impaired in the absence of neuromuscular deficits. CAS may occur as a result of known neurological impairment or as an idiopathic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.
Childhood Apraxia of Speech Assessment
Dynamic Evaluatin of Motor Speech Skill (DEMSS) by Strand- coming out soon
CAS is a
motor PLANNING issue and also affects prosody
breakdown in motor planning, speech movement disorder
CAS: difference from adult apraxia:
childhood does not have neurological deficit
similar to adult apraxia due to lack of volitional control
CAS can occur with:
ADD, intellectual disability, Cerebral palsy, sensorineural hearing loss
CAS can be controversial because
there is no neurological impairment
CAS salient Features:
- Difficulty in volitional production of phonemes and sequence of phonemes the child can otherwise produce (child lengthens sounds or segments sounds or parts of a word)
- Inconsistent speech errors
- Distorted vowels and diphthong reduction (monophthongization)
- Flat prosody or equal stress on each syllable
CAS other characteristics:
- Groping (physical groping for trial and error production)
- Difficulty executing isolated and sequenced oral movements on command
- Difficulty with sound imitation (and motor imitation)
- Increased errors with increased utterance length
- Poor oral awareness
- Moderate to severe speech intelligibility (varies based on complexity of utterance)
- Addition errors (quink for queen)- not typical additions
- Prolongation errors
- Predominance of omissions and substitutions
- Errors are very unusual
- No typical pattern- very difficult to do phonological process analysis
- Devoicing errors
- Inconsistent hyper-nasality
- Metathetic errors (Metathesis)
- Slow development of speech (delayed)
- Reduced phonetic inventory
- Reduced percentage of consonants correct (PCC)
Vowel Errors (Davis, et. Al. 2005)
- In children with CAS, vowels were inaccurate (15-39%) even when they had acquired a relatively complete vowel inventory (NORM: is 8% at 2 years, and 7% at 3 years)
- CAS children showed no consistent pattern of errors
- CAS children did NOT use mot stable vowel as substitute for errored vowels-whereas phonological children DID
- CAS children had decreased rhotic vowels compared to norms
- Example: A child may say “hup” for “hop” or may distort a vowel so that it does not sounds like an English vowel.
Lengthened and disrupted coarticulatory tranistions between sounds and syllables:
- A child with CAS produces a word, there may be lengthy pauses or breaks between the sounds and/or syllables within the word. This may be due to difficulty coordinating the motor movement of the articulators from one sound to the next. Or, the child may have a problem coordinating “voicing” such as going from a voiceless consonant to a voiced vowel (learning to play piano-long pauses while you figure out the next note).
- Example: A child may be trying to say the word “top” and my effortfully separate each sound, resulting in a production that sounds like “t”———“awe”—“puh”. Or a child may pause between sounds, syllables, and words so that this utterance sounds “choppy” (I—-want—huh—nee—oz—for—suh-nack- instead of “I want Honeyo’s for snack.”)
Inappropriate prosody, especially in the realization of lexical or phrasal stress
- Melody of speech pattern in affected, lacking inflection and appropriate stress pattern. A child may lack expression and sound robotic (like when learning to play the piano, notes separated, not fluid-not melodic)
- Example: when asked who’s toy the child might say “It’s my toy” without placing stress on MY or the child may separate each letter in a word and produce in an over-precise way again resulting in robotic or staccato production.
CAS Prognosis
Progress in therapy is slow
Prognosis not great- but can be treated
With CAS- also at risk for
phonological awareness deficits which correlates to rhyming, reading, spelling, and writing deficits later
CAS _____ language is better than _______________
receptive
expressive
May have deficits in auditory _____________, auditory ____________, and auditory ____________
perception
discrimination
memory
CAS children have
Increased self-awareness that speech is impaired
CAS muscle tone
Mildly low muscle tone and can have motor skill delays- often clumsy or awkward
May present with ________ or _________apraxia also
oral
limb
- Pretend you are licking an ice cream cone- cannot
- Give them an ice cream cone- response is automatic and they can
Assessment of CAS:
- Look at automatic versus volitional control
- Look at simple versus complex speaking tasks
- Look at consistency of production of the same word (major feature)
- Look at prosody during speech sample
- Apraxia stress is equal and segmented (breaks between and within words)
- Look at phonetic inventory (may or may not be limited, may just be a breakdown at conversation level)
- Look at vowels and vowel imitation
- Look at language, receptive will most likely be better
- Oral mechanism exam- groping, nonverbal oral motor tasks
- Phonological awareness assessment can be included
- Check stimulability- nonverbal cue, verbal and nonverbal cue, add tactile cue (see if you can get any correct production)
- Look at functional communication skills, can they express wants and needs and how do they express themselves
BUILD YOUR OWN ASSESSMENT
Build you own assessment and include Goldman-Fristoe to get standard score
Speech sample
o Natural sample with the parent
o Elicited speech sample with SLP (e.g. tell me about)
Imitation Tasks
o Imitate more than once (look for inconsistencies)
List of words organized by syllable shape- beginning with simple and moving to complex (simple syllable shapes to one to two word utterances)
-representative sample of all vowels and diphthongs
-representative sample of all developmentally appropriate consonants
-include some strings of words and phrases that get progressively longer, building on each other
• Have child say words in imitation and listen for: (have them say at least 2x to get instant %
-vowels
-Consistency from trial to trial
-prosody
-coarticulatory transitions between sounds and syllables
-then comment on other features noted.
Oral Motor Exam
o Oral Apraxia Assessment: Nonverbal oral tasks
Language Assessement
Articulation assessment (Goldman-Fristoe) to get standard score
o Can add a vowel column to note production of vowels
o Have them say each word twice to see consistency
o You can reorder the Goldman-Fristoe from easy to harder words and listen to how they produce multisyllabic words (segmenting or producing equal stress)
AAC assessment (if nonverbal)
o Boardmaker pictures
o iPad
• Take these in to see how functional they can be with these types of AAC
Cerebral Palsy
- A non-progressive neuromotor disorder resulting from brain damage before, during, or shortly after birth
- 2 in 1000 live births result in CP
- No single etiology: can be due to intrauterine infection, radiation exposure, trauma during birth, and can also be due to head trauma at a later age, mother drug use, anoxia, abrupted placenta (placenta separates from uterine wall- delivery right away)
CP categorized based on ______________________
neurological impairment
Spastic CP
o Increased muscle tone and exaggerated stretch reflex, slow effortful jerking movements related to pyramidal lesions
o 50% of those who have CP have spastic CP- most common
Athetoid CP
o Slow writhing involuntary movements when attempting volitional actions
o Muscle tone fluctuates from normal at rest to hypertonic when attempting a voluntary movement
o Increase involuntary movement with increased stress and distraction
o Due to extrapyramidal lesions
o 10% of those with CP have Athetoid CP
Ataxic CP
o Cerebellum lesions
o Affects equilibrium
o 5-10% of those with CP have ataxic
Rigid CP
o All muscles are affected simultaneously
o Constant muscle tone
o Movements are slow, effortful
o Damage is in the pyramidal regions
o 1% of those with CP have rigid
Mixed CP
o One type usually dominates even with mixed
o Most common spastic and athetoid – occurs in 30% of those with CP
CP: Degree of neurological impairment affects degree of _______________________
speech impairment
___________ of children with CP show obvious speech impairment
75-80%
Can result in nonverbal individuals, may be working with AAC
CP Speech characteristics
All speech subsystems are affected with CP
Movements are effortful and jerky- speech also sounds effortful and jerky
Difficulty with prosody
CP Articulatory errors:
- Inefficient or imprecise articulation due to muscle strength, range of motion, and muscle tone impairments
- May present with slurred speech- especially those who are ataxic
- Those with Athetosis have increased articulation errors than those with spastic CP
- Difficulty with tongue tip sounds
- Predominance of omissions
- Difficulty prolonging sounds
- Greater errors in the final position (more final consonant deletion)
- Articulatory conspicuousness (just sounds different)
CP Common phonological processes:
- Cluster reduction
- Stopping
- Gliding
- Fronting
- Depalatalization
CP Resonatory errors:
- Hypernasality due to velopharyngeal mechanism dysfunction
- May present with nasal emission
- Overall poor oral resonance
CP Phonatory errors:
- Difficulty controlling loudness
- Random loud bursts
- Strained vocal quality due to hyper adduction of the VFs
- Some present with more of a weak breathy voice due to hypo adduction of the VFs
- Some present with a high pitch
CP Respiratory errors:
- Poor breath support
- Rapid breathing
- Air wastage
- Excessive diaphragmatic breathing
CP Prosodic errors:
- Monotone
- Monoloud
- Lack of smooth flowing speech
- Overall dysprosody
- Slow Diadochokinetic rates
CP Associated problems:
- Intellectual disabiilty
- ADD
- Hearing loss
- Language disorders
Assessment of CP:
Work with team of professionals o PT- posture, trunk stabilization o OT- bringing food to mouth, posture, tone o Social workers o Parents o Psycholinguists o Medical doctors o Audiologists
Often see child before 1st birthday
Work early on swallowing and feeding
Oral motor exam (very important) o Look at head control o Coordination of suck, swallow, breathe patterns o Vocal quality o Breath support o Vocal fold abduction and adduction
Psych report- know mental development (helpful for setting goals)
Behavior checklist o Chewing o Swallowing o Biting o Sucking o Talking (all components, speech and language)
Cleft Lip & Palate
Cleft
• Opening in a normally closed structure, hard palate, soft palate, lip, all of the above
• 50% of clefts are lip and palate
• Occurs in utero
• Lips close at 5th or 6th week of gestation
• Palate closes at 8th or 9th week of gestation
• Occurs in 1/500 to 750 live births
• Predominate in Native Americans
• Affects males 2X more than females
• Multifactorial in origin
o Can be genetic or environmental/from toxic factors
Cleft
Articulation & Phonological disorders:
- More difficulty with voiced sounds
- Difficulty with pressure consonants (stops, fricatives, and affricates) because you must be able to build up intraoral pressure and cannot because of leak in system
- Substitute nasals for nonnasals
- Produce nasal emission (esp. on voiceless consonants)
- Distorted vowels
- Reduced speech intelligibility
Errors due to velopharyngeal mechanism inadequacy
o Substituting glottal stops for anterior stops (sound like glottal click)
o Pharyngeal fricatives for palatal fricatives
o Pharyngeal stops
Cleft
Laryngeal pathologies & phonatory disorders:
- Higher risk of vocal nodules because of the greater tension and strain on the vocal folds because they are producing so many laryngeal and glottal sounds rather than oral sounds
- Excessive adduction of the VFs- strain and hoarse voice
- Edema of the VFs
- Monotonous in pitch
Cleft
Resonance disorders
• Hypernasal
Cleft
Associated Problems:
- Eustachian tubes developed around the same time as the palate 8-9 gestation week
- Hearing impairment due to recurrent middle ear infection – Eustachian tubes not draining properly
- Conductive hearing loss in approximately 50% of those with cleft
- Language disorder- if genetic syndrome
Cleft
Assessment:
- Cleft palate team
- In depth case history- surgeries
- Work with audiologist
Oral mechanism exam
o Velopharyngeal mechanism
Articulation assessment
o Include lots of pressure consonants and nasal sounds versus non-nasal sounds
Conversational speech sample
Reading sample if old enough
Vocal quality
Resonance
Genetic Syndromes
Down Syndrome
- Occurs in 1 in 700 births
- Extra copy of chromosome 21
- Trisomy 21
- Larger range of cognitive impairment- determines severity of speech impairment
- Relative macroglossia: smaller oral cavity making tongue look larger and protrudes
- Tongue thrust during speech and swallow
Impaired jaw stability
o Work on stabilizing jaw movements
- Low muscle tone
- Frequency otitis media
- Overall delayed speech development
Genetic Syndromes
Fragile X Syndrome
- Occurs in 1 in 4000 births
- Mutation on the X chromosome- turn off a particular section
- Occurs more often in males because they only have one X chromosome
- Poor speech intelligibility
- Varying degrees of cognitive impairment- which affects speech development
- Generally follow normal pattern of development of speech- but at a much slower rate (classic delay)
Sensory Variables: Hearing loss
What aspects of hearing loss have been shown to affect speech perception and production?
- Normal acquisition of speech- you have to be able to hear others production (adult target) and hear yourself for self-monitoring for correct productions
- Affect hearing loss has on speech has to do with level of hearing sensitivity, speech recognition skills, and the configuration of the hearing loss
- 2-3% of school age children have a hearing impairment that is greater than 25dB HL
- Hard of hearing- still have residual hearing in order to perceive sounds- just need amplification assistance
- Deaf- not able to use hearing at all to acquire speech
- Early onset of deafness greatly affects the acquisition of speech
- Born without hearing- greatest speech and language impairment
Hearing
Severity levels
o Slight 16-25 dB o Mild 26-40 dB o Moderate 41-70 dB o Severe 71-90 dB o Profound 91<
Sensorineural Hearing Loss
• Affect the inner ear- auditory nerve- hairs of cochlea (cilia)
Causes: o Presbycusis o Exposure to excessively loud noise o Vascular accident that affect blood flow to the cochlea o Viral or bacteria infections (meningitis) o Fetal alcohol syndrome o Oto-toxicity o Maternal drug addiction o Low birth weight o 8th cranial tumor o Demyelination o Congenital disorders
Conductive Hearing Loss
- Affects the middle ear
- 1/3 of children who have a conductive hearing loss- it is due to recurrent otitis media (can cause permanent damage- but can be treated (preventable)
Causes:
o Otitis media
o Otisis externa (swimmers ear): inflammation of the external auditory canal
o Osteosclerosis: foot plate of the stapes is attached to the oval window
o Collapsed ear canal
o Stenosis- narrowing of external auditory canal
o Aural atresia- closed external auditory canal
o Disarticulation of ossicular chain
o Osteomas- benign bony tumors of the external auditory canal
Mixed Hearing Loss
Both conductive and sensorineural
Factors that determine if speech disorder exists:
- Degree of hearing loss
- Age of onset
- Age of intervention onset
- Quality of intervention
- Family support
- Presence of other physical, cognitive, and sensory impairments
Characteristics of Speech in Hearing Impaired
Errors of omission
- Final consonant deletion
- Omission of /s/ (high frequency voiceless sound)
- Initial consonant deletion
- Omission of voiceless fricatives
Characteristics of Speech in Hearing Impaired
Errors of substitution
- Voiced for voiceless
- Nasals for non-nasals
- Vowel substitutions
- /w/ for /r/ (sounds that provide kinesthetic feedback are easier to produce)
Characteristics of Speech in Hearing Impaired
Errors of distortion
• Tendency to produce the wrong amount of force
o Too hard
o Too soft
• Degree of force of fricatives and stops
• Duration of vowels usually longer than normal
• Hypernasality with vowel production
• Diphthongs produced with incorrect timing of first and second vowel
• *Be prepared for a lot of narrow transcription
Characteristics of Speech in Hearing Impaired
Errors of addition
- Epenthesis (produce vowel between consonants)
- Aspirate the final stop consonant (over-exaggerate)
- Produce diphthongization of monothongal vowels
Characteristics of Speech in Hearing Impaired
Voice & Resonance Problems
- High pitched
- More harsh
- More hoarse
- Nasal emission on voiced consonants
- Hypernasality on voiced consonants and vowels
Characteristics of Speech in Hearing Impaired
Prosodic problems
- Abnormal intonation
- Abnormal rhythm
- Slow rate of speech
- Inappropriate pauses
Hearing impaired
Associated Language Problems
- Grammatical morphemes (past tense, plurals, verb endings (present progressive))
- Pragmatics
- Very literal
Trouble with abstract language
o Metaphors
o Idioms
o Humor
- Difficulty with multiple meaning words
- Limited vocabulary
- Poor word comprehension
- Poor reading comprehension
- Writing mirrors their speech (verbal output)
Assessment of Hearing Loss
- Know degree of hearing loss (talk to audiologist)
- Articulation test using narrow phonetic transcription
- Reading sample
- Writing sample
- Assess language
- Assess voice, prosody, and resonance
When to begin working on phonology with a child:
around when they can combine 2 word utterances and have approximately 50 words in their repertoire (usually around 18-24 months).
Prior to that: may be working on speech but not phonology.
Look at prelinguistic speech acquisition stages and see if they are following it normally (babbling, intonation, etc. ) and take into account parent and functional concern.
Phonological Awareness
- Underlying knowledge that words are made up of sounds and sound combinations
- Ability to reflect on or think about- and manipulate sounds and utterances
- The child’s ability to break down the word and analyze it
- Phonological skills are essential to reading and spelling
Phonological Awareness includes the following skills:
Rhyming Alliteration Phoneme Isolation Sound Blending Syllable Identification Sound segmentation Invented spellings Phoneme Manipulation
Rhyming:
- Ability to identify words that sound alike
- Ability to produce a word that sounds like another word
- Ability to distinguish rhyming from non-rhyming words
- Can be seen as early as age 2
- Earliest benchmark of phonological awareness
Alliteration:
• Ability to identify words that begin or end with a certain sound
Phoneme Isolation:
• Ability to identify whether a specific sound occurs in the beginning, middle, or end of a word
Sound Blending:
• Ability to blend 2 or more sounds that are temporarily separated with pauses
Syllable Identification:
• Ability to identify the number of syllables in a word through clapping, tapping, or verbally producing the number of syllables
Sound segmentation:
- Ability to break down a word into its individual sound components
- Develops closer to age 6
Invented spellings:
• Child spells the word phonetically how it sounds
Phoneme Manipulation:
- The skill is deleting, adding, or substituting a sound in a word to create other words
- Most advanced skill
Deficiency in these phonological awareness skills leads to higher risk of
spelling and reading problems
The best predictors of literacy outcomes are thought to be
sound segmentation and phoneme manipulation.
Children first learn words and then learn to break them down into
segments
Vocabulary development and letter knowledge are very important for phonological awareness
in the preschool years
Children’s development of phonological awareness follows a continuum from
whole words to segments
Metalinguistic awareness
refers to the ability to objectify language as a process as well as a thing
Metaphonological (skills):
The ability to manipulate speech sounds auditorily.
Role of SLP: Phonological Awareness
Prevention: • Incorporation of phonological awareness in all therapy • Introduce new vocabulary • Nursery rhymes • Auditory discrimination, minimal pairs
Identification:
• Working with teachers, reading specialists, and special education teachers to identify children who may need help with phonological awareness skills
Assessment:
• Assess all phonological skills
Treatment:
• Age appropriate phonological awareness activities
• Make sure word is written orthographically along with picture on artic cards
• Dog /d/ /o/ /g/ /dog/
• Story books
• Nursery rhymes
• Take home cards with pictures and they write the word (inventive spelling)
• Play around with sounds
Standardized Tests to Assess Phonological Awareness skills include:
- Comprehensive Test of Phonological Processing
- Test of Phonological Awareness- Second edition
- Test of Awareness of Language Concepts
- Phonological Awareness Test
- Test of Phonological Awareness Skills
- Assessment of Sound Awareness and Conceptualization Test-3
- Test of Phonological Awareness in Spanish
Treatment of Phonological Awareness Skills:
- Include phonological awareness as part of therapy when treating a preschool-aged child for articulation or phonological disorder or write specific goals if needed
- Stimuli
- Feedback
- Reinforcement
If the child is still having difficulty with phonological awareness by the end of _______________
first grade (or kindergarten)
- definitely initiate therapy
Read out loud to children _________ per day!
30 minutes
