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
