Midterm Flashcards
List the four major events in the development of the neural tube, cranial nerve,and pharyngeal arches.
Formation of the embryonic disc: differentiation into the endoderm, mesoderm, and ectoderm (gastrulation)
Formation of the neural plate
Migration of the neural crest cells to become cranial nerves
Development and fusion of pharyngeal arches
State the typical ages that these behaviours appear: solid food introduction, cup drinking, straw drinking, munching, self-feeding with fingers, management of combination of textures.
Solid food introduction: 3-6 months Cup drinking: 6-9 months Straw drinking: 12 months Munching: 6-9 months Self-feeding with fingers: 8-10 months Management of combined textures: >18 months
At what age does the transition to solid food occur and what skills parallel this transition?
Transition to solid food occurs around 7-9 months. Around this age:
- the up and down munching pattern emerges
- the tongue thrust reflex begins to disappear
- the child learns to swallow with tongue tip elevation
- begins to use lateral tongue movement to control position of bolus
- the child begins eating in an upright position
Why is posture important to functional feeding?
Posture is foundational for safe feeding position as it provides airway protection/safety, helps avoid reflux, and improving breath-swallow coordination.
What is considered a normal feeding duration?
20-30 minutes.
How does the aerodigestrive tract differ in children versus adults?
In a child, there is much less open space in the child’s pharynx. The palate is much flatter and the larynx sits further back (less tilted forward).
Identify the five main categories associated with feeding and swallowing disorders in children.
Neurologic: CP, ABI, intellectual disability, developmental delay
Anatomic/Structural: congenital (cleft palate), acquired (tracheostomy, vocal fold paralysis)
Genetic: chromosomal, syndromic, inborn errors of metabolism
Secondary to systemic illness: respiratory, gastrointestinal, congenital cardiac anomalies
Psychosocial/behavioural: oral deprivation, iatrogenic
Describe the importance of the caregivers role in dysphagia assessment and management in pediatrics.
Feeding is a social and reciprocal event that depends on the abilities of both the caregiver and the child.
The cues between the infant and caregiver are important, as a mismatch in cues can lead to feeding problems. Additionally, stress from either influences the other and the transition through feeding stages partially depends on the caregiver.
Some question examples include:
- Signs of respiratory problems
- Feeding duration
- Weight loss or lack of weight gain
- Retching or vomiting
- Stress during mealtime for either child or parent
What is the importance of dysphagia screening in adults with stroke?
Dysphagia screenings play a key role in reducing negative outcomes such as pneumonia, mortality, dependency, and the length of a hospital stay. Delaying a screening and assessment may increase the risk of health outcomes.
Identify and provide examples of the two main modes of AAC.
Unaided: does not require external materials, typically involves sound, movement, or change in position to convey meaning, produces dynamic messages
- Ex. speech & vocalizations, gestures, body language, facial expressions, sign language, sign systems
Aided: requires external aids or equipment, typically involves graphic symbols, and create more permanent messages
- Ex. low tech (communication boards), high tch (dynavox, ipad, smartphone)
Define multimodality as it applies to AAC systems.
Multimodality means that the system supports communication via multiple modes at all times. This allows accommodation of communication partners and includes at least one unaided mode.
What are the different methods of customizing communicative concepts?
Selection set Customizing vocabulary Representation Customizing representation Acceleration strategies
What is a selection set?
A group of communicative concepts available as part of an AAC system at any given time. Consists of vocabulary and representation of that vocabulary.
What must you consider when customizing vocabulary?
Must support all 4 purposes of communication (expressing wants and needs, exchanging information, developing social closeness, and fulfill social etiquette routines). Make sure to consider the current stage and future developments of language and literacy.
What are the different representations on AAC?
Symbol: anything that represents something, can be spoken, graphic, or manual
Referent: that which the symbol represents, includes objects, actions, people, etc.
What must be considered when customizing representation?
Common aided symbols include two-dimensional line drawings, photographs, orthography, product logos, morse code, and arbitrary symbols or three dimentional identical objects, similar objects, associated objects, miniature objects, or part of an object.
Leaning of symbols if affected by physical configuration of the symbol (size, colour, complexity), the characteristics of the individual (language, cognition, interests, experiences, and culture), and iconicity.
Define iconicity
Iconicity: the guessability of a symbol (transparent, translucent, opaque)
What are the different acceleration strategies?
Message prediction
Encoding strategies
Iconic encoding
What is message prediction?
Partner of system attempts to anticipate elements of the message
Options offered change based on the message that has already been formulated and can be fixed (same choices always presented) or dynamic (choices are offered based on history and frequency of use)
What are encoding strategies?
Can be alpha (letter), alpha numeric, numeric, or arbitrary.
Whatis iconic encoding?
Sequences of icons are combined to store word, phrase, or sentence messages and icons are chosen for sematic associations.
What are different organization considerations?
Types of displays
Customizing grouping
Customizing symbol presentation
What are the different types of displays?
Fixed: visible symbols and layout are unchanging, have multiple levels, stores a finite number of communicative concepts, and the number of messages depends on the symbol system
Dynamic: symbols and layout are dynamic, infinite number of communicative concepts, requires navigation of device operations and communicative concepts.
What are the different ways to customize grouping?
Taxonomic: categories of words (e.g. people, places) -> adults
Schematic: events and experiences (e.g. my classroom) -> children
Semantic/grammatical: agent, action, object
Alphabetic order
Importance/frequency of use
What are the different ways to customize symbol presentation?
Traditional grid: rows and columns of symbols in boxes with clear visual boundaries between symbols with one symbol/message per box and that can be arranged according to any grouping strategy.
Visual scene layout: communicative concepts are represented within a scene with the vocabulary embedded under the symbol hotspots, no distinct visual boundaries between symbols.
What are the different different types of selection?
Direct: point at a target in selection set using a body part or an adaptive tool
- Unassisted (uses body part only) or assisted (uses tool)
Indirect: indirect target from selection set as an indicator scans each choice.
What are the different ways to customize direct selection?
Choose effector (body part that makes the selection) and make sure movements are easy, voluntary, and consistent, do not trigger a reflex pattern, and are socially acceptable.
Choose an adaptive tool considering physical and cognitive demands
Choose an activation strategy: timed (sustained effector contact), release (disengaged effector contact), and averaged (average time effector)
Select response signal executed by the effector: vocalizations, consistent body movements, activation of an input device.
Select input device considering cognitive and physical demands (e.g. switch, microswitch, joystick)
Select scanning mode
Select scanning pattern
What are the different scanning modes?
Automatic (begins automatically, ceases when interrupted by response signal)
Inverse (begins on response signal, ceases when response signal is stopped)
Step (1st signal moves scanning along one step at a time, 2nd signal indicates selection)
What are the different scanning patterns?
Single symbol techniques: linear (left to right, up down), circular (clockwise or counterclockwise), or directed (joystick/switches)
Grouped symbol techniques: row-column (scans rows then symbol by symbol), or group-item (scans groups then symbol by symbol)
What are the different considerations for output?
Types of output
Customizing low/light tech
Customizing high tech
What are the different types of output?
Two main types of output/feedback: activation (indicates a target was selected) or message (provides information about the message formulated or selected)
Can be visual, auditory, or tactile
What are some output customizations for low/light tech?
Activation feedback: auditory (partner speaks selected communicative concepts, vocalization on selection of target), or visual (partner points to chosen symbol)
Message feedback: auditory (partner repeats message) or visual (partner points out message)
What are some output customizations for high tech?
Activation feedback: auditory (digital tone from device), visual (concept visible in message bar), or tactile (click from a switch)
Message feedback: visual (whole sentence is visible via LCD display) or auditory (whole sentence read aloud by system)
Synthesized speech: computer-produced speech where text is entered via a keyboard, converted to a pronunciation code using a dictionary and an algorithm where pronunciation and voices are customizable.
Digitized speech: human recorded speech from natural speech or environmental sounds that have been recorded, stored, and reproduced.
Define the four domains of communicative competence?
Linguistic: knowledge of language and linguistic code of the AAC system.
Operational: technical skills for system operation.
Social: pragmatic/socio-linguistic skills, socio-relational skills
Strategic: problem solving skills for system management, management of interactions.
What are some individual factors that influenc communicative competence for individuals with severe disabilities?
Physical factors: range of motion, motor control/coordination, strength, endurance, reflexes
Cognitive: memory, linguistic and literacy skills, and executive function.
Sensory factors: visual, auditory and tactile function
Psychosocial factors: motivation, attitude towards AAC, confidence, resilience
Client preferences: inclinations toward or away from certain devices, access techniques
What are some environmental factors that influence communicative competence for individuals with severe disabilities?
Physical environment: light, noise, seating/position/equipment, consistent or changing location, system itself.
Social and cultural environment: other individuals/communication partners, beliefs, traditions, norms
Environmental barriers/support: policy, practice, attitude, knowledge, and skill
Describe the participation model for AAC and identify its relationship with communicative competence.
It is a model to implement AAC. It begins with identifying participation patterns and communication needs. From there, participation barriers are identified, either opportunity barriers or access barriers. Once these are accessed, interventions can be planned and implemented followed by instructions provided to the person using AAC and facilitator. The intervention effectiveness is then evaluated by looking at that person’s participation. If they are participating, move to follow up, if not, go back to identifying participation barriers.
Model draws heavily on the concept of communicative competence
Some key connections = takes a participatory approach, find out what are the main communication needs
Definition of access takes into account communicative context
What are opportunity barriers? List some types.
Those imposed by people other than the individual who uses the AAC system and that are not eliminated by providing the system.
o Policy barriers: legislation or regulatory decisions
o Practice barriers: common interventions or procedures
o Knowledge barriers: lack of information about AAC
o Skill barriers: lack of ability to apply information AAC
o Attitude barriers: beliefs about AAC
What are access barriers?
Capabilities, attitudes, and resource limitations of the individual who uses AAC.
Access is the right, means, or opportunity to use or benefit from something, approach or see someone, obtain or retrieve information from a person, environment, or artifact, and provide use or benefit from something or someone.
Name a key derivative related to swallowing for the 3 layers after gastrulation.
Endoderm: inner muscosal lining
Mesoderm: Bones, muscles, connective tissue
Ectoderm: skin, nervous system
Define communicative comcepts.
Inclusion and representation of concepts needed to construct messages.
Define organization strategy.
Arrangement and presentation of communicative concepts for message construction.
Define selection technique.
Method of physical construction of the message.
Define output method.
Information on the process and outcome of method construction.
Define communicative competence.
The quality of being functionally adequate in daily communication or having sufficient knowledge, judgement, and skill to communicate
What are some evidence based strategies for optimizing communicative competence for communicative concepts?
Children need both core and fringe vocab
AAC can be used to promote language and literacy development (e.g. ALL and Just-In-Time programming)
There is a hierarchy to symbols and a developmental pattern of learning
The iconicity of the symbol system impact learnability
Children perform better when the symbols reflect their conceptualization which usually includes depictions of scenes or events and familiar experiences.
What are some evidence based strategies for optimizing communicative competence for organization?
Visual scenes: beneficial for kids ages 2-3 and may be beneficial for those with developmental delays or severe language difficulties.
Children are equally capable of using traditional grids by 4/5
What are some evidence based strategies for optimizing communicative competence for selection?
Positioning impacts the accuracy of direct selection and may impact speed
Scanning is harder for younger children but the ability to understand and select improves with age
With scanning, preschool age do better with simpler, linear scanning, and made more errors with larger scanning arrays.
Typically developing 2 yr did better with modified scanning (e.g. change in animation size)
What are some evidence based strategies for optimizing communicative competence for output?
Digitized is more intelligible for kids
Those with intellectual disabilities have a hard time with synthesized speech
Noise affects intelligibility
Practice and exposure improve intelligibility
Context impacts intelligibility: words < sentences < discourse
What is the prevelence of complex communication needs in the ICU?
15% of people admitted to a university hospital do not have sufficient communication to meet their needs
What are some consideringations for providing AAC to patients in the ICU regarding purposes of communication?
Report symptoms, ask questions, being socially cose to practitioners and family, directing care
What are some consideringations for providing AAC to patients in the ICU regarding vocabulary needs?
Vocabulary in the ICU can be very specific and individuals with communication issues may not have access to this vocabulary.
What are some consideringations for providing AAC to patients in the ICU regarding psychosocial impact?
Loss of control, fear, panic, worry, stress, withdrawl are all things experience in acute care.
What are some consideringations for providing AAC to patients in the ICU regarding physical concerns?
Use of high tech vs. low tech, mounting and activation required.
Summarize the direct service delivery model of providing AAC services in the ICU.
An ICU staff enters an order for the AAC team assessment. The AAC team maintains a unique wait list and has specific electronic record keeping. They also have a loan cupboard of high and low tech equipment accessible by the AAC team. Graphics are available for staff at any time as they are placed in wall baskets in the ICU. Equipment is loaned out to patients in the ICU and when they are transferred to the acute ward. The AAC team considers a prescription if long-term use is needed through one of the provincial AAC clinics. They have approximately 12 open cases at a time, averaging 10 new patients a month.
List some of the equipment available for AAC patients in the ICU.
Some of the equipment for access includes switches, mounts, adapted mice, software such as GRID 2&3 and Proloquo to go, and low tech devices such as Step by step, Talking Brix, ITalk 2, and Motion Talker.
What are some communication partner training strategies that can be implemented in the ICU?
Some options for communication partner training includes aided language stimulation, partner assisted scanning, supportive conversation, and barrier reduction.
What are some AAC options for mechanically ventialed individuals?
Strategies for ventilated individuals include the electrolarynx and speech valves
What are some things that need to be considered when implementing AAC in the ICU?
Establish a reliable yes/no
Use motor moments that are repetitive and easy that can be shaped in access methods (make sure they aren’t tics/triggers)
Consider any visual or cognitive considerations, ESL and hearing impairments.
How are social networks used in the ICU for individual’s with AAC?
Assesses a social network in consecutive circles, with family at the center, then friends, paid works, aquaintances, and community.
What are some assessments done in the ICU for individuals using AAC?
Social network Talking mats AFROM Test of Aided Symbol Production Therapy Outcome Measure Goal Attainment Scale (GAS)
What are talking mats?
Mats used to communicate using symbols and images
What is the AFROM?
A framework to look at the possible barriers to communication outcome measurements in aphasia, including langaue and related impairments, environment, participation, and personal factors (similar to ICF
What is the therapy outcome measure?
Measures outcomes on a scale of 0-5 of impairment for physical, cognitive, speech and language, and sensory through activity, participation, and wellbeing.
Describe the role of the SLP in the AAC team in critical care.
Assessment:
- Analyze the client’s communication needs in the ICU
- Determine non-verbal communication abilities of the client
- Determine pre-intentional and intentional communication
- Assess cognitive communication abilities e.g. attention, auditory and visual processing of information, memory, verbal reasoning/deduction
- Assess speech and language abilities
Describe the role of the OT in the AAC team in critical care.
Determining functional status:
- Motor skill: especially evaluating the upper extremity, safe neck movement, and quality of any voluntary, functional movements.
- Neurological skills including sensory function
- Fine motor and handwriting/keyboarding skills
- Cognitive ability and visual spatial skills
- Occular-motor ability
- Psychosocial issues or status
- Ability to use different access methods/switches
- Ability to use voice recognition technology if voice is intact but body is paralyzed
Define moral intuition.
A moral argument that is rational and defensible, and is demonstrated within reason and evidence.
Define social inclusion.
Social inclusion is the process of improving the terms on which individuals and groups take part in society—improving the ability, opportunity, and dignity of those disadvantaged on the basis of their identity or health condition.
What is a substitute decision maker?
A family member, friend, or other legal representative who has been granted power of attorney for personal care.
What are some benefits of patient inclusion in end-of-life decisions?
Less invasive medical procedures
Patients understand options of care and scope of available treatments
Patients constructively discuss critical care plans with HCP and family members
Patients relieving family members of burden
HCP express appreciation and appear less stressed as they gain an understanding of the patient’s symptoms, needs, wants, and feelings
What are some barriers to including patients in goals-of-care discussions at the end-of-life?
Family not accepting prognosis Family disagree re: goal of care Family not understanding treatment Patient has no capacity to decide Patient doesn’t understand treatment Language barriers
Define speech sound disorders.
An umbrella term referring to any combination of difficulties with perception, motor production, and/or the phonological representation of speech sounds and speech segments.
What are subsets of motor speech disorders?
CAS, dysarthria, and motor speech not otherwise specified (MSD-NOS)
What is CAS?
Difficulty executing the volitional motor plan for speech in absence of paralysis
Core impairment in planning and/or programming spatiotemporal parameters of movement sequences
What are the 3 core features of CAS?
Inconsistent errors in consonant and vowels in repeated pronunciation
Lengthened and disrupted coarticulatory transitions between syllables and sounds
Inappropriate prosody, especially in the realization of lexical or phrasal stress
What are some other things you may see with CAS?
May also see vowel and consonant distortions, inconsistent voicing errors, prosodic errors, especially equal stress and segmentation, awkward and/or imprecise movement transitions, and groping and/or trial and error behaviour.
What are some co-occuring characteristics of CAS?
Delayed language development, espressive language problems, like word order confusion and gramamtical errors, problems with spelling, reading, and writing, and problems with social language/pragmatics.
May also observe with non speech sensory and motor problems such as motor delays, motor clumsiness, oral and limb apraxia, feeding
What should you watch for when looking for CAS?
When observing for CAS, watch for speech motor control of the motor hierarchy, the quality of movements (transitions, groping, hesitations, and/or trial and error), consistency, prosody, and the impact of length and complexity.
What is MSD-NOS?
“Mixed” Signs of motor planning and subtle motor control difficulties, but not enough to indicate a motor planning disorder or dysarthria.
Describe dysarthria.
Weakness, or paralysis of the speech musculature that affect respiration, phonation, articulation and/or resonance.
Compare the three motor speech disorders based on these characteristics: number of errors, predominant error type, ability to imitate, diadochokinesis, and error consistency.
Number of errors: Much more (CAS), minimal to moderate (NOS), moderate (D)
Predominant error type: substitutions, omissions, and additions (CAS), substitutions, omissions, disortions, additions (NOS), mostly omissions and distortions (D)
Ability to imitate: difficult, easy to moderate, easy
Diadochokinesis: poor, normal, slow
Error consistency: no, yes, yes
What are the steps in identifying a child with a motor speech disorder?
Develop a profile of the child’s developmental history and communication skills
Identify speech production and intelligibility as an area of concern
Complete a comprehensive speech production assessment
Identify the presence of motor speech involvement
Check for prereqs
Create intervention goals
Choose targets to achieve the goals
Choose appropriate intervention method
What are the steps to gaining a differential diagnosis?
A differential diagnosis is a result of a thorough assessment and/or a block of diagnositic therapy.
Diagnostic assessment , Identify SSD, Identify motor speech involvement, Diagnostic intervention, Identify CAS
What is in a child’s profile?
Case history
Hearing screening
Spoken-language testing (respective and expressive, phonological processing, social communication)
Literacy assessment
Structural functional examination of systems required for speech
What prerequisite skills are required for motor speech intervention?
Social communication skills: interntional communicator, partner skills, basic revision and repair skills
Receptive language: adeduate comprehension to follow instructions
Expressive language: verbal or non-verbal communicator
Attention and self regulation: can attend to and participate in adult directed tasks, able to take multiple turns, has good visual and auditory attention, able to control impulsive behaviour
What do you need to confirm with the profile?
The profile confirms moderate-severe speech sound disorder, motor control and/or planning issues, poor intelligibility, speech is the primary area of concern, child has the prerequisite skills, and family and child are able to participate in the intervention.
What is the care pathway?
The care pathway to support identification and intervention is a multi-tiered pathway to support identification and intervention for children 18-48 months. It is divided into two parts: under and over 36 months. It identifies 3 different treatment models for young children at various stages of development and identified motor speech needs. The model view the identification of motor speech difficulties as a process based on a child’s profile and response to intervention and describes the process for making decisions at each point in the pathway.
Describe the steps to the care pathway for <30 months.
INitial assessment Expressive comm. is primary area of concern Level 1: diagnostic expressive communication intervention Reassesmsent <36 months (go to monitor or speech isn't are of concern) Speech is primary area of conern Level 2: early speech intervention Reassessment >36 months Motor speech is primary area of concern Level 3: Motor speech therapy Reassessment CAS is primary area of concer Motor speech intervention for CAS
What do treatment foals need to address?
Control and accuracy of articulatory movement in the context of speech production and integrate movement aspects of speech production with phonological knowledge.
Make sure to identify the speech motor movements that child is having difficulty with based of the hierarchy.
Summarize the motor speech hierarchy.
Stage I – Tone: body and facial tone, reflexes
Stage II – phonation: airstream, phonation, resonance
Stage III – Jaw (vertical plane): range, grading, midline movement
Stave IV – Facial (horizontal plane): bilabials, rounding, retraction, individual lip movement
Stage V – Tongue (anterior/posterior plane): independent movement from jaw.
Stage VI – sequenced movement (multiple planes)
Stage VII – prosody
Explain the principles behind choosing motor movement goals.
Individualize for the child
Promote early success and generaliztaion
Encourage prosody
Increase effectiveness of verbal communication
Functional for both speech and language needs
Develop speech motor control in a systematic manner progressing from simple to more complex general movements following a developmental progression as a general rule
Select sounds, syllable shapes, words which use the targeted movements
What are some considerations for choosing airstream control goals?
Establish 3 types of air streams: any single voiced oral phoneme (/a/), any single nasal phoneme (/m/), and single voiceless phoneme
Established sustained phonation using steady jaw position.
Establish oral/nasal control
Establish use of sounds consistently and volitionally for communication
What are some considerations for choosing jaw control goals?
Develop control of jaw movement: range, stability, controlled open-close movement, then graded
Establish isolated phonemes: C= /p,b,m/, V = /ae, a, carrot/
First combine CV, CCVCV, VC syllable shapes: baa, ma, mama, up
Then in CVCs: hop
What are some considerations for choosing lip control goals?
Develop control of lip movement: rounding, retraction, independent lip movement
Established isolated phonemes: v=/u,o/ for lip rounding, /I,e/ for retraction
Target independent lip movement using basic syllable shapes : me, eat, mimi, boo
Introduce CVC for independent bilabials /p, b, m/: beep, peep, boom, home
What are some considerations for choosing tongue control goals?
Develop control of tongue tip
/t, d, n/ if not already in their repertoire: dadda, done,dot, mat, bat
May need to use “jaw assisted tongue” to give experience feeling this new sound
Then get independent tongue tip elevation by eliminating jaw help (use horizontal vowels): eat, boot, in, no, boat, meat, two
What are some considerations for choosing integration goals?
Add a new plane of movement (integrate jaw movement with lip movement): first across two syllables (daddy, happy, puppy, mommy) then diphthongs (want, out, down, bye, my)
What are some considerations for choosing expanding tongue movement and phoneme repertoire goals?
Develop back tongue control: /k+g/ + low vowels /ae, a/ (walk, back, pack, muck) then all vowels and /k, g/ in initial position (come, go, avoid words with /t, d, n/ at first, take, cut) Refine tongue control: /s/ Check stimulability and functional use of both to decide which would be a better phoneme to target next and continue with other tongue sounds Sequence movement (belnds, multisyllabic words with multiple changes in direction of movement, ice cubes)
Explain the principles behind selection of vocabulary targets.
Select target vocabulary that is functional for language: increasing vocabulary, length of utternance and grammatical complexity, improve social interaction, and is important to the child and parents, expands upon existing sound repertoire and syllable shapes
Consider basic motor control parameters of the MSH
Expands upon existing sound repertoire and syllable shapes
Expose the child to vocabulary that is meaningful and achievable and supports early speech motor skill and phonological development
What are some of the variables to control?
Linguistic parameters: consonants, vowels, syllable and word shapes, phonological processes, linguistic complexity
Motor parameters: level of subsystem control, complexity of motor movement
o Place of articulation
o Voiced/voiceless/nasal
o Direction of movement (vertical/jaw, horizontal/lip rounding and retraction, anterior/posterior:tongue tip/back
o Integration of planes: consonant clusters, multisyllabic words
Functionality of the vocabulary
Number of targets
Amount of support provided
What must be considered when selecting vocabulary targets?
When choosing target vocabulary, select sounds, syllable shapes, words which use the targeted movements. Don’t forget specific phoneme and syllable movement patterns and the number of changing parameters across word/phrase.
How might we map syllable shapes onto motor control?
Phonation control: V, VV
Jaw control: VC, CVC, CVCV
Jaw assisted lip control: C, CV, VC, CVC, CVCV, VCV
Independent lip control, V, VC, VCVV, CVCVV, VCVVC, VCVVCV (wee, one, wash)
Jaw assisted tongue control: CV, VC, CVCV
What are some examples of target vocabulary for various motor controls?
Monitoring midline movement of jaw: boot, boat, book, put, push, poke
Improve lip control (independent of jaw, appropriate tension of contact, rounding, sequenced movement): wee, one, wash
Improve tongue control (tongue tip elevation independent of jaw): eat, teddy, daddy
Improve phonation control in complex movements (in /h/ phrases and oral/nasal control vowels after nasals): I have a…/in a hole/put it here OR mummy, man, no, done
