ch. 9-11

Most common developmental motor impairment

cerebral palsy

Stimulus-Shift Approach B.This ___ step sequence is utilized for each phoneme _position__ •____ •____ •____ • The client should work all the way through the tasks/steps targeting one position before introducing another position.

9 Initial Final Medial

Hearing Impairment Diagnostic •Data needed: •____ of onset •_____ and type •Age hearing loss was _____ and a hearing device was ______ •Length of previous ______ efforts •Speech _______ measures/Spontaneous speech sample •____ and ____ testing of language skills •Phonetic and phonological assessments •_______ assessment

Age Etiology identified implemented intervention intelligibility Formal informal Speech-motor

Factors that affect articulatory complexity of words a.____ of the word b.______ of the target sound in the word c.Syllable ____ d.Syllable ____ e._____ factors f.____ with the word

Length Position structure stress Coarticulatory Familiarity

Traditional-Motor Approach •____ _____ is the basic unit targeted • •Therapy begins in _____ ▫Follows a sequence of remediation •_____ speech sound is targeted •Target _____ _____ (production of speech sounds)

Speech sound isolation Individual speech form

Cerebral PalsyDefinition and General Features •_______ disorder of motor control • Caused by damage to the developing ______ during pre-, peri-, or early _____ periods •Results in a wide variety of _______ disabilities

Non-progressive brain postnatal motor

Establishing Target Sounds (Minimal Opposition Contrast Therapy AKA Minimal Pair Therapy)(Lowe, 1994) 1._____ production and the ______(s) should be the first considered possibility 2.____-_____-______ features should be considered (for both target sound and substitution) •The _number__ of _____ are counted(between the target sound and substitution) 3.Target should reflect the ___ number of differences in production features 4.Child's ____ and _____ ____ of the phonemic system should be considered (_____ developing sounds have priority.) 5.Substitutions that affect _______ the most should have priority •Consider ____ of occurrence 6.________ sounds have priority over non-stimulable sounds

Norm substitution Place manner voicing differences least age developmental level Earlier intelligibility frequency Stimulable

Cleft PalateDiagnostic •Central diagnostic issues: •Phonatory, resonatory, and articulatory effects of velopharyngeal port insufficiency (VPI): • •_____ abnormalities - corrected largely by surgical and/or prosthetic measures • •_____ deficits - may remain after structural abnormalities are addressed •May result in - hypernasal resonance, nasal air emission, sound distortions, and sound substitutions •_______ Insufficiency • •Impairs _____ pressure buildup necessary for norm production of many speech sounds

Structural Functional Velopharyngeal intraoral

u[s] - one of top ___ sounds in frequency of occurrence; produced in practically every utterance u u[z] ranks ___

five 11th

Interdental /s/ and /z/ uFrequent form of distortion u uTongue placement is too _____ uResults in crossing phonemic boundaries to [θ] and [ð]

forward

Tongue Tip Down" Lateral [s] Misarticulation: u uTongue tip behind lower teeth eliminates the problem of the contact of the ___ ____ and the _____ ________ u ________ of the tongue is important u uEliminate lateral jaw and lip movement using visual feedback

tongue tip alveolar ridge uGrooving

Phonetic Placement[l] - DONT LEWARN uNorm production: u ____ and ____ edges of the tongue are in direct contact with the alveolar ridge u uLateral edges of the tongue are not elevated but rather ____ - allowing free passage of air to the right and left of contact at the alveolar ridge u uvisibility of the articulation is helpful when establishing the placement

uApex coronal relaxed

Types of misarticulations of /s/ and /z/

uInterdental u uAddental (Dentalized) u uLateral u uPalatal uStrident u uStopping (Substitution) u uNasal

Morphemic Function[l] uWord-Final Clusters can signal: u ____ •dolls, halls u _____ •Jill's, Bill's u ___ -person singular •he sails, she rolls

uPlurality upossessive uThird

_______ is a portion of our clinical responsibility - only way to ensure that therapy was successful and _______ has occurred u uUltimate therapeutic goal: norm production in all _____, ______ settings

uReevaluation ____generalization__ natural conversational

Strident [s], [z][s] and [z] ______, irritating auditory impressions, a _______ component u uImbalance between___ _____ and the ______ through which the air must flow u uToo much ___ ____ or too ______ of an opening between articulators

uShrill whistle-like air pressure opening air pressure narrow

uCommon substitutions for [l]

u[w] and [j], [r],

uNorm productions can be articulated two different ways: •Apico-aleolar fricative - tongue tip ___; most common Predorsal-alveolar fricative - tongue tip ______ ____ _____ of the tongue is essential - directs the airstream toward the opening between the articulators u___ ___ of the tongue must be elevated and touch the first molars to avoid lateral air escape

up down Sagittal grooving Lateral edges

Phonetic DescriptionConsonantal [r] uProduction is extremely ______ •Variable between ______ •______ dependent uTwo types: (Shriberg & Kent, 2013) u •______ [r] • •______ [r]

variable speakers context Bunched Retroflexed

Phonetic Description[k] and [g] uVoiceless or voiced postdorsal-___ ___ (lingua-velar stop-plosives) u uBack of tongue is _____ creating complete blockage of expiratory airflow at anterior portion of the velum u u___ ___--up occurs until it is released into the oral cavity u u/k/ - typically ______ pressure and more _____ than [g] [k] - ____, but not always (not in the ____ position and not in _____) [g] - unaspirated

velar stops raised Air build higher tension aspirated medial clusters

uMost clinicians automatically begin with ________ uReasoning - decreased complication by not having the ______ component

voiceless [s] voicing

• •Target sounds chosen based on: ▫ 1.Relative _______ of occurrence ● 2.Effect on ______ (Remember: ______ affect intelligibility more than ______) ● 3.Child's ___ and _______ development

frequency intelegibility deletions substitutions age phonological

Childhood Apraxia of Speech (CAS)Speech Motor 5.Difficulty producing and maintaining appropriate _____ •Might voice unvoiced sounds and devoice voiced sounds (Lewis et al., 2004) • 6.____ and _____ errors(e.g., Nijland et al., 2002)

voicing Vowel diphthong

Spontaneous PhaseMaximal Oppositions Contrast Approach 1.Word pairs are produced ______ the clinician's model ● 2.Criterion for mastery = 90% (without a model) over 3-12 consecutive sessions

without

Phonemic-Based Therapy •Focuses on _____ than ___ sound at one time(or an entire class of sounds) • •_______ is assumed to occur to other sounds or sound classes • •Target phonemic _____ (contrastive use of phonemes to establish meaning differences)

more one Generalization function

•Near-Minimal Pairs - pairs of words that differ by ____ than ____ phoneme; however... ▫Vowel ______ and ______ target sound remains constant in both words ▫Example: sir-third sore-thorn

more one preceding following

submucous cleft •intact ____ _____ covering a cleft •__-shaped indentation in this area might be felt with the finger •____ ____(divided uvula) or bluish tint - may be a sign

mucous membrane V Bifid uvula

Important to remember that some children with CP cannot achieve "_____" articulation. Reasonable _____ is the goal! •Consider ____ ______ to promote meaningful communicative exchange.

normal compensation augmentative communication

uA diagnosis is •NOT based on the ____ of ______ involved (can be single or multiple errors) • •IS based on whether the errors are _______ or _______ in nature (must analyze the data) u •Should not use a ______ motor approach automatically with all clients who exhibit a ____-sound error • •If difficulty with function of the sound in the language system exists - likely to be a _____-based disorder •Treated __differently than an ______-based disorder

number sounds articulatory phonological traditional single phonemic articulation

Cycles Training 1.No _______ level of mastery Targeted patterns in the cycle are used to ______ the emergence of a specific ______ or _____ (not ____ of it) Attempt to approximate closely the way _______ development ______ occurs as a gradual process ● 2.Several sounds are targeted within ____ cycle ● 3.Designed explicitly for highly ______ children (severe to profound range)

predetermined stimulate sound pattern mastery phonological normally one unintelligible

Sound Modification Methods[f] to [s] Method Goal is _____ [s] --- This method assumes that the tongue tip for [f] is already behind lower incisors

predorsal

Cerebral PalsyClinical Implications: Therapeutics - DONT LWERN - 1.Consonants that are realized correctly in _____ positions but are misarticulated in ______ positions should be treated first 2._____ should be treated before _____ 3.Training articulatory _____ and _____ that fall short of the target due to motor involvement should be delayed •Compensatory articulatory efforts for sounds difficult to produce should be trained instead 4.Multiple ______ stimulation approach should be used 5.Voice-voiceless distinctions should be trained by _____ the speech process

prevocalic postvocalic Distortions substitutions omissions substitutions auditory-visual slowing

uSecond most frequently occurring sound category

r

Sound Modification Methods[t] to [s] Method A.Use a series of _____ [t] _______ - typically produce intermittent [s]-like fricatives B.Produce [t] while prolonging the __ ___

rapid repetitions stop phase

Because [k] and [g] misarticulations are often _______ of one speech sound for another, it is especially important that the client be evaluated for a _________ disorder

substitutions phonemic-based

ØAn established set of ______ approaches for the treatment of CAS does not exist •But... many different remediation approaches have been suggested

therapeutic

excessive anterior tongue movement during swallowing and a more anterior tongue positon during rest

tongue thrust

frequency of occurence [l] - DONT LEARN uRanks ___ in children's speech and ___ in adult's speech (Carterette & Jones, 1974) u Frequent ____ uRealized in all word _____ u uAppears to occur more frequently in ____ and ____ word positions than in initial positions

8th 5th clusters positions medial final

** The more _____ the utterance is, the more likely a breakdown in _____ accuracy will occur

complex articulatory

Comparison of Minimal Pair Therapy MethodsTargets based on - Sounds that demonstrate major class distinctions - As many distinctive feature differences as possible. - •Frequency of occurence of phonological process - the effect the process has on intelligibility - the child's age and phonological development. - A sound that the child can make versus one that is a substitution

- Maximal Oppositions - Phonological Process - Minimal Oppositions

DEF. - Minimal pair words have place, manner, and voicing similarities with ideally only 1 production difference. - Targets should be maximally different based on distinctive features. - Based on phonological processes that occur most often in children's speech.

- Minimal Oppositions - Maximal Oppositions - Phonological Process

Comparison of Minimal Pair Therapy MethodsNecessary stimulability of sound: - It is assumed that sounds are stimulable. - Stimulable sounds have priority as targets. Nonstimulable sounds are preferred targets.

- Phonological Process - Minimal Oppositions - Maximal Oppositions

positioning of articulators for a specific articulation without sound production

silent posturing

Comparison of Minimal Pair Therapy MethodsSeverity of Disorder:

....

Childhood Apraxia of Speech (CAS):Articulatory/Phonological Characteristics 1____ ____ on consonants and vowels in repeated productions of syllables or words 2._____ and _____ coarticulatory transitions between sounds and syllables 3.Inappropriate _____ (both word and sentence stress) Inappropriate ____ was found to be the only linguistic domain that differentiated CAS from just delayed ____ development

.Inconsistent errors Lengthened disrupted prosody stress speech

Phonemic-Based Therapy Approaches

1.Minimal Opposition __contrast__ Therapy ● 2.Maximal Oppositions Approach ● 3.Phonological Process Therapy ● 4.Cycles Training

u[k] - ranked in top ___ most frequent u u[g] - ranks approximately ___ u

10 15

Speech Sound Disorders with Concurrent Language Problems: Therapeutic Suggestions •Estimated co-occurrence rate of speech AND language disorders is --- _____% • •Intervention needs to target BOTH _______ AND any additional deficient _____ areas ▫To increase time efficiency in the therapy session - combine ______ and ______ goals

35-60 phonology language language phonology

More than ___% of SLP's work in public schools and, therefore, encounter much group therapy

50

uMay occur in the initial or final position in a syllable (but frequency in each position varies) u u[s] - In 1st, 2nd, and 3rd grade children: (Carterette and Jones, 1974) •Initial - ___% •Medial and Final positions (combined) - ___% u u[z] - more than __% in word-final position

50 50 90

How to Use Cycles TrainingEstablishing a Cycle •Each phoneme in a pattern is targeted for ___ minutes per cycle • •Only ____ phonological pattern or phoneme is targeted in any one session • •Typically, cycle 1 has between _____ and ____ different patterns or phonemes targeted • •If the goal is a specific phonological pattern rather than an individual phoneme, at least ____ exemplars of the pattern should be presented in two consecutive 60-minute time intervals before moving to the next phoneme or pattern i.e., stopping (/s/ and /f/)

60 one three six two

Eliciting a Norm Production u_______ __________ u_____ ______ Method u________ ________ Method

Auditory Stimulation/Imitation Phonetic Placement Sound Modification

Cerebral PalsyCommon Causes •_____ and ____ infections •_____ in the brain (hemorrhaging) •A lack of ____ to the brain before, during or after birth (_asphyxia_) •Prenatal exposure to ____ and ______, mercury poisoning from fish, and toxoplasmosis from ___/undercooked meat •____ injuries sustained during birth or in the first few years •A lower ____ weight corresponds with a higher risk of CP

Bacterial viral Bleeding oxygen drugs alchol raw Head birth

Ø"Neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., no abnormal reflexes, no abnormal tone)."

CAS

Hearing ImpairmentSensorineural Hearing Loss •Occurs as a consequence of damage to the: •____ (including the hair cells) •Auditory ___ ___ • •___ conductions and ___ conduction thresholds are typically comparable • •Causes of a sensorineural auditory dysfunction include: •Illnesses (i.e., mumps, exposure prenatally to cytomeglavirus), genetic factors, drugs, head trauma, malformation of inner ear, aging, etc.

Cochlea (8th) nerve Air bone

Cleft PalateDiagnostic - DONT LEARN •Patterns seen in children with cleft palate (not typical for those with intact oral and pharyngeal mechanisms) 1._______ distortions associated with nasal emissions ● 2._____ distortion secondary to hypernasality ● 3._______ articulations (Triggered by the impossibility of accumulating enough _____ pressure for the regular production of these pressure consonants)

Consonant Vowel Compensatory intraoral

•Any patterns or phonemes that a child does not have would be acceptable targets for ___ ____ • •Consider Stimulability - select most _______ sounds or patterns to facilitate immediate success • •Unacceptable targets include ---/ŋ/, /θ/, /ð/, syllabic /l/, and weak syllable deletion

Cycle 1. stimulable

•Speech production is affected by: • •_____ of hearing impairment • _______ involved

Degree frequencies

minimal opposition contrast therapy •Target sounds that are _______ in production

similar

How to Select Target Sounds?Cycles Training ● 1._____ developing ______ patterns ● 2.______/_____ contrasts ● 3./___/ clusters • 4._____

Early phonological Posterior/anterior s Liquids

Treatment Principles Separating _____ and _____ in actual therapy is often _impossible_!!! --- They are an interactive unity that work together

FORM FUNCTION

supporting contexts; words in which the target sound is __correctly____ produced Aka: "key words

Facilitating Contexts

DONT LEARN Connecting Phonology to MorphosyntaxRemediation Suggestions 1.Goal: _______________ -target words that incorporate grammatical morphemes in contrasting pairs that end in VC structures 2.Goal: ____ ____ ______or _____ - incorporate grammatical morphemes in a word-final VCC structure In _____ minimal pair words could be used systematically to represent other grammatical morphem 4.______ and ____ pronouns could be used in sentences 5.Consider ____ and _____ of the utterance _______ complexity affects productional accuracy

Final Consonant Deletion Consonant Cluster reduction Deletion sentences Subject object length complexity Syntactical

Phonemic ApproachThree Basic Principles 1._____ of sounds with similar ______ of ____ are targeted ● 2.____ _____ that were previously neutralized are _______ ● 3.A _______ communicative context is emphasized

Groups patterns errors Phonemic contrasts established naturalistic

Cerebral PalsyClinical Implications: Therapeutics - Dont learn •Address pre-speech areas noted above - •____ control •Coordination of _____ patterns with ___ production •______ control •Communication and speech-language stimulation •Infants: begin with ____ play and ____ practice •For older children: facilitate desired _____ while inhibiting the abnormal reflex patterns • •

Head respiratory voice Posture vocal babbling movements

uses minimal pair pictures client repeats clinician's model

Imitation Phase

Childhood Apraxia of Speech (CAS) Therapeutics 1._____ services are needed ● 2.Remediation should progress ______ through hierarchies of task difficulty ● 3.Remediation stresses ____ of movements ● 4.Many repetitions of ____ ____ are required in drill-oriented sessions 5.Determine need for _____ discrimination tasks ● 6.Remediation should emphasize ____-monitoring ● 7.Input from _____ modalities is needed ● 8.Remediation should include manipulation of _____ features as an integral part of the total remedial program 9.Teach compensatory strategies, if necessary. Includes: •_____ overall rate of speech •Increasing use of _____ between words and syllables •Vowel ______ •Intrusion of a _____ vowel between consonants in a cluster • 10. Provide successful experiences!!

Intensive systematically sequences speech movements auditory self multiple prosodic slowing pauses prolongation schwa

DONT LEARN 7._____ ____ •Client imitates a _complete sentence presented by the clinician •Criterion: 38/40 • 8.______ •Client verbalizes the sentence with no clinician model 9.______ •Client relates own story utilizing 2-3 picture stimuli •Criterion: 18/20

Intraverbal stimulus Sentence Story

Moderate to severe phonological disorders. At least 6 sounds were missing from phonemic inventory.

Maximal Oppositions

Moderate, moderate to severe, or severe phonological disorders.

Minimal Oppositions

Maximal Oppositions Approach Imitation Phase • 1.______ ________ picture cards are presented to the client ● 2.Client imitates clinician's _____ of picture ● 3.Criterion for mastery = ____% over 2-7 consecutive sessions Continue this phase until criterion has been met

Minimal pair model 75

•Minimal Oppositions Contrast Therapy AKA Minimal Pair Therapy ____ ____are used as the beginning unit of therapy ▫Target sounds differ in only ___ (or two___ production features Place Manner Voicing • •Both speech "____" and "____" are united for this therapy approach ▫This is a "______-based__" approach - BUT differences in "phonetic" production features are used to determine the minimal contrast

Minimal pairs one ) form function _phonemic

Auditory Stimulation/Imitation ______ the target sound and have the client ______ the sound •"Watch me and do exactly what I do" u _____ and _____ way to achieve the target sound u uNot always _____, however

Model imitate uEasiest quickest___ successful

Maximal Oppositions Approach is beneficial for...

Moderate to severe phonemic-based disorders

Articulation-Based Speech Sound Errors u____ ______ problems u uAn inability to produce certain _____ ____ uA ______ or ____ Approach is typically used (aka: Phonetic Approach)

Motor production speech sounds____ _traditional____ Motor

How to Select SoundsMaximal Oppositions Approach •Select two sounds _____ in the child's inventory (i.e., two _____ sounds) • •These two sounds should be _____ different according to distinctive features ● 1.Number of unique distinctive features that differentiate the two sounds (_____ distinctive feature differences = ______ feature distinction) ● 2.Nature of the feature (major or nonmajor class feature) (____ class features = maximum feature distinction)

NOT unknown maximally more maximum Major

phonemic-based therapy •The ______ is the basic unit differentiating between word meanings ▫Therapy begins at ___ level ▫Stimuli - _____ ____ - phonemes are arranged contrastively between words •Focuses on phonological system (______) ▫Inventory and distribution of ____ ___ ▫Syllable shapes and phonemic contrasts used ▫Error patterns displayed

Phoneme word minimal pairs _language_ speech sounds

This has not been evaluated. The child should demonstrate only a limited number of phonological processes

Phonological Process

Cycles Training _____ _____ are trained successively during specific time periods known as ____ •Goal is to increase _______ in a relatively short time

Phonological patterns cycle intelligibility

[s] and [z] _______ Difficult to Produce ______ ______ opening between articulators must be maintained over a long period (fricatives are the longest sounds in duration) uMust maintain right amount of ______ airflow uIf the balance between the creation of the narrow opening and the expiratory air pressure is off - becomes perceptually noticeable u

Physiologically uFricatives uNarrow expiratory

DONT LEARN 5.** ____________ (_skip__ if the client does not read!) •Client identifies the printed word •Criterion: 38/40 • 6.______ picture/word with______ ____ •Client identifies the printed word in conjunction with completing a sentence presented by the clinician (cloze procedure) •Example: "I put the shoe on my sentence." (foot)

Printed word stimulus Printed intraverbal stimulus

Cerebral PalsyThree Types of Involvement

Spasticity Dyskinesia Ataxia

if errors are articulation-based, the best treatment option could be a __________________ Approach uBut... •Portions of a _____ approach may still be beneficial for children with _phonemic_-based disorders

Traditional/Phonetic/Motor phonetic

Childhood Apraxia of Speech (CAS)Speech Motor 3.____ ____ not typically found in speech sound disorders •Includes sound additions, prolongations of vowels and consonants, repetitions of sounds and syllables, and unusual substitutions (Lewis et al. 2003: McCabe, Rosenthal, & McLeod, 1998) • 4.Large percentage of _____ errors (e.g., Lewis et al., 2003) •Sound and syllable omissions - most _____ type of errors noted with CAS (could be related to the complexity of the speech tasks)

Unusual errors omission frequent

How is Minimal Opposition Contrast Therapy Used?Steps Involved: DONT LEEARN 1.Discussion of ______ - child points to confirm concepts portrayed •Points to picture in _______ to a question •Example: "fig-pig" --- "Which one is a fruit?", "Which one is an animal?" 2.Discrimination _____ and ____ - discrimination between the two sounds is tested 3.______ Training - elicitation of minimal pair words 4._____ Training - once the target word is accurately produced

Words response Testing Training Production Carryover

Possible criterion for dismissal in spontaneous speech - ____%

__50__

uTraditional/Phonetic/Motor Approaches - treat each error sound... •________ •____ after another

___individually___ One

Isolation uGoal is to elicit a norm production of the target sound _____ u uIf a norm or near-norm production cannot be obtained in a reasonable time frame (5-10 min): •Change the technique used u uCan often take several sessions to achieve a "_______" production

__alone_ correct

Group Therapy Suggestions uGroup by _____ level u ____ number of children in each group ____ is best _____ is do-able uFour or more - difficulties can arise u uPut those with similar ___ ___ __ in one group, if possible

__grade_ uLimit uTwo uThree speech sound disorders

Goal is to maintain accuracy of the target sound as words are placed into short, ______ phrases and sentences •Not _____ phrases and sentences yet u uMove from highly structured to less structured tasks during this phase uUsing a _____ ___ with the target word at the END is the easiest way to elicit uCould embed one target word IN the carrier phrase - which can be modified to create some degree of +_______

__structured spontaneous carrier phrase spontaneity

Spontaneous Speech uGoal is to maintain ______ when the target sound appears spontaneously in conversation _________ - transfer of behavior (accuracy of target sound) to conversational speech in various settings - uAfter a determined accuracy level is reached in the therapy setting, will want to focus on correct production _____ the therapy session in various contexts

accuracy u____carryover____ outside

Nonsense Syllables uGoal is to maintain ______ of the target consonant when embedded in _____ vowel contexts uEliminates the ________ of the "old" error with the "new" productions of the target sound that is inherent in meaningful word material u uYears of practice with the ___ aberrant articulation of the target sound often override the ____ articulation, especially in _____ words

accuracy varying Interference_ old new familiar

uTwo factors to consider prior to implementing sensory-perceptual training (ear training) •_____ of client Are ____ _____ difficulties noted

age__ auditory discrimination

Lateral [s], [z][ɬ] and [ɮ] uLateral ___ flow u uTip of tongue in direct contact with the ___ ___ u uNo ___ ____ of tongue u u"Lateral lisp"

air alveolar ridge sagittal grooving

Advantages to Beginning with [z] 1.Voiced consonants are normally produced with less ___ _____ than voiceless ones ● 2.Voicing component can ____ minor ________ differences •Increased practice with [___] often leads to acceptable [__] production 3.____ ______ •If [s] is placed in a CV or VC context, must change ______ halfway through the utterance (can maintain voicing with [z] ●

air pressure mask productional z s coarticulatory consideration voicing

Hearing Impairment Conductive Hearing Loss •Transmission problems affecting the travel of _________ sound waves from the _____ auditory canal to the ___ ear •___ ___ - any inflammation of the middle ear •Prominent medical condition causing conductive hearing loss •Common in children

air-conducted external inner Otitis media

2.Posterior/anterior contrasts - speech is examined to see if either _____ or ___ sounds are absent ● 3./s/ clusters - speech is examined to see whether /__/ clusters are produced ▫Word _____ /s/ clusters are the most facilitating ▫______ /s/ - not targeted until a later cycle • 4.Liquids - speech examined to see if /__/ and /__/ are produced 4.If absent, should be stimulated during each cycle

alveolar velar s final Singleton l r

Phonetic Placement[k] and [g] [t] and [d] Substitutions: Prevent the tip of the tongue from touching the ___ ___ uCan also try placing a tongue _____ flat and transversely across the client's tongue ● uTilt had back and try to "______" - demonstrates the posterior positioning on the tongue

alveolar ridge depressor gargle

Hearing Impairment Therapeutics Two prerequisites 1.Improvement of the residual hearing by speech signal ______ or _____ implant and the methodical _____ of its application 2.Maximal use of the level of _____ hearing for speech perception through systematic _____ training

amplification cochlear habituation residual articulatory

uImportant to know the exact ______ characteristics during the sound realization u uSolely knowing that there is a ______ seldom provides enough diagnostic information

articulation distortion

•Phonological process therapy bridges the gap between the _________ of phonological _____ and their ______ ▫ ▫Targets _____ processes

assessment errors treatment specific

Therapy - Phonetic PlacementApico-Alveolar Placement"Tongue Tip Up Interdental or Dentalized Misarticualations: u uTongue tip must be moved ____ to the alveolar ridge u uLateral edges of tongue must be ______, edges of tongue must touch first ____, and the tongue is ____ u uVisual and auditory feedback is necessary

back elevated molars grooved

ØA _____ cluster of symptoms represent CAS - including _____, _____, and ____ deficits • •Not all symptoms must be ____ • •There is ____ one specific characteristic or symptom that must be present • •Reported symptoms are not ____ to CAS

broad speech nonspeech language present NOT exclusive

division of a continuous structure by a cleavage, a split prominently caused by a failure of the palate to fuse during fetal development

clefting

Phonetic Placement Method Goal is to give the client as many _____ as possible to the ________ of the articulators and the handling of the outgoing _____

clues _positioning___ airstream

▫If treatment focused first on sounds that the child _____ ______ produce and only later targeted sounds that appeared in some _______, the most _________ occurred. (Gierut, 1985) ▫ ▫If the order of treatment proceeded from _____ to _____ phonological knowledge, generalization was very ____.

could not contexts generalization most least limited

Hearing ImpairmentDegree of Hearing Loss •Categorized by reference to _____ (dB) levels •Indicates the increase in ____ needed to make sounds audible

decibel intensity

Addental (Dentalized) [s], [z][s̪] and [z̪] uAka... "______" u ____ frequent form of distortion u uTongue tip is too close to ___ ____ of upper incisors u uTongue placement is too far ____ u ___/flat sound impression

dentalized uMost posterior surface forward uDull

Cleft PalateDiagnostic Important to find and distinguish between error patterns that are _____ in nature and those that have ____ or physiological basis as a result of the cleft.

developmental structural

Therapy Functional Nasal Problems[s] and [z] unot a ___ ____ placement u uInadequate ___ _____ leads to nasal emission

deviant tongue velopharyngeal closure

ØIt IS within the scope of practice... for the SLP to: • •Make the primary _____ of CAS • Design, implement, and monitor the appropriate individualized speech-language _____ program

diagnosis treatment

Maximal Oppositions Approach •Target sounds that are very _______ in production _____ ____ ______ are used

different Minimal word pairs

ØChallenge is to ____ CAS from speech delay, a dysarthria, and a speech sound disorder that might be moderate to severe in nature.

differentiate

Hearing ImpairmentDefinition and General Features •Hearing Impairment (Hearing Loss) - generic term for any ______ ability in normal sound reception • Typically described by ____ and ______ of auditory dysfunction

diminished type degree

any property that separates a subset of elements from a group A simple way of determining that a group of elements have or do not have a certain trait, characteristic, aspect, property or feature

distinctive feature

•Maximal Oppositions - refers to differences in ________ ________• •These differences vary along two dimensions: ● 1.______ of unique ______ that differentiate between the ____ phonemes ● 2._______ of the features •Major Class Features - including ______ _______, and ______ (Chomsky and Halle, 1968) Nonmajor Class Features

distinctive features Number features two Nature consonantal, sonorant, and vocalic

Common CharacteristicsChildhood Apraxia of Speech (CAS) andDevelopmental Speech Sound Disorders ØOnset is ____ in the developmental period ØCourse of treatment is ____ term often extending into ____ ØCurrently, there is no validated list of _____ features of CAS that ______ this symptom complex from other types of childhood speech sound disorders - including those primarily caused by ________ delay or _______ disorder(dysarthria) (ASHA, 2007b)

early long adulthood diagnostic differentiates phonological neuromuscular

Specific Auditory Perceptual Skills uAbility to differentiate between ______ production and ____ sound uIf testing reveals no difficulties with specific discrimination tasks, sensory-perceptual training is likely ____ needed

error target not

Cerebral PalsyThree Types of Involvement Spasticity •most _____ •increased muscle tone (_hypertonia_) •movements may look stiff and jerky 2.Dyskinesia •variable movement that is ______ in the arms, legs, face, and trunk •Athetosis •slow, ______, involuntary muscle movements •may cause grimacing and drooling 3.Ataxia •_____ common •main symptom is lack of ______ of hypotonic muscle actions

frequent involuntary unwanted least coordination

•Those with speech sound disorders may have difficulty producing some ___ ___

grammatical morphemes

•ongoing series of movements of the articulators in an attempt to find the desired articulatory position

groping behavior

Variables to Consider When Encountering Difficulty with Speech Sounds 1.)Could be the result of a ___ ___- specifically a high-frequency hearing loss if difficulties are with [__] or [__ 2.Minor _____ changes can affect the sound production 3.An ____ ____ pattern disorder needs to be considered (i.e., tongue thrust) 4.___ _____ abilities need to be evaluated

hearing loss s z structural oral muscle Auditory discrimination

Phonetic Placement Method uInstruct the client _____ to produce the target sound •_____ - Positioning the articulators •____ - Modification of the airstream (breath) •____ - on/off uAnalyze the ____ sound and the _____ sound production - determine which articulatory changes need to be initiated

how__ Place Manner Voicing target error

•Typically a phonological process is ______ and ______ (based on frequency of _____) - then ___ ____ ____ are used for therapy

identified selected occurrence minimal pair contrasts

Cleft PalateArticulatory/Phonological Characteristics •Developmental Speech Language Delays •Compensatory errors •Specific errors in the placement of articulators due to _______ closure of the ______ valve or a ___ or ____ in the hard palate (Witzel, 1995) •Attempt to modify the airstream below the _______ valve

inadequate velopharyngeal cleft fistula velopharyngeal

Remember: The goal is to appraise the client's ______ possibilities and determine the most ______ means of therapy. u Every client presents a different set of challenges

individual efficient

uLight (or clear) [l] uTypically in _____ word position when /l/ ______ a vowel or follows an initial _____ ulike, leap, play, sleep

initial precedes consonant

uTarget sound in the ____ position of the word appears to be the __easiest___ ______ syllables generally easier than closed syllables uCV easier than CVC - Target sound is easier to produce in a ______ syllable as opposed to an unstressed one - Target sounds that appear _____ are typically easier than when it occurs more than once - oTarget sound as a ______ is normally easier than when part of a consonant cluster _____ words usually articulated more accurately than unfamiliar words

initial u____open___ __stressed__ once singleton Familiar

uMay occur in initial and final positions of syllables u uMost [g] sounds occur ______ words u uMost [k] sounds - fairly equally distributed across ___, ____, and ___ word positions

initiating initial medial final

Hearing ImpairmentSevere to Profound Loss •Speech is less _____ • •May have difficulties with - respiration, phonation, speech rate, consonant production, vowels, suprasegmentals, coarticulatory movements, resonance, and voice quality (Culbertson, 2007; Ling, 2002) • Particular difficulty with affricates, fricatives, liquids, semivowels, plosives, and sometimes nasals

intelligble

Hearing ImpairmentMild to Moderate Loss •Speech is generally ______ (Eisenberg, 2007) • •Most common errors involve production of specific _____ - primarily affricates, fricatives, and consonant blends • •Consonant production - characterized by _____ and _____ • •Vowel production - generally _____ (Eisenberg, 2007) • •Errors typically described as resembling those of younger children

intelligible consonants deletions distortions accurate

Normal Development[ r] uConsonantal [r] - develops relatively ____; frequently still in ____ during the preschool years By 7 years of age only ___% were able to produce uCentral vowels with r-coloring - appear to be the ____ vowels to be mastered Approximately ____% of children from 6-7 years of age were able to use vocalic [r] correctly in the middle of the word -i.e., "earring

late error 75 last 80

Lateral [s] Misarticulation:T ongue Tip Up" uRaise the ___ ____ of the tongue so the edges of tongue touch the first upper molars u uDirect airstream over the ___ of the tongue - releasing the contact of the tongue with the alveolar ridge u uEliminate the ___ _ and ___ ____ using visual feedback u

lateral edges tip lateral jaw lip movement

When to use Phonological Process Therapy •Those with only a ______ number of phonological processes (mild) ▫ ▫Other approaches better for more severe difficulties ______ _____ _____ ______

limited Cycles training Maximal oppositions

Phonetic DescriptionRetroflexed [r] uVoiced apico-prepalatal central approximant (___________) uTip of tongue points to the ____ ______ or prepalatal areas u ulateral edges of the tongue are ____ u ______ of the tongue is depressed - making the elevation of the tongue appear even more pronounced u uTip of the tongue may be slightly bent backward or curled ___

lingua-palatal alveolar ridge raised uDorsum up

BUNCHED r uVoiced mediodorsal-mediopalatal central approximant (___________ u ______ of the tongue is elevated toward the palate while the tongue tip points slightly ______ uSides of the tongue touch the bicuspids and molars u uTongue position and lip rounding can vary with coarticulation

lingua-palatal) uCorpus downward

Sound Modification Methods[ʃ] to [s] Method 1.Eliminate ___ ___ associated with [ʃ] •smile while saying [ʃ] 2.Move tongue slightly ____ to change the place where the friction occurs 3.Increase ____ ____ of the tongue •Raise the ___ ___ of the tongue touching the upper molars

lip rounding forward sagittal grooving lateral edges

Cerebral Palsy •Variations in _____ •_____ in phonation • •____ voice • •_____ voice • •____ and ____ variation • •Problems in coordinating voicing and articulation •Could result in: • •Variations in _____ within an utterance • •Lack of _______ caused by nasality problems •Difficulties in achieving speech sound productions • •Sound _____ • •Disorganized _____ system •Possibly leading to problems with language and learning to ___

loudness interruptions Breathy Harsh Pitch and intensity nasality intelligibility distortions phonological read

Cleft PalateEtiology •Failure of the regular ___ ____ of the embryo's oral-facial structures •Occurs between ____ and ____ weeks of gestation •Possibility of a rupture of already fused ______ elements (Kitamura, 1991) It is "a clinical outcome of many possible diseases" - No ______ cause exists

median fusion 8th 12th oral-facial single

Cleft PalateDiagnostic •Initial diagnosis in a newborn is a _____ task (nature, site, extent) • •Requires _____-term care with a team of ______ - including an otolaryngologist, pediatrician, audiologist SLP, orthodontist, etc. • •Challenging to ____ - due to changing nature of the findings; ongoing process •Prone to ___ ___ infections (and concomitant conductive hearing loss)

medical long specialists assess middle ear

How is Minimal Opposition Contrast Therapy Used? •Two target sounds are selected and placed in ____ -____ words • •Target sounds are placed in the ____ position ▫pan - fan ▫pin - fin ▫pour - four If meaningful minimal pairs cannot be found for contrastive phonemes (or are not appropriate for the client), then ____ ______ ___ should be used

minimal pair initial near-minimal pairs

1.Echoic stimulus Client imitates the clinician's ______ of a word containing the ____ phoneme (no pictures) 1.Echoic stimulus with picture •Client imitates the ______ in conjunction with presentation of a _____ of the word 3.Picture stimulus •Client identifies the _____ with __no_ clinician model 3.Picture stimulus paired with printed word •Client imitates the _____ in conjunction with presentation of the ___ ____

model target clinician _picture___ picture clinician written word

Childhood Apraxia of Speech (CAS): Definition and General Features Occurs in three clinical contexts (ASHA, 2007b) 1. Known ______ etiologies •i.e., intrauterine stroke, infections, trauma ● 2.Result of complex _________ disorders •i.e., genetic, metabolic, syndrome ● 3.Idiopathic _____ disorder with no known neurological or complex behavioral disorders

neurological neurobehavioral neurogenic

uMultiple-Sound Approach (for ______-based disorders) •_____ error sounds are treated ______

phonemic Several simultaneously

Traditional/Phonetic/Motor Approach uTeach each error sound ____ at a time in a sequence uRequires an understanding of: •How the sound is ______ produced(Remember - there can be multiple ways and The client's specific ______

one _normally_ misarticulation

Childhood Apraxia of Speech (CAS):Demographics ØMore than 80% have at least ___ family member with reported speech and/or language disorders (Velleman, 2003) ØHigher rates of ___ ____ than other speech sound disorders,which suggests genetic basis (Lewis et al., 2004) Ø___ ____ - symptoms of CAS are common (Kumin & Adams, 2000) ØAutism spectrum disorder ØApproximately 60% have speech problems About 13% report primarily symptoms of CAS

one family history Down syndrome

Nasal [s], [z][s̃] and [z̃] uNasality during [s] production may be ______ or _____ u •_____ - result form physiological anomalies or neuromotor problems •___ ____ • •_____ nasality may be a result of faulty learning of sound patterns or maintenance of a learned pattern that was originally organic

organic functional organic Cleft palate Functional

Palatal [s], [z][sʲ] and [zʲ] uMore _____ placement of active and ____ articulators; position is too far ____ u uSagittal _____ of the tongue may be more flattened than for [s] and [z] u Approaches a [ʃ] qua

palatal passive back grooving

•clefting Examples: • •Cleft ____ • •Cleft c___ _____ and___ ___ clefts are among the most frequent congenital anomalies

palate lipe palatal upper lip

When to use Minimal Opposition Contrast TherapyAKA Minimal Pair Therapy •Beneficial for clients with: ▫Moderate, moderate-to-severe, or severe _______ impairments ▫Normal hearing ▫Age-appropriate receptive language skills ▫No evidence of oral-motor difficulties(Weiner, 1981) ▫Increased ______ for the target sound(Lowe, 1994) ▫Consistent ______ speech errors(Baker, 2010) ▫ •Not beneficial for clients with: ▫Sound _______ and ______(This procedure targets the ______ of one phoneme for another)

phonological stimulability phonological _distoritions____ _assimilations__ substitution

often used to assess error patterns in speech

phonological processes

Cleft Palate •Four goals when implementing therapy: 1.Improve ______ of consonant productions by promoting a more __-__ place of articulation ● 2.Improve ______ valve function and decrease ____ resonance quality ● 3.Modify _____ articulations ● If developmental phonological errors exist, improve _____ system

placement forward velopharyngeal hypernasal compensatory phonological

Childhood Apraxia of Speech (CAS): ØMain difficulty - "the ______ and/or ______ of ______ parameters of movement sequencesthat results in errors in speech sound ______ and ____." Brain cant tell mouth what to do

planning programming spatiotemporal production prosody

Phonetic Description[l] uVoiced apico-alveolar laterals uTypically, tongue tip touches the alveolar ridge during production uCoronal areas are _____ - allows air to escape laterally u uTwo varieties - both represent one phoneme - /l/ u"_____" (or "clear") [l] u"_____" [l]

relaxed light dark

Phonetic DescriptionCentral Vowels with r-coloring [ɝ] [ɚ] uAka: _____ or ______ vowels u §[__] •Stressed •Some degree of lip rounding •Example: / ˈtɝ.kɪ / • §[___] •Unstressed •Example: / ˈʃʊ.gɚ / uArticulations comparable to the "retroflexed" and "bunched" consonantal [r] productions

rhotic rhotacized ɝ ɚ

Nasal [s], [z][s̃] and [z̃] uFunctional Problem •Higher degree of probability if the nasality is restricted to [__] and [__]. •Usually accompanied by a normal tongue placement for [s] and [z]. uOrganic Problem •Usually have an effect on ____ _____ _____ u

s z ALL speech sounds

Childhood Apraxia of SpeechSpeech Motor 1.Difficulty _____ speech sounds and syllables ----Difficulty seems to increase as _________ of utterance increases\ ----Poor performance on maximum repetition of ______ and slow _____ rates 2..More errors made in sound classes involving more complex ___ ____ -----Larger percentage of difficulty with consonant ______, ______, and _____

sequencing complexity/length syllables diadochokinetic oral gestures clusters fricatives affricates

- group of vowels and specific consonants that demonstrate increased sonority (or more relative loudness) in relationship to other sounds with the same length, stress, and pitch vowels, liquids, nasals, and glides)

sonorant

2.Discrimination Testing and Training - discrimination between the two _____ is tested - DONT LEARN • •Clinician repeats the two words in _______ order • •Child _____ to the picture that is named • •Criteria for mastery = __ consecutive correct responses in a row • •If criteria for mastery is not met --•Poor ___ _____ or memory skills may be the cause --•Address these skills before continuing program

sounds random points 7 auditory discrimination

Hearing Impairment Therapeutics •Main goal is to improve overall ___ ___ •Involves: •Structured work on _______ errors •Selection of a suitable _____ treatment program

speech intelligibility articulation phonetic

cerebral palsy ØDifficulties include: • •Lack of volitional ________ control --- Central clinical feature • •General movement and coordination problems • Disturbances in cognition, perception, sensation, language, hearing, emotional behavior, feeding, and seizure control

speech-motor

Where to begin therapy?[r] and Central Vowels with r-coloring uConsonantal [r] or Central Vowels with r-coloring? §Based on ______ §Based on ____ ____ of the error sound ___ ____ - how noticeable is the sound error to listeners? u uWhich type of [r] production? Bunched or Retroflexed [r]? uBased on ______ u u

stimulability perceptual saliency uPerceptual saliency stimulability

Stimulus-Shift Approach developed This program can be used only when the target sound is ____.

stimulable

❖Present the ____ as directed by the approach you have chosen ❖Take ____ for each response ❖Provide immediate and explicit _____ •Shape response if needed ❖Provide _____

stimuli data feedback __reinforcement___

t] for [s] Substitution"Stopping"[t] and [d] uChange in manner of articulation; aka: ______ u uTongue tip is in ___ ____ with the alveolar ridge; thus, contact must be ______ so that a _____ opening occurs

stopping direct contact eliminated narrow

Cleft PalateTherapeutics •Many undergo _____ to repair the palate by ___ months of age • •May not exhibit compensatory sound productions errors • •Other children require ____ intervention • Approximately ___% of children with repaired cleft palate will develop speech deficits that require additional intervention

surgery 18 therapeutic 20

1.Early developing phonological patterns - DONT LEARN ● ▫______ - refers to two- and three- syllable equal stress word combinations (i.e., cowboy, cowboy hat) Looking to see whether the vowel nuclei exist, not in respect to the accurate production of all sounds ▫_____ _______ consonants - include CV structures with the following phonemes: /m, n, p, b, t, d, w/ ▫ ▫______ _____consonants - include VC structures with the phonemes /p, t/ and/or /k, m, n/ ▫ ▫Other word structures - both CVC and VCV words are found in the child's speech

syllableness Word-initial singleton Word-final singleton

uConsonantal [r] - occurs in initiating ______ or specific _____ uCentral vowels with r-coloring - function as syllable _____

syllables clusters nuclei

Sound Modification Method Deriving the ____ sound from a _______ _______ sound that can be accurately produced

target phonetically _similar__

Words uGoal is to maintain accuracy of the target sound in the context of ____ u uLarge variation in this phase •From CV structures to multisyllabic words in which the target sound appears several times (often in consonant clusters) u ______ organize from relatively easy to more complex words

words u__traditional___

Linguistic FunctionMinimal Pairs uSounds frequently substituted for [k] and [g]

§[t] and [d]

uSounds frequently substituted for [r]:

§[w], [j], and [l]

______ and _____ of errors is probably the most frequent pattern characterizing this disorder Ø ØOften highly ______ Ø _____ of progress in spite of considerable amount of therapy over a long period of time

ØInconsistency variability unintelligible ØLack

Cerebral PalsyArticulatory/Phonological Characteristics • ______, _____, and _____ problems Ø _____ abnormalities Ø ______ inadequacies

ØRespiratory phonatory articulatory ØProsodic Øvelopharyngeal

uDark [l] u uHas an [___] or [__] quality caused by the _____ of the tongue's posterior portion u uHigh-back elevation produces a ______ upper surface of the tongue behind the alveolar occlusion uFound in word-____ positions as syllabics and when it precedes a _____ ui.e., full, kettle, cold (Heffner, 1975)

ʊ o elevation concave final consonant

Speech Sound Disorders in Selected Populations

•Childhood Apraxia of Speech (CAS) •Cleft Palate •Cerebral Palsy (CP) •Hearing Impairment

•Refers to the presence of a cleft at midline •

•median cleft