Clinical methods week 5, methods Week 4 language

Client Centered (Oriented): Facilitative play: extensions (expatiations-semantics)

"kitty eat" - "yes, the kitty is very hungry" --adding semantic content

Writing Plan of Care: Treatment Plan Guidelines

(1) Heading includes (2) Description of problem (3) Prognostic statement (4) Goals (5) Procedures (6) Generalization and maintenance (7) Probes (8) Dismissal criterion (9) Follow-up

**Two types of Voice Disorders:

(1) Organic—result from pathology or disease that affects the anatomy or physiology of the larynx and other regions of the vocal tract (2)Functional—dysphonias related to vocal abuse/misuse or psychogenic factors in the absence of an identifiable physical etiology

**Things you are looking for in an evaluation:

(1) case history. (2) respiratory support. (3) intensity, (4) quality, (5) resonance, (6) prosody.

3 parties involved in AAC

(1) client (2) communication advocate (3) trainer/facilitator

3 different intervention techniques used a lot for stuttering intervention.

(1) modification, (2) shaping, and (3) delayed auditory feedback--

Atypical Disfluencies

(Test matching questions) • Three or more within-word disfluencies per 100 words • Disfluencies on more than 10% of syllables spoken • Predominant use of prolongations, blocks, and part-word repetitions • Presence of secondary behaviors/increased tension • Vowel neutralization (schwa) during repetitions --(e.g. buh-buh-beat) • Duration of a single instance of disfluency that exceeds two seconds • Uncontrolled or abrupt changes in pitch or loudness

**Normal Disfluencies

(test matching question) • Hesitations • Interjections of sounds, syllables, or words • Revisions/repetitions of words, phrases, or sentences • Normal rhythm and stress patterns • No tension or tremors noted

Fluency therapy 2 types of treatment approaches

1. Fluency shaping 2. Modification

2 types of aphasia

1. Fluent (wernicke's) --Transcortical Sensory Aphasia (Fluent Aphasias) --Subcortical Aphasia Syndromes (Borderline Fluent) 2. non-fluent (broca's) --Transcortical Motor Aphasia (Nonfluent Aphasias) --Global Aphasia (Nonfluent Aphasia)

**National Reading Panel (2001) Five Areas for Reading Success

1. Phonological sensitivity (phonology) 2. Phonics: relationship between letters or letter combinations and the phonemes 3. Fluency: ability to read a text accurately and quickly 4. Vocabulary: knowledge of word meanings (semantics) 5. Text comprehension (semantics, syntax, morphology, pragmatics, metacognition)

Three Phases of Swallowing:

1. The oral phase (voluntary) --can be divided into an oral preparatory phase and an oral phase. • Oral preparatory—biting, chewing, forming a bolus • Oral—the bolus is propelled to the back of the mouth for swallowing with the trigger of the swallow reflex 2. pharyngeal phase (involuntary) , --the bolus travels through the pharynx and cricopharyngeal sphincter into the esophagus. 3. esophageal phase (involuntary), --bolus moves through esophagus to the stomach.

PACE is designed for

= functional commutation

What Is Aphasia?

Aphasia is an acquired communication disorder that can impair to varying degrees: • Auditory processing of language • Auditory comprehension of language • Expressive language • Reading • Writing • Gestural and nonverbal communication

Client Centered-Adult

Conversational group techniques: •attending, •negotiating goals, •rewarding, •response to feelings, •focusing, •summarizing, •gatekeeping, •modeling, •mediating

Swallowing disorder =

Disfasia

Prevalence

Moats (2010) • 20% of school-age children—very poor readers • An additional 20% do not read fluently and are unable to enjoy independent reading—40% • National Assessment of Education Progress (NAEP)—38% of fourth-grade students in the US scored at a level ―below basic reading‖—we have a problem!

**Respiratory Support: Determine s/z ratios

Normal sustained /s/ in • children is 10 seconds • adults is 20 seconds. • Have the client sustain each phoneme while your time with a stopwatch. • Repeat each phoneme twice. • Compare the longest /s/ and /z/. • Divide the /s/ time by the /z/ time to get the ratio. If you have a ratio of 1:2 or greater, possible vocal fold pathology is involved. • Normal sustained /s/ in children is 10 seconds and in adults is 20 seconds.

Early Red Flags: Alphabet Knowledge

Preschool: • Difficulty learning and remembering the names of letters in the alphabet • Difficulty recognizing letters in his/her own • Difficulty learning numbers • Difficulty with word retrieval

Early Red Flags: Phonological Awareness

Preschool: • Difficulty with rhyming • Poor auditory memory for nursery rhymes and chants • Mispronunciation of familiar words • Speech/language: phonological development

SOAP Notes

Subjective objective assessment plan

Hybrid Approach: Script Therapy

Target behaviors are taught within a familiar routine or script— --example: birthday party/slumber party/haircut/doctor --older adolescence and adults

Social Networks to Consider in AAC: Third network

acquaintances (neighbors, etc.)

Broca's Aphasia (Nonfluent Aphasias) characteristics:

agrammatism --Agrammatism: speech consists mainly of substantive words with fewer functor words • Effortful speech • Short phrases • Anomia • Sometimes Apraxia is also present • Articulatory errors • Phonemic paraphasias • Auditory comprehension fairly good --More difficult with length and multiple speakers • Reading and writing skills similar to client's verbal skills • Mild dysarthria can be present • Impaired processing

Respiratory Support: Thoracic breathing—

between clavicular and diaphragmatic-chest movement may be noted

Social Networks to Consider in AAC: Second network

close, reliable friends

Client Centered (Oriented): Facilitative play: recasts

completely change the design of the sentence "kitty eat" - "is the kitty eating?" --Change it to an interrogative (question) vs. a declarative statement.

Cancellations—

during a disfluency, speaker is encouraged to complete the words without attempting to break out of the disfluency

Pull-outs—

during a disfluency, speaker taught to stop in the middle, mentally rehearse the word and then reproduce it

Client Centered (Oriented): Facilitative play: expansions (syntax)

expanding syntax, ex: "kitty eat" - "yes, kitty is eating" --if your child says, kitty eat, you might say, ** yes, kitty eats a lot. You're expanding the syntactical representation that they have there versus extensions or expatiations.

Social Networks to Consider in AAC: First network

family

Respiratory Support: Diaphragmatic-thoracic breathing-

lower thoracic/ abdominal muscles move —very little chest movement --optimal breathing

Social Networks to Consider in AAC: Fourth network

professionals

Respiratory Support: Clavicular breathing—

shoulders move up and down

Preparatory sets—

speaker encouraged to anticipate an imminent disfluency and pause briefly to mentally rehearse fluent production before the word is attempted

Client Centered (Oriented): Facilitative play: parallel talk

talk about what clients doing while both playing with same thing --you and your client both have the same activity, and you're talking about what they are doing while you're both playing with the same thing.

Phonology: Phonemic awareness plays a significant role in

the development of reading and spelling abilities

Two Means of Sending Messages: Direct selection: Scanning

the user is offered available messages by a mechanical device or communication partner. The messages are offered sequentially until the AAC user indicates the messages he or she wants to communicate.

Two Means of Sending Messages: Direct selection

the user selects a message by touching a key pad, touching an item or object, depressing an electronic key, pointing or some other direct means.

Morphological awareness is related

to children's spelling, word-level reading, and reading comprehension abilities

Social Networks to Consider in AAC: Fifth network

unfamiliar communication partners (bus drivers, waiters, etc.)

Client Centered (Oriented): Facilitative play: self-talk

you talk about your doing --the clinician have chosen something that you're playing with or utilizing. And you talk about what you yourself are doing.

Functional voice disorders (slp's)

• Abuse/misuse • Vocal nodules • Contact ulcers • Ventricular dysphonia • Psychogenic • Conversion dysphonia • Mutational falsetto

Voice Evaluations Case History

• Abusive behaviors • Alcoholintake • Caffeine intake • Allergies/ medications • Smoking • Mouth breathing • Singing/ drama/ yelling • Medical aspects • Medications • Reflux • Other organic issues: edema, cancer, etc. --we're going to have ruled out organic issues. If there is an organic issue, then that has to be taken care of by medical staff.

Schuell's Stimulation Approach

• Basis: auditory processing impairments underlie aphasia • Purpose: stress intensive auditory stimulation controlled for length, rate, and loudness • Establishing rapport and promoting self- esteem is very important • Useful for any type of aphasia

**Clinician Directed Approach

• Behavioral approach • Behaviorist theory—clinician controlled. --Example: stimulus, behavior (response), consequence (reinforcement) • May include drill, drill play, clinician modeling

**Preschool (2-5 years)

• Brown's morphemes (-ing, 's) • Semantic relations (agent+object/action) • Literacy emerging

AAC: Three things need to determine appropriate intervention tasks

• Case History - etiology, previous therapies, trials • Review all testing • Consider vision and hearing & all physical limitations • Assess as a team

Voice Evaluations

• Case history • Respiratory support • Intensity levels • Conversational sample • Quality • Pitch • Resonance • Prosody

Assessment

• Case history information: parental history of dyslexia/reading disorder, predict with 40-50% likelihood that a child will have a reading disability • Comprehensive Test of Phonological Processing Second Edition (CTOPP2) • The Phonological Awareness Test Second Edition ( PAT2) • Test of Integrated Language and Literacy (TILLS) • Informal assessment

Stuttering

• Characterized by an abnormally high frequency and/or duration of stoppages in the forward flow of speech • Occurs in 1-1.5% of population • Males out number females 3:1 • Onset is usually between two and five years of age and may emerge in a sudden or severe manner

Secondary stuttering Behaviors: avoidance:

• Circumlocutions • Unfilled pauses • Struggle within or between words • Use of ―"um" or other interjections

**Client Centered (Oriented) approach

• Client directs—includes waiting for client to initiate, interpret the behavior, and responding to the behavior • Includes: facilitative play, daily activities, daily routines, vocational (work) activities • Facilitative play includes: self-talk, parallel talk, expansions (syntax), extensions (expatiations-semantics), recasts --ASD

Hybrid Approach

• Combination of both clinician directed and child centered • Four types: Milieu teaching, script therapy, focused stimulation, and conversational coaching

Identifying Signs of Dyslexia/RD: Second Grade-Middle School

• Confuses words that are in a similar category or sound alike, such as /tornado/ for /volcano/, /lotion/ for /ocean/ • Mispronunciation of long, unfamiliar, or complicated words • Trouble remembering dates, names, telephone numbers, random lists • Difficulty with word reading Trouble finishing tests on time • Low self-esteem Slow and awkward oral reading • Speech/language: five areas of language • Avoids reading out loud • Word retrieval difficulties-searches for specific word and often ends up using vague language, such as "stuff" or "thing"

Secondary stuttering Behaviors

• Develop over time as learned reactions to the core behaviors • Categorized as escape or avoidance behaviors • Escape and Avoidance

AAC Devices: Low-tech devices

• Devices that do not use electronic instruments --Notepads, message boards, PECS

AAC Devices: High tech devices

• Devices that use electronic instruments --Computers, iPad (proloquo2go), dynavox

Intervention Techniques: Fluency shaping

• Easy onset/prevoice exhalation • Decreased speaking rate (prolonged speech) • Light articulatory contacts • Continuous phonation

Hybrid Approach: Conversational Coaching

• Facilitates functional communication skills of adults with aphasia or possibly clients with pragmatic issues. --Example: what to say to hairdresser • Conversational group techniques: attending, negotiating goals, rewarding, response to feelings, focusing, summarizing, gatekeeping, modeling, mediating

Identifying Signs of Dyslexia/RD: Kindergarten and First Grade

• Fails to understand that words come apart (i.e. /snowman/ can be pulled apart into /snow/ and /man/, /man/ can be broken down as /m/, /a/, /n/) • Narrative retell • Complains about how hard reading is • Cannot sound out simple words like cat, map, nap-lacks strategy to decode single words • Relies on context clues to recognize a word • Oral vocabulary/syntax/morphology

Hybrid Approach: Focused Stimulation

• False assertions—clinician purposefully makes mistake • Forced alternatives—questions are posed by the clinician providing a model for the target behavior. --Example: You do like it or you don't like it?—attempting to get negative

Wernicke's Aphasia (Fluent Aphasias) Characteristics:

• Fluent jargon speech • Appropriate prosody and articulation • Empty meaning • Severe difficulty processing verbal input • ―"Press of speech" • Poor self-monitoring skills • Prognosis: dependent on client's degree of auditory comprehension • Difficulty associating meaning of sounds with written symbols (written to spoken words) • Lack awareness that writing does not make sense • Anomia • Concerns: --Paranoid tendencies, lack of interest in therapy, depression

3 signs or symptoms with feeding disorder

• Food aversion (refusals) • Problem feeder (>20 foods) • Neophobia: (fear of new things) • Failure to thrive: (Weight that is consistently below the third to fifth percentile for age)

Secondary stuttering Behaviors: escape:

• Head nods • Eye blinks • Foot taps • Jaw tremors

Resonance

• Hyponasality—too little • Hypernasality—too much •Assimilative nasality: when sounds preceding or following a nasal consonant are also nasalized. •Usually a judgement call on the part of the listener—can use nasometer, spirometer, etc. for objective measures.

**Hybrid Approach: Milieu Teaching (has 2 parts)

• Includes using ongoing activities as the basis for the intervention and utilizes operant conditioning techniques of imitation, modeling, and reinforcement into a naturalistic setting. • Incidental teaching and Mand-model are two types: (1) Incidental teaching requires the clinician to wait on the client's initiation (verbal or nonverbal) to begin obtaining responses. (2) Mand-Model does not wait on the client's initiation. (demand model)

Adolescence (10-18 Years)

• Language (verbal and written): more complex • Develop an identity • Independence from family • Career plans • Develop moral/ethical values • 10-14 years: develop primary focus of communication for academic and personal/social purposes • 14-16 years: vocational is added • 16-20 years: communication for personal/social/career Metacognitive/executive functioning— awareness of one's own problem-solving abilities/self-regulating behaviors (usually in latter adolescence)

**Language Intervention: Infants (What are ways infants communicate)

• Localization (look to sound) • Joint attention • Mutual gaze • Joint attention/routines • Vocalizations • Communicative intent • Non-symbolic play/symbolic play • Vocabulary

Prosody

• Monotone • Normal rise/fall of stress/intonation patterns

Quality

• Normal voice • Breathy voice (VF's not closing) • Shrill voice (high pitch) • Harsh voice (force voice) • Hoarse voice (adema of VF, cannot come together- swollen) • Phonation breaks • Pitch breaks

Fluency Evaluation

• Note any secondary motor behaviors— hands, feet, head, neck, etc. • Note any respiratory or phonatory factors—gasping, pitch breaks, intensity levels • Note speech rate—too fast, too slow • Interview client/caregiver concerning feelings about stuttering—note avoidances

Risk Status of Children With Speech-Language Impairments

• Over 50% of children with Language Impairments will have academic difficulties (Lewis, Freebairn, and Taylor, 2000) • ―One of the most compelling findings from recent reading research is that children who get off to a poor start in reading rarely catch up."

PECS

• Picture Exchange Communication System • By Pyramid Educational Consultants • Formal Training Required• Rooted in Applied BehaviorAnalysis

Phonological sensitivity: 4 to 6 Years of Age

• Produces rhyming words • Counts the number of syllables in words • Blends syllables • Blends phonemes • Segments phonemes • Isolates sounds

Promoting Aphasics' Communication Effectiveness (PACE) 1977, 1993, 2000

• Purpose: functional conversational communication • Client chooses turn-taking mode • Emphasize effective exchange of info, not linguistic precision --Use many stimulus cards—place face down on table --Take turns drawing cards from stack and communicating info without naming picture --Encourage mode of communication (verbal, gestures, written, etc.) --Continually add new cards to promote exchange of new info --Provide natural feedback --Reinforce/acknowledge understanding; provide verbal word; possibly expand on utterance --Vary and adapt to client's needs when necessary --Exchange role of speaker/listener • Phase I: everyday object • picture cards • Phase II: verb picture cards

Phonological sensitivity: Preschool 3-4 Years of Age

• Recites nursery rhymes • Produces rhyme by pattern • Recognizes alliteration • Segments sentences • Completes a rhyme sequence • Segments syllables

Alaryngeal Speech

• Refers to voice that emanates from a sound source other than the larynx • Result of a total laryngectomy in which the entire larynx is removed due to a malignant tumor or severe trauma • Mechanical devices can be installed to compensate for this loss.

Intervention Techniques

• Relaxing muscles • Reducing loudness • Softening glottal attacks • Adjusting pitch • Phonating on inhalation • Pushing/pulling • Increasing loudness • Client education • Symptomatic therapy • Referral to other specialist when needed

Levels of Support

• Repetition: Repeat the word with reduced rate of speech; feel the word on your mouth incorporating all modalities --Make sound perceptually salient through exaggerated pronunciation—―use of Clear speech‖ • Visuals/gestures: --Incorporate movement and motor activities when needed --Use visual cues: blocks, tokens, bingo chips, pictures, sticky notes, sound strings, theme- based manipulative (fade as criterion met) • Correction/ model/request: --If in error, you model with visuals, request client to produce again with visuals

Core stuttering Behaviors: Basic manifestations beyond the voluntary control of the stutterer

• Repetitions of sounds, syllables, or whole words • Prolongations of single sounds • Blocks of airflow/voicing during speech

Fluency Assessment

• SSI—Stuttering Severity Instrument by Riley • Mower's interview • Eclectic fluency evaluation

Intervention Techniques: Stuttering modification/management

• Self-analysis • Relaxation • Desensitization Three-part sequence • Cancellations—during a disfluency, speaker is encouraged to complete the words without attempting to break out of the disfluency • Pull-outs—during a disfluency, speaker taught to stop in the middle, mentally rehearse the word and then reproduce it • Preparatory sets—speaker encouraged to anticipate an imminent disfluency and pause briefly to mentally rehearse fluent production before the word is attempted

Considerations when looking at AAC

• Skill level of client—including: literacy, motor, etc. -what can they do, what can they not do. • Cognitive ability • Communication partners --who's gonna be using this

Intervention Techniques: Delayed auditory feedback

• Speaker's own words are returned through headphones after a few milliseconds of delay --speecheasy

Phonological sensitivity: 7 Years and Up

• Syllable manipulation • Phoneme blending and segmentation of increased complexity • Phoneme manipulation • Deletion • Addition • Substitution • Transposition • Reversal

Language Sample

• Take a 500 word sample of conversational speech and reading (if a reader) • Count number of disfluencies in the sample • Divide the total disfluencies by the total words. • Change number to % If over 5%, have a possible problem • In the sample, note kinds of disfluencies- part word, whole word repetitions, prolongations, interjections, pauses, broken words, incomplete phrases, and revisions • Count each kind of disfluency

Phonemic awareness/sensitivity

• The ability to notice, think about and work with individual sounds in words • Isolating and manipulating sounds in words through the use of oral segmenting and blending activities

Literacy Defined

• The ability to read, write, and spell • The ability to use • Language proficiently

Theme-Based treatment

• The narrative platform provides an authentic learning opportunity and encourages active participation in intervention. • Strategic learning must be developed within a meaningful context. (Provides a shared learning context for mediated learning with a rich information base - information that can be examined from multiple perspectives).

Esophageal Speech

• This method of communication consists of using air passing through a narrow constriction in the esophagus as an alternative source of sound for speech. --projects air and speaks on a burp • Tracheoesophageal speech is an alternative to esophageal speech in which a small device made of silicone is inserted into a surgically created opening between the trachea and esophagus to allow air from the lungs to reach the PE segment.

Pitch

• Too high • Too low • Monotone • Habitual pitch: average pitch a client uses; voice disorder is present if the client uses a pitch two or more tones away from the optimum pitch for his/her age, gender • Discriminate/imitate pitch patterns

Intensity: Judgments based on:

• Too loud • Too soft/quiet • Monoloudness (same tone) • Limited variation (increase and lowering intensity) • Excessive variation (talks loud then low)

School-Age (5-10 Years)

• Verbal language—more complex (irregular plurals/past tense) • Literacy—basic for decoding and reading fluency • Spelling and written composition (third and fourth grade)

Organic voice disorders

• Vocal fold paralysis • Laryngeal webs • Papilloma • Edema • Tumor • Granuloma • Neurologic/ endocrine disease

What Is It AAC?

• Ways other than speech that people use to communicate. • It may include electronic devices, picture displays, picture books, printed words or symbols. It may also include body language, gestures, facial expressions, sign language, and vocalizations.

**Client Centered (Oriented): Facilitative play includes:

• self-talk --you talk about your doing •parallel talk --talk about what clients doing while both playing with same thing •expansions (syntax) --expanding syntax, ex: "kitty eat" - "yes, kitty is eating" •extensions (expatiations-semantics) --"kitty eat" - "yes, the kitty is very hungry" •recasts --completely change the design of the sentence "kitty eat" - "is the kitty eating?" declarative to interrogative (question)

To determine pitch:

• use a piano or pitch pipe • A quick way to determine optimal pitch is to have the client: --cough, --yawn-sigh, --or answer a yes/no question with "mmm- hhmm" (yes) or "hhmmm" (no).