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0-3 years: Early monitoring and speech-language stimulation:
Team SLP?
- monitors communication development and intervention needs
- Counsel and educate parents
- Home-based intervention; daily S-L routines
- Prevent development of CMA (glottal stops, nasal fricative, growls)
- Monitor VP closure status post-palatoplasty
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Goals of Early Intervention-Prelinguistic? (4)
- Educate and training for parents
- Increase frequency of vocalizations
- Increase diversity of vocalizations
- Increase communicative opportunities
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Goals of Early Intervention-Linguistic (3)?
- Increase CV shape inventory
- Increase expressive vocabulary
- Teach oral versus nasal airflow distinction, as necessary, after initial palatal surgery
-
About ___ of all children with CP +/- CL will need speech therapy at some point in their developement?
1/2
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3-5 years: Intervention?
- Faciliatate and shape oral airflow and oral articulation learning
- Prevent habituation of atypical placements and airflow
- VP closure status may not be known -dx therapy
- Early language development activities-as necessary
-
School age and beyond:
Treat ? i.e.?
the learned errors
- Persistent use of maladaptive CMAs (also backed oral productions)
- Persistent directions of the air stream into the nasal cavity and out the nose instead or oral direction and emission
- Assessing the interactive relationship between VP closure and CMAs (it works both ways)
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Early monitoring & intervention: infant, toddler, preschool years Provide info to parents:
before or by 3 months of age: (4)?
- Discuss expected impact of cleft on speech
- Monitor baby's speech and language development
- Give suggestions for enhancing baby's early communicative development
- Answer questions
-
Early monitoring & intervention: infant, toddler, preschool years Provide info to parents:
5-6 months of age/before onset of babbling:?
- Give more specific info
- encourage and guid baby's vocal development
-
Early monitoring & intervention: infant, toddler, preschool years Provide info to parents:
Monitor at 6 month intervals throughout preschool years?
- Ensure that early communicative behaviors are developing appropriately
- Determine if more direct intervention is necessary
-
Speech Intervention?
Aims?
Prevents?
In young children (0-3 or 4)
Therapy objectives for?
- to facilitate and shape oral airflow and oral articulation learning
- development of atypical placements
- VP closure status may or may not be known
- CMAs are the same
-
With prelinguistic child?
_____services?
Encourage?
Help?
Model?
____ routine?
Discourage?
- Home-based
- a variety of vocalizations, non speech sounds
- parents identify early sounds, not in inventory, especially vowels; say & sing
- "baby talk" re: exaggerated intination and loudness
- "Hi" and "bye-bye"
- "growls", nasal fricative and snorts; model oral consonants and vowels
-
Prelinguistic child:
Use ___ games?
Teach parent?
Goal:?
Prior to ____, advise parents to encourage ___?
Teach?
- babbling
- how to do interactive/turn-taking games
- Expand phonetic inventory and syllable shapes
- palatoplasty, advise parents to encourage syllables the baby can produce easily-nasal, glides, /l/
- Imitation-body gestures, facial and vocalization gestures, speech gestures
-
Monitor post-palatoplasty:
Expansion of?
Watch for ?
- phonetic inventory, numbers, types of sounds, and expressive/naming vocabulary
- early indicators of VPI/A:
- no increase in oral stops
- many nasal productions
- moderate or > hypernasality
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Intervention in preschool years (3-5 years)
Teach? use?
Use ____ techniques to teach ____?
Include ?
Teach?
- identity, location, and actions of orals structures:
- use mirror, pictures, lateral diagram
- phonetic placement
- sounds not in the inventory
- orthographic symbol
- sound production contrasts:
- oral vs oral
- oral vs non-oral
-
Intervention in preschool years (3-5 years)
Teach difference between ?
Changing the label in ?
Include?
- oral vs nasal airflow
- PSNE
- sufficient practice of new productions so they become stabilized
-
Speech treatment options-school aged child:
Physical management? (3)
- surgery
- prosthetics
- orthodontics
-
Speech treatment options-school aged child:
Behavioral management?
- Speech therapy
- VP port therapy
-
Therapy for cleft palate speech in school-aged youngsters:
Speech therapy in the form of?
- Articulation Tx
- Phonological Tx
- Modifies the sound system
-
Therapy for cleft palate speech in school-aged youngsters:
VP port Tx which aims to modify ?
VP closure behavior
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Treatable or not?
Obligatory errors in general are? and include?
- not treatable
- Pervasive NAE and HN caused by VPI/S
- NAE due to fistula(s)
- Adaptive oral misarticulations
-
Treatable errors include?
- Maladaptive CMAs
- Backed oral productions
- learned NE patterns
-
Therapy approach:
remember CP speech errors are ___, not ___?
The key problem is?
But:?
Some children will also need?
- deviant, delayed
- learning how to make the sounds
- one size does not fit all
- phonological tx for sound usage errors
-
When to start therapy:
Some children will already have ?
You may see children ?
You may see yet?
- received speech intervention
- who are not under team care-you need to determine why and refer them to a team
- undiagnosed VP problems
-
Therapy frequency and duration:
Tx should take place?
at least ___?
___ sessions last ___?
Have ___?
Hard to acomplish in most ___?
- daily
- twice a week
- Individual 30 mins
- Daily speech homework with clear instructions and accountability-10 minutes
- public school settings
-
Phonetic Placement:?
- Tactile placement cues
- Schematic illustrations for placing learning
-
Useful materials for phonetic placement?
stim sticks, flat tooth picks, tongue blades, orthodontic elastics, button on a thread, lateral diagrams to show place of prodcution of desired target and place contrasts between targets and errors.
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Oral airflow teaching activity?
Oral vs nasal contrasts
-
Using materials for Oral airflow
materials for blowing activities: bubbles using wand or pipe; whistles; blowing against easily moved objects
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Materials for monitoring for Oral vs nasal airflow?
flexible listening tubes (See Scape), mirrors and air paddles for auditory discrim and for self monitoring production
-
Oral airflow feedback monitors?
- See Scape
- Listening tube
- Paper deflector
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General Tx (outcome) goals for cleft palate speech?
Eliminate
Replace
Modify/eliminate
- maladaptive compensatory misarticulations (may improve VP function) and learned nasal emission
- the maladaptive articulations with correct oral productions
- backing patterns
-
Tx Components (as necessary)
Establish
Select
Get
Teach
Practice
- "place map" for consonants; reliable self-monitoring
- appropriate (inital) tx targets
- the desired target sound(s) into the speech sound inventory
- correct oral target versus error sound contrasts
- reliable self-monitoring
- target production in increasingly more complex contexts
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Teach 'phonetic placement language and concepts'
teach?
- names for speech structures
- locations and directions
-
Target sound selection where to start tx?
Consider?(6)
- Stimulability
- Visibility
- Place of production
- voicing
- manner
- developmental schedule
-
Tx:
voicing?
unvoiced before voiced, especially with glottals
-
Tx:
Manner?
for oral pressure consonants, fricatives before stops, especially if child produces both pharyngeal fricatives and glottals.
-
Tx:
developmental schedule?
within a place category or manner class, consider normal acquistion sequence (p< t< k)
-
Get sound into the inventory:
Use _____ to establish oral place targets
For ____, new place learning & facilitating associated target manner and voicing?
For learned___, eliminating habitual nasal directing of airflow?
- phonetic placement techniques
- Maladaptive CMAs
- NE, oral direction of airflow learning
-
Teach correct oral target versus error sound contrasts:
Use ___ diagram
___ versus ___
____ teaching of?
Builds?
- lateral
- /k/ VS pharyngeal stop
- multi-modality of target sound production and contrast with error sound: watch, listen, feel
- the basis for self-monitoring and self correction
-
Teach place contrasts:
Use?
Pair with?
- diagrammatic, visual representation for aberrant vs target place contrasts
- auditory discrimination tasks
-
Place contrasts: for auditory discrimination and production
Children need to be able to do the aud discrim task in order to ?
Teach child to ?
Negative practice paired with ? is a successful technique with articulation disorders?
- learn and internalize the prodcution
- make the error sound-target sound contrasts
- glottal vs oral stop
- oral airflow vs nasal airflow
- desired/correct behavior
-
Operational framework for conducting tx for CMAs:
Teach?
Ensure?
Establish?
- concepts that underlie place learning
- adequate speech discrimination skills
- oral target place and eliminate non-oral error place
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Eliminating glottal stop substitutions:
If /h/ is not in the inventory, teach ?
Use ? to elicit ANY oral articulation.
Practice?
Select ?
Then add?
For oral stops, teach?
RE: target slection, do not ?
- /h/ first (and whispered speech help break up glottals)
- sound play
- /h/ + vowel CVs and whispered speech
- unvoiced target(s)
- fricative manner to oral place
- stop manner in that place
- work on oral stops before homorganic nasal are established
-
Moving backed articulations up/forward: eliminating pharyngeal stops:
The goal is to establish?
Facilitate ___ with ___ and ___ ?
Use ?
May need to establish?
- /k,g/
- placement, visual and tactile kinesthetic (T-K) teaching and monitoring
- front (high) vowels to get to anterior place
- fricative before stop
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Moving backed articulations up/forward: eliminating pharyngeal fricative substitutions
The goal is to establish?
Use?
Don't forget about?
RE:?
- /s,z/,"sh","ch", "dge"
- similar procedures as for pharyngeal stop
- auditory identification and discrimination to teach error vs oral contrasts
- production (post-vocalic, syllable-final may be easier)
-
Modifying compensatory co-productions:eliminating the maladaptive place
Goal:?
Use?
Use?
Incorporate?
- eliminate the aberrant glottal and/or pharyngeal place for stopping or constricting airflow
- Lateral diagram to explain co-production
- whispered speech and intrusive /h/
- sustained oral airflow procedures
-
Modifying compensatory co-productions:eliminating the maladaptive place (cont)
Use ____ to discourage ____?
Use ?
___ to facilitate s and sh
___ to facilitate s and sh
- high anterior vowels
- pharyngeal (tongue) constriction for fricatives
- successive approximation, correct fricatives, to faciliate target
- th and f
- t:
-
Differentiating mid-dorsum palatal stops:
goal is?
Use?
Teach?
If not, just work to establish?
- differentiate the mid dorsum palatal stop into alveolar /t,d/ and velar /k,g/ articulations
- lateral diagram to teach correct place and place contrasts
- auditory discrimination of target vs error-if you can
- production or desired target
-
Behavioral modification procedures:
target ?
____ for advancement to new targets or more complex levels
___ type and schedule
- behavior response frequency
- criterion levels
- reinforcement
-
Interfacing with the cleft palate/craniofacial team:
Establish and maintain frequent contact with the team caring for the child:
Send?
Obtain?
Attend?
Participate?
- speech progress reports to the team
- speech, hearing and team reports
- team visits with family
- in the coordinated care of the patient
-
Positive surgical results are obtained in kids/adults whose only residual speech problems are?
obligatory nasal emission and hypernasality due to persisting velopharyngeal insufficiency
-
Positive speech results are obtained when?
- speech intervention starts early
- speech therapist has a good grasp of speech anatomy and physiology and articulatory phonetics
- *Elimination of CMA reveals adequate VP closure
- Speech intervention is coordinated with team care
- Parents are used as therapy assistants
-
Treating ingressive airflow:
Demonstrate ___ vs ___ airflow on ____?
Practice?
Identify & start ?
Use?
Use?
- ingressive vs egressive -fricatives (stops are too quick)
- blowing and apply to speech
- airflow practice with fricatives on which the child does NOT use ingressive airflow
- visual monitoring (see scape)
- tactile teaching and monitoring (hand inb front of mouth)
-
Strategies for modifying (perception of) hypernasality?
- Increasing mouth opening
- Use light articulatory contacts
- Decrease rate of speech
- (no evidence to support it)
-
When efforts to modify (hyper)nasality are unsuccessful after 6-8 weeks of tx the tx should be ?
abandoned and alternative treatments should be considered
-
VP Port Tx
Goals:
- To change muscle strength, mass, capacity
- To change control of VP activity by improving muscle coordination, range of velar movement, consistency of closure
- To change respiratory, laryngeal, oral articulatory behaviors to reduce speech nasalization, but not necessarily improving VP function
-
Approaches to improve VP function have included ?
muscle training (whistling, blowing, CPAP) "physical tx for speech mechanism"
Information feedback (endoscopy, nasometer) "biofeddback devices"
-
Information feedback (VP Port Tx)
- See Scape
- Videonasendoscopy
- Nasometer: documents oral/nasal acoustic resonance balance, can be used in non-medical setting
- accelerometer, velograph, photodector, PERCI
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