1. 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
  2. Goals of Early Intervention-Prelinguistic? (4)
    • Educate and training for parents
    • Increase frequency of vocalizations
    • Increase diversity of vocalizations
    • Increase communicative opportunities
  3. 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
  4. About ___ of all children with CP +/- CL will need speech therapy at some point in their developement?
  5. 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
  6. 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)
  7. 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
  8. 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
  9. 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
  10. Speech Intervention?
    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
  11. With prelinguistic child?
    ____ routine?
    • 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
  12. Prelinguistic child:
    Use ___ games?
    Teach parent?
    Prior to ____, advise parents to encourage ___?
    • 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
  13. 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
  14. Intervention in preschool years (3-5 years)
    Teach? use?
    Use ____ techniques to teach ____?
    Include ?
    • 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
  15. Intervention in preschool years (3-5 years)
    Teach difference between ?
    Changing the label in ?
    • oral vs nasal airflow
    • PSNE
    • sufficient practice of new productions so they become stabilized
  16. Speech treatment options-school aged child:
    Physical management? (3)
    • surgery
    • prosthetics
    • orthodontics
  17. Speech treatment options-school aged child:
    Behavioral management?
    • Speech therapy
    • VP port therapy
  18. Therapy for cleft palate speech in school-aged youngsters:
    Speech therapy in the form of?
    • Articulation Tx
    • Phonological Tx
    • Modifies the sound system
  19. Therapy for cleft palate speech in school-aged youngsters:

    VP port Tx which aims to modify ?
    VP closure behavior
  20. 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
  21. Treatable errors include?
    • Maladaptive CMAs
    • Backed oral productions
    • learned NE patterns
  22. Therapy approach:
    remember CP speech errors are ___, not ___?
    The key problem is?
    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
  23. 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
  24. 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
  25. Phonetic Placement:?
    • Tactile placement cues
    • Schematic illustrations for placing learning
  26. 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.
  27. Oral airflow teaching activity?
    Oral vs nasal contrasts
  28. Using materials for Oral airflow
    materials for blowing activities: bubbles using wand or pipe; whistles; blowing against easily moved objects
  29. 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
  30. Oral airflow feedback monitors?
    • See Scape
    • Listening tube
    • Paper deflector
  31. General Tx (outcome) goals for cleft palate speech?
    • maladaptive compensatory misarticulations (may improve VP function) and learned nasal emission
    • the maladaptive articulations with correct oral productions
    • backing patterns
  32. Tx Components (as necessary)
    • "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
  33. Teach 'phonetic placement language and concepts'
    • names for speech structures
    • locations and directions
  34. Target sound selection where to start tx?
    • Stimulability
    • Visibility
    • Place of production
    • voicing
    • manner
    • developmental schedule
  35. Tx:
    unvoiced before voiced, especially with glottals
  36. Tx:
    for oral pressure consonants, fricatives before stops, especially if child produces both pharyngeal fricatives and glottals.
  37. Tx:
    developmental schedule?
    within a place category or manner class, consider normal acquistion sequence (p< t< k)
  38. 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
  39. Teach correct oral target versus error sound contrasts:
    Use ___ diagram
    ___ versus ___
    ____ teaching of?
    • 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
  40. Teach place contrasts:
    Pair with?
    • diagrammatic, visual representation for aberrant vs target place contrasts
    • auditory discrimination tasks
  41. 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
  42. Operational framework for conducting tx for CMAs:
    • concepts that underlie place learning
    • adequate speech discrimination skills
    • oral target place and eliminate non-oral error place
  43. Eliminating glottal stop substitutions:
    If /h/ is not in the inventory, teach ?
    Use ? to elicit ANY oral articulation.
    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
  44. 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
  45. Moving backed articulations up/forward: eliminating pharyngeal fricative substitutions

    The goal is to establish?
    Don't forget about?
    • /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)
  46. Modifying compensatory co-productions:eliminating the maladaptive place
    • 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
  47. 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:
  48. Differentiating mid-dorsum palatal stops:
    goal is?
    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
  49. Behavioral modification procedures:
    target ?
    ____ for advancement to new targets or more complex levels
    ___ type and schedule
    • behavior response frequency
    • criterion levels
    • reinforcement
  50. Interfacing with the cleft palate/craniofacial team:
    Establish and maintain frequent contact with the team caring for the child:
    • speech progress reports to the team
    • speech, hearing and team reports
    • team visits with family
    • in the coordinated care of the patient
  51. Positive surgical results are obtained in kids/adults whose only residual speech problems are?
    obligatory nasal emission and hypernasality due to persisting velopharyngeal insufficiency
  52. 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
  53. Treating ingressive airflow:
    Demonstrate ___ vs ___ airflow on ____?
    Identify & start ?
    • 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)
  54. Strategies for modifying (perception of) hypernasality?
    • Increasing mouth opening
    • Use light articulatory contacts
    • Decrease rate of speech
    • (no evidence to support it)
  55. 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
  56. VP Port Tx
    • 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
  57. Approaches to improve VP function have included ?
    muscle training (whistling, blowing, CPAP) "physical tx for speech mechanism"

    Information feedback (endoscopy, nasometer) "biofeddback devices"
  58. 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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