specific treatment programs and approaches

1. SPECIFIC TREATMENT PROGRAMS AND APPROACHES

3. II. TRADITIONAL APPROACH A. Background

4. B. Part One: Ear Training (pp. 399-400) Phase 1: identification Phase 2: isolation Phase 3: stimulation Phase 4: discrimination

5. (p. 400) There are two forms of discrimination In error detection, the child has to tell when the SLP produces the sound in error In error correction, the child must explain why the sound was in error and how it can be corrected

6. C. Part 2: Production Training�Sound Establishment D. Part 3: Production Training�Sound Stabilization (begin at the most complex level possible) Stage 1: Isolation Stage 2: Nonsense syllables (not functional) Stage 3: Words Stage 4: phrases (2-4 word phrases) Stage 5: sentences Stage 6: conversation

7. To help establish the production of sentences: (p. 404) 1. Slow-motion speech- 2. Shadowing-

8. E. Part 4: Transfer/Carryover (don�t worry about definitions�use them interchangeably) Vary settings, interlocutors/audience, stimuli Speech assignments Follow-up (maintenance) sessions

9. 2010 CSHA Dr. Steve Skelton

11. ACTIVITIES AND IDEAS FOR ELICITING AT LEAST 150 PRODUCTIONS PER GROUP SESSION

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16. OTHER IDEAS FOR CENTERS

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19. III. MULTIPLE PHONEME APPROACH (test 4: just lecture notes and summary on pp. 416-417) A. Introduction (McCabe & Bradley) For children with 6+ errors Highly structured Use multimodal cues to teach multiple phonemes simultaneously

20. B. Phase 1: Establishment Step 1: Establishment of sound production Step 2: Holding procedure (all sounds in isolation in each tx session)

21. C. Phase 2: Transfer Syllables?Words ?Phrases and sentences?reading/story/conversation D. Phase 3: Maintenance 90% accuracy across speaking situations with no external modeling

22. IV. MCDONALD�S SENSORIMOTOR APPROACH A. Introduction�Assumptions: 1. 2. 3.

23. B. Part 1: Heighten Child�s Responsiveness Practice syllables with nonerror sounds Begin with CVCV syllables Then go to trisyllables Vary vocal emphasis on syllables

24. C. Part 2: Reinforce Correct Articulation of Error Sound Use facilitative contexts: e.g. watch-sun

25. McDonald�s (Part 2 continued) 1. Slo-mo 2. Equal stress on both syllables 3. Primary stress on first syllable 4. Primary stress on second syllable 5. Child prolongs target until clinician signals to go on (e.g., watchsssssssssun) 6. Practice in short sentences

26. D. Part 3: Facilitate Correct Articulation of the Target Sound in Various Contexts

27. Beach-seal

28. V. Shine & Proust�s Sensorimotor Approach Based on McDonald, but more structured Emphasizes orientation to the speech helpers (articulators)

29. V. DISTINCTIVE FEATURE APPROACH (lecture only!) Based on distinctive feature analysis Teach a relevant sound that is missing the feature, hope for generalization E.g., for feature of stridency, teach /f/ and hope it will generalize to /s, z, sh/

30. VI. PAIRED-STIMULI APPROACH A. Introduction Developed by Irwin & Weston, 1971 Good for children with a few sound errors Capitalizes on a key word

31. B. Step 1: Word Level Select a target sound for tx Identify 4 key words: 2 with target in word-initial position and 2 with target in word-final position

32. C. Step 2: Sentence Level Use Key Word #1 with 10 training words, only evoke the target in a sentence FR3 schedule of reinforcement (3 responses for 1 token) Do 2nd, 3rd, 4th key words and then do some alternations

33. D. Step 3: Conversational Level Clinician and child converse Clinician stops the conversation immediately if the child produces a sound incorrectly

34. VII. CONTRAST THERAPY APPROACH/PHONOLOGICAL CONTRAST APPROACHES (pp. 432 on) Minimal contrast training� use minimal pairs which only differ by one feature (tea-key) Maximal pair training� sounds differ by at least 2 features (cane-lane; ten-men)

35. (pp. 436-437) Multiple oppositions/multiple contrasts approach Not on exam

36. Begin with perceptual training Then, go to production training where the child has to produce minimal pairs Good for use with adults also

37. VIII. HODSON�S CYCLES APPROACH (on exam!)** A. Introduction General Procedures 1. Stimulation (multimodal cues) 2. Production training 3. Semantic awareness contrasts

39. B. Selection of Target Patterns and Phonemes Top Priority: 1. Early-developing phonological patterns: Initial and final consonant deletion of stops, nasals, and glides CVC and VCV word structures Posterior-anterior contrasts (k-g, t-d, h) /s/ clusters--word initial clusters /sp, st, sm, sn, sk/ and word-final clusters /ts, ps, ks/ Liquids /r/ and /l/ and clusters containing these liquids

40. 2. Secondary Patterns A. Voicing contrasts, vowel contrasts B. Singleton stridents C. Other consonant clusters D. Other (metathesis, reduplication, multisyllabic words, complex consonant sequences)

41. C. Structure of Remediation Cycles 1. Train each phoneme exemplar within a target pattern for 60 min per cycle before going to the next phoneme 2. Train 2 or more target phonemes in successive weeks within a pattern before changing to the next target pattern (2+ hours on each pattern within a cycle)

42. 3. Target only one phonological pattern per session 4. When all target patterns have been taught, a cycle is complete 5. Initiate the second cycle. Review patterns not yet corrected, introduce new ones as necessary **to become intelligible, most children need 3- 6 cycles of therapy

43. D. Structure of Therapy Sessions 1. 2. 3. 4. 5. 6.

44. E. Home Program Caretakers are asked to read the 12-item word list once a day. Child is asked to name the 3-5 pictures once a day (may also produce other target words)

45. IX. Oral-Motor Exercises PBH do not believe that oral motor exercises are beneficial for anybody They say research has not proven that oral motor exercises help Roseberry�s position: these exercises are very helpful for children with oral motor problems

46. X. Language Treatment for Phonological Disorders PBH: research is inconclusive re: the question: Can language therapy improve children�s artic/phono skills? Bottom line: If the child has a language and phonological disorder, best to do both language and artic/phonology therapy simultaneously. In other words, don�t just do language therapy and hope that somehow artic/phonological skills will magically improve too ?

47. XI. Combining Therapy for Language and Articulatory-Phonological Disorders We can connect phonology to children�s morphosyntactic skills If children have final consonant deletion or cluster reduction, they will have problems with some morphemes

48. These morphemes include: Past tense �ed Plural �s Regular 3rd person �s Possessive �s

49. Therapy suggestions: If the child has final consonant deletion, use minimal pairs which include grammatical morphemes

50. For example (FCD): Plurals: toe-toes key-keys Possessives: Joe-Joe�s Ray-Ray�s Regular past tense �ed show- showed

51. If the child uses cluster reduction: Plurals boat-boats cup-cups Possessives cat-cat�s Dad-Dad�s Regular past walk-walked Irregular past drink-drank hold-held

52. We can also connect phonology to semantics: Children with language impairments often have difficulty with verbs For velar fronting: tame-came; taught-caught Stopping of fricatives: tee-see, toe-sew, tip-ship Final consonant deletion: shoe-shoot, ray-rake; say-sail

53. XII. Developing a Lexicon for Young Highly Unintelligible Children with Accompanying Language Disorders Use early-developing consonants with words that are key in children�s environments For example, we can teach: No, puppy, baby, bye-bye, yes, happy, mama, dada, baba (bottle), more (?), mine, please (peez), kay (okay), potty, pee, kitty, why, go, wawa, eat

54. If the child only says a few words:

55. DeThorne et al. 5/09 American Journal of Speech-Language Pathology Looked at alternatives to imitation for facilitating early speech development Premise: when little kids won�t talk, trying to have them imitate us often does not work Focused on kids who don�t have any underlying problems like CAS or dysarthria

56. Ideas for therapy:

57.

58. Another idea was: Imitate child Research has found that the extent to which mothers imitated their 13-month old children predicted the timing of the children�s later language milestones

59. For example, if the child said �ba!� the mother said �Ball!� This predicted the timing of things like the child�s development of her first 50 words and using two-word combinations We can even imitate non-speech movements (e.g., smiling, yawning)

60. Another therapy idea from DeThorne et al. 2009:

61. We can also� Use headphones for slight amplification Use an echo microphone or other device Use mirrors, puppets

62. XIII. TEACHING /K/ AND /G/ The dorsum of the tongue must raise to contact the soft palate and form a seal which completely blocks the air stream The back of the tongue must suddenly pull away from the velum to create a burst of air

63. Strategies for eliciting these phonemes:

64. Tell the child to hold his tongue against his lower teeth and hold his hand in front of his mouth to feel the burst of air as he imitates you�tell him to raise the back of his tongue Use a mirror, and have the client imitate you Use a tongue depressor to push the tongue upward and backward in the oral cavity

67. XIV. TEACHING /S/ AND /Z/ I like to refer to these sounds with animal analogies /s/ is the snake sound, and /z/ is the bee sound

68. Types of Lisps Type 1: the frontal lisp

69. Type 2: The interdental lisp

70. Type 3: the lateral lisp

71. However, we can� Have the child strongly aspirate a /t/ Use a bite block to stabilize production A bite block helps the jaw to not move around Have the child say /t t t t t t ssssss/ Eventually you can get away from the bite block

72. .

73. Try this yourself� And notice that when you make a really strong /t/, your tongue tip drops into perfect position for a predorsal /s/ ? Tell the child that when her tongue drops down, hold it there and produce an /s/

74. Other techniques for /s/ include:

75. To develop a central airstream:

76. Other techniques: Tell the child to make a smile and hide his tongue behind the white gate (teeth) while resting his tongue along his upper back teeth Tell him to blow out a straight, fine stream of air Place your finger in the center of his lips/teeth for an additional cue

77. Also�

78. XV. TECHNIQUES FOR /l/ One of the most common errors in children is y/l (�I yike that yamp.�) I like to tell kids about the �magic spot� (the alveolar ridge) It is very important for kids to have perfect awareness of the alveolar ridge and know exactly where their tongue is to be placed

80. One of my very favorite techniques�

81. Be sure�

82. Other tx ideas for /l/:

83. Use the ribbon technique Place a �� ribbon across the front of the client�s tongue so that the ends hang down to her chin. Then, tell her to put her tongue tip on her alveolar ridge. Have here say /l/ while you gently pull down on the sides of the ribbon, which allows lateral airflow.

84. I do like�

85. XVI. TECHNIQUES FOR /th/ One of the very most common errors is f/th Mark did this until he had artic therapy in first grade His SLP called /th/ a �lip cooler� (could also be called tongue cooler or angry goose sound)

86. To teach /th/ production: Use a mirror Mr. Mouth is very helpful for children Tell the client to open his teeth slightly The tongue tip must protrude between the upper and lower central incisors

87. I have found that� Many adult accent clients are not comfortable with their tongue protruding They feel like the whole world is staring at them I do a lot of desensitization and do the exercises in the mirror along with them The mirror is super helpful, because they can see that they do not look like idiots

88. If the client sticks her tongue out too far� Hold a tongue depressor about �� in front of her teeth If she can feel the tongue depressor when she produces /th/, her tongue is coming out too far

89. /th/ can be shaped from several phonemes:

90. To direct airflow through the oral cavity:

91. XVII. I HATE /r/!

92. A. INTRODUCTION�ORAL MOTOR EXERCISES Remediating /r/ is one of the most frustrating jobs that SLPs have It is a very complex sound that requires precision and muscle strength The use of oral motor techniques for helping clients with /r/ problems is hotly debated Some say that there is no research to support the efficacy of oral motor exercises�this is true

93. However� Clinically, I and many of my friends in the profession have found them to be extremely beneficial I have a hypothesis that because so many children were bottle fed and/or used pacifiers, tongue strength did not develop adequately Remember, for a baby, nursing requires far more work than drinking from a bottle!

94. There are many oral motor exercises�

95. Other fun oral motor exercises�

97. One SLP I know�

98. Have the client practice:

99. B. /r/ WITH SMALL CHILDREN Hodson believes that we can begin working on /r/ when children are as young as 3 or 4 With these little ones, we don�t drill to precision�but we �get it on their radar�

100. How do we do this with young kids? I like to get them a stuffed tiger and talk about the growling tiger sound I ask the family to put the tiger in a prominent spot and talk about the /r/ regularly

101. For example, when they are reading books with their children�

102. C. SPECIFIC TECHNIQUES

103. It is best to start each session�

105. We need to be sure� That children are sitting up straight with their feet on the floor Their bodies need to be stable

106. It is very important�

108. I like shaping /r/ from /i/--�eeeeeeeerrrr� It is helpful to have clients smile, because then they cannot make a /w/

109. A great technique is from PROMPT�the SLP puts her fist under the client�s chin and pushes upward�this elevates the tongue We can use a tongue depressor to push the client�s tongue back in her mouth

110. The biggest thing with /r/� Is PRACTICE /r/ is hard because strong lingual muscles are needed If the client does not practice, there will not be progress

111. Remember that the foundation of all articulation therapy is: PRACTICE Retraining muscles Repetitions!!