EPG2012 Clinical Workshop 23 rd April Alan Wrench & Sara Wood

1. EPG2012 Clinical Workshop 23rd April Alan Wrench & Sara Wood

2. EPG assessment and therapy • Cleft palate • Hearing impairment • Apraxia of speech • Dysarthria • Neurological (acquired and developmental) • Functional articulation disorders • Lateralisation • Down’s syndrome • Dysfluency • Glossectomy • Malocclusion and osteotomy

3. EPG therapy • Client selection • aetiological or maintaining factors: • sensory loss • structural and functional abnormalities • cognitive ability • auditory discrimination or linguistic difficulties • medical factors • poor attention / motivation • dentition • practical issues related to wearing the palate • age of client

4. Assessment protocol • Before assessment you must check the EPG palate is functioning and clients must have acclimatised to the palate • EPG is an additional assessment procedure • standard word list • additional probe lists • high quality audio recordings • minimum of 3 recordings • prior to therapy • on completion of therapy • 3 months or more after completion of therapy • EPG patterns described according to error classification scheme

5. Creating word lists • Consider using vowels from different areas of the vowel quadrilateral including a central vowel • 3 vowels (e.g., open – closed – mid) • 5 vowels (e.g., open front –open back –closed front –closed back – mid) • sample different syllable positions. Consider syllable-initial word-initial (kitkat), syllable-final within-word (kitkat), syllable-initial within-word (kitkat), and syllable-final word-final (kitkat) • sample both singleton and consonant cluster contexts (e.g., top and stop)

6. Creating word lists • Consider coarticulatoryeffects (e.g., if examining velars, consider words that do and do not contain alveolars such as cap vs. cakevscatvscatkin) • sample both high and low frequency words • sample both monosyllabic and polysyllabic words • Consider the most suitable modality for your client’s age, literacy level, and co-occurring condition (words, pictures or both). • spontaneous and imitated productions. • pre-fix sample words with either “the”or “a”in order to provide an open mouth posture prior to the target.

7. Error patterns revealed with EPG

8. Spatial abnormalities • Differ qualitatively from idealized patterns • increased spatial variability • broader or increased tongue-palate contact • frequently affect fricatives • lateralized fricatives are a heterogenic group • skewness on sibilants • overshoot and undershoot

9. Increased spatial variability

10. Increased area of lingual palatal contacts Alveolar closure during “a tap” produced by a 9 year old girl with DS

11. Undifferentiated gestures(UG) • Impaired motor control • errors appear relatively frequently in the speech of school-aged children with functional speech disorders • at maximum constriction, contact in the midsagittal region is not confined to the anterior region of the palate for alveolar targets • contact extends back into palatal and even velar regions

12. UG “door”

13. Covert contrasts • Instrumentally measurable differences between target phonemes that are neutralized in listeners’ perceptions (Hewlett, 1988) • originally reported using acoustic analysis to measure spectral and temporal aspects of normal child speech • all studies describing covert contrasts using EPG have investigated children with speech disorders

14. Covert contrasts

15. Overshoot Anomic aphasic “a shark”

16. Temporal and serial ordering abnormalities • Abnormal durations • stutterers • functional articulation disorders • acquired neurogenic speech disorders • increased temporal variability • misdirected articulatory gestures (MAGs) • abnormal transitional timing for successive articulatory gestures • repetitions • metatheses

17. Abnormal duration of contacts

18. Misdirected Articulatory Gestures (MAG) • Gestures that are spatially normal but that occur in an inappropriate place in the target utterance • not always detected through auditory analysis • never seen in the speech of non-pathological speakers

19. Inaudible double velar/alveolar MAG produced during bilabial stop by Conduction aphasic

20. Distorted spatial patterns 10-year old boy with functional articulation disorder

21. Sequencing “clock” (control)

22. Sequencing “clock” (control)

23. Disturbed temporal overlap (apraxic)

24. Disturbed temporal overlap (Broca’s)

25. Sequencing “kitkat” (control)

26. Disturbed temporal overlap (conduction aphasic)

27. Target selection • Consider typical sequence of consonant acquisition • Consonants that most impact intelligibility • Socially important targets • Non-developmental errors (e.g., lateralization) • Variable or inconsistent errors   • Stimulable consonants are less likely to be selected • may respond to more traditional non-instrumental intervention • stimulable consonants are selected in EPG intervention if client • becomes de-motivated • success has been limited • progress has plateaued.

28. EPG therapy • Demonstration and verbal explanations • relationship between tongue patterns and resulting sound • linking visual display to client’s own tongue and hard palate • highlighting the difference between client’s patterns and those of normal speaker • Learning new motor skills • Transfer into naturalistic contexts • removing visual feedback • removing palate

29. Therapy • Frequency & Duration: important because client may outgrow palate • Portable Training Unit (PTU)

30. Session One (post assessment) • Orientate client to EPG display, allow them to play around for a while. Ensure they understand the relationship between themselves and the screen, but there is no need at this point to talk about their particular errors • Choose one, or two if you can, lingual-palatal consonants that you know are in the client’s phonetic inventory • Spend the first week copying patterns for these sounds

31. Following sessions • Basic articulation therapy with visual feedback • Start by demonstrating the pattern you would like the child to achieve, talk about its distinctive features • Try to get the child to achieve the pattern – may be achievable without phonation

32. Therapy • Use the EPG feedback window • Take turns to attempt the pattern • Ask the client to identify when you achieve the correct pattern (you can freeze the palate display by clicking on the palate- children enjoy doing this for both themselves and the therapist)

33. EPG Feedback Client Target

34. Home Practice

35. Target patterns • Where a child has atypical anatomy they may achieve an acceptable speech sound with an atypical pattern. You can save the client’s pattern and use it as a model.

36. (Silent posture) Consonant + schwa or facilitative vowel (CV or VC) Consonant + other vowels, VC and CV CVC Single words with and without visual feedback

37. Measuring clinical effectiveness • Record short target sound wordlist every week to monitor progress • Use recordings as a therapy tool by playing back recordings to children and have them rate themselves, both for the way it sounds and the way the pattern looks to increase self monitoring and awareness skills

38. Therapy: complex words • Children with dyspraxia may be able to achieve the sound but find it difficult to achieve it in complex words (words with varying place of articulation) • Make an EPG “map” of key vocabulary c a t

39. Case Studies

40. Intractable Speech Disorders • Speech sound production errors persisting beyond stage of normal childhood development • Unresponsive to conventional speech therapy

41. Clinical Headache! • Expensive for service providers in terms of time and resources • Increase waiting times • Possible detrimental effect on child’s educational and social development

42. Clinical Effectiveness • Accurate diagnosis absolute pre- requisite for clinical effectiveness • Standard clinical test procedures are subjective • intra-subject variability • inter-subject variability • ‘normalisation’ of subtle distinctions

43. Case study 1 • 10 year old with Down’s Syndrome • bilingual - Hungarian & English • referred to SLT when 7 years • initial assessment highlighted significant articulation difficulties, delayed expressive and receptive language • regular SLT to improve articulation

44. Assessment • EAT revealed: • velar fronting (k, g,  t, d, n) • palato-alveolar fronting (sh s) • cluster reduction for “tr, kr,str, kl, fl,pl” • voicing errors • vowel distortions • raw score 29, age equivalent <3 years

45. Pre-therapy

46. Pre-therapy COG values

47. Therapy • 12 sessions spanning 4 months • use of a Portable Training Unit between sessions • reassessment after 10 sessions (EPG) • reassessment after 12 sessions (EPG)

48. Mid-therapy

49. Double articulation

50. Backing