TREATMENT METHODOLOGY FOR ARTICULATION AND PHONOLOGY

1. TREATMENT METHODOLOGY FOR ARTICULATION AND PHONOLOGY Willis/Pancamo

2. Intervention • What should be the therapy targets? • What treatment approach should I use?

3. Training Approaches • Vertical/Deep – intense practice on a limited # of targets. Tx moves through a hierarchy of difficulty. Tends to be most appropriate for kids with relatively few errors. • Horizontal – attacks goals broadly; assumes that simultaneous exposure to a wide range of targets will facilitate production of phonemes or sd. patterns. Tends to be most appropriate for client with multiple errors • Cyclical - client practices given target for predetermined amount of time, then moves on to another target. Focus on the original target resumes later on in the tx program

4. Articulation Model vs. Phonological Model • Articulation Model emphasizes the motor component of speech. Focuses on the incorrect production of individual phonemes. • Phonological Model emphasizes the linguistic component of speech. Focuses on rule-governed errors that affect multiple speech sounds and follow a predictable pattern.

5. Intervention Approaches for Phonological Disorders • Phonological Process Targets • Used for children with phonological disorders who exhibit multiple phonemic errors with poor intelligibility • Cycles approach • Very structured • Begins with the sound the child is most stimulable for • Utilizes auditory bombardment • Metaphon Approach • Incorporates the child as an active cognitive participant • So, the child must be aware of his incorrect productions, want to modify it, and have the neuromotor capability of accurately producing the target sound

6. Intervention Approaches for Phonological Disorders • When using a phonological processes approach, teach the underlying concept in a non-speech task before introducing it in a speech task • Phonological Processes that a child uses only occasionally may be more easily modified • If using distinctive feature approach, early targets should only differ by one feature to increase success • Distinctive feature approach predicts generalization based on phonemes with common features. So, probe ahead to see if spontaneous acquisition has occurred • Parent training/education

7. Intervention Approaches for Articulation Disorders • Single-Phoneme Targets • Perceptual/Ear Training • Identification of the target sound • Location of the target sound • Stimulation • Discrimination • Production Training • Stabilization • Carry Over/Generalization

8. Intervention Approaches for Articulation Disorders • Stimulability Training • Used to increase the number of sounds in a child with a very limited phonemic repertoire • (e.g. Developmental Apraxia)

9. Selecting Goals • Developmental Approach – tx targets are identified based on the order of acquisition in normally developing children • Nondevelopmental approach – tx targets are chosen specifically for each client • Targets that are most relevant to child or family • Targets that are most stimulable • Targets that are most visible when produced • Targets that will result in greatest gain in improving overall speech intelligibility

10. Influences on Intelligibility • Articulatory • Omissions →Substitutions → Distortions • WI → WM → WF • Errors that occur on the most frequent sounds in a language • Phonological • WIConsonant Deletion • Glottal replacement of WM consonants

11. Influences on Intelligibility

12. Tx for a Functional Disorder • Helpful Hints: • Do not include more than one error sound in a stimulus word, phrase or sentence in the initial stages of therapy • Pay attention to phonetic context of words that contain the target phoneme. • Tx sessions that elicit the greatest # of sound productions will be most effective in establishing correct production as an automatic behavior • Evaluate oral motor function • Use books that contain target sounds as immersion activities (www.speechville.com, worksheet on Moodle) • Instruct parents to respond consistently to the content of the child’s utterance before pointing out speech errors or modeling correct productions

13. Tx for Organic Disorder • The selection of initial therapy targets for organic disorders is based on developmental approach b/c the accompanying articulation deficits are the direct result of structural/neurologic anomalies and are not developmental in nature

14. Therapy Guidelines • Hierarchy • Isolation with model • Isolation without model • Syllable level with model **** • Syllable level without model**** • Word level with model • Word level without model • What position in words? • Carrier phrase with model • Carrier phrase without model • Phrase with model • Phrase without model • What position is the target word within the phrase? • Sentence level with model • Sentence level without model • Structured Activity • Spontaneous (Connected) Speech

15. Session Design • Basic Training Protocol • 1. Clinician presents stimulus • 2. Clinician waits for client to respond • 3. Clinician presents appropriate consequence or event. • 4. Clinician records response • 5. Clinician removes stimulus

16. Session Design • Task Order • easy -hard-easy • Work Efficiency/Pace • Each session should provide the client with the maximum # of opportunities to practice target behaviors • The pace of each session must be geared to the learning styles and rate of each client

17. Session Design • Materials • Should be client specific based on age, developmental level, language level and gender. Should be interesting to that client • Avoid time-consuming or complicated activities that result in decreased # of client responses/session. • Proxemics • Should be socially/culturally acceptable • Sitting very close to a child can aid in reducing impulsive or distractible bx • Can change depending on the specific activity you are doing

18. Key Teaching Strategies • Direct modeling- clinician demonstrates a specific bx to provide an example for the client to imitate. • Used in early stages of tx (establishment) or when tx bx shifts to higher level of difficulty • Indirect modeling- clinician demonstrates a specific bx frequently to expose the client to numerous well-formed examples of the tx bx. • Shaping by successive approximation – tx bx is broken down into small components and taught in an ascending sequence of difficulty. • Prompts – clinician provided additional verbal or nonverbal cues to facilitate a client’s production of a correct response • Attentional, using exaggerated loudness or duration, hand cues , verbal cues , written cues

19. Key Teaching Strategies • Fading - stimulus or consequence manipulations are reduced in gradual steps while maintaining the target response. • Client produces multiple imitations for each clinician model • Progressive reduction of the length of the bx modeled by the clinician • Expansion- clinician reformulates a client’s utterance into a more mature or complete version • Negative practice- client is required to intentionally produce a txbx in error • Best used on a short-term basis, only after the client demonstrates the ability to produce a given target consistently at the level of imitation • Target –specific feedback –clinician provides specific information regarding the accuracy or inaccuracy of a client’s response relative to the specific target bx

20. HOMEWORK • Useful after the establishment and stabilization of txbx has occurred • Promotes generalization • Purpose of HW is to provide practice of an existing skill rather than teaching a new one • Should be given only after client has demonstrated a basic ability to accurately evaluate his or her own performance • Assigned in amounts that are perceived as manageable by the client/fmly • Should be assigned on a regular basis • Should be given with simple written instructions

21. Oral Motor Considerations • Speech is not an isolated act but the product of a highly complex and synchronized oral motor system. • Oral Motor function affects neuromuscular control and organization needed for the production of intelligible speech. • OM deficits include: hypersensitivity, hyposensitivity, weakness, and incoordination of oral structures

22. Oral Motor Therapy“To do or not to do” • Proponents: • Speech is founded on earlier developing non-speech motor patterns. • Reduced muscle tone in the oral-facial area results in limited strength of the articulators used for speech. • Normal movement and sensation significantly influence motor learning. (Piaget) • Speech is highly complex and is more easily learned when it is broken into smaller components (when you have to teach it that way)

23. Oral Motor Tx“To do or not to do” • Nay Sayers • Little evidence-based research to demonstrate causal relationship rather than correlational relationship. • (See handout on Moodle for additional info)

24. Oral Motor Tx • Potential Candidates • Weak production of bilabials, droolers • Poor production of sounds requiring tongue elevation • Poor differential production of midrange vowels • Hypernasality • Forward resting posture of the tongue

25. Basic Goals of an OM Program • Heighten consciousness of the oral mechanism • Normalize sensitivity to stimulation in the oral area • Inhibit primitive or abnormal oral reflexes in order to enhance normal movement patterns • Increase differentiation and stabilization of the oral structures • Refine articulation movements by increasing the strength and ROM of the oral mechanism

26. Hierarchy of OM Treatment • Address Postural & Positioning Issues • Normalize oral sensitivity • Increase Jaw Control • Increase Muscle Tone in Lips • Increase Muscle Tone in Tongue

27. Oral Motor Treatment • General Guidelines • Apply stimulation systematically and follow the same sequence of steps each time • Work from outside-in • Use firm, slow touch vs. light, quick strokes • Use visual feedback (mirror) to facilitate child’s ability to categorize new perceptions and improve tolerance of stimulation • Explain procedures before and during implementation