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Disorders of Articulation and Phronology

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					Disorders of Articulation & Phonology
November 8, 2007
Primary Source for Lecture: Articulation and Phonological Disorders. 5th Edition. J. E. Bernthal and N. W. Bankson. Pearson. 2004.

What is articulation?
• Articulation is part of speech production • Articulation is the process by which sounds, syllables, and words are formed when your tongue, jaw, teeth, lips, and palate alter the air stream coming from the vocal folds • Phonation is the periodic opening and closing of the glottis/vocal cords that, accompanied by breath under lung pressure, constitutes a source of vocal sound (voicing)

Intelligibility
• How well a child’s speech is understood by others • Intelligibility is usually better for familiar listeners • Intelligibility increases as a child gets older • A child should be 100% intelligible to all listeners by 4 years of age

Intelligibility
• Intelligibility is better if syntax is simplified and words have fewer consonant clusters • Intelligibility is better when the context is known • Speakers who are seen as well as heard are more intelligible than when heard only

What is an articulation problem?
• A person has an articulation problem when he or she produces sounds, syllables, or words incorrectly (sound errors) • Most sound errors fall into one of three categories: • Omissions (/It/ for /hIt) • Substitutions (use of /w/ for /r/) • Additions (epenthesis as in /sʌnou/ for “snow”) • Distortions (when the sound is said inaccurately due to too little or too great force, too much or too little nasality, imprecise vowel or consonant articulation, or improper vowel duration of vowels or consonants)

Causes of articulation problems
• Physical handicaps or malformations (cerebral palsy, cleft palate, hearing loss) • Abnormal dentition or malocclusion (overbite/underbite, missing teeth) • Most articulation problems occur in the absence of any obvious physical abnormality or disability • The cause of these functional articulation problems may be faulty learning of speech sounds

Tongue Abnormalities
• Ankyloglossia – tongue-tied, short lingual frenum • Macroglossia – enlarged tongue • Microglossia – small tongue

Cleft lip & palate
• Cleft lip repaired early on with surgery • Cleft palate – multiple surgeries to correct • Development of speech is compromised until palate is completed corrected, which may take several years • Issues are often related to production of high pressure sounds: fricatives, affricates, and nasals • These children will develop their own sounds (sound distortions) until they can physically produce the sounds correctly, however, by then they require therapy to correct existing sound errors

Velopharyngeal Competence
• Separation of the nasal cavity from the oral cavity during speech production • Inadequate velopharyngeal competence
• Hypernasality • Reduced intraoral breath pressure • Nasal air emission during pressure consonants

Denasality
• When air is blocked from the nasal passage during production of nasal consonants • May be due to enlarged tonsils or adnoids

Average Age of Masterey
• • • • 2-3 years = p, b, m, w, h and all vowels 3-4 years = d, t, n, g, k, f, y 4-5 years = r, l, s, ch, sh, z 5-6 years = j, v, th, zh

• By age 3, a child’s speech should be at least 80% intelligible and by age 4, it should be 100% intelligible, even though there may still be a few error sounds.

Classification of Consonants
The classification of consonants are based on three aspects of articulation: 1. place of articulation 2. manner of articulation 3. voicing (using phonation or not using phonation)

Placement of Articulation
• • • • • • • Bilabial – both lips Labiodental – lip and teeth Interdental – between teeth Alveolar – tongue and alveolar ridge Alveopalatal – tongue and hard palate Velar – tongue and soft palate Glottal – glottis

Manner of Articulation
• • • • • • Stop or Plosive /p b t d k g/ Fricative /f v ð θ s z ʃ ʒ h/ Affricate /ʧ ʤ/ Nasal /m n / Liquid /r l/ Glide /w j/

Consonants Classification
Place, Manner & Voicing

Glides

w

j

Vowel Classification
The classification of vowels is based on four major aspects: 1. tongue height (high vs. low) 2. tongue backness (front vs. back) 3. lip rounding (rounded vs. unrounded) 4. tenseness of the articulators (tense vs. lax)

Tongue Height
• How much space is there between the tongue and the roof of the mouth • There are 3 primary height distinctions: high, mid, & low

/i/

/E/

/u/

Tongue Backness
• How far is the raised body of the tongue is from the back of the mouth • There are 3 primary height distinctions: front, back, and central.
central /i/
/u/ back 

Lip Rounding
• Some vowels are formed with a high degree of lip rounding. • Such vowels are called rounded vowels. Some vowels, such as /i/ and /e/ are formed without such rounding and are called unrounded vowels.

Tense vs. Lax
• Some vowels, such as the vowels /i/ are formed with a high degree of tenseness. • Such vowels are called tense vowels. • Some vowels, such as /I/ and /e/ are formed without a high degree of tenseness, and are called lax vowels.

Vowel Classification

Additional classification of /r/
• /r/ is sometimes a vowel and sometimes a consonant • It effects the production of sounds that precede or follow it • As a result, there are many “types” of /r/
•/ar/ as in car •/ir/ as in ear •/er/ as in her •/eir/ as in air •/or/ as in door •/Er/ as in flower

•/air/ as in fire
•Prevocalic /r/ as in red •/rl/ as in world

Goldman-Fristoe Test of Articulation
• Measures articulation of consonant sounds Ages: 2 through 21 years Administration Time: 5-15 minutes • Sounds in words • Sounds in sentences

Assessment of /r/
• The Entire World of R Screening Kit • Evaluate all 21 variations of the /r/ phoneme

• Made by
• www.sayitright.org

Intervention for Articulation
• Consistently focus only on target until corrected • Use appropriate elicitation strategies based on target selection • Use phonetically consistent probe lists

Intervention for Articulation
"The hallmark of traditional therapy lies in its sequence of activities for: (1) identifying the standard sound (2) discriminating it from its error through scanning and comparing (3) varying and correcting the various productions until it is produced correctly (4) strengthening and stabilizing it in all contexts and speaking situations."
Van Riper, 1978 p. 179

Practice Target Sounds in Hierarchical Patten
1. 2. 3. 4. 5. 6. 7. Isolation Single Words Phrases Sentences Structured Conversation Spontaneous Conversation Maintenance

Therapy Strategies
• • • • • • • • Modeling Cueing Feedback Self-perception Self-evaluation Discrimination Generalization Habitualization

Therapy Strategies
• Articulation therapy appears optimal if it occurs 3x week for 20 minutes per session • Good practice daily improves progress • Children benefit from individual and/or group intervention as long as they have ample time to practice targeted sounds

Therapy

Apraxia Childhood Apraxia of Speech (CAS)

Apraxia- Diagnostic indicators
• Strand (2003) argues that there are five key potential diagnostic characteristics of apraxia in young children. The five characteristics identified by Strand are: • Difficulty in achieving and maintaining articulatory configurations • Presence of vowel distortions • Limited consonant and vowel repertoire • Use of simple syllable shapes • Difficulty completing a movement gesture for a phoneme easily produced in a simple context but not in a longer one (Strand, 2003, p. 77)

Apraxia in very young children
• Restrictions and gaps in sound repertoire (both consonant and vowel), including the possibility that the child may have acquired some later developing sounds while be missing earlier developing sounds. • Child may demonstrate very limited use of syllables, possible use of an extended single sound or few vocalizations at all. The children may have difficulty combining the sounds that they do have. • Limited variation of vowels and the use of a centralized vowel in a multipurpose way. • Vocalizations may have speech-like melody but syllables or discernable words may not be present. • Words may seem to disappear from use more than would be expected for a typically developing child of the same age. • Predictable utterances may be easier than novel utterances (Davis and Velleman, 2000, p.182)

Additional nonspeech characteristics
• Idiosyncratic gestures or signs • Feeding difficulties such as difficulty eating mixed textures • Drooling • Late development of motor skills overall • Oral motor incoordination (Davis and Velleman, 2000)

Therapy with young children who have apraxia
Two primary goals: 1 - establish a consistent form of communication 2 - develop and consistently use oral communication • Respond to any appropriate mode of communication • Responding to gestures and other attempts at communication • Unless there is agreement on which gesture, sound or picture will represent which meaning, communication will not be successful. So, for example, a child can use gestures or sign that are not correct if they use the same gesture for the same meaning consistently.

Setting Expectations: Parents as Collaborators
• Clinicians need to involve parents in therapy opportunities for children with apraxia; to the greatest extent they are able and willing. • Parents are able to share important information from the home and community environments. • Parents are important informants on the likes, dislikes, and personality characteristics of their children. • Additionally, parents are valuable speech practice partners for their children in their everyday life experiences together. (Stoeckel, 2001)

SLP Responsibilities to Parents
• Educate parents re: CAS and intervention • Educate parents re: networking/support availability • Teach child needed skills in a flexible, productive manner • Assure high expectations from the child • Be able to explain goals and changes in therapy strategies • Assure periodic observations either on-line or via videotape • Work with parents to motivate and reinforce child’s learning (Hammer and Stoeckel, 2001)

Setting Expectations: Children as Risk-takers
• • • • A young child with suspected apraxia of speech arrives in speech therapy having already experienced failure in efforts to communicate orally. Families may also feel like failures in helping their child to communicate. Clinicians should set early boundaries and expectations around communication exchanges as well as teach these skills to parents if necessary. Risk taking requires trusting that the situation or person to whom we are communicating is safe and predictable. It also generally requires that the effort be worth the risk. If these conditions are met most children will attempt to use what speech or communication they have to interact. The major issue, however, is how to create this environment? One proposition is the creation of boundaries. Boundaries, in this context, refer to the physical, mental, and emotional conditions that surround the child and are based upon realistic expectations for performance. Children with apraxia of speech need to feel as if they can trust in the therapeutic process and have success. Reasonable expectations, based on the capability of the child’s speech motor system, need to be implemented and reinforced so that the child also uses what they can produce orally in communication exchanges. (Hayden, 2002)

•
•

•

• Oral Communication Goals • Depending on the child, Velleman and Davis state that increasing vocalizations of any kind may be the place to start.Some suggestions they have that reduce communication pressure on the child are: • Speech in conjunction with movement ("whee" while sliding down a slide, as example) • Sound effects • Verbal routines with songs, predictable books, rhymes, etc. • Speech in unison with another person • Props such as puppets, little people, stuffed animals, etc. • (Davis and Velleman, 2000)

Where to start with very young children
• Words with distinctive pitch patterns (e.g.: uh-oh, wow, whee, yay) • Words with strong emotional meaning • Words that can be paired with actions (e.g.: whee, hi, oops, • Words with very early consonants (e.g.: [h], glides) and simple syllable shapes (e.g.: hi, uh-oh, wow, whee, yay) • Sound effects: animal noises, vehicle sounds, etc. (Velleman, 2002, page 66) • Also, sounds that may be in the childs current repertoire can be used to expand oral communication: words beginning with a sound in the repertoire that also have functional meanings such as "more" "mine" if the child can make an /m/ are examples.

Expanding Sounds and Syllables
• Velleman and Davis (2000) discuss adding two goals when a child has begun to consistently use vocalization to communicate: • Expansion of sounds • Expansion of syllable structures • The use of the sounds and structures is more important than accuracy.

Suggestions for expansion of sounds:
• Expand to include more diverse consonant and vowel sounds produced in different parts of the mouth • Sounds with varied pitch and loudness levels • Short and long utterances

Suggestions for expanding structures:
• Syllables rather than individual phonemes should be the focus • Be systematic with teaching sounds and syllables in word structures. (as an example; Davis and Velleman recommend, "New word shapes, e.g., CVC "bag" when a child produces mostly CV words such as 'moo', the clinician should include ONLY sounds that the child can already produce, in some word position" (Davis and Velleman, 2000, p. 185) • This strategy is described as the, "Old forms, new function - old functions, new forms" rule. • Goals should target EITHER new structure or a new sound, not both at the same time.

Speech Movement Goals and Training
• • • • • • • • Addressing the underlying nature of the problem of apraxia in children which is speech in motion or the ability to plan accurate, well timed speech movements sound to sound, syllable to syllable, in order to produce old and new words. Clinicians need to keep in mind therapy opportunities that allow young children to build flexibility and reliability into their motor systems. Activities that use the same syllable but with a change at the end first work on the same syllable repeated, (e.g.: ma ma ma ma). Next, introduce one change at the end of the repeated syllables, e.g.: ma ma ma moo or moo moo moo do. Alternating the syllables takes the activity one step further, i.e.: ma, moo, ma, moo or moo, do, moo, do, moo. As competence is built with these activities the most complex practice with syllables moves further so that the child produces varied syllables/sounds: ma, moo, may, my, mow. (Davis and Velleman, 2000) Further, in young children the approach will need to be fun, silly, engaging in order to elicit the child’s attention, involvement and effort.

Incorporate principles of motor learning
• Many repetitions • Use of counting books but instead of counting the objects on a page, simply point to the object and repeat its "name" each time it appears on the page. For example, a counting book of animals has 4 dogs on the page for the number 4. Instead of counting "1, 2, 3, 4", you can guide the child to point to each dog and say "pup, pup, pup, pup" or depending on their skill, "doggie, doggie, doggie, doggie". • While playing "house" and setting the table, each time a cup is put down saying "cup, cup, cup". • Pretending to eat: "yum, yum, yum" • Practice • Distributed vs. massed practice opportunities • Appropriate use of feedback (Davis and Velleman, 2000, p. 187)

Practice
• Core vocabulary books are another way to elicit practice from the child and can also incorporate parents or other communication partners. • The photos should consist of meaningful people, toys, and objects in the child's life as well as words that contain initially targeted sound sequences. • This book often serves as a child's first success at expansion of functional communication interactions with significant others. (Hammer, Apraxia-kids website)

Providing Motivation/Keeping the Childs Attention
• Play presents many opportunities for repetitive sequences • An astute, engaging clinician can use low-pressure opportunities and engaging play to help children with apraxia take risks with their speech attempts. (Hammer, 2003) • Keeping attention of young children with apraxia:
• Change positions after every 10 20 practice trials (stand up, sit backward, put hands on head, sit under the table, march, swing arms, etc) • Change inflection (most helpful when child has some accuracy; place stress on different words, use low pitch, high pitch, exaggerate the target word or phrase) • Use various dolls, puppets, animals that the child can speak for and change the selection after a number of practice trials.

(Strand and Skinder, 1999, p. 128)

Therapy for children…
• While clinicians must make therapy fun and engaging, it is not sufficient to be able to say the child enjoyed the therapy session or that the session went well because the child cooperated. • That alone will not effectively provide what the child needs, which is the opportunity for a high number of repetitions of speech targets and the clinicians thoughtful feedback about performance and results. • Therapy for children with apraxia of all ages is designed to shape speech motor skill. If the child isn’t saying much in the therapy session, the clinician is not going to be able to achieve this goal (Strand and Skinder, 1999)

Apraxia - Things to keep in mind
• Children with apraxia may not follow the typical "developmental" sequence for acquiring new sounds. (Hammer, 2003; Davis and Velleman, 2000) • Children with apraxia of speech need some early success with speech. They need to know it is worth it to trust and cooperate with the clinician. (Hammer, 2003) • Children with apraxia seem to have periods where sometimes they seem to 'plateau'. (Davis and Velleman, 2000) • Play is the medium for these young children with apraxia to provide activity that builds in speech movement training. (Hammer, 2003) • Parents need help and direct mentoring to understand their role and how they can effectively practice with the young child at home. (Hammer and Stoeckel, 2001) • Break up sessions into several activities that have repetitive practice vs. one long activity (Davis and Velleman, 2000, Strand and Skinder 1999) • Just as with older children with apraxia, younger children need feedback about their performance such as knowledge of results (did they get the word right) and more specific knowledge about performance (for example, "you need your lips out for that"). (Davis and Velleman, 2000; Hammer, 2003; Strand and Skinder 1999)

Apraxia or Something Else?
• Once a period of therapy has commenced and the SLP has experience with a particular child suspected to have apraxia of speech, it may become clearer as to whether or not the child’s primary difficulty is with speech motor planning and programming. • Even if a child does not receive the apraxia diagnosis, the therapy recommendations outlined above may play a role in the treatment plan. Some have noted the possibility of a continuum of severity in children’s speech motor planning ability (McCauley, 2002). • According to McCauley, A child's failure to respond to treatment methods in which the goal is to teach the child phonologic patterns (e.g., the Cycles Approach or minimal pairs) would also suggest the possibility that greater attention to motor factors in speech learning could prove beneficial. (McCauley, 2002).

Apraxia - Conclusion
• In summary, while it is difficult to diagnose children with apraxia of speech at very young ages, it is still possible to provide speech therapy to them in a manner that meets the needs of children who may have a motor-planning component to their speech production difficulties. • In early phases, attention to increasing overall communication and oral communication in particular, expanding sounds and syllable shapes, gaining multiple repetitions of syllables and words for speech movement practice, functional communication, and solid parent involvement can assist young children suspected to have apraxia of speech.

Common Phonological Processes

Phonological Processes
• Error patterns of phonology • Some are typically in early speech development • A child can have delayed phonology or disordered phonology

Weak Syllable Deletion
• Description: The omission of a weak (unstressed) syllable that either comes before or after a stressed syllable. • Examples: "telephone" pronounced as "tefone" "yellow" pronounced as "yell" "above" pronounced as "bov" " tomato" pronounced as "may-toe" "probably" pronounced as "prob-lee" "paper" pronounced as "pape"

Final Consonant Deletion
• Description: This process occurs when a child reduces a syllable by omitting the final consonant of that syllable. • Examples: "pot" pronounced as "paw" "bake" pronounced as "bay" "nice" pronounced as "nie" "cat" pronounced as "ca" "coat" pronounced as "koe" "phone" pronounced as "foe"

Reduplication
• Description: Reduplication is characterized by the repetition of a syllable. • Examples: "daddy" pronounced as "dada" "baby" pronounced as "bay-bay" "movie" pronounced as "moo-moo" "water" pronounced as "wawa"

Labial Assimilation
• Description: The production of a nonlabial phoneme with a labial place of articulation This happens because there is a labial phoneme elsewhere in the word. • Examples: "book" pronounced as "bup" "mad" pronounced as "mab" "cap" pronounced as "pap"

Alveolar Assimilation
• Description: This process occurs when a phoneme is produced with an alveolar place of articulation due to the presence of an alveolar phoneme elsewhere in the word. • Examples: "time" pronounced as "tine" "bat" pronounced as "dat" "neck" pronounced as "net" "shut" pronounced as "sut"

Velar Assimilation
• Description: This process occurs when a phoneme is produced with a velar place of articulation due to the presence of a velar phoneme elsewhere in the word. • Examples: "cup" pronounced as 'kuk" "gone" pronounced as "gong" "take" pronounced as "kake" "doggy" pronounced as "goggy"

Gliding
• Description: Replacing the consonants /l/ and /r/ with the consonants /w/ and /j/. • Examples: "rabbit" pronounced as "wabbit" "hello" pronounced as "heyo" "look" pronounced as "wook" "carrot" pronounced as "cawet"

Vocalization
• Description: This process is also referred to as "vowelization" because it is the substitution of a vowel for an /l/ or /r/ that follows a vowel. This process is commonly found in words that end in "r" and "el" sounds. • Examples: "tiger" pronounced as "tie-goo" "turn" pronounced as "ton" "third" pronounced as "thud" "water" pronounced as "wato“

Devoicing
• Description: When a syllable-final voiced phoneme that precedes a pause or silence between words is unvoiced, it is called devoicing. • Examples: "bad" pronounced as "bat" "led" pronounced as "let" "card" pronounced as "cart"

Prevocalic Voicing
• Description: When an unvoiced consonant preceding the vowel of a syllable is voiced, it is called prevocalic voicing. • Examples: "pig" pronounced as "big" "cup" pronounced as "gup" "pear" pronounced as "bear" "train" pronounced as "drain"

Cluster Reduction
• Description: When a consonant is deleted from a consonant cluster the error is referred to as a cluster reduction. If there are three adjacent consonants in the same syllable, one or two of the consonants may be deleted. • Examples: "snow" pronounced as "no" " help" pronounced as "hep" "play" pronounced as "pay" "stripe" pronounced as "tripe" or "type" or "ripe" "green" pronounced as "geen"

Stopping
• Description: The substitution of a stop for a fricative or an affricate. • Examples: "sake" pronounced as "take" (fricative replaces a stop) "zoo" pronounced as "do" (fricative replaces stop) "Jane" pronounced as "dane" (affricate replaces stop)

Fronting
• Description: The substitution of a velar consonants and palatal consonants with an alveolar place of articulation. • Examples: "cat" pronounced as "tat" (velar fronting) "get" pronounced as "det" (palatal fronting) "cookie" pronounced as "tootie" (velar fronting) "match" pronounced as "mat" (palatal fronting)

Deaffrication
• Description: The substitution of a fricative for an affricate • Examples: "chip" pronounced as "ship" "matches" pronounced as "mashes" "ledge" pronounced as "lez" "chalk" pronounced as "shock"

Atypical Processes
Glottal Replacement - Description: "The substitution of a glottal stop for another consonant" - Example: Replacing the "k" sound in the word "pick" with a glottal stop Backing - Description: The substitution of velar stoops for consonants that are usually produced further back in the mouth. - Example: "time" pronounced as "kime" "zoom" pronounced as "goom"

Atypical Processes
Initial Consonant Deletion - Description: When a single consonant at the beginning of a word is omitted it is called initial consonant deletion. - Example: "cut" pronounced as "ut" "game" pronounced as "aim“ Stops Replacing Glides - Description: "the substitution of a stop for a glide" - Example: "yes" pronounced as "des" "wait" pronounced as "bait" Fricative Replacing Stops - Description: "the substitution of a fricative for a stop" - Example: "sit" pronounced as "sis" "doll" pronounced as "zoll"

Processes that disappear by age 3 years
1. Unstressed syllable deletion (example: telphone for telephone) 2. Final Consonant Deletion 3. Consonant Assimilation 4. Reduplication 5. Velar Fronting (phonemes /k/ and /g/ are substituted for sounds made in the front. Example: tookie for cookie or doat for goat) 6. Prevocalic voicing (“gat” for “cat”)

Processes persisting after 3 years:
1. Cluster Reduction 2. Epenthasis - A vowel is misplaced or inserted in a word (example, balack for black) 3. Gliding 4. Vocalization - Consonants are replaced by vowels (example, boyd for bird) 5. Stopping - Fricative sounds are replaced by stops (example, toup for soup or pit for peach) 6. Depalatlization 7. Final Devoicing

Processes that Persist
• By the first grade, or by age 7, these processes should be resolved. • The most common processes that persist are stopping, gliding, and cluster reduction. • When these processes persist speech therapy is indicated.

Assessment of Articulation
• Articulation inventory – what sounds does the child have in his/her repertoire • Articulation screening/test – how does child produce sounds in isolation, in words and in sentences • Speech sample – how does child produce sounds in conversational speech • Can child imitate correct sounds when modeled and cued? (stimulable)

Phonological Assessment
• • • • • • Oral motor structures Phonetic Inventory What sounds are missing? Articulation errors Motor planning Phonological Analysis

Phonological Analysis
• HAPP-3 Hodson Assessment of Phonological Patterns • Ages 2 years and up • Time: 15-20 minutes

Phonological analysis  Therapy
• List word productions • Identify each error by process or articualtion error • Identify the most prominent processes and the ones that are having the greatest impact on speech inteligibility • Target speech sounds if stimulable • Target reduction of processes if stimulable

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