Comparison of ten
interventions for a
seven-year-old with
unintelligible speech
SC28: Short course
American Speech-Language-Hearing Association Convention, Boston
1:30-4:30pm 17 November, 2007
1
Overview of the course
1.
2.
3.
4.
5.
6.
7.
Introducing Jarrod
Core Vocabulary
Cycles Approach
Learnability Theory
PROMPT
Profiling Approach
Other Intervention Approaches
Nonlinear Approach
Psycholinguistic Approach
Systemic Perspective
Parents and Children Together
8.
9.
10.
International Classification of Functioning, Disability & Health
Intervention Outcomes for Jarrod
Comparison of approaches and discussion between authors and
audience
2
1
Presenters
L to R: Deborah Hayden, Barbara Dodd PhD, Alison Holm PhD,
Michele Morrisette PhD, Martin J. Ball PhD, Nicole Müller PhD,
Raul Prezas, Kathryn Spiller (informa), Sharynne McLeod PhD, Beth McIntosh
3
The short course is based on
Advances in Speech-Language Pathology (2006)
volume 8(3)
Special issue: Intervention for a child with unintelligible
speech
www.informaworld.com/advances
Free editorial:
http://www.informaworld.com/smpp/content~content=a757990620~
db=all~order=page
10 free video demonstrations of Jarrod
http://www.informaworld.com/smpp/content~content=a757990620~
db=all~tab=multimedia
Note. The name of the journal has changed to
International Journal of Speech-Language Pathology
from 2008: www.informaworld.com/ijslp
4
2
Aim to explore
Coherence between
Theory
Practice
Congruence between
Assessment
Intervention goals
Intervention
(cf. Kamhi, 1992; Schwartz, 1992; Williams, 2002)
5
Learner outcomes
1.
2.
3.
Identify characteristics of major
assessment/intervention approaches for
children with unintelligible speech
Compare principles and procedures of the
various approaches presented in this session
and determine similarities and differences
Apply principles of the International
Classification of Functioning, Disability and
Health – Children and Youth for children with
unintelligible speech
6
3
1. Introducing Jarrod
Alison Holm & Sharon Crosbie
Perinatal Research Centre,
The University of Queensland, Australia
[email protected]
7
Referral
Education Queensland SLP referred child
from current caseload
family provided with detailed information
about the study
informed signed parental consent was
obtained with specific consent to allow
audio and video use
8
4
Assessment process
experienced registered paediatric SLPs
administered the assessments
Jarrod was not familiar with assessors
assessment in quiet withdrawal rooms at
school
three 75-minute assessment sessions
breaks taken between tasks
9
Assessment behaviour
Jarrod compliant with all testing
occasionally needed direction to stay
focused
responded well to verbal encouragement
eye contact was generally appropriate
interactions were confident and he willingly
initiated conversation
10
5
Assessment battery
7 speech assessments
oromotor assessment
3 psycholinguistic assessment tasks
3 phonemic awareness assessments
assessment of activity and participation
11
Speech assessments
Diagnostic Evaluation of Articulation & Phonology
DEAP - Dodd, Zhu, Crosbie, Holm & Ozanne, 2002
widely-used, standardised speech assessment with
Australian normative data
subtests administered:
Articulation Assessment
Phonology Assessment
Connected Speech Picture Description
Inconsistency Assessment
12
6
Bernhardt’s supplemental word list
Bernhardt, Stemberger & Major, 2006
required some items to supplement the DEAP to provide:
extra stress patterns or word shapes
extra consonant clusters
extra segments to increase the sampling of some sounds
words to allow morphology/phonology comparisons
two to three elicited sentences that allow variations in stress
patterns
13
Hodson Assessment of Phonological Patterns
HAPP-3 - Hodson, 2004
American standardized test that is norm-referenced and
criterion-referenced
designed for children with highly unintelligible speech
spontaneous productions of 50 target words elicited from
48 stimulus items (common objects/toys, including three
crayons, three body parts, and a few pictures)
14
7
Systemic Phonological Protocol
SPP - Williams, 2003
single word naming of black and white drawings
presented on cards
modified administration - a reduced number of words
were elicited through forced choice (e.g., “Is it a boat or a
snail?”)
15
Morrisette supplemental word list
Morrisette, Farris & Gierut, 2006
90 words from the Phonological Knowledge Protocol and
Onset Cluster Probe
supplemental words were elicited as a spontaneous
picture-naming task
16
8
Metaphon Screening Test - The Quick Screener
Bowen, 1996
single word elicitation task
modified version of the first 44 words of the nonstandardized Screening Test from the Metaphon
Resource Pack
17
Connected speech sample
connected speech sample was elicited by asking Jarrod
to talk about a movie he had seen recently
18
9
Oromotor assessment
Verbal Motor Production Assessment
VMPAC - Hayden & Square, 1999
systematic assessment of the neuromotor integrity of the
motor speech system
normed and standardised
systematically probes which effect of sensory input
(auditory, visual, tactual) on motor-speech performance
19
Psycholinguistic assessments
Children’s Test of Nonword Repetition
CNRep - Gathercole & Baddeley, 1996
standardised test of short-term memory
repeat single unfamiliar spoken items (“nonwords”) such
as blonterstaping and woogalamic
audio cassette was played containing 40 nonwords
child listens to each nonword and attempts to repeat it
Jarrod completed the CNRep task in two sections
20
10
Auditory lexical discrimination tests
Locke, 1980
Jarrod looked at 12 pictures in turn and to decide if two
or three spoken stimuli had been said correctly
toy was used to explain the task: Jarrod was told that the
toy was sometimes "clever" and sometimes "silly"
task required correctly accepting words and correctly
rejecting non-words
21
Same-different test
Bridgemann & Snowling, 1988
assessed Jarrod’s auditory discrimination of real and
non-words
Jarrod was asked to say if a pair of stimuli (words or
non-words) sounded the same or different
30 nonwords and 30 real words administered
22
11
Phonemic awareness
assessments
Preschool Inventory of Phonological Awareness
PIPA - Dodd, Crosbie, McIntosh, Teitzel & Ozanne, 2000
standardised battery of tasks to assess children’s early
phonological awareness development
Australian normative data
Jarrod completed three of the subtests of the PIPA:
Rhyme Awareness
Phoneme Isolation
Letter Knowledge
23
Queensland University Inventory of Literacy
QUIL - Dodd, Holm, Oerlemans & McCormick, 1996
Australian standardised assessment of phonological
awareness
5 QUIL subtests administered:
Nonword Spelling
Nonword Reading
Syllable Segmentation
Spoken Rhyme Recognition
Phoneme Manipulation
24
12
Sutherland Phonological Awareness Test - Revised
SPAT-R - Neilson, 2003
simple standardised diagnostic overview of phonological
awareness skills
widely used throughout Australia
25
Assessment of Activity and
Participation
Speech Participation and Activity -Children
SPAA-C - McLeod, 2004
contains questions about the daily lives of children and
impact of having a speech impairment
children indicate how they feel about different scenarios
relating to speaking
26
13
Transcription
transcription of the speech assessments
was conducted by an independent
phonetician/speech-language pathologist
impressionistic transcription of the audiofile was augmented by on-line visual
inspection of waveforms, spectrograms
and pitch extraction
27
Case History - Jarrod
7;0 years old at initial assessment
Jarrod’s mother description: happy, healthy boy, good
sense of humour
Jarrod’s class teacher identified “poor social skills as a
result of poor communication skills”
aware of his communication difficulties
not inhibited by his speech difficulties
doesn’t get frustrated when people don’t understand
mother and teacher report
usually understand him within a known conversational context
very difficult to understand without context
unfamiliar people - rarely understand
28
14
Family Background and Context
Jarrod lives with his mother and 10 year-old sister
regular contact with father and extended family members
English only
Jarrod’s mother
book-keeper (accounting)
works part-time during school hours
completed Year 11
Jarrod’s father
builder
works full-time
completed Year 10 of high school
had a speech disorder and went to speech therapy as a child
some persistent current speech errors
29
Developmental History
pregnancy and birth history uneventful
Jarrod born full-term at average weight
breast-fed for 6 months
no history of feeding difficulties
all gross motor development milestones were
achieved within normal limits
occupational therapy assessment has identified
fine motor difficulties
30
15
Medical History
diagnosed with asthma at 15 months and has
used a nebuliser, Ventolin and Flexotide
hospitalised twice due to asthma
diagnosed with Attention Deficit Hyperactivity
Disorder
medicated with Ritalin to improve concentration
Ritalin for approximately 2 months prior to the initial
assessment
attention much easier to maintain when he had taken
his medication
31
Audiological History
history of otitis media requiring two sets of
grommets (at 2 and 4 years of age)
hearing test at age 4;01 years indicating
adequate hearing
32
16
Educational History
age 4-5 years
preschool and
Special Education Development Unit
age 6 years
mainstream Year 1 class
age 7 years
Intensive Language Class (small group all with
communication difficulties)
repeating Year 1 curriculum
33
Speech and Language History
late developing speech
30 months old before using words
might have been earlier but she couldn’t
understand him
referred to speech therapy by his family doctor
when he was 4;0 years
private speech therapy for 5 months
(no details available about diagnosis or therapy)
34
17
referred to school-based SLP at age 4;08 years
by preschool teacher
diagnosed with severe speech delay/disorder
and mild oromotor difficulties
individual therapy recommended and specialist
educational placement
private speech-language pathologist for seven
intervention sessions when he was 5;03 years
intervention focused on listening, imitation of
CVC words, sound awareness and pronouns
35
Language Skills
Clinical Evaluation of Language
Fundamentals – 4
Core Language Score of 111
Receptive Language Score was 103
Expressive Language Score was 112
36
18
Non-verbal Abilities
4;11 years - Wechsler Preschool and Primary Scales of
Intelligence
Full Scale Intelligence Quotient of 81 (10th percentile)
Verbal Intelligence Quotient of 81 (10th percentile)
Processing Speed Index of 71 (3rd percentile)
Performance Intelligence Quotient of 93 (32nd percentile)
7;0 years - Wechsler Intelligence Scale for Children-IV
Verbal Comprehension Index (VCI) of 81 (10th percentile)
Perceptual Reasoning Index (PRI) of 111 (76th percentile)
37
2. Core Vocabulary
Barbara Dodd, Alison Holm,
Sharon Crosbie & Beth McIntosh
Perinatal Research Centre,
The University of Queensland, Australia
[email protected]
38
19
Clinical Decision Making
‘Clinical decision making’ refers to how speechlanguage pathologists (SLPs) manage the care
of individuals with suspected communication
difficulties
SLPs usually take a problem-solving approach
when determining appropriate clinical action
This brief talk will consider our perspective on
the clinical management of Jarrod
39
Clinical decisions:
1.
2.
3.
4.
5.
6.
7.
Is intervention indicated?
What is the client’s diagnosis?
What service delivery model should be used?
What are the goals of intervention?
How will generalization be aided?
What discharge criteria are set?
How will efficacy be evaluated?
40
20
Is intervention indicated?
Yes
Uneven profile of ability (e.g., language WNL
as compared to unintelligible speech)
Concern expressed by Jarrod, family and
school
Some evidence that his speech disorder is
affecting social behaviour and learning
41
What is Jarrod’s diagnosis?
Inconsistent speech disorder
80% inconsistency score on DEAP’s Consistency
Subtest
Ability to articulate all but three phonemes on the
DEAP’s Articulation Subtest
No obvious oro-motor signs on the DEAP’s Oro-motor
subtest (DDK, isolated and sequenced movements)
Note: some sound distortion and prosodic disturbance
perhaps due to long assessment)
Very low performance on PCC, PVC, PPC compared
to normative data
42
21
Diagnosis (cont)
Poor performance on expressive vocabulary
Contradictory PA performance (lexical decision OK,
but poor comparison of sound sequences)
Better in imitation than spontaneous production
Range of syllable and word shapes produced, no oromotor signs of groping, dysfluency, produced an
accent when role playing a television character
43
Inconsistent Speech Disorder
Deficit: Phonological Assembly
An impaired ability to plan a sequence of
phonemes that governs phonetic planning
and motor implementation. The deficit is postlexical but before motor planning
Core vocabulary targets phonological
assembly
44
22
Choice of intervention approach
Research evidence links diagnosis with
specific intervention approaches:
Inconsistency -> Core Vocabulary
Articulation -> Individual speech sound
Consistent errors -> Phonological Contrast
CAS -> PROMPT
45
What service delivery model should
be chosen?
Research evidence on core vocabulary
implementation suggests:
Agent: SLP + parent and school input
Individual therapy: tailored to Jarrod
Twice weekly, 30 minute sessions
One session in clinic and one at school
8 weeks: 8 hours of intervention
46
23
What are the goals of Intervention?
Ultimate goal (prognosis)
age appropriate speech
Long-term goal (for the episode of intervention
planned)
Consistency of best production of a minimum of 50
words
Generalization of consistency to non-treated words
Improved accuracy (PCC and PVC)
47
Short term goals (session goals)
Pre-therapy case conference:
explain approach
select Jarrod’s core vocabulary
make role of parent and teacher clear
1st weekly session
elicits and drills best production of up to 10 words
Assesses consistency of taught words and generalisation
2nd weekly session
Practice in single words, carrier phrases and formulated
sentences; direct teaching of ‘problem’ words
48
24
What discharge criteria should be
set?
Reassess after one episode of care
Jarrod’s history and age suggest he may
need more than one episode of care
The second episode of care may use a
different intervention approach. If his
speech errors become consistent, Jarrod
may benefit from phonological contrast
intervention
49
How should efficacy be assessed?
Establish a pre-therapy base-line (three speech
samples over 2 months, plus non-treated control
data e.g., expressive vocabulary)
Implement intervention
Re-assessment immediately post therapy and at
3 and 6 month follow-up (by a clinician not
involved and unaware of whether child has
received intervention)
50
25
Argument
Intervention approach is dependent on
differential diagnosis of a child’s speech
disorder
Type of intervention approach should be
determined by diagnosis
Inconsistent errors are best treated using
a core vocabulary approach
51
3. Cycles Approach
Barbara W. Hodson
with Raul Prezas
Wichita State University, USA
[email protected]
52
26
PURPOSE: ANALYZE PHONOLOGICAL
DEVIATIONS of 7-year-old IN ORDER TO
Identify Deficient Phonological PATTERNS
Syllable/word Structure Omissions (e.g., Final C)
Consonant Category Deficiencies (e.g., Velars)
Substitutions & other Strategies (e.g., Stopping)
Determine SEVERITY of Child’s Phonological Impairment (Mild, Moderate, Severe, Profound)
Identify OPTIMAL TARGET PATTERNS to
Expedite Intelligibility Gains, and
Obtain BASELINE DATA to be used for
Comparison Following Treatment for
53
Evidence-Based Practice
Table 1. JARROD’S MAJOR HAPP-3*
PHONOLOGICAL DEVIATIONS @ AGE 7:0
Omissions
Syllables
Occurrences
%ages
[Word/Syllable Structures]
1
6
Consonant Sequences/Clusters
36
92
Consonant Singletons
Prevocalic
Intervocalic
Postvocalic
0
2
22
0
14
69
*Hodson Assessment of Phonological Patterns-3rd ed. (2004)
Scored by Software: Hodson Computerized Assessment of
Phonological Patterns (2003)
54
27
JARROD’S PHONOLOGICAL SCORES-2
Occurrences
Consonant Category Deficiencies
Sonorants
Liquids
Nasals
Obstruents
Stridents
Velars (e.g., Fronting)
Anterior Nonstridents (e.g., Backing)
%ages
17
89
5
24
41
98
20
91
11
37
--------------------------------------------------Total Occurrences Major Phonological Deviations
157
Severity Interval
Low Profound
55
JARROD’S INVENTORY & STRATEGIES
Produced all English Cs except /s/, /l/, &
Palatal Sibilants in Sample Provided
Occurrences
Major Strategies
Gliding
19
Glottal Stop Replacement/Insertion 18
Stopping
14
Prevocalic Voicing
11
Fronting
5
56
28
Table 2. POTENTIAL OPTIMAL PRIMARY
TARGET PATTERNS FOR BEGINNING CYCLES
Word Structures (when phonemes are omitted)
“Syllableness” (for omitted vowels, dipthongs, etc.)
2-syllable compound words
3-syllable compound words
Singleton Consonants (when consistently omitted)
CV (word-initial /p/, /b/, /m/, /w/)
VC (Voiceless final stops /p, t, k/; possibly final /m,n/)
VCV (e.g., apple, if child omits all medial consonants)
/s/ Clusters
Word-initial (e.g., /sp/, /st/, depending on child’s repertoire)
Word-final (e.g., /ts/, /ps/)
57
Table 2-POTENTIAL OPTIMAL TARGET
PATTERNS continued
Anterior-Posterior Contrasts
Velars (if Fronter)—when Stimulable
Word-final /k/ first; word-initial /k/ or /g/
Occasionally /h/
Alveolars (if Backer)
Liquids (Facilitate even if not Stimulable)
Prevocalic /l/
Prevocalic /r/ (also /kr,gr/ if child has Velars)
58
29
RECOMMENDATIONS for JARROD’S CYCLE
ONE TARGETS [1 hour per phoneme]
Final Consonants
Final /p/
Final /t/
Final /m/
/s/ Clusters
Initial /sp/
Initial /st/
Initial /sm/
Initial /sn/
Final /ts/ ??
Velars
Final /k/
Initial /g/
Initial /k/
/k/ vowel /k/
Liquids
[Stimulate even if not Stimulable]
Initial /l/
Initial /r/
59
GENERAL COMMENTS
Regarding Targets
Approximately 60 mn per PHONEME target
At least 2 phonemes per target PATTERN
Reassess phonology between cycles
Recycle Primary Patterns as needed
until begin to emerge in conversation
Proceed to Secondary Patterns after
Early developing patterns established
/s/ Clusters emerging in conversation
Velars and Alveolars used contrastively
Practice words for Liquids produced without Glides
60
30
UNDERLYING CONCEPTS for CYCLES
PHONOLOGICAL REMEDIATION APPROACH
Phonological acquisition is gradual
Children acquire sound system primarily by
listening
Associate kindsthetic & auditory sensations for
later self-monitoring
Phonetic environment can facilitate (or inhibit)
correct sound production
Children actively involved in phonological
acquisition
Children tend to generalize
An optimal “match” facilitates a child’s learning61
MAJOR RECOMMENDATIONS
Identifify Consistent Broad Deviations
Determine Priorities [clients, time, individual/group]
Select Optimal Targets [patterns, phonemes, words]
Increase Complexity Gradually
Facilitate Development of Awareness
[auditory, kinesthetic, semantic]
Incorporate
Slight Amplification
Tactile Cues [as needed]
Models [particularly for new target]
Enhance Metaphonological Awareness &
Early Literacy Skills
62
31
PRIMARY REFERENCES
Hodson, B. (2007). Evaluating and Enhancing Children’s
Phonological Systems: Research and Theory to Practice.
Greenville, SC: Thinking Publications/Super Duper.
Hodson, B. (2005). Enhancing Phonological and
Metaphonological Skills of Children with Highly
Unintelligible Speech. Rockville, MD: American SpeechLanguage-Hearing Association.
Hodson, B. (2004). Hodson Assessment of Phonological
Patterns-3rd ed. Austin, TX: ProEd.
Hodson, B. (2003). Hodson Computerized Analysis of
Phonological Patterns. Wichita, KS: Phonocomp Software.
Porter, J., & Hodson, B. (2001). Collaborating to obtain
phonological acquisition data for local schools. Language,
Speech, and Hearing Services in Schools, 32, 165-171.
63
4. Learnability Theory
Michele L. Morrisette,
Ashley W. Farris & Judith A. Gierut
Indiana University, USA
[email protected]
64
32
Acknowledgements
National Institutes of Health DC001694
PI: Judith A. Gierut; Co-PI: Daniel A. Dinnsen
65
Learnability theory
Model change in acquisition
(e.g. Matthews & Demopoulus, 1989; Pinker, 1984; Tesar &
Smolensky 1998; Wexler, 1982; Wexler & Culicover, 1980)
Role of input as a trigger for change
(e.g. Marcus, 1993; Pinker, 1995; Wexler, 1982)
Complex targets as input in treatment
(e.g. Gierut, 2001; Gierut, 2007 in AJSLP, Vol. 16, 2007)
66
33
Onset clusters as complex targets
2-element onset clusters
C1C2
e.g. /fr–/ ‘friend’
3-element onset clusters
C1C2C3
e.g. /spr–/ ‘spray’
67
Jarrod’s use of onset clusters
2-element onset clusters
Cluster reduction e.g. target /tw–/ → [w]
Liquid gliding
e.g. target /bl–/ → [bw]
3-element onset clusters
Cluster reduction & liquid gliding
e.g. target /spr–/ → [w]
68
34
Jarrod’s use of onset clusters
2-element onset clusters
Cluster reduction e.g. target /tw–/ → [w]
Liquid gliding
e.g. target /bl–/ → [bw]
3-element onset clusters
Cluster reduction & liquid gliding
e.g. target /spr–/ → [w]
69
Experimental test
3-element onset clusters
C1C2C3
/spl– spr– str– skr– skw– /
(Gierut & Champion, 2001)
70
35
Evidence-based findings
(Gierut & Champion, 2001)
Monitored accuracy
Posttreatment change?
3-element onset
clusters
2-element onset
clusters
Affricates
Other singletons
71
Evidence-based findings
(Gierut & Champion, 2001)
Monitored accuracy
3-element onset
clusters
2-element onset
clusters
Posttreatment change?
Trigger for change
Affricates
Other singletons
72
36
Evidence-based findings
(Gierut & Champion, 2001)
Monitored accuracy
3-element onset
clusters
2-element onset
clusters
Posttreatment change?
Trigger for change
YES
Affricates
YES
Other singletons
YES
73
2 patterns of change
(Gierut & Champion, 2001)
Monitored accuracy
2-element onset
clusters
Posttreatment change?
Widespread
gains
Minimal
gains
C+liq and /s/+C
/s/+C only
Affricates
YES
Other singletons
YES
74
37
Phonemic status as predictor
(Gierut & Champion, 2001)
Monitored accuracy
2-element onset
clusters
Posttreatment change?
C2 & C3 =
phonemes
C1 & C2 =
phonemes
C+liq and /s/+C
/s/+C only
Affricates
YES
Other singletons
YES
75
Widespread gains
C1 C2 C3
s
p
l
e.g. If the child uses /p/ & /l/ as phonemes,
Teach /spl–/ = widespread gains
76
38
Minimal gains
C1 C2 C3
s
p
l
e.g. If the child uses /s/ & /p/ as phonemes,
Avoid /spl–/ = minimal gains
77
Identify minimal pairs
2 productions that differ by one phoneme
Independent of context & accuracy
[k i p]
[l i p]
‘keep’
‘sleep’
[d u s]
[d u f]
‘juice’
‘tooth’
78
39
Determining phonemic status
C1
C2
C3
s
s
s
s
s
p
p
t
k
k
l
r
r
r
w
79
Is /s/ a phoneme?
C1
C2
C3
s
s
s
s
s
p
p
t
k
k
l
r
r
r
w
80
40
Are /p t k/ phonemes?
C1
C2
C3
s
s
s
s
s
p
p
t
k
k
l
r
r
r
w
81
Are /l r w/ phonemes?
C1
C2
C3
s
s
s
s
s
p
p
t
k
k
l
r
r
r
w
82
41
Application to Jarrod
C1
C2
C3
/s/
/p t k/
/l r w/
No minimal pairs [pa] ‘car’ – [ba] ‘bath’
Not phonemic
/p/ = phonemic
[ren] ‘rain’ – [ben] ‘van’
[wo] ‘blue’ – [no] ‘nose’
/r w/ = phonemic
83
Are C2 & C3 phonemes?
C1
C2
C3
s
s
s
s
s
p
p
t
k
k
l
r
r
r
w
84
42
Teach /spr–/ = Widespread gains
C1
C2
C3
s
s
s
s
s
p
p
t
k
k
l
r
r
r
w
85
Other logical possibilities
Only one segment is phonemic
e.g. minimal pairs for C1, not C2 or C3
All segments are phonemic
e.g. minimal pairs for C1, C2, and C3
None of the segments are phonemic
e.g. no minimal pairs for C1, C2, or C3
2-element onset clusters recommended
(See Gierut, 1999; Morrisette et al, 2006)
86
43
Intervention approach
Production practice in words
Imitative followed by spontaneous productions
Time & performance based criterion for advancement
Corrective, but graded feedback
Vary emphasis on C1C2C3 v. C1+C2 v. C2+C3
e.g. model ‘spray’ as /spre/ v. /sp–re/ v. /s–pre/
Successive approximation
Allow any C + C + C as correct, then shape to target
87
Monitoring for change
During & following treatment
Based on predictions for learning
2-element onset clusters, affricates &
other singletons
Sample productions in multiple exemplars &
word positions
88
44
Resources
Gierut, J. A. (1999). Syllable onsets: Clusters and adjuncts in
acquisition. Journal of Speech, Language and Hearing Research,
42, 708-726.
Gierut, J. A., & Champion, A. H. (2001). Syllable onsets II: Threeelement clusters in phonological treatment. Journal of Speech,
Language and Hearing Research, 44, 886-904.
Morrisette, M. L., Farris, A. W., & Gierut, J. A. (2006). Applications of
learnability theory to clinical phonology. Advances in SpeechLanguage Pathology, 8, 207-219.
[email protected]
89
5. PROMPT
Deborah Hayden
The PROMPT Institute, USA
[email protected]
90
45
PROMPT
Is a tactually grounded approach for reorganizing
and or developing motor speech actions
(e.g. phonemes, words, phrases) used in interactive
communication.
Is useful for children who are “therapy resistant”
or have had limited success with auditory-visual
approaches.
Develops motor-phoneme links or
“the motor requirements and interactions that
produce the acoustic characteristics which represent
cognitive and linguistic constructs, retain meaning
and symbolize language and language form”, in
systematic way for use in interactive communication.
91
Three Uses of PROMPT
To Develop An Interactive Awareness/
Focus for Oral Communication
Develop attention and waiting
Good for children/adults in a pre-linguistic or early
linguistic stage (either developmental or after cortical
damage)
Emphasizes one or two motor-phonemes or actions,
interaction and awareness to face, not really working on
subsystem control at this level.
Normally uses parameter prompts sometimes a surface
prompt and/or a syllable prompt.
1.
Associate a sound to an action.
92
46
Three Uses of PROMPT
2. To develop integrated multimulti-sensory (tactile(tactilekinesthetic) associative mapping for cognitive or
linguistic concepts
Associate tactual-auditory, sensory information to cognitive-linguistic
making association between motor map and concept.
Usually used when the motor or cognitive information is above the
level of the child/adult-to teach them that the concept is related to the
motor-auditory map. No expectation of production e.g. map in the word
“ball” with surface prompts to teach that the concept of ball is related to
the motor map.
Bring awareness to the concept but not the subsystem control, per se.
If you have a cognitive-linguistic focus then mapping is helpful to
develop concept about what’s in the world, receptive language.
To bring sensations in environment to level of cognition.
93
Three Uses of PROMPT
3. To Develop, Balance Or Restructure Speech
Subsystems At The Motor-phoneme, Word Or
Phrase Levels
Used for developing/integrating each subsystem
(phonatory, mandibular, labial-facial, lingual) into the
dynamic, hierarchical whole.
Necessary to rebalance speech subsystems for dynamic
control so they may be used flexibly with a minimal amount
of effort (appropriate muscular contraction, range, grading,
force, duration, transition), during spontaneous, phrase
production.
94
47
Shifts for SLP
Motor actions paired with auditory rather than
auditory alone.
Phonological suggests child systematically
simplifies phonological system- whereas- motor
approach views child as using what motor
resources they have available to them.
Uses ‘Stage’ or ‘Plane of Movement’ in thinking
about how sounds, and then phonemes, are
developed and used.
Strong emphasis on vowels and diphthongs as
well as consonants.
‘Speech through Speech!’ no oral motor
Proximity to client and tactile cueing
95
PROMPT Assessment
The PROMPT Conceptual Framework
The Motor Speech Hierarchy (VMPAC)
EMCS ( Early Motor Control Scales)
Other standardized instruments
To develop:
A Communication Focus
MSH speech subsystem priorities
Communication goals which embed objectives from
the physical-sensory, cognitive-linguistic and socialemotional domains.
96
48
The PROMPT Conceptual Framework
Stresses the need to thoroughly evaluate
all areas of client function, determine the
environments in which communication is
the “most critical.”
Utilize a wide variety of appraisal/evaluation
procedures and or approaches.
Evaluate the entire neuromotor system as
well as cognitive and psycho-social
domains.
Utilize input from several other
professionals.
97
PROMPT Conceptual Framework
Child
Environment
Physical
Sensory
Cognitive
Linguistic
Communication
Skeletal Structure
Neuromuscular Integrity
Sensation
Perception
Concept Formulation
Social
Emotional
Interpersonal Interaction
Trust
Behavioral Outcomes
98
49
In Jarrod’s Case: (7 yrs)
VMPAC Data:
typical
Global Motor Control 100%
Focal Motor Control 100%
Sequencing
100%
100%
Connected Control
Speech Characteristics 100%
Jarrod
95%
46%
57%
53%
85%
99
Jarrod Conceptual Framework
Physical-Sensory:
Overall normal tone, well balanced skeletal relationships for
gross motor development.
Fine motor skills for arm, hand and speech subsystems were
poor. Unbalanced speech subsystems were observed poor
control over mandibular excursion. Mandibular “attractor state”.
Cognitive-Linguistic:
Within normal limits (at time of testing) for most areas.
Exceptions included sensation and discrimination tasks that
involved processing of non-word forms, sequenced lexical
tasks, and abstract phonological tasks
Social-Emotional:
Early and on-going impulsivity and attention issues that have
created some anxiety and behavior. Also awareness of
communication difficulties
100
50
JARROD’S TREATMENT PRIORTIES:
1.Interactive communication routines for social
interactions
2. To develop normal speech subsystem control and
flexibility’
3. Improve academic proficiency and literacy skills
101
PROMPT Motor Speech Treatment Hierarchy…
102
51
PROMPT Technique…
A dynamic tactiletactile-kinesthetic method of treatment for motor
speech disorders which uses touch pressure, kinesthetic,
and proprioceptive cues.
PROMPT Types
Parameter – provides support and stabilizes the mandible or
broad facial musculature
Syllable Prompting – provides holistic muscle shaping in CV
and VC productions
Complex – provides as much information as possible about
mandible excursion, place, amount of facial or labial
contraction and width of lingual contraction
Surface – provides signaling transition and timing delivered in
one plane of movement to the mandible, labial-facial or
mylohyoid musculature
103
Jarrod Motor Speech Hierarchy
Stage I & II: All functions achieved
∗Stage III: Poor stability and symmetry, over excursion and
#1
sliding, poor grading, bilabials closure often
through jaw.
∗ Stage IV: Poor precision of independent bilabials
#3
productions, individual labial productions rarely
achieved, lip rounding and retraction poorly
produced and poorly timed.
∗Stage
V:
∗Stage
VI: Difficulty moving from vertical to horizontal plane as well
#2
Possible in isolation or well practiced tasks. In
spontaneous production” attractor state” prevails
and starting place or previous position impacts
coordinated actions.
as moving from anterior to posterior plane.
Stage VII: Timing and prosody issues, inconsistent resonance.
104
52
Jarrod’s Initial Targets
Stage III:
vertical plane
III: MandibularPriority
MandibularPriority #1
Stabilize, reduce and grade mandibular actions. Targets :
/i/, /u
/, /Q
/u/, /ei
/ei/,
/Q/, /Å
/Å/, /p
/p, /b
/b/, /m
/m/
(parameter & surface prompts)
Stage IV:
Labial-facial Priority #3 horizontal plane
IV: LabialUse appropriate range and independent contractions in
labial-facial musculature.
Targets: /i/, /u/, /œ/, /p/, /b/, /m/, /s/ and diphthongs across two
planes of movement.
(syllable & surface prompts
Stage V:
anterior-posterior
V: Lingual Priority #2 anteriorIncrease labial independence from the mandible from
anterior to mid-back lingual regions.
Targets: /t/, /d/, /n/ ,/s/, /l/, /S/, /r/
(surface & complex prompts)
105
What is the Clinician’s Role?
The speech-language pathologists acts
as an “external programmer” for
speech; manipulating the mandible,
labial-facial and lingual area in order to
provide a framework for spatial and
temporal aspects of speech production.
106
53
Client Must Learn
To Interact Appropriately: (listen, wait, signal
or can moderate behavior)
Routines and Boundaries
Appropriate Speech-Motor Behaviors
Use The Behaviors To Communicate
Effectively
107
Rapport Between SLP & Client
SLP Must Touch Client’s Face, Head, Neck and
Shoulders (minimally)
Pressure is Light, Moderate, or Firm (light to
moderate on facial tissues, moderate to firm on
mylohyoid)- Timing is variable
If SLP is Comfortable, Child Will Be: TRUST
Each Client Needs Different Support Strategies
108
54
Treatment Efficacy
Research evidence on PROMPT suggests:
Alternate focus across All domains as required
Work in Stages/Planes of Movement to develop more
refined motor actions (sounds, words, phrases) rather
than on single phonemes per se
Work across Three Stages at once with varying priorities
Treatment is always functional/interactive/reciprocal
Prompts are continually faded until auditory model is all
that is required.
Once or twice a week therapy: 45 minute sessions
Assess efficacy using pre-therapy baseline, probes,
post-test and follow-up.
109
6. Profiling Approach
Nicole Müller, Martin J. Ball
& Ben Rutter
University of Louisiana at Lafayette
[email protected]
110
55
Problems with standardized tests
Data often acquired in non-naturalistic way
Client may not fit the standard population
Data often selective, not comprehensive
Numerical scores don’t tell clinician what
items were incorrect and in what contexts,
and how far off target they were
Scores don’t directly inform remediation
111
Linguistic Profiling
The ideal characteristics of a linguistically
valid assessment can be summed up as
follows
the assessment should be comprehensive
rather than selective;
The data used in the assessment should
be drawn from natural interactions;
if several examples of a token occur, all
should be analyzed, and the contexts
within which they occur taken into account;
112
56
Linguistic Profiling
The result of the assessment should be an
overall picture of the client’s performance
at the linguistic level concerned,
from which the assessor can easily infer
their abilities and impairments,
and which can explicitly aid in the planning
of intervention
113
PACS
For the analysis presented in this paper,
we chose to use Grunwell’s (1985)
Phonological Analysis of Child Speech
(PACS).
the analyses include the following:
phonetic range and distribution of consonant
sounds
use of this phonetic inventory at different
positions within word and syllable structure
114
57
PACS
the possible combinations of consonants at
these positions
A developmental metric
A communicative adequacy metric
Other aspects by choice, including
phonotactics, processes, features, variability,
homophony, and loss of contrast
Charts are available to display this
information
115
The Data
Connected speech: Fish story and
spontaneous speech
DEAP & Morrisette lists
Total of around 200 tokens
Transcribed into narrow phonetic
transcription using IPA and extIPA
116
58
First Step in PACS Analysis
The first two PACS analyses charts show
target phoneme realizations for singletons
(Table 1)
and for clusters (Table 2)
in four word positions: syllable initial word
initial (SIWI), syllable initial within word
(SIWW), syllable final within word (SFWW)
and syllable final word final (SFWF).
117
Tables 1 & 2
Tables show high variability in realizations
of targets, both singletons and clusters,
but also that this variability depends on the
position of target within syllable structure
Some of J’s sounds occur mostly as
singletons and others mostly in clusters
118
59
Phonetic Inventory & Distribution
Table 3 lists J’s phones in the four word
positions in terms of articulatory features
We see, e.g., that Jarrod has a nasal
system that looks pretty much like the
expected target system, with little variation
However, J’s phonetic inventory at
different places of structure has several
‘non-English’ sounds
119
Contrastive Phones
Table 4 shows J’s contrastive phones (i.e.
the equivalents of ‘phonemes’ in his
idiolect)
The table shows these at 3 places in
structure with direct comparison to target
phonemes
Insufficient data to show SFWW
120
60
Table 4
Table 4 shows that J has considerable
difference in contrastive units across the
different word positions
E.g. in SIWI he has at least ⎟m⎟, ⎟n⎜, ⎟b⎜,
⎟d⎜,⎟w⎜ and ⎟h⎜
In SWWF he has glottals and deletions for
most targets other than nasals
121
Developmental Metric
Table 5 shows the Developmental
Assessment chart of PACS – similar to
that of Crystal et al’s LARSP for syntax
It shows that J is operating at just below
Stage IV (2;6 - 3;0 normal developmental
age)
However, not all these sounds are fully
acquired by J
122
61
Table 5
This developmental assessment doesn’t
account for J’s variability
His current position on Table 5 would
suggest a need to work next on fricatives;
one could as well argue that voicing and
place of articulation errors should be a
priority, or lessening variability
123
Communicative Adequacy Metric
Table 6 illustrates a communicative
adequacy analysis of J’s speech.
This is divided into a section examining
the multiple loss of phonemic contrasts,
and a section looking at the establishment
or otherwise of basic feature contrasts.
124
62
Table 6 – multiple loss of contrasts
Table 6 suggests that Jarrod’s ⎟d⎜ and ⎟j⎜ are
responsible for a large amount of the loss of
contrastivity apparent in his speech.
his bilabial approximant with simultaneous
rhoticization is the cause of much loss of
contrast with onset clusters
A communicative adequacy analysis suggests
these units need to be prioritized in intervention.
125
Table 6 – feature contrasts
Not established or only partly established:
Stop - fricative
Stop – affricate
Voicing
Velar, and post-alveolar
Dental – alveolar contrast needs correct
realization
126
63
Remediation
J does not seem to have much awareness
of how unintelligible his speech is
But he is old enough to benefit from overt
feedback about his speech
We feel the electropalatography and
electroglottography or spectrography
would be beneficial
127
Targets for remediation
A first target would be the establishment of a
consistent alveolar placement of singleton /t, d/.
This could also help distinguish dental, alveolar
and postalveolar fricatives. EPG
Once this is established, the major placement
contrasts (e.g. alveolar – velar) in singletons can
be targeted, thus extending Jarrod’s functional
phonetic inventory. EPG
Once the singleton placements are stabilized,
we may expect that correct productions carry
over into clusters, as well.
128
64
Targets for remediation
The lack of a functional voicing contrast
should be worked on in conjunction with
place of articulation and feedback given on
aspiration as well as voicing. EGG
The SFWF position is the most deficient,
so these previous targets (especially
fricatives) should be emphasized in this
word position.
129
7. Other Intervention
Approaches
Nicole Müller & Martin J. Ball
University of Louisiana at Lafayette
[email protected]
130
65
4 other approaches
Nonlinear Constraint-Based Approach
B. May Bernhardt, Joseph Stemberger, Eva Major
Psycholinguistic Approach
Joy Stackhouse, Michelle Pascoe & Hilary Gardner
Systemic Perspective
A. Lynn Williams
Parents and Children Together
Caroline Bowen and Linda Cupples
131
7a Nonlinear
Constraint-Based
Approach
B. May Bernhardt,
Joseph Stemberger & Eva Major
University of British Columbia, Canada
132
66
Nonlinear Constraint-Based Approach
B. May Bernhardt, Joseph Stemberger, Eva Major
1.
Identifies strengths and needs at various levels of
the phonological hierarchy:
-- phrase, word and syllable structure
-- segments and features
2.
Identifies any other relevant factors (strengths,
challenges)
-- perceptual systems, oral mechanism
-- language and cognition
-- other personal or environmental factors
133
Hierarchy: Phrase to Feature
Phrase
Word
Word
Foot Foot
Syllable Syllable
Onset Rime (moras)
Segments (Phonemes)
Features
the living room
the – living room
living-room
li-ving-room
l-i v-ing r-oom
l-i-v-i-ng r-oo-m
134
67
Workbook in Nonlinear Phonology for
Clinical Application (2000)
Area of Focus
Phrase &
Word
Structure >
(+ supraseg)
Features &
Segments >
New stuff
Old stuff in new ways
Consider Strengths and Needs
1. New (but existing) word position
1. Word length
for existing segments
2. Word shape (CV..)
2. New sequences of existing
3. Stress patterns
features into existing word positions
e.g. C1-C2: Lab-Cor
Individual Features
Feature Combinations
(existing features > new segment)
e.g. [Labial] of [b]
+ [-voiced] of [t] >
[p]
The client >
Variability, Perception, Oral Mech, Language, Personal-Social
135
Goal Selection and Order
Alternating cycle of structural and feature goals
If a child is a risk-taker, and has no other
significant associated factors
more complex structures and features are targeted
at first.
If a child has significant associated factors
less challenging targets are chosen at first
Strengths are used as supports for the needs
established word structures and word positions are
used to target new features, and vice versa.
136
68
Bernhardt et al. (2007): Jarrod
Re-transcribed all the words for our section (had
supplemented DEAP to get a broader
representation of segments and word structures)
For analysis, used:
scan sheets from Workbook in NLP (phonological
analysis for goal-setting)
Computerized Articulation and Phonology Evaluation
System (CAPES, Masterson & Bernhardt, 2001) for
quantitative analysis support
137
Nonlinear: Suggested Target Order
Above all: Build J’s Communicative Competence!
Take into account his needs for attention, focus, morphology,
perception, oral mechanism use, general learning, literacy
1. New Structure:
Iambic stress in 2-3 syl. words,
phrases
2. New Feature:
[+lateral] /l/ in CV(V)(+nasal)
3. Old Structure, New Ways:
CVC and CVCV, with labial,
coronal stops, nasals (velars
+ voiceless WI stops in Block 2?)
4. Oldish Features Combined:
Fricatives in VC and CV(C)
5. More New Structure:
CCV(C) with /s/C, /kw/, /tw/
138
69
Bernhardt supplemental list
to DEAP
dragon
box
animal
blue
watches
planting
glove
wind (verb)
sister
burnt
heavy
thing
game
horse
raced
paint
gorilla
toothbrush
toothpaste
rocks
rainbow
desk
page
pages
mother
puppy
zebra
see
yeh
139
7b Psycholinguistic
Approach
Joy Stackhouse,
Michelle Pascoe* &
Hilary Gardner
University of Sheffield, UK
*University of Cape Town, South Africa
140
70
Different Perspectives
When working with children such as Jarrod, it is important
to adopt a range of perspectives to understand the nature
of their difficulties and to plan appropriate intervention.
These perspectives include:
Educational
Medical
Linguistic
Psycholinguistic
Psychosocial
The aim of this presentation is to introduce the principles of
a psycholinguistic approach in particular and how it was
applied to Jarrod’s case data.
141
What is a Psycholinguistic Approach?
A psycholinguistic approach is based on the
premise that children’s speech difficulties arise
from a breakdown in one, two or all of the
following speech processing domains
speech input processing, e.g. auditory
discrimination.
lexical representations, e.g. where components
of words are stored: semantic, phonological,
motor, grammatical and orthographic.
speech output processing, e.g. programming
and production of speech.
142
71
This is illustrated in the following simple
speech processing model where input
skills are on the left, stored linguistic
knowledge at the top and output skills on
the right ( from Stackhouse and Wells, 1997, p9)
143
A Simple Speech Processing Model
(from Stackhouse and Wells, 1997)
144
72
Asking Questions
A psycholinguistic approach involves asking specific
questions about a child’s speech processing skills within
this simple model
Answering these questions can be done through
interpreting:
specifically devised tasks as included in our
Compendium of Auditory and Speech Tasks (2007)
performance on published tests
progress made with therapy tasks
observations
case history information and reports from others.
145
A Speech Processing Profile
Answering these questions results in a
comprehensive profile of a child’s speech
input, output and representation skills
Jarrod’s speech processing strengths and
weaknesses were profiled and formed a
basis for planning and evaluating
intervention
146
73
Examples from Jarrod’s Speech
Processing Profile
INPUT: Can the child discriminate between real words?
Single segments – YES; Clusters - NO
REPRESENTATIONS:
Are the child’s phonological representations accurate?
Not always – difficulties with rhyme
SPEECH OUTPUT:
Can the child access accurate motor programmes? NO
PHONOLOGICAL AWARENESS OUTPUT:
Can the child manipulate phonological units?
Syllables – YES; Phonemes – NO
147
Speech Processing Summary
Jarrod therefore has both input and output
speech processing difficulties which
impact not only on his speech production
but also on his ability to develop
phonological awareness.
Transferring this information to a speech
processing box model illustrates where his
difficulties are:
148
74
Jarrod had difficulties with:
Phonological recognition and representation;
Motor programming and stored motor programs; Motor planning and execution
149
Jarrod’s Strengths
However, a psycholinguistic approach also identifies what
a child CAN do as well as what they can’t.
Jarrod’s strengths include:
a) awareness of syllable structure,
b) auditory discrimination of simple words,
c) some use of simplifying processes,
d) some alphabetic knowledge,
e) imitated attempts better (e.g. produced voiceless
plosives on imitation ),
f) becoming aware of need to change speech output
150
75
Intervention Objectives
Based on Jarrod’s psycholinguistic profile we
can use his strengths to target specific
intervention objectives, for example:
expand use of onsets to include fricatives
mark codas with fricatives or plosives
attempt more clusters
stabilize 2+ syllable words
reduce glottalisation across word boundaries
(work on connected speech)
develop phonological awareness of segments
link speech and phonological awareness skills
with letter knowledge
151
Combining Perspectives
These targets and activities were the result of
combining the information derived from a
psycholinguistic approach to investigate Jarrod’s
speech processing skills (input, storage and
output), a linguistic approach to analysing his
speech output phonetically and phonologically,
and an educational approach to the impact of
the above on his literacy development.
152
76
BUT……..
However good a therapy programme is on
paper, or however attractive the materials, it is
probably the interaction between the child and
the therapist/listener that is the key to a
successful outcome.
“It is argued that a major part of an SLTs skills lies
in the handling of the interactional sequence as
much as in the choice of therapeutic approach
or phonological targets for remediation.”
(Gardner,H., 2006. Child Language Teaching and Therapy, 22. p28)
153
Integrated 3-way Approach
(From Pascoe et al, 2006)
Our intervention plan for Jarrod is therefore based on
combining the following:
Psycholinguistic
Phonetics/
Phonology
Interaction
154
77
Summary
A psycholinguistic approach is a particular way
of thinking about a child’s speech and literacy
development and ensures active questioning
about how and why we do what we do in
intervention.
It does not require any special materials. Anyone
can do it! The approach, in different forms, has
been helpful in training parents and teaching
assistants as well a developing the skills of
speech and language therapists/pathologists.
155
References
For further information about using a Psycholinguistic Approach see the
following:
Stackhouse, J. and Wells, B. (1997) Children's Speech and Literacy
Difficulties 1: A Psycholinguistic Framework. London: Whurr
Publishers.
Stackhouse, J. and Wells, B. (Eds) (2001) Children's Speech and
Literacy Difficulties 2: Identification and Intervention. London: Whurr
Publishers .
Pascoe, M. Stackhouse, J. and Wells, B (2006) Persisting Speech
Difficulties in Children. Children's Speech and Literacy Difficulties 3.
Chichester:Wiley.
Stackhouse, J., Vance, M. Pascoe, M. and Wells, B. ( 2007)
Compendium of Auditory and Speech Tasks. Children's Speech
and Literacy Difficulties 4 . Chichester:Wiley
156
78
7c Systemic
Perspective
A. Lynn Williams
University of Tennessee, USA
157
Systemic Perspective
A. Lynn Williams
Systemic approach links analysis-target selectionintervention together in a package.
Systemic Phonological Analysis of Child Speech (SPACS)
incorporates independent and relational analyses that describe
the child’s system (phonetic inventory and distribution of sounds)
that is then mapped onto the adult system using phoneme
collapses
Distance Metric selects intervention targets that increase the
relevant frame of learning required by choosing targets that
represent the greatest distance in phonetic properties relative to
adult target as well as the targets to each other
Multiple Oppositions utilizes larger contrastive treatment sets to
focus on the multiple homonymy that exists across a rule set, or
phoneme collapse
158
79
Systemic Perspective
Assessment: SPACS
SPACS revealed that Jarrod had a limited sound
system
Phonetic inventory consisted primarily of anterior
stops, nasals, and glides (inventory constraint)
WI inventory was larger than WF inventory (positional
constraint)
Production of clusters was limited to occasional labial
stop + sonorant (sequence constraint)
These inventory, positional, and sequence
constraints resulted in several one-to-many
correspondences, as represented by the
phoneme collapses shown on the following slide
159
Systemic Perspective
Assessment: SPACS
Jarrod’s word-initial phoneme collapses
b
(p)
b
(t)
(g)
f
v
(T)
sp
d
d
(t)
(k)
(g)
(D)
(dZ)
(h)
(l)
st
w
(w)
(r)
tr
kr
gr
sw
skr
spl
str
skw
j
j
s
z
S
tS
(dZ)
(l)
kl
kj
gl
sl
160
80
Systemic Perspective
Assessment: SPACS
Jarrod’s Word-Final Phoneme Collapse
(p)
(b)
(t)
d
Ø
/
(p)
(t)
(k)
g
f
v
T
s
z
S
tS
dZ
(m)
(n)
(N)
161
Systemic Perspective
Target Selection: Distance Metric
The SPACS revealed mirror rules word-initially that involved
labial/non-labial obstruents and labial/non-labial sonorants.
Thus, targets from each set of mirror rules should lead to
generalization to targets involved in the other phoneme collapse.
labial obstruents and clusters to [b]
nonlabial sonorants and clusters to [j]
Word-final targets would be selected from the phoneme collapse to
null.
Specifically, the targets from each of these phoneme
collapses selected using the DM would be:
b ~ f, sp/# __
j ~ s, S, tS, gl / # __
O
~ t, v, z, dZ / __ #
162
81
Systemic Perspective
Intervention: Multiple Oppositions
MO approach assumes that learning is facilitated
by the size and nature of the linguistic “chunks”
that are presented to the child
Larger treatment sets address several error sounds
simultaneously from one rule set to facilitate systemic
sound learning, which is based on principles of
distributed learning
Further, the larger treatment sets confront the child
with the extent of phonological change that must
be achieved while exposing Jarrod to the
relatedness of the target sounds within a rule set.
163
Systemic Perspective
Intervention: Multiple Oppositions
Goal
[b] ~ f, sp / # ___
[j] ~ s, S, tS, gl / # ___
Ø ~ t, v, z, dZ / ___ #
Contrast Word Pairs
bat ~ fat, spat
buy ~ fie, spy
bit ~ fit, spit
bin ~ fin, spin
bead ~ feed, speed
you ~ Sue, shoe, chew, glue
ye ~ see, she, chi, glee
yo ~ sew, show, Cho, glow
yum ~ sum, /ʃʌm/, chum, glum
yip ~ sip, ship, chip, /glɪp/
K ~ Kate, cave, K’s, cage
weigh ~ wait, wave, weighs, wage
stay ~ state, stave, stays, stage
pay ~ /pet/, pave, pays, page
A ~ eight, /ev/, A’s, age
164
82
7d Parents and
Children Together
Caroline Bowen & Linda Cupples
Macquarie University, Australia
165
PACT
TWO PRINCIPLES
1.
Phonemic change is motivated by
homophony (listener confusion) and
enhanced in therapy by raising the child’s
and parents’ metalinguistic awareness of
the sound system.
2.
Heightened perceptual saliency of
contrasts makes new contrasts easier to
learn.
166
83
PACT
THREEFOLD FOUNDATION
1. The modification of a group, or groups, of
sounds produced in error, in a patterned way.
2. An emphasis on featural contrasts and
syllable structures rather than accurate sound
production.
3. Making it explicit to the child that the function
of phonology (contrasts) is communication.
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Parents and Children Together
PACT is broad-based
- it is a word-based (phonemic/linguistic) approach
but it also includes phonetic procedures as required
PACT is family-centred
- family takes part in assessment and therapy
PACT is evidence-based
- efficacy data are available for children aged 2;11
to 4;9 at the outset of therapy, with mild through to
severe phonological disorders (in PCC terms)
PACT was not regarded by these authors as the
‘best therapy’ for Jarrod – luckily there are many to
choose from!
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Why not choose PACT?
Jarrod’s diagnosis
- inconsistent speech disorder
- difficulty with syllable/word structures
2. Jarrod’s age (7)
- older than children in the efficacy study
- PACT games might be too ‘young’ for him
- once-weekly intervention not optimal
Bowen & Cupples saw Core Vocabulary therapy
(targeting consistency and by default accuracy) plus
Phonotactic Therapy (targeting word shapes) as a
more beneficial combination of approaches for him.
1.
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PACT: 5 Interacting Components
1.
2.
3.
4.
5.
parent / family education
metalinguistic training
phonetic production training
multiple exemplar training:
minimal contrasts therapy
auditory bombardment
homework
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1. parent / family education
PACT information
and resources, and
the Quick Screener
are freely available
on Bowen’s site.
Parents observe administration
and scoring of the screener.
This is a first step in
(a) learning to help their child
become intelligible
(b) understanding what the SLP
is trying to do and why.
Info about the systematic nature
of phonology, speech
development, modelling,
recasting, homework strategies,
etc are shared according to need.
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2. metalinguistic training
Child/parents/SLP, talk and think about the
features of speech sounds: [phonetic level]
and about how sounds are contrasted in words
to convey meaning: /phonemic level/
simple PA activities are incorporated
self-corrections are discussed, and practiced
using the ‘fixed up one’ routine (example)
In therapy and at home, a 50:50 balance
between ‘talking tasks’ and ‘thinking and
listening tasks’ is considered desirable
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3. phonetic production training
Stimulability techniques (Miccio, 2005) are
used to establish production of absent or
distorted phones, to two syllable positions
e.g., [su:], [u:s], or failing that, to produce
reasonable approximations in the same
sound class, in syllables.
Traditional techniques and facilitative
contexts are used.
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4. Multiple exemplar training:
- auditory bombardment
- minimal contrasts therapy
Parent and therapist read to the child, without
amplification, auditory input word-lists of up to
15 words representing a target.
The child classifies words pictured on cards
according to their sound properties.
Minimal pairs games and tasks are used, see:
www.speech-language therapy.com/audbom.html
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5. homework
Caregivers are carefully instructed in specific
techniques relevant to their own child, to use in
homework sessions and everyday conversation.
The techniques include modelling, recasting,
encouraging self monitoring and self-correction
by the child and enhancing the child’s
awareness of this process, using labelled praise,
providing focused auditory input, and doing a
range of multiple exemplar activities.
Home practice of therapy targets happens in 5-7
minute “bursts”, once, twice or three times daily.
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Blocks and breaks schedule
PACT is delivered in alternating blocks/breaks
≈10 weeks therapy / ≈10 weeks no therapy …
…thereby accommodating to the gradual
nature of speech acquisition in typical
development.
In blocks and in the breaks parents apply
skills learned in ‘family education’ component.
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8. International
Classification of
Functioning, Disability
and Health
Sharynne McLeod
Charles Sturt University, Australia
[email protected]
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ICF is endorsed and/or used by
American Speech-Language-Hearing
Association (ASHA)
Scope of Practice in Speech-Language Pathology
(ASHA, 2001)
Preferred Practice Patterns for the Profession of SpeechLanguage Pathology (ASHA, 2004a)
Scope of Practice in Audiology (ASHA, 2004b)
Quality of Communication Life Scale (Paul et al., 2004)
Royal College of Speech and Language
Therapists (RCSLT)
Canadian Association of Speech-Language
Pathologists and Audiologists (CASLPA)
Speech Pathology Australia (SPA)
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Development of ICF
World Health Organization aimed to
create a common language for comparison of
data across
countries, health care disciplines, services & time
to provide a systematic coding scheme for
health information systems
to provide a scientific basis for consequences
of health conditions
Source: www.who.int/classification/icf
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ICF presents an holistic approach
For all people
of all ages
across all nations
from a perspective of health and wellness
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90
World Health Organization’s
Development of the ICF-CY
ICIDH (1980)
International Classification of Impairments, Disabilities, and Handicaps
ICIDH-2 (1999)
International Classification of Functioning and Disability Beta-2
ICF (2001)
International Classification of Functioning, Disability and Health
ICF-CY (2007)
International Classification of Functioning, Disability and Health: Children &
Youth Version
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Transition
ICIDH (1980)
International
Classification
of
Impairments,
Disabilities &
Handicaps
ICF (2001)
International
Classification
of
Functioning,
Disability &
Health
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ICF and ICF-CY
Is not an assessment or intervention tool
Is a classification system
Is a theoretical framework
Biological
Psychological
Sociological perspectives
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International Classification of
Functioning, Disability and Health (ICF)
Health Condition
(disorder/disease)
Body Function &
Structure
(Impairment)
(Impairment)
Activities
(Limitation)
Environmental
Factors
Participation
(Restriction)
Personal
Factors
Source: www.who.int/classification/icf
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Body Function: SLPs’ typical focus
for children with speech impairment
ICF
Sample 1
(n = 109)
Body Structure 0.0%
Sample 2
(n = 90)
0.0%
Body Function 80.6%
86.5%
(intelligibility + sound production)
Activity and
Participation
7.3%
2.2%
Combination
12.0%
11.1%
McLeod, S. (2004). Speech pathologists’ application of the ICF to children with
speech impairment Advances in Speech-Language Pathology, 6 (1), 75-81.
185
Body Structure
“Anatomical parts of the body such as organs,
limbs and their components” (WHO, 2001, p. 10)
Within normal limits for Jarrod
“speech disorder of unknown origin”
(Shriberg & Kwiatkowski, 1988)
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Body Function
“physiological functions of body systems
(including psychological functions)” (WHO, 2001, p. 10)
b3 Voice and speech functions
b320 Articulation functions
This code includes phonological functions
This code includes almost all assessment tools and
interventions used in this seminar
b330 Fluency and rhythm of speech
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Body Function
b230 Hearing functions
b2300 Sound detection
b2301 Sound discrimination
b2302 Localization of sound source
b2303 Lateralization of sound
b2304 Speech discrimination
Most of these areas
were assessed under
the psycholinguistic framework
(Stackhouse et al.)
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Body Function
b140-b189 Specific mental functions
b144 Memory functions
b156 Perceptual functions
b1560 Auditory perception of sounds
b1646 Problem solving
b167 Mental functions of language
b1670 Reception of language
b1671 Expression of language
b176 Mental functions of sequencing complex
movements
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Body Function
“…improvement in function
is often the litmus text that society
uses to evaluate effectiveness of
programs and treatments.”
(Lollar & Simeonsson, 2005, p. 323)
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Activities and Participation
Activity: “the execution of a task or action by an
individual” (WHO, 2001, p. 10)
Participation: “involvement in a life situation” (WHO,
2001, p. 10)
d130-d159 Basic learning & acquiring knowledge
d3 Communicating
d310-d329 Communicating – receiving
d330-d349 Communicating – producing
d350 Conversation
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Speech Participation and Activity
Assessment of Children (SPAA-C)
A.Questions
for the child
B.Questions for friends
C.Questions for siblings
D.Questions for parents
E.Questions for teachers
F.Questions for others
McLeod, S. (2004). Speech pathologists' application of the ICF to children with
speech impairment. Advances in Speech-Language Pathology, 6(1), 75-81.
192
96
1. How do you feel about the way you talk?
2. How do you feel when you talk to your best
friend?
☺
3. How do you feel when you talk to your 10year-old sister?
4. How do you feel when you talk to your
Mom and Dad?
☺
5. How do you feel when you talk to your
school teachers?
6. How do you feel when your teachers ask
you a question?
7. How do you feel when you play with the
children at school?
☺
☺
8. How do you feel when people don’t
understand what you say?
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A similar response from a different 7-yearold with severely unintelligible speech
McLeod, S., Daniel, G. & Barr, J. (2006). Using children’s drawings to listen to how children feel about their speech.
In C. Heine & L. Brown (Eds.) Proceedings of the 2006 Speech Pathology Australia National Conference (pp. 38-45). 194
Melbourne: Speech Pathology Australia.
97
Activities and Participation
d240 Handling stress and other
psychological demands
SLP: When don’t you like to talk to people?
Jarrod: It annoys me when they don’t understand.
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Activities and Participation
d7500 Informal relationships with friends
d7504 Informal relationships with peers
“He tries to communicate with peers, yet
they don’t understand him and he can get
frustrated.”- Educational psychologist (4;11)
“He may also have difficulty maintaining
peer relationships.”- SLP (6;10)
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Activities and Participation
d760 Family relationships
Parent-child relationships
Sibling relationships (Barr, McLeod & Daniel, 2008, LSHSS)
d820 School education
d920 Recreation and leisure
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Environmental factors
e3 Support and relationships
e310 Immediate family
e320 Friends
e355 Health professionals
e4 Attitudes
May be
barriers or
facilitators
e420 Individual attitudes of friends
e460 Societal attitudes
e5 Services, systems and policies
e580 Health systems and policies
e586 Special education and training services,
systems, and policies
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Personal factors
Not specified in the ICF or ICF-CY
Includes “gender, race, age, other health
conditions…habits, upbringing, coping styles,
social background… overall behavior patterns
and character style…”
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Goals
Intervention should focus on Body Function using an
approach outlined by the previous authors
Intervention should also focus on
Activities and Participation
Environmental Factors
The focus should be directed towards
Jarrod
his family, friends, teachers and
society
(cf Bronfenbrenner’s ecological model of the child)
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Summary
The components of the ICF and ICF-CY and
their interrelationship are relevant for children
with speech impairment
Speech-language pathologists
traditionally focus on Body Function (and Structure)
additional consideration of Activity and Participation,
Environmental and Personal Factors is important
ICF-CY is beneficial for holistically considering
children such as Jarrod and their milieu
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9.Intervention
Outcomes
Beth McIntosh & Sharon Crosbie
Perinatal Research Centre,
The University of Queensland, Australia
[email protected]
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Core Vocabulary principles
Service delivery: 1-to-1
Two 30 minute sessions per week
Parent must be involved, working at home
(~15 mins) most days and monitoring best
production of target words
Number of words taught is crucial (>50)
Word mastery dependent on practice/drill
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Core Vocabulary
The child, parents and teacher select a list
of at least 50 words that are functionally
‘powerful’ for the child
Names
Places
Functional words
Favourite things
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CV therapy weekly structure
Monitor consistency
of production of
target words
Session A
Select target words
(up to 10)
Establish best production
Session B
Drill best production of
target words
Monitor consistency
of production of
target words
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Eliciting Best Production
Work with the child to establish best production
using modelling, cueing, breaking words into
syllables and sounds. Describe the word
structure.
Each word should be produced 20 times per
session in games, with positive and corrective
feedback being given.
Parents must monitor and practice ONLY the
words chosen each week.
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Core Vocabulary therapy
At the end of Session B the child produces the
10 words three times
Words produced consistently removed from the list of
50 words
Words produced inconsistently remain on the list from
which the next week’s 10 words are randomly chosen
Untreated probes (a set of 10 untreated words
elicited three times) monitors generalisation
once a fortnight
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Core Vocabulary - Jarrod
Case Conference - Jarrod, his mum, his
teacher, classroom assistant, SLP
selection functionally “powerful” words
16 sessions over 8 weeks
30-minute sessions at school
2 SLP’s
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Jarrod’s targets
Dad
thank you
blue teddy
markets
park
sister’s name
McDonalds
Neopets
school
Mrs X
Grandad
chicken nuggets
lion
bakery
calendar
Aunty x
chippies
zebra
gate
telephone
Uncle y
yoghurt
Sabre Leoman
car
climbing
3 cousins names
milk
Gomamon
library
jumping
teacher’s name
lollies
Yu-gi-oh
music
friend
Rosie (cat)
snakes
Spiderman
swimming
bicycle
Timmy (cat)
drink
Astroboy
motor program
cards
Honey (dog)
hot chocolate
Scooby Doo
telephone
numbers (3-7)
3 friends names
play station
Digimon
computer
school
hello
dvd
Toy World
playground
puffer
goodbye
Spyro
movies
shopping centre
tablet
please
Simpsons
supermarket
K-mart
reading
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Session A - Jarrod
10 words randomly selected from word list
Target: consistency of all productions in session
Syllables drilled sound-by-sound then
reassembled
Developmental errors accepted [SIpi] accepted
for chippies; [jIpi] initial attempt
Home/class practice daily (usually 3 times a day)
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Session B - Jarrod
10 words practiced in games
Reinforced best production
Consistent production of the 10 target
words reinforced at all times in everyday
communication at home and school
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Progress Post therapy
64 words produced consistently over 16
sessions
Inconsistency decreased from 80% to 36%
as measured on DEAP Inconsistency
Consonant accuracy increased by 22%
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% Consonants Correct
Quantitative changes
100
80
PCC
PVC
PPC
60
40
20
0
Initial
Final
Session
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Qualitative changes
3 sounds were correctly produced on all occasions
(/n, h, j/)
3 sounds were either produced correctly or omitted
(/b, d, g/)
For most sounds the number of realisations halved, e.g.
/l/ had 5 realisations as compared to 11
/l/: [l, v, d, r, j] as compared to [l, ø, p, b, w, t, d, r, g, /]
12 sounds limited to 2 or 3 realisations, e.g.
/r/: [r, w] as compared to [r, w, t, d, j, ø]
/d, j, ø/ were used most frequently as substitutions but
less often.
Glottal stops less prominent
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Pre
Post
215
Intervention Summary
Clinical hypothesis
Underlying phonological planning deficit
Jarrod received a 8-week block of core vocabulary therapy
Intervention resulted in
significant changes in his speech skills
speech became significantly more consistent
Jarrod’s mother and teacher were both pleased with the changes
Future intervention was planned to target the phonological
error patterns evident in his speech
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10. Comparison of
approaches and
discussion
Sharynne McLeod
Charles Sturt University, Australia
[email protected]
217
10 approaches
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Core Vocabulary
Cycles Approach
Learnability Theory
PROMPT
Only one approach
Profiling Approach
(PACT) was not seen
Nonlinear Approach
as appropriate for
Jarrod
Psycholinguistic Approach
Systemic Perspective
Parents and Children Together (PACT)
International Classification of Functioning,
Disability & Health (ICF-CY)
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109
Range of assessments
Speech
Consonants and consonant clusters
Phonological processes
Vowels, stress, multisyllabic words
Perception
Nonword repetition, same/different, audtiroy lexical discrimination
Oromusculature/motor speech
Hearing
Literacy and phonemic awareness
Case history
Activities, participation, environmental and personal factors
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Most common intervention goals
FOR JARROD
Global speech goals
Intelligibility, system-wide restructuring
Specific speech goals
Consonants
fricatives, velars, liquids, voicing
Syllable shapes
consonant clusters, final consonants
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Range of intervention goals
FOR JARROD
Global speech goals
Intelligibility, functionality, system-wide restructuring, consistency
Specific speech goals
Consonants
fricatives, velars, liquids, alveolars, voicing
Syllable shapes
consonant clusters (2 & 3 element), final consonants, multi syllabic words
Vowels
Stress
Speech motor control
Speech perception
Phonological awareness, literacy
Self-monitoring, self correction
FOR OTHERS
Parent training
Environmental goals: Peers, siblings, school, health/education system, society
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Jarrod today
Received intervention focussing on
Core vocabulary
Phonological patterns
PROMPT
Literacy and phonological awareness
Now has intelligible speech under
controlled circumstances
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Previous considerations
Seminars in Speech and Language
(Shelton, 1993)
Grand rounds for sound system disorder: Matthew
American Journal of Speech-Language
Pathology (Williams, 2002)
Perspectives in the assessment of children’s speech
223
“Clinicians need to make skillful use of
a tremendous store of information…”
Knowledge about
Children
Environments
Maturation
Learning
Phonetics
Phonology
Clinicians’
Interpersonal skills
Experience
Behavior
(Shelton, 1993, p. 175)
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Researchers need to
Undertake comparative research on
assessment,
target selection and
intervention
“My sense of the field is that it needs simplification…
We seem to be moving to greater complexity…”
(Shelton, 1993, p. 166, 167)
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This short course has presented
10 different approaches
To assessment
To target selection
To intervention
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Different approaches are suitable for
Different children
The same child at different times
Different contexts
Different SLPs
Every
child
is
unique
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Evidence-based practice
Theoretical evidence
Clinical expertise
Clients’ choice
Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Hayes, R. B., & Richardson, W. S. (1996).
228
Evidence-based medicine: What is is and what is isn't. British Medical Journal, 312, 71-72.
114
Comparison of ten
interventions for a
seven-year-old with
unintelligible speech
SC28: Short course
American Speech-Language-Hearing Association Convention, Boston
1:30-4:30pm 17 November, 2007
229
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