VIVA 22/11/18
Speech Pathology Management Plan
Name: JJ
MRN: *******
Date of Birth: XX
Chronological Age: 4 years; 4 month
Background
• Family history of communication impairment (both brothers)
• Referred by mother as displaying similar tendencies to his elder brothers and was unlike his peers
• Reported behavioral issues
• Hearing WNL
• Initial assessment conducted by a private SLP (Handover only included a single word analysis). A moderate-severe phonological impairment was
identified
General Rationale:
• EBP is not just about using evidence to decide a course of intervention. Rather, it combines the use of evidence with clinical expertise to make sound
clinical decisions tailored to individual clients (Baker, 2008).
• Bernhardt and Holdgrafer (2001) point out, inaccurate or incomplete analysis can result in intervention continuing for much longer than it needs to.
• Olswang and Bain (1994) treatment outcome measures of success:
1. Is the child responding to the intervention programme? = Treatment data
2. Is clinically significant and important change occurring? = Generalization probe data
3. Is intervention responsible for the change? = control data
4. How long should a therapy target be treated? = Generalization probe data
• There is evidence showing that children with speech impairments often have poor phonological awareness, which has been considered a predictor
of early reading ability and literacy skills (Foy & Mann, 2003).
• The importance of early intervention has been highlighted in a number of studies (Otaiba, Cynthia, Puranik, Ziolkowski & Montgomery, 2008).
• Choose target sounds that have a high impact on intelligibility (Grunwell, 2008).
• Criterion: needs to be achieving around 80% at each level before moving up the articulation hierarchy to ensure that the sound is being produced
correctly and that generalization can occur (Grunwell, 2008).
• Child with a phonological impairment has difficulty learning the rules of language rather than learning the production/articulation of the sounds in
the language.
• The primary goal of phonological treatment is to induce change in a child' presenting knowledge of the sound system of the surrounding speech
community (Gierut, 2005)
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VIVA 22/11/18
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Real change; infers an underlying change in linguistic knowledge (new places/manner of articulation, new syllable word shapes etc.)
Target atypical processes, as they are not a characteristic of normal developing speech. (Grunwell and Edwards).
Least Knowledge (Markedness) – Gierut (2005): Greater system wide change, target later sounds implies earlier sounds.
Gordon-Brannan & Hodson (2000) determined that children above the age of 4;0 with speech intelligibility score of less than 66% (less than 2/3rds
of utterances understood by unfamiliar listeners) intervention should be considered for.
JJ’s Identified phonological processes occurring more that once in the sample
• Cluster reduction (/l, r/)
• Cluster simplification (l, r/)
• Affrication (/l, r/ clusters)
• Fronting (Velars and fricatives)
• Coalescence (/l, r/ clusters)
• Gliding
Overall Goal/s: Improve JJ’s intelligibility so that people who do not know JJ can understand him. Specifically;
v JJ will be able to produce the velar sounds /k/ /g/ in all syllable positions to 90% accuracy.
v JJ will be able to produce /sk/ word initial cluster to 80% accuracy.
v JJ will be able to produce /fl/ word initial cluster to 80% accuracy.
These goals involve;
1. The elimination fronting.
• Targeted using a minimal pairs approach of clusters.
Rationale:
− JJ is fronting the consonants /k/, /g/ and /s/.
− By 3;6 years of age fronting is no longer an age appropriate process (Bowen, 2011).
− Ongoing speech sound difficulties are known to potentially impact on literacy development.
− Social confidence and competence can be impacted upon due to impacts on intelligibility and the obvious nature of the phonological process.
2. Acquisition of velars;
• Commence using the articulation therapy to ensure correct production and Stimulability
• Proceed to a minimal pairs approach using /sk/ and /st/ clusters once independent production has reached 80% accuracy.
Rationale:
− JJ is consistent with his singleton representation of /k/ thus the minimal pairs approach is appropriate.
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VIVA 22/11/18
− By 3;0 years of age velar sounds /k/ /ng/ and /g/ should be in the child’s inventory (Goldman & Fristoe, 2000).
− Depending on the results from the first session (language analysis) minimal pairs may not be appropriate.
− Velars may emerge first in word-final then in word-initial position in English so it is important to closely monitor and praise for correct productions
(Bernhardt & Stemberger, 1998; Vihman & Hochberg, 1986).
− Target non-stimulable sounds, because if a non-stimulable sound is made stimulable to two syllable positions, it is likely to be added to the child’s
inventory, even without direct treatment (Miccio, Elbert & Forrest, 1999).
− /k/–/t/ differ in terms of place, dorsal versus coronal. If the place distinction is learned in treatment of /k/–/t/ pairs, this same dorsal coronal contrast
should be carried over to other dorsal-coronal pairs such as /g/–/d/ and /ŋ/– /n/ (Gieuriut, 2002)
3. Elimination of cluster reduction and simplification
• /sk/ clusters will be targeted as it has the smallest sonority difference and therefor is the most difficult for JJ to acquire and in turn will promote the
highest generalisation.
• /fl/ clusters will be targeted as it not only targets the acquisition of a liquid but it also targets the cluster reduction and simplification of /l/ blends.
/fl/ was chosen as the error is consistent thus minimal pairs therapy would be appropriate.
Rationale:
− JJ predominantly reduced clusters to one of the two constituents; there were 5 instances of affrication and 3 instances of coalescence nil evidence of
initial /s/ clusters.
− By 4;0 years of age cluster reduction is no longer an age appropriate process (Bowen, 2011).
− To eliminate cluster reduction: priority to more marked consonants as it implies the necessary presence of another feature (Gierut & Champion,
2001),
− Clusters with small sonority differences of 2, 3 or 4 may better promote generalised change to singletons and clusters (Gierut, 1999)
− Consonant clusters should be chosen over singleton consonants to facilitate widespread change in children’s phonological systems (Gierut, 1998)
− A minimal pairs approach is effective in treating phonological processes.
− Targeting ‘sk’ reflects a least knowledge approach that may increase generalization of treatment effect as clusters imply singletons.
− Targeting /sk/ works on clusters and implies singletons due to markedness and low sonority rating.
− Research suggests selecting, treatment targets, later developing sounds and clusters, as training them will result in greater system-wide change
(Gierut, Morrisette, Hughes & Rowland, 1996).
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VIVA 22/11/18
Session Plan Week 1
General rationale for further assessment:
− Further assessment is required to determine if a problem with speech, language is still present as there was no date of current assessment
and it only briefly touched on speech and not all communication modalities (Paul, 2007).
− Necessary in establishing a baseline level of functioning where all area’s of communication function are examined. Important in determining
area’s of difficulty and relative area’s of strength.
− Necessary in establishing appropriate goals for intervention, as assessments provides essential clinical information useful for selecting
appropriate therapy goals.
− It will help guide service delivery allowing for meaningful and effective intervention to occur (Worrall, Sherratt, Rogers, Howe, Hersh,
Ferguson & Davidson, 2010)
− Used as a measure of change in order to continually evaluate the clients progress and the effectiveness of the intervention process.
− The early identification, diagnosis and treatment of language impairments are important steps in planning effective management (Salter,
Jutai, Foley, Hellings & Teasell, 2006).
Goal 1: Case History and rapport building.
Aim: Determine any underlying factors or red flags contributing the speech and language deficits.
Time: 5 minutes
Measure: Case History Form
Rationale:
− Roter (2000) suggests that through building rapport with patient the patient-clinician relationship strengthens. The patient trusts the clinician,
facilitating communication, so not only the clinician gains insight into the patient’s perspective of their disease/impairments but the patient in turn is
more likely to be compliant
− Building an appropriate relationship with the client is important as it allows the client to feel comfortable, structures participation in therapy, allows
for information to be conveyed, and encourages co-operation (Horton, 2007).
− It is important to obtain a case history, including medical, social, family & milestones, in order to gain a holistic depiction of the client and assist in
appropriate assessment selection and interpretation (Bowen, 2012).
− A case history is not only collecting information about an individual child. It also aims to develop a relationship and cooperativeness (Gumpert,
2010).
− The Case History identifies any red flags that may be a factor or a contributing factor to Speech and Language difficulties.
Activity:
− This will be sent to the family prior to the first session to save time but it will also be discussed during the session.
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VIVA 22/11/18
Goal 2: Connected speech sample.
Aim: information about production of sounds in connected speech using a variety of talking tasks, which elicit the most language (e.g., storytelling or
retelling, describing pictures, normal conversation about a topic of interest)
Time: 10 minutes
Measure: Speech intelligibility (precent), range of vocabulary, evidence of any phonological processes.
Parent measure: The Intelligibility in Context Scale (ICS) (McLeod et al. 2012b)
Rationale:
− Since the ultimate objective is correct production of sounds in spontaneous conversation it is important to examine the child’s speech in
connected speech.
− It allows for error patterns to be observed in a variety of phonetic contexts, and to judge the severity of the problem and the intelligibility of
the speaker in continuous discourse (Bernthal, Bankson & Flipsen 2009)
− It also has the advantage of allowing the clinician to transcribe sound production within the context of the child’s own vocabulary and in
running speech which includes their natural prosodic patterns.
Activity:
− Picture description
− Play based language activity
Teaching strategies:
− Descriptive language.
− Limit questions, rather use statements and interactive language
− Monitor JJs reactions and engagement.
− Encourage mum to participate.
Goal 3: OMA and palate examination.
Time: 5 minutes
Aim: Evaluate the structure and function of the speech mechanism to assess whether the system is adequate for speech production.
Measure: DEAP OMA assessment in addition to a full palate assessment
Rationale:
− To ensure there are no structural or organic barriers impacting JJ’s speech.
− Assessment investigates diadochokinetic (DDK) ability, examining p-t-k sequencing in terms of accuracy, precision and fluency of articulation;
isolated oromotor gestures (tongue elevation) and sequencing of two gestures (e.g., kiss and blow).
− Ensure no structural abnormalities both at rest and during phonation.
Teaching strategies:
− Allow JJ to have a turn eliciting the activities.
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VIVA 22/11/18
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Demonstrate on Mo if JJ is reserved.
Introduce the OMA in a fun way, for example "How many teeth have you got? Let's count them".
Goal 4: DEAP phonological analysis
Aim: Identifies units of production and allows all sounds in the language to be elicited in a number of contexts; however, it may or may not accurately reflect
production of the same sounds in connected speech.
Time: 10 minutes
Measure: DEAP phonological analysis assessment
− Provides the following quantitative measures with standard scores:
• Percent consonants correct (PCC)
• Percent vowels correct (PVC)
• Percent phonemes correct (PPC)
• Single-words vs continuous speech ratio (SvsC)
Rationale:
• DEAP has quantifiable data on the phonological acquisition of children in the UK and Australia, which could be used for comparison purposes
(Brebner, 2013).
• Establishing a phonetic inventory is important because this inventory can be used as the basis for determining the developmental
appropriateness of a child's sound production (Bleile, 2004) identifying targets for stimulability testing (Powell &Miccio, 1996), and/or selecting
goals (Davis, 2005; Gierut, 2005) or treatment targets within a phonological pattern (Hodson & Paden, 1991).
• The use of norm-referenced, standardized, single-word tests is a typical part of an evaluation for SSD (Skahan et al., 2007).
• Single-word standardized tests have been designed to provide a time-efficient means to elicit a diverse speech sample that includes
opportunities for production of all consonants and, in some tests, for production of vowels.
• An additional advantage is SLP knows what the child is trying to say. This can facilitate transcription and also enable the SLP to compare the
child's productions to adult targets (Bernhardt&Holdgrafer, 2001a; Grunwell, 1985; Hodson et al., 2002; Velleman, 1998).
• The availability of norms for identifying SSD (Skahan et al., 2007). This is important because quantitative test results may be required by school
districts to qualify for services or may be required by third-party payers to receive coverage for SLP services (Klein, 1996; Tyler & Tolbert, 2002).
• Gather a baseline measure in order to; track change and to evaluate the effectiveness of intervention, address a broad range of targets to
evaluate generalization.
Goal 5: CELP-P2 core language.
Aim: Determine language levels by assessing both receptive and expressive.
Time: 15 minutes
Measure: Core language subtests
Rationale:
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VIVA 22/11/18
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Determine if there is evidence of expressive or receptive language deficits.
Language impairment may affect treatment and intervention strategies.
May also be influencing JJ’s behaviour.
Using standardised test allows comparison against age norms whilst also providing a baseline for intervention, which can be used to measure
success.
The CELF-P2 is norm-referenced for children from 3:0–6:11 years and yields two core subscales of receptive and expressive language (Wake, 2012).
Scores from a standardized assessment, like the CELF-P2, are often required for children to be eligible for language assistance in the classroom.
The CELF-P2 measures a broad range of receptive and expressive language skills in young children and is often used to evaluate the aspects of
language necessary for preschool children to make the transition to school. It is relatively easy to administer and has been found to have positive
psychometric validity (Friberg, 2010).
Teaching strategies:
• Visual timetable.
• Verbal encouragement.
• Sticker chart
• Neutral feedback
Goal 6: Stimulability probe
Aim: determine whether a sound is likely to be acquired without intervention and to determine the level and/or type of production which instruction might
begin.
Time: 5 minutes
Measure: Metalinguistic cues
Rationale:
• Targeting non-stimulable sounds (to make them stimulable) via exploratory sound production and phonetic placement techniques increases the
chances of generalization, once stimulability has been achieved (Rvachew, Rafaat & Martin, 1999).
• Targeting stimulable sounds yields short term but limited gains, in terms of generalization (Powell & Miccio, 1996).
Teaching strategies:
− Use of gestural cueing for place or manner of production (e.g., using a long sweeping hand gesture for fricatives vs. a short, "chopping" gesture for
stops);
− “Throaty sounds”, “gurgle sounds”
− Make a ‘U’ shape with fingers and place on the angles of the mandible if the child is comfortable.
H/W/Parent Training:
Rationale
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VIVA 22/11/18
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H/W is essential to ensure maximum gain in the shortest timeframe and increase generalization.
Parent training is required on minimal pair’s therapy, stepping up complexity to carrier phrases and sentence level as appropriate (dictated by a 90%
accuracy rate spontaneously).
Isabella Johnston