The Unintelligible
Preschooler:
Assessment and
Treatment
Feb. 11-12, 2000
1
Peter Flipsen Jr., Ph.D.
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Assistant Professor of
Communication Disorders
Minnesota State University,
Mankato
ASHA Certified (CCC-SLP)
Minnesota Title Registered (SLP)
Canadian Certified (S-LP(C))
2
Course Objectives:
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Identify factors that contribute to the
intelligibility of speech
Select appropriate test materials for
unintelligible preschoolers
Identify the nature of intelligibility deficits
in unintelligible preschoolers
Select appropriate treatment strategies
Incorporate parents into treatment
programs
3
Overview
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Part 1 - Assessment
Review intelligibility as a concept
Review factors contributing to
intelligibility
Review assessment of intelligibility
Discuss possible factors
contributing to intelligibility deficits
Review procedures for evaluating
each of the factors
4
Overview
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Part 2 – Intervention
Dealing with short-term issues
Dealing with structural problems
Dealing with motor problems
Dealing with resonance problems
Dealing with linguistic problems
Incorporating parents
5
Pretest
6
Who Are We Talking
About?
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Preschool children who are
otherwise typically-developing but
who present with speech that is
unusually difficult to understand
One or both parents may be good
“translators” but most unfamiliar
listeners have difficulty
communicating with these children.
7
Some examples:
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Faustin – age 6;0
Dylan – age 5;1
Aaron – age 4;1
8
Who these children are
not.
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Not hearing impaired
No obvious structural problems
No frank neurological impairments
No major cognitive deficits
No problems with receptive
language
9
Consequences of
Being Unintelligible
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Communication is not effective
May reduce attempts to speak
Limits practice time for learning
language
Increasing frustration
May lead to behavior problems
Reduced message complexity
Shorter utterances more easily
understood
10
Consequences of
Being Unintelligible
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Limited practice time may account
for why many of these children
also have expressive language
delays (Miller & Leddy, 1998)
Some emerging evidence that
significant delays in speech
acquisition lead to later problems
with reading acquisition
11
Historical Pattern
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Up until the early 70s these
children were seen as having
“functional articulation disorders”
Implied that it was a problem
learning how to say the sounds
1970s -sudden shift to saying they
had “phonological impairments”
Implied that it was a problem
knowing where to use the sounds
12
The Clinical Puzzle
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Difficult to define the specific
nature of the problem these
children are having
Also difficult to know what the best
treatment approach might be
13
The Clinical Solution?
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Both of the historical labels
assumed that this was a single
group
No single approach to treatment
seems to work for all of them
Very likely the problems are based
in a variety of causes
Need to identify the likely cause for
each child if possible
14
Part I - Assessment
15
The Concept of
Intelligibility
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Understandability
How effectively a person can get
their message across
The goal of every communication
event
“… the functional common
denominator of verbal behavior.”
- Kent et al. (1994)
16
Factors Affecting
Intelligibility
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The listener
The listening environment
The speaking context
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(pragmatic and linguistic)
The speaker
17
Listener Factors
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Hearing acuity
For most clinical purposes, we
select listeners with normal hearing
Receptive language skills
For most clinical purposes, we
select listeners with normal skills
18
Listener Factors
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Familiarity with speaker personally
Parents (and anyone who spends
much time with these children)
quickly become “biased” listeners
Learn to ‘translate’ the abnormal
patterns
19
Flipsen (1995)
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Study of parents as “familiar”
listeners
Four children tested longitudinally
while in therapy
Made recordings of children
speaking single words (Y-B test)
Mothers, fathers and unfamiliar
listeners tried to identify words
20
Flipsen (1995)
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Mothers understood significantly
more of the words than any of the
other listeners
Fathers were not significantly
better than the unfamiliar listeners
Appeared that mothers were
spending much more time with the
children (not formally measured)
21
Listener Factors
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Familiarity with the material being
produced
If you’ve heard the “Rainbow
passage” 50 times you come to
know what to expect
If you chose the sentences to be
read you know what to expect
22
Listener Factors
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Familiarity with the speaker’s
population
Particular disorder groups do tend
to have similar overall speech
patterns
The more time you’ve spent with
those groups the more easily you
are able to understand them
23
Listener Factors
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Familiarity with disordered speech
in general
Experienced SLPs better at
understanding disordered speech
than non-SLPs
24
Environmental Factors
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Affect both speaker and listener
Noise levels
Presence / absence of visual
distractions
Comfort level
THESE CAN USUALLY BE
CONTROLLED FOR MOST
CLINICAL PURPOSES
25
Contextual Factors
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Speaking Task
Conversation
 Monologue
 Reading
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Material being produced
Connected Text
 Sentences
 Single words

26
Contextual Factors
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Usually see an interaction between
level of intelligibility and the type of
material being produced
Speakers with milder intelligibility
deficits tend to do better with
connected contexts
Speakers with more severe
intelligibility deficits tend to do
better with single-word context
27
Fig. 1
28
Fig. 1a
29
Speaker Factors
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Cognitive skills
Usually doesn’t impact intelligibility
except at very low levels
Poor presuppositional skills – may
not provide all the necessary info
May also see speech motor skills
deficits in those with more severe
cognitive deficits
30
Speaker Factors
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Expressive language skills
Vague vocabulary may be a
problem
Missing morphological markers
may also interfere
Force the listener to have to work
harder to process the information
31
Speaker Factors
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Phonological skills
Includes knowledge of:
phonemes
allophones
morpheme structure rules and
sequential constraints
morphophonemic rules
32
Speaker Factors
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Speech Motor Skills
Ability to formulate and transmit
the neuromotor instructions
Frank dysarthria and dyspraxia
readily reduce intelligibility
Affect both accuracy and timing of
segment production
33
Speaker Factors
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Hearing Acuity
Clearly if you can’t hear what
you’re producing, you will have
difficulty producing it accurately
Not a factor in the group we’re
discussing
34
Speaker Factors
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Auditory Perceptual Skills
Not a major issue for all these
children
Some may have problems with
perceiving the difference between
sounds they have difficulty
producing and what substitute
35
Speaker Factors
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Status of the physical mechanism
Most minor structural problems are
not a problem by themselves
It is possible however for several of
these to combine with each other
to make the task of producing
speech more difficult
36
Speaker Factors
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Voice Quality
Harsh or hoarse voice adds noise
to the signal making it harder to
understand
Higher pitched voices in children
are by definition ‘thinner’ (fewer
harmonics) making them more
susceptible to effects of other
factors
37
Speaker Factors
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Resonance Status
Hyponasal (denasal) speech can
be harder to understand because
of the loss of oral-nasal contrasts
Nasal consonants account for
about 10% of all speech sounds
Rarely a major factor however
38
Speaker Factors
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Hypernasal speech has a more
serious impact on intelligibility
Nasal cavity resonances are low
intensity (hard to hear)
Nasal cavity has anti-resonances
that cancel out some acoustic
energy making the output even
harder to hear
39
Speaker Factors
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Articulation Skills
The ability to produce the
individual speech sounds
Speakers with few errors may still
be unintelligible
Speakers with many errors may be
quite intelligible
40
Fig. 2
41
Fig 2a
42
Fig 2b
43
Speaker Factors
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Speech sound production skill only
accounts for 20-50% of the
variance in intelligibility
44
Speaker Factors
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Prosodic Skills
Excessively fast or slow rate may
reduce intelligibility
Clutterers use extreme rate – hard
to process what they are saying
Classic strategy in adult dysarthria
is to have them slow down
If speech is too slow, listener may
lose track of the whole message
45
Speaker Factors
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Atypical stress patterns may also
reduce intelligibility
e.g., stress on wrong word in
sentence or on the wrong syllable
in a word or too little stress
Listeners rely on stress to assist
with sorting out the words
e.g., many N-V pairs differ only on
stress
46
Speaker Factors
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Motivation and effort
We all know people who appear to
“mumble” at times but can make
themselves understood if they
choose to
And when we ask some speakers
to repeat, they may change what
they do and the result is an
improved signal
47
Speaker Factors
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Nonverbal communication skills
(i.e., gestures) may play a role
Recent study by Garcia & Cobb
(1998) showed that gestures also
contribute to message
understanding in adult dysarthria
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(only 2 speakers studied however)
48
Intelligibility and
Severity
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NOT the same thing though often
highly correlated.
A child producing many speech
sound distortions may be quite
intelligible but may be rated as
moderately impaired.
A child with a harsh voice may be
quite intelligible but listeners have
to work harder to understand him.
49
Intelligibility
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Clearly a very complex
phenomenon
It is not surprising that it is not well
understood by clinicians
50
Intelligibility
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Probably not meaningful to speak
of a single value.
Each individual probably has a
range of “intelligibility potentials”
(Kent et al., 1994).
51
Reporting Intelligibility
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To be meaningful, the following
need to be reported:
Some value
The material being produced
The listener (s).
52
Examples
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X was 68% intelligible when
producing single words recorded
on audiotape as judged by an
unfamiliar SLP
82% of the words produced by X
when reading 5-8 word sentences
on a video recording were
intelligible as judged by his
parents.
53
Developmental Aspects
of Intelligibility
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Children are not fully intelligible
even with first real words
Usually only approximations of
adult forms
Not a great deal of data on how
intelligibility develops
54
Developmental Aspects

Weiss, Gordon & Lillywhite (1987)
present some data (from
conversational speech):
18 months 25%
 24 months
50%
 30 months
64%
 36 months
80%
 42 months
92%
 48 months 100%

55
Developmental Aspects
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Despite being fully intelligible, the
average 4 year-old child is still has
not mastered all the speech
sounds.
Enough of the sounds are correct
that listeners can sort out what is
actually intended.
56
Developmental Aspects
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Good “rough” index is that %
intelligible in conversation for an
unfamiliar listener should =
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age in years divided by 4.
e.g., 3 year old = ¾ (75%).
 e.g., 4 year old = 4/4 (100%)

57
Measuring Intelligibility
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Despite the importance of
intelligibility, we don’t do a very
good job of measuring it
We tend to rely on informal ratings
that have poor reliability
We have tended to assume that
speech sound production accounts
for most of it (clearly not true)
58
Measuring Intelligibility
(general guidelines)
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Clinician working with the child
should NOT act as the judge if at
all possible.
Record all measurement events
and SAVE them!
Try to use unfamiliar, untrained
listeners each time
Parents, older siblings OK if you
use them each time (socially valid)
59
General Guidelines
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If you have to be the judge, listen
to the “after” tape first, then the
“before” .
Do the judging all in one sitting.
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General Guidelines
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Record the same type of material
each time
Use the same tape recorder each
time for recording
Record in the same place each
time
Listen in the same place each time
61
Measuring Intelligibility
(specific procedures)
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Informal ratings
Very widely used
After a diagnostic session, clinician
makes a decision about ‘how
intelligible’ the child was
Often a % estimate
May be a general statement
62
Exercise #1
63
Specific Procedures
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Labeled rating scales
Many available
Usually make judgments based on
a connected speech sample
(conversation or reading)
64
Labeled Scales
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A typical 3-point scale
1 = readily intelligible
2 = intelligible if topic known
3 = unintelligible, even with careful
listening
Source: Bleile (1997)
65
Labeled Scales
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A typical 5-point scale
1 = completely intelligible
2 = mostly intelligible
3 = somewhat intelligible
4 = mostly unintelligible
5 = completely unintelligible
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Source: Bleile (1997)
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66
Labeled Scales
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A typical 7-point scale
1 = intelligible
2 = listener attention needed
3 = occasional repetition of words
needed
4 = repetitions/rephrasing necessary
5 = isolated words understood
6 = occasionally understood by adult
7 = unintelligible
Source: Shprintzen & Bardach (1995)
67
Exercise #2
68
Specific Procedures
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Formal procedures
Involve either preset stimuli or
transcription of connected speech
69
Specific Procedures
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Yorkston-Beukelman test
Actual title: Assessment of the
Intelligibility of Dysarthric Speech
Acronym = A.I.D.S.
Prefer to call it the Y-B test
70
Y-B Test
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Has both single word and sentence
stimuli
Single words = choose 1 randomly
from each of 50 sets of 12 words
Children repeat the words; adults
read them
Listener’s task can be either
transcription or multiple choice
71
Figure 10
72
Figure 11
73
Exercise #3
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Items 26-50 on Y-B test
74
Y-B Test
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22 Sentences = choose 2 from
each of 11 sets of 100
Range from 5 - 15 words long
Speaker must be able to read
Listener’s task = transcribe
Reporting for both versions =
% words correct
75
Preschool Speech
Intelligibility Measure
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Morris, Wilcox & Schooling (1995)
Modified the single word version of
the Y-B test (no sentences)
Changed some of the words that
were not appropriate for young
children
Recently published through
Communication Skill Builders
(name changed to “Children’s …”)
76
Weiss Test
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Included in the Weiss Articulation
Test (Weiss, 1980)
Transcribe a sample of 200 words
Report % words understood
77
Shriberg’s Intelligibility
Index (II)
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Transcribe a conversational
sample of at least 90 different
words
This size of sample ensures that
your sample should include all of
the phonemes of English
Report % words understood
78
Word Counting Problem
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With connected speech that is hard
to understand, we have a counting
problem.
How do we count the words if we
don’t know what the words are?
In longer stretches of unintelligible
speech, how do we know where
one word ends and the next one
begins?
79
Word Counting Problem
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Solution = listeners can reliably
detect syllable pulses
Put X for each syllable you hear
Group syllables into words
Typically-developing preschool
speech is approximately:
70% 1 syllable words
 20% 2 syllable words
 10% 3+ syllable words
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80
Word Counting Problem
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Assume sequences of 4 syllables
or fewer are all single words
With sequences of 5 syllables,
assume first 3 are single words
and last 2 make up a 2-syllable
word
E.g., X X X (XX)
Etc
81
Exercise #4a-4c
82
So why are these
children Unintelligible?
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There are many reasons why a
preschool child’s speech might be
unintelligible.
No one-size-fits-all solution
Need to identify the source for
each particular child
Should greatly improve our
chances for intervention success.
83
Possible Sources
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Prosodic problems
Structural problems
Resonance problems
Speech Motor problems
Linguistic problems
84
Prosodic Problems
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By themselves likely insufficient to
account for reduced intelligibility
May contribute to the problem
however
85
Assessing Prosody
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No well established procedures
available
General impressions insufficient
Need some type of structured
approach
86
Assessing Prosody
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Most straightforward way is to
listen to a sample of about 30
utterances
Assess rate, stress, loudness, and
phrasing on each utterance
Rate each as “normal” or “nonnormal” on each variable
87
Assessing Prosody
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No well established criteria for
normal
Shriberg’s system:
Problem = any non-normal rating
occurring on at least 20% of
utterances
Borderline = any non-normal rating
occurring on 10-20% of utterances
Probably too liberal
88
Assessing Prosody
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Recommend:
Problem = any variable that is
rated as ‘non-normal’ on at least
30% of the utterances rated
89
Structural Problems
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NOT talking about major issues
like a cleft palate or other
craniofacial anomalies
May see a series of small
problems that by themselves are
not a problem
Combinations of small problems
sometimes create difficulties
90
Oral-Facial Exam
Review
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Principles from Mason (1982)
Examine structure and function
Examine form and symmetry
Relationships as important as the
parts themselves
Abnormalities on the outside may
indicate problems on the inside
Not all parts of the oral-facial
complex grow at the same rate
91
Oral-Facial Growth
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Maxillary arch and tongue grow at
about the same pace
Reach adult size by age 11-13
Tongue growing most rapidly
between 5 ½ and 7 ½ years
Mandible grows slower
Reaches adult size by age 18-20
92
External Structure
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See form
Front view
Normal face = 5 “eyes” wide
93
Fig. 3
94
Fig. 3a
95
External Structure
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Face has 3 vertical divisions
Upper face = hairline to eyebrows
Midface = eyebrows to base of
nose
Lower face = base of nose to chin
Upper face = lower face in height
96
Fig. 4
97
Front View of Face
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Intercanthal width = Width between
the eyes
Alar base width = width of base of
nose
Normally: intercanthal width = alar
base width
Lips corners should line up with
medial edges of the irises
98
Fig. 5
99
Front View of Face
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Nasal ala should be of equal size
and shape
Columella (division between
nostrils) should be complete
Philtrum (trough between nose and
lips) should be well-defined
Cupid’s bow (upper edge of lips)
should be well-defined
100
Lip Incompetence
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At rest, the lips of a normal adult
should be together
Called lip “competence”
Expected in adults
For 80% of children under age 12,
the lips are apart at rest
Called lip “incompetence”
This is NORMAL in children
101
Lip Incompetence



Recall that the mandible is slower
growing than the maxilla
Result = in children the mandible is
smaller than maxilla
Tends to draw the lower lip back
away from the upper lip
102
Mouth Breathing

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Unknown how common this is
NOT indicated by “lips apart” at
rest
Could be (quite normal) lip
incompetence
Requires airflow studies to confirm
103
Front View of Face


Lower lip should cover up a small
portion of the upper incisor teeth
Look for surgical scars and
document if present
104
Lateral View of Face
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
Auditory meatus should line up
with zygomatic arch (cheekbone)
A single lowset ear is not
uncommon
Embryologically the ears start out
in the neck and migrate up the side
of the face to their final position
105
Lateral View of Face
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
Both pinnas should be complete
Profile line runs from bridge of
nose down through base of nose to
tip of chin
Should be straight or slightly
convex (curved outward)
106
Lateral View of Face

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
Esthetic line runs from tip of nose
to tip of chin
The lips should be at the line or
slightly behind
More likely at the line for children
The lower lip should be slightly
closer than the upper lip
107
Lateral View of Face




Angle where upper lip joins with
the base of the nose = Naso-labial
angle
Normally = 90-110 degrees
Smaller = maxilla protruding
Larger = maxilla retracted
108
Exercise #5
109
Internal Structure

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
Are all the teeth present?
Make note of any missing ones
Gaps between teeth (diastemas)
common in children
110
Occlusion
Relationship between upper and
lower molars (NOT front teeth)
 Normal = upper 1st molar ½ a tooth
ahead of lower 1st molar
 Class II = reversed situation
st
 Class III = upper 1 molar more
than ½ a tooth forward of lower
111
Teeth




Entire upper dental arch slightly
wider than lower dental arch
All upper teeth should be
positioned slightly outside of lower
teeth when they meet
If any upper tooth is inside of a
lower tooth, this = crossbite
Crossbite can occur anywhere
112
Teeth

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Upper central incisors should be
slightly ahead of lower
If too far ahead, this = overjet
If behind, this = underjet
When teeth are together, all upper
should contact lower
If not, this = openbite
Openbite can occur anywhere
113
Teeth


Upper central incisors, should
cover 1/3 to ½ of lower incisors
If more than ½, this = closed bite
114
Tongue



At rest, tongue should sit behind
the lower central incisors
The sides of the tongue should rest
on the lower back teeth
The lingual frenum should allow
the tongue tip to easily touch the
alveolar ridge
115
Tongue


Macroglossia (enlgarged tongue) =
rare. Usually signals some active
disease process
Down syndrome – actually have
normal tongue in small oral cavity
116
Palate

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Two possible shapes to palate:
1. High and narrow
2. Shallow and wide
Midline should be pinkish or white
(not purple)
Torus palatinus = overgrowth of
tissue where primary palate meets
main palate
Seen in about 1/7 of population
117
Fig. 6
118
Velum



Soft palate + uvula
Should hang symmetrically
Bifid uvula may signal submucous
cleft but often doesn’t
119
Tonsils



Note if present
Normally not visible in older
children and adults
Atrophy (get smaller) after puberty
120
Tonsils



If really large they can displace the
posterior fauces
May result in widening of the
pharyngeal space (situation is
called “cryptic” tonsils)
If long-standing, fauces may
remain in pushed-back position
even after tonsils atrophy
121
Cryptic Tonsils


Uvula should be the last thing you
see before the posterior
pharyngeal wall
If posterior fauces are pushed
back, the upper edge may be
visible between the uvula and the
pharyngeal wall
122
Fig. 7
123
Exercise #6
124
Consequences of
Structural Problems



Some differences observed may
have consequences for speech
Many children adapt to the
differences and we don’t see any
problems with speech
Our concern is with the children
who fail to adapt
125
Dental Problems


Class II malocclusion (upper teeth
retracted) – results in less frontback space for tongue to move in
Class III malocclusion (upper teeth
protruded) – results in alveolar
ridge being further forward than
usual; tongue has farther to move
than usual
126
Dental Problems




Openbite – tongue has a tendency
to want to fill in the open space
May create abnormal resting
position for tongue possibly leading
to abnormal movement patterns
Anterior closed bite – alveolar
ridge is lower than usual
Ridge harder to reach especially in
connected speech
127
Ankyloglossia




Tongue-tie
Doesn’t always create a problem
If present and speech is a problem,
might be worth considering having
it “clipped”
Not usually the main cause but
may be contributing
128
Palatal Shape


Really narrow or really shallow
palate may restrict tongue
movement
May make it difficult to efficiently
move between positions
129
Tonsils



Very large tonsils may restrict
movement of the back of tongue
May also make it difficult to get
palatal closure
Cryptic tonsils may account for
some cases of mild hypernasality
130
Case studies



1. Overjet and shallow palate
2. Anterior openbite &
fingersucking
3. Large tonsils and /r/
131
Developmental
Problems



In very rare cases, reduced
intelligibility may reflect an overall
immature vocal tract
Oral cavity needs to be large
enough for tongue to move rapidly
between positions
Unclear if this will have a major
impact on intelligibility
132
Developmental
Problems






Case study – 4 year-old Aaron
All sounds in words ageappropriate (P.A.T.)
Cluster reduction = delayed
Connected speech 65-70%
intelligible
15th percentile for height / weight
Very small oral cavity may be
restricting rapid tongue movement
133
Developmental
Problems



Useful to obtain (or have access
to) percentile rank charts for height
and weight for children
Could also get this info on a
particular child from the family
physician
See Kent (1994) “Reference
Manual” published by Pro-Ed
134
Oral-Facial Function


Oral-facial exam form includes
“external function” checks –
looking at nonspeech movements
to assess integrity of cranial nerves
and nerve-muscle connections
Looking for muscle weakness
(dysarthria)
135
Internal Function




All tasks include speech sounds
No need to measure “fast”
productions – probably doesn’t
represent speech abilities
Diadochokinetic rate measures of
doubtful usefulness
Accuracy and sequencing
problems almost always seen at
normal rates
136
Internal Function



Make sure head is level
For some children opening mouth
completely make cause them to
“lock up”
May need to have them close
mouth slightly to get out of this
137
Resonance Evaluation


Having child say /a/ and watching
for elevation only tells you if the
velum can elevate
Can’t see VP closure (which
includes movement of pharyngeal
walls)
138
Resonance Evaluation


Need sample of connected speech
to judge hyper- or hyponasality
Probably worth having other
listeners to make judgments as
well
139
Resonance Evaluation


Remember that mild nasality is
expected on vowels that occur next
to nasal consonants (assimilative
nasality).
Nasality that only occurs on
specific sounds may represent an
articulatory problem
140
Structured Stimuli


If hypernasality suspected, ask
child to imitate you saying two
types of sentences (lots of nasals
or no nasals)
Compare productions on the two
types.
141
Pittsburgh Sentences








1. Mama made lemon jam
2. Put the baby in the buggy
3. Kindly give Kate the cake
4. Go get the wagon for the girl
5. Sissy sees the sun in the sky
6. The ship goes in shallow water
7. Jim and Charlie chew gum
8. Please tie the stamps with string
142
Resonance Evaluation


Ignore “stopping” in #5 - 8 if child
has not acquired the later fricatives
or affricates
Ignore “velar fronting” in #3 and #4
if child has not acquired velars
143
Resonance Evaluation



If you suspect a problem with the
velum, need to have a formal
instrumental assessment
Best = direct exam with either
nasopharyngoscope or
videoflouroscopy
Next best = indirect exam with
oral-nasal airflow measurements
144
Respiratory Function



Record maximum prolongation of
/a/
Preschoolers should be able to
prolong for at least 5 seconds
Children above grade 2 = at least 9
seconds
145
Developmental Apraxia
of Speech (DAS)


Other than the dysarthrias
associated with cerebral palsy, this
is the classic childhood motor
speech problem
Need specific positive signs (NOT
enough to say progress in therapy
has been slow)
146
DAS Formal Tests




Screening Test for Developmental
Apraxia of Speech (STDAS)
Available from Pro-Ed
Kaufman Speech Praxis Test for
Children (KSPT)
Available from Wayne State
University Press
147
DAS Clinical Criteria





Significant problems with
consonant production
May see vowel errors
Errors increase as length of unit
increases
Errors often include more than 2
features
Errors often inconsistent
148
DAS Clinical Criteria





Difficulty with producing sequences
involving changing place of artic.
May see groping movements
May see oral apraxia (problems
with nonspeech movements)
May have history of ‘neurological
event’
May have problems with timing
and control of nasality and prosody
149
DAS Clinical Criteria




Usually have normal nonverbal IQ
Usually have normal receptive
language skills
Usually have normal hearing
Usually don’t have muscle
weakness
150
DAS – Specific
Procedures


Pay attention to phonetic inventory
(often very limited)
Note syllable shape inventory (may
also be limited)
151
Inventories


Phonetic inventory – all the sounds
child is capable of producing (not
necessarily used where they
should be)
Includes sounds that occur
accidentally; suggests child is
capable of producing it
152
Inventories


Phonemic inventories – sounds
produced correctly and used where
they should be
List of correct sounds on a
traditional articulation test = the
phonemic inventory
153
Inventories



Syllable shape inventories – range
of different syllable forms used
Often restricted in DAS
Most common shapes in children =
CV, CVC, VC, V, CCV, VCC,
CVCC, and CCVC.
154
DAS – Specific
Procedures




Stimulability usually quite poor
Sequencing (p-t-k etc.) tasks
frequently a problem
Note awareness – often very
aware that speech is difficult
Compare imitated to spontaneous
(often better at imitation)
155
Linguistic Problems



Also called “phonological”
problems
In recent years, we’ve tended to
lump all unintelligible children
without obvious organic problems
into this group
Need to rule out prosodic,
structural, resonance or speech
motor problems first
156
Linguistic Assessment




Essential problem = loss of
contrasts in speech
Often quite unaware of their
problem (though some are;
especially as they get older)
“fis” phenomenon
May be more concerned with
social aspects of speech than the
details
157
Linguistic Assessment



Multiple errors present when given
conventional articulation tests
More efficient to describe errors in
terms of “patterns” or “processes”
Provide an organizational
framework for intervention
158
Linguistic Assessment




Major emphasis on sound errors
Ideally we should base our
analysis on conversational speech
Problematic for children with very
unintelligible speech
Problem is not knowing what the
intended words are so we don’t
know what the target sounds are
supposed to be
159
Linguistic Assessment


Need to use a structured singleword procedure for most of these
children
Several published ones available
160
Khan-Lewis Procedure


Do a reanalysis of the productions
from the Goldman-Fristoe to yield
a process analysis
Advantage = don’t need to get
another sample
161
Hodson’s APP-R

See handout
162
Exercise #7

APP-R practice analysis
163
Auditory Discrimination



For some children, their “linguistic”
problem may be based in trouble
discriminating particular sounds
they are having trouble with
No reason to expect a generalized
problem with speech discrimination
Pay particular attention here if child
has a history of lots of OME
164
Auditory Discrimination




Check to see if they can
discriminate between the sound
they use and the intended target
Provide several opportunities
Could use picture pointing tasks
Could use ‘same-not the same’
tasks but be sure they understand
the concept of “same”
165
Part II - Intervention
166
Short-Term Problems






Unintelligibility = primary concern
Not always the listener’s fault
Scudder et al. (1993) suggest we
can train these children to engage
in “conversational repair”
They tend to just repeat
Try teaching them to revise (use
different words)
Train to add information
167
Structural Problems



Dental problems – make referral
for orthodontic assessment
Ankyloglossia – if obvious and
child is unintelligible, recommend
that it be clipped
Be sure parents understand that
the procedure by itself will not
“cure” the problem but will likely
help the therapeutic process
168
Palatal Shape Problems



Usually not correctable. Surgery
usually only done in cases of
severe craniofacial problems.
Impact may be reduced somewhat
on its own with craniofacial growth
May want to try rate control (teach
them to slow down) though this is
often difficult with preschoolers
169
Tonsils



May affect hearing indirectly (i.e.,
contribute to otitis media)
If they also restrict speech
movements, it might be worth
recommending removal
Remember that this is a medical
decision. ENT may have other
reasons for not removing them
170
Developmental
Problems with Structure



Recall previous case study
May be a case of “watch and see”
For case study - worked on
production of consonant clusters
(which were delayed) as an
indirect way to get him to slow
down. Proved somewhat helpful.
171
Resonance Problems



Speech therapy alone will NOT
solve a velopharyngeal problem
(except in rare cases of phoneme
specific nasality)
Little or no good evidence that
nonspeech activities (e.g., blowing,
sucking) make any difference
Almost always requires surgical or
prosthetic management
172
DAS Intervention




Two important principles:
1. Need to teach new behaviors
2. Need lots of practice BUT want
to be sure to avoid excessive
repetition of the same things (want
to teach flexibility)
3. Watch frustration if steps in
progression are too hard
173
DAS Intervention




Nonsense material often too
abstract for very young children
Better to associate real-world
syllables with meaning
e.g., “go” in some active game
Make activities sequential (focus
on completing tasks)
174
DAS Intervention




Want to expand both phonetic and
syllable shape inventories
Begin with sounds already in the
phonetic inventory
Teach new sounds using syllable
shapes they already use
Teach new syllable shapes using
sounds already in inventory
175
DAS Intervention





Visual stimuli often helpful
Create picture stimuli for each
sound and practice in games
Combine stimuli to help create
sound sequence practice
Aim for both accuracy and
flexibility
LOTS of production practice
176
Nuffield Dyspraxia
Programme


British program
Package of stimuli for treatment
Nuffield Hearing and Speech
Centre - London
 Phone 071 278 8527
 Fax 071 833 5518

177
Linguistic Problems


Intervention arising from APP-R
See handout
178
More on Hodson


Hodson spends most of her time
talking about single words
These children are very stimulable


Single words less of an issue
Need to move up to connected
speech level fairly quickly
179
Connected Speech



Can take the single word targets
being used and put them into
sentences
Yes even with preschoolers!
Production focus is on the target
180
Connected Speech




Use pictures previously used for
single word practice
Have child choose 4-6 pictures
Have them make up short
sentences for each word
Practice several times and send as
homework
181
Fig. 8
182
Hodson’s Limitations




Hodson provides a good basis for
assessment and selection of
targets
Is not very specific on how to teach
the child where to use the new
sounds
Relies on games and assumes
child will do it on their own
Doesn’t always work
183
Bowen’s Additions



Includes several elements that fill
in the gaps left by Hodson
Bowen prefers other assessment
protocols but Hodson is more
accessible here
Recommend: Use Hodson for
assessment and selecting targets
and Bowen for specific intervention
procedures
184
Bowen’s Additions






Outlined in recommended reading
1. Parent involvement
2. Use of metalinguistic tasks
3. Specific production activities
4. Multiple exemplar techniques
5. Homework
185
Parent Involvement



As much as possible parents
should be involved right from the
beginning
Parents should see initial
assessment (video?)
Should know the entire
management plan (see the big
picture)
186
Parent Involvement


Information and activities outlined
in her book: “Developmental
Phonological Disorders: A Practical
Guide for Families and Teachers”
Available from Amazon.com or
bn.com ($18.95 US)
187
Parent Involvement


See also Caroline Bowen’s
website:
http://members.tripod.com/Caroline
_Bowen/home.html
188
Metalinguistic Tasks



Intended to focus child’s attention
on the sounds being produced
Teaching self-monitoring
Several ways to do this
189
Metalinguistic Tasks



Traditional associations between
pictures and sounds (sometimes
called metaphonetics)
Segmentation – teach sorting of
words that begin or end with the
same sound
Rhyming – read rhyming books
such as Dr Suess and talk about
“words that rhyme”
190
Metalinguistic Tasks


Judgment activities – you produce
correct and incorrect versions and
ask child to judge
Revision and repair – talk about
what would happen if you make a
mistake and how you would correct
it
191
Production Activities



Here Bowen recognizes that
sometimes you have to directly
teach production of a sound
Even children whose main problem
is a linguistic one may need this
Traditional articulation therapy
activities
192
Multiple Exemplar
Techniques




Minimal pairs production activities
1. Point to picture of word
produced – focuses listening
2. Find rhyming pairs
3. Say one of a pair and child finds
the one that rhymes
193
Multiple Exemplar
Techniques



4. Child produces both members of
the pair one after the other
5. Child as teacher – judgment
tasks (produce pair and ask if
same or different)
6. Silly sentences – produce both
members of pair sentences and
child identifies the “silly” one
194
Homework



Should reinforce what is being
done in the therapy sessions
Activities can be more naturalistic
however
Parent needs to see the activities
directly (observe or video)
195
Homework




Doesn’t have to be major time
commitment
5-7 minutes per day
5-6 days per week
Suggests no practice the morning
of therapy sessions (OK after)
196
Homework Activities






Naturalistic activities – usual
interactions
Modeling of correct productions of
the current target
Corrective feedback
Encouraging self-monitoring
Encouraging self-correction
Reinforce revisions and repairs
197
Typical Bowen Session






Focused auditory stimulation
Minimal contrasts task
Judgment of correctness task
Phonetic production activities (if
needed)
Focused auditory stimulation
Parent instruction (if present but
could also do it on a video)
198
Homework Books




Include space at front for
communications if parent is not
attending sessions
Include pages constructed for
sentence practice (my addition)
Add new pages as new targets are
worked on
Probably don’t want more than 810 pages in book at any one time
199
An Alternate View



So far we’ve been assuming that a
single problem accounts for all the
errors for each child
For some children, some errors
may be motor problems, some
audit. discrim. and some linguistic
Need to check each sound (could
group by error source for
treatment) – see handout
200
Figure 9
201
Summary




Unintelligible Preschoolers are not
a single group
Assessment crucial to identifying
the source of the problem
Intervention should be focused
As far as possible parents should
be included in intervention
202
Posttest
203
Workshop Evaluations
204
The End
205