***PRAXIS NEED TO KNOW

Infant-directed speech (IDS) is a speech style used by caregivers when interacting with babies and young children. It features exaggerated prosody, higher pitch, slower tempo, simpler syntax, and repetitive content compared to adult-directed speech (ADS), which is the typical speech style used between adults.

"Motherese" or "parentese" refers to the speech style characterized by higher pitch, exaggerated intonation, and simplified syntax that caregivers naturally use when addressing infants. It captures infants' attention, supports language acquisition, and fosters emotional bonding.

Caregivers switch to using IDS to enhance infants' attention, engagement, and language learning. Benefits of IDS include aiding speech sound discrimination, promoting early vocabulary acquisition, and supporting the development of social and communicative skills.

IDS exhibits acoustic features like higher pitch, wider pitch range, slower tempo, and exaggerated intonation. These features help capture infants' attention and facilitate language acquisition by highlighting key linguistic information.

Emotional prosody in IDS involves using varied pitch contours and emotional tones to convey affective content. This emotional emphasis helps infants discern emotional states and provides a foundation for learning emotional expression and social cues.

Scaffolding in language development refers to caregivers adapting their language to match the child's developmental level, providing a supportive learning environment. IDS serves as a natural form of scaffolding, making language more accessible to infants.

As children's language proficiency increases, the transition from IDS to ADS occurs naturally. This transition reflects the child's growing linguistic abilities and understanding of more complex sentence structures and content.

The use of IDS can vary across cultures and languages. Different cultures might emphasize certain prosodic features or strategies based on their linguistic norms and social practices.

Excessive use of IDS as a child grows older can potentially lead to difficulties in understanding and using adult-like language structures. Children need exposure to ADS to learn more complex grammar and vocabulary.

Joint attention refers to the ability to share attention with another person and focus on the same object or event. IDS enhances joint attention by guiding infants' attention to important visual and auditory cues, fostering social and cognitive development.

Research shows that IDS benefits language development by enhancing vocabulary acquisition, supporting phonological and prosodic sensitivity, and facilitating early communication skills.

Adults might use IDS-like speech when interacting with non-infant listeners, such as pets or other adults, to capture attention, emphasize emotional content, or convey enthusiasm. This suggests that some features of IDS have universal communicative functions.

An interpreter plays a crucial role in facilitating communication between a speech-language pathologist, the client, and their family when a language barrier is present. Challenges may include interpreting errors, potential cultural differences, and managing the flow of conversation. These challenges can be addressed through clear instructions to the interpreter, using a trained medical interpreter, and establishing a collaborative relationship.

Cultural competence is vital when working with interpreters. SLPs should understand the client's cultural background, values, and communication norms to ensure that interventions are culturally sensitive. This involves recognizing diverse communication styles, addressing cultural taboos, and adapting intervention approaches accordingly.

Preparation for an interpreter-assisted session includes explaining the interpreter's role, discussing confidentiality, and outlining session objectives. Privacy and confidentiality should be maintained, and interpreters should be informed about the nature of the content to ensure their understanding of specialized terminology.

Linguistic and cultural triangulation involves SLPs, interpreters, and clients collaboratively working together. This approach ensures that communication is accurate, culturally appropriate, and that the message remains consistent throughout the session.

Building rapport with both the client and interpreter involves creating a supportive and respectful environment. Taking time to introduce all participants, acknowledging cultural differences, and addressing any concerns fosters trust and effective communication.

Choosing an appropriate interpreter requires assessing their language proficiency, familiarity with specialized terminology, cultural sensitivity, and qualifications as a medical interpreter. A trained, qualified interpreter who understands both languages and has experience in healthcare settings is crucial.

Maintaining professional boundaries ensures that interpreters do not take on an advocacy or decision-making role. They should convey information neutrally without altering the content or context. SLPs should provide clear instructions to interpreters regarding their role in the session.

Strategies to maximize communication with interpreters involve using simple language, speaking directly to the client, allowing time for interpretation, and using visual aids to support understanding. Effective communication techniques enhance comprehension for all participants.

Accurate interpretation of assessment results is crucial. SLPs can provide interpreters with instructions for specific tasks, ensure they understand the purpose of assessments, and verify that interpretation aligns with the client's responses.

Interpreters play a vital role in family-centered care by facilitating discussions, conveying information, and ensuring the family's understanding of intervention plans. Their involvement supports collaborative decision-making and the provision of culturally responsive care.

Feedback and debriefing sessions with interpreters allow for open communication. SLPs can discuss challenges, clarify terminology, and improve the collaboration process. Regular communication helps identify areas for improvement and ensures effective future sessions.

When bilingual SLPs also act as interpreters, ethical considerations include maintaining objectivity, refraining from advocating for their own treatment approach, and prioritizing the best interests of the client. Clear boundaries must be established to prevent potential conflicts of interest.

The term "cookie bite audiogram" refers to a specific configuration of hearing loss on an audiogram where there is a noticeable "bite" taken out of the hearing thresholds at mid-frequency ranges.

The typical shape of a cookie bite audiogram is characterized by normal or near-normal hearing thresholds at low and high frequencies, but a significant drop in hearing sensitivity at mid-frequency ranges. This configuration creates a dip or "bite" in the audiogram's graph at those mid-frequencies.

The specific frequency range often affected in a cookie bite audiogram is typically around 2000 to 4000 Hz. This configuration can affect speech perception, as these mid-frequency ranges are important for perceiving consonant sounds in speech.

The most likely underlying cause of a cookie bite audiogram is congenital or hereditary sensorineural hearing loss. Genetic factors and conditions such as hereditary hearing loss or specific mutations can contribute to this audiogram configuration.

Individuals with a cookie bite audiogram might face challenges in perceiving certain speech sounds, particularly consonants, which are crucial for speech clarity. They might also struggle in noisy environments or when trying to understand speech with multiple talkers.

Hearing aids can be beneficial for individuals with a cookie bite audiogram, especially those equipped with features to enhance mid-frequency amplification. Customized fitting and programming are important to address the specific hearing needs of this configuration.

A cookie bite audiogram can impact an individual's ability to understand speech, especially in situations with competing background noise. The drop in mid-frequency sensitivity can result in reduced clarity for consonant sounds, affecting speech discrimination.

The configuration of a cookie bite audiogram can be either congenital or acquired later in life. Congenital causes may include genetic factors, while acquired causes can include factors such as noise exposure, ototoxic medications, or medical conditions affecting the auditory system.

Auditory rehabilitation strategies for individuals with a cookie bite audiogram might include auditory training, speechreading, and use of assistive listening devices. Audiologists and speech-language pathologists can play a role in providing support, education, and guidance in using these strategies effectively.

MBS involves the use of radiographic imaging, typically using barium contrast, to visualize the movement of food and liquids during swallowing. FEES utilizes a flexible endoscope to directly visualize the pharyngeal and laryngeal structures during swallowing, without radiation exposure. MBS requires radiation, while FEES does not.

In MBS, the patient ingests food and liquid mixed with barium. Radiographic images are taken while the patient swallows, providing a dynamic view of the swallowing process. The images reveal oral, pharyngeal, and esophageal phases of swallowing.

In FEES, a flexible endoscope is passed through the nasal passages to the pharynx. The endoscope provides a real-time view of the pharyngeal and laryngeal structures during swallowing. The clinician can assess structures, movement, and any signs of aspiration.

MBS offers dynamic imaging of the entire swallow, making it effective for identifying aspiration and silent aspiration. It provides a clear view of bolus movement and allows the assessment of various food and liquid consistencies.

FEES allows direct visualization of the pharyngeal and laryngeal structures, providing insights into structural abnormalities, movement, and signs of aspiration. It can be performed at the bedside, offering convenience for certain patients.

MBS involves radiation exposure due to the use of X-rays for imaging. FEES does not involve radiation exposure, making it a safer option, especially for individuals who need frequent assessments.

FEES provides real-time visual feedback, allowing clinicians to observe swallowing issues as they happen and make immediate recommendations for compensatory strategies or changes in food textures.

MBS is effective in identifying aspiration and silent aspiration by showing the movement of material into the airway. The radiographic images capture the moment of penetration and aspiration.

Clinicians might choose FEES over MBS when the patient cannot tolerate barium ingestion or radiation exposure is a concern. MBS might be preferred when a comprehensive view of the entire swallow process is needed.

Information from MBS or FEES guides treatment planning by identifying the specific phase(s) of swallowing affected, pinpointing structural issues, recommending diet modifications, and suggesting appropriate swallowing strategies.

Dysphagia is more common among older individuals, and prevalence is positively associated with sarcopenia (Barczi et al., 2000; Bhattacharyya, 2014).

Parkinson's disease: 35% to 82% (Kalf et al., 2012)

Stroke populations: 37% to 78% (Martino et al., 2005; Falsetti et al., 2009)

ALS or Lou Gehrig's disease: Up to 90% (Coates & Bakheit, 1997)

Critical illness: 3% to 62% (Macht et al., 2013)

Dementia: 13% to 57% (Alagiakrishnan et al., 2013)

Coughing and throat clearing could result from various factors such as gastroesophageal reflux, esophageal dysmotility, and common medications, rather than direct penetration or aspiration of a bolus

Stroke

Traumatic brain injury

Spinal cord injury

Dementia

Parkinson's disease

Multiple sclerosis

Amyotrophic lateral sclerosis (ALS)

Muscular dystrophy

Developmental disabilities (e.g., intellectual disability)

Post-polio syndrome

Myasthenia gravis

Polymyositis and dermatomyositis

Dysphagia can result from problems affecting the head and neck, such as:

Cancer in the oral cavity, pharynx, nasopharynx, or esophagus

Radiation and/or chemoradiation for head and neck cancer treatment

Trauma or surgery involving the head and neck

Decayed or missing teeth

Critical care procedures like oral intubation and tracheostomy

Dysphagia can also be associated with factors like:

Side effects of medications

Metabolic disturbances (e.g., hyperthyroidism)

Infectious diseases (e.g., COVID-19, sepsis, AIDS)

Pulmonary diseases (e.g., COPD)

Gastroesophageal reflux disease (GERD)

Following cardiothoracic surgery

Decompensation

Frailty

SLPs often serve as coordinators for dysphagia teams, leading in tasks such as:

Identifying core team members and support services.

Facilitating communication between team members.

Documenting team activity.

Consulting with team members actively.

Assisting in discharge planning.

A swallowing screening identifies individuals who need further assessment and can be performed by an SLP or other members of the care team. Its purpose is to determine if a comprehensive assessment or referral for further services is necessary.

Instrumental assessment provides visualization of swallowing anatomy and physiology, aiding in diagnosis and treatment. The two main types are videofluoroscopic swallowing study (VFSS) or modified barium swallow study (MBSS), and flexible endoscopic evaluation of swallowing (FEES).

Indications for an instrumental exam include concerns about swallow function's safety, efficiency, or impact on nutritional and pulmonary health, as well as the need for differential diagnosis, identification of disordered physiology, or determining a treatment plan.

General contraindications include unstable medical condition, severe agitation or inability to follow commands, and anatomical deviations that prevent barium use or endoscopy.

Instrumental examination assesses anatomy, physiology, bolus control, timing, laryngeal penetration, aspiration, secretions, and safety and efficiency of bolus consistencies and volumes. It requires advanced knowledge and skills to administer, interpret, and inform treatment decisions.

Other procedures include ultrasonography, which observes tongue and hyoid movement, and high-resolution manometry, measuring pressures in the pharynx and esophagus.

The primary goals of dysphagia intervention are to support adequate nutrition and hydration, determine optimum supports to maximize the patient's quality of life, and develop a treatment plan to improve the safety and efficiency of swallowing.

The two main categories of dysphagia treatment approaches are rehabilitative techniques (designed to create lasting change in swallowing function) and compensatory techniques (altering the swallow without creating lasting functional change).

Rehabilitative techniques are exercises designed to create lasting change in an individual's swallowing over time by improving underlying physiological function. An example is exercises to improve laryngeal elevation.

Compensatory techniques alter the swallow without creating lasting functional change. An example is head rotation during the swallow to direct the bolus toward one of the lateral channels of the pharyngeal cavity.

The super-supraglottic swallow is a rehabilitative technique that aims to increase closure at the entrance to the airway and may also serve as a compensation to protect the airway.

Factors to consider include clinical presentation of swallowing difficulties, impact of modifications on swallowing physiology, aspiration risk, co-morbidities, impact on medications, and patient/care partner preferences.

Biofeedback incorporates the patient's ability to sense changes and aids in the treatment of feeding or swallowing disorders by using visual information from assessments to make physiological changes during swallowing.

The Mendelsohn maneuver is designed to elevate the larynx and open the esophagus during the swallow to prevent food/liquid from falling into the airway.

Prosthetics or intraoral appliances can be used to normalize pressure and movement in the intraoral cavity for patients with structural deficits/damage to the oropharyngeal mechanism.

Common medical options include anti-reflux medications, prokinetic agents, and salivary management.

Common surgical options include medialization thyroplasty, injection of biomaterials, stents, laryngotracheal separation, laryngectomy, and dilation.

Stickler syndrome, 22q11.2 deletion syndrome, Apert syndrome, and Treacher Collins syndrome

The signs and symptoms associated with clefting depend on factors such as the type (cleft lip, cleft palate, or both), severity of the cleft, and whether the cleft is associated with a craniofacial syndrome.

Normal VP closure separates the nasal and oral cavities, allowing for speech with balanced oral and nasal resonance. It enables the production of oral pressure consonants and prevents nasal air escape during oral consonant production.

Velopharyngeal dysfunction (VPD) is a general term that refers to the inadequate closure of the velopharyngeal port. Velopharyngeal insufficiency (VPI) is due to structural abnormalities (e.g., cleft palate), velopharyngeal incompetence is due to neurogenic causes, and velopharyngeal mislearning is due to faulty articulation.

Common causes of VPD include cleft palate or submucous cleft palate, short palate, deep pharynx, weak palatal muscle function due to neurological disorders, enlarged tonsils, irregular adenoid pad, and adenoidectomy.

Hypernasality is excessive resonance in the nasal cavity during the production of vowels and vocalic consonants, resulting from coupling of the oral and nasal cavities. Nasal air emission is audible or inaudible release of air from the nasal cavity during oral pressure consonant production. These phenomena are caused by inadequate VP closure or structural abnormalities.

Obligatory errors occur due to structural abnormalities that result in distortions of speech sounds. These errors require physical management, such as orthodontics, surgery, or prosthetic intervention, to correct the underlying structural abnormality.

Compensatory errors are learned maladaptive articulations that develop in response to abnormal structures found in VPD. They involve changes in articulatory placement but maintain the same manner of production. These errors are treated through behavioral intervention (speech therapy).

Learned nasal emission is a maladaptive articulation error where nasal fricatives are produced to replace oral fricatives. It is caused by faulty articulation and can result in phoneme-specific nasal emission or pharyngeal-specific hypernasality.

Babies with cleft palate may exhibit delayed onset of canonical babbling, restricted consonant inventory, and slowed expressive vocabulary growth compared to their peers without cleft palate.

Dental anomalies and malocclusion can interfere with tongue tip movement and alter the tongue's relationship with the alveolar ridge. This can lead to obligatory distortions and compensatory articulations in speech production.

The recommended approach is a team-based treatment model that includes a range of professionals from different fields, such as surgeons, orthodontists, speech-language pathologists, audiologists, nurses, psychologists, and more.

A cleft palate team must have, as a minimum, a surgeon, an orthodontist, and a speech-language pathologist.

Treatment involves normalizing both the structure (surgical or orthodontic) and function (therapy) of the affected areas. It may also include early feeding intervention, dental care, audiology monitoring, and psychological services.

The goal of feeding intervention is to ensure adequate and efficient intake for hydration, nutrition, and medical status prior to surgery, while also minimizing stress for the infant and family.

Strategies include upright feeding position, jaw and cheek support, appropriate nipple size and positioning, pacing of flow rate, burping, and limiting feeding time.

NAM is a presurgical appliance used to align maxillary segments in infants with cleft lip and palate. It can also function as a dental plate and potentially improve feeding.

Modifications include using nipples with wide bases, one-way valve nipples, squeezable bottles, and nipples with enlarged holes to control milk flow.

Breastfeeding success varies based on the type and severity of the cleft. Babies with cleft palate may require expressing milk and using a bottle for delivery in addition to breastfeeding.

Speech therapy aims to correct compensatory misarticulations through techniques like phonetic placement, auditory and tactile cues, and visual cues. Therapy targets eliminating these errors for improved speech and intelligibility.

for targeting phoneme-specific nasal emission, such as

a dental mirror placed under the nose,

a stethoscope (placed against the side of the nose), and

plastic tubing or drinking straw for self-monitoring one’s own productions (one end is placed at the patient’s/client’s nostril entrance, and the other end is placed by the ear).

to monitor oral versus nasal speech and provide real-time visual feedback. A nasometer is used in cases of phoneme-specific disorders or nasalization errors (not to treat consistent hypernasality).

to provide visual feedback about the actions of the VP mechanism during speech (Brunner et al., 2005), which may help individuals improve VP movements when they have the physical ability to achieve VP closure but do not do so because of faulty articulation (e.g., phoneme-specific nasal emission; Brunner et al., 2005; Witzel et al., 1988).

a computer-based technique for training correct oral articulation placements. Electropalatography provides a visual feedback display of the tongue’s contact with the hard palate during speech (Lee et al., 2009).

are at increased risk for airway obstruction, dysphagia, and aspiration due to micrognathia (undersized lower jaw) and glossoptosis (displacement of the tongue), which position the tongue toward or even against the posterior pharyngeal wall

In infants with 22q11.2 deletion syndrome, laryngeal, neurologic, or cardiac abnormalities may exacerbate feeding difficulties (e.g., Cuneo, 2001; Golding-Kushner & Shprintzen, 2011) and may contribute to fatigue (Cuneo, 2001).

upper lip & primary palate close; secondary palate begins to form

hard palate fuses; velum begins to close

complete fusion of velum & uvula

submucous or occult cleft palate.

von Langenbeck surgical method.

tensor veli palatini muscle.

A ratio of 60-80 generally indicates adequate tissue for velopharyngeal closure for speech.