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What are the multicultural constructs?
- Degree of acculturation
- Family type
- Belief Systems
What are terms used to describe language?
- Acquiring a second language
- Dual Language learners
- English Language Learners (ELL)
- Bilingual (speak two or more languages)
- L1-Native language
- L2- second language
What is code switching
ALternating use of each language/dialect depending on context or listener needs
What are the statistics of CLD
- Population in US = 25%
- CLD in schools = 14%
- Projected to increase over 30% by 2015
- Pevalence rate of com dis = 6.2 million
- International adopetees
- -China and eastern europe inadequate nutrition, lack of stimulation = signiicant developmental impairments
Describe socioeconomic status
- Ranking by position in society on class, status, power, financial resources, level of education, and occupation.
- Described as high, middle, or low
- Predictor of school performance, crime
- SES may be a better predictor of cognitive-communicative behaviors than other factors such as racial-ethnic background
SES is ___ predictor than cultural/ethnic
- low educational progres
- high unemployment
- more behavior probs
- More crime
What are clinical considerations for children
- Proficiency, Dominance
- Acquisition of LD
- L1 influences L2 (language interference transfer, language loss.
What is BICS and CLAPS
- Basic Interpersonal Communication Skills- Social 2-3 years to develop
- Cognitive Academic Language Proficiency Skills- academic learning 5-7 years to develop
What are the 2 patterns of 2nd language acquisition.
- Simultaneous- exposed to and acquires L1 and L2 from birth.
- Sequential/ Successive - L2 is introduced later in childhood, usually after 3 y/o
What are the Educational models
- dual immersion
what are the clinical considerations for adults with CLD
- The same type and severity of aphasia may be present in both languages OR severity may be greater in one language for bilingual speakers.
- Emphasize a cross-linguistic approach to enhance recovery
- Use similar words from both languages for word retrieval practice.
- Conduct tx in language common to clinician and client, but home practice in other language.
Discuss the initiation of any assesment
- Initiated for a reason
- Chief complain or presenting issue or problem
- Assessments are initiated in different ways (self referral, teacher, parent, physician, another professional.
What are initial questions to ask for assessment
- Are the clients speech, language, and hearing within normal limits
- Is the client at risk for developing a disorder
- What are the characteristics of impairment, disability, and handicap
- What is the cause of the behaviors constituting the communication disorder
- Is there any reason why the clinician cannot or should not provide treatment?
If the referral is medical it comes from who? if it is clinic it comes from who?
- Self, parent, friend, other professional
What is the process of referral for educational setting?
- Referral by teacher or parent
- Process starts may be changed due to RTI tears
- 1st step : BIT/SAT team suggests other interventions. May include screening.
If regular ed interventions are not successful...
- Refer to specialist for dx
- OT, PT
- Get a CMAP as and ORDER to start evaluation process
- IEP process dictates the timeline by which all work is completed.
When an SLP gets a referral they need to...
- informed constent: permission papers must be signed, IDEA, HIPAA
- Read records: permanent/confidential file; medical chart- do before you see client or patient.
Discuss the process of making a dx plan
- Interview teacher, parent, client, significant others (case history)
- Standardized, norm-referenced assessment instruments
- Criterion-referenced assessment.
- Informal assessments
- Observation of typical behavior in functional environment (know normal behavior and development)
- Screen other disorders or differences if not the "chief complaint"
What are informal assessments
- incldue dynamic assessment
- language samples
what other disorders may you screen?
- voice, pragmatics, language
- oral mechanism screening
- hearing screening
After the Dx plan, what is the next step in schools
- MDT, multidisciplinary team or MDET
- Minimally:SLP, reg ed teacher, parent
- Maybe: Special ed teacher OT, PT, Social worker case manager, nurse
- Looks at results of textsing
- determines whether student is eligible for school-based tx
Describe the evaluation report.
- Should stand on its own
- State what was assessed and how
- Interpret what the scores mean in functional terms
- integrate data
- use clinical judgment to state the significance of the findings
- use language non-professionals will understand
Describe the IEP
- Individual education plan
- decides upon the goals and objectives to be addressed in tx
- goals must be related to regular or general education curriculum
- states time allotted for tx and where
- Accommodations in regular ed classroom
- Cultural and not a disorder
What are the two approaches for choosing treatment targets for children with articulation or phonological disorders. Describe each
- 1. developmental approach: Identify targets based on normal ages of acquisition os speech sounds, typically present error sounds in order that normal children learn sounds.
- 2. non-developmental approach: Client specific, degree of perceived deviance associated with child's errors, phonological
Describe the client specific appraoch
- targets relevant to child
- targets most stimulable, regardless of typical development
- Targets most visible when produced.
Describe the degree of perceived deviance associated with childs errors.
- Articulatory (omission, substitutions, distortions, initial position errors, medial position errors, final position errors. Errors on most frequent sounds
- Phonological (most unintellibillity, initial consonant deletion, gloattal replacement of medial consonants.)
Describe the verticle goal strategy
- Intense practive on limited number of targets
- Target /l/ first until mastered then move on to /r/
- good if client only has few errors
- traditional artic treatment
- Van Riper
- Isolation, syllables, words, sentences, conversation
Describe the horizontal goal strategy
- Simultaneous exposure to a wide variety of targets will facilitate a client's ability to produce phonemes or sound patterns
- Less intense practice to a large number of targets, even in same seesion.
- Appropriate for clients with multiple errors.
Describe the Cyclical goal strategy
- Combine vertical and horizontal approaches
- Practice intensely on target for given amount of time, then move to another target
- Cycle is repeated until targets emerge into spontaneous speech.
- Change targets regardless of progress and keep repeating cycle.
there is no significant evidance or connection between _____ and speech sound production.only recomended for _____
- Oral motor exercises
- awareness of oral mechanism
Describe an articulation disorder and the 2 kinds.
- Phonemes produced incorrectly. This is a motor component of speech
- Functional (without cause) and Organic (cause)
Describe a functional articulation disorder
- Speech production errors in the absence of identifiable etiology (normal hearing, no significant structural anormalities, No neurological dysfunction.
- Selection of tx targets from either developmental or non-developmental approach
What are the speech characteristics of a functional articulation disorder
What are helpful hints for treating a functional articulation disorder.
- Don't include more than one error sound in a stimulus word in initial stages of tx.
- Pay attention to phonetic context of words--some consonant-vowel sequences are more difficult
- Motor skill- so more practice is needed
- Counsel parents about responses to errors to avoid
Describe phonological disorders
- The phonological system governs the ways in which sounds in a language can be combined to form words
- Difficulty in acquiring a phonological system, not necessarily in production of the sounds.
Describe the phonological disorder treatment approaches
- 1. phonological processes strategy used by 1..5 - 4 y/o children to simplify production of classes of speech sounds- persistance using this is disorder and treat by teaching rule.
- 2. distinctive features -artic and acoustic properites- teach place manner and voicing.
What are three organic articulation disorders.
- Cleft palate
- hearing impairment
- Childhood apraxia of speech (CAS)
Describe Cleft Palate
- Congenital malformation of palate and/or lip
- bilateral or unilateral
- Interdisciplinary team
- Surgical repair of lip, palate and pharyngeal flap
- Speech treatment begins both before and after surgery
What are the speech characteristics of Cleft palate
Velopharyngeal incompetence (VPI): Audible emission of air, hypernasal resonance, articulation errors. Most freqent errors on fricatives, affricates and plosives distortions and omissions.
Describe a hearing impairment
- Significant loss in auditory acuity
- Sensorineural, mixed, conductive
- the more severe the less articulation
- midl to moderate patients tolerate tx best
- Speech intelligiibility affected by profound HL
What are the speech charicteristics of a hearing impairment
- Omission of initial and/or final consonants, blends
- substitution of voiced consonants for voiceless
- Substitution of stops for nasals, fricatives, and affricates
- Substitution and insertion of schwa
- nasalization of vowels.
What are the treatment approaches for hearing impairment
- oral-emphasizes spoken language
- manual emphasizes ASL
- Total communication combination
- Cochlear implants with speech therapy.
- Speech motor planning disorder with reduced ability to volitionally sequence movements of articulators for speech perhaps from neuologic diysfunctions.
- Receptive language aboilites are better than expressive
- Can be unintelligible to not verbal
what are the speech characteristics associated with CAS
- Repertoir of phenemes is extremely restriceted
- Reduced ability to imitate sound- especiall muliti syllables
- Most omission, substitution, distortion (inluding vowels) addition prolongation
- Errors on sounds requiring complex artic movements.
- Prosodic errors
- struggling or grouping movements
- Errors increase with length and complexity
- Ability to sequence phonemes is reduced.
CAS treatment approaches
- Progress is slow
- Repeated practice --systeatic drill necessary
- shorter, more frequent session
- must use visual, tactile and auditory cues,
- work on melody and rhythm
- Consider AAC system temporarily.
How is accent reduction the same, and how is it different
place manner and voicing
- Includes cultural education: idioms, humor,
- Syntax, stress intonation
- Adults, generally as clients
What are accent reduction treatment approaches.
- Careful analysis of differences
- Often vowels and prosody are different
- Determine what differences contribute most to intelligibility problems and target these first
Define a language disorder
- The abnormal acquistion, comprehension, or use of spoken or written language
- Includes receptive and expressive language skills.
- May involve any aspect of the form, content or use of linguistic system
- Primary vs Secondary disorder (autism and language)
- Developmental vs acquired
- Delayed vs deviant acquisition
- Range of severity
- *SPOKEN AND WRITTEN
- 1. vocabulary
- 2. parts of words that go togehter
- 3. how words are ordered and combined for sentences
- 4. social skills
- 5. systems and rules of how sounds are put together in words.
Describe emergent literacy and metalignuistic awareness
- Awarenss of world of print and understanding of functions of literacy.
- Metalinguistic awareness: awareness of and ability to manipulate aspects of the linguistic system (eg: phonological awareness)
- Vocabulary and word retrieval (rapid naming for decoding)
- Deficits in vocab and word retrieval most common characteristics of language impairment.
What is literacy, reading, writing.
- Literacy: development of reading and writing skills
- Reading: decoding, comprehension, vocabulary, fluency, phonemic awareness
- Writing: spelling, conventions, compose text at sentence level and beyond.
What is the basis of development for literacy?
Tx approaches vary according to theoretical orientations which are
- linguistic developmental
- behavioral developmental
what is the intervetion for birth to 3 years with a language disorder
- Go to home
- provide intervetion indirectly (monitoring, stimulation and prevention
- Family centered approach: Services delivered at home or center based, interdisciplinary model, repeated exposures and stimulation.
Early intervention critical for childre at risk for language due to:
prematurity, low birth weight, family history, medical complications, hearing
What are the treatment targets for birth - 3 years
- joint attention
- mutual gaze
- joint action and routines
- communicative intentions
- non-symbolic play and symbolic play
- initial vocabulary
What is the intervention for 3-5 years
- Most development of linguistic system
- Rapid growth in vocabulary
- MLU increases
- Syntax acquisition
- Morphological forms emerge
- Can understand and produce sentence forms
- Emergent literacy continues
What are examples of emergent literacy
- shared book reading and sense of story
- alphabetic letter knowledge
- adult modeling of literacy activities
- experience with writing materials.
What do we know about language development of elementary school.
- Mostly intelligable
- MLU is increasing until about 9 years old
- More complex sentences, relative clauses, passive voice
- Learning to decode, comp. should be developing.
What are the treatment targets for school age with language disorder
- exression and comprehension(narrative/expository)
k-3 you ___ to ____
3rd to 12th you ____ to _____
- learn to read
- read to learn
Goals are programmed to addess....
the demands and expectations of educational curriculum
Describe treatment activities
Activities need to be functional --related to educational curriculum. (drills, memory card game)
What are classroom like activities
Books, reading, writing.
What are treatment targets for adolescents?
- expression and comprehension.
What are treatment targets for adolescents 10-14?
What are treatment targets for adolescents 14-16?
What are treatment targets for adolescents 16-20?
- Communication skills for academic and personal-scocial
- Communication skills for academic and personal social and career.
- Communication skills for personal social and career.
Goals for adolescents are
Programmed to address the demands and expectations of academic, social, and career
What are treatment activities for adolescents.
- textbooks, magazines, newspapers, interest area
- Motivation is key, adolescents must feel that they have choices and must take ownership for achieving those goals.
What are the stages of swallowing?
- Anticipatory phase
- Oral phase
- pharyngeal phase
- esophageal phase
Describe the Anticipatory phase?
- Occurs before any food reaches the mouth
- Decisions made regarding type, rate, and quantity of oral intake
Describe the Oral Preparatory phase
- Food manipulation in mouth, forming bolus
- sufficient saliva production
- Mastication (chewing)
- Labial (lip) seal maintained
- Buccal (cheek) musculature
Describe the Oral Transport phase?
- Tongue begins posterior (back of mouth) movement of the bolus
- Labial (lip) and Buccal (cheek) muscles contract
- Tongue elevates from front to back and bolus is propelled toward oropharynx (through the oral cavity and pharynx)
Describe the Pharyngeal phase
- Triggered when bolus approaches the anterior faucial arches and tongue base
- closure of velopharyngeal port
- Contraction of pharyngeal walls and posterior tongue base movement
- Laryngeal closure (airway closure)
- Opening of upper esophageal sphincter.
Describe the Laryngeal closure (Airway closure).
- True and False vocal folds contract
- Larynx and Hyoid Elevate and move Anteriorly
- Arytenoid cartilages approximate base of epiglottis
- Top third of epiglottis folds down horizontally.
Describe the Esophageal Stage.
- Long, flaccid muscular tube with tonically contracted muscle at both ends
- Esophageal transit times vary from 8-20 sec
- Peristallic wave pushes bolus through esophagus until the LES opens to allow bolus to enter stomach.
Define aspiration, penetration, residue
- Aspiration = entry of food or liquid into the airway below the true vocal folds.
- Penetration = entry of food or liquid into the larynx at some level down to but not below the true vocal folds
- Residue = food or liquid that is left behind in the mouth or pharynx after the swallow.
What are the etiologies associated with Dysphagia?
- CVA stroke
- Brain Tumor
- Progressive Disorders
What are the Clinical implications of Aspiration
- Pneumonia or poor lung condition
- low grade fevers
- abnormal pulse oximetry
- increased oxygen requirement
- decreased overall respiratory status
What are the signs and symptoms associated with dysphagia and aspiration risk
- Wet voice/poor vocal quality
- Decreased oral motor function
- Throat clearing
- Multiple swallows
- Patient complaints (weight loss, lengthy meals)
Describe the Bedside exam
- Patient History/ Chart Review (medical status, respiratory status, current feeding methods)
- Interview/ Observation (Level of responsiveness, behavioral characteristics, positioning)
- Oral Mechanism Exam (Lips, tongue, soft palate, cheeks, mandible, and larynx, strength, coordination, range of motion)
- Non Instrumental Clinical Evaluation (dry swallows, trials swallows, oral motor function, observations after swallow)
Describe the modified barium swallow
- study of anatomy and physiology
- Oral, pharyngeal, and cervical esophageal stage s of the swallow
- Define management and treatment strategies that will improve swallowing safety and efficiency.
Compare Bedside and Modified evaluation
- *Typically complete prior to MBSS
- *Purpose is to identify aspiration risk and determine need for further evaluation
- *Provides subjective signs.
- *Requires barium
- *Purpose is to identify impairments and determine appropriate mgt and treatment
- *Trial postures/ maneuvers
- *Provides obective evidence
- *Silent Aspiration
What are the Compensatory Strategies and describe them.
- Diet Modifications: liquid (thin, nectar thick, honey thick) Solid (blenderized, puree, mechanical soft)
- Postural techniques: Chin down, tilting head backward, rotating head, head tilt to side, lying on side or back.
- Increased Sensory Input: Modifiny presentation of bolus, thermal tactile stimulation
- Voluntary Maneuvers: supraglottic swallow, super supraglottic swallow, effortful swallow, mendelsohn maneuver, masako maneuver
What are the Therapy techniques and describe them.
- Oral Motor Exercises: range of motion tongue exercises, resistance exercises, bolus control exercises.
- Pharyngeal Exercises: Vocal fold adduction exercises, tongue base exercises, laryngeal elevation
Describe Neuromuscular Electrical Stim
Combined with OM and Pharyngeal Exercises, swallowing trials
- Language Disorder
- due to brain damage (usually a hemorage or blockage)
- results in impairment in comprehension and/ or formulation of language.
- can affect oral and written language
What is the etiology of Aphasia
- Cerebrovascular accident (CVA)- stroke
- Head trauma (TBI)
- Disease- ex: encephalitis
What are the deficits of aphasia?
- Damage to language area of brain (usually left hemisphere)
- Motor and sensory deficits (hemiplegia, hemiparesis, hemianopsia
What are the two categories of aphasia
- Fluent: poor comprehension with relatively spared speech, impaired word-retrieval, paraphasisas, neologisms, perseveration (wernicke's)
- NonFluent: poor output with relatively spared comprehension, reduced vocab, agrammatism, impairments in artic rate and prosody speech is labored and effortful
What is the tx efficacy of aphasia
- may have spontaneous recovery (2-3 months or 1 yr)
- Need frequent treatment of 2 or more hours per week)
- More improvement in receptive, then speech production, then expression
What are the goals for tx of aphasia?
- goal is to improve communicationskills within constraints of neurological damage
- Focus is on care not cure
- Establish compensatory/maintenance strategies for functional language skills
- Consider pre-morbid status.
What are the two theoretical orientations of aphasia tx
- Restorative/Linguistic: intensive and repeated sensory stimulation. direct instruction , gain as much as possible
- Sustititive/compensatory: use whatever modalities available to communicate. used when there is more damage.
Describe group tx and self curing for word retrieval
- Group tx: social setting, family members
- Self-cuing for word retrieval: Automatic sequences (days of week) Paired verbal associates (salt and pepper) sentance completion (use a broom to sweep the ____)
Describe constraint induced language therapy and stimulation facilitation.
- Constraint induced language therapy: massed practice (30 hrs in 2 weeks), shapig, constrain-no non verbal (tie hands down)
- Stimulation Facilitation: Focus on semantics and syntax, intensive auditory stimulation, high number of responses.
- *Both are Restorative linguistic
Describe the Melodic intonation therapy and the amer-ind approaches.
- Melodic intonation therapy: restorative linguistic, recuits participation of right hemisphere to improve verbal production in left hemisphere, rythm and unision
- Amer-Ind: sutitutive/compensatory, gestural system based on american indian hand talk, telegraphic, no grammar
Describe visual Action therapy and promoting aphasics communicative effectiveness (PACE)
- Visual Action Therapy: substitutive/compensatory, non-vocal, single gesture level to communicate.
- Promoting Aphasics communicative effectiveness (PACE): Substitutive compensatory, convey message by whatever means
- Life Participation Apprach to Aphasia: Functional compensatory, maximize clients reengagement in life based on clients and families decisions of what is important.
- imaired muscular control over speech mechanism
- Result of central or peripheral nervous system damage
- Etiology: stroke, brain tumor, tbi, toxins, chemo.
- inaccurate and/or labored performance in rapid, repetitive movement of articulators (slurred)
- can affect respiration, phonation, resonance, articulation, prosody
- speech musculature: paralysis, weakness, decreased tone, incoordination
- Can be reduced range of motion or invlountary and unihibited movement.
What is the prognosis of dysarthria?
- No spontaneous recovery with some
- Remission can occur for some neuromuscular diseases
- Degenerative disease-prognosis is pore.
- Co-occuring with aphasia
- TX is generally effective.
Describe the behavioral prosthetic and medical procedures for approaches to dysarthria>
- Behavioral: verbal reinforcemtn, metronome pacing, biofeedback, delated auditory feedback, pacing boards
- Prosthetic devices: palatal lift to decrease hypernasal resonance
- Medical/surgical procedures: Medicaitons, pharyngeal flap, phonosurgery, pallidotomy
- Deep brain stimulation: Surgically implanted device to electrically stimulate targeted area of brain.
- AAC: for worst cases
Define Apraxia of speech
- Inability to plan and sequence volitional motor movements
- Due to CNS damage despite intact muscle strength and coordination
- can affect limbs or articulation
- difficulty positioning speech muscles, sequencing muscle movements for voluntary production of speech but no muscle weakness.
What is the etiology of Apraxia
- Lesion in left frontal lobe near broca's area
- CVA, TBI, tumors, disease processes
- Frequently co-occurs with aphasia
- unpredictable and inconsistent errors
- substitutions and transpositions are more frequent errors
- complex consonant blends often substituted for simpler phonemes
- difficulty initiating speech
- Accuracy deteriorates as word length increases
- automatic speech better
- speech rate slowed
- incorrect prosody
What is the prognosis of apraxia and the tx efficacy.
- spontaneous recovery follows initial neurological insult
- No good evidence at this point
What is the goal of apraxia treatment>
- increase voluntary control over articulatory movements for speech
- severe/profound- intelligible speech not realistic, try alternative communication
Structure of tx
- drill, repeated practice
- 8 step task continuum-integral stimulation
- clinician provides model then fades prompting
content of tx
- initiate phonation: work from cough to prolonged phonation
- Increase smoothness and length of speech: automatic speech
- phonemic drill
- nnnn to na to nana to new to nine