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Speech Correction

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Text that popularized motor techniques used by clinicians for decades - phonetic motor approach - errors treated individually - hierarchy

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Level of accuracy for mastery

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80%

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Van Riper's Articulation Hierarchy

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1. Isolation 2. Syllable Shapes CV / VC 3. CVC Word Shapes 4. Words - Initial Position - Final Position - Medial position 5. Phrases 6. Structured Sentences 7. Unstructured Sentences 8. Structured Conversation 9. Unstructured Conversation (in and out of treatment room)

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Where to begin

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Stimulability Specific Contexts Intelligibility Developmental

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Stimulability

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if sound is stimulable it might be easier for patient to produce

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Specific Contexts

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If sound is produced corrected within a specific context it might be a good place to start

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Intelligibility

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if the sound is frequently occuring, it will affect patient's intelligibility the most

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Developmental

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early developing speech sounds should be targeted first

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Sound in Isolation

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goal of this phase is to elicit normal production of target sound in isolation - by itself

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Phonetic Placement

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- help patient position articulators to produced target sound correctly

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Tools for phonetic placement

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mirror, tongue blade, gloves, fun dip, suckers - give child increased sensory information

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Sound practice

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goal is to be as error free as possible in practice

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Syllable Shapes

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start with VC or CV - whichever is easier for child

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Word Level

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goal is to maintain accuracy of target sound in single words

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medial position

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True medial or a short phrase such as "my sun"

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Short vs Long term goals

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- Short term goals include cuing - specific and goal driven - many short term goals to reach long term goal - long term goals are a 16wk+ outlook - NO CUING

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Factors that affect complexity of words

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Length Position Syllable Structure Syllable Stress Familiarity

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Length

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Fewer is easier

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Position

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initial is easier, then final, then medial

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Syllable Structure

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open is easier than closed

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Syllable stress

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sound in stressed syllable is easier

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Familiarity

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familiar/age appropriate words are typically easier

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Phrase / Sentence level

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goal is accuracy of sound production as words are placed in structured phrases and sentences

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Stable carrier phrase

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"I see a ___" / "She has the ___"

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Phrase progression

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Stable carrier phrase -> variety of phrases -> structured sentence High structure -> less structured

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Sentences

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load sentences with multiple opportunities to produce the sound and vary the word positions

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Spontaneous Speech

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goal is accurate production when sound appears spontaneously in conversation

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Eliciting spontaneous speech

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story retell, picture description, etc 1-2 minutes - structure conversation so certain topics or pictures contain words with target speech sounds

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Prompts in spontaneous speech

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hand signal that prompts for error and signals child to catch and correct error (goal - less than 3 prompts - in a given time period)

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Carryover

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minimum 50% accuracy in clinic spontaneous speech - have parents/teachers/etc assist in monitoring - activities for parent/teacher to do at home/school

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Treatment goals

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must be measurable and achievable - Long Term and Short Term

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Long Term Goal

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what you expect to accomplish in an authorized period of time - all long term goals assume child will be independent (no cuing)

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Short Term Goals

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roadmap to meeting the Long Term goal - small measurable steps that show progress through DATA - every short term goal will have some level of cuing

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Critical pieces for a goal

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Performance Condition Criterion

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Performance

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What will the patient do (produce /s/)

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Condition

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Under what condition will he do it? (in isolation)

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Criterion

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What level of accuracy do you expect (with 80% accuracy)

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Long term goals take into account:

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stimulability, cognitive abilities, HL/autism/other problems

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Goal attack strategy

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Vertical vs Horizontal

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Vertical

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intense practice on one or two targets until the child reaches a specific criterion level before moving to the next sound

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Horizontal

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less intense practice with multiple sounds that are addressed individually or interactively in the same session (BUT each sound has its OWN goal) (2 or 3 sounds, 3 if 2 are a cognate pair)

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Percentage correct

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if goal is under 50%, need to change something - cuing, stimuli, etc - faulty practice bad

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Elements of Articulation Therapy

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Sound selection stimulus word selection motivational reinforcement cuing techniques models of presentation feedback leveling data recording

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Stimulus - Response - Reward

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child must understand that he has to do what you ask - if he does he gets rewarded, if he doesn't he loses something fun MUST MAKE REWARD SOMETHING THE CHILD WANTS - may have to teach this concept

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What if the child doesn't imitate

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1. start with full body actions (jumping, clapping, marching) 2. Use a mirror and begin non-speech motor movements (stick out tongue, pucker lips, blow air) 3. Begin to shape specific, visual phonemes

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Frame the stimulus with:

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"Watch me and do what I do"

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Sound selection

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Developmental Non-Developmental Stimulability Visbility

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Non-developmental

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degree of occurrence in speech impact on intelligiblity

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Facilitating contexts (key words)

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phonetic aspects of neighboring speech sounds that support the sound features that need to be acquired - was sound correct in any words? neighboring sounds = facilitating - most likely found during stimulability testing

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Facilitating context examples

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d/g substitution but can produce g in 'finger' (ng) w/r substitution but can produce r in 'creek' (k) bw/bl sub can say "blue" (u) t/s sub but can say "key" (i)

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Choosing stimulus sounds

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- NEVER pair target sound with the error (child will assimilate) - no OTHER speech errors should be in stimulus words you choose - MUST meet parameters of short term goal - Only contain target error - age appropriate and user friendly

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Motivational reinforcement

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- ipad apps - turn taking card game and board games - motor movement - earning chips toward prize - positive feedback (because rarely get pos feedback on speech!)

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Cues

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tools used to effectively remediate speech sound errors start with a lot, then take away

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Cues - Most to Least helpful

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Phonetic Placement Direct Imitation Sound Modification Verbal Cues Hand Cues Vocal Phonics Tactile Prompt

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Phonetic Placement cue

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manipulation of the articulators using a tongue depressor or gloved finger to manually move teh lips, jaw, tongue into proper position (fun dip, cold things, make them feel it)

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Direct Imitation cue

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"Watch me and do what I do" (mirror helpful)

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Sound modification

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clinician derives target sound from a phonetically similar sound the patient can already produce

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Verbal cues

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describe position of articulators while you demonstrate (close your teeth and blow skinny air)

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Hand Cues

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visually alert the patient to the manner, place and voicing of the target sound (1 finger voiceless 4 fingers voiced)

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Vocal Phonics

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provide imagery to associate with the target sound (popcorn for popping /p/ sound)

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Tactile

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provides sensory information through touch. Helps child feel the way the sound is produced (clap for t vs run finger down for s, feel vibrations of nasal on cheek)

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Prompt

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alerts the child to an error but does NOT provide a cue for repair

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Multimodality cues

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verbal, visual, and tactile cues used together to give child maximal sensory input (most helpful) (for severe kids)

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Models of presentation - Single Word Productions

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Single Word Productions - verbal model - delayed verbal model - verbal model with multiple repetitions // work away from verbal model as quickly as possible // - picture stimulus - written word - breaking the therapeautic set - sentence completion - naming from description

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verbal model

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direct imitation - 1 to 1 reinforcement

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delayed verbal model

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give word followed by distractor or signal - hold in head 10-15 sec before repeat

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verbal model with multiple repetitions

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give word, child says word and 5 repetitions - hold finger up to know word was correct

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picture stimulus

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picture card

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written word

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for older children, map graphemes, know where sound falls

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breaking the therapeautic set

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move from target position words to a different articulator position (maximally different) to see if they remember how to get articulators back into place (go, gum, gym, sun, go) - only 1 needed to interrupt

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sentence completion

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language component - less difficult language task "I have a piece of bubble ____ (gum)"

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naming from description

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more difficult language task interferes with correct sound - makes them think about it

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Models of Presentation - Coarticulation

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Stable phrases mixed phrases controlled sentences loaded sentences narration/storytelling discourse

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stable phrases

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same carrier phrase each time "I see a___"

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mixed phrases

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change phrase a little "mom has a cat" "I see a cat"

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controlled sentences

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one target per sentence - control # of target sounds

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loaded sentences

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multiple targets in multiple positions

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narration/storrytelling

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sequence pictures to tell story, story retelling - use prompts

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discourse

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conversation "tell me about..."

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Feedback

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- must know production is right or wrong and WHY - if wrong, help fix - if right, tell why it was right (you blew good air) - feedback MUST BE MEANINGFUL and DONE ON EVERY PRODUCTION

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Leveling

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moves child up or down hierarchy - goal is independent production with no help from SLP - no skill, SLP must wean away to promote generalization - shifts burden of accuracy from SLP to child - it must become a cognitive task

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Level up by:

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- decreasing type and amount of cues you use - increasing complexity of stimulus word shape - moving sound into coarticulation

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level down if child is not successful

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- add cuing strategies - alter word shapes - NEVER PRACTICE AN ERROR

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Data Recording

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- every production scored +/- - data must fit parameter of goal - percentage figured for each goal - percentage determines if level up/level down/continue - data determines if patient needs more or less support - ensures accurate clinical decision making - keep you from having to guess about progress - critical to listen and judge every production

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