Unintelligible Young Children: Assessment and Treatment Peter Flipsen Jr., PhD, CCC-SLP, S-LP(C) Idaho State University http://www.isu.edu/~flippete/default.html http://www.SLPinfo.org Flipsen - SC Scottish Rite Centers - Sept 08

Part A. Assessment Flipsen - SC Scottish Rite Centers - Sept 08

Intelligibility How well a normal hearing listener is able to recover the intended message from a speaker. How understandable are they? Not the same as “severity” though clearly related. Severity usually relates to particular disorders. Flipsen - SC Scottish Rite Centers - Sept 08

Becoming intelligible? Making yourself understood = the ultimate goal of communication. We’re not born with the ability to do this. It takes time to develop. Flipsen - SC Scottish Rite Centers - Sept 08

Becoming intelligible? Normal hearing, typically-developing children develop this ability fairly quickly. From Flipsen (2006) and Coplan & Gleason (1988): Age (years) % Understood * 1 25 2 50 3 75 4 100 ** * in conversational interaction with unfamiliar listeners. ** still some speech sound errors likely. Flipsen - SC Scottish Rite Centers - Sept 08

Being intelligible? Getting a message across requires a complex interaction of: 1. Good listening conditions, and 2. A listener who is paying attention, has normal hearing, and speaks the same language, and 3. A speaker who effectively and efficiently integrates their knowledge of how the language works and how speech is produced. Flipsen - SC Scottish Rite Centers - Sept 08

Our Focus For our purposes we will assume: 1. The problem lies primarily with the speaker. 2. The speaker has normal hearing. 3. The speaker has no other obvious or documented reason for having difficulty with speech. No significant cognitive, structural, or neurological impairment. Flipsen - SC Scottish Rite Centers - Sept 08

An intelligible speaker must: 1. have something to say (cognitive skill). 2. know the rules of the language (syntax, morphology, phonology) and word meanings (linguistic skill). 3. know how to convert the message into a motor plan (praxis skill). 4. be able to carry out the motor plan (articulatory skill). Flipsen - SC Scottish Rite Centers - Sept 08

Intelligibility and Speech Sound Accuracy Intelligibility = % words understood by normal hearing listeners. Clearly the biggest factor involved is accuracy of speech sound production. Not the only thing involved. Flipsen - SC Scottish Rite Centers - Sept 08

Flipsen - SC Scottish Rite Centers - Sept 08

The Role of Context Intelligibility also varies a lot depending on the message. In connected speech, if a few details are incorrect the rest of the utterance can help listeners “fill in the blanks”. Some speakers therefore do better in conversation than they might in single words. But context may get in the way for speakers who get many details wrong. May be easier to understand in single words. Flipsen - SC Scottish Rite Centers - Sept 08

The Role of Context For speakers with lots of errors, we should pay most attention to intelligibility in single words. Change should appear here first. Won’t immediately transfer to conversation. As they progress we will also want to monitor how they do in conversation. WE WILL NEED TO USE MULTIPLE TOOLS. Flipsen - SC Scottish Rite Centers - Sept 08

Measuring Intelligibility Flipsen - SC Scottish Rite Centers - Sept 08

General Guidelines for Measuring Intelligibility Clinician working with the child should NOT act as the judge if at all possible. Record all measurement events and SAVE them! Best to use unfamiliar, untrained listeners each time. OK to use parents, older siblings if you use them each time (social validity). Flipsen - SC Scottish Rite Centers - Sept 08

General Guidelines for Measuring Intelligibility Record the same type of material each time. Use the same tape recorder each time for recording. Record in the same place each time. Have judgments done under the same conditions each time. Flipsen - SC Scottish Rite Centers - Sept 08

Specific Procedures for Measuring Intelligibility A widely used approach = informal ratings. After a diagnostic session, clinician makes a decision about ‘how intelligible’ the child was. Often a % estimate. May be a general statement. Flipsen - SC Scottish Rite Centers - Sept 08

Exercise #1 Flipsen - SC Scottish Rite Centers - Sept 08

Specific Procedures Labeled rating scales. Many available. Usually make judgments based on a connected speech sample (conversation or reading). May also be done as a ‘general impression’ at the end of an assessment session. Flipsen - SC Scottish Rite Centers - Sept 08

Labeled Scales A typical 3-point scale: 1 = readily intelligible 2 = intelligible if topic known 3 = unintelligible, even with careful listening Source: Bleile (1996) Flipsen - SC Scottish Rite Centers - Sept 08

Labeled Scales A typical 5-point scale: 1 = completely intelligible 2 = mostly intelligible 3 = somewhat intelligible 4 = mostly unintelligible 5 = completely unintelligible Source: Bleile (1996) Flipsen - SC Scottish Rite Centers - Sept 08

Labeled Scales 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) Flipsen - SC Scottish Rite Centers - Sept 08

Concerns with Rating Scales 1. Different listeners interpret the labels differently. 2. Listeners don’t treat all points on the scale equally. E.g., Amount of change needed to move between points is usually unequal. 3. Often not sensitive enough to use for monitoring change. Flipsen - SC Scottish Rite Centers - Sept 08

Specific Procedures Several more formal procedures are available. Involve either preset stimuli or transcription of connected speech. May use “forced-choice” or “write-down” procedures. Flipsen - SC Scottish Rite Centers - Sept 08

Specific Procedures Yorkston-Beukelman test Acronym = A.I.D.S. Assessment of the Intelligibility of Dysarthric Speech Acronym = A.I.D.S. Prefer to call it the Y-B test Flipsen - SC Scottish Rite Centers - Sept 08

Y-B Test Has both single word and sentence forms Sentence form only useful for older children and adults. Single words = choose 1 randomly from each of 50 sets of 12 words. Client repeats the words (or reads if older). Listener’s task = transcription or multiple choice. Flipsen - SC Scottish Rite Centers - Sept 08

Figure 10 Flipsen - SC Scottish Rite Centers - Sept 08

Exercise #2 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Flipsen - SC Scottish Rite Centers - Sept 08

Children’s Speech Intelligibility Measure (CSIM) Wilcox & Morris (1999). Modified the single word version of the Y- B test (no sentences). Changed some of the words that were not appropriate for young children. Published by the Psychological Corporation. Flipsen - SC Scottish Rite Centers - Sept 08

Beginners’ Intelligibility Test (BIT) Osberger et al (1994). See handout. Originally designed for children with hearing loss. OK to use with young, normal hearing children. Four sets of 10 short sentences. Randomly choose one list each time. Child imitates the clinician; ask listeners to transcribe. Calculate % words understood. Flipsen - SC Scottish Rite Centers - Sept 08

Shriberg’s Intelligibility Index (II) Transcribe a conversational sample of at least 100 words. Only need regular spelling! Put X for each word not understood. Report % words understood. Probably the best overall way to look at intelligibility since conversational speech is the most socially valid context. Flipsen - SC Scottish Rite Centers - Sept 08

So where’s the problem? Remember that an intelligible speaker must: 1. have something to say (cognitive skill). 2. know the rules of the language (syntax, morphology, phonology) and word meanings (linguistic skill). 3. know how to convert the message into a motor plan (praxis skill). 4. be able to carry out the motor plan (articulatory skill). PROVIDES US WITH A MODEL FOR IDENTIFYING THE SOURCE OF THE PROBLEM. Flipsen - SC Scottish Rite Centers - Sept 08

Possible sources of Reduced Intelligibility? 1. Linguistic issues – not being able to correctly translate the intended message into a conventional language form. Problems with semantics, syntax, morphology, or phonology. 2. Praxis issues – not being able to translate the form into a motor program. 3. Articulatory issues – not being able to physical produce the message. Flipsen - SC Scottish Rite Centers - Sept 08

Possible sources of Reduced Intelligibility? For our purposes here, we’ll assume we know how to identify problems with language above the phoneme level. Problems at the phoneme level could be: Praxis problems (i.e., CAS)to be dealt with separately later. Phonological or articulatory – often the most difficult to separate. Flipsen - SC Scottish Rite Centers - Sept 08

Artic vs. Phonology: A Quick Historical Review Up until the mid 1970s we assumed speech sound problems were all about “articulation”. Applied traditional artic therapy. Then we learned about “phonology” and we realized children were learning a “sound system”. Assessment shifted to looking for ‘patterns of errors’ (also called “processes”). Treatment shifted to ‘contrasts’ and ‘meaning’ and ‘minimal pairs’. Flipsen - SC Scottish Rite Centers - Sept 08

Current Status: Some “shaky” assumptions 1. Perhaps we don’t need to worry about perceptual errors. No. It’s true, these children don’t have general perceptual problems. Perceptual problems related to specific errors are not that common but we should check! 2. We can assume that the child with many errors must have a phonological problem. No. Child could have a “motor learning” problem. Flipsen - SC Scottish Rite Centers - Sept 08

More “shaky” assumptions. 3. We can assume that the child with few errors must have an articulatory problem. No. Child may not have figured out where that sound fits in the sound system. 4. Calling an error a “phonological process” means the problem is phonological. No. By themselves these labels tell us NOTHING about what is going on inside the child’s head. E.g., “velar fronting” only says that velar sounds are being replaced by sounds further back in the mouth. Flipsen - SC Scottish Rite Centers - Sept 08

Phonological Processes? Phonological process terms can be useful. They do help us look for WHAT MIGHT BE systematic patterns of errors. They can help us focus our intervention efforts if we do eventually determine the nature of the problem. BUT without further detailed analysis, we can’t know for certain whether the problem is articulatory or phonological. Flipsen - SC Scottish Rite Centers - Sept 08

More “shaky” assumptions. 5. We can assume that if a sound is stimulable, the problem must be phonological. Not necessarily, though it might be. Stimulability in isolation or nonsense syllables may only signal the beginnings of motor skill learning. Stimulability in more than one word position makes it more likely that the problem is phonological. Also depends on how stimulability is measured. Should use a verbal imitation model only. Flipsen - SC Scottish Rite Centers - Sept 08

How Speech is Learned Need to be able to hear the differences among the speech sounds of the language. Perceptual skills. Need to be able to physically produce the sounds. Articulatory (motor) skills. Need to know how the sounds are used to contrast meaning in the language. Phonological knowledge. Happens gradually and at different rates for different sounds. Flipsen - SC Scottish Rite Centers - Sept 08

Speech Sound Problems Could be perceptual. Could be articulatory. Could be phonological. And because of different rates of development: THE PROBLEM MAY BE DIFFERENT FOR DIFFERENT SPEECH SOUNDS – even within the same child. We need to evaluate each error independently. Flipsen - SC Scottish Rite Centers - Sept 08

Identifying Perceptual Problems At least two ways to do this: 1. Same/different tasks – present a pair of words (or syllables or sounds) and ask child to judge if they are the same or different. Child must understand the concepts of ‘same’ and ‘different’ not always true for very young children. Only requires the child to hold items in working memory and compare them. Doesn’t get at ‘underlying representation’ (what is stored in long-term memory). Flipsen - SC Scottish Rite Centers - Sept 08

Identifying Perceptual Problems 2. Judgment tasks – present child with a word (correct production or containing their usual error). Child has to decide if the word was produced correctly. Requires use of working memory BUT also requires them to compare what they heard to their underlying representation. Better approach. Flipsen - SC Scottish Rite Centers - Sept 08

Identifying Perceptual Problems Need several examples to control for guessing. Need a way to ensure that the child understands the task. Use a sound that is similar to the error sound but which the child has no difficulty with. Locke (1980) developed his “Speech Production – Perception Task” (SP-PT). Allows you to create a unique criterion- referenced test for each error sound. Flipsen - SC Scottish Rite Centers - Sept 08

Flipsen - SC Scottish Rite Centers - Sept 08

Is the error articulatory or phonological? Relatively few errors are perceptual BUT: Should still check (may save time later). Some evidence that for SOME children working on perception alone may solve the problem. The big problem is usually separating articulatory and phonological errors. Need to ask a series of questions (none sufficient alone). 1. Stimulability – across word positions and levels (discussed previously). Flipsen - SC Scottish Rite Centers - Sept 08

Articulatory or Phonological? 2. Is the sound ever correct? If correct in particular words: May just be an over-learned word (doesn’t tell us much). If correct in particular word positions: May be an articulatory problem. May not have learned the co-articulatory aspects in particular word positions. May be a phonological problem. May not have figured out that the sound can be used in more than one position. Flipsen - SC Scottish Rite Centers - Sept 08

Articulatory or Phonological? 3. Does the sound ever appear accidentally? Is the sound ever used as a substitute for something else. E.g., /c/ never correct but used in place of /s/. Suggests child is capable of producing /c/. But could just be an over-learned word. If never used accidentally: Sound likely not in inventory suggesting a phonological problem. But may not have learned to physically produce it. Flipsen - SC Scottish Rite Centers - Sept 08

Articulatory or Phonological? 4. Is contrast between target and substitution being “marked” in some other way? Narrow transcription may reveal subtle differences: E.g., t/s substitution (stopping error). Have them produce minimal pairs: nice/night. Listen for a difference in final /s/. May produce /ne]t(/ /ne]t)/ May be marking the difference using aspiration vs. no aspiration rather than fricative vs. stop. Flipsen - SC Scottish Rite Centers - Sept 08

Marking? With omission errors, look for evidence that the child at least knows that the missing sound is supposed to be there. Some limitation may be preventing them from actually producing it. E.g., omits final /n/. Have them produce minimal pair: can / cat Listen for differences in nasal quality on the vowel. Flipsen - SC Scottish Rite Centers - Sept 08

No One Question Provides all the Answers! Led to the development of the decision tree. Can use data from an artic test or transcription of connected speech. Look at each error separately. Treat each sound depending on what the problem is for that sound. With multiple errors of the same type, look for patterns. May be able to treat some of the errors and see generalization to other related errors. Flipsen - SC Scottish Rite Centers - Sept 08

Flipsen - SC Scottish Rite Centers - Sept 08

Childhood Apraxia of Speech (CAS) Controversial category. Still some who argue it doesn’t exist (i.e., that it is just a severe form of speech delay). Now very much a minority opinion. Has also been called: Developmental apraxia of speech. Developmental verbal apraxia. Developmental dyspraxia. CAS = ASHA’s new preferred term. Flipsen - SC Scottish Rite Centers - Sept 08

CAS ASHA expert panel prepared a technical report and drafted a position statement. Both have been reviewed by the ASHA membership. Some revisions were made and the revised version has now been approved by ASHA’s legislative council. See ASHA website for final versions. Flipsen - SC Scottish Rite Centers - Sept 08

Definition of CAS “ Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). CAS occurs as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.” - ASHA 2007 position statement. Flipsen - SC Scottish Rite Centers - Sept 08

Core Problem Neurological disorder. Difficulty with precision and sequencing of the movements for speech. May have a co-occurring oral apraxia. Errors of both speech production and prosody. But no actual neuromuscular deficits seen. May have co-occurring dysarthria. Flipsen - SC Scottish Rite Centers - Sept 08

Possible Causes Depends on the individual child: a. due to some known neurological problem? b. by association with some other neurobehavioral disorder that may or may not have a known cause? c. idiopathic (unknown)? Flipsen - SC Scottish Rite Centers - Sept 08

Diagnostic Markers for CAS NO CONSENSUS on the necessary and sufficient features. Three emerging features: 1. Inconsistent errors on repeated productions of syllables and words. 2. lengthened and disrupted transitions between sounds and syllables. 3. inappropriate prosody, particularly as it relates to the use of stress. Flipsen - SC Scottish Rite Centers - Sept 08

1. Variability / Inconsistency A symptom of CAS? BUT these terms are used at least 3 different ways: 1. Using the same phoneme differently in different word positions. May just be a positional constraint. 2. Using the same phoneme differently in different words. May just be a fossilized form. 3. Multiple attempts at the same word result in different output (also called “token-to- token” variability). This appears to be more unique to CAS. Flipsen - SC Scottish Rite Centers - Sept 08

1. Variability / Inconsistency Assessment can be tricky. Avoid having them repeat the words immediately. Better to go through a list of words once completely; then repeat entire list. Dodd et al. test (Diagnostic Evaluation of Articulation and Phonology; DEAP) has consistency subtest that is normed. Published by Harcourt. Flipsen - SC Scottish Rite Centers - Sept 08

2. Problems with Transitions Difficult to make the change from one position to another. Difficulty with getting the sequence organized as the targets get longer (requires more elaborate motor plans). See poor performance on DDK and other sequencing tasks. Flipsen - SC Scottish Rite Centers - Sept 08

Assessing Transitions Two types of DDK tasks: AMR – alternating motion rates. Repeat at the same place of articulation such as in /ppp/ /ttt/ /kkk/. SMR – sequential motion rates. Repeat while changing place of articulation such as in /ppt/ /ptt/ /ttk/ /tkk/ /ptk/ CAS = breaks down most easily when place changes (i.e., in SMRs but not necessarily in AMRs). Flipsen - SC Scottish Rite Centers - Sept 08

A note about DDKs DDK tasks usually involve “maximum performance”. Ask client to perform tasks “as fast as you can”. Problem with transitions in CAS is occurring at normal rates. SMRs should be a problem at normal rate. Probably don’t need to look at fast rates. Note: This is Flipsen’s perspective (not part of ASHA panel documents). Flipsen - SC Scottish Rite Centers - Sept 08

3. Prosodic Disturbances? Difficult to evaluate clinically on a routine basis. Excess and equal stress? Seen with Prosody-Voice Screening Profile (PVSP; Shriberg et al, 1990). Seen with linguistic analysis of stress. Seen with acoustic measures. Inconsistent nasality? Motor planning for VP port? Flipsen - SC Scottish Rite Centers - Sept 08

Prevalence (how common) of CAS)? No good population studies. Sharp increases seen in recent years in the number of cases identified. Several possible explanations: 1. Demands of early identification – tend to use non-speech indicators. Not reliable. 2. Availability of workshops and other information – excess emphasis? 3. Reimbursement issues. 4. Lack of diagnostic guidelines. Flipsen - SC Scottish Rite Centers - Sept 08

Prevalence of CAS? Currently the best guess is that CAS likely only occurs in 1-2 out of 1000 children (i.e., less than 2 tenths of 1%). BUT THIS IS OUT OF THE WHOLE POPULATION. Given that SSD occur in about 10% of the population, we probably should be seeing CAS in no more than 2-3% of our caseloads. Delaney & Kent (2004) report about 4% of speech referrals seen over 6 years at a large, metropolitan hospital. Flipsen - SC Scottish Rite Centers - Sept 08

Existing Tests and CAS None of the currently available tests appears to adequately test for it. See http://www.SLPinfo.org for a detailed analysis and a more detailed discussion of CAS. Flipsen - SC Scottish Rite Centers - Sept 08

Part B. Intervention Flipsen - SC Scottish Rite Centers - Sept 08

Intervention Focus Speech is the problem so we should focus our attention on real Speech. Even for CAS, we should only use “speech-motor” activities rather than “oral-motor” activities Might consider for a co-morbid oral apraxia. Activities should include at least a single speech sound. Flipsen - SC Scottish Rite Centers - Sept 08

Intervention Focus No good justification for practicing smaller “parts” of the movements except to improve awareness. Should never take up more than a few minutes of each session. Flipsen - SC Scottish Rite Centers - Sept 08

Perceptual problems need Perceptual Therapy? Traditional ear training? Auditory bombardment? Hodson’s adjunct to phonological therapy. Focused auditory stimulation? Lots of input on targets in play contexts. Intended for very young children who may not be ready for the structure of production practice. Speech Assessment and Interactive Learning Softward (SAILS) program? http://www.avaaz.com Flipsen - SC Scottish Rite Centers - Sept 08

Phonetic vs. Phonemic Therapy Yes they are different – or at least they should be! Not necessarily mutually exclusive however. For errors that are phonetically-based, phonetic therapy may need to be followed by phonemic therapy. Phonemic therapy provides practice with both motor and linguistic aspects. Flipsen - SC Scottish Rite Centers - Sept 08

Phonetic Therapy Also called traditional articulation therapy or articulatory therapy. Teaching the physical aspects of producing the sound. Conventional series of steps: Teach production of the sound in isolation; progress to production in syllables, words, phrases etc. Flipsen - SC Scottish Rite Centers - Sept 08

Phonemic Therapy Also called a cognitive-linguistic or phonological approach. Focuses on teaching the child the function of the sound. Change in sound = change in meaning. Contrasts = central to the process. Flipsen - SC Scottish Rite Centers - Sept 08

Phonemic Therapy: Principles 1. May be treating a pattern of errors – child has not fully learned the sound system. If using an articulation test as the data source, you will need to transcribe the entire target word to see the larger error pattern(s). Flipsen - SC Scottish Rite Centers - Sept 08

Phonemic Therapy: Principles 2. Child is usually not producing contrasts between sounds as adults do. Need to teach the appropriate contrast. Focus on how different sounds result in different meaning. Flipsen - SC Scottish Rite Centers - Sept 08

Loss of Contrasts: Homonymy When contrasts are lost, words that are normally different become homonyms (they sound the same). E.g., Child who uses stops for fricatives: /tu/ for both “shoe” and “two”. /b4t/ for both “but” and “bus”. /pl3]t/ for both “place” and “plate”. Flipsen - SC Scottish Rite Centers - Sept 08

Phonemic Therapy: Principles 3. Use Naturalistic contexts. Usually work with real words in meaningful contexts. Very helpful to have several "exemplars" of each target (e.g., several different "dogs"). Flipsen - SC Scottish Rite Centers - Sept 08

Phonemic Therapy: Principles 4. Shouldn't need to work on all possible targets. Select targets that represent the error pattern. Assume that a rule will be learned and carryover to the other targets will occur automatically (though it may not in every case). Flipsen - SC Scottish Rite Centers - Sept 08

Target Selection Selecting targets for phonemic therapy begins with describing the errors. Need to look for patterns. At least two ways to do this: 1. Natural phonological processes. 2. Look for phoneme “collapses” (homonymy). Flipsen - SC Scottish Rite Centers - Sept 08

Target Selection: Processes With natural processes the targets would be the correct productions. Contrast correct form with what the child usually does. For example: Cluster reduction: “stop” vs. “top” Stopping: “sea” vs. “tea” Velar fronting: “kite” vs. “tight” Flipsen - SC Scottish Rite Centers - Sept 08

Target Selection: Collapses With phoneme collapses, the first step is to look for which contrasts are lost. For example, a child produces the following errors: To/Sue, to/shoe, tea/key At least three phonemes have been collapsed into one. Flipsen - SC Scottish Rite Centers - Sept 08

Target Selection: Collapses If you view the errors as phoneme collapses a second step is necessary. We need to decide how to present the contrast. Several possible approaches. No solid evidence in favor of any of them so far. Flipsen - SC Scottish Rite Centers - Sept 08

Target Selection: Collapses 1. Minimal contrast – present target and contrasting words that differ by the fewest features (e.g., differ on place or manner only). Usually only present one contrast at a time. E.g., only present t/k (place difference) or only present t/s (manner difference). Based on the idea of making the difference between the target and the error as small as possible so there is nothing else to get in the way. Flipsen - SC Scottish Rite Centers - Sept 08

Target Selection: Collapses 2. Maximal contrast – present target and contrasting word that differ by the most features (e.g., place, manner and voicing). Again only present one contrast at a time. k/v differ on all 3 articulatory features. Based on the idea of making the target and the error so different that the contrast really stands out. Flipsen - SC Scottish Rite Centers - Sept 08

Target Selection: Collapses 3. Multiple contrasts – present several targets at once and contrast all of them with what the child usually does . E.g., if the child collapses 4 phonemes into 1, present all 4 contrasts at the same time. E.g., Work on targets “tea, she, sea, key” all at once. Based on the idea of creating the most disruption and stimulating the child to reorganize the system. Flipsen - SC Scottish Rite Centers - Sept 08

Phonemic Therapy Regardless of how targets are selected, the idea is to choose activities that allow the child to see how changing sounds results in changes in meaning. Working at the word level and above. Failure to provide the appropriate sound should result in a failure to communicate. Flipsen - SC Scottish Rite Centers - Sept 08

Phonemic Therapy: Basic Plan 1. Select contrasts to present. 2. Discuss target words to clarify meaning. 3. Confirm discrimination between words. 4. Production practice – often use role reversal; child attempts words and SLP picks up pictures. Provide opportunity for child to “repair” errors. 5. Carryover training – practice above word level (not always specified in some programs). Video demo. Flipsen - SC Scottish Rite Centers - Sept 08

A note about error types Some may disagree but it is assumed here that: Distortion errors represent phonetic errors. Reflect some difficulty with precision of production. Haven’t completely figured out the physical aspects of production. Flipsen - SC Scottish Rite Centers - Sept 08

Intervention for CAS Not clear yet what approach is best. Two general strategies: 1. Improve functional communication. Could also work for very severe forms of artic or phonological problems. An interim step only. 2. Work on the Core problem. Flipsen - SC Scottish Rite Centers - Sept 08

Improving Functional Communication 1. Use AAC Probably best only for most severe cases. NO evidence that it will discourage speech. There is actually evidence it encourages speech. Child sees the effect of communication. Child ultimately sees the limits of AAC (especially slow output rate) and sees the value of speech. Flipsen - SC Scottish Rite Centers - Sept 08

Improving Functional Communication 2. Use a “Core Vocabulary” approach Identify about 50 highly functional words for the child. Pick about 10 words each week to work on and practice heavily to make productions automatic. May have to accept less than perfect output. Need everyone in the child’s environment to know what is expected. Probe all words every 2 weeks and eliminate words that are being produced consistently correctly. Flipsen - SC Scottish Rite Centers - Sept 08

Working on the Core CAS Problem Lots of production practice but avoid repetitive drill of the same target. Vary targets frequently to encourage flexibility. Don’t change too many things at once when adding new targets. Teach new speech sound targets in syllable shapes the child can handle. Teach new syllable shapes using speech sounds child has already mastered. Flipsen - SC Scottish Rite Centers - Sept 08

Working on the Core CAS Problem When working above the word level, keep syntax and vocabulary below their developmental level to minimize programming demands. Include practice with variations in prosody. E.g., varying rates, contrastive stress drills, questions vs. statements. Flipsen - SC Scottish Rite Centers - Sept 08

Deciding on an Approach Even when having a solid diagnosis there are lots of Tx choices. Evidence base is lacking for much of it (i.e., there is not a lot of high level evidence to support particular approaches). Need to make a ‘best guess’ and then carefully document whether change is a result of your efforts. See http://towertotrenches.com Flipsen - SC Scottish Rite Centers - Sept 08

General Question Time Flipsen - SC Scottish Rite Centers - Sept 08