Speech sound disorder

Speech sound disorder

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  EFFECTIVE INTERVENTION FORTHE TREATMENT OF SPEECH SOUND DISORDERS Anshita Singh Audiologist & speech language pathologist
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  OVERVIEW  Speech sounddisorders is an umbrella term referring to any combination of difficulties with perception, motor production, and/or the phonological representation of speech sounds and speech segments (including phonotactic rules that govern syllable shape, structure, and stress, as well as prosody) that impact speech intelligibility
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  CAUSES  Known causesof speech sound disorders include motor-based disorders (apraxia and dysarthria), structurally based disorders and conditions (e.g., cleft palate and other craniofacial anomalies), syndrome/condition-related disorders (e.g., Down syndrome) and sensory-based conditions (e.g., hearing impairment).
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  CONT…. Even so, anumber of studies have identified risk and protective factors associated with speech sound disorders in children. Risk factors include  pre- and perinatal problems;  oral sucking habits (e.g., excessive sucking of pacifiers or thumb)  ear, nose, and throat problems;  family history of speech and language problems;  low parental education;  lack of support for learning in the home.  a more persistent and sociable temperament,  a higher level of maternal well-being.
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  ARTICULATION DISORDER  Speechsound disorders can impact the form of speech sounds or the function of speech sounds within a language. Disorders that impact the form of speech sounds are traditionally referred to as articulation disorders and are associated with structural (e.g., cleft palate) and motor-based difficulties (e.g., apraxia).
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  PHONOLOGICAL DISORDER  Speechsound disorders that impact the way speech sounds (phonemes) function within a language are traditionally referred to as phonological disorders; they result from impairments in the phonological representation of speech sounds and speech segments—the system that generates and uses phonemes and phoneme rules and patterns within the context of spoken language.
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  INCIDENCE & PREVALENCE As per the country wide sample survey conducted by Government of India in 2011, census listed speech impairment (7.5%) as the fifth highest disability (Males-56.25%, Females43.8%). In India, Sreeraj, Suma, Jayaram, Sandeep, Mahima and Shreyank (2013) found that the prevalence of individuals at risk of communication disorders was 6.07%. the prevalence of was found to be speech and language disorder was 9.42%.(AIISH)
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  SIGNS & SYMPTOMS omissions/deletions—certain sounds are not produced but omitted or deleted (e.g., "cu" for "cup" and "poon" for "spoon");  substitutions—one or more sounds are substituted, which may result in loss of phonemic contrast (e.g., "dood" for "good" and "wabbit" for "rabbit");  additions—one or more extra sounds are added or inserted into a word (e.g., "buhlack" for "black");
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  CONT….  distortions—sounds arealtered or changed (e.g., a lateral "s");  whole-word/syllable-level errors—weak syllables are deleted (e.g., "tephone" for "telephone"), a syllable is repeated or deleted (e.g., "dada" for "dad" or "wawa" for "water");
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  INFLUENCE OF DIALECT Not all sound substitutions and omissions are speech errors. Instead, they may be related to a feature of a speaker's dialect (a rule-governed language system that reflects the regional and social background of its speakers). Dialectal variations of a language may cross all linguistic parameters, including phonology, morphology, syntax, semantics, and pragmatics.
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  INFLUENCE OF ACCENT An accent is the unique way that speech is pronounced by a group of people speaking the same language and is a natural part of spoken language. Accents may be regional; for example, someone from Kerala may sound different from someone from Bihar. Foreign accents occur when a set of phonetic traits of one language are carried over when a person learns a new language. Accents, like dialects, are not speech or language disorders but rather only reflect differences.
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  ASSESSMENT  Screening  ComprehensiveAssessment
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  SCREENING  Screening isconducted whenever a speech sound disorder is suspected or as part of a comprehensive speech and language evaluation for a child with communication concerns. The purpose of the screening is to identify those who require further speech-language/communication assessment or referral to other professional services.
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  CONT….  Screening mayresult in  suggestions to encourage normal speech sound development and the prevention of speech-language impairment;  plans to monitor speech and language development;  referral for further speech and language assessment, including  a comprehensive speech sound assessment, if the child's speech sound system is not appropriate for his/her age and/or linguistic community,  a comprehensive language assessment,  a complete audiology assessment,  a comprehensive oral motor/oral musculature assessment;  referral for medical or other professional services.
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  COMPREHENSIVE ASSESSMENT  Individualssuspected of having a speech sound disorder based on screening results are referred to an SLP for a comprehensive assessment. The assessment protocol may include an evaluation of language and literacy skills  Comprehensive assessment for speech sound disorders typically includes  case history;  oral mechanism examination;  hearing screening;
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  CONT….  speech soundassessment (single-word testing and connected speech sampling), including  severity,  intelligibility,  stimulability,  speech perception;  spoken-language testing, including  receptive and expressive language assessment,  phonological processing;  literacy assessment.
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  CONT….  Assessment mayresult in  diagnosis of a speech sound disorder,  description of the characteristics and severity of the disorder,  recommendations for intervention targets,  identification of factors that might contribute to the speech sound disorder,  diagnosis of a spoken language (listening and speaking) disorder,  identification of literacy problems,  monitoring of literacy learning progress in students with identified speech sound disorders by SLPs and other professionals in the school setting,  referral to other professionals as needed.
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  CASE HISTORY  Thecase history typically includes gathering information about  family's concerns about the child's speech;  history of middle ear infections;  history of speech, language, and/or literacy difficulties in the family;  languages used in the home;  primary language spoken by the child;  teacher's perception of the child's intelligibility and participation in the school setting and how the child's speech compares with that of peers in the classroom;  family's and other communication partners' perception of intelligibility.
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  ORAL MECHANISM EXAMINATION The oral mechanism examination evaluates the structure and function of the speech mechanism to assess whether the system is adequate for speech production. This examination typically includes assessment of  occlusion and specific tooth deviations;  hard and soft palate (clefts, fistulas, bifid uvula);  function (strength and range of motion) of the lips, jaw, tongue, and velum;  placement of the tongue at rest and during speech to rule out tongue thrust, an oral myofunctional phenomenon, that can affect production of some sounds (e.g., /s/,/z/, "sh", "zh", "ch" and "j").
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  HARING SCREENING  ahearing screening is conducted during the comprehensive speech sound assessment. The screening typically includes  otoscopic inspection of the ear canal and tympanic membrane,  puretone audiometry,  immittance testing to assess middle ear function.
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  SPEECH SOUND ASSESSMENT The acquisition of speech sounds is a developmental process, and children often demonstrate "typical" errors and phonological patterns during this acquisition period. For example, it is considered typical and acceptable for younger children to replace later-acquired sounds, such as /s/, with earlier-acquired sounds, such as /t/, up until a certain age range. Developmentally appropriate errors and patterns are taken into consideration during assessment for speech sound disorders in order to differentiate typical errors from those that are unusual or not age-appropriate.
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  CONT….  Single-Word Testing—providesidentifiable units of production and allows all sounds in the language to be elicited in a number of contexts; however, it may or may not accurately reflect production of the same sounds in connected speech.  Connected Speech Sampling—provides information about production of sounds in connected speech using a variety of talking tasks (e.g., storytelling or retelling, describing pictures, normal conversation about a topic of interest) and communication partners (e.g., peers, siblings, parents, clinician).
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  CONT….  Assessment procedurestypically evaluate the child's speech sound system, including  sounds, sound combinations, and syllable shapes produced accurately, including  sounds in various word positions (e.g., initial, within word, and final word position) and indifferent phonetic contexts,  phoneme sequences (e.g., vowel combinations, consonant clusters, and blends),  syllable shapes (e.g., simple CV to complex CCVCC);  speech sound errors, including  error type(s) (e.g., deletions, omissions, substitutions, distortions, additions),  error distribution (e.g., position of sound in word),
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  CONT….  articulation errors—relativelyconsistent errors, with preserved phonemic contrasts (e.g., /l/ and /r/ are consistently distorted, but clearly different from one another;  error patterns (i.e., phonological patterns)— systematic sound changes or simplifications that affect a class of sounds (e.g., fricatives), sequences of sounds (e.g., consonant clusters), or syllable structures (e.g., complex syllable structures or multisyllabic words.
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  SEVERITY  Severity isa qualitative judgment made by the clinician that indicates the significance of the speech sound disorder on the child's communication functioning in daily activities. It is typically defined along a continuum from mild to severe or profound.  Prezas and Hodson (2010) utilize a continuum from mild (omissions are rare; few substitutions) to profound (extensive omissions and many substitutions; extremely limited phonemic and phonotactic repertoires), with distortions.
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  CONT….  Shriberg andKwiatkowski (1982a, 1982b) proposed a quantitative approach in which the percentage of consonants correct (PCC) is used to determine severity on a continuum from mild to severe. This type of calculation most closely aligns with the listener's perceptions of severity. For example, a PCC of 85-100 is considered "mild," while a PCC of less than 50 is considered "severe."
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  INTELLIGIBILITY  Intelligibility isa subjective, perceptual judgment, based on how much of the child's spontaneous speech is understood by the listener. Intelligibility can range from "intelligible" (message is completely understood) to "unintelligible" (message is not understood). Intelligibility is a factor that is frequently used when judging the severity of the child's speech problem . The rating is on a 5-point Likert scale: 1 = Never; 2 = Rarely; 3 = Sometimes; 4 = Usually; 5 = Always Procedures that are “always.
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  CONT….  A guidelinefor expected intelligibility can be calculated by dividing the child's age in years by four and converting that number into a percentage: 2-year-old: 50%; 3-year-old: 75%; 4-yearold: 100% (Hodson, 2011)  Articulation tests were poor predictors of connected speech intelligibility. “Children may correctly articulate a variety of consonants and vowels in single words but still not have readily intelligible connected speech.”
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  CONT….  Several factorscan influence the intelligibility of speech, including  level of communication (e.g., single words vs. conversation);  listener's familiarity with the speaker's speech pattern;  speaker's rate, inflection, stress patterns, pauses, voice quality, loudness, and fluency;  social environment (e.g., familiar vs. unfamiliar conversational partners, one-on-one vs. group conversation);  communication cues for listener (e.g., known vs. unknown context);  signal-to-noise ratio (e.g., amount of background noise);  listener's skill.
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  STIMULABILITY  Stimulability testingexamines the child's ability to produce or imitate a misarticulated sound correctly when a model is provided by the clinician. It provides information about how well the individual imitates the sound in one or more contexts (e.g., isolation, syllable, word, phrase) and helps determine the level of cueing necessary to achieve the best production (e.g., auditory model; auditory and visual model; auditory, visual, and verbal model; tactile cues).
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  CONT…. Stimulability testing isused to  determine if the sound(s) are likely to be acquired without intervention,  select appropriate therapy targets,  predict improvement in therapy.  attests to the child’s ability to perceive, to recognize as different, and to produce the sound in question.  If the child is not stimulable for a sound, then one might question the child’s: Motoric abilities, Perceptual abilities, Linguistic abilities, Attention (focus), Non-compliance.
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  CONT….  If achild is stimulable for a sound, then that sound is likely to be added to the child’s phonetic inventory, even without direct treatment on that sound.  If a child is NOT stimulable for a sound, then the likelihood of short term gains is poor; normalization without therapy is much poorer than normalization for sounds that the child is stimulable for.
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  SPEECH PERCEPTION TESTING Speech perception testing is used to determine if a child is able to perceive the difference between the standard production of a sound and his/her own error production. A number of different test paradigms are used to assess speech sound discrimination, including  Auditory Discrimination  Picture Identification  Pronunciation Accuracy/Inaccuracy,(Speech production–perception task, Mispronunciations detection task, Lexical decision/judgment task)
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  SPECIAL CONSIDERATIONS  Youngchildren might not be able to follow directions for standardized tests, might have limited expressive vocabulary, and might produce words that are unintelligible. Other children, regardless of age, may produce less intelligible speech or be reluctant to speak in an assessment setting. Strategies for collecting an adequate speech sample with these populations include
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  CONT….  obtaining aspeech sample during the assessment session using play activities,  involving parents/caregivers in the session to encourage talking,  asking parents/caregivers to supplement data from the assessment session by recording the child's speech at home during spontaneous conversation,  asking parents/caregivers to keep a log of the child's intended words and how these are pronounced
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  SPOKEN LANGUAGE TESTING Language testing is included in a comprehensive speech sound assessment because of the high incidence of co-occurring language problems in children with speech sound disorders. Typically, the assessment begins with a screening of receptive language and expressive language. A full language battery is performed if indicated by screening results. Phonological Processing  Phonological processing is the use of the sounds of one's language (i.e., phonemes) to process spoken and written language.The broad category of phonological processing includes phonological awareness, phonological working memory, and phonological retrieval
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  CONT….  Phonological Awareness—theawareness of the sound structure of a language and the ability to consciously analyze and manipulate this structure via a range of tasks, such as speech sound segmentation and blending at the word, onset-rime, syllable, and phonemic levels.  Phonological Working Memory—involves storing phoneme information in a temporary, short-term memory as Nonword repetition (e.g., repeat /pæg/) is one example of a phonological working memory task.
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  CONT….  Phonological Retrieval—theability to recall the phonemes associated with specific graphemes, which can be assessed by rapid naming tasks (e.g., rapid naming of letters and numbers).  All three components of phonological processing are important for speech production as well as the development of spoken and written language skills.
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  LITERACY ASSESSMENT [READINGAND WRITING]  Difficulties with the speech processing system (e.g., listening, discriminating speech sounds, remembering speech sounds, producing speech sounds) can lead to both speech production and phonological awareness difficulties that can hamper the development of literacy.  For typically developing children, speech production and phonological awareness develop in a mutually supportive way  The understanding that sounds are represented by symbolic code (e.g., letters and letter combinations) is essential for reading and spelling.
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  COMPONENTS OF LITERACYASSESSMENT  Print Awareness—recognizing that books have a front and back and that the direction of words is from left to right and recognizing where words on the page start and stop.  Alphabet Knowledge—including naming/printing alphabetic letters from A to Z.  Sound-Symbol Correspondence—knowing that letters have sounds and knowing the sounds for corresponding letters and letter combinations.  Reading Decoding—using sound-symbol knowledge to segment and blend sounds in grade-level words.  Spelling—using sound-symbol knowledge to spell grade-level words.  Reading Fluency—reading smoothly without frequent or significant pausing.  Reading Comprehension—understanding grade-level text, including the ability to make inferences.
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  PERCENT OF CONSONANTCORRECT (PCC)  An objective severity metric; The examiner makes correct/incorrect judgments of individuals sounds produced.  PCC = Number of Correct Consonants/Number of Correct + Incorrect Consonants *100  Only evaluates consonants; Originally based only on conversational speech;  Efficient and valid approach for children 4 to 6 years old
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  TREATMENT  treatment approacheshave traditionally focused on articulation production and others have been more phonological/language-based. Articulation approaches target each sound deviation and are often selected by the clinician when the child's errors are assumed to be motor-based; the aim is correct production of the target sound(s). Phonological approaches target a group of sounds with similar error patterns, although the actual treatment of exemplars of the error pattern may target individual sounds.
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  CONT….  The sequenceof most treatment approaches for speech sound disorders are reflected in the following phases of therapy:  Establishment—eliciting target behaviors and stabilizing production on a voluntary level.  Generalization—facilitating carry-over of sound productions at increasingly challenging levels (e.g., syllables, words, phrases/sentences, conversational speaking).  Maintenance—stabilizing target behaviors and making production more automatic; encouraging self-monitoring of speech and self-correction of errors.
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  CONT….  Treatment selectionwill depend on a number of factors, including the child's age, the type of speech sound errors, the severity of the disorder, and the degree to which the disorder affects overall intelligibility
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  CONTRAST THERAPY  Contrasttherapy focuses on production using contrasting word pairs instead of individual sounds. This approach emphasizes sound contrasts necessary to differentiate one word from another  Minimal Oppositions— also known as "minimal pairs" therapy, uses pairs of words that differ by only one phoneme or single feature  in an effort to establish contrasts not present in the child's phonological system (e.g., pot vs. spot, key vs. tea; )
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  CONT….  Maximal Oppositions—Wordpairs have multiple feature contrasts (maximal oppositions) features can differ on place , manner and voicing (e.g., manner of production and place of production, such as /m/ vs. /s/, mack/shake  Treatment Of The Empty Set—similar to maximal opposition contrasts, but uses pairs of words containing two maximally opposing sounds that are unknown to the child—ideally, an obstruent with a sonorant (e.g., /l/ vs. /s/; Gierut, 1992).  Multiple Oppositions—a variation of the minimal opposition contrast approach that uses pairs of words contrasting a child's error sound with three or four strategically selected sounds that reflect both maximal classification and maximal distinction (Williams, 2000a, 2000b).
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  CORE VOCABULARY APPROACH A core vocabulary approach focuses on whole-word production and is used for children with inconsistent speech sound production who may be resistant to more traditional therapy approaches. Words selected for practice are those that are used frequently in the child's functional communication. A list of frequently used words is developed (e.g., based on observation, parent report, and/or teacher report), and a number of words from this list are selected each week for treatment. The child is taught his "best" word production, and the words are practiced until consistently produced .
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  CYCLES APPROACH  Thecycles approach targets phonological pattern errors and is designed for highly unintelligible children who have extensive omissions, some substitutions, and a restricted use of consonants. The goal is to increase intelligibility within a short period of time, and treatment is scheduled in cycles ranging from 5 to 16 weeks. During each cycle, one or more phonological patterns are targeted. After each cycle has been completed, another cycle begins, targeting one or more different phonological patterns. Recycling of phonological patterns continues until the targeted patterns are present in the child's spontaneous speech .
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  DISTINCTIVE FEATURE THERAPY Distinctive feature therapy focuses on elements of phonemes that are lacking in a child's repertoire (e.g., frication, nasality, voicing, and place of articulation) and is typically used for children who primarily substitute one sound for another. This approach uses tasks (e.g., minimal pair contrasts) that compare the phonetic elements/features of the target sound with those of its substitution or some other sound contrast. Patterns of features can be identified and targeted; producing one contrast often generalizes to other sounds that share the targeted feature.
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  NATURALISTIC SPEECH INTELLIGIBILITY INTERVENTION Naturalist speech intelligibility intervention directs treatment of the targeted sound in naturalistic activities that provide the child with frequent opportunities for the sound to occur. For example, using a McDonald's menu, the child can be asked questions about items that contain the targeted sound(s). The child's error productions are recast without the use of imitative prompts or direct motor training. This approach is used with children who are intelligible enough to be able to use the recasts effectively
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  NON-SPEECH ORAL-MOTOR THERAPY Non-speech oral-motor therapy involves the use of oral-motor training prior to teaching sounds or as a supplement to speech sound instruction. The rationale behind this approach is that immature or deficient oral-motor control or strength may be causing poor articulation and that it is necessary to teach control of the articulators before working on correct production of sounds.
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  SPEECH SOUND PERCEPTIONTRAINING  Speech perception training is a procedure used to help the child acquire a stable perceptual representation for the target phoneme or phonological structure. The goal is to ensure that the child is attending to the appropriate acoustic cues (i.e., one that ensures reliable perception of the target in a variety of listening contexts).  Recommended procedures include (1) auditory bombardment in which many and varied exemplars of the target are presented to the child, sometimes in a meaningful context such as a story and often with amplification, and  (2) identification tasks in which the child identifies correct and incorrect versions of the target (e.g., "rat" is a correct exemplar of the word corresponding to a rodent whereas "wat" is not). Traditionally the speech stimuli used in these tasks are presented live-voice by the speech-language therapist but more recently computer technology has been used which has the advantage of allowing for the presentation of more varied stimuli representing, for example, multiple voices and a range of error types.
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  TECHNOLOGIES  There area number of techniques used in therapy to increase awareness of the target sound and/or to provide feedback about placement and movement of the articulators. These include  use of a mirror for visual feedback of place and movement of articulators;  use of gestural cueing for place or manner of production (e.g., using a long sweeping hand gesture for fricatives vs. a short, "chopping" gesture for stops);
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  CONT….  ultrasound imaging(placing an ultrasound transducer under the chin) used as a biofeedback technique to visualize articulatory positioning and movement for vowel production  palatography (using various coloring agents or a palatal device with electrodes) to record and visualize contact of the tongue on the palate while the child makes different speech sounds  amplification of target sounds to improve attention, reduce distractibility, and increase sound awareness and discrimination—for example, auditory bombardment with low-level amplification is used  spectral biofeedback through a visual representation of the acoustic signal of speech
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  CONT….  tactile biofeedbackusing tools, devices, or substances placed within the mouth (e.g., tongue depressors, peanut butter) to provide feedback on correct tongue placement and coordination  Associate Speech Sounds with Hand/Body Motions (multi-modal input increases children’s ability to retain newly learned speech sounds. Hand motions serve as retrieval cues for remembering).  Associate Speech Sounds with Alliterative Characters of Interest to the Child. (interesting characters increase interest in the activity and encourage full participation. Enhances the opportunity for a child to develop conscious awareness of the newly learned sound segments
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  CONT….  For example:P Putt-putt pig b Baby bear t Talkie turkey d Dirty dog k Coughing cow g Goofy goat f Fussy fish v Viney violet ‘ Thinking thumb s Silly snake z Zippy zebra c Shy sheepy  Encourage Vocal Practice (do not use drill; instead, encourage vocal practice by including sound elicitation activities that involve turn-taking and requesting)
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  CHILDREN WITH PERSISTINGSPEECH DIFFICULTIES  For some children, speech difficulties persist throughout their school years and into adulthood.  This is define as persisting speech difficulties (PSD)  Difficulties in the normal development of speech that do not resolve as the child matures or even after they receive specific help for these problems  The population of children with PSD is heterogeneous, varying in etiology, severity, and the nature of their difficulties and includes children with
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  CONT….  speech sounddisorders of unknown etiology (i.e., typical articulation and phonological disorders),  motor-based speech disorders (e.g., childhood apraxia of speech, dysarthria),  medical conditions and sensory-based problems (e.g., chronic otitis media, hearing loss),  structure-based speech disorders (e.g., cleft lip/palate, other craniofacial anomalies).  A child with PSD may be at risk for-  difficulty communicating effectively when speaking,  difficulty acquiring literacy skills,  psychosocial problems (e.g., low self-esteem, at increased risk of bullying).
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  INTERVENTION APPROACHES  Itdepend on the child's diagnosis (e.g., structural vs. condition-related) and his/her area(s) of difficulty (e.g., speaking, literacy, and/or psychosocial issues). In designing an effective treatment protocol, the SLP considers  a psycholinguistic approach to identify the level at which speech processing is disrupted, including  input/perception (auditory discrimination of sounds and words),  storage (underlying lexical representation),  speech output (planning and production of sounds needed for speech);  phonological (linguistic) approaches to treat the level or levels of identified disruption, using specific interventions and stimuli (e.g., minimal pairs, maximal pairs, metaphon approaches);
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  CONT….  medical andsurgical intervention (e.g., for children with cleft lip/palate or other physical conditions);  collaboration with teachers and other school personnel to support the child and to facilitate his/her access to academic curriculum;  management of psychosocial factors, including self- esteem issues and bullying
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  REFERENCES  Intervention ofspeech sound disorders (ASHA CSC)  Effective intervention of the treatment of the speech sound disorder-Susan Rvachew  Speech sound disorder (ASHA)  What we know about children's speech sound disorder & treatment- Children’s health Queensland hospital and health service