Speech Sound Disorders and its management

2. WORKSHOP NO 2

3. SPEECH SOUND DISORDERS
Presented by
Fouzia Saleemi
CC-M Phil (Speech Language Pathologist)

4. SPEECH SOUND DISORDERS
Speech sound disorders are speech disorder in
which some speech sounds in a child's language are
either
 not produced
 not produced correctly
 or are not used correctly

6. Speech sound disorders 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.

8. STAGES OF THE SPEAKING PROCESS:
Breathing stage
Phonation stage
Resonation stage
Articulation stage

9. SPEECH MECHANISM

14. A MODEL OF SPEECH PROCESSING AND
UNDERLYING DEFICITS IN SPEECH SOUND
DISORDERS

15. CLASSIFICATION OF CHILDREN'S SPEECH
SOUND DISORDERS
 Speech Delay-Genetic (SD-GEN)
 Speech Delay OME (SD-OME)
 Speech Delay-Developmental Psychosocial
Involvement (SD-DPI)
 Motor Speech Disorder Apraxia of Speech (MSD-AOS)
 Motor Speech Disorder Dysarthria (MSD-DYS)
 Motor Speech Disorder Not Otherwise Specified
(MSD-NOS)
 Speech Errors-Sibilants (SE-/s/
 Speech Errors-Rhotics (SE-/r/)
 Undifferentiated Speech Delay (USD)
 Undifferentiated SS Disorder (USSD)

16. SPEECH DISORDERS
Motor Speech
Disorders
CAS
Dysarthria
Functional
Speech
Disorders
Articulation
Phonological

17. CHILDHOOD APRAXIA OF SPEECH
Childhood apraxia of speech (CAS) is a motor
speech disorder. Children with CAS have problems
saying sounds, syllables, and words. This is not
because of muscle weakness or paralysis. The brain
has problems planning to move the body parts (e.g.,
lips, jaw, tongue) needed for speech. The child
knows what he or she wants to say, but his/her
brain has difficulty coordinating the muscle
movements necessary to say those words.

20. TYPES OF APRAXIA
Ideomotor apraxia
 These patients have deficits in their ability to plan or
complete motor actions that rely on semantic memory.
They are able to explain how to perform an action,
but unable to "imagine" or act out a movement such
as "pretend to brush your teeth" or "pucker as though
you bit into a sour lemon." The ability to perform an
action automatically when cued, however, remains
intact. This is known as automatic-voluntary
dissociation.

21. Ideational/conceptual apraxia:
 Patients have an inability to conceptualize a task
and impaired ability to complete multistep
actions. Consists of an inability to select and
carry out an appropriate motor program.

22. WHAT ARE SOME SIGNS OR SYMPTOMS OF
CHILDHOOD APRAXIA OF SPEECH?
Not all children with CAS are the same. All of the
signs and symptoms listed below may not be
present in every child. It is important to have your
child evaluated by a speech-language pathologist
(SLP) who has knowledge of CAS to rule out other
causes of speech problems. General things to look
for include the following:

23. A VERY YOUNG CHILD
 Does not coo or babble as an infant
 First words are late, and they may be missing
sounds
 Only a few different consonant and vowel sounds
 Problems combining sounds; may show long
pauses between sounds
 Simplifies words by replacing difficult sounds
with easier ones or by deleting difficult sounds
(although all children do this, the child with
apraxia of speech does so more often)
 May have problems eating.

24. AN OLDER CHILD
 Makes inconsistent sound errors that are not the result
of immaturity
 Can understand language much better than he or she can
talk
 Has difficulty imitating speech, but imitated speech is more
clear than spontaneous speech.
 May appear to be groping when attempting to produce
sounds or to coordinate the lips, tongue, and jaw for
purposeful movement
 Has more difficulty saying longer words or phrases
clearly than shorter ones.
 Appears to have more difficulty when he or she is anxious
 Is hard to understand, especially for an unfamiliar listener
 Sounds choppy, monotonous, or stresses the wrong
syllable or word.

25. POTENTIAL OTHER PROBLEMS
 Delayed language development.
 Other expressive language problems like word
order confusions and word recall.
 Difficulties with fine motor
movement/coordination
 Over sensitive (hypersensitive) or under sensitive
(hyposensitive) in their mouths (e.g., may not like
tooth brushing or crunchy foods, may not be able
to identify an object in their mouth through
touch).
 Children with CAS or other speech problems may
have problems when learning to read, spell, and
write.

26. CAS, as defined in ASHA, 2007a, can occur
 in association with known neurological etiologies
(e.g., intrauterine or early childhood stroke,
infection, trauma, brain cancer/tumor resection;
 as primary or secondary signs within complex
neurobehavioral disorders (e.g., autism, epilepsy,
and syndromes, such as fragile X, Rett syndrome,
and Prader-Willi syndrome;)
 as an idiopathic neurogenic speech sound
disorder (i.e., children with no observable
neurologic abnormalities or neurobehavioral
disorders or conditions).

27. HOW IS CHILDHOOD APRAXIA OF SPEECH
DIAGNOSED?
The Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition (American Psychiatric
Association [APA], 2013) uses the term verbal
dyspraxia to describe this disorder and discusses
it within the Speech Sound Disorders category,
under the subheading, "Associated Features
Supporting Diagnosis." Verbal dyspraxia is
described in the DSM-5 as a disorder in which
"other areas of motor coordination may be
impaired as in developmental coordination
disorder."

28. DYSARTHRIA
 Dysarthria is a motor speech disorder. It results
from impaired movement of the muscles used for
speech production, including the lips, tongue,
vocal folds, and/or diaphragm. The type and
severity of dysarthria depend on which area of
the nervous system is affected.

30. WHAT ARE SOME SIGNS OR SYMPTOMS OF
DYSARTHRIA?
 A person with dysarthria may demonstrate the
following speech characteristics:
 "Slurred," "choppy," or "mumbled" speech that
may be difficult to understand
 Slow rate of speech
 Rapid rate of speech with a "mumbling" quality
 Limited tongue, lip, and jaw movement
 Abnormal pitch and rhythm when speaking
 Changes in voice quality, such as hoarse or
breathy voice or speech that sounds "nasal" or
"stuffy"

31. WHAT CAUSES DYSARTHRIA?
Dysarthria is caused by damage to the brain. This may
occur at birth, as in cerebral palsy or muscular
dystrophy, or may occur later in life due to one of many
different conditions that involve the nervous system,
including
 stroke,
 brain injury,
 tumors,
 Parkinson's disease,
 Lou Gehrig's disease/amyotrophic lateral sclerosis
(ALS),
 Huntington's disease,
 multiple sclerosis.

32. ARTICULATION
DISORDERS

33.  What are the Articulation
Definition:
„When the exhaled air from lungs is transformed
into a meaningful sequence of sounds by the
action of different articulators is called
articulation.‟

34. ARTICULATION ERRORS
 The inability to correctly produce speech sounds
because of imprecise placement of articulators
and improper manner of air flow.
 The person with articulation disorder have
difficulty producing and using age-appropriate
speech sounds.

35. ARTICULATION ERRORS
Substitution Omission
Distortion Addition
Errors

36. CAUSE OF ARTICULATION DISORDER
Organic Disorders
Functional
Disorders
Development
Disorders
Articulation Errors

37. ORGANIC ARTICULATION DISORDERS
Defination:
Anatomical factors are one which deals with the
structure of organ ,physiological factors
encompasses function of the organ,phathology
deals with disease or disorder.This may lead to
organic articulation disorders.

38. Cleft Palate/Lip Benign Ulcer of Tongue
Short frenum of upper lip Macroglossia
Micrognathia Carcinomatous ulcer of
tongue
Prognathisum Adenoids
Alveolar Abscess uvulitis
Nasal Polyps Cerebral Palsy
Deflected Nasal Septum Mental Retardation
Fracture of Mandible/Maxilla Dysarthria
Bone Tumor Of Jaw Apraxia
Lingua Frenum Bell’s palsy
Nerve palsy Hearing Loss
Organic Articulation
Disorders

39. PHONOLOGICAL PROCESS

40. Phonological disorder is a type of
speech disorder known as an articulation
disorder. Children with phonological
disorder do not use some or all of the speech
sounds expected for their age group.

41. PHONOLOGY
 Phonology refers to the speech sound system of a
language. Phonological development refers to the
emergence in children of a properly organized
speech sound system. It involves three aspects:
 the way the sound is stored in the child's mind
 the way the sound is actually said by the child
 the rules or processes that map between the two

43. INTELLIGIBILITY TRACK
 By 18 months a child's speech is normally 25%
intelligible
 By 24 months a child's speech is normally 50 -
75% intelligible
 By 36 months a child's speech is normally 75-
100% intelligible

45. CLINICAL DECISION MAKING OF
SPEECH DISORDERS

46. ASSESSMENT SCALE
Disorder/delay
Mild Moderate Severe
No disorder

47. MANAGEMENT OF DISORDERS

48. INTERVENTION APPROACHES
 Core Vocabulary Therapy
 Cycles Therapy (Patterns Intervention)
 Dynamic Temporal and Tactile Cueing (DTTC) and
Integral Stimulation
 Imagery Therapy
 Metaphon
 Minimal Pair Therapies
 Nonlinear / Phonotactic Therapy
 Perceptual Therapy and SAILS
 Psycholinguistic Framework
 Stimuability Therapy
 Target Selection in Phonological Intervention
 Traditional Articulation Therapy

49. CORE VOCABULARY THERAPY
The Core Vocabulary Therapy procedure begins
with the child, parents and teacher selecting, with
the therapist‟s help if required, 50 words that are
functionally „powerful‟ for the child, and „mean
something‟ to him or her, such as, names: family,
friends, teacher, pets; places: school, library, a
park, swimming, McDonalds; functional words:
please, thank you, toilet; favorite things: sport,
superheroes, games and characters. Timothy's
words below serve as an example.

51. Ten words are selected from the list and best
production is drilled in twice-weekly sessions. At
the end of the week the child produces the 10 words
three times. Words produced consistently are
removed from the list of 50 words. Words that are
inconsistently produced remain on the list from
which the next week‟s 10 words are randomly
chosen.

52. CYCLES THERAPY (PATTERNS
INTERVENTION)
 This approach combines traditional and linguistic
approaches and was devised for SLPs/SLTs
working with highly unintelligible children.
 The eight underlying concepts of the Cycles
approach are:

53.  Children with normal hearing typically acquire the
adult sound system primarily by listening.
 Phonological acquisition is a gradual process.
 Phonetic environment in words can facilitate or
inhibit correct sound productions.
 Children associate auditory and kinaesthetic
sensations that enable later self-monitoring.
 Children generalise new speech production skills to
other targets.
 An optimal „match‟ facilitates learning.
 Children learn best when they are actively
involved/engaged in phonological remediation.
 Enhancing a child‟s metaphonological skills facilitates
the child‟s speech improvement and also development
of early literacy skills

54. INTERVENTION PROCEDURES
 Cycles
 Focused Auditory Input
 Facilitative Contexts, Active Involvement,
Self-monitoring and Generalization
 Optimal Match

55. DYNAMIC TEMPORAL AND TACTILE CUEING
(DTTC) AND INTEGRAL STIMULATION
 DTTC allows for what Strand calls „a continuous
shaping of the movement gesture‟, with the goal
of
 (1) improving motor planning, and
 (2) programming speech processing as speech and
language acquisition progresses.

56. INTERVENTION PROCEDURES
1. Imitation
2. Simultaneous production with prolonged
vowels (most clinician support)
3. Reduction of vowel length
4. Gradual increase of rate to normal
5. Reduction of therapist’s vocal loudness,
eventually miming
6. Direct imitation
7. Introduction of a one or two second S-R
delay
8. Spontaneous production

57. IMAGERY THERAPY
 In Imagery Therapy (Klein 1996a, b) error and
target are contrasted and the feature difference
is usually minimal. This intervention proceeds in
three steps
 Identification and production of the contrast in
nonsense syllables
 Identification, classification, and production of
the contrast in single words
 Production in narratives and conversational
speech

58. METAPHON
 Metaphon (Dean & Howell, 1986; Dean, Howell, Hill
& Waters, 1990; Dean, Howell, Waters & Reid, 1995)
is based on the principle that homophony motivates
phonemic change.
 Phonological analysis is performed using the test in
the Metaphon Resource Pack (or the phonological
assessment of choice) and errors are described in
terms of phonological processes. Target vs. substitute
sound pairs are selected for treatment. Feature
contrasts are usually minimal or near-minimal. The
essence of Metaphon is in two overlapping treatment
phases followed by a discrete final phase.
 Metaphonetic skills are trained to improve a child‟s
„cognitive awareness‟ of the properties of the sound
system, while metalinguistic tasks are used to
develop more successful use of repair strategies.

59. MINIMAL PAIR THERAPIES
“All phonological approaches focus on teaching
children the function of sounds, particularly that
changing sounds changes meaning, and that
making meaning is a necessary to communication.
All rest on the principle that once it is introduced
to a child‟s system, a featural contrast will show
generalization to other relevant phonemic pairs.

60.  The Threefold Foundation of all Minimal
Pair Approaches
 1. To modify a group, or groups, of sounds
produced in error, in a patterned way.
 2. To highlight featural contrasts rather than
accurate sound production.
 3. To emphasize the use of sounds for
communicative purposes.

61. NONLINEAR / PHONOTACTIC THERAPY
Phonotactic development (the ability to produce
'syllable shapes' and 'word shapes' such as CV, VC,
CVC, CCV, VCC, CCVCC, etc.

62. Syllable Hierarchy (KAUFMAN SPEECH PRAXIS KIT)
• Simple Phonemic/ Syllabic Level:
• V simple vowels in isolation-‐ /a, u, i, ɔ, ᴧ, Ɛ, I/
• VV vowel to vowel (diphthongs)-‐ /aI, ou, eI, au, ɔI/
• C simple consonant in isolation-‐ /m, t, p, b, h, d, n/
• CVCV repetitive syllables (reduplication)-‐ /mama/, /dada/, bᴧbᴧ/
• CV consonant to vowel-‐ /du/, /mi/, /bu/
• VCV vowel to consonant to vowel-‐ /apo/, /obo/
• CV1CV2 repetitive syllables with vowel change-‐ /bᴧbo/ (bubble), /mami/
(mommy), /pᴧpi/ (puppy)
• CVC simple monosyllables with assimilation-‐ pop, mom, dad, tot
• CVC simple consonant synthesis-‐ Man, pin, hot, boat, home, hop, mad
• C1V1C2V2 simple bisyllabics with consonant and vowel change-‐ happy,
tummy, muddy

63. NUFFIELD APPROACH

64. PERCEPTUAL THERAPY AND SAILS
The Speech Assessment and Interactive Learning
System (SAILS) is a computer based tool that can
be used to improve children‟s speech perception
skills. SAILS targets commonly misarticulated
consonant phonemes in the onset (initial) and coda
(final) position of words. The program is based on
recordings of naturally produced words. These
words were recorded from English-speaking adult
talkers with accurate speech, child talkers with
accurate speech, and child talkers with a speech
sound disorder.

65. PSYCHOLINGUISTIC FRAMEWORK
The psycholinguistic
approach (Stackhouse and
Wells, 1997; Stackhouse,
Wells, Pascoe and Rees,
2002; Stackhouse, Pascoe
and Gardner, 2006)
provides an inclusive
means of investigating,
describing and profiling
children‟s speech and
literacy difficulties
through the application of
a speech processing model
and a developmental
phase models of speech
and literacy.

66. STIMUABILITY THERAPY
Traditionally, „stimulable‟ has meant that a
consonant or vowel can be produced in isolation by
a child, in direct imitation of an auditory and visual
model with or without instructions, cues, imagery,
feedback and encouragement. We know that if a
child is not stimulable for a sound there is poor
probability of short-term progress with that sound.
That is, the sound is unlikely to „spontaneously
correct‟ or magically „become stimulable‟.

67. TARGET SELECTION IN PHONOLOGICAL
INTERVENTION

68. TRADITIONAL ARTICULATION THERAPY
Powers began this therapy with auditory
discrimination training. A sound was identified,
named, discriminated from other speech sounds,
and then discriminated in contexts of increasing
complexity.

69. ORAL MOTOR THERAPIES

70. HOW OFTEN AND WHERE TO PERFORM
ORAL PLAY THERAPY
 Can be done in therapy,
the session room, or
home!
 Therapy: 5-10 minutes of
a 30 minute session/15
minutes of a 60 minute
session
 Home: 5 minutes to 1
hour depending on the
child
 Session room: 10-20
minute activity in a
group.
70

71.  Oral motor exercises are important in non verbal
or late talker children for increasing muscle tone
/ muscle strength so speech is possible.
 Even for children that already talk – these are
great ideas for improving speech clarity

72. PASSIVE ACTIVITIES
 BLOWING/BREATHING
 SUCKING
 CHEWING AND JAW STRENGTH
 LICKING
 TONGUE SOUNDS

73. ORAL-MOTOR CLASSROOM ACTIVITIES :
BLOWING
 Bubbles
 Whistles
 Feathers
 Cotton balls
 Ping pong balls
 Breath on a mirror
 Party blowers
 Soap bubbles with
colored water
 Painting with balls
 Soap and water
painting
 Kazoos
 Pinwheels
 Mobiles
 kleenex
73

74. ORAL-MOTOR SUCKING
 Strengthen suck : sugar is not good for
droolers and citrus encourages sucking
 practice sound as you pretend to feed a doll
(tongue on top of mouth w/ pressure)
 straws with thick milkshake or nectar to
strengthen suck.
(Orange wedges, peanut butter , popsicles,
puddings, Caramel suckers, Jelly cubes, chew,
juice bars,Cranberry juices and lemonade)
74

75. INCREASING JAW CONTROL, FACILITATE
MUNCH, AND 3-DIMENSIONAL CHEW
 Munch-crunch
 Apples
 Carrots
 Chips
 Corn chips
 Graham crackers
 Pretzels
 Popcorn
 Chew
 Bubble gum
 Cheese
 Dried fruits
 French fries
 Fruit roll-ups
 Licorice sticks
 Raisins
 Skittles
75

76. ORAL-MOTOR LICKING
 popsicles
 suckers
 ice cream cones
 lick out bowl (never mind etiquette)
 lick off something sticky from top lip, bottom lip
or corners of mouth
 pretend to be like a kitty, licking paws

77. ORAL MOTOR -TONGUE SOUNDS
 imitate motoric activities
 clicking
 la la la to music
 blow “raspberry” with tongue etc

78. MANAGEMENT PLAN FOR ACTIVE
PARTICIPATION OF CHILDREN

79. SPIROMETER ACTIVITY(BLOWING )

80. SPIROMETER ACTIVITY(SUCKING )

81. ORAL-MOTOR EXERCISES - TOUNGE
 Tongue Push-Ups
 Tongue Pops
 Back and Forth
 Pointy Tongue
 Find the Stick
 Quick Strength
 Throat Scratches
 Tapping
 Icing
 Brushing

82.  Whistle
 Fish Mouth
 Pucker-Smile
 Jaw Aerobics
 Jaw Curls
 Watch the Muscle
 Massage
 Water Hold
 Cotton
 Tactile Stimulation for Lips