Therapy for Articulation Disorder/Principles of Motor Learning and Their Application to Therapy

CC10 SSD

Traditional Motor Approach or Phonetic Approach

• A clinician instructs a client in how to position the articulators to produce a speech sound that is considered to be within normal limits

• Therapy progresses from one target sound to the next

• Tasks are used to improve auditory discrimination skills and principles of motor learning

• The clinician must understand normal before they can understand disorder

Where do I begin?

1. Intelligibility

2. Developmentally Earlier Sounds

3. Stimulability

4. Correct Production of the Sound in a Specific context

Mastery Level

80% to 90% in structured intervention is generally accepted as ready to move to the next stage

Dismissal/Carryover

Termination criteria is spontaneous contexts should be set at 50% accuracy as progress will continue after termination of therapy

Sensory Perceptual Training

Begins with discriminating between the target and other sounds. There is no production in this step

Identifications

The sound in isolation with contrasted with other similar and dissimilar sounds beginning with sounds that are very different and moving to sounds that are similar

Isolation

Done in word initial, medial, and final positions and the client is asked to identify the sound and state in which position it occurred

• Sometimes this can take a long time

• It may need to be done in stages or you may have to try several different things (perception, use a mirror, minimal pairs)

• Imitation

Stimulation

Done by bombarding the client with variations of the target sound and having them identify it. Vary the sound with loudness, duratin, different speakers

Discrimination

When error productions of the target sound is presented by the clinician and the client is asked to detect the error production and say what is wrong with it

Phonetic Placement

Clinician instructs the client on how to position the articulations

Sound Modifications

Use a sound that the client can produce and instruct them on how to change that sound into the target sound - this requires careful monitoring and lots of feedback

Sounds in Context

Coarticulation sometimes facilitates or aides in appropriate production in one context when the client produces the same phoneme in error in another context. The supporting coarticulation context is the facilitating context. An SLP can use the coarticulation to help the client isolate the correct production of the sound by separating it into syllables and reducing the sounds until the client can produce the target correctly. In order to do this, you must understand the context in which the sound occurs. 

Example: 

d/g - used in “fog” [fɔd] ; student is able to say “finger” with a correct /g/. 

Nonsense Syllables

Order the nonsense syllables used in therapy from those that are easiest for the client, to those that are more difficult. Typically it looks like this: 

• CV

• VC

• VCV

• CVC

This step is often skipped because of context, but sometimes it is necessary to go back to this step (if they are less than 50% accurate in 2 sessions at the word level, moving to nonsense syllables is recommended. Be creative in this step. 

Words

There are many different kinds of words-one open syllable (CV) to multisyllabic words with the same target in it more than once to words with consonant clusters. Be mindful of this during therapy and arrange the words accordingly. 

Words with few syllables, target in the initial word position, open syllables, and stressed syllables are typically easier to produce. 

Consider: Coarticulation

Context

Familiarity with the word

Structured Contexts-Phrases and Sentences

This stage is very structured and the elicitation should be predictable and contain words that the clinician knows that the client is proficient with the target sound. You may begin this while you are still at the word level with the words that the client uses accurately.

A carrier phrases with the target word at the end is an easy way to accomplish this.

Spontaneous Speech

Using the target sounds in various settings is called carryover.

Begin with short conversations and increase the time as the client becomes proficient. Make sure that the client knows the goal. 

After getting proficient with this in therapy, moving outside of the therapy room is important. Parents and teachers can help. 

Dismissal and Re-evaluation

When a student has met their goals and is using the target sounds in conversation approximately 50% of the time, dismissal should be considered. The student should carry over those sounds after dismissal. 

Children should be re-evaluated before dismissal to determine if they are within normal limits. (There are other things to consider here, for instance, if their speech sound errors are no longer impacting their access to the curriculum or if parent has decided that they don’t want their child pulled from class and opt for out-patient therapy after school)

What is Motor Learning?

“A set of complex processes associated with either experience or practice that leads to permanent changes in the possibilities associated with a specific motor skill.”

1. Performance during acquisition of a specific skill should be measured separately from performance after the completion of acquisition.

2. There should be a pre-practice portion of intervention.

3. A practice phase of intervention that incorporates conditions of practice and feedback occur

Practice amount, large or small? More learning=more practice. 

Higher frequency of practice =more rapid acquisition of the targets, better performance in the session, better generalization. Multiple oppositions and minimal pair therapy should include a minimum dose of 50 trails in a 30 minute session, 2 times per week. The more severe the disorder, the higher the frequency. 

Practice distribution, massed versus distributed?

How practice is distributed over time. 3 times per week would be massed (less time between sessions). 2 times per month would be distributed (more time between sessions)

Massed is best, but at times children become unmotivated. Increase in massed distribution for more severe children and decrease to distributed practices as severity decreases. 

What does practice look like?

• Practice variability, constant vs. variable

  • Practicing a motor skill in the same way and in the same context versus practicing the same skill with variations.

    • Variable can be defined as practicing a speech sound in varying linguistic contexts. (changing the vowels)- this promotes learning or permanent retention of the skill. 

      • Randomized variable practice - 

        • Word-initial singletons and clusters

        • Word-final singletons and clusters

        • Intervocalic productions in syllables

        • Words

        • Two to four word phrases

        • Sentences

        • Sound within a conversational topic

At least 150 productions in each 30 minute production, 2 times per week.

Blocked Practice Schedule

Practice the target 10 times, then move to the next target and produce it 10 times. 

• Blocked may be better for individuals with Apraxia of Speech

• One method is to use block practice at the beginning of therapy and them move to random practice.

Random Practice Schedule

Different sequences and patterns occurring arbitrary with no perceptible pattern.

Complex Practice Task

Two or three consonant clusters is more complex

We move from simple to complex

The Complexity Approach has been shown to be more effective for children with phonological disorders

Simple Practice Task

Isolation is simple

We typically move from simple to more complex

Whole Practice Fraction

Practicing the motor skill as a whole

Has a place in therapy

Part Practice Fraction

Breaking motor skills into smaller parts

Has a place in therapy

Practice Accuracy: Errorless vs learning with errors

Learning with errors allows the client to refine and define the motor skill, but some techniques suggest that finding targets where the child can have 100% success is more beneficial (i.e. cycles).

Internal Attentional Focus

Asking the child to focus on the mouth movements or lingual position

Begin with internal and then move to external

External Attentional Focus

Asking the client to evaluate or judge the perceptual quality of a sound

Begin with internal and then move to external

Feedback Type

Knowledge of results versus knowledge of performance

Feedback Frequency

High vs. Low

Feedback Timing

Immediate vs delayed