LCD 322 Test 1

Evidence-based practice (EBP)

Involves using techniques that research has proven to work

EBP triangle

• Clinical expertise

• Client perspectives

• Evidence

PICO

Method of framing a clinical question:

P = population

I = intervention

C = comparison

O = outcome

Internal evidence

• Data that you systematically collect directly from your clients to ensure that they’re making progress.

• May include subjective observations of your client as well as objective performance data compiled across time.

External evidence

• Evidence from scientific literature—particularly the results, data, statistical analysis, and conclusions of a study.

• Helps you determine whether an approach or a service delivery model might be effective at implementing change in individuals like your client.

Effectiveness

The probability of benefit from an intervention method under average condition

Efficacy

The probability of benefit from an intervention method under ideal conditions.

• Refers to an identified population (ex: global aphasia), not to individuals.

• Treatment protocol should be focused, and the population should be clearly identified.

• Research should be conducted under optimal intervention conditions.

Efficiency

Results from application of the quickest method involving the least effort and the greatest positive benefit

Speech

The process of producing the acoustic representations or sounds of language. Features:

• Articulation - how speech sounds are formed.

• Fluency - the smooth, forward flow of communication.

• Rate - the speed at which we talk.

Examples of nonverbal communication

• Artifacts

• Kinesics

• Proxemics

• Chronemics

Kinesics

Body language

Proxemics

Physical distance between people

Chronemics

The effect of time on communication

Disorders of articulation

• Difficulty producing speech sounds correctly.

• Can be difficult to distinguish if speech-sound errors indicate an impairment of phonology or articulation.

  • Error patterns point to phonological disturbances.

• Ex: dysarthria, apraxia.

Dysarthria

Poor speech articulation caused by paralysis, weakness, or poor coordination of the muscles for speech

Apraxia

Disorder of motor programming (organization + planning); unrelated to muscle weakness

Stuttering

• When disfluencies exceed the norm and/or are accompanied by excessive tension, struggle, and fear.

  • Fillers (er, um, ya know).

  • Hesitations (unexpected pauses).

  • Repetitions (g-g-go).

  • Prolongations (wwwwwell…).

• Developmental _____ is first noticed before 6 y/o.

• Adult onset dysfluency can be caused by advanced age, accidents, and disease.

Disorders of voice

• Caused by vocal abuse: physical tension, excessive yelling/coughing, smoking, and alcohol consumption.

• Hoarseness - voice lacks clarity and is noisy. D/t pathologies affecting VF vibration.

Disorders of form

• Issues with phonology, morphology, syntax.

• Ex: not producing the ends of words, incorrect word order, run-on sentences.

• Causes: sensory limitations (hearing problems, perceptual difficulties), limited exposure to correct models, neurological disorders.

Disorders of content

• Issues with semantics: limited vocabularies, misuse of words, word-finding difficulties.

• Ex: difficulty understanding abstract language (metaphors, sarcasm), “thing” in replacement for the name of an object.

• Causes: limited experience/concrete learning style, cerebrovascular accidents, head trauma, cognitive impairments.

Disorders of use

• Issues with pragmatics: limited/unacceptable conversational, social, and narrative skills; deficits in spoken vocabulary.

• Ex: difficulty staying on a topic, inappropriate responses to questions, constantly interrupting conversational partner.

• Causes: ASD, environment, attention-deficits, neurologic disorders.

Prevalence

The number of people within a specified population who have a particular disorder or condition at a given point in time

Incidence

The number of new cases of a disease or disorder in a particular time period

Etiology

The cause of a disorder

Functional/idiopathic etiology

No known cause. Possible factors include:

• Behavioral - children with older siblings and overindulgent parents may not feel the need to learn language.

• Programming - Childhood Apraxia of Speech (CAS) cannot program articulators.

• Psychological - a bad home environment.

• Modeling - if a caretaker has a lisp, the child might imitate it.

• Middle ear infections - multiple infections can lead to hearing issues affecting articulation/phonology.

Organic etiology

Has a known cause. Possible factors include:

• Neurologic problems - stroke, traumatic brain injury (TBI).

• Cancer - laryngectomy/glossectomy may affect speech production.

• Neurodegenerative diseases - ALS, Parkinson’s disease.

• Congenital issues -  cerebral palsy, Down syndrome, Pierre Robin syndrome.

• Acquired issues - injury, cancer, most dysarthrias.

• Structural issues - cleft palate or orofacial anomalies, often leading to resonant issues.

• Motor/neurological - execution (dysarthria) and planning (apraxia) difficulties.

• Sensory/perceptual - hearing impairment.

• Psychological - most common with voice disorders.

• Systemic - diseases causing weakness throughout the body; ex: Scleroderma, Myelitis.

Predisposing factors

Factors that underlie the problem (genetic factors)

Precipitating factors

Factors that triggered the disorder (stroke)

Maintaining/perpetuating factors

Factors that continue or add to the problem

Acute

A disorder with a sudden onset and short-term duration.

Ex: stroke, heart attack, TBI.

Chronic

When a disorder persists after spontaneous recovery, it is considered ____.

Ex: dysarthria still present 6 months post-stroke.

Progressive

A disorder that worsens over time.

Ex: PD, ALS, PSP, HD, MSA-C, MS.

Prognosis

Predicted outcome of treatment

Referral

Suggested appointment for evaluation, often initiated by doctors

Screening

Quick assessment to determine if there is a problem; no follow-up if no issues; comprehensive evaluation done if so

Comprehensive evaluation

• Covers all aspects: oral mechanism, hearing, speech, language (expressive & receptive), fluency, voice, swallowing, cognition.

• Depth of evaluation depends on judgment and age.

Subjective tests

Facility-created tests for specific facets

Objective tests

Published tests with extensive research

Case history

•  Includes relevant background information, such as:

  • Family’s concerns about the child’s speech, language, and literacy skills.

  • History of middle ear infections.

  • Family history of speech and language difficulties (+ reading and writing).

  • The language(s) and dialect(s) used in the home.

  • Teacher’s report of the child’s intelligibility, the child’s participation in the school setting, and how the child’s speech compares with that of peers in the classroom.

Oral peripheral sensory evaluation

• Assesses presence/function of structures.

  • Dental occlusion and specific tooth deviations.

  • Structure of hard and soft palate (clefts, fistulas, bifid uvula).

  • Function (range of motion) of the lips, jaw, tongue, and velum.

Hearing screening

Assesses:

• Otoscopic inspection of the ear canal and tympanic membrane.

• Pure-tone audiometry.

• Immittance testing to assess middle ear function.

Diadochokenesis

The ability to perform rapid, alternating movements, particularly those involving the speech muscles – /ptk/

Speech sound disorder (SSD)

Any difficulty or a combination of difficulties with perception, motor production, or phonological representation of speech sounds and speech segments, including phonotactic rules governing permissible speech sound sequences in a language. 

• Not all languages share the same speech sounds as mainstream American English. These influences do not indicate one.

Organic SSDs result from:

• Motor/neurological disorders

• Structural abnormalities

• Sensory/perceptual disorders

Speech sound errors

• Omissions/deletions

• Substitutions

• Additions

• Disortions

• Syllable-level errors

• Inconsistent whole-word productions

Omissions/deletions

Certain sounds are omitted or deleted.

• (e.g., /kʌ/ for “cup” and /pun/ for “spoon”)

Substitutions

One or more sounds are substituted, which may result in loss of phonemic contrast.

• /θɪŋ/ for “sing” and /wæbɪt/ for “rabbit”

Additions

One or more extra sounds are added or inserted into a word.

• /bəlæk/ for “black”

Distortions

Sounds are altered or changed.

• Ex: a lateral /s/)

Phonological processes

• Final consonant deletion

• Weak syllable deletion

• Reduplication

• Consonant cluster reduction

• Assimilation

• Stopping

• Fronting

These are considered language-based issues.

Final consonant deletion

Reduces CVC structure to more familiar CV.

• /kæt/ becomes /kæ/

Weak syllable deletion

Reduces number of syllables to conform to the child’s ability to produce multisyllable words.

• /tɛlɪfoʊn/ becomes /tɛfoʊn/

Reduplication

Syllables in multisyllable words repeat.

• /beɪbi/ becomes /bibi/

Consonant cluster reduction

Reduces CCV+ structures to the more familiar CV.

• /tri/ becomes /ti/

Assimilation

One consonant becomes like another, although the vowel is usually not affected.

• /dɔgi/ becomes /gɔgi/

Stopping

Fricatives are replaced by stops.

• /ðɪs/ becomes /dɪs/

Fronting

Velars are replaced with more anteriorly produced sounds.

• /goʊ/ becomes /doʊ/

Accents

Systematic variations in speech production marked by differences in phonological and/or prosodic features, including rate and fluency, that are perceived as different from any native, mainstream, regional, or dialectal form of speech

Dialects

Rule-governed language systems that reflect the regional and social background of its speakers.

• These rules cross all linguistic parameters, including phonology, morphology, syntax, semantics, and pragmatics.

Accent modification

An elective service sought by individuals who want to change or modify their speech

Causes of SSDs

• Biological sex.

  • Incidence is higher in males than females.

• Pre- and perinatal problems.

  • Maternal stress, infections, delivery complications, preterm delivery, low birthweight.

• Family history.

  • Children who have family members (parents or siblings) with speech and/or language difficulties were more likely to have a speech disorder.

• Persistent otitis media with effusion (middle ear infection).

  • Associated with impaired speech development and hearing loss.

Speech sound assessment

Evaluates speech production using standardized tests and other methods. Assesses both single words and connected speech.

• Single word testing.

• Connected speech testing.

Severity

A qualitative judgment made by the clinician indicating the impact of the SSD on functional communication. Typically defined along a continuum from mild to severe or profound:

• Mild - rare omissions and few substitutions.

• Profound - extensive omissions and many substitutions; extremely limited phonemic and phonotactic repertoires.

Intelligibility

A perceptual judgment based on how much of the child’s spontaneous speech the listener understands.

• Varies along a continuum ranging from intelligible to unintelligible.

Stimulability

The child’s ability to accurately imitate a model of the target speech sound that the child currently misarticulates

Speech perception

The ability to perceive acoustic differences between speech sounds

Phonological processing

The use of sounds of one’s language (phonemes) to process spoken and written language

Phonological awareness

The awareness 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

Steps for treatment of SSDs

1. Establishment - eliciting target sounds and stabilizing production on a voluntary level.

2. Generalization - facilitating carryover of sound productions at increasingly challenging levels.

3. Maintenance - stabilizing target sound production and making it more automatic; encouraging self-monitoring of speech and self-correction of errors.

Types of target attacks

• Vertical

• Horizontal

• Cyclical

Vertical attack

Intense practice on one or two targets until the child reaches a specific criterion level (conversational) before proceeding to the next target(s)

Horizontal attack

Less intense practice on a few targets. Multiple targets are addressed individually or interactively in the same session, providing more exposure

Cyclical attack

Incorporating elements of both horizontal and vertical attacks

Contextual utilization approach

• Type of SSD treatment.

• Focuses on producing speech sounds in syllable-based contexts.

• Helps children who use a sound inconsistently.

• Aims to facilitate consistent sound production in various contexts.

Core vocabulary approach

• Type of SSD treatment.

• Targets whole-word production for children with inconsistent speech.

• Uses frequently used words in the child's communication.

• Suitable for those resistant to traditional therapy methods.

Cycles approach

• Type of SSD treatment.

• Targets phonological pattern errors in children with unclear speech.

• Treatment is scheduled in cycles (5-16 weeks).

• Focuses on stimulating the emergence of sounds, not mastery.

• Designed for children with highly unintelligible speech with extensive omissions,  some substitutions, and a restricted use of consonants.

Integrated phonological awareness (IPA)

• Type of SSD/CAS treatment.

• Improves understanding of sound structure in spoken language.

• Combines phoneme awareness with letter-sound knowledge.

• Phoneme manipulation, phoneme identity, phoneme segmentation, phoneme blending, and linking speech to print.

• Best for children 4-7 y/o with mild-severe CAS + language impairment.

Metaphon therapy

• Type of SSD treatment.

• Teaches awareness of phonological structure in language.

• Focuses on sound properties that need to be contrasted. 

• Assumes that children with phonological disorders have failed to acquire the rules of the phonological system.

• Phase 1: expands knowledge of sound systems.

• Phase 2: applies this knowledge in communication and self-monitoring.

Naturalistic speech intelligibility intervention

• Type of SSD treatment.

• Targets sounds in natural activities (menus, books).

• Uses recasting of errors without direct prompts.

• Effective for children who can use recasts well.

Phonological contrast approaches

• Type of SSD treatment.

• Focus on sound contrasts to differentiate words. Types:

  • Minimal oppositions

  • Maximal oppositions

  • Treatment of the empty set

  • Multiple oppositions

Speech motor chaining

• Type of SSD treatment.

• Involves repeated practice of speech targets. Phases include:

  • Prepractice/elicitation: distinguishing correct vs. incorrect sounds.

  • Structured practice: progresses from syllables to sentences.

    • Syllables → monosyllabic words → multisyllabic words → phrases → self-generated sentences.

  • Randomized practice: varies stimuli for better learning.

Speech sound perception training

• Helps children develop stable perceptions of target sounds.

• Focuses on attending to acoustic cues in different contexts according to a language-specific strategy.

• Includes tasks like identification and discrimination of sounds.

Dynamic temporal and tactile cueing (DTTC)

• Type of SSD/CAS treatment.

• Intensive motor-based treatment for severe apraxia of speech.

• Targets a small number of functional words and phrases.

• Involves drill-type practice for better speech production.

• Emphasizes shaping of movement gestures.

• Hierarchy of temporal delay - allows child to take increasing responsibility for executing the motor plans.

  • Simultaneous production → immediate repetition → repetition after delay → spontaneous production.

Persisting speech difficulties

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

Traditional approach

SSD treatment that hierarchically focuses on one or two sounds at a time

Minimal oppositions/pairs

Uses pairs of words that differ by only one phoneme signaling a change in meaning.

• /doʊɹ/ vs. /soʊɹ/

Phoneme collapse

When one sound substitutes many sounds, such as /d/ for /d, f, tʃ, s, t, st/

Phonological process approach

• Treatment for SSDs.

• Looks at the process that's happening, rather than specific error (ex: fronting).

• Might carry over through whole phonemic repertoire

• Start at sound level, see stimulability (prognostic indicator).

Goldman-Fristoe test of articulation

• Old test is appropriate for kids ages 3-7; new one is 3-21.

• Sounds in sentences, sounds in words, spontaneous language, and stimulability.

• Plate picture faces child, script faces clinical, model word with mouth covered if child doesn’t say desired word.

• Newer version looks at vowels.

Childhood apraxia of speech (CAS)

• Believed to be caused by  deficits in the planning and programming of movement gestures for speech production.

• Often occurs along with language and phonologic impairment (deficit relates most towards a child's ability to specify parameters of movement).

• Main speech characteristics:

  • Vowel and consonant distortions.

  • Inconsistent voicing errors.

  • Prosodic errors, especially equal stress and segmentation.

  • Awkward and/or imprecise movement transitions.

  • Groping and/or trial and error behavior.

Praxis

Planning/programming movement

Muscle tone

• State of partial contraction of muscle fibers at rest and in response to passive stretch.

• Maintained by processes with special influence by the cerebellum:

  • Gamma loop

  • Stretch reflex

• Not the same as reduced strength.

Strength

• Associated with muscle contraction causing movement of a structure.

• Movement requires recruitment of upper motor neurons (UMN) to communicate with lower motor neurons (LMN).

• LMN innervates muscles, leading to contraction and movement.

  • Each LMN sends fibers that branch around multiple muscle fibers.

  • Each muscle fiber may receive input from several LMNs.

• Increases through:

  • Overloading the muscle.

  • Increasing size and number of muscle fibers (muscle mass).

  • Recruiting more motor units.

  • Increasing firing rate of motor units.

Parameters of movement

• Range of motion

• Direction of movement

• Speed

• Force

• Amount of muscle tension

Oral non-verbal apraxia

Difficulty with non speech volitional movement (kiss, cough, lip smack)

Ataxic dysarthria

• Only dysarthria not associated with weakness.

• Impaired coordination in movement of the oral articulators.

  • Inaccurate movements, inconsistent voicing errors, imprecise articulatory contacts, incoordination of respiratory stream.

• Deficits in cerebellum.

• Can be difficult to differentiate between it and CAS in children.

Ataxic gait

Wide stance, unsteadiness in trunk, tendency to lunge/jerk sideways

Protocol for CAS testing

• Language sample

• Test of articulation/phonology

• Structural/functional examination

• Motor speech examination (biggest indicator)

Motor speech exam (MSE)

Allows the clinician to observe speech production across utterances that vary systematically in length and phonemic complexity.

• Allows observations of those behaviors frequently associated with deficits in speech praxis (distortions, timing errors, dysprosody, inconsistency) across hierarchically organized stimuli.

• Dynamic assessment encouraged.

Dynamic assessment

Cueing is provided to facilitate performance and thereby reveal emerging skills