Speech Pathology Final

Early intervention

a voluntary program that provides early identification, services, and supports to eligible children - infants, toddlers, and preschool children from birth through age five - and their families

pretend play

play skill used by EI, where children use their imagination to act out scenarios and take on different roles. It provides a natural and engaging environment for children to develop crucial language and communication skills

prelinguistic skills

• joint and sustained attention

• play skill development

• vocal play development

• imitation development

• comprehension

• initiating behaviors

• gesture use and symbolic expression

jargon

part of vocal play development, when kids say a string of nonsensical syllables or pretend words that make no sense, or maybe only one word that makes sense - basically gibberish

reduplicated babble

part of vocal play development, the stage of babbling where infants repeat the same syllables or sound repeatedly

joint attention

a prelinguistic skill, when two or more people share focus on the same object, event, or activity - a kid looking where a parent looks

difference between infant/toddler vs preschool early intervention

INFANT:

• birth through age 2

• services in home or natural setting

• caregiver coaching is primary means of service delivery

• individual sessions with caregivers

• most often frequency, year round, hour long sessions, once a week

• prelingusistic skills

• functional communication skills

• language expansion

• communicative functions

• feeding and swallowing

PRESCHOOL:

• age 3-5 (K and 1st grade)

• IEPs

• services delivered in least restrictive environment, school or community based center

• some individual sessions, but mostly group sessions

• 30 min sessions, once a week

• speech sounds

• receptive language

• expressive language

• communication functions

• fluency

imitation development

• often develops up its. own hierarchy of skills

  • actions with/wo objects

  • faces

  • play sounds

  • words in routines

  • spontaneous words

  • phrases

• actions —→ verbal

• general —→ symbolic

• imitation at 18 months can be used as predictor of language development at 36 months

gestures development

• 9-12 months: claps, wave, arms up

• 9-13 months: blow kiss

• 9-15 months: high-five

• 12-18 months: point

• 13-15 months: shake head no

• 16-18 months: nod head yes

what counts as a word when kids begin verbal expression

symbolic: uses a SIGN, word or specific sound to stand for something as referent

consistent: observed numerous times, ideally across different days

spontaneous: not dependent on adult model prior for imitation

intentional: used with purpose, differentiated from babble/jargon

structures of an early intervention session

SS-OO-PP-RR

• Set Stage

• Observe and look for Opportunities to embed

• Problem solve and Plan

• Reflection and Review

why it is so important to involve parents/caregivers (caregiver coaching)

• equipping natural communicators with strategies to use throughout the week

• using and building off what they already. have.

• embedding daily routines, interactions, and play with targets and skills to work on them, all about intentionality

• relationship centered therapy- ongoing, open dialogue with parents regarding what’s working, what’s difficult, what they’re hearing and seeing throughout the week

all of the different settings EI can occur

natural environment, school, clinic

bilingualism

speaking 2 different languages

over identification

• over diagnosis of speech impairment results in an educational. disparity

• typical minorities children are pulled out. of class for unnecessary speech therapy

under identification

• underdiagnosis of communication disorders results in a health disparity

• communication disorders that are left untreated can result in behavioral disturbance, aggressive behavior, poor academic and linguistic outcomes, and hyperactive symptoms later in childhood

cross-linguistic effects

the influence one language has on the other in terms of speech, language, and cognitive processes, defined as the production of a language specific phoneme found in a production of the bilinguals other language

generalization

the extent to which a clients improved performance in one language after intervention translates to improved performance in their other language

translanguaging

recognizes and utilizes the full linguistic repertoire of multilingual individuals, rather than treating languages as separate entities

phonetic inventory

the complete set of speech sounds a person can produce in their native languages

language disorders and bilingualism (myths vs facts)

• growing up bilingual does not lead to increased likelihood of language disorders

the problems surrounding standardized testing with bilingual children

using standardized tests is not an accurate representation of their language skills if they are only being tested in a standardized fashion with one of those languages. They are often over diagnosed or under diagnosed as a result of standardized testing not accurately reflecting the whole person

error analysis/substitution error analyses

• identifying and analyzing speech and language errors in individuals who speak two languages, considering both the individuals linguistic skills and the influence of their bilingualism

• examine targets: phonemes that the child is avoiding

• examine substitues: phones the child is using in place of those target phonemes

relational analysis

• overall accuracy

• compares a Childs speech productions to adult targets in both of their languages

roles of an interpreter in speech/language evaluations for bilingual children, current mandates for schools

• helps ensure accurate data collection and informed decision-making regarding a clients speech and language abilities in both languages

“unexpected skills” vs low skills or no skills

“unexpected skills” is about atypical patterns, which could mean strengths or concerns, low skills is about lack of proficiency and may suggest a developmental delay, no skills is extreme and rare- severe delays or very limited exposure

neurodiversity

the idea that neurological differences are natural and should be respected as part of human diversity, shifts focus from “deficits” to differences in how people think, learn, and communicate

masking

when a neurodiverse person consciously or unconsciously hides their natural behaviors to fit into social norms

least restrictive environment

autistic students should spend as much time of their learning days with their neurotypical peers as possible

strength-based approach

applies neuro diversity through an affirming lens, shows that they are not deficits but differences

difference between “autistic person” and “person with autism”

why is it so important to be neuro-affirming

• provide ethical and person centered care

• reduces the needs for autistic individuals to mask

• reassures their competencies by taking strength based approach

the CURRENT clinical definition of autism

• persistent deficits in social communication and social interaction across multiple contexts AND restricted, repetitive patterns of behavior, interests, or activities

restricted and repetitive behaviors

• stereotyped or repetitive motor movements, use of objects, or speech (simple motor, stereotypes, lining up toys or flipping objects, echolalia)

• insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (extreme distress at small changes, difficulties with transitions, rigid thinking patters, greeting rituals, need to take same route or eat same food every day)

• highly restricted, fixated interests that are abnormal in intensity or focus

• hyper- or hyperactivity to sensory input or unusual interest in sensory aspects of the environment

person centered care

basically shifting from “what is wrong with this person” to “how can we support this persons unique communication, goals, and identity?”

• respects autonomy

• celebrates neurodiversity

• listening to lived experience

self advocacy in the realm of autism

• an important skill to reach academic and employment goals

• can involve role-playing, or perspective taking

Dysphagia

difficulty swallowing

aspiration

food or liquid getting into the airway/trachea/”wrong pipe”

videofluroscopic swallowing study (VFSS) pediatrics

Fiberoptic endoscopic evaluation of swallowing (FEES) pediatrics

• requires use of dyed food (often blue or green)

• think scope through the nose to the pharynx to observes anatomy and movement during swallowing, secretion management, signs of aspiration, swallow timing and coordination

difference between feeding and swallowing in peds

Feeding:

• the process of getting food or liquid to the mouth

• sensory, motor, and behavioral aspects of eating

Swallowing:

• physiological act of moving it from mouth to stomach

• essentially getting the food to the stomach safely

some underlying causes of feeding disorders

• neurological conditions; cerebral palsy, Down syndrome, etc.

• structural/anatomical issues; cleft lip/palate, tongue tie, etc.

• sensory processing differences; aversion to textures, smells, or appearance of food

• behavioral or psychosocial factors

signs/symptoms of dysphagia (pediatric)

• frequent coughing while drinking

• multiple choking episodes

• other medical complexities

• crying while eating

• swatting at bottle or foods

• liquid or food dribbling out of the mouth

• really long feeding times

general milestones for feeding and swallowing (birth to three)

within first year:

• brings hands to breast or bottle

• tries to hold a spoon

• takes a small bite from a larger portion of food

12 to 18 months:

• drinks from straw without help

• uses the tongue to move food from side to side in the mouth

• begins to feed self with utensils

18-24 months:

• sits without support

• chews food on both sides of the mouth consistently

2-3 years:

• drinks from an open cup without spilling

• chews and swallows a variety of food or textures without gagging

videofluroscopic swallow study/MBS (VFSS)

X-ray with barium shows full swallow in motion, gives full oral/pharyngeal/esophageal phases

three phases of swallowing

oral

• voluntary

• involves chewing, forming a bolus, and moving it to the back of the mouth

• requires intact lips, tongue, and jaw coordination

pharyngeal phase

• involuntary

• bolus moves through the throat, airway closes to prevent aspiration

• involves the soft palate, larynx, and pharyngeal constrictors

esophageal phase

• involuntary

• bolus passes through the esophagus via peristalsis into the stomach

• controlled by the central and enteric nervous systems

some underlying causes of dysphagia (adults)

• neurological conditions

• structural changes

• muscle disorders

• aging-related decline (presbyphagia)

• cognitive impairments

• gastroesophageal issues

signs and symptoms of dysphagia (adults)

• coughing or choking during/after meals

• wet or gurgle voice

• recurrent pneumonia or chest infections

• weight loss or dehydration

• food sticking in the throat or chest

• prolonged eating time or fatigue while eating

• drooling, pocketing food in cheeks

• silent aspiration (no overt signs-but food/liquid enters airway)

compensatory strategies (treatment)

• postural adjustments: chin tuck, head turn

• diet modifications

• smaller bites/sips

• double swalllows

• alternating solids and liquids

• environmental changes

• cueing and pacing to slow rate of intake

purpose of thickened liquids

• slows down the liquid flow, allowing more time for airway closure

• reduces the risk of aspiration in people with delayed swallow reflex

• helps improve control during the pharyngeal phase

how a multidisciplinary team functions in a hospital setting as it relates to dysphagia

example:

SLP: leads swallow eval. recommends diet and provides therapy

nurse: monitors intake, implements strategies, observes for signs of aspiration

physician: manages underlying conditions

OT: may assist with self feeding, positioning, adaptive tools

explaining why an SLP is involved with swallowing

same anatomy as speaking pretty much

hyper nasality

occurs when too much air escapes through the nose during speech

cleft lip/ cleft palate

congenital malformations where the lip and/or palate do not fuse properly in utero, can be unilateral or bilateral, affects feeding, speech, hearing, and facial growth

velopharyngeal port dysfunction (incompetence vs insufficiency)

incompetence: neuromuscular issue- structure intact, but movement/closure is weak

insufficiency: structural issue - tissue is missing or abnormal

sub mucous cleft

• a cleft hidden under the mucosal lining of the soft palate, may go undiagnosed until speech issues or feeding problems arise

obturators

dr george f grant created the first, it is a prosthetic appliance for cleft palate patients when surgery does not solve the problem and/or is contradicted

resonance disorder

imbalance in oral vs nasal sound energy

hyper nasality

hypo nasality: too little nasal airflow

mixed

nasal speech sounds

nasal consonants: /m/,/n/

these should resonate through the nose

the rule of ten - what it is for

10 weeks, 10 pounds, 10 grams of hemoglobin in order to determine if a baby is ready for cleft lip repair, ensures they are strong enough

possible precautions/risks for cleft lip/palate

• feeding difficulties

• speech delays/errors

• middle ear infections

• hearing loss

• dental and orthodontic issues

• psychosocial impact and stigma

the role of slp with treatment of cleft lip/palate (with both feeding and speech)

• introduce special bottles for feeding (for newborns)- help with feeding/swallowing, this is accpetable doesn’t have to be specifically about the bottles

• help with assessment to determine the right type of intervention and appropriate supports

• speech therapy to help with resonance issues and speed sound production both before and after surgical repair or in partnership with a device. the individual will have to work on awareness and training the soft palate to produce certain sounds

auditory complications that can occur along with clefts

otitis media with effusion is very common

can lead to conductive hearing loss

many children with palate get pressure equalization tubes

be familiar with corrective surgeries

• cleft lip repair (rule of tens)

• cleft palate repair (9-12 months)

• pharyngeal flap or sphincter pharyngoplasty (often later if VPI persists)

• alveolar bone grafting (7-9 years)

muscle tension dysphonia

voice changes related to how the person is using their voice and not related to. any structural/anatomical abnormalities

common causes: post sickness, stress, changes in voice demand or task, no cause

common complaints: discomfort while speaking, inconsistent voice symptoms, periods of normal voice, throat tightness, increased effort with speaking

vocal fold atrophy

common causes: aging

common complaints: weakness, thinness, increased effort, unpredictable, increased throat clearing, lack of control

vocal fold paralysis

common causes: post surgery, upper respiratory infection (virus), mass, other nerve injuries

common complaints: shortness of breath with talking, cant project, change in modal pitch, quick to fatigue, effortful

vocal fold nodules

common causes: heavy voice use, repeatedly or over a long period of time, high occupational voice demands, extroverted/talkativeness

common complaints: frequent voice loss following loud events or increased vocal demands, prolonged periods of hoarseness or persistent hoarseness, loss of upper range, effortful voice-often sounds better when louder

hoarseness

abnormal voice quality, breathy, raspy, harsh, usually results from vocal fold irritation, swelling or dysfunction

laryngoscopy

• a medical procedure used to examine the larynx and vocal cords. it can be done either way through the mouth (indirect or direct laryngoscopy) or via the nose (fiberoptic or flexible laryngoscopy)

• it provides a clear view of the vocal fold structures

voice handicap index -10 (VHI-10)

gives you the patients perspective of the impact of their voice issues. helps to better understand what the patient is experiencing and the limitations they are perceiving as a direct result to their voice issues- it has nothing to do with how the voice sounds- it is a good tracking tool to help compare how the voice is improving or not improving over a course of treatment

congruency (as it relates to voice)

the harmony between the physical mechanics, emotional expression, and social context of voice production achieving it is important for effective communication, and when there’s disconnect, whether through tension, misuse, or emotional distress it can lead to voice disorders. SLP therapy addressing both the physical and psychological aspects of voice helps to restore it and improve vocal health

how to determine if someones has a voice disorder

tests (laryngoscopy, FEES, etc.), case history, VHI-10, VAS scale of pain, auditory perceptual, we care about loudness, average pitch, number of breaths during a passage, average airflow during phonation, CSID

the different systems involved with voice production

respiratory system, the laryngeal system (vocal folds), the resonator system, and the articulatory system

upper airway disorders (paradoxical vocal fold motion disorder or ILO, EILO)

inducible laryngeal obstruction (ILO): a condition in which there is intermittent adduction of the vocal folds that interferes with breathing. When this is suspected SLPs may be consulted to help identify abnormal laryngeal and respiratory function and to teach various techniques to improve laryngeal and respiratory control

exercise-induced laryngeal obstruction (EILO): EILO is most often diagnosed in adolescence and is typically due to obstruction at the laryngeal level due. to inappropriate glottic closure or adduction/collapse of supraglottic airway obstruction during exercise

paradoxical vocal fold motion disorder (PVFM): condition where the vocal cords close or tighten inappropriately during breathing, rather than opening as they should during inhalation, can cause difficulty breathing and may be mistaken for other respiratory disorders like asthma

some important considerations for gender affirming voice care

• highlight vocal choices

• provide education/knowledge about instrument

• discuss techniques that optimize vocal mechanism (aka voice therapy)

• provide guidance and support while exploring the instrument

• provide models and feedback

• not everyone wants this but the client needs to feel comfortable exploring the spectrum

important questions to ask during a case history for voice evaluation

• general health

• voice related medical history

• family history

• onset and duration of symptoms

• specific symptoms

• speech patterns

• quality of voice

• voice use habits

• lifestyle and habits

• psychological and emotional factors.

• previous treatment

• expectations

indirect vs direct voice therapy

indirect therapy: counseling, educating, adapting, vocal hygiene

direct therapy: altering and/or modifying voice production through techniques, exercises, tasks etc

desensitization

clinicians should be desensitized so they dont exhibit or reinforce negative stereotypes, behaviors, or thoughts in the public or their clients

covert stuttering

• switching sounds or words

• choosing not to speak

• leaving a situation

• not participating in class

• not volunteering for school play or activity etc.

blocks

a type of speech disruption where the person experiences a pause or inability to move their speech forward due to difficulty initiating or maintaining the flow of air or sound

repetitions

• repeated production of sounds, syllables, words, or phrases during speech

prolongations

• extended duration of sounds during speech, stretching or holding out a sound longer than normal

typical disfluencies vs stuttering like disfluencies

typical disfluencies are a part of normal speech development, particularly in young children, while stuttering like disfluencies are more disruptive, persistent, and often accompanied by physical tension or struggle or frustrasting

what does therapy look like for stuttering?

understand the nature of stuttering, help to identify stuttering-like vs non stuttering like disfluencies, educate patients and families about stuttering and debunk myths, counsel patients and families about the challenges of stuttering, learn more about patients needs and experiences, provide options and behavioral techniques to allow the patient to feel more in control, motivate patients to become desensitized to stuttering

risk factors for persistence of stuttering

• genetic factors

• age of onset

• gender

• severity of initial struttering

• co-occuring speech and language delays

• emotional or behavioral factors

• frequency and type of disfluencies

• family and environmental factors

• family history

managing a child who stutters vs an adult (through SLP lens)

children: fluency development, fluency shaping, indirect therapy, reassurance, anxiety reduction, short term, coping with teasing

adults: fluency enhancement, stuttering modification, addressing self esteem, workplace communication, long term

fluency vs stuttering (considering the conversation of fluency as a “gatekeeping term”

the idea that if we use the term “fluency” to describe somones’s stuttering condition, there are many people who are covert stutters who may miss out on potentially helpful services given the lack of diagnosis if we continue to use this characteristic as the leading description for the stuttering condition

suggestions for parents when communicating with their children who are stuttering

• stay calm and patient

• dont interrupt

• use positive reinforcement

• model relaxed and slow speech

• be attentive and supportive

• create a low pressure environment

• foster emotional safety

• avoid overcorrecting

• educate others/ normalize stuttering

motor speech disorder

• speech disturbances resulting from neurologic impairments

• affects sensorimotor planning, programming, control, and execution

• distinguishable by perceptual characteristics

dysarthria

a group of motor speech disorders that results from neurological damage affecting the muscles involved in speech production, can affect articulation, voice quality, pitch, loudness, and prosody (rhythm and melody of speech), results from damage to CNS, stroke, cerebral palsy, multiple sclerosis

apraxia of speech

motor speech disorder that affects the ability to plan and coordinate the movements required for speech, problem with the brains ability to plan and sequence the motor movements needed to produce speech

motor planning

• goal oriented

• articulator specific

• core motor plans are recalled from sensorimotor memory during speech

• plan consecutive movements (spatial and temporal goals)

• adaptation of specifications

motor programming

set of muscle commands structured before movement sequence begins that can be delivered without external feedback

intelligibility (as it relates to speech)

“understandability” of speech- acoustic output of the speaker readily understood by the listener

what a motor speech disorder is NOT (not related to structural abnormalities or hearing loss, etc.)

• peripheral structural abnormalities

• results from sensorineural hearing loss

• results from language or higher level cognitive impairment

how SLPs diagnose motor speech disorders (what’s the gold standard?)

using perceptual methods involving listening to and analyzing speech by a skilled clinician, using both clinical judgment and structured rating scales to assess aspects like articulation, prosody, voice. quality, and intelligibility

all of the speech subsystems

• respiration- speak on exhalation

• phonation- voice

• resonance- degree to which voice is transmitted through oral versus nasal cavities

• articulation- specific, distinguishable sounds that when combined give meaning

• prosody- stress, intonation, and rhythm of speech

lesion location= type of speech deficits

deviant characteristics provide clues to lesion location

SLPs role in diagnosis and treatment in general

goal of treatment is to improve communication. not all patients are appropriate for treatment, cessation of treatment if goals are met, plateaus, or patient leaves