the late eight - coestudents with communication disorders (including speech sound disorders) are...
TRANSCRIPT
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Ken Bleile
Portland, OR
October 9th, 2015
The Late Eight
Outline
� Introduction
� Questions
� Conclusions
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Questions I get Asked A lot
� An articulation approach?
� Does speech still belong in school?
� The best grade to begin?
�What about speech discrimination?
� Treat a stimulable sound?
� Phonetic placement and shaping?
� A best approach?
Resources and References
� Cheat sheets
� Demonstrations
� Phonetic placement and shaping
� References
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Disclosure Statement
� Financial-- Author of The Manual of Articulation and Phonological Disorders: A Book for Students and Clinicians (3rd Ed) and The Late Eight (2nd Ed) and receives royalty payments.
� Nonfinancial-- No relevant nonfinancial relationship exists.
Introduction
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Question
�Why are the late eight late?
Short Answer
� Too many consonants, not enough mouth
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The Late Eight
[θ] [ð]
[s] [z]
[l]
[r]
[∫][t∫]
Why they are Late
Sounds Acquired by 24 Months
Most Closed
� Stops b d g p t k m n ŋ
� Affricates
� Fricatives
� Liquids
� Glides h w
Most Open
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Mastery of Sound Classes
Period Sound class Age
Early Stops, nasals, glides >3 years
Mid Affricates, liquids, 3;0-4;0
fricatives
Late Interdental fricatives 4;6
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Questions
Question
� If the late eight are hard to articulate, should they be treated using an articulation approach?
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Short Answer
� Not necessarily.
Two Observations
1. Treatment approaches typically are not either solely “articulatory” or “phonological.”
Example: Prompt
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2. Not all articulation approaches are alike, nor are all phonological approaches similar.
Examples: Speech Assessment and Interactive Learning System (SAILS) and Maximal Oppositions
Major Phonological Approaches
� Minimal Pairs Approaches
� Morphosyntax Intervention
� Parents and Children Together (PACT)
� Maximal Oppositions
� Speech Assessment and Interactive Learning System (SAILS)
� Dynamic Systems and Whole Language
� Metaphon Therapy
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Major Articulation Approaches
� PROMPT
� Nuffield Centre Dyspraxia Programme
� Van Riper approach
� Paired-stimuli (Key Word) Approach
� Sensory-motor Approach
� Motoric Automatization of Articulatory Performance
� Motor Learning
� Five Minute Therapy
The More Essential Problem
� Sometimes treatment is conceived of as one of these….
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A Treatment Pill
Pills
�With a pill, you diagnose a problem and give a pill to correct it
� Example: If a student has an articulation problem, give an articulation approach pill. If a phonological problem, give a phonological approach pill
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The Pill Problem
� The trouble is that many times treatment doesn’t act like a pill
Three Examples
� A student experiences an articulation problem, but improves because she finds the language activities engaging
� A student experiences a phonological problem, but improves because he wants to impress the clinician (or maybe wants to impress a girl)
� A student improves because she is ready to work on speech issues
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Pill Problems
� Believing treatment is a pill can cause lots of problems
� An illustration: Non-speech oral motor and music approaches
The Disagreement
� First View: Clinical testimonials attest that children improve using non-speech oral motor and music approaches
� Contrary View: Clinical research strongly suggests non-speech oral motor approaches are based on faulty empirical and theoretical foundations
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A Possible Explanation
� I don’t doubt the honesty of testimonials that report success using non-speech approaches
� Possibly, success has less to do with the non-speech part of the approach than with other variables, perhaps the activities employed or the clinician’s treatment skills
Summary
� Even when a student improves in speech it is notoriously difficult to determine why improvement occurred
� Testimonials are better at telling you “a student got better” than telling you why a student got better
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Clinical Implications
� Treat the person, not the problem… treatment isn’t really a pill
� Even when you understand the underlying speech deficit, the deficit area is only one variable that affects treatment success
� Unpill variables that may affect treatment: motivation, language abilities, interests, personality, etc.
A Little More Specifically…
� A student unable to pronounce a sound often benefits from treatment that appeals to the mind as well as the mouth
� Phonological treatment emphasizes practicing speech in real words in meaningful contexts to promote better communication
� Articulation treatment provides opportunities to develop self-monitoring skills during extensive successful motor practice
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Studies
� Muttiah, Georges, & Brackenbury, 2011
� McCauley, Strand, Lof, Schooling, & Frymark, 2009
� Lof, 2009
� Powell, 2009
� Ruscello, 2008
� Lass & Pannbacker, 2008
� Clark, 2003
A Question
�With the emphasis on the new curriculum standards , does treatment of the late eight still belong in school?
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Short Answer
� In most places around the country, it’s become harder for students with late eight difficulties to receive help unless the problem is shown to impact educational success. The unless may not be a bad thing.
Speech in the School
� It’s fairly easy to show that a speech sound disorder impacts school success and future employment
� A student with a speech sound disorder may be at risk for academic failure, underachievement, and social isolation
� The opposite is also true: speech success contributes to school success
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School Matters
� Six reasons not to let the late eight drop out of school:
1. Speech sound disorders impact a student’s education, sense of well-being, and future employment
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Single Sound Errors
� Even single sound errors, which may not interfere with intelligibility or reading success, gain in importance as a student transitions through school and, after completing school, seeks employment
2. Success in treating speech sound disorders contributes to school success in the following areas of a curriculum: speaking and listening, language and reading, science, and social interactions
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3. Students with speech sound disorders are at risk for educational failure
Academic Challenges
� Approximately 75% to 85% of preschoolers with speech sound disorders also experience language disorders
� 50%–70% of school-aged students with speech disorders experience general academic difficulty through high school
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4. Students with speech sound disorders are at risk for being judged negatively by teachers
Poor Perceptions
Even when a student does not experience academic difficulties, at least one third of grade school teachers perceive students with reduced intelligibility as having less academic potential than peers
(Overby, Carrell, & Bernthal, 2007)
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Underestimate Abilities
� My clinical impression is that statistics underestimate academic difficulties of students with speech sound disorders.
� The underestimation arises because a student may still succeed at academic work, but may do so at less than full potential, partially because teachers may underestimate their academic potential.
5. A speech sound disorder may result in social isolation.
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Social Isolation
� Students with communication disorders (including speech sound disorders) are more likely than peers to be bullied, experience poorer peer relationships, and enjoy school less.
(McCormack, Harrison, McLeod, & McAllister, 2011).
6. Lastly, if 1-5 weren’t enough, speech sound disorders are the most commonly found developmental problem in school aged students
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Extend of Challenge
� 6% of school-aged students
� 92% on caseloads
� 18% not English at home
� 1 in 4 adults in NYC
Summary
� Speech sound disorders contribute to educational failure, and remediation of speech sound disorders contributes to educational success
� Difficulty with late acquired sounds is the world’s most frequently occurring communication disorder, affecting both children and adults learning English as a second language
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Clinical Implication
� Students, teachers, and families all benefit from linking speech services to the school curriculum.
� In treatment, the goal is speech, the avenue is language, the vehicle is the curriculum.
Studies
� Gierut, 1998
� Felsenfeld, Broen, & McGue, 1994
� Overby, Carrell, & Bernthal, 2007
� Shriberg & Kwiatkowski, 1988
� Paul & Shriberg, 1982
� Ruscello, St. Louis, & Mason, 1991
� Overby, Carrell, & Bernthal, 2007
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And More Studies
� Slater, 1992
� American Speech-Language-Hearing Association, 2006
� Law, Boyle, Harris, Harkness, & Nye, 2000
� Gierut, 1998
� Van Dyke & Holte, 2003
� Felsenfeld, Broen, & McGue, 1994
And One More Study that Didn’t Fit on the Previous Page
� McCormack, Harrison, McLeod, & McAllister, 2011
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Question
� Is there a best age to treat the late eight?
Short Answer
�When it comes to treating speech, earlier is generally better
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Convergence of Evidence
Evidence from at least five sources suggest that speech is best acquired early:
1. First language
2. Second language
3. Disability
4. Brain injury
5. Neurological development
First Language
Speech (even the late eight) is the earliest acquired language area
Age at which sound acquired by 75%:
● 5;0: [s] and [ʃ]
● 5;6: [ð]
● 6;0: [θ], [z], [ʧ], [r], and [l]
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Second Language (Wow-- this is Depressing)
Disability: Down syndrome
5 Years 12 Years
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Brain Injury: Hemispherectomy
Neurological Development
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Sequences
Perception and Production
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Speech Perception
� Person with a mature auditory cortex:
Mature Auditory Cortex
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Speech Production
� Though the development of the speech production system lags years behind the speech perception system, even an old timer like this guy has a mature Broca’sArea:
Mature Broca’s Area
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Summary
�When it comes to treating speech, earlier is generally better
Clinical Implications
� Best: Begin treatment before starting school
� Next Best: Begin treatment the second semester of kindergarten and, if needed, through 1st and 2nd grade
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Worrisome Answers
�Worrisome: Begin treatment after 8 years
� Very worrisome: Begin treatment in middle school
Implications for Home Programs
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Studies
� Smit, A., Hand, L., Frelinger, J., Bernthal, J., & Byrd, A. (1990).
� Miller, J. (1988).
� Miller, J. (1999).
� Stark, R., Bleile, K., Brandt, J., Freeman, J., & Vining, E. (1995).
More Studies
� Maurer, 2005
� Casey, Gledd, & Thomas, 2000
�Werker & Tees, 2005
� Pascallis, de Haan, & Nelson, 2002
� Simonds & Scheibel, 1989
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And Several More Studies
� Scheibel, 1993
� Schade & van Groenigen, 1961
� Lancaster, Keusch, Levin, Pring, & Martin, 2010
� Bowen, 2015
Question
� How can babies have mature speech perception and students have speech discrimination problems?
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Short Answer
� Students’ discrimination problems almost always are unrelated to problems in speech perception
� As an aside, the single best change I ever made in my clinical practice occurred when I realized that discrimination problems weren’t what I was taught to believe they were
Background
� Discrimination training is based on the observation that many children appear not to realize they are making speech errors
� Traditionally, problems in the speech perception system are thought to cause of discrimination difficulties.
� Discrimination training typically is undertaken at the beginning of treatment before beginning to practice speech production
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Primary Auditory Cortex
� The problem with this conception is that, based on neurological development of the auditory cortex, infants under one year possess mature speech perception systems
Real Perception-Based Discrimination Problems
� Vietnamese tones
� https://www.youtube.com/watch?v=-1xdgS-3lGA
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Other Explanations
� Speech discrimination is trickier (and more interesting) than it first might appear
Non-perception based Discrimination Problems
� Example: English [p] in clusters such as in spy is voiceless and unaspirated, similar to a sound in Thai
� Example: [r] in pride is unvoiced, and [r] in bride is voiced
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� The reverse is also true: we sometimes discriminate between things that aren’t really there.
Average Fundamental Frequencies
� Male = 120 to 150
� Female = 210
� Children (5 yr to 6 yr) = 240-250
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� Interestingly, we discriminate between the voices of men, women, and children on telephones, even though common telephones –to save money– filter out all information below 300 Hz
An Experiment
� 200 hz
� https://www.youtube.com/watch?v=YOnBu8CClmQ
� 1000 hz
� https://www.youtube.com/watch?v=R7D1f6U6TpU
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A Different Explanation
https://www.youtube.com/watch?v=Ahg6qcgoay4
Summary
� One of the most human things people do is not pay attention to their speech
� Rather, people pay attention is on what they intend to say, not the sounds that come out of the mouth
� Students’ “discrimination problems” really may be problems with attention and focus.
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� The challenge of discrimination training is to help a student recognize that what they intend to say differs from what comes out of their mouth
� A good discrimination activity is a reminder to a student, saying, “Yo, pay attention: this is what we’re working on.”
Clinical Implications
� I’ve found more success not separating discrimination training from regular speech practice
� By infusing discrimination within speech practice I believe I’m better able to facilitate language, reading, self-awareness, and generalization
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Focus Activities
Five reminders that improve focus while practicing speech:
� * Minimal Pairs
� Deletion
� Self-correction
� * Old Way/New Way
� Similar Sound
Minimal Pairs
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Adult, child, and a puppet read a book.
Puppet: My turn to read.
The puppet holds the book and begins reading.
Puppet: Once upon a lime… I mean once upon a mime. No, a crime. A chime. A dime.
The adult and child pretend to be surprised.
Adult: No, silly puppet. It’s not, Once upon a lime. A lime is green and sour tasting. Not a mine, not a crime, not a chime, not a dime. It’s, Once upon a time.”
Puppet. Oh. Sorry. I’ll start again. Once upon a time…”
Deletions
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Adult: Words are like trains. You can add and take away parts of words. Zoom is like a train with three parts. “z-oo-m.” Let’s take away the first sound. That leaves only two cars, the vowel and [m]. Can you say zoom without the first sound?
Child: Um.
Adult: Now say it with the first sound.
Child: Zoom.
Adult: That’s good. Now try it with and without the first sound.
Child: Um. Zoom. Um Zoom.
Self Correction
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Adult: You’ve been getting good at our treatment sound. Would you now say it in the word bush? I want you to say bush three times. Listen carefully to yourself each time you say it and change how you say it if it doesn’t sound quite right. The trick is to listen to yourself rather than for me to tell you if it is right or not. Shall we give it a try?
Child: Sure.
Adult: Now say bush three times. Listen to yourself.
Child: bus.
The child looks at the clinician, who, carefully, does not indicate if the sound was pronounced correctly or not.
Child. Bush. Bush.
Adult: What do you think? Did you pronounce our treatment sound correctly?
Child: I thought it got better as I went along.
Old Way/New Way
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An adult and the child sit together in a treatment room.
Adult: You are really making lots of progress. Do you remember how you used to say [r]?
Child: As a double u.
Adult: That’s right. I’d like you to say race the old way, then the new way, and then the old way again. Okay?
Child: Wace. Race. Wace.
Similar Sound
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Adult: For this next activity I’d like you to compare our treatment sound with a very similar sound.
Child: Okay.
Adult. Our treatment sound is [s] in see, and the sound we are comparing it to is the sound that begins she. Say see, then she, then see, listening to yourself and feeling the difference between [s] and the other sound.
Child. See. She. See.
The Orchestra…
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Illustration
� Clinician: What is a word for ocean that starts with the snake sound?
� Student: Sea.� Clinician: That’s right. Do you remember how you used to say the s sound?
� Student: th� Clinician: Good. Now say sea the new way, the old way, and then the new way again.
� Student: Sea. Thea. Sea.� Clinician: Great. Now say sea three times, listening to yourself and trying to make the sound the new way.
� Student: Sea. Sea. Sea.� Clinician: How do you think you did?
Studies
� Mather, 2006
� Hageman, 2013
� Baker, 2010
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A Question
� Should a clinician provide treatment for a sound for which a student is stimulable?
Short Answer
� It depends on the student
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Background: Most Knowledge
�Within a most knowledge approach, a clinician usually selects a sound for which a student is stimulable
� Stimulability is an odd old word –circa 1930s– that means capacity
� If a student is stimulable for a sound, he or demonstrates capacity to pronounce it
Stimulable Sound
� The logic of selecting a stimulabletreatment sound is that a child experiences less frustration because he or she begins with some capacity to pronounce it.
� Another reason to select a stimulablesound is that, because a child can already pronounce it correctly, during treatment a child is practicing success.
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Background: Least Knowledge
� A clinician following a least knowledge approach selects treatment sounds least like the sounds that a student has capacity to pronounce
� The logic for selecting a non-stimulablesound for treatment is:
1. The student learns more by selecting treatment sounds least similar to sounds that the student can produce.
2. A student may acquire the sound without treatment, since the sound already is being pronounced correctly in some contexts.
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Get Some Religion
� A great deal of discussion, sometimes approached with religious fervor, is devoted to whether to treat a sound that a student has limited capacity to pronounce vs. treating a sound that a student cannot pronounce under any circumstance
Good vs. Evil
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What Does the Research Say?
� Research does not offer an unequivocal resolution to the stimulability question
� Studies exist students improving using most knowledge approaches, and others show improvement using least knowledge approaches
The Problem
�Why does data support both positions--that is, some students appear to self-correct a stimulable sound without treatment, while others require speech treatment to learn?
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This May be the Reason Why
This May be What we’re Trying to Fit them Into
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Summary
� One size does not fit all when it comes to stimulability: not all children who are stimulable improve without treatment
Clinical Hypothesis
Based on studies that show not all children with SSDs acquire stimulable sounds without treatment.
� Person factors may be the most important variable in deciding whether to treat a stimulable sound, including a student’s age, maturity, attention, cognitive skills, and ability to tolerate failure
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A Suggestion
� Stimulability is more a “person decision” than a “linguistic decision.”
� That is, whether or not to select a stimulable sound for treatment has more to do with personality factors than linguistic abilities.
Clinical Implications
� Select a stimulable sound within a type of most knowledge approach with a younger student with less tolerance for failure.
� Many times, first treat a stimulable sound to build a student’s confidence and sense of success, and later work on non-stimulable sounds.
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Capacity
� Because capacity to produce the treatment sound already exists, the clinician can more quickly generalize success to other words or phonetic environments, rather than focusing treatment on the often frustrating and time-consuming task of teaching a treatment sound that a person shows no capacity to produce in any circumstance.
Non-stimulable Sounds
� Selecting a stimulable sound may not be an option for an older school-aged student or an adult learning a second language.
� In such situations, per force a nonstimulable sound must be selected.
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Selected Studies
� Dietrich, 1983
� Shine, 1989
� Powell, 1991
� Powell, Elbert, and Dinnsen, 1991
� Gierut, 1998
Question
�What exactly is phonetic placement and shaping? Do you have any favorites?
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Short Answer
� Phonetic placement and shaping are ways to convert a non-stimulable sound into a stimulable sound. And, yes, I have favorites, but they’re more like “flavors of the month” rather than “the very best flavor ever.”
Background: Definitions
� Phonetic placement: Use of articulatory postures (typically, tongue and lip positions) for speech production.
� Shaping: Use of a sound a student can already produce (either a speech error or another sound) to learn a new sound.
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Favorite Flavors
[s]
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Shaping [ʃ] to [s]
1. Instruct the student to say [ʃ].
2. Ask the student to retract his or her lips into a smile. Often, this results in the tongue moving forward slightly into the position for [s]. If needed, however, instruct the student to move the tongue slightly forward. The resulting sound is [s].
Shaping [ʪ] to [s]
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Simplest
1. Demonstrate air flowing through a straw
protruding from the side of the mouth when a lateral [s] is made and air flowing through a straw placed in the front of the mouth when a correct [s] is made.
2. Encourage the student to close the teeth
and to direct the airflow through a straw placed in front of the mouth.
Not So Simple (10 Steps!), but Effective
� Search terms: Caroline Bowen, The Butterfly Procedure
� http://www.speech-language-therapy.com/index.php?option=com_content&view=article&id=86:lisp&catid=11&Itemid=101
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[ɚ]
Phonetic Placement of [ɚ]
� Instruct the student to lie on their back, relax the mouth, and say [ɚ].
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Shaping of [k] to [ɚ]
1. Instruct the student to lower the tongue tip.
2. Ask the student to raise up the back of the tongue as for a silent [k].
3. Ask the student to make the sides of the back of the tongue touch the insides of the back teeth.
4. Ask the student to turn on the voice box, resulting in [ɚ].
Side note: If the Student Can’t Make [k]
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Placement Example: [k]
1. Ask the student to place the tongue tip behind the lower front teeth. (If needed, a tongue depressor may be used to keep the tongue in place.)
2. Ask the student to hump the back of the tongue and say [ku].
[r]
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Shaping [ɚ] to [r]
1. Ask the student to say [ɚ].
2. Next, ask the student to say [ɚ] followed by [i] or some other vowel.
3. Instruct the student to say [ɚi] several times as quickly as possible, resulting in [ɚri]. After [ɚri] is established, instruct the student to say [ɚ] silently, resulting in [ri].
Phonetic Placement of [r]
1. Tuck the chin
2. Make a grin.
3. Tongue in track.
4. Now curl it back.
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Explanation
� The components are a relaxed tongue resting on the floor of the mouth (tuck the chin), spread lips (make a grin), the tongue positioned so its sides rest against the insides of the lower teeth (tongue in track), and the tongue tip curled back (now curl it back).
For Bunched [r]
� For bunched [r], instruct the student to place the sides of the tongue in the track between the upper teeth and then curve the tongue tip down behind the lower front teeth.
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Summary
� Phonetic placement and shaping are ways to make a non-stimulable sound stimulable
Clinical ImplicationsSuggestions for Students
1. Try not to rush it. The client has gone their entire life not saying the sound, so this may take some time. (Unless you get lucky and the client picks it up right away, which sometimes happens.)
2. Including other modalities in your lessons can help—for example, mirrors, pictures, verbal descriptions, and touch cues
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3. A useful trick is to include language and focus activities that don’t require a production component as part of your treatment, such as identifying the sound while reading, minimal pairs, deletions, etc.
4. If the student appears frustrated, consider making phonetic placement and shaping just one part of a lesson that contains lots of success elsewhere
5. When putting a newly established sound with other sounds, it helps to pay close attention to surrounding sounds, which can make the newly learned sound easier or harder to pronounce
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Key Environments
� For many students –though not all– a key environment for [s] is before or after [i], or in a consonant cluster containing [t] Examples: see, kiss, steep and pots
� For many students a key environment for [k] is syllable final position and after [u]
Example: duke
� For many students a key environment for [r] is before [i] or in a consonant cluster, especially next to [k]
Examples: Crete, read, greet, tree, and dream
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Question
� Is there a best approach to teaching the late eight?
Short Answer
� The best approaches are those that a clinician can use eclectically.
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Value of Approaches
� A value of an approach –especially if it is published-- is that it has a basis in research and careful description makes the results replicable
� It can be easy to carry out because you do the same thing each time, with each student
Over Dependence
� The danger sometimes is not that a clinician will fail to master the thoughts embodied in an approach; the danger sometimes is that the approach will master the thoughts of the clinician.
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A Question…
The Right Rock?
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Improvement
� Speech improvement probably involves many factors in addition to the approach that a clinician follows
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Psychology Literature: Approach or Clinician?
� How much of improvement is due to the approach and how much is due to the clinician? 50%/50%? 90?/10%? Other?
Approaches and Judgment
� Adherence to an approach and clinical judgment are not in opposition
� Instead, the question is: What is the major driver of clinical success?
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If You believe the Approach is Primary…
� You ask how best to teach a student or clinician to understand and execute the approach
� The research literature suggests this is the dominate perspective in our profession
If You Believe the Clinician is Primary…
� You ask how clinical judgment is developed, maintained and grown, perhaps studying such factors such as,
�What makes a clinician good?
�What is a reasonable case load?
�What role does experience play?
� Can you teach clinical judgement?
�What role does personality play?
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Results
Research
� The literature in psychology suggests the 75% variable is the clinician
� My hypothesis –and it is only an hypothesis-- is that the clinician plays the same central role in the treatment of speech sound disorders
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Why?
� A clinician adapts and adjusts in a way that an approach cannot
An Analogy
Electronic Teachers Parents
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Summary
� A clinician’s judgment and skills is a primary driver of successful treatment
Clinical Implications
� People are too diverse and complex to expect one approach to provide the right answer for everyone
� The best approach is one that allows a clinician to use it eclectically, picking and choosing among its components and ideas as well as components of other approaches
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Studies
� Metzoff, Kuhl, Movelian, & Sejnowski, 2009
� Kuhl, 2007
� Beutler et al, 2004
� Staines, 2008
� Zebrowski, 2007
�
Conclusions
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General Principles
● In treatment, the goal is speech, the avenue is language, and the vehicle is the curriculum
● Generalization, school success, and student interest are all facilitated when treatment engages the mind as it practices the mouth
Articulation and Phonology
● Because speech is part of language,
speech treatment benefits from
opportunities to develop language and
literacy
● Because speech is also a motor skill,
speech treatment benefits from lots of
opportunities to practice speech
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Age Effects
● Neurological evidence from many
sources suggests that speech is an early
developing system
● Because speech is an early acquisition,
treatment is most successful when begun
as young as possible
Discrimination
● Discrimination problems are more a problem in focus and attention than a speech perception difficulty
● Focus activities serve to mentally tap the student’s shoulder, reminding the student to focus and pay attention. They also are fun.
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Success and Capacity
● To encourage success, most often select
treatment sounds a student is capable
of producing under restricted conditions
● Because a high level of success is not
always possible, techniques such as
phonetic placement and shaping can help
establish a sound in a student’s speech
Approaches
● Given the diversity of people, it is hard also to believe that a single approach will work for everyone
● Approaches, used eclectically, are
important tools, just like these:
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� But mastery of the tools will not result in this…
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� To achieve art, you need a clinician
