Praxis Review

Ch. 1 Anatomy, Neuroanatomy, and Physiology of the Speech Mechanism

1. RESPIRATION
Respiration Breathing (inhalation and exhalation)/the exchange of gas between an organism and its environment; supplies energy for speech
Inhalation Draws air into the lungs; brings oxygen to blood; when the lungs expand, the pressure within the lungs is reduced and air moves into the lungs to equalize pressure in- and outside of the lungs

inhalation  chest and lungs expand  diaphragm lowers  air flows in through the nose and mouth  air goes down pharynx and between open vocal folds  air continues downward
through trachea and bronchial tubes  air reaches lungs
Exhalation Helps get rid of mixed air and gases that result from respiratory metabolism; caused by muscle contraction to reduce the volume of the chest cavity and creates positive pressure within the
lungs; speech occurs during exhalation
Framework of Respiration
Lungs Soft, spongy, porous, elastic, pink structures located in the thoracic cavity where the exchange of gas in respiration takes place; R-lung is shorter, broader and bigger
Bronchi Tubes composed of cartilaginous rings that extend from the lungs upward to the trachea; subdivide into bronchioles (become progressively less cartilaginous and more muscular) and
communicate with the alveolar ducts that open into tiny air sacs in the lungs
Trachea A tube formed by ~20 cartilaginous rings (incomplete in the back where connected to esophagus) connected to the cricoid cartilage and the larynx and functions as a passageway for air
Spinal Column Consists of 32-33 individual vertebrae divided into 5 segments (7 cervical, 12 thoracic-attached to the ribs, 5 lumbar, 5 sacral, 3-4 coccygeal-fused form coccyx)
Sternum i.e. Breastbone; made up of 3 parts (manubrium-attached to clavicle and first rib, body/corpus-attached to cartilage of ribs 2-7, xiphoid process)
Rib Cage Composed of 12 pairs of ribs, sternum and 12 thoracic vertebrae
Muscles of Respiration
Thoracic Muscles of  Diaphragm: the primary muscle of inspiration; a thick dome-shaped muscle that separates the abdomen and thorax (innervates C3-C5)
Inspiration  External intercostal muscles: a primary muscle of inspiration; i.e. the 11 pairs of muscles between the ribs; raise the ribs up and out to increase the diameter of the thoracic cavity for
inhalation (innervates T2-T11)
 Serratus posterior superior: elevates rib cage (innervates C7, T1-T4)
 Levator costarum brevis: elevates rib cage (innervates T1-T12)
 Levator costarum longis: elevates rib cage (innervates T2-T12)
 Sternocleidomastoid: accessory muscle of the neck that elevates the sternum and rib cage
 Trapezius: accessory muscle of the neck that controls the head and elongates the neck
 Pectoralis major: increases transverse dimension of rib cage through elevation of sternum (innervates C4-T1)
 Pectoralis minor: increases transverse dimension of rib cage (innervates C4-T1)
 Serratus anterior: elevates ribs 1-9 (innervates C5-C7)
 Levator scapulae: elevates scapula; supports neck (innervates C3-C5)
 Rhomboideus major: stabilizes shoulder girdle (innervates C5)
 Rhomboideus minor: stabilizes shoulder girdle (innervates C5)
 Internal intercostal: a primary muscle of inspiration; depresses ribs 1-11 (innervates T2-T11)
 Innermost intercostal: depresses ribs 1-11 (innervates T2-T11)
 Transversus thoracis: depresses ribs 2-6 (innervates T2-T6)
Abdominal Muscles  Latissimus dorsi: stabilizes posterior abdominal wall for expiration (innervates C6-C8)
of Expiration  Rectus abdominis: flexes vertebral column (innervates T7-T12)
 Transversus abdominis: compresses abdomen (innervates T7-T12)
 Internal oblique abdominis: compresses abdomen; flexes and rotates trunk (innervates T7-T12)
 Quadratis lumborum: supports abdominal compression through bilateral contraction, which fixes abdominal walls (innervates T12, L1-L4)

2. PHONATION
Larynx i.e. the voice box and home of the vocal folds; musculo-cartilagninous structure that lies at the top of the trachea; valving mechanism; serves as protection for the trachea while swallowing; aids
cough reflex; closes vocal folds to build subglottic pressure
Laryngeal Structures
Hyoid Bone Superior boundary of the phonatory system; serves as point of attachment for many tongue muscles; made up of corpus and 2 greater cornua and 2 lesser cornua; doesn’t articulate with bones
Epiglottis A protective, leaf-like piece of cartilage; drops to cover the larynx during swallowing
Thyroid Cartilage Largest cartilage; protects the larynx; formed by two plates fused at midline (i.e. thyroid notch)
Cricoid Cartilage Completely surrounds the trachea; often seen as the uppermost tracheal ring
Arytenoid Cartilages Small, pyramid shaped cartilages connected to the cricoid cartilage through the cricoarytenoid joint, which permits sliding and circular movements
Corniculate Small, cone-shaped cartilages that sit on the apex of the arytenoids; assist in reducing laryngeal opening when a person is swallowing
Cartilages
Cuneiform Cartilages Stiffen/tense the aryepiglottic folds; located under the mucous membrane covering the aryepiglottic folds
Laryngeal Muscles
Intrinsic Primarily responsible for controlling sound production; major functions include opening/closing/tensing/relaxing the vocal folds; both attachments are within the larynx
Abductors (open the VFs):
 Posterior cricoarytenoid: adducts vocal folds (innervates CN X-vagus; recurrent laryngeal nerve branch)
Adductors (close the VFs):
 Lateral cricoarytenoid: adducts vocal folds; increases medial compression (innervates CN X-vagus; recurrent laryngeal nerve branch)
 Transverse arytenoid: adducts vocal folds (innervates CN X-vagus; recurrent laryngeal nerve branch)
 Oblique arytenoid: pulls apex of arytenoids in medial direction (innervates CN X-vagus; recurrent laryngeal nerve branch)
Tensors:
 Thyroarytenoid: the internal thyroarytenoid (i.e. vocalis muscle/vocal folds) is the primary portion of the thyroarytenoid muscle, which vibrates and produces sound (innervates CN X-
vagus; recurrent laryngeal nerve branch)
 Cricothyroid: lengthens and tenses vocal folds; made up of pars recta and pars oblique (innervates CN X-vagus; external branch of the superior laryngeal nerve branch)
Extrinsic Primary function is to support the larynx and fix its position by elevating or depressing the laryngeal structure; only one attachment is within the larynx
 Elevators: i.e. suprahyoid muscles; elevate the larynx
o Digastric (innervates CN V-trigeminal and VII-facial)
o Geniohyoid (innervates CN XII-hypoglossal and C1)
o Mylohyoid (innervates CN V-trigeminal)
o Stylohyoid (innervates CN VII-facial)
o Hyoglossus (innervates CN XII-hypoglossal)
o Genioglossus (innervates CN XII-hypoglossal)
 Depressors: i.e. infrahyoid muscles; depress the larynx
o Thyrohyoid (innervates XII-hypoglossal and C1)
o Omohyoid (innervates C1-C3)
o Sternothyroid (innervates C1-C3)
o Sternohyoid (innervates C1-C3)
Vocal Folds
Vocal Folds Vibrate to produce sound; composed of three layers
1. Epithelium/outer cover
2. Lamina propria/middle layer
3. Vocalis muscle/body-provides stability and mass to the fold)
Aryepiglottic Folds Separate the laryngeal vestibule from the pharynx and help preserve the airway; composed of a ring of connective tissue and muscle extending form the tips of the arytenoids to the larynx
Ventricular/ False Vibrate only at very low fundamental frequencies and usually not during typical phonation; compress during activities of coughing and lifting heavy items
Vocal Folds
Physiology of Phonation
Myoelastic- The vocal folds vibrate because of the forces of pressure of air and the elasticity of the vocal folds
Aerodynamic Theory
Air flows out of the lungs and is temporarily stopped by closed vocal folds  increase in subglottic pressure  blows vocal folds apart  vocal folds are sent into vibration  air moves with
increased velocity through glottal opening  pressure between edges of vocal folds’ decreases  vocal folds are sucked back together
Bernoulli Effect Caused by the increased speed of air passing between the vocal folds; the sucking motion of the vocal folds towards one another

air flows out of the lungs and is temporarily stopped by closed vocal folds  increase in subglottic pressure  blows vocal folds apart  vocal folds are sent into vibration  there is a cycle of
opening and closing the vocal folds, repeated >100x/sec during vocalization
Mucosal Wave Critical to vibration of vocal folds (i.e. phonation); may be impacted by abnormal growths (i.e. nodules)
Action
the cover (i.e. epithelium and superficial lamina propia, i.e. Reinke’s space) and the transition (i.e. intermediate and deep layers of lamina propia) over the vocalis muscle slide and produce a
wave  wave travels across the superior surface of the vocal fold  wave dissipates before reaching inner surface of thyroid cartilage
Neuroanatomy of the Vocal Mechanism
Cortical Areas Primary cortical areas involved in speech-motor control and phonation include: primary motor cortex, Broca’s area, somatosensory cortex, supplementary motor cortex
Cerebellum Regulates motor movement; key to the coordination of laryngeal muscles for phonation and the effective functioning of other speech systems (i.e. respiration)
Cranial Nerves  CN VII-Facial: innervates posterior belly of digastric muscle
  CN X-Vagus: innervates the larynx; includes primary branches:
o Superior laryngeal nerve: internal branch provides all sensory information to the larynx and the external branch supplies motor innervation solely to the cricothyroid
muscle
o Recurrent laryngeal nerve: supplies all motor innervation to the interarytenoid, posterior cricoarytenoid, thyroarytenoid, and lateral cricoarytenoid and supplies all
sensory information below the vocal folds

3. RESONATION and ARTICULATION

Resonation
Resonation The modification of laryngeal tone by selective dampening or enhancement of specific frequencies; primary resonators include pharynx, nasal cavity and oral cavity
Pharynx i.e. the throat; part of the upper airway, located superiorly and posteriorly to the larynx; size and shape of the pharynx are modified by the position of the tongue (i.e. forward vs. back) and the
vertical positioning of the larynx (i.e. high vs. low)
Nasal Cavity Produces nasals (m,n,ng) by relaxation and lowering of soft palate/velum which couples the nasal and oral cavities
Velum The raising and retracting of velum during productions of sounds helps make contact with posterior pharyngeal wall and separates the oral and nasal cavity (cavities uncoupled produced with
oral resonance); elevated and retracted for production of all other oral sounds in English
Oral Cavity Primary resonating structure for English sounds (besides nasals)
Source-Filter Theory Depicts the vocal tract as a series of linked tubes (pharynx, nasal cavity, oral cavity) providing the variable resonating cavity to produce speech; energy from vibrating vocal folds (i.e. the source)
is modified by the resonance characteristics of the vocal tract (i.e. the filter); changes in the configuration and shape determine the sound
Articulation
Articulation The movement of speech structures to produce speech sounds; primary articulatory structures include the pharynx, the soft palate, the hard palate, the mandible, the teeth, the tongue, the lips
and the cheeks
Pharynx Divided into three segments:
1. Laryngopharynx: begins immediately superior to the larynx and ends at base of tongue
2. Oropharynx: extends up to the soft palate
3. Nasopharynx: ends where the two nasal cavities begin
Muscles of the pharynx:
 Salpingopharyngeus: Elevates lateral pharyngeal wall (innervates CN X-vagus and XI-spinal accessory, i.e. pharyngeal plexus)
 Stylopharyngeus: elevates and opens pharynx (innervates CN IX-glossopharyngeal)
 Superior pharyngeal constrictor: constricts pharynx diameter; pulls pharyngeal wall forward (innervates CN X-vagus and XI-spinal accessory, i.e. pharyngeal plexus)
 Middle pharyngeal constrictor: narrows diameter of pharynx (innervates CN X-vagus and XI-spinal accessory, i.e. pharyngeal plexus)
 Inferior pharyngeal constrictor, cricopharyngeus: constricts superior orifice of esophagus (innervates CN x-vagus and XI-spinal accessory, i.e. pharyngeal plexus)
 Inferior pharyngeal constrictor, thyropharyngeus: reduced diameter of lower pharynx (innervates CN X-vagus and XI- spinal accessory, i.e. pharyngeal plexus)
Soft Palate i.e. the velum; a flexible muscular structure at the juncture of the oropharynx and the nasopharynx; can be elevated or depressed

Muscles of the soft palate:

 Levator veli palatini: primary elevator of the velum (innervates CN X-vagus and XI-spinal accessory, i.e. pharyngeal plexus)
 Tensor veli palatini: tenses velum; dilates Eustachian tube (innervates V-trigeminal)
 Platoglossus: elevates and depresses velum (innervates CN X-vagus and XI-spinal accessory, i.e. pharyngeal plexus)
 Palatopharyngeus: narrows pharyngeal cavity; lowers velum; elevates larynx (innervates CN X-vagus and XI-spinal accessory, i.e. pharyngeal plexus)
Uvula Small, cone-shaped structure at the tip of the velum
Velopharyngeal Occurs when the soft palate is raised and retracted and the muscles of the pharynx move inward to meet the muscles of the soft palate causing a sphincter-like action and nasal port closure
Closure
Hard Palate A bony, hard plate that serves as the roof of the mouth and the floor of the nose; part of the maxillae (i.e. paired maxillary bones); maxillary bone made up of:
1. Premaxilla: front portion housing the four upper front teeth (i.e. incisors)
2. Palatine process: i.e. the hard palate; consists of two pieces of bone that grow and fuse at midline in utero (failure of fusion  cleft palate)
3. Alveolar process: outer edges of maxillary bone housing the molar, bicuspid and cuspid teeth
Maxillary bone joins with palatine bone posteriorly, which then attaches to the soft palate
Mandible i.e. the lower jaw; houses the lower teeth and forms the floor of the mouth; formed by fusion of two bones but considered to be one bone in adults; alveolar arch is the part of the mandible
that houses the teeth; mandible is attached to the temporal bone of the skull by the temporomandibular joint; muscles of the mandible open and close the mouth and aid in chewing food and
can be categorized as elevators or depressors:
Elevators: masseter, temporalis, medial (internal) pterygoid, lateral (external) pterygoid elevate and protrude the mandible (innervates CN V-trigeminal)
Depressors: anterior belly of digastric (CN V-trigeminal), posterior belly of digastric (CN VII)-facial, geniogyoid (CN XII-facial, C1) and mylohyoid (CN V-trigeminal) depress the mandible

Teeth Lower dental arch is a part of the mandible and the upper dental arch is a part of the maxillary bone; primary function is mastication, but also help produce speech sounds; babies have 20
 deciduous (i.e. temporary) teeth; adults have 32 teeth (8 incisors, 4 canine, 8 premolar, 12 molar)
Tongue Important in eating and speech production (i.e. articulation of linguadentals, lingua-alveolars, lingual palatals, affricates and constricts the air passage to produce fricatives)

Four major parts of the tongue:

 Tip: the thinnest and most flexible part of the tongue; plays an important role in articulation
 Blade: a small region adjacent to the tip; portion of the tongue that lies inferior to alveolar ridge at rest
 Dorsum: large area of the tongue that lies in contact with the hard and soft palates
 Root: back and bottom portion of the tongue
 Lingual frenulum: i.e. frenum; connects mandible with inferior portion of tongue and stabilizes tongue during movement

Intrinsic muscles of the tongue:

 Superior longitudinal muscle: shortens tongue; turns tip up; assists in turning lateral margins upward (innervates CN XII-facial)
 Inferior longitudinal muscle: shortens tongue; pulls tip down; assists in retraction (innervates CN XII-facial)
 Transverse muscles: narrows and elongates the tongue (innervates CN XII-facial)
 Vertical muscles: flattens tongue (innervates CN XII-facial)

Extrinsic muscles of the tongue:

 Genioglossus: forms bulk of tongue; tongue retraction; draws tongue down; draws tongue anteriorly to protrude tip or press tip against alveolar ridge and teeth
(innervates CN XII-facial)
 Styloglossus: draws tongue up and back; draws sides of tongue up to make dorsum concave (innervates CN XII-facial)
 Hyoglossus: retracts and depresses tongue (innervates CN XII-facial)
 Chondroglossus: depresses tongue (innervates CN XII-facial)
 Palatoglossus: elevates tongue (and depresses velum)
Lips Primary muscle is orbicularis oris
Cheeks Primary muscle is buccinaator (a large flat muscle whose inner surface is covered with mucous membrane)
Facial Muscles  Mentalis: pulls lower lip out; wrinkles and elevates chin (innervates CN XII-facial)
 Platysma: depresses mandible (innervates CN XII-facial)
 Risorius: retracts lips at corners (innervates CN XII-facial)
 Buccinator: constricts oropharynx; moves food onto grinding surface of molars (innervates CN XII-facial)
 Depressor labii inferioris: pulls lip down and out to dilate orifice (innervates CN XII-facial)
 Depressor anguli oris: i.e. triangularis; helps to press lower and upper lips together; depresses corners of mouth (innervates CN XII-facial)
 Zygomatic minor: elevates upper lip (innervates CN XII-facial)
 Zygomatic major: retracts and elevates angle of mouth (innervates CN XII-facial)
 Orbicularis oris inferioris and superioris: pulls lips together; seals lips; serves as point of insertion for other muscles; interacts with other muscles to produce facial expressions
(innervates CN XII-facial)
 Levator anguli oris: draws corner of mouth up and toward medial (innervates CN XII-facial)
 Levator labii superioris: elevates upper lip (innervates CN XII-facial)
 Levator labii superioris alaeque nasi: elevates upper lip (innervates CN XII-facial)

Neuroanatomy and Neurophysiology: The Nervous System

1. NEURONS and NEURAL TRANSMISSION
Anatomy and Physiology of Nerve Cells
Glial Cells/ Cells of the CNS; do not transmit nerve impulses; mainly support and protect the nerve cells; include astrocytes, oligodendroglia, ependymal cells, and micrologia
Neurologia
Schwann Cells Cells of the PNS
Satellite Cells Cells of the PNS
Neurons Most important type of nerve cells; receive, process and transmit information; made up of two parts (nerve fibers and soma/cell body)
Nucleus Core of the soma; covered in membrane
Dendrites Short fibers extending from the soma; receive neural impulses from axons of other cells and transmit impulses to the cell body
Axons Long fibers extending from the soma; wrapped in myelin sheath (which facilitates impulse transfer); have terminal/end buttons at the tip that makes contact/sits close to the dendrites of other
neurons; send out impulses generated within the neuron
Nervous System An organization of nerves according to specific spatial, structural and functional principles
 Synapses Junctures between neurons where communication takes place; consists of the terminal button of one neuron, the receptive site of another neuron and the synaptic cleft/space between the two
Neural Transmission
Neural Transmission A chemical process of information exchange at the level of the synapse
Neurotransmitter A chemical contained within the terminal buttons that helps make contact between two cells by diffusing itself across the synaptic space; become bound to receptors in the postsynaptic
membrane; may cause the inhibition/excitation of the next neuron; dopamine and acetylcholine are the two most important neurotransmitters in the motor system
Sensory/Afferent Cranial nerves that carry sensory impulses from peripheral sense organs toward the brain
Neurons
Motor/Efferent Cranial nerves that transmit impulses away from CNS; cause glandular secretions/muscular contractions (i.e. movement)
Neurons
Interneurons The most common type of neuron in the nervous system; links neurons with other neurons; plays an important role in controlling movement

2. PERIPHERAL AND AUTONOMIC NERVOUS SYSTEM

Peripheral Nervous System
Peripheral Nervous A collection of nerves outside the skull and spinal column that carry sensory impulses originating in the peripheral sense organs to the brain, and motor impulses originating in the brain to the
System glands and muscles of the body; contains three types of nerves (cranial, spinal and autonomic)
Cranial Nerves Emerge from the brainstem and are attached to the base of the brain; 12 pairs; part of the lower motor system; receive much of their innervations form the corticobulbar tract of the pyramidal
system; exit through the foramina/holes in the base of the skull at different levels of the brainstem and top portion of the spinal cord; numbered for vertical order of which they exit the skull

I-Olfactory: sense of smell (sensory)

II-Optic: vision (sensory)
III-Oculomotor: eye movement (motor)
IV-Trochlear: eye movement (motor)
V-Trigeminal: face (sensory); jaw (motor)
VI-Abducens: eye movement (motor)
VII-Facial: tongue (sensory); face (motor)
VIII-Acoustic/Vestibulocochlear: hearing and balance (sensory)
IX- Glossopharyngeal: Tongue and pharynx (sensory); pharynx only (motor)
X-Vagus: larynx, respiratory cardiac, and gastrointestinal system (sensory and motor)
XI-Spinal Accessory: shoulder, arm and throat movements (motor)
XII-Hypoglossal: mostly tongue movements (motor)

CN V, VII, VIII, IX, X, XI, XII are associated with speech, language and hearing
Trigeminal Nerve (CN It’s sensory fibers are composed of three branches: ophthalmic, maxillary, mandibular
V) 1. The ophthalmic branch has sensory branches to the nose, eyes and forehead
2. The maxillary branch has sensory branches to the upper lip, maxilla, upper cheek area, upper teeth, maxillary sinus and palate
3. The mandibular branch has sensory branches to the mandible, lower teeth, lower lip, tongue, part of the cheek and part of the external ear
It’s motor fibers innervate the jaw muscles, including the temporalis, lateral and medial pterygoids, masseter, tensor veli palatinI, tensor tympani, mylohyoid and anterior belly of the digastric
muscle.

Damage may result in inability to close the mouth, difficulty chewing and trigeminal neuroglia (sharp pain in the facial area)
Facial Nerve Sensory fibers are responsible for taste sensations on the anterior 2/3 of the tongue; motor fibers innervate muscles important to facial expression and speech (i.e. buccinators, zygomatic,
(CN VII) orbicularis oris, orbicularis oculi, platysma, stapedius, stylohyoid, frontalis, procerus, nasalis, depressor labii inferioris, depressor anguli oris, auricular muscles, various labial muscles, and the
posterior belly of the digastric muscle)

Damage may result in a mask-like appearance with min-no facial expression

Vestibulocochlear/ Composed of two branches: vestibular, acoustic
Acoustic Nerve 1. The vestibular branch is primarily responsible for maintenance of equilibrium/balance
(CN VIII) 2. The acoustic branch transmits sensory information from the cochlea of the inner ear to primary auditory cortex fo the brain (where it is interpreted)

Damage may result in hearing loss, balance difficulties, or both

Glossopharyngeal Mixed components: sensory, motor, autonomic
Nerve (CN IX) 1. The sensory component assists in processing taste sensation from the posterior 1/3 of the tongue and provides general sensation for the tympanic cavity, ear canal, Eustachian tube,
faucial pillars, tonsils, soft palate and pharynx
 2. The motor fibers innervate the stylopharyngus (a muscle that raises and dilates the pharynx)
3. Also may supply motor fibers to the pharyngeal plexus (which innervates the upper pharyngeal constrictor muscles) –

Damage may create difficulty swallowing, unilateral loss of the gag reflex and loss of taste/sensation from the posterior 1/3 of the tongue
Vagus Nerve i.e. the wandering nerve (b/c it extends into the chest and stomach; mixed components: motor, sensory, autonomic
(CN X) 1. The motor fibers supply the digestive system, heart and lungs
2. The sensory fibers convey information from the digestive system, heart, trachea, pharynx and lungs
Has two branches: recurrent laryngeal nerve, pharyngeal branch
1. The recurrent laryngeal nerve regulates the intrinsic muscles of the larynx (excluding the cricothyroid, which is supplied by the superior laryngeal branch); damage may result in
total/partial paralysis of the vocal folds
2. The pharyngeal branch supplies the pharyngeal constrictors and all the muscles of the velum (except the tensor tympani, which is innervated by the trigeminal nerve)

Damage may result in difficulty swallowing, paralysis of the velum and voice problems
Spinal Accessory Supplies the trapezius and sternocleidomastoid muscles, which assist in head and shoulder movements; cranial fibers innervate the uvula and levator veli palatini muscles of the soft palate
Nerve (CN XI)
Damage may result in neck weakness, paralysis of the sternocleidomastoid, inability to turn head, inability to shrug shoulders or raise the arm above shoulder level
Hypoglossal Nerve Runs under the tongue; supplies three extrinsic tongue muscles (styloglossus, hyloglossus and genioglossus; supplies all intrinsic muscles of the tongue
(CN XII)
Damage may result in tongue paralysis, diminished intelligibility and swallowing problems
Spinal Nerves Controls various bodily activities; can be motor, sensory or mixed; transmit information from the CNS to the muscles and carry sensory information from the peripheral receptors to the CNS; 31
pairs of spinal nerves that are attached to the spinal cord through two roots (efferent/ventral and afferent/dorsal); pairs divided into segments named for the region of the spinal cord to which
they are attached

8 pairs of cervical spinal nerves (C1-C8)

12 pairs of thoracic spinal nerves (T1-T12)
5 pairs of lumbar spinal nerves (L1-L5)
5 pairs of sacral spinal nerves (S1-S5)
1 pair of coccygeal spinal nerves (Co1)
Spinal Cord Structures There are three important spinal cord structures: conus medullaris, cauda equine, filum terminale
1. Conus medullaris is where the spinal cord ends at the L1 vertebra level
2. Cauda medullaris is the lowermost nerves
3. Filum terminale is where there are no spinal cord segments
Autonomic Nervous System
Autonomic Nervous Generally viewed as a part of the PNS; controls and regulates the internal environment of our bodies with two branches (sympathetic and parasympathetic) that supply the body’s smooth
System muscles and various glands that secrete hormones; does not have a direct effect on speech, language or hearing
Sympathetic Nervous Mobilizes the body for “fight or flight” situations; activation accelerates the heart rate, dilates the pupils, raises blood pressure and increases blood flow to the peripheral body structures
System causing a feeling of arousal; although not directly impacting speech, people who stutter may experience increased dysfluency with activation of the sympathetic nervous system
Parasympathetic Brings the body back to a state of relaxation; lowers blood pressure, slows heart rate; increases activity within stomach and generally relaxes the body causing a more relaxed and calm feeling
Nervous System

4. CENTRAL NERVOUS SYSTEM

Central Nervous System
Central Nervous Acts as a motor command center for planning, originating and carrying out the transmission of messages; composed of the spinal cord and the brain and is enclosed within the vertebral
System column and the cranial structure; key structures of the brain include the brainstem, the reticular activating system, the diencephalon, the basal ganglia, the cerebellum and the cerebrum;
other key structures/systems of the CNS include the pyramidal and extrapyramidal systems, connecting fibers within the brain, the cerebral ventricles, the protective layers of the brain and
structures that provide the cerebral blood supply
The Brain
Brain Acts as a “central station” that coordinates activity, integrates information and issues commands; the most important structure in the body for language, speech, and hearing
Brainstem The oldest part of the brain; connects the spinal cord and the brain via the diencephalon; serves as a bridge between the cerebellum and all other CNS structures

Internally composed of:

1. Longitudinal fiber tracts
2. Cranial nerve nuclei
3. Reticular formation
 Key structures of the brainstem include:
1. Midbrain: i.e. the mesencephalon, is a narrow structure that connects the brainstem and the cerebellum; the substantia nigra runs the vertical length of the midbrain’ controls many
motor and sensory functions (including postural reflexes, visual reflexes, eye movements and coordination of vestibular-generated eye and head movements); contains the cranial
nerve nuclei for the trochlear (IV) and oculomotor (III) nerves
2. Pons: i.e. metencephalon, is a round, bulging structure that bridges the two halves of the cerebellum; with the midbrain, connects the cerebellum and various cerebral structures
through the inferior and middle peduncles; transmits information relative to movement from the cerebral hemispheres to the cerebellum; contains many descending motor fibers
and is involved with balance and hearing; houses the nuclei for the trigeminal (V) and facial (VII) nerves ***important for speech production
3. Medulla: i.e. the myelencephalon is the uppermost portion of the spinal cord, entering the cranial cavity through the foramen magnum at the base of the skull; contains fibers that
originate in the cerebellum and cerebrum and move downward to form the spinal cord; includes several centers that control vital, automatic bodily functions (such as breathing,
digestion, heart rate and blood pressure); houses cranial nerve nuclei for the vestibulocochlear (VIII), glossopharyngeal (IX), vagus (X), accessory (XI) and hypoglossal (XII) nerves;
contains nerve fibers (i.e. pyramidal tracts) that carry commands from the motor center of the brain to various muscles contralaterally ***important for speech production
Reticular Activating A structure within the midbrain, brainstem and upper portion of the spinal cord; integrates motor impulses flowing out of the brain with sensory impulses flowing into it; plays a role in the
System execution of motor activity; the primary mechanism of attention and consciousness
Diencephalon Located above the midbrain and between the brainstem and cerebral hemispheres; composed of:
1. Third ventricle: a tall and narrow space filled with cerebrospinal fluid
2. Thalamus: the largest structure in the diencephalon that regulates sensory information to the brain and relays sensory impulses to various portions of the cerebral cortex; critical for
maintenance of consciousness and alertness
3. Hypothalamus: helps integrate the actions of the autonomic nervous system and controls emotions
Basal Ganglia Structures primarily composed of gray matter that are found deep within the brain; highly complex system of neural pathways that have connections with many subcortical and cortical areas
that receive input from the frontal lobe and relay information back to the higher centers of the brain via the thalamus; composed of the corpus striatum (i.e. the globus pallidus, the putamen
and the caudate nucleus); part of the extrapyramidal system (which helps to regulate and modify cortically initiated motor movements)

Damage may result in unusual body postures, dysarthria, changes in body tone and involuntary/uncontrolled movements
***important for speech production
Cerebellum i.e. the “little brain”, consists of two hemispheres; primary fiber bundles serve as connections between the brainstem and the cerebellum (i.e. the superior, middle and inferior cerebellar
peduncles); afferent fibers mediate sensorimotor information to the cerebellum; efferent fibers transmit information from the cerebellum to the brain stem; receives neural impulses from
other brain centers and helps coordinate and regulate those impulses; regulates equilibrium, body posture and coordinates fine motor movements

Damage may result in a neurological disorder (i.e. ataxia), abnormal gait, disturbed balance, ataxic dysarthria and other communication disorders
***important for speech production
Cerebrum Complex structure of intricate neural connections with gray cells on top; includes the topmost portion of the brain and arranged in 6 layers, each consisting of different types of cells;
composed of gyri (i.e. ridges), sulcus (i.e. shallow valleys) and fissures (i.e. deeper valleys), including:
1. Longitudinal fissure: divides left and right hemispheres
2. Fissure of Rolando/central sulcus: divides the anterior and posterior half of the brain
3. Sylvian fissure/lateral cerebral fissure: starts at the inferior portion of the frontal lobe and moves laterally and upward
There are four lobes in the cerebrum:
1. Frontal: located on the anterior portion of the cerebrum; attributes to function of deliberate plans and intentions that dictate a person’s conscious behavior; contains areas critical
to speech production (i.e. the primary motor cortex, supplementary motor cortex and brocas area);
 Primary motor cortex/motor strip is located on the precentral gyrus and contralaterally controls voluntary movement of skeletal muscles through the pyramidal system
and modified by the extrapyramidal system
 Supplementary motor cortex is involved in the motor planning of speech and plays a secondary role in regulating muscle movements
 Broca’s area controls the lip, tongue, jaw and laryngeal movements and is highly involved in speech production
2. Parietal: located on the upper sides of the cerebrum; is the primary somatic sensory area, integrating somesthetic sensations (such as pain, pressure, temperature and touch)
 Postcentral gyrus/sensory cortex/sensory strip is the primary sensory area that integrates and controls somesthetic sensory impulses
 Supramarginal gyrus is critical for speech and language; damage may result in conduction aphasia and agraphia
 Angular gyrus is critical for speech and language; damage may result in difficulties in writing, reading, naming and transcortical sensory aphasia
3. Occipital: located behind the parietal lobe, occipital lobe is the primary visual cortex
4. Temporal: makes up the lower 1/3 of the cerebrum; composed of 3 major gyri (superior/upper temporal gyrus, middle temporal gyrus, inferior/lower temporal gyrus)
 Heschl’s gyri is critical for speech and hearing and is composed of the primary auditory cortex and the auditory association cortex; the primary auditory cortex receives
sound stimuli from the acoustic nerve bilaterally and the auditory association area synthesizes the information to be recognized as whole units
 Wernicke’s area is critical to the comprehension of written and spoken language; damage may result in fluent but meaningless speech and difficulties with
comprehension
Pyramidal System The direct motor activation pathway that is primarily responsible for facilitating (fine) voluntary muscle movement; composed of two tracts:
 1. Corticospinal Tract: has nerve fibers that descend from the motor cortex of each hemisphere and continue to course vertically through the midbrain and pons to communicate with
spinal nerves at different levels and then exit the vertebrae foramina through the spinal column to innervate the muscles of the trunk and limbs contralaterally
2. Corticobulbar Tract: critical to speech production; control all voluntary movements of the speech muscles; originate in the motor cortex and course downward along the
corticospinal tract and terminate in the brainstem; innervate muscles of the larynx, pharynx, soft palate, tongue, face and lips
3. Lower motor neurons: motor neurons in the spinal and cranial nerves; part of the peripheral nervous system; activity eventually results in muscular movement
4. Upper motor neurons: motor fibers within the central nervous system; descending motor fibers; include pathways of pyramidal and extrapyramidal systems
Extrapyramidal System Transmits impulses that control the postural support needed by fine motor movements; composed of different subcortical nuclei (including the red nucleus, the substantia nigra, the
subthalamus and the basal ganglia); indirect activation system; activity begins in the cerebral cortex and ultimately influences lower motor neurons; helps maintain pressure, tone and regulate
movements resulting from lower motor neuron activity

Damage may result in motor disturbances (i.e. involuntary movement disorders)

Connecting Fibers to Keep information flowing throughout the brain; there are three types of fibers depending on nature of connections:
the Brain 1. Projection fibers: create connections between the cortex and subcortical structures (i.e. cerebellum, basal ganglia, brainstem and spinal cord); originate primarily in the premotor
and primary motor areas in the frontal lobe and form the upper motor neuron system of the pyramidal tract (i.e. the direct activation pathway for voluntary motor movements);
afferent projection fibers relay sensory information from the peripheral sense organs to the brain; efferent projection fibers relay motor commands to the glands and muscles
2. Association fibers: connect areas within a hemisphere to maintain communication; arcuate fasciculus is the most important bundle of superior longitudinal fibers that connects
Broca’s and Wernickes area (important for verbal memory, language acquisition and meaningful language production
3. Commissural fibers: interhemispheric connectors; corpus callosum is most important and connects the two hemispheres
Cerebral Ventricles A system of cavities deep within the brain filled with cerebrospinal fluid, which is produced by the choroid plexus and circulates throughout the nervous system to nourish neural tissues,
remove waste, cushion the brain and regulate intracranial pressure; there are four cerebral ventricles (2 lateral ventricles, third ventricle and fourth ventricle)
Protective Layers of The spinal cord is protected by the vertebral column, the brain is protected by a layer of skin, the skull and the meninges, which are composed of dura mater (thick, tough, outermost
the Brain membrane which adheres to the skull and the arachnoid), arachnoid (the semitransparent, thin and delicate, web-like and vascular middle layer – cerebrospinal fluid fills the subarachnoid
space), and the pia mater (delicate, thin, transparent membrane adhering to the brain
Cerebral Blood Supply The brain requires 25% of the body’s oxygen and 20% of it’s blood supply; lack of blood supply to the brain can cause damage within 4-6 min (i.e. stroke); there are four major structures that
supply blood to the brain:
1. Aorta: main artery of the heart that carries blood from the left ventricle to the rest of the body (besides the lungs)
2. Vertebral arteries: (R & L) emerge from two subclavian arteries that supply blood to the upper extremities; as they branch up, merge to form the basilar artery, which then divides
again into two posterior cerebral arteries which supply the temporal and occipital lobes; other arteries supply the inner ear, cerebellum and pons
3. Carotid arteries: (R & L) enter the neck, branch to an internal and external artery and enter the brain; external moves towards the face and branches into smaller arteries to supply
the muscles of the mouth, nose, forehead and face; internal is the major supplier of blood to the brain; middle (a branch of the internal) supplies the cortex/frontal lobe – areas
involved with motor and sensory functions and language, speech and hearing functions; anterior artery supplies parietal and frontal lobes, corpus callosum and basal ganglia
4. Circle of Willis: formed at the base of the brain where the two carotid and two vertebral arteries join and anterior and posterior communicating arteries; provides a common blood
supply to various cerebral branches

Ch. 2 Physiological and Acoustic Phonetics: A Speech Science Foundation

1. LANGUAGE AND PHONETICS
Language and Phonetics
Language A code or system of symbols used to express concepts formed through exposure and experience
Speech The production of language
Phonology The scientific study of the sound systems and patterns used to create the sounds and words of a language
Phonemes The smallest units of sound that can affect meaning
Allophones Variations of phonemes that do not impact meaning
Phonemic The abstract system of sounds
Phonetic Concrete productions of specific sounds; divided into categories:
1. Acoustic phonetics: examines the relationship between articulation and the acoustic signal of speech; studies the acoustic properties of sound waves (i.e. periodicity and
aperiodocity)
2. Auditory phonetics: the study of hearing, perception and the brain’s processing of speech
3. Articulatory/physiological phonetics: the study of speech sound production – how the physiological movements of the articulators produce individual sounds
4. Applied (clinical) phonetics: the study of the practical application of research in articulatory, perceptual, acoustic and experimental phonetics (ex: phonetic analysis of speech
disorders)
5. Experimental phonetics: involves the use of objective laboratory and experimental techniques to scientifically analyze speech sounds
6. Descriptive phonetics: refers to the study and explanation of the unique sound properties of various dialects and languages
 Anatomy and Physiology
Respiration Inhalation and exhalation are necessary components of breathing for speech
Phonation Created by vocal fold vibration; necessary for all voiced sounds
Resonation The medication of sound by structures or cavities through which sounds pass
Articulation The production of speech sounds

2. PHONETIC TRANSCRIPTION
IPA Production of Segmentals: Consonants and Vowels
Diacritics:

Syllable Smallest phonetic unit; composed of onset (initial consonant/consonant cluster), nucleus (vowel/dipthong in the middle) and coda (consonant at the end); rhyme is the nucleus and coda
together; can be open (ending in vowels) or closed (ending in consonant)
Classifying Speech Sounds
Consonants Speech sounds produced by articulatroy movements that modify the airstream in some manner by interrupting it, stopping it, or creating a narrow opening through which it must pass
Vowels Produced with an open vocal tract; resonance patterns are shaped by the vocal tract; all vowels are voiced
Distinctive Feature Each phoneme is a collection of independent features and is described according to a cluster of features that are either present or absent in that phoneme; features are marked as present (+)
Analysis or absent (-)

Place-Voice-Manner Categorizes consonants in terms of three parameters:

Analysis 1. Place of articulation refers to the location of the sound’s production within the speech sound mechanism; indicating the primary articulators that shape the sound
2. Voicing refers to vocal fold vibration during production of sounds
3. Manner of articulation refers to the degree or type of constriction of the vocal tract during consonant production
3. THE EFFECTS OF CONTEXT ON SPEECH SOUND PRODUCTION
Dynamics of Speech Production
Citation Form Sounds produced deliberately in isolation
Speech Contexts Words, phrases and sentences; sounds produced in context may differ from production in isolation
Phonetic Context The surrounding speech sounds influencing the target sound
Coarticualtion The change a sound goes through in connected speech
Assimilation Causes a sound to change to a different sound
Suprasegmentals
Suprasegmentals i.e. features of prosody; add meaning, variety and color to running speech; involve larger units than individual units, or segmentals, such as syllables, words, phrases and sentences; several
variables (i.e. culture, linguistic background, emotional state, gender, age, etc.) can impact the suprasegmentals; features include length, stress, rate, pitch, volume and juncture
Length Related to syllable perception and production; syllables with longer vowels end to have shorter consonants, and vice versa
Stress Can change the meaning of words; include primary and secondary/weak stress; stressed syllables are loud, long, higher in pitch and require greater muscular effort; unstressed syllables are
soft, shorter, lower in pitch and require less muscular effort
Rate Refers to the speed of speech; a measure of the number of words/syllables produced per unit of time; increased rate of speech tends to have reduced duration of vowels/consonants produced
with less articulatory effort
Pitch The auditory sensation/perception of the frequency with which the vocal folds vibrate; determined by mass, tension and elasticity of the vocal folds; can be used to indicate different meanings
of spoken units
Intensity Sound pressure; the sensory correlate of intensity is loudness; the sensation/perception of loudness is amplitude
Juncture i.e. vocal punctuation; a combination of suprasegmentals (such as intonation and pausing) that indicate special distinctions or grammatical divisions in speech

4. SPEECH SCIENCE: PHYSIOLOGICAL PHONETICS, ACOUSTIC PHONETICS AND SPEECH PERCEPTION

Acoustics The study of the physical properties of sound and how sound is generated and propagated
Psychoacoustics The study of how humans respond to sound as a physical phenomenon
Sound Physically defined as the result of a vibration or disturbance in the molecules of a medium; psychologically defined as a vibration/disturbance in the air that is potentially audible
Sound Waves Movements of particles in a medium containing expansions and contractions of molecules
Compression/ A phase of sound in which the vibratory movements of an object increase the density of air molecules because the molecules are compressed/condensed
Condensation
Rarefaction The thinning of air molecules when the vibrating object returns to equilibrium
Simple Harmonic i.e. sine wave, the back and forth movement of particles when the movement is symmetrical and periodic
Motion
Sinusoidal Is a wave with horizontal and vertical symmetry because it contains one peak/crest and one valley/trough; contains a single frequency and is the result of simple harmonic motion
Motion/Wave
Aperiodic Waves Those that do not repeat themselves at regular intervals; vibratory patterns are random and difficult to predict from one-time interval to the next
Periodic Waves Sound waves that repeat themselves at regular intervals and are predictable; whole number multiples of the fundamental frequency (i.e. harmonics)
Amplitude The magnitude and direction of displacement; acoustically defined as the strength or magnitude of a sound signal; the greater the amplitude, the louder the signal
Intensity The quality of sound that creates the sensation of loudness; physically defined as the amount of energy transmitted per second over an area of 1 square meter; measured in terms of watts per
square meter and is also expressed in decibels
Bel A logarithmic unit of measure of sound intensity; decibel is a measure of sound intensity that equals 1/10 of a bel
Displacement Change in position; air molecules are displaced due to vibratory action of an object
 Oscillation The back and forth movement of air molecules because of a vibrating object
Force Produces acceleration of a body in the direction of its application
Elasticity Allows matter to recover its form and volume when subject to distortion
Velocity Change in position; measured in terms of distance an object moves per the time and direction it takes as it moves
Frequency The rate of vibratory motion that is measured in terms of the number of cycles completed per second, or in terms of hertz (i.e. the unit of measure for frequency – cycles per second)
Natural Frequency The frequency with which a source of sound normally vibrates, determined by the source’s mass and stiffness
Formant Frequency A frequency region with concentrated acoustic energy; is the center frequency of a formant (which is a resonance)
Fundamental The lowest frequency of a periodic wave; the first harmonic
Frequency
Octave An indication of the interval between two frequencies; always maintain a ratio of 1:2 – each octave doubles in frequency
Impedance Acoustic, mechanical or electrical resistance to motion of sound transmission
Pressure The amount of force per unit area; pressure of sound can be measured and expressed in terms of decibels at a certain sound pressure level (dB SPL)
Reflection The phenomenon of sound waves traveling back after hitting an obstacle, with no change in the speed of propagation
Refraction The bending of the sound wave due to change in its speed of propagation; happens when sound waves change mediums
Transmitting Medium Any matter that carries or transmits sound (air, liquids and solids can all transmit sound); the mass and elasticity of a transmitting medium affects sound
Spectogram A sound in a three-dimensional display of time, intensity and frequency; frequency plotted on the vertical axis (increasing from top to bottom), intensity represented on the gray
scale/blackness and time appearing on the horizontal axis
Voice Onset Time The time between the release of the stop consonant and the beginning of the vowel

Ch. 3 Language Development in Children

1. LANGUAGE
Language
Language Behaviorally defined as a form of social behavior that is shaped and maintained by a verbal community; linguistically defined as a code/system of symbols that represent concepts formed
through exposure and experience
Morphology The study of word structure; describes how words are formed out of more basic elements of language, called morphemes
Morpheme The smallest meaningful unit of language; there are three types of morphemes:
1. Base/root/free morphemes are words that have meaning and cannot be broken down into smaller parts *i.e. ocean, establish, book, etc.)
2. Bound/grammatical morphemes cannot contain meaning by themselves and must be bound to a free morpheme to have meaning (i.e. –s, -ing, -ed, etc.)
3. Allomorphs are variations of morphemes that do not alter the original meaning of the morpheme (i.e. boxes, leaves, cats)
Syntax The study of sentence structure; examines the arrangement of words to form meaningful sentences, the word order and overall structure of a sentence, and a collection of rules that specify
the ways and order in which words may be combined to form sentences in a particular language; English basic syntactic structure is subject + verb + object
Sentences 1. Passive sentences: the subject receives the action of the verb (i.e. “The cat was pet by Mark.”)
2. Active sentences: the subject performs the actions of the verb (“Mark pet the cat.”)
3. Interrogatives: questions (“Did you see that gorgeous sunset?”)
4. Declaratives: statements (“The sunset was gorgeous.”)
5. Imperatives: commands (“Shut the door.”)
6. Exclamatory sentences: express strong feeling (“I never said that!”)
7. Compound sentences: contain 2+ independent clauses joined by a comma and a conjunction or by a semicolon (clause: a subject and a predicate; independent/main clause: a
subject and a predicate and can stand alone)
8. Complex sentence: contains one independent clause and 1+ dependent/subordinate clauses (dependent/subordinate clause: a subject and a predicate but cannot stand alone)
Semantics The study of the meaning of language; includes a person’s vocabulary/lexicon (including knowledge of antonyms, synonyms, multiple meanings, humor, figurative language (metaphors,
idioms, proverbs), and deictic words)
Semantic Categories Used to sort words; includes recurrence (concept of more), rejection, causality, etc.
Overextension Often occurs during early stages of language development in which the child categorizes items too generally (i.e. All round items are balls)
Underextension Often occurs during early stages of language development in which child categorizes items too specifically (i.e. only Oreos are cookies)
World Knowledge Involves a person’s autobiographical and experiential memory and understanding of particular events
Word Knowledge Primarily verbal and contains word and symbol definitions; usually dependent on child’s world knowledge
Pragmatics The study of rules that govern the use of language in social situations; places greater emphasis on functions/uses of language than on structure; functions of language include labeling,
protesting and commenting; functions of utterances include providing the listeners with adequate information without redundancy, making a sequence of statements coherent and logical,
taking turns with other speakers, maintaining a topic and repairing communication breakdowns; language context involves where the utterance takes place, to whom the utterance is directed
and what/who are present at the time; can be heavily influenced by culture
Cohesion The ability to order and organize utterances in a message so that they build logically on one another
 Direct Speech A directly formed command/question
Indirect Speech Requests formed indirectly to convey politeness
Discourse How utterances are related to one another; related to the connected flow of language
Narratives A form of discourse in which the speaker tells a story

2. TYPICAL LANGUAGE DEVELOPMENT

Role of the Caregiver in Language Development
Motherese/Child Speech that includes several characteristics that help babies attend and respond to what they are hearing; initially produced with a higher pitch, greater pitch fluctuations, slower rate of
Directed Speech (CDS) speech and increased clarity/fluency; characterized by shorter/simpler utterances with longer pauses between utterances; words generally refer to events or objects in the here and now
Important  Eye contact
Interactions/Skills  Turn-taking
 Motivation to communicate
 High quality interactions (high amount of talking and caregiver responsiveness)
Birth – 1 Year
Birth – 3 Months  Displays startle response to loud sound
 Visually tracks/moves eyes to source of sound
 Attends to and turns head towards voice/sound source
 Smiles reflexively
 Cries for assistance
 Quiets when picked up
 Ceases activity/coos back when person talks (by 2 months)
 Vocalizes predominantly vowels
4 – 6 Months  Responds by raising arms when mother says “come here” and reaches toward child (by 6 months)
 Moves/looks toward family members when they are named
 Explores the vocal mechanism through vocal play with growling, squealing, yelling, making raspberries, (bilabial trills), etc.
 Begins to produce adult-like vowels
 Begins marginal babbling; produces double syllables; puts lips together for /m/
 Varies pitch of vocalizations
 Responds to name (5 months)
 Vocalizes pleasure and displeasure
 Varies volume, pitch and rate of vocalizations
7 – 9 Months  Looks at some common objects when the objects’ names are spoken
 Comprehends “no”
 Begins to use some gestural language; plays pat-a-cake, peek-a-boo; shakes head for “no”
 Uses a wide variety of sound combinations
 Uses inflected vocal play and intonation patterns
 Imitates intonation and speech sounds of others (9 months)
 Uses variegated babbling (9 months)
 Uncovers hidden toy (beginning of object permanence)
10 – 12 Months  Understands up to 10 words (ex: no, bye-bye, etc.); understands one simple direction (ex: sit down), especially when accompanied by a gesture
 Begins to relate symbol and object; uses first true word
 Gives object upon request
 Obeys some commands
 Understands and follows simple directions regarding body action
 Looks in correct place for hidden toys (object permanence)
 Turns head instantly to own name
 Gestures/vocalizes to indicate wants/needs
 Jabbers loudly; uses a wide variety of sounds and intonations; varies pitch when vocalizing
 Uses all consonant and vowel sounds in vocal play
Pragmatics Infants develop pragmatic skills through the following stages:
1. Using perlocutionary behavior in which “signals“ have an effect on the listener/observer but lack of communication intent (i.e. reflexively smiling)
2. At 9-10 months, uses illocutionary behavior in which signaling is used to carry out some socially organized action (i.e. pointing and lauging); intentional communication
3. At 12 months, enters locutionary stage in which they begin to use words
4. Child establishes joint reference, or the ability to focus attention on an event or objects as directed by another person (caregivers begin by establishing eye contact in the early
 months; later, they point to or name objects that both they and the child can focus on)
1 – 2 Years
Syntax 12 – 18 months
 Typically developing children 12 – 18 months use 1 word sentences and are in the holophrastic single-word phrase (in which one word represents a complex idea)
 Average MLU is 1.0-2.0
 Children use sentence-like words and communicate relationships by using one word plus vocal and body cues and can serve several basic functions (i.e. the emphatic/imperative
statement, the question or the declarative statement)
 Most children produce 50 words by 18 months of age
18 – 24 months
 begin to put two words together
 at 2 years they may use 3-4 word responses and use “and” to form a conjoined sentence with 51% of utterances consist of nouns
Semantics  Show understanding of some words and simple commands, including “no”
 Around 18 months, the child understands about 200 words
 Use nominals and verbs frequently in reference to things of greatest importance in the chidl’s environment
 Uses semantic relations
 Uses overextensions
 Answers the question “What’s this?; responds to y/n questions by nodding or shaking head
 Follows one-step commands or simple directions accompanied by gestures
 Follows directions using 1-2 spatial concepts
 Points to 1-5 body parts on command; points to recognized objects
 Listens to simple stories (19-24 months)
 Asks for “more”
 Refers to self with pronoun and name (19-24 months)
 Verbalizes immediate experiences
 Begins to use some verbs and adjectives
Relations Expressed by  Attribution: child uses an adjective; a property or characteristic of an event, person or object
Single-Word  Actions: child requests or labels an action; child indicates movement relationships between objects and people
Utterances  Locative action: child refers to a change in an objects location
 Existence: child attends to an item or object present in the immediate environment, especially a novel one
 Nonexistence: child expects an action or object to be present when it is not; something was present but disappeared
 Denial: child denies a statement or previous utterance
 Rejection: child does not want something to happen; child refuses to an object or action
 Recurrence: an event happens again; an object reappears or replaces another
 Possession: child identifies something as belonging to him or her, or to another person
Semantic Relations  Notice: hi + noun
Expressed by Two-  Nomination: demonstrative + noun
Word Utterances  Instrumental: verb + noun
 Conjunction: noun + noun
 Recurrence: more + noun
 Action-object: verb + noun
 Action-indirect object: verb + noun
 Agent-action: noun (agent) + verb
 Agent-object: noun (agent) + noun
 Possessor-possession: noun (possessor) + noun
 Attribute-entity: adjective/attributive + noun
 Entity + locative: noun + locative
 Action + locative: verb + noun
Pragmatics  Child uses verbal and nonverbal communication to control the behavior of others, satisfy needs and wants, interact with others, express emotions or interest, imagine, inform and
explore and categorize
 Presuppositions emerge (expressions that have shared meaning)
 Understand some rules of dialogue and act as speaker and listener
 Halladay describes/categorizes listeners’ responses as:
 Imaginative: children pretend and use language to create an environment with communicative function
 Heuristic: children attempt to have their environment and events explained to them and organize/investigate their environment
  Regulatory: children attempt to control the behavior of others
 Personal: children express own feelings and attitude; self-awareness
 Informative: children can tell something; communicate experiences
 Instrumental: attempt to get assistance/things from others
 Interactional: initiate interactions with others
 Dore looked at children’s intentions:
 Practicing language
 Protesting (i.e. no/resisting)
 Greeting
 Calling/addressing
 Requesting action
 Requesting an answer
 Labeling
 Repeating/imitating
 Answering
2 – 3 Years
Syntax  Use word combinations; beginning phrase and sentence structure
 Average MLU of 2.0-4.0; at 36 months average MLU 3-4
 Combine 3-4 words in SVO format
 Uses telegraphic speech (OV word order)
 Asks wh- questions
 Expresses negation by adding “no”/”not” in front of verbs
Semantics  Comprehension usually precedes production
 At 30 months, child can comprehend up to 2,400 words and express 200-600 words
 At 36 months, child comprehends up to 3,600 words
 Meanings learned in sequence (objects  events  actions  adjectives  adverbs  spatial concepts  temporal/time concepts)
 First pronouns are self-referents (i.e. “I”, “me”)
 Answer simple wh- questions
 Identify simple body parts
 Carry out 1-2 part commands
 Give simple account of experiences
Morphology  Use of bound morphemes expands between 2-3 years old
 Develop inflections, spatial prepositions, plurals, possessives, articles and pronouns
 Develop simple, irregular past tense
 Develop copular were
 Develop “is” + adjective
 Develop regular past tense verbs
 Overregularizes past tense inflection
 Overregularizesplural morphemes
 Use some memorized contractions
Pragmatics  Have communicative intent
 Demonstrate rapid topic shifts
 Communication includes criticism, commands, requests, threats, questions and answers

3 – 4 Years
Syntax  Learns clause-connecting devices
 Begins using complex verb phrases, modal verbs, tag questions, embedded forms and passive voices
 Uses mostly complete sentences; at 48 months MLU 3.0-5.0
 Uses mostly nouns, verbs and personal pronouns
 Acquires “do” insertions and ability to make transformations
 Uses negation
 Begins using complex and compound sentences
Semantics  Comprehends up to 4,200 words by 42 months; comprehends up to 5,600 words at 48 months
 Uses 900-1,000 words expressively
  Asks how, why and when questions
 Understands common opposites
 Knows full name, name of street, nursery rhymes
 Labels most things
 Relates experiences and reports in sequential matter
 Can recite poem/song from memory
 Answers questions appropriately
 Uses pronouns “you”, “they”, “us” and “them
 Understands concepts such as heavy-light, empty-full, etc.
 Understands agent-action
 Supplies last word of sentence
Morphology  Uses irregular plural forms, third person singular present tense, simple past and present progressives and negatives, inflection to convert adjective to causatives, simple plural
forms, “is” at beginning of questions, contracted forms of modals, “and” as conjunction, “is”/”are”/”am” in sentences
 Uses possessive markers consistently (43-48 months)
 Begins to use reflexive pronoun “myself” (43-48 months)
 Begins to use conjunction “because” (43-48 months)
Pragmatics  Topic maintenance
 Modify speech to age of listener
 Produce indirectives
 Uses requesting
 Responds with structures such as “yes”/”no”/”because”; expresses agreement of denial
 Uses conversational devices such as boundary markers, calls, accompaniments, politeness markers
 Uses communicative functions such as role-playing/fantasies, protests and objections, jokes, game markers, claims, warnings and teasing
4 – 5 Years
Syntax  MLU 4.5-7.0 by 5 years
 Speaks in complete sentences
 Uses complex sentences
 Uses future tense
 Uses “if…so” in sentences
 Uses passive voice
Semantics  Uses concrete meanings and words and responds to some abstract ideas appropriately
 Expressive range of 1,500-2,000 words
 Comprehends 5,600 words at 48 months and 6,500 words at 54 months and 9,600 at 60 months
 Can name items in a category
 Uses pronouns, “why”/”how”, “what do”/”does”/”did” in questions
 Understands time concepts/answers simple when questions
 Asks meaning of words
 Tells long stories accurately
 Can give whole name
 Understands right and left
 Can define 10 common words
 Shows objects by use and functions
 Identifies past and future
 Demands explanations
Morphology  Uses comparatives
 Uses “could”/”would”
 Uses irregular plurals
Pragmatics  Topic maintenance over successive utterances
 Egocentric monologues
 Indirect speech acts
 Tell jokes/riddles (around 5 years)
5 – 6 Years
Syntax  Average MLU 6.0-8.0
 Uses present, past and future tenses
  Uses conjunctions
 Asks “how” questions
 Uses “if” sentences
 Comprehends verb tenses in the passive voice
 Uses a language form that approximates the adult model
Semantics  Knows spatial relations and prepositions
 Defines objects by use and composition
 Tells long stories of past and present events
 Comprehends 13,000-16,000 words by age 6
 State similarities/differences
 Name rank of object
 Name days of week
 Comprehends first and last
 Knows functions of body parts
Morphology  Knows passive forms of main verbs
 Knows indefinite pronouns
 Uses irregular plurals and general, pronouns, superlatives
 Begins to use adverbial word endings
Pragmatics  Understands humor/surprise
 Recognize socially offensive message and reword politely
 Modifies speech according to listener
 Asks permission to use objects belonging to others
 Contributes to adult conversation
6 – 7 Years
Syntax  Uses reflexive pronouns, passive voice
 Average MLU of 7.3
Semantics  Comprehends 20,000-26,000 words
 Understands seasons
 Forms letters and numbers
 Tells time related to specific daily schedule
Morphology  Uses irregular comparatives
 Improves irregular past tense and plurals
 Begins to produce gerunds (a noun form produced by adding –ing to a verb infinitive)
 Acquires use of derivational morphemes (in which verbs are changed into nouns)
Pragmatics  Become aware of mistakes in other people’s speech
 May use slang and mild profanity
7 – 8 Years
Syntax  Average MLU 7.0-9.0
 Predominantly complex sentence forms
Semantics  Interprets jokes and riddles literally
 Anticipates story endings
 Uses some figurative language and details in description
 Creates conversation suggested by a picture
 Enjoys telling stories in sequence
Morphology  Uses most irregular verb forms
 Uses superlatives
 Uses adverbs
Pragmatics  Initiates and maintains conversation in small groups
 Role-play
 Uses nonlinguistic and nonverbal communicative behaviors
Development of Literacy Milestones
Phonological A child’s ability to detect and manipulate sounds and syllable s in words
Awareness
Print Knowledge Children’s emergent knowledge about functions and forms of written language
 Morphological The recognition, understanding and use of word parts that carry significance
Awareness

3. THEORIES OF LANGUAGE DEVELOPMENT

Behavioral Theory
Skinner’s System of Explains the acquisition of verbal behavior (a form of social behavior maintained by the actions of a verbal community which are acquired under appropriate conditions of stimulation,
Behavioral Analysis response and reinforcement); verbal behavior acquisition is aided by learning and events in the child’s environment and social interaction and produced under social stimulation; language is
NOT acquired by an innate knowledge of the universal rules of grammar; meaning is controlling relation between verbal responses and their causes; clinicians use behavioral theory to teach
language by targeting any observable behavior and manipulating the elements of a stimulus, a response and some type of reinforcement
Verbal Behavior A form of social behavior maintained by the actions of a verbal community which are acquired under appropriate conditions of stimulation, response and reinforcement; broken down into
cause-effect (functional) units:
1. Mands: involve requests
2. Tacts: verbal response stimulated by physical objects and events
3. Echoics: imitative verbal responses whose stimuli are the speech of another person
4. Autoclitics: secondary verbal behaviors that comment on or clarify the cause of primary verbal behaviors
5. Intraverbals: class of verbal behaviors determined by the speaker’s prior verbal behaviors
Nativist Theory
Chompsky’s Nativist a.k.a. the transformational generative theory of grammar; an influential theory of syntax stating that children are born with a language acquisition device (LAD); nativists believe children are
Theory born with the innate capacity to learn language; few implications for assessment and treatment, however, therapy should focus heavily on syntax in selecting treatment goals
Language Acquisition Assumed to be a specialized language processor that is a physiological part of the brain that knows about languages in general, because it contains the universal rules of language; integrates
Device universal rules and language specific rules to help child acquire language quickly
Language Competence The knowledge of the rules of universal grammar is innate and the child learns language relatively independently of the environment
Language The actual production of language; production is imperfect due to factors such as fatigue and distraction
Performance
Surface Structure The actual arrangement of words in a syntactic order
Deep structure Primarily contains the rules of sentence formation
Transformation An operation that connects the deep and surface structure and yields different forms of sentences
Cognitive Theory
Cognitive Theory Has been described as a variant of the nativist theory; emphasizes cognition (i.e. knowledge and mental processes such as memory, attention and visual/auditory perception) and focuses on
child’s regulation of learning and on internal aspects of behavior; language acquisition is made possible by cognition and general intellectual processes and language is only one expression of a
more general set of cognitive activities and proper development of the cognitive system is a necessary precursor of linguistic expression; a child must acquire concepts prior to acquiring words;
believe that although nonlinguistic and cognitive precursors are innate, language is not; clinicians must assess cognitive precursors to language and facilitate the development of precursors
prior to addressing language difficulties
Strong Cognition States that there are cognitive abilities that are essential prerequisites to language skills and without these prerequisite cognitive abilities, language skills will not be optimally developed
Hypotheses
Piaget’s Stages of 1. Sensorimotor (0-2 years): usually divided into 6 sub-stages (birth-2 mo; 2-4 mo; 4-8 mo; 8-12 mo; 12-18 mo; 18-24 mo); includes developmental milestones (speech and motor) and
Cognitive development of curiosity and experimentation with language
Develeopment 2. Preoperational (2-7 years): divided into two sub-stages (preconceptual, 2-4 yr; intuitive, 4-7 yr); includes attempts to effectively categorize/classify language and allowing perception
to guide thought and language
3. Concrete Operational (7-11 years): includes child becoming more aware of others and improved conversational skills
4. Formal Operational (11+ years): “adult-like” use of language
Weak Cognition States that while cognition accounts for some of a child’s language abilities, it cannot account for all of them; some aspects of language do not develop directly as a result of underlying
Hypothesis cognitive skills; research has shown that although cognition does impact language, some language and cognitive skills develop simultaneously
Information-Processing Theory
Information- Views the human information-processing system as a mechanism that encodes stimuli from the environment, operates on interpretations of those stimuli, stores the results in memory and
Processing Theory permits retrieval of previously stored information; primarily concerned with how language is learned and steps to handle/process incoming and outgoing information (i.e. organization,
memory, transfer, attention and discrimination); it is important to address memory and speed of processing in therapy for children with language impairments to facilitate cognitive
processing skills
Phonological Deals with the processes involved in the ability to mentally manipulate phonological aspects of language
Processing
Temporal Auditory Deals with the ability to perceive the brief acoustic events that comprise speech sounds and track changes in these events as they happen quickly in the speech of other people; researchers
Processing interested in overall processing capacity and speed of processing in children
Auditory Enable children to identify the difference between sound stimuli
Discrimination
 Auditory Attention The ability to ignore irrelevant acoustic stimuli and focus on important information
Auditory Memory The ability to mentally store speech stimuli, or remember what one has heard
Auditory Rate The ability to process acoustic stimuli that are presented at different rates or speeds
Auditory Sequencing The ability to identify temporal order in which auditory stimuli occur
Social Interaction Theory
Social Interaction Assumes that the structure of human language has arisen from language’s social-communicative function in human relations; emphasize language function; language develops because people
Theory are motivated to interact socially with others around them

Ch. 4 Language Disorders in Children

1. INTRODUCTION TO CHILDREN WITH LANGUAGE DISORDERS
Description of  Limited amount of language: significant deficiency in the quantity of language learned and understood
Language Disorders in  Deficient grammar: syntactic structures and morphologic features may be difficult
Children  Inadequate or inappropriate social communication: i.e. difficulty with pragmatics; includes failure to initiate conversation and inappropriately interrupting the speaker
 Deficient nonverbal communication skills: use of gestures, facial expressions and proper body language may be limited
 Deficient literacy skills: includes difficulty with reading, writing and spelling
 Cognitive deficits: includes deficits in working memory, attention and speed of processing
Risk Factors for  Prenatal conditions (i.e. maternal drug abuse and infections)
Language Disorders in  Perinatal conditions (i.e. labor complications)
Children  Neonatal conditions (i.e. premature birth)
 Presence of genetic syndrome
 Environmental factors (i.e. poverty, abuse/neglect)
 Prelinguistic communication deficits
 Delayed production of first words
 Lack of social skills

2. CHILDREN WITH SPECIFIC LANGUAGE IMPAIRMENT

Characteristics of Children with Specific Language Impairment
General  Language impairment not secondary to other developmental disabilities
Characteristics of  No sensorimotor issues, intellectual deficits or significant neurological impairment
Children with SLI  May have cognitive deficits
Normal Variation Believes that children with SLI are at the lower end of the normal continuum of language skills, just as some people have poor math or musical skills
Underlying Deficits Believes that SLI is due to deficits in cognitive, auditory, perceptual and intellectual functions that underlie language; frontal lobe abnormalities are common in children with SLI
Speech and Language  Articulatory and phonological problems (i.e. speech sound problems)  poor intelligibility and extended presence of phonological processes
Deficits  May use less complex syllable and sentence structure and have fewer consonants in their phonetic repertoire
 Late stating to talk and have a slow rate of word acquisition
 Word finding/word retrieval difficulties
 Difficulty learning abstract or figurative words
 Morphological problems (i.e. perceptual problems, syntactic problems, omissions)
 Lower MLU
 Difficulty with pragmatic skills (i.e. topic initiation, turn taking, topic maintenance, discourse/narrative skills, etc.)
Cognitive Processing/  Decreased speed of processing
Executive Functioning  Decreased attention to task
Deficits  Difficulty with working memory
 Decreased emotional control
 Difficulty task shifting
 Difficulty planning and organizing

3. CHILDREN WITH LANGUAGE PROBLEMS ASSOCIATED WITH PHYSICAL AND SENSORY DISABILITIES
Intellectual Disability
Intellectual Disability Disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social and pragmatic domains; can be affected by inherited
genetic syndromes; environmentally produced abnormalities occurring prenatally (i.e. rubella, maternal health issues, trauma, etc.), postnatally (i.e. TBI, low birthweight, cranial abnormalities,
etc.); often have decreased attention, physical abnormalities and difficulties with gross and fine motor skills
Language and Cognition tends to be depressed and language tends to be delayed (i.e. decreased vocabulary, gap between comprehension and expressive skills, poor morphologic skills, reduced syntax and
Cognitive Deficits reduced pragmatic skills)
Autism Spectrum Disorder
ASD Persistent deficits in social communication and social interaction across multiple contexts as manifested by deficits in social-emotional reciprocity, deficits in nonverbal communicative
behaviors used for social interaction and deficits in developing, maintaining and understanding relationships; includes all those diagnosed with autistic disorder, Asperger’s disorder or PDD-NOS
Characteristics  Generally, below average intelligence
 Lack of responsiveness to and awareness of other people
 Preference for solitude and objects
 Lack of interest in verbal and nonverbal communication
 Stereotypic body movement
 Insistence on routines
 Dislike of being touched
 Self-injurious behaviors
 For some children, unusual talent in specific area
 In ~25% of children, seizures
 Hyper- or hyposensitivity to sensory stimulation
Language Difficulties  Inadequate or lack of response to speech
 Lack of interest in human voices; better responses to environmental noise
 Slow acquisition of speech sound production and language
 Use of language in a meaningless, stereotypic manner (including echolalia)
 Perseveration on words/phrases
 Faster learning of concrete than abstract words
 Deficits in comprehension and use of figurative language
 Lack of generalization of word meanings
 Lack of understanding the relationship between words
 Social communication problems
Associated Difficulties  Motor deficits
 Central auditory problems
 Intellectual disability
 Evidence of brain injury/abnormal brain electrical activity
 Hearing loss
***important to utilize multidisciplinary team for assessment and intervention
SCERTS Model Treatment paradigm targeting goals in Social Communication and Emotional Regulation by implementing Transactional Supports, including visual supports, environmental arrangements and
communication style adjustments

Naturalistic Social skills are taught in informal settings not primarily designed for instruction (i.e. the child’s home)
Interventions
Developmental-Social Focuses on increasing the adult’s responsiveness to a child and establishing balanced turns between the adult and child; can increase joint engagement and support development of social
Pragmatic Perspective communication skills
Brain Injury
Traumatic Brain Injury Cerebral damage caused by external physical force; can be focal (i.e. restricted to one area of the brain) or diffused (i.e. more widespread damage); multidisciplinary team is always necessary
with the involvement of medical personnel; immediate effects of TBI include coma/loss of consciousness, confusion, abnormal behaviors and motor dysfunctions; however effects usually
change over time
Cognitive and  Difficulty with comprehension
Language Difficulties  Difficulty with word retrieval
Associated with TBI  Syntactic difficulties (i.e. limited MLU)
 Reading and writing difficulties
 Pragmatic difficulties
 Difficulty with attention, focus and memory
 Difficulties with reasoning and organization
 Low tolerance for frustration
 Reduced speed of processing
 Inability to identify weaknesses
Cerebral Palsy A disorder of early childhood in which the immature nervous system is affected resulting in muscular incoordination and associated problems; can occur as a result of prenatal, perinatal or
postnatal brain injury; may experience paralysis of various body parts (i.e. hemiplegia-R or L side paralysis; paraplegia-legs/lower trunk paralysis; monoplegia-paralysis of single limb; diplegia-
 paralysis of 2 legs or arms; quadriplegia-paralysis of all 4 limbs)
Ataxic CP Involves disturbed balance, awkward gait and uncoordinated movements due to cerebellar damage
Athetoid CP Characterized by slow, writing, involuntary movements due to damage to the indirect motor pathways, especially the basal ganglia
Spastic Involves increased spasticity (i.e. increased tone and rigidity of muscles), as well as stiff, abrupt, jerky, slow movements due to damage to the motor cortex or direct motor pathways
Speech and Language Depend heavily on type of CP and presence of associated problems; treatment should involve multidisciplinary team and use of aac if necessary
Difficulties Associated
with CP

4. CHILDREN WITH LANGUAGE PROBLEMS ASSOCIATED TO PHYSICAL AND SOCIAL-ENVIRONMENTAL FACTORS

Language Problems There is no demonstrated causal relationship between poverty and language learning difficulties, however limited access to health care, low SES and low educational levels of caretakers are
Related to Poverty associated with limited early language experience for children; some deficits of children from backgrounds of poverty with language learning difficulties exhibit deficits in reading and writing,
referencing time and temporal concepts, delayed vocabulary, delayed morphosyntactic skills and less verbalization
Language Problems Research has found a relationship between communication disorders and NA, however impact on language depends greatly on the extent and severity of the NA; children who experience NA
Related to Neglect and are often deprived of adequate language stimulation and tend to have expressive language delays
Abuse (NA)
Language Problems Language difficulties may be related to maternal drug/alcohol use during pregnancy; children with fetal alcohol spectrum disorder often have growth problems, CNS dysfunction, abnormal
Related to Parental craniofacial features, organ malformation, behavior problems, learning and academic problems, speech and swallowing problems and language and cognitive problems; children prenatally
Drug and Alcohol exposed to drugs often have motor and neurological problems, affective and behavioral problems, social attachment and related problems, cognitive skill impairments and language learning
Abuse problems
Language Problems ADHD is characterized by difficulties in attention and hyperactivity/impulsivity (i.e. executive functioning) and children with ADHD are at higher risk for language impairment in pragmatic,
Related to Attention- syntactic and semantic skills
Deficit/Hyperactivity
Disorder (ADHD)

5. ASSESSMENT PRINCIPLES AND PROCEDURES

Language Assessment
General Principles and  Obtain results of other testing prior completed (i.e. visual, audiological, psychological, cognitive, intelligence, etc.)
Procedures  Obtain relevant medical data
 Interview family members
 Obtain data on educational achievement (i.e. grades, writing sample, classroom expectations, etc.)
Screening A process of quickly obtaining a general overview of a child’s language skills used to decide whether further assessment is necessary; pass (WNL) or fail (further assessment necessary)
Standardized Provide clinicians with a quantitative means of comparing the child’s performance to the performance of large group of children in a similar age category; when choosing an assessment clinician
Assessment must consider limitations (i.e. sample demographic, ability for child to participate, environment, cultural/ethnic diversity, etc.); should be used as supplements to language samples and other
alternative assessment approaches
Alternative Tend to sample more naturalistic communication skills and expand the scope of assessment to include more information about the child’s daily functioning; more sensitive to cultural
Assessment differences; include criterion-referenced assessment, dynamic assessment, assessment of information processing skills, portfolio assessment, etc.
Approaches
Language Sampling A measure of communication skills vital to a diagnosis of language impairment in children; procedure of recording a student’s language under natural conditions and then analyzing content
using published protocol (i.e. language assessment, remediation and screening procedure, developmental sentence scoring, language sampling, analysis and training procedure, etc.); should
calculate child’s MLU (MLU = # of morphemes/# of utterances) and type-token ratio (TTR = # of different words in sample/# of words in sample)
Rules for Counting Count as 2 morphemes:
Morphemes 1. Regular past tense -ed (i.e. washed)
2. Present progressive –ing (i.e. writing)
3. Possessive marker ‘s (i.e. Mommy’s)
4. Plural marker –s (i.e. cookies)
5. Third person singular present tense marker (i.e. swims)
Count as 1 morpheme:
1. Compound words – 2 or more free morphemes (i.e. birthday)
2. Proper names (i.e. Dr. Cho)
3. Each recurrence of a word for emphasis (i.e. no no no)
4. Ritualized reduplications (i.e. night night)
5. Contracted negatives (i.e. don’t)
6. Diminutives (i.e. dolly)
7. Irregular past-tense verbs (i.e. swam)
 8. Auxiliary verbs (i.e. is, will)
9. Catenatives (i.e. gotta, wanna)
Do not count
1. Fillers (i.e. um)
2. Dysfluencies, except the one complete form (i.e. l-l-lollipop)
Assessment of Infants and Toddlers
Established Risk  Congenital malformations
Factors for Language  Genetic syndromes
Disorders in Infants  Atypical developmental disorders
and Toddlers  Neurological disorders
 Chronic illness
 Severe infectious disease/toxic exposure
Experienced  Serious prenatal and natal complications
Conditions Putting  Behavior disorders
Infants and Toddlers  Chronic otitis media
At Risk for Language  Family history of predisposing genetic or medical conditions
Disorders  Chronic or severe physical illness, mental illness or ID
 Care giver or parental substance abuse, low level of education or neglect/abuse
Prelinguistic  Difficulty establishing eye contact, mutual gaze and joint reference
Behavioral Deficiencies  Communication of needs through gestures over verbalizations
in Infants and Toddlers  Reduced amount of babbling, fewer consonants in babbling and less complex babbling
Late Talkers Characterized by a significant expressive language delay at 24-30 months of age; children are generally less vocal and verbal; typically catch up to typically developing peers
General Assessment  Make a family-centered communication assessment of infants and toddlers in both home and clinical settings
Guidelines/Procedures  Collect extensive family history
for Infants and  Create a multidisciplinary team
Toddlers  Take into consideration diversity of culture and ethnicity
Specific Assessment  Must assess comprehension and production of language, hearing, infant readiness for communication, infant-caregiver interaction and play activities
Guidelines and  Collect parent/caregiver questionnaires to gather patient history
Procedures for Infants
and Toddlers
Language-Related Assess the infant’s attention and physiological state and the infant’s readiness for communication
Skills
Language Use language development milestones to assess the presence or absence of verbal communication behaviors and language comprehension skills through direct observation and/or parent
Comprehension and report
Verbal Communication
Infant-Caregiver Looking to see infant’s responsiveness, caregiver modification of interaction, caregiver focus, and level of caregiver physical contact and expression of affection
Interaction
Play Activities Assess if there is any aggression/uncooperative behaviors, ability/willingness to share, verbalizations, interaction with peers; results in the observation of:
1. Solitary play: plays independently and does not notice other children
2. Parallel play: mimics other children but does not actively engage with them
3. Associative play: more interested in other children than toys
4. Cooperative play: organization within child’s play
Assessment of Preschool and Elementary Age Children
Description of 1. Difficulty in comprehending spoken language: includes problems with comprehending syntactically longer and more complex productions and comprehending the meaning of
Language Disorders in complex words, phrases, sentences and abstract terms
Pre-K and Elementary 2. Slow or delayed language onset: includes delayed babbling, slower vocabulary growth rate, delayed acquisition of vocabulary, slowness in combining words into phrases and
Age Children sentences, overall slower acquisition of language milestones
3. Limited language output or expressive language: includes generally limited verbal repertoire, lack of complex r longer word productions, limited amount of vocabulary produced and
comprehended, lack of abstract words in child’s repertoire
4. Problematic syntactic skills: includes use of shorter and simpler sentences, limited variety of syntactic structure
5. Problematic pragmatic skills: includes difficulty with initiating and maintaining conversation, turn taking, maintaining eye contact and using narrative skills
6. Problematic learning of grammatical morphemes: includes difficulty with comparatives and superlatives, omission of bound morphemes, incorrect use of learned grammatical
morphemes including overgeneralizations
General Assessment Make use of initial screen, then if necessary use social assessment (i.e. patient history), evaluate reading and writing, evaluate language skills (i.e. semantics, syntax, morphology and pragmatics
Guidelines/Procedures of expressive and receptive language) and assess family constellation and communication factors
for Elementary Age
Children
Specific Assessment Collect a speech and language sample for a typical analysis of language functions, assessing the child’s syntactic skills, morphologic skills, semantic skills, pragmatic skills and language
Guidelines/Procedures comprehension
for Elementary Age
Children
Standardized Tests for Consider individualized difference when determining the most appropriate and effective standardized test
Elementary Age
Children
Response to Model of (dynamic) assessment in which at-risk students who are struggling in classrooms are given increasing amounts of targeted individual and small group support within the classroom
Intervention before a special education referral is made; if the student does not respond to instruction through increased success in academic performance, they are then referred for a special education
evaluation
Assessment of Adolescents
Description of Syntactic problems include:
Language Disorders in  Limited MLU and difficulty using complex sentences with subordinate clauses
Adolescents  Difficulty using cohesion devices or connectives
 Lack of agreement
 Persistent use of syntactic errors
 Limited use of low frequency structures
Semantic problems include:
 Word retrieval problems in conversational speech  dysfluencies
 Problems with word-definition skills and word-relation skills
 Difficulty understanding and correctly using figurative language or words with abstract/multiple meanings
Pragmatic problems include:
 Difficulty modifying statements or adding new information
 Inappropriate use of gestures and other nonverbal cues
 Difficulty maintain topic of conversation, asking relevant questions and making relevant comments during conversation
Literacy problems include:
 Grammatical errors
 Difficulty reading
 Spelling difficulties
 Poor formation of letters
 Lack of punctuation
 Poor organization of narratives
 Lack of appropriate detail
General Assessment Begin with a screening, if necessary then obtain a case history using social assessment methodologies, evaluate reading and writing, evaluate language skills (i.e. semantics, syntax, morphology
Guidelines/Procedures and pragmatics of expressive and receptive language) and assess family constellation and communication factors
for Adolescents
Specific Assessment Obtain an extended speech and language sample to assess syntactic skills, semantic skills, pragmatic skills, reading and writing skills
Guidelines/Procedures
for Adolescents
Standardized Tests for Many clinicians use non-standardized procedures to assess language problems in adolescents
Adolescents

6. TREATMENT PRINCIPLES AND PROCEDURES

General Principles  Therapy should involve family as much as possible
 Clinicians should focus on academic and social language
 Clinicians should select literacy skills when appropriate
 Clinicians should select language treatment targets that are culturally and linguistically appropriate for the child and family
 Clinicians should use EBP when selecting treatment approaches
 Clinicians should use multimodal approach to treatment and collaborate/create multidisciplinary team
Specific Techniques
Discrete Trial Useful in initial stages of treatment when skills have to be shaped or established; not efficient for generalization of skill; conducted by:
Procedure 1. Clinician places a stimulus picture in front of the child and asks them a relevant question
2. The clinician immediately models the correct response and waits a few seconds for the child to imitate the model response
3. The clinician reinforces the child for correct imitation and gives corrective feedback if necessary
Basic Behavioral 1. Instructions: giving adequate instructions regarding targeted language skill and how it is performed
Techniques 2. Modeling: used to teach a nonexistent skill and should be followed by child’s imitation
3. Prompting: clinician gives hints for target skill when modeling is no longer needed
4. Shaping: a complex response is broken down into smaller components that are taught sequentially to achieve the final target skill
5. Manual guidance: offering physical assistance to produce a response
6. Fading: minimizes the need for special procedures to evoke language responses
7. Immediate, response-contingent feedback: promptly delivered positive reinforcement for correct responses and constructive feedback for incorrect responses
Expansion Clinician expands a child’s telegraphic or incomplete utterance into a more grammatically complete utterance
Extension The clinician comments on the child’s utterances and adds new and relevant information; efficacy supported by research
Focused Stimulation The clinician repeatedly models a target structure to stimulate the child to use it; usually done during play activity; clinician uses various stimulus materials, talks about them and repeatedly
models target skill
Milieu Teaching Refers to a group of techniques that have been experimentally evaluated and shown to be effective in teaching a variety of language skills to children; teaches functional communication skills
through the use of typical, everyday verbal interactions that arise naturally; techniques that constitute milieu teaching are:
1. Incidental teaching: the adult waits for the child to initiate verbal speech and pays full attention to the stimulus that prompts a response from the child, prompts an elaboration of
the response and praises the child and hands over desired object when child elaborates
2. Mand-model: variation of incidental teaching method teaches language through the use of typical adult-child interactions in play-oriented settings; the clinician designs a naturalistic
interaction situation with a desirable object, then mands (i.e. demands) a response from the child (modeling appropriate response if not spontaneously presented) and praises child
for imitating or responding correctly without model by giving child the desired item
3. Time delay: the clinician waits fo the child to initiate verbal responses to stimuli separated by a predetermined waiting period; without prompting a response the clinician looks at
the child for at least 15 sec, if the child does not initiate the clinician prompts or models a response, the clinician gives the desired object only when the child produces target
response
Joint Routines/ Routinized, repetitive activities are frequently used in early language stimulation
Interactions
Joint Book Reading Clinician stimulates language in children through the use of systematic storybook reading; allows for repetitive use and practice of the same concepts and phrases and helpful in establishing
(Dialogic Reading) joint attention; promotes language and literacy skills in children
Narrative Skills Narratives (i.e. speaker’s descriptions of events and experiences) should be produced in a cohesive, logically consistent, temporally sequenced manner; clinicians can promote narrative skills by
Training letting children act out stories using scripts, video modeling and peer training, getting children involved in routinized daily activities and ask children to tell stories or narrate new events or
experiences
Story Grammar Clinicians can teach and model elements of story grammar including setting statements, initiating events, internal response, story theme, goals of characters, direct consequences and
conclusions
Parallel Talk Clinician plays with the child and describes comments upon what the child is doing and the objects the child is interested in
Recasting Recasting children’s limited productions into longer or syntactically different forms can be useful in teaching complex grammatical forms
Self-Talk The clinician describes her own activity as she plays with the child; using language structures that are appropriate for the child
Teaching Literacy Skills Important to include and educate family in creating a literacy rich environment for the child; the clinician should incorporate literacy training into language intervention through increasing
morphological and phonological awareness (i.e. rhyming, syllable awareness, phonemic isolation and sound blending) and target vocabulary skills
Targeting Executive Research has shown that targeting executive functioning as well as language skills can lead to an improvement in both areas; clinician can work towards improving working memory, attention
Functioning/Cognitive and processing speed
Processing Skills
Augmentative and Alternative Communication
AAC A multimodal intervention approach using forms of communication such as picture communication boards, manual sign language and computerized or electronic devices that produce speech;
provide alternative means of communication for children with extremely limited oral communication skills; helps the child express wants and needs, transfer information, promote social
closeness, participate in social routines and communicate with oneself
Revised Participation Clinicians are required to identify the communication needs of an individual through a participation inventory, assess barriers to communication imposed by others, assess access barriers and
Model assess the client’s motor, language, literacy and other capabilities
Gestural (Unaided) No instruments or external aids are used; the child uses gestures and other patterns movements (which may or may not be accompanied by some speech); types of gestural aac include:
AAC 1. Pantomime: mostly uses gestures and dynamic movements involving the entire body or parts of the body
2. Eye-blink encoding: the child learns to communicate a message by a specific number of blinks
3. American indian hand talk: a sign-language system developed by N. American Indians where gestures and movements are used as pictorial representations of concepts and ideas
4. American sign language: consists of manual signs for the 26 letters of the alphabet and words and phrases
 5. Limited manual sign systems: composed of several different systems with limited number of gestures and signs
6. Left-hand manual alphabet: composed of concrete gestures that approximate printed letters of the alphabet
Gestural-Assisted Gestures or movements are combined with an instrument or message-display device; gestures are used to display messages on a mechanical device or to scan/select messages displayed on a
(Aided) AAC non-mechanical device; types of symbols used are:
1. Picsyms: graphic symbols representing nouns, verbs and prepositions
2. Pic symbols: white drawings on black background
3. Blissymbols: semi-iconic and abstract symbols that can be taught to speakers of any linguistic and cultural background
4. Sig symbols: ideographic/pictographic symbols based on ASL
5. Rebuses: pictures that represent events or objects along with words, grammatical morphemes or both
6. Premack-type symbols/carrier symbols: abstract plastic shapes associated with a word or phrase
7. Picture exchange communication system (PECS): a low-tech method of communication using pictures to communicate
Neuro-Assisted (Aided) Uses bio-electrical signals to activate and display messages on a computer monitor; useful for children who have such profound motoric impairments and limited hand mobility that they cannot
AAC use a manual switching device

Ch. 5 Speech Sound Development and Disorders

1. FOUNDATIONS OF ARTICULATION AND PHONOLOGY
Basic Definitions
Articulation Approach Looks at children’s acquisition of individual phonemes and emphasizes speech-motor control
Phonological Approach Studies children’s acquisition of sound patterns and the processes of underlying such patterns; focuses on the knowledge of the rules of the sound system of language
Naturalness The greater number of languages a sound occurs in, the greater the naturalness of the sound
Unmarked Sounds Those that appear to be natural; tend to be easier to acquire  acquired earlier
Marked Sounds Those that are less natural and are later acquired
Phoneme Class of speech sounds
Allophones Variations of a phoneme
Phonemic The abstract system of sounds
Phonetic Concrete productions of specific sounds
Distinctive Features Paradigm
Distinctive Feature Used to classify vowels and consonants based on their distinctive features; based on the assumption that a phoneme is a collection of independent features and a distinctive feature is a unique
Paradigm characteristic of a phoneme that distinguishes it from others; uses a binary system of classifying whether features are present (+) or absent (-)
Place-Voice-Manner Paradigm
Place-Voice-Manner Used to classify consonants according to three parameters:
Paradigm 1. Place of articulation: describes the location of the constriction
2. Voicing: describes the presence of absence of vocal fold vibrations in the production of consonants
3. Manner of articulation: describes the degree or type of constriction in the vocal tract
Manner of Articulation 1. Stops: produced by completely stopping the airflow (/p, b, t, d, k, g/)
Categories 2. Fricatives: produced by severely constricting the oral cavity and then forcing the air through it (/f, v, th, s, z, sh, ss, h/)
3. Affricates: combination of stops and fricatives (/ch, dh/)
4. Glides: produced by gradually changing the shape of the articulators (/w, j/)
5. Liquids: produced with the least restriction of the oral cavity (/r, l/)
Place of Articulation 1. Bilabials: produced primarily by the two lips (/p, b, m, w/)
Categories 2. Labiodentals: produced by contact of the lips and teeth (/f, v/)
3. Linguadentals: produced by the tongue making contact with the upper teeth (/th/)
4. Lingua-alveolars: produced by raising the tip of the tongue to make contact with the alveolar ridge (/t, d, s, z, n, l/)
5. Linguapalatals: produced by the tongue coming in contact with the hard palate (/sh, ss, ch, dg, r, j/)
6. Linguavelars: produced by the back of the tongue raising to contact the velum (/k, g, ng/)
7. Glottal: produced by keeping the vocal folds open and letting the air pass through them (/h/)

2. ACQUISITION OF ARTICULATORY AND PHONOLOGICAL SKILLS: TYPICAL DEVELOPMENT

Theories of Development
Behavioral Theory Based on conditioning and learning; focuses on describing observable and overt behaviors; emphasizes child development through interactions with the caregiver through classical conditioning
Structural Theory Based on the assumption that phonological development follows an innate, universal and hierarchical order of acquisition of distinctive features
Natural Phonology Proposes that natural phonological processes are innate processes that simplify the adult target word; children learn to suppress processes that do not occur in their languages; use of
Theory phonological processes is constraints on production that lead to simplification of the adult model
Generative Phonology Theory of the sound structure of human languages; based on the assumption that phonological descriptions are dependent on information from other linguistic levels and that phonological
Theory rules map underlying representations onto surface pronunciations
Linear Phonology Based on the premise that all speech segments are arranged in a sequential order, that all speech sounds have equal value and that all distinctive features are equal; characterized by rules that
Theory operate in a domain of linear strings of segments and assume that phonological properties are linear strings of segments and that sound segments are composed of a bundle of independent
characteristics or features
Nonlinear Phonology An alternative to linear phonology to account for the influence of stress and tone features in levels of representation independent of segmental or linear representation; assume that there is
Theory some sort of hierarchy that helps to organize both segmental and suprasegmental phonological units and properties
Infant Development: Perception and Production
Perception Types of methodologies of perception are high-amplitude sucking paradigm and visually reinforced head turn; results have concluded:
 4-17 week old infants can discriminate between some vowels
 2 month old infants can discriminate ba and ga
 2-3 month old infants can discriminate ra and la
 1-4 month old infants can discriminate between va and sa, sa and sha, pa and ba
 6-8 month old infants can discriminate between sa and za
Production Structural differences can constrain an infants productions; stages of vocal development include:
1. Phonation stage: birth-1 month – speech-like sounds are rare and most vocalizations are reflexive
2. Cooing or going stage: 2-4 months – most productions are acoustically similar to /u/ and some velar consonants may occur
3. Expansion stage: 4-6 months – infant plays with the speech mechanism through growls, squeals, yells and raspberries; some CV combinations and vowel-like sounds may occur
4. Canonical or reduplicated babbling stage: 6-8 months – produces strings of CV syllables; by 8 months, children with HL will fall behind in language development
5. Variegated or nonreduplicated babbling stage: 8 months-1 year – adult like CV syllable sequences with a variety of consonants and vowels appearing in single vocalizations
First word usually occurs ~1 year
Typical Articulation Development in Children
Articulation Looks at children’s development of single phonemes and focuses on the age of mastery for single phonemes based on speech-motor control; research has found that:
Development  Vowels are acquired before consonants
Approach  Nasal consonants are usually earliest to be acquired
 Stops and glides are acquired before fricatives
 Liquids are mastered relatively late
 Consonant clusters are acquired later than most sounds
Overall Intelligibility
Intelligibility A perceptual judgement made by a listener largely based on the percentage of words in a speech sample that the listener understands; assumes the listener is an adult unfamiliar with the child;
intelligibility development is:
 2 years, child is 60-70% intelligible
 3 years, child is 75-80% intelligible
 4 years, child is 90-100% intelligible
Typical Phonological Development in Children
Substitution Processes Groups of phonological processes in which one class of sounds is substituted for another:
1. Vocalization: a vowel is substituted for a syllabic consonant (ex: noodoo for noodle)
2. Gliding: a liquid consonant is produced as a glide (ex: wamp for lamp; jate for late; wing for ring)
3. Velar fronting: an alveolar or a dental replaces a velar, usually in the initial position (ex: tea for key)
4. Stopping: a fricative or affricate is replaced by a stop (too for shoe)
5. Depalatization: substitutes an alveolar fricative for a platal affricate (ex: wats for watch) or substitutes an alveolar fricative for a palatal fricative (ex: sip for ship)
6. Affrication: an affricate is produced in a place of a fricative or a stop (ex: chun for sun)
7. Deaffrication: a fricative replaces an affricate (seap for cheap)
8. Backing: a posteriorly placed consonant is produced instead of an anteriorly placed consonant; velars are substituted for alveolars (Ex: gen for den)
9. Glottal replacement: glottal stop is produced in place of another consonant
Assimilation Processes Sounds are changed by the influence of neighboring sounds:
1. Reduplication: a child repeats a pattern (ex: wawa for water)
2. Regressive assimilation/consonant harmony: occurs due to the influence of a later occurring sound on an earlier sound (ex: guck for duck)
3. Progressive assimilation/consonant harmony: earlier occurring sound influences a later occurring sound (kick for kiss)
4. Voicing assimilation: devoicing (pick for pig) or voicing (bad for pad)
Syllable Structure Affects the structure of entire syllables, not just certain sounds:
Processes 1. Unstressed/weak syllable deletion: omission of an unstressed syllable (ex: mato for tomato)
2. Final consonant deletion: final consonant is omitted (ex: be for bed)
3. Epenthesis: a schwa vowel is inserted between the consonants in an initial cluster (ex: turee for tree) or after a final voiced stop (ex: stopu for stop)
 4. Consonant cluster simplification/reduction: a consonant or consonants in a cluster are depleted (ex: peed for speed)
5. Diminutization: addition of ee to the target form (ex: doggy for dog)
6. Metathesis: production of sounds in a word in reversed order; i.e. spoonerism (ex: peek for keep)

3. SPEECH SOUND DISORDERS

General Factors Related to Speech Sound Disorders
Gender There is some evidence that female children generally have articulatory skills slightly superior to those of male children, however difference is small; more boys have speech sound disorders
than girls
Intelligence Not causally related to speech sound disorders; many children with intellectual disabilities also have speech sound disorders
Birth Order and Sibling There is some evidence that firstborn and only children have better articulation skills; it has been suggested that the greater the age difference between siblings, the better the articulation of
Status the younger child – if siblings are closer in age, younger children may have inadequate model for articulation from the older child
Socioeconomic Status SES is not a strong factor in the etiology of articulation disorders; more children from lower SES backgrounds make more errors of articulation – may be related to inadequate health care
Language Younger children with severe speech sound disorders are more likely to demonstrate language problems; young children with speech sound disorders may be at risk for problems with reading
Development and and spelling at the elementary school level
Academic Performance
Auditory Some children with speech sound disorders have poor auditory discrimination, however some children’s auditory discrimination is WNL; there does not appear to be a strong relationship
Discrimination Skills between speech sound disorders and auditory discrimination skills
Description of Articulatory Errors
Substitutions An incorrect sound is produced in place of a correct sound (ex: tink for think)
Omissions/Deletion Required sounds are omitted in words (i.e. bo for bot)
Labialization Sounds are produced with excessive lip rounding
Nasalization Oral sounds are produced with inappropriate, usually excessive, nasal resonance (often occurs with oral stops like /g/)
Pharyngeal Fricative Fricatives are produced in the pharyngeal area
Devoicing Voiced sounds are produced with limited vocal fold vibrations or without vocal fold vibrations entirely (i.e .dock fo dog)
Frontal Lisp Sibilant consonants are produced with the tongue tip placed too far forward (between or against the teeth) (usually occurs with /s, z/)
Lateral Lisp Sibilant consonants are produced with air flowing inappropriately over the sides of the tongue (usually occurs with /s, z/)
Stridency Deletion Strident sounds are omitted – sometimes described as a phonological process (ex: top for stop)
Unaspirated Aspirated sounds (i.e. /k, t/) are produced without aspiration
Initial, Medial, Final Errors in the production of a beginning, medial or final sound of a word
Position Errors
Prevocalic, Errors occur with reference to consonant position in syllables would involve a postvocalic error (ex: gog for dog involves a prevocalic error)
Intervocalic,
Postvocalic Errors
Organically Based Disorders
Oral Structural 1. Ankyloglossia (i.e. tongue tie): a short lingual frenum reduces tongue tip mobility and can limit production of tip-alveolar sounds (i.e. /t, d/)
Variables 2. Dental deviations (i.e. maloclussion): deviations in the shape and dimensions of the mandible and maxilla and the positioning of independent teeth; class I malocclusion, arches are
properly aligned with some misaligned teeth; class II malocclusion, overbite; class III malocclusion, underbite
3. Oral motor coordination skills: frequently evaluated through ddk; poor ddk can be associated with decreased articulatory precision
4. Orofacial myofunctional disorders (i.e. tongue thrust): interferes with normal speech or physical, dentofacial or psychosocial development (i.e. swallowing, labial and lingual rest and
speech posture differences); during deviant swallow and speech tongue tip pushes against the front teeth/may protrude; often related to errors in the production of /s, z, sh, ss, ch,
dg, t, d, l, n/)
Hearing Loss The degree of hearing loss is frequently related to the severity of the speech sound disorder problem – difficulty with speech production can stem from the inability to self-monitor speech 
frequent substitutions, distortions and omissions
Neuropathologies 1. Dysarthria: a speech motor disorder caused by PNS or CNS damage causing paralysis, weakness or incoordination of the muscles of speech; speech usually characterized by
monotone/pitch, deviant voice quality, variable speech rate, hypernasality, reduced intelligibility; children with dysarthria often have voicing errors (i.e. devoicing), difficulty with
alveolar fricatives, affricates, labiodental fricatives and palatal liquids; treatment includes increasing muscle tone and strength, increasing range and rate of motion and treating other
parameters (i.e. respiration) that impact intelligibility
2. Apraxia: caused by CNS damage; difficulty programming precise movements necessary for speech (motor programming/planning disorder); children with CAS often exhibit groping
behaviors and poor intelligibility due to inconsistent and multiple articulation errors; CAS speech is often slow and effortful with prolongation and repetition of speech sounds and
syllables, most difficulty occurs with consonant clusters, fricatives, affricates stops and nasals) with omissions and substitutions, voicing and devoicing errors, difficulty with
nonspeech movements, feeding difficulties and substantially delayed speech production with limited sound inventory and inconsistency in sound productions; children with CAS
often have difficulty with phonological representation; treatment involves extensive drills, imitations, decreased rate of speech, normal prosody and increased production accuracy
sometimes using tactile cueing
4. ASSESSMENT OF SPEECH SOUND DISORDERS
Screening
Screens A brief initial procedure that helps determine whether further/formal testing is appropriate
Assessment Objectives
General Assessment 1. Case history
Objectives 2. Screening
3. Oral peripheral assessment
4. Hearing screening
5. Language assessment
6. Assess child’s performance in single-word vs. conversational speech
7. Assess presence of phonological processes
8. Evaluate performance based on developmental norms
9. Evaluate stimulability of misarticulated speech sounds
10. Identify potential treatment targets
Related Assessment 1. Audiological assessment
Objectives 2. Physical/neurological disabilities
3. Dental abnormalities impacting intelligibility
4. Possible influences of another language or dialect
5. Concomitant language problems
6. Intellectual and behavioral assessment
Assessment Procedures
Case History Gather information from family and teachers to collect an overview of what is determined to be the child’s areas of difficulty; should include developmental, medical, educational, family and
social history
Orofacial Assessment Clinician exams facial and oral structures to determine if an organic problem may impact child’s speech
Hearing Screening Completed to determine whether the possibility of a hearing loss is impacting the child’s speech/language development
Specific Components of Assessment
Conversational Speech Many children make more errors at the conversational level; allows clinician to assess stress, rate, intonation, syllable structure and intelligibility; optimal to collect 50-100 utterances
Sample
Evoked Speech Sample 1. Intonation: child imitates the clinician’s model of a single word; can be immediate or delayed
2. Naming: child names object’s or pictures
3. Sentence completion: child finishes clinician’s sentences
Stimulability Sample Assesses whether a child can imitate the clinician’s model when given auditory and visual cues
Standardized Tests May be more reliable with highly unintelligible children; satisfy the requirements of many school districts; standardized articulation tests assess child’s production of each phoneme in the initial,
medial and final position and compare child’s performance to the norm
Scoring and Analysis of Assessment Data
Independent Analysis A child’s speech patterns are described without reference to the adult model of the language of the child’s community; can include all or just some vocalization; provides important information
about the phonology of young children who make many errors in sound production; typically used with very young speakers or speakers with limited phonological repertoires (up until about 50
words)
Relational Analysis A child’s speech is compared to the adult model of the community; more commonly used in a clinical setting
Standard Procedures 1. Use IPA and diacritics
2. Note consistency and frequency of errors
3. Note phonemic contexts
4. Calculate intelligibility
5. Note and analyze speech errors, especially if patterns are present
6. Used published guidelines to determine presence of phonological processes
7. Calculate percentage of consonants correct (PCC = total # of correct consonants produced/total # of consonants produced x 100); >85% mild, 60-85% mild to moderate, 50-65%
moderate to severe, <50% severe
8. Decide whether child should receive services
9. Distinguish SSD from hearing impairment and typical/developmentally appropriate errors
10. Make a statement of prognosis

5. TREATMENT OF SPEECH SOUND DISORDERS

General Considerations for Treatment
Categories of Approaches can be motor or linguistic, or can intertwine both motor and linguistic approaches
Treatment
Basic Procedures  Thorough assessment determining any existing patterns
 Selection and prioritization of intervention targets
 Establishment of baseline targets and specific training for targets
 Preparation of generalization and maintenance activities
Multimodal Approach Utilizing auditory, visual and kinesthetic cueing; clinicians also incorporate language and meaning based activities to give treatment meaning to everyday life outside of therapy
Communicative Focuses on functionality of words within a child’s communication environment
Potency
Developmental Based on selection of early-developing targets that follow a developmental sequence and are assumed to be easier for children to produce; based on the premise that speech sounds have a
Treatment Approach motoric basis and should follow a sequential order based on the ease of sound acquisition
Complexity Treatment i.e. the least knowledge approach; recommends targeting sounds that are nonstimulable, always incorrect, and later developing; based on the underlying assumption that presenting more
Approach complex input to the child will lead to the child’s learning simpler untrained sounds and force the child to learn the complex target; although considered more efficient, may initially take longer
to improve intelligibility (can increase early frustrations due to insufficient communication)
Non-Speech Oral Used as a precursor to teaching sounds or as a supplement to teaching sounds; includes activities like blowing horns, wagging the tongue, sucking liquid through straw, etc.
Motor Training
Motor Based Approaches
Motor Based Most successful with children who have only a few phonemes in error, are more intelligible and have physical difficulty producing target phonemes
Approaches
Van Riper’s Traditional The foundation for motor approaches to articulation therapy focusing on auditory discrimination/perceptual training, phonetic placement and drill-like repetition and practice at increasingly
Approach complex motor levels until target phonemes become automatized; a bottom-up drill approach focusing on discrete skills – progression of therapy goes from simple to complex; used when
clinicians view articulation errors as resulting from motor difficulties in which the child is unable to produce the sound
 Auditory discrimination/perceptual training: teaches clients to distinguish between correct and incorrect productions of speech based on the assumption that auditory discrimination
training is a precursor to speech sound production
 Phonetic placement: used when client cannot imitate the modeled production of a phoneme; has the child produce the sound in isolation  syllables  words  phrases 
sentences  reading  comprehension
Focuses on establishing correct auditory perception of phonemes and training accurate motor production of individual phonemes with the goal being accurate production in conversation
McDonald’s Based on the assumption that the syllable is the basic unit of speech production (not the phoneme) and places heavy importance on principles of coarticulation; a bottom-up drill approach to
Sensorimotor therapy with training beginning at the syllable level; clinician should identify phonetic contexts where misarticulated sounds were produced correctly; clinician should:
Approach 1. Heighten the client’s responsiveness to connected motor productions; begin with non-error sounds in a variety of bi- and tri-syllabic contexts with differing stress patterns
2. Train correct production of misarticulated sounds; have client produce syllable in phonetic context where it was already produced correctly in varying stress and sentence patterns
3. Vary the phonetic contexts and practice target sounds
4. Generalize by facilitating transfer to other phonetic contexts and then to natural conversation
More appropriate for children with oral-motor coordination difficulties
Linguistic Approaches
Linguistic Approaches May be combined with motor approaches; assumes the child has a rule-governed system with specific patterns, but this system differs from the adult system in the child’s community; therapy
focuses on following adult patterns; primary goal is to establish phonological rules in a client’s repertoire and focuses on building and reorganizing children’s phonological representations;
target sounds are called exemplars; most linguistic treatments use minimal pairs (i.e. pairs of word differing by one feature) to show child how production affects meaning
Distinctive Features Establishes missing distinctive features or feature contrasts by teaching relevant sounds assuming that teaching a feature in the context fo a few sounds will result in generalized production of
Approach other sounds with the same features; often try to find patterns in child’s misarticulations
Contrast Approaches 1. Minimal pair contrast therapy: clinician uses pairs of words that differ by only one feature where one is the correct production and one is the incorrect production
2. Maximal contrast therapy/maximal opposition approach: selected word pairs contain maximum numbers of phonemic contrasts
Phonological Process Based on the assumption that a child’s multiple errors reflect the operation of certain phonological rules and that the problem is essentially phonemic; children’s errors are grouped and
Approach described as phonological processes
Hodson and Paden’s Phonological pattern approach designed to treat children with multiple misarticulations and highly unintelligible speech, error patterns targeted for remediation based on stimulability,
Cycles Approach intelligibility and percentage of occurrence; based on the belief that phonological acquisition is gradual, treatment should focus on introducing correct patterns and give the child limited
practice with them and then return at a later time; a cycle runs 5-16 weeks and each child usually requires 3-6 cycles; each sound error receives 1 hour of treatment per cycle before moving to
the next sound in the error pattern; each treatment session involves a review of previous session’s target words, auditory bombardment, activities involving new target words, play break, more
activities involving new target words and repeating auditory bombardment and dismissal
Core Vocabulary (Consistency) Approach
Core Vocabulary Designed for children who have inconsistent errors on the same words in the absence of CAS, having an impaired ability to phonologically program the sequence of phonemes making up a
Approach word; therapy revolves around 70 core vocabulary words selected for the child and is conducted individually, twice a week for 30 min for 8 weeks; goal is to increase intelligibility and
consistency of productions
Phonological Awareness Treatment
 Phonological The explicit awareness of sound structure of a language, or attention to the internal structure of words; viewed as a subcategory of metalinguistic awareness; difficulty with phonological
Awareness awareness has been associated with later literacy difficulties
Phonological Encourages conscious awareness of word structure and the sounds that make up a word; treatment aims to increase child’s awareness of sound structures of language; clinicians can draw
Awareness Treatment attention to written word with associated picture cue, use alliteration activities, read storybooks, make sound cards, etc.

6. ADULTS WHO SPEAK A FOREIGN LANGUAGE

Principles of Assessment
Procedures 1. Determine who in the person’s life is having trouble understanding them in English
2. Collect speech sample
3. Have 1-2 unfamiliar listeners determine intelligibility
4. List client’s speech sound errors and speech rate
5. Assess word and sentence level stress and prosody
6. Perform an oral peripheral assessment
7. Carefully assess other factors that could contribute to level of intelligibility
Principles of Accent Training
Accent Training Addresses speech differences (not disorders) in adults where English is L2; must consider what parameters are impacting intelligibility the most; select culturally and linguistically appropriate
training materials; utilize multimodal approach

Ch. 6 Fluency and it’s Disorders

1. FLUENCY AND STUTTERING
Definition and Description of Fluency
Fluent Speech Produced with relative ease (i.e. less effort and tension); flows smoothly and continuously; relatively rapid; rhythmic
Definition and Description of Stuttering
Stuttering Disorder of fluency and rhythm of speech; characterized by increased effort and halting flow
Stuttering Definition in 1. Stuttering is defined as an anticipatory, apprehensive, and hypertonic avoidance reaction; stuttering is not the same as dysfluency; begins when a child learns to avoid speaking
Terms of Personal and situations and comes to have anxiety over anticipatory speaking difficulties
Social Consequences 2. Stuttering is defined as what a person does to avoid stuttering; based on the assumption that stuttering is essentially an attempt to avoid negative consequences of normal
nonfluencies
3. Stuttering is defined as a social role conflict; the primary problem of stuttering is that the person who stutters cannot play certain social roles normally
Stuttering Definition in Stuttering is referred to in molar or global terms under the central notion that an expert judge determines the presence of stuttering
Terms of Unspecified
Behaviors
Stuttering Definition Some definitions of stuttering include only certain types of dysfluencies; some may be of clinical significance whereas others may be a part of normal speech
Limited to Certain
Types of Dysfluencies
Stuttering Definition Some experts believe that stuttering may be due to some kind of psychopathology or that it may be a neurotic reaction (i.e. anxiety, frustration, apprehension, etc.)
Based on
Psychopathology
(Neurosis)
Stuttering Definition Many experts describe stuttering in terms of the frequency and duration of dysfluencies and tend to include all types of dysfluencies in their definitions/descriptions of stuttering; based on the
Based on All Types of belief that all forms of dysfluencies disrupt fluency and create a fluency disorder if their frequency or duration is excessive
Dysfluncies
Stuttering Definition 1. Stuttering is that class of fluency failure that is a result of classically conditioned negative emotion (i.e. part-word repetition and sound prolongations) and all other dysfluencies are a
Based on Etiology result of operant conditioning
2. People who stutter are less likely than their fluent peers to have developed unilateral dominance (and are often ambidextrous), they stutter because of their lack of unilateral
cerebral dominance (based on the cerebral dominance theory)
Forms of Dysfluencies
Repetitions Saying the same element of speech more than once; three types:
1. Part-word repetition: i.e. sound or syllable repetition; repetition of a part of a word or a sound or syllable
2. Whole-word repetition: repetition of an entire word more than once; word repeated may be of single or multiple syllables
3. Phrase repetition: repetition of more than one word
Sound Prolongations Sounds produced for a duration longer than typical
Silent Prolongations An articulatory posture held for a duration longer than average but with no vocalization
Interjections Extraneous elements introduced into the speech sequence; three types:
1. Sound/syllabic interjections
2. Word interjections
3. Phrase interjections
Pauses Silent intervals in the speech sequence at inappropriate junctures or of unusually long duration
Broken Words Silent intervals within words, also known as intralexical pauses
Incomplete Sentences Often described as incomplete phrases, these are grammatically incomplete productions
Revisions Changes in wording that do not change overall meaning of an utterance
Incidence and Prevalence of Stuttering
Incidence The rate of occurrence in a specified group of people; studied by a longitudinal method; a predictive statement
Prevalence The number of individuals who currently have a particular disease or disorder; uses a cross-sectional method of study
Incidence and 1964 study by Andrew and Harris followed more than 1,000 newborns for 15 years and found that:
Prevalence in the 1. The lifetime expectancy of stuttering is about 5%, more recent studies have found as high as 8-11%  5-11% of people will stutter in their lifetime
General Population 2. Prevalence of stuttering in the use is .72-1%; is higher in early childhood
3. The risk of developing a stutter varies by age; typically beginning between the ages of 3-6; by age 5, the risk of developing a stutter is primarily over; adult onset of stuttering is rare
Prevalence and Stuttering is more common in males (3:1 - 5:1 male:female)
Gender Ratio
Familial Prevalence The frequency with which a given condition appears in successive generations of blood relatives; the prevalence of stuttering is higher among relatives than the general population
Concordance The occurrence of the same clinical condition in both members of a twin pair
Prevalence and The concordance rate of stuttering for identical twins is higher than fraternal twins and ordinary siblings
Concordance Rates in
Twins
Prevalence in Selected Higher prevalence has been found in people with developmental or intellectual disabilities and people with brain injuries; a lower prevalence has been reported for deaf and hard of hearing
Populations people
Prevalence and No irrefutable evidence has been found on causality of socioeconomic status and ethnocultural variables on stuttering
Socioeconomic/
Ethnocultural
Variables
Natural Recovery i.e. spontaneous recovery; refers to the disappearance of stuttering without professional help
Persistence Studies have concluded that stuttering persists in 11.7% of those who begin to stutter and disappears in 88.3%
Onset and Development of Stuttering
Onset of Stuttering Begins as an increase in the frequency of dysfluencies with reports of whole-word and syllable repetitions; children usually become dysfluent on function and content words; adults are typically
dysfluent on content words
Development of Increase in dysfluency can be sudden or gradual but remains highly variable for some time; stuttering that persists becomes chronic; child stutters mostly on nouns, verbs, adjectives and
Stuttering adverbs; stuttering increases when a child becomes excited; with chronic stuttering, specific word/situational fears cause increased muscular tension during dysfluent speech and anticipation of
stuttering becomes a symptom itself
Associated Motor Behaviors
Motor Behaviors i.e. secondary stutterings; vary across individuals; can become accidentally reinforced over time; ninclude:
 Excessive muscular effort
 Facial grimaces; lip pursing; rapid open/close of mouth; tongue clicking
 Hand and foot movements
 Rapid eye blinking
Associated Breathing Abnormalities
Breathing A function of stuttering, NOT a respiratory disorder; include:
Abnormalities  Attempts to speak on inhalation
 Holding breath before talking
 Attempting to speak without air supply
 Rapid and jerky breathing during speech
Negative Emotions and Avoidance Behaviors
Negative Emotions Include anxiety, apprehension, fear, frustration and embarrassment
Avoidance Avoid certain social or speaking situations, specific sounds or words
The Loci of Stuttering
Loci of Stuttering The locations in a speech sequence where stutterings are typically observed; stuttering is most likely to occur:
 With consonants rather than words
 On the first sound/syllable of a word
 On the first word in a phrase/sentence
 On the first word in a grammatical clause
 On longer words
 With less frequently used words
 On content words
Stimulus Control in Stuttering
Stimulus Control Patterns of variation to control an environmental factor under which fluency is impacted
Adaptation Effect Systematic reduction in the frequency of stuttering when a short printed passage is repeatedly read aloud; adaptation has been explained as an experimental extinction of stuttering response
due to a deconfirmation of the expectancy of stuttering, reactive inhibition, fear reduction and rehearsal affect; important characteristics include reduction in stuttering is greatest during first
few readings with magnitude of reduction progressively less on further readings; the greater the time interval the less degree of adaptation with no transfer between passages; less severe
stuttering tends to adapt more than severe stuttering
Consistency Effect The occurrence of stuttering on the same word or loci when a passage is read aloud repeatedly; based on the observation that stuttering tends to occur on the same words or loci and that
consistency remains when subjects reread a passage after weeks of interval
Adjacency Effect The occurrence of new stuttering on words that surround previously stuttered words; research has shown that words that were fluently read were eventually stuttered and that newly stuttered
words were often adjacent to previously stuttered words; adjacency effect is evident and may be horizontal or vertical in terms of newly stuttered words location in relation to previously
stuttered words
Audience Size Effect The observation that the frequency of stuttering increases with an increase in audience size; characterized by a marked decrease in stuttering with no audience, corresponding increase in
amount of stuttering with increase in number of listeners, reduced amount of stuttering with reduced hearing and greater amount of stuttering when listeners can hear the person who stutters

People Who Stutter and Their Family

Personality Variables Anxiety, level of aspiration, obsessive-compulsive behaviors, oral and anal eroticism, passive dependency, hostility and aggression, self-concept, social adjustment, body image, etc.; research
has found that amongst people who stutter there is no distinctive personality, they are not clinically maladjusted or chronically anxious, however they may have low self-esteem (may be a
result of their stuttering)
Parental Variables Unrealistic parental standards of fluency, high pressure situation, etc; research has found that parents of stutterers do not exhibit unique personality patterns, are not clinically maladjusted or
neurotic, and may have high standards of behavior (however, not clinically significant)
Theories of Stuttering
Genetic Hypothesis Based on the assumption that persons who stutter have a genetic basis for stuttering; based on observations that there is a higher familial prevalence for stutterers, there is a well-established
gender ratio and that stuttering shows higher concordance rate among monozygotic twins; studies have found a variety of chromosomal abnormalities that may be related to stuttering
Neurophysiological Based on the assumption that a stutterer’s neurophysiological speech system is deviant compared to that of typically developing peers; variations of neurophysiological hypotheses include:
Hypothesis 1. Laryngeal dysfunction hypothesis: stuttering is due to aberrant laryngeal functions and the etiology may be defective neuromotor control of the laryngeal mechanism; evidence
supporting the laryngeal dysfunction hypothesis includes slightly delayed voice onset time in stutterers. Increased laryngeal tension, aberrant muscle behavior and excessive
laryngeal muscle activity during stuttered speech
2. Cerebral dominance theory of stuttering: suggests that people who stutter may not have a dominant hemisphere to process language  inefficient neuromotor control of speech
mechanism
3. Cerebral blood flow theory: reduced cerebral blood flow in the frontal lobe
4. Abnormal brain waves
5. Reduced brain initiation: speech is slower due to reduced activity
6. Reduced central auditory function
7. Unspecified auditory feedback problems
Recent brain studies show little consistency on brain regions active during stuttered speech; many researchers believe that abnormal neuroanatomy and physiology may be associated with
developmental stuttering
Learning, Conditioning 1. Stuttering as an operant behavior: stuttering is learned based on changed consequences
and Related 2. Stuttering as speech disruption due to classically conditioned negative emotion: stuttering consists of fluency disruption due to classically conditioned negative emotion
Hypotheses 3. Stuttering as an avoidance behavior: the diagnosogenic theory states that when parents punish a child’s normal nonfluency, the child develops anticipatory, apprehensive and
hypertonic avoidance reactions that are stutters
4. Stuttering as approach-avoidance: based on the belief that a stuttering person’s hesitations and repetitions indicate a conflict between a desire to approach speaking situations and
an equally strong desire to avoid them
5. Stuttering as a reaction of tension and fragmentation: i.e. anticipatory struggle hypothesis; stuttering is essentially a response of tension and fragmentation in speech; stuttering has
many origins, most relating to severe communicative pressure leading to failure
6. Stuttering due to demands exceeding capacities: implies an interaction between a child’s inherent linguistic, cognitive, motoric, or emotional capacity for effective and fluent
 communication and environmental demands made on the child for realizing such communication
7. Stuttering as a form of psychoneurosis: stuttering is due to an underlying psychopathology, and stutterings themselves are merely symptoms of deep-seated psychological conflicts

2. ASSESSMENT AND TREATMENT OF STUTTERING

Assessment of Stuttering
Case History Should include:
 Onset and development of stuttering
 Familial prevalence of stuttering
 Prior clinical services received
 Current education/occupation
 General health history
 Language and speech development history
Assessment of Clinician should:
Frequency and Types  Collect a speech sample including spontaneous and elicited speech
of Dysfluency
Assessment of Clinician should:
Variability  Have parent/family rate different speaking situations in which stutter varies
 If possible, collect speech samples across various environments/speaking situations and compare
Assessment of Clinician should:
Associated Motor  Use clinical observation skills
Behaviors  Collect information from parents/family/client regarding behaviors
Assessment of Clinician should:
Avoidance Behaviors  Collect information regarding avoided situations from parents/family/client (include list of avoided sounds/words, hierarchy of avoided sounds/words)
 Collect information on avoidance reactions
 Note any words/sounds avoided during interaction
Assessment of Speech Clinician should:
and Articulatory Rate  Calculate speech rate (i.e. # of words/syllables spoken per min from at least three 2 min samples of continuous speech)
 Calculate articulatory rate (i.e. # of syllables produced while discounting all stutterings and pauses that exceed 2 sec)
Assessment of Clinician should:
Negative Emotional  Collect information regarding negative emotions about speech, particular speaking situations, specific audiences, etc.
Reactions  Administer Andrews and Cutlers modified S-scale, as well as the Behavior Assessment Battery to assess negative attitudes and emotions associated with speech and avoidance
behaviors
Assessment of Clinician should:
Stuttering Severity  Calculate percent dysfluency rate (higher percentage of words spoke or read stuttered, the greater the severity)
 Administer an assessment instrument such as the Stuttering Severity Instrument
Comprehensive 1. Behavior Assessment Battery for School Age Children
Assessment 2. Overall Assessment of the Speaker’s Experience of Stuttering (OASES)
Instruments
Diagnostic Criteria  A dysfluency rate that exceeds 5% of spoken words when all dysfluencies are counted
 A certain frequency of part-word repetitions, speech-sound prolongations, and broken words (at least 2% of the words spoken)
 Excessive duration of dysfluencies (1 sec or longer)
 Other criteria adopted by the clinician
Treatment of Stuttering
General Treatment 1. Achieve reduction in the amount of stuttering
Goals 2. Establish normal-sounding fluency
3. Reducing associated motor behaviors
4. Reducing avoidance
5. Counseling client and family members as needed
Psychological Methods Operate under the assumption that stuttering is a psychological disorder with underlying conscious or unconscious psychological conflicts or that stuttering and psychological problems coexist;
of Treatment treatment consists of attempting to resolve these conflicts through various methods:
 Discussing psychological problems, feelings, emotions and attitudes towards stuttering
 Discussing and resolving potential conflicts
 Reeducation about new approaches to stuttering
There is no evidence that psychological methods alone are effective in the treatment of stuttering
 Fluent Stuttering Van Riper’s fluent stuttering approach, i.e. stutter-more-frequently approach; based on the belief that modifying the severity and visible abnormality of stuttering is the most realistic goal;
Method involves the following steps:
1. Teaching stuttering identification
2. Desensitizing the client to his or her stuttering
3. Modifying stuttering (i.e. facing speech without avoidance, using cancellations, pull-outs and preparatory sets)
4. Stabilizing the treatment gains
5. Counseling the client
Fluency Shaping Model i.e. speak-more-fluently approach; goal is to establish normal fluency/stutter free speech through various treatment targets and procedures including:
 Teaching airflow management
 Teaching gentle, soft, relaxed and easy onset of phonation, beginning after the initiation of exhalation
 Teaching a reduced rate of speech through syllable prolongation with no pauses with continuous phonation
Camperdown Program is an abbreviated fluency shaping program including prolonged speech; beginning with a slow rate of speech as seen in a video and gradually progressing to quicker rates
Fluency Reinforcement Positively reinforcing fluent speech in naturalistic conversational contexts; more effective with younger children, however becomes increasingly successful with older children and adults by
Method incorporating slow rate of speech; ex: Lindcombe Program
Masking and Delayed Based on the observation that when a stuttering person hears his or her own speech with a fraction of a second’s delay, most of the dysfluencies are reduced and that auditory masking also
Auditory Feedback improves fluency; delayed auditory feedback has the capacity to induce a slower rate of speech
Techniques
Direct Stuttering Aim to reduce stuttering directly, without teaching specific fluency skills of modifying stuttering into less abnormal forms in order to establish more natural-sounding fluency; direct stuttering
Reduction Methods reduction methods include:
1. Pause-and-talk (time-out): the person who stutters is taught to pause after each dysfluency and then resume talking
2. Response cost: for every instance of stuttering, the clinician takes away a token, which is awarded for every fluent production; a clinician can vary token procedures as they see fit
Special Considerations  Parent counseling and training
for Preschool and Early  Child counseling (preparation for negative social situations)
School-Age Children  Selecting effective reinforcers
 Simple fluency reinforcement and naturalistic play – child should enjoy therapy
Special Considerations  Teaching self-monitoring skills
for Older Students and  Fluency shaping and pause-and-talk methods
Adolescents  Fluency skills
 Counseling (addressing fear and avoidance)
 Teacher and parent training
Special Considerations  Teaching self-monitoring skills
for Adults  Client counseling
 Fluency shaping and pause-and-talk
 Spousal counseling and training
Generalizations, Clinician should follow these steps:
Maintenance and 1. When fluency is at targeted level in 3-5 clinical sessions, clinician can invite unfamiliar people into sessions so client can engage in conversation
Working with Families 2. Involve parents and family in training and treatment
3. Take client out of clinic room and into more natural settings
4. Teach self-monitoring skills
5. Periodic follow ups to monitor progress and maintenance of skills
Pharmacological Tranquilizers and sedatives may reduce severity of stuttering but may have large side effects
Treatment

3. NEUROGENIC STUTTERING
Definition and Etiology of Neurogenic Stuttering
Neurogenic Stuttering A form of fluency disorder associated with documented neuropathology; neuropathological conditions associated with apraxia of speech, dysarthria or aphasia can cause neurogenic stuttering
Etiologic Factors of 1. Cerebral vascular disorders that cause strokes and head trauma
Neurologic Stuttering 2. Extrapyramidal diseases
3. Drug toxicity
Description of Neurogenic Stuttering
Characteristics of  Evidence of neuropathology and neurologic symptoms that are consistent with the diagnosed neurological disease
Neurogenic Stuttering  Adult onset of stuttering, often in older people with documented neuropathology
 A generally increased rate of dysfluencies, common to stuttering of early onset and neurogenic stuttering
 Repetition of medial and final syllables in words, dysfluent production of function words and imitated speech, rapid speech rate
 No/minimal adaptation effect, reduction in stuttering upon repeated reading, minimal variability in stuttering frequency across environments/situations, minimal effects of delayed

auditory feedback, no obvious anxiety
Assessment and Treatment of Neurogenic Stuttering
Assessment Procedure 1. Collect case history
2. Assessment of potentially coexisting aphasia, apraxia, dysarthria and dementia
3. Assessment of stuttering (including differential evaluation to rule out childhood onset)
Treatment Treatment is done in the context of other speech or language disorders that coexist; most clinicians handle treatment systematically and on an individualized basis; no efficacy studies on the
treatment of neurogenic stuttering have been published

4. CLUTTERING
Definition and Description of Cluttering
Cluttering A disorder of fluency characterized by reduced speech intelligibility, rapid and irregular rate, imprecise articulation, dysfluencies, disorganized language, poor prosody and inefficient
management of discourse; often coexists with stuttering
Characteristics of  Rapid but disordered articulation  unintelligible speech
Cluttering  Rate variations
 Impaired prosodic features with frequent pauses
 Impaired fluency (often word and phrase repetitions, interjections and revisions)
 Omission and compression of sounds and syllables
 Jerky/stumbling rhythm
 Monotonous tone
 Spoonerisms
 Disorganized language production and thought process
 Lack of concern/reduced awareness of difficulties  less anxiety
Etiology of Cluttering Cause of cluttering is unknown
Assessment and Treatment of Cluttering
Assessment of Assessed much like stuttering of early childhood onset, with an emphasis on its special features; clinicians may administer Cluttering Severity Instrument
Cluttering
Treatment of There is little/no controlled treatment research on cluttering; clinicians generally treat cluttering in a similar manner to stuttering, often focusing on reducing rate of speech and increasing
Cluttering child’s awareness of deficits

Ch. 7 Voice and it’s Disorders

1. VOCAL ANATOMY AND PHYSIOLOGY
The Larynx
Basic Principles The larynx is a biological valve located at the top of the trachea and protects the airway from food, liquids and other particles; the larynx houses the vocal folds (which are layered structures
composed of the epithelium, thyroarytenoid muscle and lamina propria), the ventricular/false vocal folds, the aryepiglottic folds, cranial nerve VII, superior laryngeal nerve and recurrent
laryngeal nerve
Cover Body Theory of The epithelium, the superficial layer of the lamina propria and much of the intermediate layer of the lamina propria vibrate as a “cover” on a relatively stationary “body”
Phonation
Mucousal Wave Action The movement of the mucous membrane of the vocal folds during vibration
Key Structures and 1. Hyoid bone: the larynx is suspended from the hyoid bone, where many extrinsic laryngeal muscles are attached
Cartilages 2. Epiglottis: a leaf-shaped cartilage attached to the hyoid bone that protects the trachea by closing down interiorly and posteriorly over the laryngeal area to direct food towards the
esophagus
3. Thyroid cartilage: the largest of the laryngeal cartilages; protects other laryngeal structures; composed of two lamina/plates of cartilage
4. Cricoid cartilage: sometimes called the uppermost tracheal ring; completely surrounds the trachea
5. Arytenoid cartilage: shaped like pyramids and positioned on the supraposterior surface of the cricoid cartilage; vocal processes are the most anterior angle of the base of the
arytenoids; the true vocal folds attach at the vocal process
6. Corniculate cartilage: small and cone-shaped and sit on the apex of the arytenoids; play a minor role in vocalization
7. Cuneiform cartilages: tiny, cone-shaped cartilage pieces under the mucous membrane that convers the aryepiglottic folds; play a minor role in phonation
8. Intrinsic laryngeal muscles: have two points of attachment within the larynx; primarily responsible for controlling vocalization; primarily adductors
a. Thyroarytenoids
b. Cricoarytenoids
c. Posterior cricoarytenoids (abductor)
d. Lateral cricoarytenoid
 e. Transverse arytenoid
f. Oblique arytenoid
9. Extrinsic laryngeal muscles: has one attachment within the larynx and one attachment outside the larynx; all extrinsic muscles are attached to the hyoid bone; give the larynx fixed
support during elevation and depression;
a. Infrahyoid muscles/depressors:
i. Thyrohyoids
ii. Omohyoids
iii. Sternothyroids
iv. Sternohyoids
b. Suprahyoid muscles/elevators:
i. Digastrics
ii. Geniohyoids
iii. Mylohyoids
iv. Stylohyoids
v. Genioglossus
vi. Hyoglossus
Voice Changes Through the Lifespan
Mean Fundamental There is a gradual decline in MFF from birth on (i.e. voices get deeper); difference between MFF in boys vs. girls becomes apparent during adolescence
Frequency (MFF)  MFF of 7-8 year old children range from 281 to 297 Hz
 MFF of 10-11 year old children ranges from 238 to 270 Hz
 MFF of 19 year old females is 217 Hz
 MFF of 19 year old male is 117 Hz
Maximum Phonation Refers to the client’s ability to sustain “ah”
Time (MPT)  MPT of 3-4 year old ranges from 7.50 to 8.95 seconds
 MPT of 5-12 year old ranges from 14.97 to 17.74 seconds
Changes Resulting  Girls voices lower 3-4 semitones
from Puberty  Boys voices lower as much as an octave, may show pitch breaks, huskiness and hoarseness due to laryngeal growth
Adulthood  Men have MFF of 100-150 Hz, typical fundamental frequency is 125 Hz
 Women have MFF of 180-250 Hz, typical fundamental frequency is 225 Hz
 Adults 18-39 years old have an MPT ranging from 20.90 to 24.60 seconds
The Geriatric Voice  Females 70-94 years old have an MFF of 201 Hz
 Males 70-89 years old have an MFF ranging from 132 to 146 Hz
 Adults aged 66-93 have an MPT ranging from 14.20 to 18.10 seconds
 Age related changes to the larynx include hardening of the cartilages, degeneration and atrophy of the intrinsic muscles, degeneration of glands in laryngeal mucosa, degenerative
changes in the lamina propria, deterioration of the cricoarytenoid joint and degenerative changes in the conus elasticus  presbyphonia (i.e. age-related voice disorder characterized
by perceptual changes in quality, range, loudness and pitch)

2. VOCAL PITCH, VOLUME AND QUALITY

Pitch
Pitch The perceptual correlate of frequency; based on frequency at which vocal folds vibrate; determined by mass, tension and elasticity of the vocal folds (thinner more tense vocal folds  higher
pitch and thicker less tense vocal folds  lower pitch)
Fundamental An individual’s habitual/typical pitch
Frequency
Frequency i.e. jitter; variations in the vocal frequency that are often heard in dysphonic patients; may be more present in individuals with voice disorders
Perturbation
Volume
Volume The perceptual correlate of intensity; determined by the intensity of sound signal (the greater the signal  the greater the perceived loudness)
Sound A disturbance in air particles taking place in the form of waves that move forward or backward in a medium (i.e. air)
Amplitude The extent of movement created by a sound
Amplitude i.e. shimmer; cycle-to-cycle variation of vocal intensity; typically seen in patients who have difficulty with regulatory of vocal fold vibration; can be used as early detection of vocal pathology
Perturbation
Quality
Quality The perceptual correlate of complexity; refers to the physical complexity of the laryngeal tone, which is modified by resonating cavities; determination of vocal quality is subjective
Hoarseness A combination of breathiness and harshness resulting from irregular vocal fold vibrations; varying fundamental frequency due to aperiodic vibration; sound breathy, low pitched and husky; may
 exhibit pitch breaks and excessive throat clearing
Harshness Described as rough, unpleasant and “gravelly” sounding; associated with excessive muscular tension and effort; vocal folds are adducted too tightly and air is released abruptly
Strain-Strangle Phonation is effortful and patient sounds as if they are “squeezing” the voice at the glottal level; initiating and sustaining phonation is difficult; talking fatigues and speakers experience tension
during speech
Breathiness Results from vocal folds being slightly open, or not firmly approximated during phonation; air escapes through the glottis and adds noise to the sound produced by the vocal folds; may be due
to organic/physical or nonorganic/functional causes; patients feel like they are running out of air; often perceived as soft with little variation in volume; speakers have restricted vocal range
Glottal Fry i.e. vocal fry; heard when the vocal folds vibrate very slowly and result in sound occurring in slow but discrete bursts and is of extremely low pitch; sounds “crackly”; may be the vibratory cycle
used near the bottom of our typical pitch; typically produced near the end of a long phrase or sentence when air flow rate and subglottal air pressure are both low and lung volume is less
Diplophonia i.e. double voice; occurs when a listener can simultaneously perceive two distinct pitches during phonation; usually occurs when the vocal folds vibrate at different frequencies due to differing
degrees of mass or tension; clients with unilateral polyp might sound diplophonic
Stridency Sounds shrill, unpleasant, high pitched and “tinny”; caused by hypertonicity or tension of the pharyngeal constrictors and elevation of the larynx

3. EVALUATION OF VOICE DISORDERS

Case History
Case History Clinician should:
 Obtain information about onset, development, duration, variability and causes of voice problems
 Obtain information about any related symptoms or problems
 Identify possible contributing factors
 Gather relevant information regarding past treatment
 Obtain information regarding daily vocal use
 Obtain information on culturally appropriate information if applicable
Team Oriented Approach
Medical Team Consist of a general practitioner, neurologist, otolaryngologist, radiologist, orthodontist, social worker, psychiatrist/psychologist, pulmonary specialist and gastroenterologist
Educational Team Consists of classroom teacher, school nurse, school psychologist and school counselor
Team for Professional Consists of voice scientists, psychologists and vocal pedagogy teachers (i.e. singing and vocal coaches)
Vocalists
Instrumental Evaluation
Indirect Laryngoscopy The specialist uses a bright light source and small mirror angled on a long, slender handle to lift the velum and press gently against the patient’s posterior pharyngeal wall area and maneuvers
(Mirror Laryngoscopy) the mirror to view the laryngeal structures during phonation and quiet respiration
Direct Laryngoscopy Performed by a surgeon while patient is under direct anesthesia; laryngoscope is introduced through the mouth into pharynx and positioned above the vocal folds; vocal function cannot be
determined; obtain a direct view of the larynx; valuable if biopsy is necessary
Flexible Fiber-Optic Uses a thin, flexible tube containing a lens and fiber-optic light bundles; tube is inserted through the patient’s nasal passage, passes it over the velum and maneuvers it into position above the
Laryngoscopy larynx; patient is able to speak during procedure so specialist can obtain a prolonged view of the vocal mechanism and photograph rapid vocal fold movement
Endoscopy Endoscopes can be rigid (introduced orally) or flexible (introduced nasally); uses a light at the tip of the scope to illuminate the structures of the larynx; with flexible endoscope the
velopharyngeal mechanism can be viewed; useful in studying anatomy and physiology of the larynx
Acoustic Analysis Results in a spectrogram reflecting the resonant characteristics of the vocal tract and harmonic nature of the glottal sound source; uses technology to produce waveforms displaying the
amplitude and frequency in a spectrogram in real time
Videostroboscopy Can be helpful in differentiating between functional and organic voice problems and to detect laryngeal neoplasms (i.e. tumors); specialist uses a flexible/rigid fiber-optic laryngoscope and a
pulsing light permitting the optical illusion of slow-motion viewing of the vocal folds during a variety of tasks; specialist places a microphone on the patients neck along the thyroid cartilage to
record the voice signal; yields information on the periodicity of vocal fold vibrations, vocal fold amplitude, glottal closure, presence and adequacy of the mucosal wave and the possible
presence of lesions/neoplasms
Electroglottography Yields an indirect measure of vocal fold closure patterns; noninvasive procedure where surface electrodes are placed on both sides of the thyroid cartilage and high-frequency electric current is
(EGG) passed between electrodes during phonation; results in formation of glottal wave to observe vocal fold vibration and detect breathy and abrupt glottal onset of phonation
Electromyography An invasive procedure that directly measures laryngeal function to study the pattern of electrical activity of the vocal folds and view muscle activity patterns; a needle is inserted into the
(EMG) patient’s peripheral laryngeal muscles and resulting electrical signals are assessed; specialist looks for reduced/increased speed of muscle activation, extraneous bursts of muscle activity or
onset/termination of muscle activity; useful for determining vocal fold pathology
Videokymography A high-speed medical imaging method used to visualize human vocal fold vibration dynamics using a modified video camera to work in standard and high-speed modes; allows visualization of
left-right vocal fold asymmetries, propagation of mucosal waves and movement of the upper and lower margins of the vocal folds
Aerodynamic Refer to the airflows, air volumes and average air pressures produced as a part of peripheral mechanics of the respiratory, laryngeal and supralaryngeal airways; use aerodynamic measures to
Measurements evaluate dysphonia, monitor voice changes and treatment progress and differentiate between laryngeal and respiratory issues; parameters include tidal volume (amount of air inhaled and
exhaled during a normal breathing cycle), vital capacity (volume of air the patient can exhale after maximum inhalation) and total lung capacity (total volume of air in the lungs); can be collected
using wet/dry spirometers, manometric devices and plethysmographs
Pitch Measurements Can be measured using Visi-Pitch; typically assesses dynamic range, intensity and frequency variability, pitch and loudness and other parameters
 Perceptual Evaluation
Perceptual Voice Clinician makes subjective judgments of many vocal parameters including pitch, volume, vocal quality, resonance, respiration and ability to sustain phonation; many rating scales are available;
Evaluation the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) is a standardized approach to evaluating and documenting auditory-perceptual judgments of voice quality using a normal rating
scale to evaluate various vocal parameters and clinicians written description
Pitch assessment Clinicians should make judgments on:
1. Patient’s habitual/typical/conversational pitch
2. Whether the patient is using optimal pitch
3. Whether the pitch is appropriate to the client’s age and gender
4. Whether the patient Is monopitched
Loudness Assessment Clinicians should make judgments on:
1. Parameters such as harshness, hoarseness, breathiness and vocal tension
2. Whether the client’s loudness is appropriate to daily situations
3. Whether the client’s voice is too soft or loud due to possible physical factors
Resonance Assessment Clinicians should make judgments on the presence of:
1. Hyponasality (absent nasal resonance on nasal sounds)
2. Hypernasality (too much nasal resonance on non-nasal sounds)
Respiration Clinician should look for various types of breathing:
Assessment 1. Clavicular breathing (elevation of shoulders on inhale with associated strain and tension)
2. Diaphragmatic-abdominal breathing (appropriate and efficient breathing using the abdominal region and lower thoracic cavity with little to no chest or shoulder movement)
3. Thoracic breathing (exhibits characteristics of clavicular and diaphragmatic-abdominal breathing with no abdominal or upper thoracic expansion upon inhalation)
Phonation Assessment Clinicians should use various measures:
1. Maximum phonation time (patient’s ability to sustain phonation)
2. s/z ratio (determines the presence of laryngeal pathology by producing the phonemes /s/ and /z/; a ratio more than 1.4 is indicative of a pathology)

4. DISORDERS OF RESONANCE AND THEIR TREATMENT

Resonance The modification of sound by the structures through which the sound passes
Medical Intervention Must identify etiology of resonance disorder as organic or functional; medical treatment can take place in the form of surgery, prostheses or both
Hypernasality
Hypernasality Results when the velopharyngeal mechanism does not close the opening to the nasal passage during the production of non-nasal sounds causing the air and sound to escape through the nose
adding unnecessary nasal resonance to non-nasal speech sounds; hypernasal patients often speak with decreased or insufficient intraoral breath pressure impacting the production of fricatives,
affricates and plosives
Etiology of Can occur as a result of functional (i.e. bad habits) or organic (i.e. cleft palate, submucous cleft, velopharyngeal inadequacy/insufficiency-VPI) factors
Hypernasality
Velopharyngeal The velopharyngeal mechanism is inadequate to achieve closure causing nasal cavities to remain unsealed from the oral cavity; can be caused by decreased muscle mass of the velum,
Inadequacy/ adenoidectomy/tonsillectomy or paresis/paralysis of the velum)
Insufficiency (VPI)
Assessment of Can include subjective, perceptual judgments or use of instrumentation (i.e. Nasometer)
Hypernasality
Treatment of  Biofeedback giving patients visual displays of oral and nasal resonance
Hypernasality  Using nasometer which allows patients to receive visual feedback including the target level of nasalance (i.e. oral-nasal ration) and the amount of nasalance the patient is producing
 Treatment techniques include using visual feedback, ear training, increase mouth nopening, increase loudness, improving articulation, changing speaking rate, decreasing pitch, etc.
Hyponasality
Hyponasality i.e. denasality; a lack of appropriate nasal resonance on nasal sounds; patients often make oral/nasal substitutions (b/m, d/n, g/ng)
Etiology of Can be temporary as a result of cold/illness; can occur as a result of obstruction in the nasal cavity (i..e nasal polyps, enlarged adenoids/tonsils, deviated septum, etc.)
Hyponasality
Assessment of Can include subjective, perceptual judgments or use of instrumentation (i.e. Nasometer)
Hyponasality
Treatment of  Biofeedback giving patients visual displays of oral and nasal resonance
Hyponasality  Using nasometer which allows patients to receive visual feedback including the target level of nasalance (i.e. oral-nasal ration) and the amount of nasalance the patient is producing
 Treatment techniques include focusing/directing tone into fasicial mask (i.e. the area above the maxillary sinuses), utilizing nasal-glide stimulation and visual aids
Assimilative Nasality
Assimilative Nasality Occurs when the sound from a nasal consonant carries over to adjacent vowels; velar openings begin too soon and last too long
Etiology of Assimilative Can be functional or organic
Nasality
 Assessment of Differs based on etiology
Assimilative Nasality
Cul-de-Sac Resonance
Cul-de-Sac Resonance Produced by backward retraction of the tongue/the tongue carried too far posteriorly in the oral cavity causing a partial closure in the back of the oral cavity and an opening at the front 
distorted voice and resonance  sounds muffled or hollow
Etiology of Cul-de-Sac Deaf people and those with neurological disorders often have difficulty making proper tongue adjustments resulting in cul-de-sac resonance; may also be present in people with no organic
Resonance deviations who have the habit of carrying the tongue too far back into the oral cavity

5. DISORDERS OF PHONATION AND THEIR TREATMENT

Carcinoma and Laryngectomy
Etiology of Laryngeal Variables contributing to laryngeal cancer are alcohol, tobacco, exposure to environmental toxins, gastroesophageal reflux, etc.; more frequent in men; early warning signs include hoarseness,
Cancer difficulty swallowing, sore throat, ear pain, apparent lump in throat/neck
Laryngeal Tumors Can be supraglottic (above the vocal folds), glottic (at the level of the vocal folds) or subglottic (below the vocal folds); tumors can metastasize (cancer spreads to other regions of the body);
lymph nodes may or may not be involved
Medical Treatment Depends on the site, type and extent of cancer; classified based on T (primary site of the tumor), N (involvement of the lymph nodes), and M (if cancer has metastasized) ; three basic types of
medical treatment:
1. Laryngectomy: surgery to remove the larynx; can be total or hemilaryngecotmy (i.e. partial)
2. Chemotherapy: may be used alone or in conjunction with other treatment methods
3. Radiation therapy: may be used alone or in conjuction with other treatment mthods
Issues in Rehabilitation Team approach is essential, including the surgeon, SLP, social worker, nurse, vocational counselor, nutritionist and a counselor for the patient and their family
of the Laryngectomee
Types of Alyaryngeal Following a laryngectomy normal voicing is not possible and breathing is different (patients typically breathe through a stoma); voicing can be accomplished by:
Speech 1. Using external devices (ex: artificial larynx/electrolarynx: a mechanical handheld device that generates sound when pressed to the neck); esophageal speech (patient speaks on
burps/belches with a pharyngeoesophageal segment as the vibratory source; can be used via interjection model or inhalation method)
2. Having surgical modifications/implanted devices in the laryngeal area (ex: Blom-Singer tracheoesophageal puncture the trachea and esophagus are connected with a shunt to
prevent the passage of fluid into the trachea)
Physical Based Disorders of Phonation
Granuloma A localized, inflammatory, vascular lesion usually composed of granular tissue in a firm rounded sac; frequently develop on the vocal process of the arytenoid cartilages in the posterior
laryngeal area as a result of vocal abuse, intubation, laryngeal injury and gastroesophageal reflux; patients sound breathy and hoarse and feel the need to frequently clear their throat
Hemangioma Localized inflammatory vascular lesion that is soft, pliable and filled with blood; occur in the posterior glottal area; usually a result of intubation or hyperacidity due to gastroesophageal reflex;
usually treated with surgery and voice therapy
Leukoplakia Benign growths of thick, whitish patches on the surface membrane of the mucosa; usually a result of tissue irritation; considered precancerous; patients may sound hoarse, low-pitched, breathy
and soft in volume; usually treated with surgery and voice therapy and by eliminating tissue irritants
Hyperkeratosis Rough, pinkish lesions appearing in the oral cavity larynx or pharynx; may involve epithelial cover of the folds and the superficial layer of the lamina propria; considered precancerous; usually a
result of tissue irritation; patients present mild-severely hoarse/harsh with reduced loudness and pitch; treatment involves eliminating tissue irritants and surgery and voice therapy
Laryngomalacia i.e. congenital laryngeal stridor/laryngomalacia; involves soft, “floppy” laryngeal cartilages (especially in the epiglottis); results in stridor or rough, breathy noise upon inhalation; usually resolves
itself by age 2-3  no treatment required, if condition persists intervention is required to address respiration difficulties
Subglottal Stenosis The narrowing of the subglottic space; can be acquired (a result of prolonged intubation) or congenital (a result of arrested development of the conus elasticus or interruption of the cricoid
cartilage during embryological development); in moderately severe cases, children will often display exercise intolerance and stridor which may require surgical intervention
Papilloma i.e. juvenile papillomas; wart-like growths caused by the human papilloma virus that are pink, white or both and can be found anywhere in the airway; tend to occur primarily in children; usually
associated with hoarseness, breathiness and low pitch; usually treated through (multiple) surgical interventions (i.e. cup forceps surgery, interferon medication and CO2 laser surgery) 
repeated surgery can result in scar tissue which may impact vocal quality
Laryngeal Trauma Refers to any kind of injury to the larynx; more apparent in children than adults; may be the result of burns, motor vehicle accidents, sports-related accidents, attempted strangulations and
gunshot wounds or attempts to swallow sharp objects); usually undergo surgery in attempt to repair laryngeal structure
Laryngeal Web A membrane that grows across the anterior portion of the glottis; may be congenital or acquired; for children with congenital web, treated via surgery and immediate placement of
tracheostomy; for adults, treatment involves surgery and temporary placement of laryngeal keel between the vocal folds to prevent them from growing back together
Paradoxical Vocal Fold i.e. laryngeal dyskinesia/episodic paroxysmal laryngospasm (EPL); inappropriate closure or adduction of true vocal folds during inhalation, exhalation or both; may display stridor or dysphonia;
Motion Disorder treatment may involve surgery and placement of tracheostomy; may have psychological or physiological causes; symptoms vary; treatment may include a combination of psychological, medical
(PVFM) and behavioral approaches
Gastroesophageal Occurs when gastric contents spontaneously empty into the esophagus when the person has not vomited/belched; patient may experience heartburn, acid indigestion, sore throat and
Reflux Disease (GERD) hoarseness; may cause contact ulcers or other pathological vocal fold changes; treatment may include use of antacids, propping up the head at night, use of prescription meds, not exercising
after eating, changing dietary habits, etc.; treatment usually includes behavioral, medical, surgical intervention and voice therapy
Paralysis and Ankylosis Vocal folds can be paralyzed when their nerve supply is cut off as a result of laryngeal injury/trauma, neurological diseases, malignant diseases, intubation trauma, stroke, vagus nerve deficits,
etc.; may result in dysphagia (due to inefficient cough), breathiness, and reduced pitch and volume; paralysis can be unilateral (speaker may sound relatively typical or exhibit aphonia) or
 bilateral (causes aphonia); ankyloses (i.e. stiffening of joints) causes restricted movement of arytenoids and can be caused by cancer, arthritis, etc. and results in inefficient vocal fold closure;
treatment may include surgical intervention by creating a bulge in the paralyzed fold to create contact via Teflon, collagen, gelfoam, autologous fat, etc. or placing an implant (thyroplasty type I)
or nerve-muscle pedicle reinnervation; vocal therapy may implement treatment such as elevating pitch, increasing loudness and breath support, head turning, hard glottal attacks, etc.
Spasmodic Dysphonia A focal laryngeal dystonia; traditionally considered psychologically based with new research indicating some neurogenic causes with possible emotional side effects caused by abnormal
functioning of the basal ganglia; two types of spasmodic dysphonia:
1. Abductor spasmodic dysphonia: caused by intermittent, involuntary, fleeting vocal fold abduction when the patient tries to phonate; results in decreased loudness and intermittent
aphonia with breathy or whispered speech; treatment includes Botox injections, speech therapy and pharmacological intervention
2. Adductor spasmodic dysphonia: characterized by overpressure due to prolonged over adduction or tight closure of the vocal folds; voice may sound choked and strangled; treatment
interventions include CO2 laser surgery, recurrent laryngeal nerve resection, botox injections, use of AAC devices and voice therapy
Neurological Based Disorders of Phonation
Multiple Sclerosis (MS) Characterized by progressive and diffuse demyelination of white matter with corresponding perseveration of axons at the brainstem, cerebellum and spinal cord; patients may have impaired
prosody, pitch and loudness control, harshness, breathiness, hypernasality, articulation breakdown, etc.; treatment includes pharamological intervention
Myasthenia Gravis Neuromuscular autoimmune disease producing fatigue and muscle weakness with a decreased amount of acetylcholine at myoneuronal junctions; patients often sound hypernasal, breathy,
hoarse, and soft in volume; dysphagia may also be present; often treated pharmacologically
Amyotrophic Lateral Progressive, fatal disease involving degeneration of the upper and lower motor neuron systems; patients often sound breathy, low pitched and monotonous and have poor respiratory control;
Sclerosis (ALS) treatment usually involves use of AAC device
Parkinson’s Disease Progressive neurological disease caused by lack of dopamine (a neurotransmitter) in the substantia nigra of the basal ganglia; patients often sound breathy, low pitched and monotonous;
(PD) treatment includes pharmacological intervention and voice therapy (ex: LSVT) to increase respiratory efforts over time
Treatment Techniques  Improve articulation through exaggerating consonants and slowing rate of speech
for Neurological  Improving resonance through increasing mouth opening, decreasing posterior tongue tension and improving velopharyngeal closure
Disorders  Improving prosody
 Improving respiration through relaxation, increasing efficiency of breathing and teaching the patient to breath as often as necessary
 Improving vocal fold approximation
Abuse-Based Disorders of Phonation
Vocally Abusive Abusive behaviors include excessive shouting, screaming, cheering, excessive talking, coughing, hard glottal attacks, throat clearing, strained and explosive vocalizations, excessive laughing and
Practices crying, speaking with inappropriate pitch/loudness, speaking in noisy environments, etc.
Vocal Nodules Small nodes that develop on the vocal folds and protrude from surrounding cells; begin red/pink and develop to be white/gray as they become fibrous; can be unilateral or bilateral; typically
appear at the junction of the anterior and middle third portion of the folds; develop as a result of prolonged vocal abuse; patient may sound breathy, hoarse or have lower pitch (due to
increased mass of vocal folds); treatment may include vocal rest, voice therapy and surgery
Polyps Masses that grow and bulge out from surrounding tissue that are filled with fluid or have vascular tissue; tend to be unilateral; patients may sound breathy and hoarse and have diplophonia
(“double voice”); treatment may include vocal rest/change in habits; two types:
1. Sessile polyps: have broad base on the vocal fold
2. Pedunculated polyps: attached to the vocal folds by a stalk
Contact Ulcers Sores or craterlike areas of ulcerated, granulated tissue that develop (usually bilaterally) along the posterior third of the glottal margin; may be caused by vocal abuse, gastroesophageal reflux
or intubation/trauma; patients may complain of vocal fatigue and pain and frequently sound hoarse and frequently throat clear; treatment may include pharmacological intervention and voice
therapy
Vocal Fold Thickening Caused by prolonged use of vocally abusive behaviors (i.e. throat clearing, screaming, etc.); results in breathy voice with lowered pitch; may be a precursor to nodules or polyps; treatment
includes vocal rest
Traumatic Laryngitis Created when the patient engages in vocally abusive behaviors that irritate the vocal folds which get swollen causing the voice to be hoarse with low-pitch and pitch breaks; treatment includes
vocal rest and voice therapy
Treatment for Abuse- Overall goal is to achieve the best sounding voice possible; treatment usually involves voice therapy, medication, surgery, vocal rest, change in habits, etc.; specific treatment techniques
Based Disorders include:
1. Open-mouth approach
2. Speak with appropriate pitch and volume
3. Reduce frequency of coughing and throat clearing
4. Reduce tension during speech
5. Chant-talk method
6. Digital manipulation of the larynx
7. Respiration training
8. Encourage vocal rest
9. Easy onset
10. Yawn-sign method
Disorders of Loudness and Pitch
Disorders of Loudness May be a result of other disorders (i.e. vocal nodules, polyps, etc.); loudness varies on an individualized basis; treatment may include respiration training and use of auditory/visual feedback
 Disorders of Pitch Typically consists of individual’s pitch not matching their age/sex/stature/etc. (Ex: mutational falsetto/puberphonia where a young man has an unusually high pitch despite normal growth and
maturation of the larynx); can be a result of psychological factors, physical factors (i.e. puberty/hormones) or both; treatment may include utilizing relaxation, yawn-sigh, open-mouth approach
and digital manipulation to reduce tension and lower pitch, coughing and glottal fry, speech range masking, use of auditory/visual feedback and possibly psychological counseling
Psychogenic Voice Disorders
Psychogenic Voice i.e. functional voice disorders; occur when the voice is abnormal in the presence of normal laryngeal structure (ex: hysterical/conversion aphonia: usually no evidence of a structural pathology
Disorders and often experience voice loss following an emotionally traumatic event)
Treatment of Treatment may include psychological treatment or behavior therapy (i.e. using masking, relaxation techniques, encouraging coughing/throat clearing, inhalation phonation, yawn-sigh approach,
Psychogenic Voice producing speech and engaging in conversation)
Disorders
Gender Issues and the Voice
Gender and Voice Usually conducted for individuals undergoing gender reassignment to achieve appropriate pitch for gender; treatment includes hormonal/testosterone therapy, surgical intervention, utilizing
Therapy pitch inflections, counseling, etc.

Ch. 8 Neurologically Based Communicative Disorders and Dysphagia

1. APHASIA
Foundational Concepts
Strokes Two types:
1. Ischemic strokes: caused by blocked/interrupted blood supply to the brain via thrombosis (i.e. collection of blood materials blocking blood flow) or embolism (i.e. traveling mass of
arterial debris/clump of tissue from a tumor that gets lodged in an artery and blocks blood flow)
2. hemorrhagic strokes: caused by bleeding in the brain due to ruptured blood vessels which may be intracranial (i.e. within the brain) or extracranial (i.e. within the meninges 
subarachnoid, subdural and epidural varieties of strokes)
Definition and Classification of Aphasia
Aphasia Definition A neurologically based language disorder (i.e. loss of language) caused by various types of neuropathologies (most commonly stroke); may or may not be accompanied by alexia, agraphia or
agnosia; treatment is concerned with verbal expression, auditory comprehension, reading, writing and nonverbal modes of communication
Classification of Classified as fluent, nonfluent or subcortical
Aphasia
Nonfluent Aphasias
Nonfluent Aphasia Characterized by limited, agrammatic, effortful, halting, and slow speech with impaired prosody
Broca’s Aphasia Nonfluent aphasia associated with lesions in Broca’s area/the posterior inferior frontal gyrus of the left hemisphere; patients may experience apraxia/dysarthria and may have right-sided
paralysis/weakness; speech characterized by:
 Nonfluent/effortful/slow/halting/uneven speech
 Limited word output, short phrases/sentences
 isarticulated/distorted speech sounds
 Agrammatic/telegraphic speech
 Impaired repetition and naming
 Poor reading/reading comprehension and writing
 Monotonous speech
Transcortical Motor Nonfluent aphasia caused by lesions in the anterior superior frontal lobe of the language-dominant hemisphere, often above/below Broca’s area (which is not affected); tend to experience
Aphasia (TMA) rigidity of upper extremities, slow/absent movement, buccofacial apraxia and R hemiparesis; speech characterized by:
 Absent/reduced spontaneous speech
 Nonfluent/paraphasic/agrammatic/telegraphic speech
 Intact repetition skills
 Echolalia/perseveration
 Limited word fluency
 Use of simple and imprecise syntactic structures
 Attempts to initiate speech associated with motor movements
 Generally good comprehension
 Slow and difficult reading/writing
Mixed Transcortical Nonfluent aphasia caused by lesions in the watershed area or the arterial border zone of the brain; rare; spares Brocas and Wernickes areas; may experience upper motor neuron paralysis, limb
Aphasia (MTA) weakness and visual field deficits; speech characterized by:
 Limited spontaneous speech
 Automatic/unintentional/involuntary nature of communication
 Severe echolalia
 Severely impaired fluency
 Severely impaired comprehension
 Difficulty naming
 Mostly unimpaired automatic speech
 Severely impaired reading and writing
Global Aphasia Nonfluent aphasia caused by lesions affecting all language areas (i.e. the perisylvian areas); may experience some kind of apraxia or R sided weakness/paralysis; most severe type of aphasia:
speech characterized by:
 Profoundly impaired language skills
 Greatly reduced fluency and speech output
 Impaired repetition, naming and comprehension
 Perseveration
 Impaired reading and writing

Fluent Aphasias
Fluent Aphasia Characterized by relatively intact fluency but generally less meaningful/meaningless speech; speech is usually flowing, abundant, easily initiated and well articulated with good prosody and
phrase length
Wernicke’s Aphasia Fluent aphasia caused by lesions in Wernicke’s area/posterior portion of the superior temporal gyrus in the left hemisphere; may experience frustration and become emotional;
paresis/paralysis are uncommon; speech is characterized by:
 Incessant, effortlessly produced, flowing speech with normal fluency and phrase length
 Rapid rate of speech
 Intact grammatical structures
 Severe word finding issues  circumlocution
 Paraphasic speech with semantic and literal paraphasias
 Empty speech
 Poor auditory comprehension, conversational turn taking and repetition
 Reading and writing difficulties
 Sound confused due to lack of insight into deficits
Transcortical Sensory Fluent aphasia caused by lesions in the temporoparietal region of the brain; Broca’s and Wernicke’s areas and arcuate fasciculus unaffected; parts of occipital lobe may be affected; may
Aphasia (TSA) experience temporary hemiparesis; speech characterized by:
 Fluent speech with normal phrase length, prosody, articulation and appropriate grammar and synax
 Paraphasic and empty speech
 Severe naming problems
 Good repetition
 Echolalia of grammatically incorrect forms
 Impaired auditory comprehension
 Difficulty following commands
 Intact automatic speech
 Good reading but poor comprehension
Conduction Aphasia Rare fluent aphasia caused by lesions in the region between Broca’s and Wernicke’s area, especially in the arcuate fasciculus; speech characterized by:
 Disproportionate impairment in repetition
 Variable speech fluency
 Paraphasic speech
 Word finding difficulties
 Good syntax, prosody and articulation
 Normal auditory comprehension
 Variable reading problems and usually writing problems
Anomic Aphasia Caused by lesions in various parts of the brain (i.e. angular gyrus, second temporal gyrus, juncture of the temporoparietal lobes); speech characterized by:
 Debilitating and pervasive word-finding difficulties
 Generally fluent speech, normal syntax
 Use of vague/nonspecific words  empty speech
  Verbal paraphasia
 Circumlocution
 Good auditory comprehension
 Intact repetition and articulation
 Normal reading and writing skills
Subcortical Aphasia
Subcortical Aphasia Caused by extensive subcortical (i.e. basal ganglia and thalamus) damage and possible involvement of left cortical areas of the brain; speech characteristics of subcortical aphasia via basal
ganglia include fluent speech, intact repetition, intact comprehension, articulation difficulties, prosody difficulties, word finding difficulties, semantic paraphasias and possible limb apraxia;
speech characteristics of subcortical aphasia via left thalamus include initial mutism  paraphasic speech, severe naming difficulties, intact auditory comprehension and repetition, impaired
reading and writing skills and hemiplegia, hemisensory loss, R-visual field deficits and possible coma
Aphasia in Bilingual Population
Patterns of Language 1. L1 more impaired than L2
Impairment 2. L2 more impaired than L1
3. L1 equally as impaired as L2
Patterns of Language 1. Recover both languages simultaneously
Recovery 2. Recover one language before/more than another
Assessment of Aphasia
Foundational Concepts Involves an evaluation of speech and language and cognitive functions; main goal is to determine presence of aphasia, type of aphasia and any coexisiting disorders
Standardized Aphasia Screening tests include the Aphasia Language Performance Scale, Sklar Aphasia Scale, Bedside Evaluation Screening Test, Aphasia Screening Test and Quick Assessment of Aphasia
Tests
Diagnostic tests include the Minnesota Test for Differential Diagnosis of Aphasia, the Boston Diagnostic Aphasia Examination, the Western Aphasia Battery, the Neurosensory Center
Comprehensive Examination for Aphasia, the Porch Index for Communicative Ability, Examining for Aphasia and Aphasia Diagnostic Profiles
Functional Assessment Utilized to target and assess functional/daily communication skills; may be more sensitive to diverse clients; commonly used functional assessments include Communicative Abilities in Daily
Tools Living, The Burden of Stroke Scale, Communicative Effectiveness Index, Functional Independence Measure, Functional Assessment of Communication Skills for Adults and Amsterdam-Nijmegan
Everyday Language Test; clinicians may also assess specific skills such as auditory attention and reading
Outline of Aphasia 1. Collect case history
Assessment 2. Conduct orofacial assessment
3. Conduct hearing screening
4. Assess specific speech and language skills including standardized, functional and informal testing
Skills Assessed in 1. Repetition skills (i.e. single words, object names, functional words, numbers, sentences, etc.)
Aphasia Patients 2. Naming skills (i.e. responsive naming, confrontational naming, word fluency, etc.)
3. Sentence/discourse production (i.e. production of single sentence when word is supplied, production of multiple sentences, discourse production and spontaneous discourse, etc)
4. Speech fluency (i.e. dysfluencies and tempo, etc.)
5. Functional communication skills (i.e. ability to make simple requests, telephone conversation, participating in conversation, facial recognition, keeping appointments, understanding
environmental signs, writing name, making a grocery list, etc.)
6. Auditory comprehension of spoken language (i.e. hearing evaluation, visual evaluation, appropriate responses to commands, comprehension of single and multistep commands, etc.)
7. Comprehension of single words (i.e. comprehension of single items and words, etc.)
8. Comprehension of sentences, paragraphs and discourse (i.e. comprehension of simple sentences as commands, brief and simple story, more complex sentences and understanding
of conversational speech, etc.)
9. Reading skills (i.e. comprehension of silently or orally read material, verbal completion of printed sentences, etc.)
10. Writing skills (i.e. graphomotor skills, general writing skills, automatic writing, propositional writing, confrontational writing, writing to dictation, narrative writing, etc,)
11. Gestures and pantomime (i.e. expression and comprehension through gestures and pantomime)
12. Automated speech and singing (i.e. recitation of automated sequences, signing, humming a tune, etc.)
13. Bilingual speakers (i.e. collect case history on history of language use, initial assessment of basic/functional skills, more detailed assessment involving both languages, etc.); may use
Bilingual Aphasia Test or Multilingual Aphasia Examination
Treatment of Aphasia
Foundational Concepts Better prognosis is associated with younger/healthier patients, patients with higher education, patients with smaller lesions, patients without other medical/behavioral disorders, patients with
good hearing, patients with normal/adequately corrected vision, patients with better motor skills, patients with better preserved language and less severe aphasia, patients who receive
immediat4 therapy, patients with good health during course of treatment, patients with involved family members
Treatment of Auditory Treatment sequence includes: comprehension of single words  comprehension of spoken sentences  discourse comprehension
Comprehension
Treatment of Verbal When targeting naming skills, subject matter should involve material related to individual patient, some cues may include semantic cues, incomplete sentences, gestural/picture cues, phonetic
Expression: Naming cues, etc.
Treatment of Verbal Involves systematically increasing the length and complexity of target responses; expands upon naming treatment; techniques may include narrating picture scenes or controlled topic
 Expression: Expanded conversation
Utterances
Treatment of Reading Treatment should be based on premorbid reading skills and may be sequenced as: survival reading skills  reading newspapers/books/magazines  reading comprehension of printed
Skills words/phrases and sentences/paragraphs and extended materials
Treatment of Writing Treatment should be based on premorbid writing skills and may be sequenced as: writing functional words/lists  writing short notes  filling out forms  writing letters; treatment
Skills approaches may include identifying words from verbal presentation, tracing printed letters, copying writing, spelling words, writing to dictation, spontaneous writing
Group Treatment May address total communication via any means, conversation skills, narrative skills, problem solving, etc.
Social Approaches Treatment goals are natural interaction, conversation, functional communication and enhancing life participation; may be accomplished through compensatory strategies
Experimental  Non-invasive brain stimulation
Approaches  Drug treatment
 Physical exercises impacting speech
 Digital devices to enhance visual and auditory feedback
Treatment of Bilingual Often similar treatment approaches are appropriate for monolingual and bilingual speakers; treatment should be tailored to what best serves the individual
Speakers
Alexia and Agraphia
Alexia Loss of previously acquired reading skills due to recent brain damage
Agraphia Loss/impairment of normally acquired writing skills due to lesions in the foot of the medial frontal gyrus of the brain, sometimes referred to as Exner’s Writing Area
Agnosia
Agnosia Impaired understanding of the meaning of certain stimuli, even though there is no peripheral sensory impairments; patients can see, feel and hear stimuli but cannot understand their meaning
Auditory Agnosia Characterized by impaired understanding of the meaning of auditory stimuli, normal peripheral hearing, difficulty in matching objects with their sound and normal visual recognition of objects
Auditory Verbal Characterized by impaired understanding of spoken words, normal peripheral hearing, normal recognition of nonverbal sounds, normal recognition of printed words and normal or near-normal
Agnosia verbal expression and reading
Visual Agnosia Characterized by impaired visual recognition of objects, which may be intermittent and normal auditory or tactile recognition of others
Tactile Agnosia Characterized by impaired tactile recognition of objects when visual feedback is blocked (as with a blindfold), impaired naming of objects clients can feel in their hands and impaired description
of objects clients can feel in their hands

2. APRAXIA OF SPEECH
Definition and Distinctions
Apraxia of Speech A neurogenic speech disorder characterized by speech sound production errors combined with prosodic deficiencies presumably due to sensorimotor problems in positioning and sequentially
moving muscles for the volitional production of speech and clinically characterized by slower rate of speech, distorted speech, sound substitutions and additions, syllable segmentations,
articulatory groping, false starts and restarts, prosodic impairments and longer utterances causing more errors than shorter utterances
Primary Progressive Apraxia associated with insidious onset and slow progress
Apraxia of Speech
(PPAOS)
Neuropathology of AOS
Etiology of AOS Caused by injury or damage to speech-motor programming areas in the dominant hemisphere
Pathologies of AOS Include vascular lesions causing strokes with damage to the speech programming structures and pathways; specifically, frontal lesions; left-hemisphere trauma
Etiology of PPAOS May be caused by degenerative neural diseases such as Alzheimer’s, MS and pathologies that cause primary progressive aphasia
Symptoms of AOS
General Symptoms Include impaired oral sensation, language deficits/disorders, dysathria, limb apraxia, nonverbal oral apraxia (NVOA), sensory deficits, etc.
Communication Deficits
Communication  Auditory processing deficits
Deficits  Slow/delayed initiation of speech
 May use reduced rate of speech as compensatory strategy
Speech Deficits  Problems in volitional/spontaneous sequencing of movements required for speech
 Highly variable speech errors
 Sound substitutions
 More pronounced difficulty with consonants
 Anticipatory substitutions
 Insertion of schwa into consonant clusters/between syllables
 Increased frequency of errors on longer words
 Easier automatic productions
 Attempts at self-correction
 Prosodic Deficits  Slower rate of speech
 Silent pauses between words
 Impaired intonation
 Fluency problems including silent pauses
Assessment of AOS
Assessment 1. Collect case history
Procedures 2. Patient/caregiver interview
3. Detailed observation of speech production
Assessment of AOS Includes:
1. Collecting a speech sample
2. Evoking imitative production of speech
3. Assessing oral reading
4. Administering DDK
5. Assessing limb movements
6. Administering standardized assessment (i.e. Apraxia Battery for Adults)

Treatment of AOS
Treatment Focus Behavioral treatment is most effective; should focus on speech movements; goals include articulatory accuracy, slower rate of speech, systematic practice, gradual increase in rate and normal
prosody
Treatment Approaches Treatment should include practice with a variety of sounds and sound combinations with repeated trials of same target response; tactile cueing may be effective

3. THE DYSARTHRIAS
Definitions of the Dysarthrias
Dyarthrias A group of neurologically based motor-speech disorders due to peripheral or central nervous system pathology resulting in paralysis, weakness or incoordination of the muscles involved in
speech production; types of dysarthrias include ataxic, flaccid, hyperkinetic, hypokinetic, spastic, mixed and unilateral upper motor neuron dysarthria
Areas Impacted Respiration, phonation, articulation, prosody and resonance
Neuropathology of the Dsyarthrias
Causes of Dysarthria  Nonprogressive neurological conditions (i.e. strokes, infections, TBI, CP, encephalitis, etc.)
 Degenerative neurological diseases (i.e. PD, ALS, Wilson’s disease, MS, Huntington’s disease, Alzheimer’s disease, etc.)
 Neurotraumatic causes (i.e. penetrating head injuries, neck trauma, skull fracture, etc.)
 Infectious diseases (i.e. AIDS, CNS tuberculosis, etc.)
 Toxic-metabolic causes (i.e. drug toxicity, carbon monoxide poisoning, etc.)
Lesion Sites Common sites of lesions include lower motor neuron, upper motor neuron, cerebellum and basal ganglia
Pathophysiology/ Include muscle weakness, spasticity, incoordination and rigidity
Neuromuscular Issues
Communicative Disorders Associated with Dysarthria
Respiratory Problems Include forced inspirations or expirations interrupting speech, audible/breathy inspiration and grunting following expiration
Phonatory Disorders Include pitch disorders, loudness disorders, vocal-quality problems, etc.
Articulation Disorders Include imprecise production of consonants, prolongation/repetition of phonemes, irregular breakdowns of articulation, distortion of vowels and weak production of pressure consonants, etc.
Prosodic Disorders Include slower, excessively faster or variable rate of speech, shorter phrase lengths and linguistic stress problems, prolongations of intervals between words/syllables, etc.
Resonance Disorders Include hypernasality, hyponasality, nasal emission, etc.
Other Characteristics Slow, fast or irregular ddk rate and pallilalia, decreased intelligibility
Types of Dysarthria
Ataxic Dysarthria Results from damage to the cerebellar system and is characterized by articulatory and prosodic problems reflecting predominantly impaired timing and coordination of muscle movements;
characteristics include:
 Gait disturbances (i.e. trunk/head instability, tremors, etc.)
 Movement disorders (i.e. over/undershooting targets, uncoordinated/jerky/inaccurate/slow/imprecise/halting movements, etc.)
 Respiratory disorders (i.e. exaggerated and paradoxical movement during speech production)
 Articulation disorders (i.e. imprecise production of consonants, irregular articulatory breakdowns, vowel distortions, etc.)
 Prosodic disorders (i.e. excessive/even stress, prolonged phonemes and intervals between words/syllables, slow rate of speech, etc.)
 Phonatory disorders (i.e. monopitch, monoloudness, harshness)
 Speech quality (i.e. impression of drunken speech)
 Resonance disorders (i.e. intermittent hyponasality in some individuals)
Flaccid Dysarthria Results from damage to the motor units of cranial or spinal nerves that supply speech muscles (i.e. lower motor neuron involvement/damage to PNS); may include single or multiple muscel
 groups; may be caused by degenerative neurological disease (i.e. ALS, motor neuron disease, progressive bulbar disease, muscle atrophy), demyelinating disease or TBI; may include
involvement of CN V (trigeminal), VII (facial), IX (glossopharyngeal), X (vagus), XI (accessory) and XII (hypoglossal); major characteristics include:
 Muscular disorders (i.e. weakenss, hypotonia, atrophy, diminished reflexes, fasciculations, contractions, rapid/progressive weakenss, etc.)
 Respiratory weakness (i.e. reduced subglottic air pressure, weak inhalation, etc.)
 Phonatory disorders (i.e. breathy voice, audible inspiration, short phrases, etc.)
 Resonance disorders (i.e. hypernasality, nasal emission and short phrases, etc.)
 Phonatory-prosodic disorders (i.e. harsh voice, monopitch, monoloudness, redued loudness, etc.)
 Articulation disorders (i.e. imprecise consonants and weak pressure consonants)
 Three disorder clusters (i.e. phonatory incompetence, resonatory incompetence and phonatory-prosodic insufficiency)
Hyperkinetic Results from damage to the basal ganglia (i.e. extrapyramidal system) and is associated with variable muscle tone and involuntary movements that interfere with speech production; any or all
Dysarthria of the speech systems may be affected but prosodic disturbances are dominant; common causes include degenerative diseases, vascular diseases, trauma or toxic/metabolic conditions; can
impact muscles of the face, jaw, tongue, palate, larynx and respiration; major characteristics include:
 Orofacial dyskinesia (i.e. abnormal involuntary, rhythmic/nonrhytmic movements of the orofacial muscles)
 Myoclonus (i.e. involuntary, rapidly occurring jerks, hiccups, palatal tremor)
 Tics (i.e. commonly of the face and shoulders, typically patterned, rapid and stereotyped)
 Chorea (i.e. purposeless, random, involuntary movements of the body)
 Dystonia (i.e. contractions of antagonistic muscles that cause abnormal postures, spasmodic torticollis, etc.)
 Tremor (i.e. rhythmic movements)
 Communicative disorders (i.e. depending on associated neurological condition)
 Respiratory problems (i.e. audible inspiration and forced and sudden inspiration or expiration)
 Phonatory disorders (i.e. voice tremor, intermittently strained voice, voice stoppage, vocal noise, harsh voice and loudness variation)
 Resonance disorders (i.e. hypernasality-typically mild)
 Articulation problems (i.e. imprecise consonant productions, slow rate of speech)
 Prosodic disorders (i.e. prolonged inter-word intervals, inappropriate silent periods, phoneme prolongations and excess/equal stress, monopitchness, monoloudness, reduced stress,
short phrases, etc.)
Hypokinetic Dysarthria Results from damage to the basal ganglia (i.e. extrapyramidal system) which may affect all aspects of speech with voice, articulation and prosody being the most impacted as a result of
muscular rigidity and reduced force and range of movement; caused by PD, stroke, toxic/metabolic conditions, trauma, etc.; characterized by:
 Tremors (i.e. facial, mouth and limb muscle tremors at rest)
 Mask-like face (i.e. infrequent blinking and no smiling)
 Micrographic writing
 Walking disorders (i.e. slow to begin with short/rapid/shuffling steps)
 Postural disturbances (i.e. involuntary flexion of the head, trunk and arm with difficulty changing positions)
 Decreased swallowing (i.e. poor secretion management)
 Respiratory problems (i.e. reduced vital capacity, irregular breathing and faster rate of respiration)
 Phonatory disorders (i.e. monopitch, low pitch, monoloudness, harsh and continuously breathy voice)
 Prosodic disorders (i.e. reduced stress, inappropriate silent intervals, short rushes of speech, variable and increased rate in segments and short phrases)
 Articulation disorders (i.e. imprecise or distorted consonants, mushed fricatives, etc.)
 Dysfluencies
 Resonance disorders (i.e. some with hypernasality)
Spastic Dysarthria Results from bilateral damage to the upper motor neurons (i.e. direct and indirect motor pathways) creating a predominant spasticity; common lesion sites include cortical areas, basal ganglia,
pons and medulla; most commonly caused by single or multiple strokes damaging the pyramidal and extrapyramidal tracts, ALS, MS, TBI, tumor, infection, etc.; characterized by:
 Spasticity and weakness
 Movement disorders (i.e. reduced range/force/speed of movements, loss of fine motor movements, increased muscle tone)
 Articulation disorders (i.e. imprecise consonant production and distorted vowels)
 Prosodic disorders (i.e. excess and equal stress, slow rate, monopitch, monoloudness, reduced stress, short phrases, etc.)
 Phonatory disorders (i.e. hyperadduction of vocal folds, continuous breathy voice, low pitch, pitch breaks, strained and strangled vocal quality, short phrases, etc.)
 Resonance disorders (i.e. predominant hypernasality due to inadequate closure of the velopharyngeal port)
Mixed Dysarthria Combination of two or more pure dysarthrias; all combinations are possible; can be caused by neurological diseases (i.e. ALS, motor neuron diseases, MS, friedreich’s ataxia, etc.); two most
common mixed forms are:
1. Flaccid-spastic: often associated with ALS; characterized by imprecise production of consonants, hypernasality, harsh voice, slow rate of speech, monopitchness, sort phrases,
distorted vowels, low pitch, monoloudness, excess and equal stress/reduced stress, prolonged intervals, prolonged phonemes and strangled quality, breathiness, audible inspiration,
inappropriate silences and nasal emissions
2. Ataxic-spastic: often associated with MS; characterized by impaired loudness control, harsh voice quality, imprecise articulation, impaired emphasis, hypernasality, inappropriate
pitch levels, decreased vital capacity, breathiness and sudden articulatory breakdowns
 Unilateral Upper Results from damage to the upper motor neurons that supply cranial and spinal nerves involved in speech production; caused by stroke, trauma, MS, vascular disorders, etc.; characterized by:
Motor Neuron  Neurological impairments (i.e. unilateral lower face weakness, unilateral tongue weakness, unilateral palatal weakness and hemiplegia/hemiparesis)
Dysarthria  Articulation disorders (i.e. imprecise consonant production, irregular articulatory breakdowns, vowel distortions, syllable repetition, etc.)
 Phonatory disorders (i.e. harsh voice, reduced loudness, strained harshness, wet hoarseness and breathiness)
 Prosodic disorders (i.e. slow rate, increased rate in segments, excess and equal stress, monopitch, monoloudness, low pitch and short phrases)
 Resonance disorders (i.e. hypernasality/nasal emissions)
 Associated disorders (i.e. dysphagia, aphasia, apraxia and right hemisphere syndrome)
Assessment of the Dysarthrias
Assessment Assessment should include:
Procedures 1. Collecting a speech sample
2. Conducting a variety of speech assessments (i.e. imitation, ddk, sustained phonation, etc.)
3. Assessing speech production mechanisms (i.e. facial symmetry/tone/tension, facial movements, emotional expressions, jaw movements, velopharyngeal mechanism/movements,
nasal airflow, laryngeal function)
4. Assess respiratory problems (i.e. observe posture and breathing habits)
5. Assess phonatory disorders (i.e. sustained phonation, observe pitch and take note of any abnormalities, taking note of voice tremors, judging quality of the voice)
6. Assess articulation disorders (i.e. consonant productions, duration of speech sounds, phoneme repetitions, irregular articulatory breakdowns, articulatory precision, etc.)
7. Assess prosodic disorders (i.e. rate of speech, phrase length, stress patterns, pauses in speech, etc.)
8. Assess resonance disorders (i.e. hyper/hyponasal speech)
9. Assess speech intelligibility
10. Assess muscle strength, speed, range, accuracy, tone and steadiness of movement involved in speech production
11. Use of standardized tests (i.e. Assessment of Intelligibility of Dysarthric Speakers, Frenchay Dysarthria Assessment, Speech Intelligibility Test for Windows)
12. Make a differential diagnosis
Treatment of the Dysarthrias
Procedures Addresses all aspects of speech production; include intensive, systematic and extensive trials/drills, instruction, demonstration, modeling (followed by imitation), shaping, prompting, fading,
differential reinforcement and other proven heavioral management procedures
Goals Should be individualized to the client and type of dysarthria exhibited; can include modifying respiratory, phonatory, articulatory, resonatory and prosodic problems and increasing the
efficiency, effectiveness, and naturalness of communication
Modification of Train consistent production of subglottic air pressure with the help of instrumentation (i.e. manometer, air pressure transducer), training maximum vowel prolongation, shaping production of
Respiration longer phrases and sentences, teaching controlled exhalation, teaching clients to push, pull or bear down during speech and nonspeech tasks, modifying postures, changing respiratory habits
Modification of Using biofeedback to shape desirable vocal intensity and training the client in use of portable amplification systems if necessary; treating aphonic clients to use artificial larynx or other
Phonation techniques
Modification of Providing feedback on nasal airflow and hypernasality by using instrumentation (i.e. mirro, nasal flow transducer, nasendoscope, etc.), training client to open mouth wider to increase oral
Resonance resonance and vocal intensity, using a nasal obturator/nose clip
Modification of Training client to utilize best posture, using bit block for jaw control and strength, simplify target, using phonetic placement, slower rate and minimal contrast pairs, teaching self-monitoring and
Articulation compensatory strategies/skills
Modification of Speech Using delayed auditory feedback, pacing board, alphabet board, metronome/hand tapping, etc.
Rate
Modification of Reducing speech rate and teaching appropriate intonation
Prosody
Modification of Pitch Using modeling and differential feedback
Modification of Vocal Through behavioral methods of modeling, shaping an differentially reinforcing greater inhalation, increased laryngeal adduction and wider mouth opening
Intensity

4. DEMENTIA
Definition and Classification of Dementia
Dementia An acquired neurological syndrome associated with persistent or progressive deterioration in intellectual functions, emotions and behavior, judgement, thinking, visuospatial skills,
constructional abilities, language and memory; typically progressive
Prevalence May be as high as 25% in people 65+ years old
Diagnosis Clinicians require that impairment be evident in at least three functions with none as a basic requirement; APA requires memory impairment to diagnose
Mild Cognitive Diagnostic category used when the problem is both mild and limited to a single domain, such as memory
Impairment (MCI)
Classification of Can be controversial, however typically classified as reversible and progressive
Dementia
Dementia of the Alzheimer Type (DAT)
Types of Alzheimer’s 1. Early onset (EOAD): onset up to age 60/65; accounts for 6% of AD
Disease (AD) 2. Late onset (LOAD): onset occurring in 70s-80s
Statistics AD accounts for 60-70% of irreversible dementia; more women than men are affected; associated with family history of down syndrome, prior brain injury and low level of education; gnetic
inheritance accounts for some cases
Neuropathology of Includes:
DAT  Neurofibrillary tangles
 Neuritic plaques/senile plaques
 Neuronal loss
 Neurochemical changes
Symptoms of Early- Includes:
Stage DAT  Subtle memory problems
 Pronounced difficulty with new learning and visuospatial problems
 Behavioral changes (i.e. self-neglect and avoidance of routine tasks)
 Depression and disorientation
Symptoms of Later- Includes:
Stage DAT  Intensified early-stage symptoms
 Severe problems recalling remote and recent events
 Widespread intellectual deterioration
 Hyperactivity
 Profound disorientation
 Difficulty managing daily routines
 Lack of affect
 Paranoid delusions and hallucination
 Aggressive or disruptive behaviors, inappropriate humor and laughter
 Seizures and physical deterioration
Language Problems Includes:
Associated with DAT  Word finding difficulties
 Difficulty comprehending abstract meanings
 Echolalia
 Empty speech/jargon/hyperfluency
 Pragmatic language difficulties
 Reading and writing difficulties
 In final stages- no meaningful speech, mutism and complete disorientation
Frontotemporal Dementia (including Pick’s Disease)
Frontotemporal i.e. frontotemporal lobar degeneration; a group of heterogenous diseases that includes a behavioral variant of FTD and primary progressive aphasia; constitutes up to 10% of dementia cases;
Dementia (FTD) typical onset is between 40-60 years old
Neuropathology of Includes:
FTD  Degeneration of nerve cells in left and right frontal lobes, temporal lobe or both
 In Pick’s disease, possibly focal atrophy involving the anterior frontal and temporal lobes, the orbital frontal lobes and the medial temporal lobes
 Presence of Pick bodies and cells in the cortical layers
 The absence of Pick bodies and cells in some variations of FTD, but the presence of atrophied, gliosed and swollen brain cells
Symptoms of Includes:
Behavioral Variant of  Notable behavioral and language changes
FTD  Behavioral disorders including uninhibited and inappropriate social behaviors and delusions
 Emotional disturbances, including depression, apathy, withdrawal, irritability, etc.
 Impaired judgement and reasoning
Language Problems Include:
Associated with FTD  Anomia
 Progressive loss of vocabulary and increased paraphasias and circumlocution
 Naming difficulties
 Limited spontaneous speech, echolalia and nonfluent speech
 Impaired comprehension
Primary Progressive Aphasia (PPA)
PPA Has a nonfluent, semantic and logopenic variant; characterized by initial aphasia with predominant language impairment and intact cognitive skills and progresses to dementia
Nonfluent Variant PPA Characterized by:
 Anomia, word finding difficulties, apraxia of speech  reduced fluency, articulation difficulties, agrammaticims, impaired repetition, slow and prosodic impairments
 Memory and cognition impaired until ~2 years post onset
 Behavioral changes including apathy, disorganization, inappropriateness and aggression within 2 years
 Slow progress with an 8-10 year survival rate
Semantic Variant PPA Characterized by:
 Progressive loss of word meaning
 Initially intact fluency and repetition  repetition of words not named/comprehended, intact phonological and motor skills, orientation to time and space
 Excessive and disinhibited speech
 Visual agnosia and prosopagnosia
 Progressively shorter sentences and phrases  mutism
 Behavioral changes in later stages, including disinhibition, irritability, compulsive behavior
Logopenic Variant PPA Characterized by:
 Slow speech with word finding pauses
 Moderate naming difficulties in early stages
 Severe difficulty repeating phrases and sentences
 Impaired sentence comprehension
 Behavioral changes including apathy, anxiety, irritability and agitation
Dementia Associated with Parkinson’s Disease
Parkinson’s Disease Dementia in individuals with PD is subcortical
and Dementia
Neuropathology of PD Include:
 Basal ganglia and brainstem deterioration
 Presence of abnormal structures called Lewy bodies, small pathologic spots in the substantia nigra
 Frontal lobe atrophy
 Reduced inhibitory dopamine
 Neurofibrillary tangles and plaques
Neurology Symptoms Include:
of PD  Slow voluntary movements (i.e. bradykinesia)
 Tremors in resting muscles
 Muscle rigidity
 Mask-like face
 Reduced eye-blinking, festinating gate, disturbed posture, freezing during movement
 Swallowing disorders
 Sleep disturbances
Speech, Language and Include:
Related Problems  Reduced speech volume
Associated with PD  Voice problems (i.e. monopitchness and monoloudness)
 Long and frequent pauses in speech
 Slow/fast or festinating speech
 Dysarthric speech
 Memory deficits, abstract reasoning and problem solving deficits
 Impaired visuospatial perception
 Impaired naming skills
 Apathy, confusion, hallucination and delirium
 Micrographia
Dementia Associated with Huntington’s Disease
Nueropathology of Include:
Huntington’s Disease  Loss of neurons in the basal ganglia
 Possible atrophy in prefontal and parietal lobes
 Reduced levels of inhibitory neurotransmitters
Symptoms of Include:
Huntington’s Disease  Chorea
  Increasingly uncontrollable tic-like movement disorders
 Gait disturbances and progressively reduced voluntary movements
 Slow movement in the advanced stages
 Behavioral disorders including irritability, emotional outbursts, false sense of superiority, depression, etc.
Speech, Language and Include:
Cognitive-Linguistic  Deterioration in intellectual functions
Problems Associated  Impaired naming skills
with Huntington’s  Dysarthria
Disease  Incontinence, sleep disturbances, sleep reversal
 Dysphagia
 Muteness in final stages
Infectious Dementia
AIDS Dementia Dementia due to HIV infection; subcortical; characterized by:
Complex/ Human  Slow onset of dementia but rapid deterioration in final stages
Immunodeficiency  Neurologic symptoms including disturbed gait, tremor, headache, seizures, ataxia, rigidity, motor weakness, facial nerve paralysis
Virus Encephalopathy  Dementia symptoms include forgetfulness, poor attention, slow/impaired thinking, apathy and loss of interest, depression, mania, confusion, hallucinations, memory loss
Dementia Due to Thought to be caused by an unconventional infection agent called a prion; characterized by:
Creutzfeldt-Jakob  Physical symptoms including fatigue and sleep disturbances
Disease  Neurological symptoms including cerebellar ataxia, tremor, rigidity, chorea, athetosis and visual problems
 Symptoms of dementia include memory problems and reasoning impairments
 Psychiatric symptoms including depression, anxiety, hallucinations, etc.
 Final stage characterized by stupor, mutism, seizures and pneumonia
Other Forms of Dementia
Types of Dementia Include:
1. Vascular dementia
2. Dementia associated with multiple cerebrovascular accidents
3. Lewy body dementia
4. Dementia associated with TBI
Assessment of Dementia
Procedures 1. Collect case history
2. Clinical examination
3. Neurological assessment
4. Communication assessment
5. Assessment of intellectual functions
Skills Assessed  Awareness and orientation
 Mood and affect
 Speech and language
 Memory and other cognitive functions
 Abnormal thinking
 Visuospatial skills
Diagnosis Definitive diagnosis of dementia is only possible through an autopsy
Standardized  The Arizona Batter for Communication Disorders of Dementia
Assessments  The Functional Linguistic Communication Inventory
 The Blessed Dementia Scale
 The Global Deterioration Scale
 The Texas Functional Living Scale
Clinical Management of Dementia
Goal Main goal is to slow the progression of symptoms as much as possible through managing daily activities, memory and communication skills via compensatory strategies and communication
training; family and caregiver support is extremely important
Compensatory Include:
Strategies  Establishing simple routine
 Keeping important information in a specific place
 Using external cues to improve memory and behavior
 Utilization of written lists
 Communication Includes:
Training  Cognitive rehabilitation
 Cognitive training
 Cognitive stimulation

5. RIGHT-HEMISPHERE BRAIN DAMAGE

Foundational Concepts
Right Hemisphere Includes:
Functions  Understanding holistic gestalt stimuli, visual perception, geometric and spatial information
 Facial recognition, drawing and copying
 Arousal, attention and orientation
 Emotional experience and expression
 Perception of musical harmony, pitch and melody
 Language comprehension in general and meanings of related words; prosodic features of communication; understanding ambiguous meaning; expressing and understanding
emotional tone of speech, understanding discourse, pragmatic language skills
Right Hemisphere Functions are diffusely organized and lesions result in varied symptoms
Organization
Symptoms of Right Hemisphere Brain Damage
Attentional and Include:
Perceptual Deficits  Left neglect
 Denial of illness (i.e. agnosognosia)
 Confabulation regarding disability
 Facial recognition deficits
 Constructional impairment
 Attentional deficits
 Disorientation
 Visuopercpetual deficits
Affective Deficits Include:
 Understanding emotions expressed by other people
 Recognizing and describing emotions
 Understanding emotional tone of voice
 Expressing emotions
Communicative Include:
Deficits  Prosodic deficits (i.e. monotone, impaired stress patterns, reduced speech rate, lack of affect and difficulty understanding prosodic meanings)
 Impaired/disorganized discourse and narrative skills
 Confabulation and excessive speech
 Difficulty understanding implied, alternate or abstract meanings
 Pragmatic deficits (i.e. deficits in conversational turn taking, topic maintenance and maintaining eye contact)
 Other communicative deficits including naming difficulties, comprehension difficulties and impaired oral reading skills
Assessment of Right Hemisphere Brain Damage
Standardized Include RIC Evaluation of Communication Problems in Right Hemisphere Dysfunction, The Mini Inventory or Right Brain Injury, The Right Hemisphere Language Battery, the Test of Visual
Assessments Neglect, the Bells Test and the Behavioral Inattention Test
Procedures Full assessment should include case history, language samples, narrative and discourse and standardized assessments
Communication Treatment of Patients with Right Hemisphere Brain Damage
Treatment Targets and 1. Denial and indifference: providing immediate feedback on errors to increase awareness
Strategies 2. Impaired attention: drawing attention to treatment stimuli, giving specific direction, repeating directions, reinforcing attention and stopping patient when attention diverts
3. Impulsive behavior: utilizing nonverbal sounds to wait before giving an impulsive response
4. Discourse problems: utilize story retelling and generation with hierarchical cues
5. Pragmatic impairments: utilizing visual feedback to show appropriate and inappropriate pragmatic behaviors to increase awareness
6. Impaired reasoning
7. Impaired inference
 8. Impaired comprehension of metaphors and idioms
9. Visual neglect: utilizing compensatory strategies

6. TRAUMATIC BRAIN INJURY

Definition and Incidence of TBI
TBI i.e. craniocerebral trauma; injury to the brain sustained by physical trauma or external force; does not include brain damage due to strokes, tumors, or progressive or transient
neuropathologies
Classifying TBI Can be open-head/penetrating, closed-head/nonpenetrating or mild/multisystem
Incidence of TBI Vary within a range of 150-367 cases per 100,000 persons in the US; annually ~1.14 million individuals sustain a TBI
Prevalence of TBI Highest for age groups 0-4 years and 15-19 years; more males than females are affected
Causes of TBI
Common Causes of TBI Most common cause of TBIs are falls; also automobile and motorcycle accidents, assaults and interpersonal violence, alcohol and drug abuse; closed-head injuries are more common than open
Types and Consequences of TBI
Open-Head Brain i.e. penetrating; involves a fractured or perforated skull, torn or lacerated meninges and an injury extending to the brain tissue; frequent causes include high-velocity missiles and low-velocity
Injuries impacts
Closed-Head Brain i.e. nonpenetrating; involve no open head wound, no penetration of a foreign substance into the brain and a damaged brain within the skull; classified as closed-head as long as the meninges
Injuries stay intact; may be acceleration-deceleration or nonacceleration type
Acceleration- More serious than nonaccelerating types; the head is set into motion by physical forces while the brain remains static  the head eventually stops moving and the brain continues to move and
Deceleration Injuries strikes the skull on the opposite side of initial impact causing the brain to lacerate/tear due to the bony projections on the base of the skull
Nonacceleration Occurs whena restrained head is hit by a moving object
Injuries
Coup Injury Brain injury at the point of impact
Contrecoup Injury Brain injury at the opposite side of the impact
Mild TBI i.e. concussion; a form of closed-head injury in which consciousness is lost for less than 20 minutes
Consequences of TBI May include death, loss of consciousness, coma, destruction of brain tissue, diffuse axonal injury, diffuse vascular injury, brainstem injury, focal lesions, infections, reduced cerebral blood flow,
increased blood pressure, swelling of brain tissue, hydrocephalus and various types of hematomas (i.e. accumulation of blood in an area of the brain)
Communication Include:
Disorders Associated  Initial mutism
with TBI  Confused language
 Dysarthria
 Naming difficulties
 Perseveration
 Reduced word fluency
 Difficulty initiating conversation
 Pragmatic difficulties
 Impaired prosody
 Difficulty with abstract language
 Difficulty with reading and writing
 Auditory comprehension deficits
Assessment of Patients with TBI
General Assessment 1. Collect case history
Procedures 2. Client observation
3. Formal assessment (i.e. Coma Recovery Scale, Scales of Cognitive Ability for TBI, Glasgow Coma Scale, Brief Test of Head Injury, Galveston Orientation and Amnesia Test, Disability
Rating Scale and Rancho Los Amigos Levels of Cognitive Function
4. Communication assessment (including speech sample, and assessment of narrative skills and discourse)
Assessment of Patient’s communication deficits will vary based on location and severity of damage; communicative problems associated with TBI include:
Communication  Dysarthria
Deficits Associated  Confused language
with TBI  Auditory comprehension difficulties
 Confrontational naming difficulties
 Perseveration of verbal responses
 Pragmatic language difficulties
 Reading and writing difficulties
Treatment of TBI
 Cognitive Clinicians train components such as attention, visual processing and memory; includes attempts to improve memory, reasoning skills and other cognitive functions
Rehabilitation
Communication Involves direct behavioral procedures training communication partners as well as patients; utilizes systematic reinforcement of attending behaviors, appropriate discourse, topic maintenance,
Treatment self-correction, etc.; goals should be functional with the initial focus on effectiveness of communication; treatment may address orientation, memory, training communication partners,
attention, discourse and pragmatics, teaching self-monitoring skills and utilizing compensatory strategies

7. SWALLOWING DISORDERS
Nature and Etiology of Swallowing Disorders
Dysphagia Impaired swallowing
Nature of Difficulty Impairment may be evident in the oral, pharyngeal and esophageal stages of swallowing; difficulties may include chewing and preparing food for swallow, initiating the swallow, propelling the
bolus through the pharynx or passing the food through the esophagus
Etiology of Dysphagia Includes:
 Strokes
 Oral and pharyngeal tumors and various neurologic diseases
 Surgical or radiation treatment
 TBI and cervical spine disease
 Poliomyelitis, COPD and CP
 Genetic factors
 Side effects of medications
Normal and Disordered Swallow
Feeding The transportation of food from the plate to the mouth; feeding disorders may occur with motor deficits
Swallowing The transportation of food from the mouth to the stomach; divided into oral prep, oral, pharyngeal and esophageal stages
Oral Prep Phase Food is placed in the mouth and masticated, turning food into a bolus to prepare for swallow; disorders of the oral prep phase may include difficulties with mastication or difficult in
forming/holding the bolus
Oral Phase Begins with the anterior-to-posterior tongue action moving the bolus posteriorly and ends as the bolus passes through the anterior faucial arches when the swallowing reflex is initiated;
disorders of the oral phase include poor/inaccurate tongue movements, food residue, premature swallow, piecemeal swallowing
Pharyngeal Phase Consists of reflex actions of the swallow; involves velopharyngeal closure, laryngeal closure by an elevated larynx to seal the airway, reflexive relaxation of the cricopharyngeal muscle for the
bolus to enter and reflexive contractions of the pharyngeal contractors to move the bolus down into the esophagus; disorders of the pharyngeal phase include difficulty propelling the bolus
through the pharynx and into the pharyngoesophageal sphincter segment, delayed/absent swallow, pharyngeal residue, inadequate airway closure  aspiration, reduced base of tongue,
laryngeal and cricopharyngeal movements/dysfunctions
Esophageal Phase Involuntary; begins when food arrives at the orifice of the esophagus; food is propelled through the esophagus by peristaltic action and gravity into the stomach; bolus entry into the esophagus
results in restored breathing and depressed larynx and soft palate; disorders of the esophageal phase include difficulty passing the bolus through the cricopharyngeus muscle, backflow of food
from esophagus to pharynx, reduced esophageal contractions, formations of diverticulum, tracheoesophageal fistula or esophageal obstruction; achalasia is a special form of esophageal
swallowing disorder to esophageal motility impairment or a failure of the lower esophageal sphincter to relax
Assessment of Swallowing Disorders
Procedure 1. Case history
2. Reviewing medical records
3. Patient/caregiver interview
4. Screen speech, voice, language and writing skills
5. Conduct a laryngeal examination to assess the base of tongue, vallecular, epiglottis, pyriform sinuses, vocal folds and ventricular folds via indirect laryngoscopy or endoscopy
6. Administer swallow assessment using different foods/consistencies giving appropriate instructions for head positions and swallows
7. Conduct FEES or MBS for an objective assessment
Treatment of Swallowing Disorders
Direct Treatment of Food or liquid is placed in the patient’s mouth to shape appropriate swallowing and is designed to reduce problems in various stages of swallowing; can be used to address various stages of
Swallowing Disorders swallowing:
1. Directly treating disorders of the oral prep phase of swallowing involves teaching the patient to better masticate the food and generally better handle food in the mouth
2. Directly treating disorders of the oral phases involves teaching the patient to utilize tongue thrust swallow and compensating via food placement
3. Directly treating disorders of the pharyngeal phase of swallowing involves teaching the patient to utilize head tilt, liquid washes, head turn and chin tuck compensatory strategies
4. Directly treating disorders of the esophageal phase of swallowing involves teaching the patient to avoid certain foods, eating smaller portions and staying upright post eating
Indirect Treatment of Involves various exercises and swallowing-related skill training designed to improve muscle strength; oral-motor control exercises aim to increase range of tongue movements, increase buccal
Swallowing Disorders tension, increasing the range of lateral movements of the jaw, strengthening lip closure and stimulate the swallow reflex through thermal stimulation, second dry swallow, liquid wash and
increasing consistency of food after stimulation
Specific Swallow Techniques designed to compensate for specific problems associated with dysphagia to help the patient gain some degree of control over certain involuntary aspects of swallowing; strategies
Maneuvers include:
 1. Supraglottic swallow: helps close the airway at the level of the vocal folds to preen aspiration by asking them patient to hold food in the mouth, take a deep breath and hold it soon
after initiating slight exhalation, then swallow while holding their breath and cough after the swallow
2. Super-supraglottic swallow: helps close the airway before and during the swallow by promoting false vocal fold closure; patient is asked to inhale and hold their breath tightly by
bearing down and swallow while holding breath and bearing down
3. Effortful swallow: increases the posterior motion of the tongue and increases pharyngeal pressure; patient is asked to squeeze as hard as possible while swallowing
4. Mendelsohn maneuver: elevates larynx and widens cricopharyngeal opening; patient palpates the laryngeal elevation while swallowing saliva and is taught to hold the laryngeal
elevation during swallowing for progressively longer durations
Neuromuscular Consists of neuromuscular electrical stimulation of the neck muscle to improve swallowing, transcranial magnetic stimulation and transcranial direct current stimulation
Rehabilitation for
Swallowing Disorders
Medical Treatment for Include:
Swallowing Disorders 1. Cricopharyngeal myotomy
2. Esophagostomy
3. Gastrostomy
4. Nasogastric feeding
5. Pharyngostomy
6. Teflon injection into the vocal folds

Ch. 9 Communication Disorders in Multicultural Population

1. FOUNDATIONAL ISSUES
General Cultural Considerations
Culture A framework through which actions are filtered as individuals go about the business of daily living; includes the beliefs, behaviors, and values of a group of people
Cultural Competence A culturally competent SLP is actively in the process of becoming aware of his or her own assumptions, actively attempts to understand the worldview of his or her culturally diverse clients and
families and is actively developing and practicing culturally relevant, sensitive and appropriate service delivery skills and practices
Stereotypes A means of categorizing others based on perceptions that are incomplete
Variables Influencing  Educational level
Individual Behavioral  Language(s) spoken
Within a Culture  Length of residence in an area
 Country of birth
 Urban vs. rural background
 Gender
 Religion
 Age
 Generational membership
 SES
 Degree of acculturation into mainstream American life

2. SPEECH-LANGUAGE CHARACTERISTICS OF CLD CLIENTS

Dialects of American English
Mainstream American i.e. MAE; used in government communication, printing, national television, etc.; can be considered the official language of the US; includes 10 major dialects of MAE (i.e. NYC, Eastern New
English England Western Pennsylvania, Appalachian, Southern, Middle Atlantic, Central Midland, Southwest, Northwest and North Central)
Dialectal Differences Can be a result several interrelated factors, including geographic region, SES, speaking situation, and subgroup membership
African American English (AAE)
Misconceptions about  All African Americans speak AAE – some do and some do not
AAE  AAE is spoken only by African Americans – may be spoken by other people of any linguistic/cultural background
 AAE is a substandard form of MAE – AAE is a dialect in its own right with roots in Africa
 AAE does not have a regular predictable system – AAE is a rule-governed system
 If children speak AAE, their use of AAE must be discontinued – children who are bidilectal tend to benefit most
 Use of standardized language tests with AAE speakers is a nonbiased indicator of actual language knowledge and skill – most assessments have been normed and standardized on
Anglo, middle-class monolingual English speakers
AAE Language Include:
Differences  Omissions of noun possessives and plurals
 Omissions of third-person singular present-tense marker
  Omission of to be forms such as is, are
 Present tense used regardless of person, number
 Lack of person-number agreement
 Present-tense forms of auxiliary have omitted
 Omission of past-tense endings
 Past tense was used regardless of person, number
 Multiple negatives
 None/any, them/those, does/do substitutions
 Etc.
AAE Articulation Include:
Differences  /l, r,/ lessened or omitted
 /f, t, d, v/ voiceless th substitution
 Consonant-cluster reduction
 Devoicing of final consonant
 i/e, b/v, n/ng substitution
 Etc.
Spanish-Influenced English
Hispanic A label of convenience used to refer to people who reside in the US but were born in or trace the background of their families to one of the Spanish-speaking Latin American nations or to S[ain
or Portugal; an ethnic label – does not denote race; constitutes one of the fastest-growing segments of the US population
Spanish Dialects in the Two major dialects are southwestern (i.e. Mexican) and Caribbean (i.e. Puerto Rican)
US
Spanish Language Include:
Differences  Adjective comes after the noun
 /s/ omission in plurals, possessives and third-person present tense
 Past tense -ed omission
 Double negatives
 No used for negation
 Adverb following the verb
 Articles omitted
 Etc.
Spanish Articulation Include:
Differences  /t, d, n/ may be dentalized
 Final consonant devoiced
 b/v, ch/sh substitutions
 /d, z. t/ voiceless th substitution
 Schwa inserted before word-initial consonant clusters
English Influenced by Asian Languages
Asian Origin Originated from Southeast Asia, South Asia and east Asia; some of the most widely spoken Asian languages in the US are Chinese, Filipino, Vietnamese, Japanese, Khmer and Korean
Characteristics of Asian Include:
Languages  Vietnamese, Chinese and Laotian are tonal languages
o Mandarin has 4 tonemes, Cantonese has 7, Vietnamese has 6 and Central and Southern Vietnamese have 5
o Chinese, Vietnamese and Laotian are largely monosyllabic
o Chinese and Vietnamese have no consonant blends
o Some Asian languages do not have specific gender pronouns
o Asian speakers’ prosody/intonation in English may sound choppy and monotonous to native English speakers
o Some Asian speakers may sound hypernasal in English
Asian Language Include:
Differences  Omission of plurals, copula, possessive, past-tense morpheme, articles, conjunctions, single present-tense, inflection on do, have
 Past-tense double moarking
 Double negative
 SVO relationship
 Misuse of pronouns, prepositions and interrogatives
Asian Articulation Include:
Differences  Final cosnonat deletion
  /r/ and voiceless th omission
 r/l, ch/sh, b/v, v/w, p/f substiutions/confusion
 Reduction of vowel length

3. LANGUAGE DIFFERENCES AND LANGUAGE IMPAIRMENT

Differentiating Language Differences From Language Impairment
Language A system of symbols used to represent concepts that are formed through exposure and experience; many bilingual/ESL students have limited language/linguistic exposure which may contribute
to language difficulties
Children Diagnosed Must have language disorder in L1 and L2, otherwise simply a language difference; there are four language-learner possibilities/outcomes:
with Language 1. Typical language-learning ability with adequate background: may need bilingual education, sheltered English or instruction in English as a second language
Disorder 2. Typical language learning ability with limitations of linguistic exposure and environmental experience : may need bilingual education, sheltered English, instruction in English as a
second language or additional enrichment experience (i.e. tutoring, etc.)
3. Language impairment with adequate background: may need bilingual special education or English special education with as much primary language input and teaching as possible
4. Language impairment with limitations of linguistic experience and environmental exposure : may need bilingual special education, English special education with primary language
support, additional enrichment experiences
Acquiring a Second Language
Typical Process of L2 Includes:
Acquisition  Interference/transfer: an error in a student’s L2 due to an influence by L1; can occur in any language modality
 Silent period: typical for L2 learners where children listen more and speak less; can last anywhere from 3-6 months
 Code-switching: alternating between languages at the word, phrase or sentence level
 Language loss: the discontinued use of L1
Considerations for Includes:
Internationally  Age of adoption is critical – the younger the better
Adopted Children  Language skills should be assessed immediately
 Language attrition of L1 occurs rapidly
 Receptive English language skills are usually acquired before expressive
 Social-pragmatics may be an important area of focus
 Adoptive parent involvement is crucial
Conversational Interactive Language Fluency and Formal Academic Language Fluency
Conversational Oral language fluency that facilitates social interaction in daily life; there is surrounding context and communication between speakers is informal and casual
informal Language
Fluency (CILF)
Formal Academic Oral and written language skills that are gained primarily through schooling; mostly taught in academic settings and is used in reading and writing; generally takes longer to develop tan CILF;
Language Fluency well-developed FALF skills essential in formal assessments
(FALF)
CILF-FALF Gap May lead to false diagnosis of “language impairment”
Simultaneous i.e. infant bilinguality; occurs when two languages are acquired simultaneously from infancy; usually taught through naturalistic environment interaction
Bilingualism
Sequential Bilingualism Occurs when a person learns L1 as an infant naturally and L2 later in life; greater diversity in rates and stages

4. ASSESSMENT OF CLD CLIENTS

Legal Considerations
Individuals with Mandated that:
Disabilities Education 1. All children, regardless of disability, are entitled to an appropriate and free education
Improvement Act of 2. Testing and evaluation materials and procedures must be selected and administered so that they are not racially or culturally discriminatory
2004 (IDEA) 3. Testing and evaluation materials must be provided and administered in the language or other mode of communication in which the child is most proficient
4. Tests must be administered to a child with a motor, speech, hearing, visual or other communication disability, or to a bilingual child, so as to reflect accurately the child’s ability in the
area tested, rather than the child’s impaired communication skill or limited English-language skill
5. Multicultural education is to be considered in guaranteeing equal educational opportunities for minorities with handicaps
Considerations in the Use of Standardized Tests
Areas of Concern Include the tests’ potential legal, psychometric, cultural and linguistic limitations in terms of validity and reliability
Formal Test Formal tests assume that test takers/students will:
Assumptions 1. Follow the cooperative principle, performing to the best of their ability and trying to provide relevant answers
2. Attempt to respond even when test tasks don’t make sense
 3. Understand test tasks
4. Have been exposed to the information and experiences inherent in a test
5. Feel comfortable enough with the examiner in the testing setting to perform optimally
CLD students’ culture, linguistic experience, exposure, etc. may impact their ability to function under these assumptions
Ecological Validity The extent to which the test/task reflects the child’s actual, daily environment and life experience
Translating Translated tests assume all children have the same exposure/experiences and may not account for structural/content differences across languages and does not account for words that do not
Standardized Tests exist in other languages; psychometric properties of a test (i.e. validity, reliability, sample size, norming populations, etc.) do not carry over to translated versions
Tests Developed in Issues arise because of great heterogeneity of various minority populations (i.e. there may be multiple dialects for the same language) and due to the lack of research on languages other than
Primary Languages English
Selecting Standardized Clinician must consider:
Tests  The purpose of the test
 The construct validity
 The appropriateness of test content
 The adequacy of norms
Administering Clinician should:
Standardized Tests  Omit biased items
 Test beyond the ceiling
 Complete testing over several sessions
 Have a parent/adult trusted by the child administer test items under clinician supervision
 Give instructions in English and L1
 Rephrase confusing instructions
 Give extra examples, demonstrations and practice items
 Give student extra time to respond
 Repeat items when necessary
 Ask student to explain incorrect answers
Interpreting Clinician should:
Standardized Scores  Review test results with family members to gain insight into student’s performance
 Interpret overall test results in a team setting
 Don’t identify a student needing special education solely on the basis of test scores
 Ascertain if students’ errors are typical of other students with similar backgrounds
 Include cautions and disclaimers in assessment reports
Alternatives to Standardized Tests
Dynamic Assessment Clinician should:
Procedure 1. Obtain a thorough case history of child’s development in all domains
2. Use observation in a variety of naturalistic contexts
3. Use questionnaires administered to teachers, parents, others who interact with the child regularly
4. Use narratives
5. Use the portfolio method of assessment, in which samples of the student’s work are gathered over time to be analyzed
6. Use language samples
7. Use school records
8. Use conceptual scoring
Dynamic Assessment Evaluates a student’s ability to learn when provided with instruction; poor performance with dynamic assessment may indicate a learning disability
Response to A form of dynamic assessment that encompasses a number of components, including having teachers and other support personnel use specialized, scientifically based instruction in the regular
Intervention (RtI) education classroom with struggling students
Differentiating LI from Accomplished through:
CLD  Assessing working memory/informational processing skills
 Performing non-word repetition tasks
 Using the Comprehensive Test of Phonological Processing Skills
Should conduct:
1. Thorough case history (i.e. parent reports health and developmental issues, vision, hearing, language and academic history)
2. Portfolio assessment (i.e. view work samples over time and assess progress)
3. Narrative assessment (i.e. of storytelling and recall)
4. Dynamic assessment (i.e. evaluate ability to learn when provide with instruction – test-teach-retest)
5. Language proficiency testing (i.e. in L1 and English; evaluate CILF and FALF)
 6. Information processing (i.e. evaluate nonword repetition, digit span, sentence repetition, rapid automatic naming)
7. Informal assessment (i.e. in naturalistic contexts; language sampling and evaluating language use)
8. RtI (i.e. in classroom setting)
Working with Interpreters in the Assessment Process
Ethical Responsibilities Clinicians should:
when Working with  Make sure permission is granted
Interpreters  Make clear the use of interpreter in reports
 Allow interpreters to carry out activities for which they have been trained
 Gives interpreter background information
 Prepare interpreter for each session
 Ensure interpreter reports exact scores from student
 Supervise the interpreter at all times

5. TREATMENT CONSIDERATIONS IN SERVICE DELIVERY TO CLD CLIENTS

Children with Language Impairments
Service Delivery Clinician should consider:
Models  A bilingual special education classroom
 A monolingual, English special education classroom with primary language support through a bilingual teacher, tutor or others
 Pull-out services in the primary language or in English with primary language support
 Consultative, collaborative service provision in which the CLD child remains in the regular classroom and the teacher receives assistance from special education personnel or ESL or
bilingual staff (RtI)
 Placement in regular bilingual education or ESL classroom with support from special education treatment principles
Intervention Activities Should:
 Acknowledge student backgrounds, experiences and promote self-esteem
 Support development of both languages
 Focus on development of vocabulary
 Promote effective communication
 Include reading, writing, listening and talking – literacy
 Be related to classroom criteria
 Build relevant cognitive processing skills
Prevalence and Incidence Rates of Medical Conditions and Communication Disorders
Hispanic Statistics Hispanics tend to have:
 Low prevalence of esophageal cancer
 High prevalence of cardiovascular disease
 Higher prevalence of strokes and diabetes
 Overall low smoking rate
African American African Americans tend to have:
Statistics  High prevalence of TBI (esp. gunshot wounds in youth), strokes and hypertension, multi-infarct dementia, laryngeal/esophageal/lung cancers
 Low incidence of cleft palate (esp. cleft lip)
 Overall low smoking rate
Asian American Asian Americans tend to have:
Statistics  High prevalence of cleft palate (esp. Japanese and Chinese Americans), nasopharyngeal cancer (esp. Chinese Americans) and strokes
 Low prevalence of Alzheimer’s disease (esp. Chinese Americans)
 Overall low rates of alcoholism and smoking
Native American Native Americans tend to have:
Statistics  Generally low prevalence of lung cancer
 High prevalence of cleft palate and otitis media
 Generally high rate of smoking
 High prevalence of alcoholism and fetal alcohol syndrome
Potential Sociocultural and Linguistic Barriers to Service Delivery
Barriers to Full Include:
Utilization of Clinical  Over classification of CLD children as needing special education services
Services  Limited access to health care
 More advanced medical issues and communication disorders
  Lack of English proficiency and access to interpreters
 Distrust of Western medicine and rehabilitation
 Lack of transportation to and from medical facilities
Adults with Neurologically Based Disorders of Communication
Strokes The leading cause of neurological impairments; associated with hypertension (i.e. high blood pressure), arteriosclerosis (i.e. high cholesterol), sickle cell anemia, diabetes, AIDS, alcohol abuse
and drug abuse
Theories of Stroke 1. Synergistic and Differential Recovery Theory: both languages are impaired but not necessarily to the same degree; one may be more affected than the other; both languages may
Recovery for Bilinguals recover but not necessarily at the same rate; 95-98% of patients recover this way
2. Anatogonistic recovery theory: one language returns at the expense of another previously recovered language; very few cases of this recovery
3. Successive recovery theory: one language returns only after another has been completely restored; few documented cases of this
4. Selective recovery theory: one of the patient’s languages never recovers and remains impaired; occurs when other language has been recovered
Sociocultural Clinician should consider patient’s family culture, SES, family relationships, premorbid educational levels, religion
Considerations in
Rehabilitation and
Assessment

Ch. 10 Audiology and Hearing Disorders

1. ANATOMY AND PHYSIOLOGY OF HEARING
The Outer Ear
The Outer Ear Composed of the auricle/pinna and the external auditory canal/external auditory meatus
Auricle/Pinna The most visible part of the ear; composed primarily of cartilage; funnels sound to the ear canal and helps to localize sound
External Auditory Goes from the pinna to the tympanic membrane/ear drum; a muscular tube made mostly of cartilage that curves slightly like an S; ~2.5 cm long and resonates the sound that enters it; has
Canal/External special cells that secrete cerumen/wax that cleans, lubricates and protects the ear from fungi, bacteria and small insects
Auditory Meatus
The Middle Ear
The Middle Ear An air filled cavity separated from the outer ear by the tympanic membrane; includes the ossicular chain; connected to the nasopharynx through the Eustachian tube
Tympanic Membrane An elastic, thin and cone shaped structure that is flexible and tough and vibrates in response to sound pressure; entire tympanic membrane responds to low frequency sounds whereas only
some parts respond to high frequency sounds; can be easily damaged or ruptured which may heal spontaneously, however repeated ruptures leaves scar tissue that limits its movement
Ossicular Chain Suspended in the middle ear by ligaments; transmits sound efficiently without distortion and amplifies incoming sound by ~30dB before transmitting it into fluids of the inner ear; composed of
three tiny bones:
1. Malleus (i.e. hammer): the largest and first in the ossicular chain; transmits vibrations from the tympanic membrane
2. Incus (i.e.anvil): connected to the malleus in a tight joint permitting little movement
3. Stapes (i.e. stirrup): the footplate/other end of the stapes is inserted into the oval window (i.e. a small opening leading to the inner ear)
Muscles of the Middle Two small muscles in the middle ear dampen the vibrations of the tympanic membrane and the ossicular chain:
Ear 1. Tensor tympani muscle: innervated by CN V (trigeminal); tenses the tympanic membrane so vibrations are reduced
2. Stapedius muscle: innervated by CN VII (facial); stiffens the ossicular chain so vibrations are reduced
Acoustic Reflex The process of contracting the muscles of the middle ear when a person hears a very loud noise that could damage their ears
The Inner Ear
The Inner Ear Begins with the oval window where the inner ear receives the mechanical vibrations of sound; a system of interconnecting tunnels (i.e. labyrinths) within the temporal bone, which are filled
with fluid (i.e. perilymph); houses two major structures (i.e. vestibular and cochlea); the vibrations created by the footplate of the stapes into the oval window create a wavelike movement in
the perilymph  through Reissner’s membrane, those movements are transmitted to endolymph which then transmit movements to the basilar membrane  hair cells in the organ of Corti
respond to vibrations in the basilar membrane and the vibrations create a shearing force on those cells – this is where mechanical forces of vibration are transformed into electrical energy 
nerve fibers then carry sound via electrical energy to the brain
Oval Window A small opening in the temporal bone that houses the inner ear
Vestibular System Contains three semicircular canals responsible for equilibrium; related to movement, balance and body posture
Cochlea A snail shaped coiled tunnel filled with endolymph fluid; measures ~3.8 cm stretched; floor of the cochlear duct is the basilar membrane which contains the organ of Corti which is bathed in
endolymph and contains several thousand hair cells/cilia that respond to sound vibrations (each ear contains ~15,5000 hair cells)
Basilar Membrane Floor of the cochlear duct; different portions respond best to sounds of different frequencies; the tip is thicker, wider and more lax and are stimulated by low frequency sounds; the base is
thinner, narrower and stiffer and are stimulated by high frequency sounds

The Auditory Nervous System

Cranial Nerve VIII – Picks up the neural impulses created by the movement of hair cells in the cochlea; a bundle of nerves with two branches (vestibular and auditory); exits through the internal auditory meatus;
 Acoustic/ signal reaches the brainstem via cerebellopontine angle and projects the nerve fibers to the temporal lobe of the brain where the primary auditory area is located
Vestibulocochlear
Vestibular Branch of Concerned with body equilibrium/balance
CN VIII
Auditory/Acoustic Supplies many hair cells of the cochlea and conducts electrical sound impulses from the cochlea to the brain
Branch of CN VIII
Cerebellopontine Point where the auditory nerve exits the temporal bone through the internal auditory meatus and enters the brainstem; most have contralateral pathways, however some are ipsilateral
Angle

2. ACOUSTICS: SOUND AND ITS PERCEPTION

Acoustics A branch of physics that studies sound as a physical event
Psychoacoustics The study of sound as the psychological experience of hearing
The Source of Sound
Source of Sound The source of sound is mechanical vibrations of an elastic objects; vibrations create waves of disturbance that travel through a medium; a sound source can be anything that sets the vibration
into motion (ex: vocal folds)
Vibrations Set into motion by a moving object; occur in cycles
Frequency The number of times a cycle of vibration repeats itself within a second
Pure Tone A tone of a single frequency
Simple Harmonic/ A tone of single frequency that repeats itself
Sinusoidal Motion
Complex Tone Two or more sounds of differing frequencies
Periodic Vibrations Have a pattern that repeats itself at regular intervals
Aperiodic Vibrations Do not have a regular pattern and occur at irregular intervals
Sound Waves
Sound Wave Back and forth movement in molecules as a result of a moving object resulting in change in air pressure
Compression When molecules are compressed together
Rarefaction When the molecules are the farthest apart
Cycle Consists of compression and rarefaction
Hertz (Hz) Refers to number of cycles per second
Frequency and Intensity
Human Frequency The human ear is capable of responding to frequencies 20-20,000 Hz
Threshold
Pitch The perceptual change in frequency
Intensity The change in loudness
Loudness The perceptual correlate of intensity
Amplitude The extent of displacement in their molecules in their back and forth motion
Logarithmic Scale A scale where one number is multiplied by itself a specified number of time
Decibels (dB) 1/10 of a bel, the basic unit of sound pressure measurement; measures sound pressure and the intensity of one sound against another
Sound Pressure Level and Hearing Level
Sound Pressure Level The intensity of sound; the value of sound pressure is the square root of power, which is measured in watts; pressure is measured in terms of pascals
(SPL)
Thresholds  Normal speech: 50-70 dB SPL
 Very loud sounds (i.e. airplane): 100 dB SPL
 Feel pain ~140 dB SPL
 Most sensitivity 1000-4000 Hz
 To stimulate normal healthy ear of a young adult, a tone of 250 Hz at 25.5 dB SPL is needed; 1000 Hz only requires 7 dB SPL
Hearing Level (HL) The lowest intensity of a sound necessary to stimulate the auditory system; audiometric zero

3. NATURE AND ETIOLOGY OF HEARING LOSS

Normal Hearing
Auditory Development  Fetal development: babies can hear in utero ~20 weeks
 Newborns: respond differentially to sounds of different intensity and frequency
 3-4 months: babies turn head towards sound source and respond to mothers’ voice consistently
 6 months: better sound discrimination and ability to localize soft speech
 young babies with normal hearing can hear better than adults
Normal Hearing Sound is conducted to the inner ear through air and bone conduction

Air Conduction Sound travels through he medium of air; sound strikes the tympanic membrane  moves the ossicles  fluid moves in the ear  vibrations in the basilar membrane of the cochlea  hair cells
supplied by the acoustic nerve respond to vibrations  sound is carried to the brain by the acoustic nerves
Bone Conduction Fluids of the inner ear are housed in the skull; the larger bones of the skull and the ossicular chain collect sound  skull bones vibrate  movement in the inner air fluids
Nature of Hearing Impairment
Hearing Impairment Refers to the condition of being hard of hearing or deaf; can be acquired (ex: after years of exposure to loud music through headphones) or congenital (ex: baby is born with hearing loss due to
anatomical malformations, maternal history of drug/alcohol abuse, maternal diseases, family history of childhood hearing impairment, etc.); extent of hearing loss can range from mild 
profound  deaf
Hard of Hearing Child who is hard of hearing has loss between 16-75 dB; acquire speech and oral language with variable proficiency; adult who is hard of hearing has loss between 25-75 dB
Deaf Children and adults who cannot hear or understand conversational speech under normal circumstances; hearing loss exceeds 75 dB and often exceeds 90 dB; Deaf refers to deafness as a
cultural identity
Hearing Loss Can be conductive, sensorineural or mixed; others manifest central auditory or retrocochlear disorders
Range and Categories  up to 15 dB – normal hearing in children; in adults upper limit of normal hearing may extend to 25dB
of Hearing Loss  16-40 dB – mild hearing loss in children  difficulty hearing faint or distant speech and may cause language delay; in adults range is 25-40 dB
 41-55 dB – moderate hearing loss  delayed speech and language acquisition, difficulty in producing certain speech sounds correctly, difficulty following conversation
 56-70 dB – moderately severe hearing loss  can understand only amplified or shouted speech
 71-90 dB – severe hearing loss  difficulty understanding even loud and amplified speech, significant difficulty in learning and producing intelligible oral language
 91+ dB – profound hearing loss  typically described as deaf, hearing does not play a major role in learning, producing and understanding spoken speech and language
Conductive Hearing Loss
Conductive Hearing The efficiency with which the sound is conducted to the middle or inner ear is diminished; in pure conductive hearing loss, bone conduction, the inner ear, acoustic nerve and auditory centers
Loss of the brain area all working normally  conductive hearing loss is never profound and people can hear their own speech well; can be temporary or permanent; can be medically
treated/managed; significant air-bone gap present (>10 dB)

Causes of Conductive Include:

Hearing Loss  Abnormalities of the external auditory canal, tympanic membrane or ossicular chain of the middle ear
 Birth defects (i.e. aural atresia, microtia, stenosis)
 Perforation
 Foreign bodies
 External otitis (i.e. infection of skin in external auditory canal)
 Bony growths and tumors
 Otitis media/middle ear effusion
 Otosclerosis (i.e. a spongy growth on the footplate of the stapes reducing movement Carhart’s notch – specific loss at 2000 Hz)
  Otospongiosis (i.e. stapes becomes too soft to vibrate)
 Collapsed ear canals
 Impacted ceruman
 Ossicular discontinuity
Otitiis Media An infection of the middle ear that is often associated with upper respiratory infections and Eustachian tube dysfunction; more typical in children; results in 20-35 dB HL conductive hearing loss;
three types:
1. Serous otitis media: the middle ear is inflamed and filled with watery or thick fluid; the Eustachian tube is blocked and does not allow fresh air to ventilate the middle ear causing the
middle ear to become airtight; increased air pressure pushes the tympanic membrane inward, reducing its mobility and limiting efficient vibration; frequently treated with antibiotics
and pressure equalizing (PE) tubes which ventilate the middle ear and restore hearing
2. Acute otitis media: sudden onset due to infection causing a quick buildup of fluid and pus causing mild-severe pain; child may have fever or experience vertigo; buildup of pressure in
middle ear may rupture the tympanic membrane which give s instant relief as pus is discharged from the ruptured membrane but causing hearing loss; typically treated with medical
and surgical procedures (i.e. myringotomy)
3. Chronic otitis media: permanent damage to the middle ear structures frequently due to erosion of the ossicles, cholosteotoma or atrophy/perforation of the tympanic membrane;
more likely to result in permanent hearing loss

Sensorineural Hearing Loss

Sensorineural Hearing A result of damage to the hair cells of the cochlea or the acoustic nerve which prevents the brain from receiving the neural impulses of the sound; outer and middle ear may be working
Loss normally; hearing loss is permanent; person usually experiences mild to profound hearing loss and have difficulty hearing themselves and others; no air-bone gap present

Recruitment A potential symptom of sensorineural hearing loss that is a disproportionate increase in the perceived loudness of sound when it is presented with linear increases in intensity
Causes of Include:
Sensorineural Hearing  Prenatal causes include otoxicdrug, maternal drug/alcohol abuse -
Loss  Prolonged noise exposure
 Old age (i.e. presbycusis) – a normal hearing person should have full use of hearing until age 60
 Birth defects
 Viral and bacterial diseases (i.e. bacterial meningitis, mumps, etc.)
 In fetuses and newborns – STORCH (i.e. Syphilis, Toxoplasmosis, Rubella, Cytomegalovirus, Herpes simplex)
 Tumor (i.e. acoustic neuroma)
 Meniere’s disease results in fluctuating sensorineural hearing loss due to excessive endolymphatic fluid pressure in the membranous labyrinth
Mixed Hearing Loss
Mixed Hearing Loss Occurs when neither the middle or inner ear is functioning properly and results in both conductive and sensorineural hearing loss; may be caused by different or the same pathology; air-bone
gap present but smaller than conductive hearing loss
 Auditory Nervous System Impairments
Central Auditory Refers to hearing losses due to disrupted sound transmission between the brainstem and the cerebrum as a result of damage or malformation; central auditory processing disorder is a person’s
Disorders inability to take in a spoken message, interpret it and make it meaningful; can be caused by tumors, TBI, HIV, asphyxia during birth, genetic disorders, infections, metabolic disturbances,
cerebrovascular diseases, drug or chemical induced problems, central degenerative diseases and demyelinating diseases; person does not have significant peripheral hearing loss however still
has difficulty understanding distorted speech; characteristics include:
 Poor auditory discrimination, integration, sequencing and closure
 Difficulty listening with background noise
 Poor auditory attention, memory and localization
 Difficulty understanding rapid speech
 Difficulty following melodic and rhythmic elements of music
 Overall academic problems, including literacy, vocabulary and pragmatic skill difficulties

**controversial due to limited empirical evidence

Retrocochlear Occurs as a result of damage to the nerve fibers along the ascending auditory pathways from the internal auditory meatus to the cortex; usually consist of pathology involving the
Disorders cerebellopontine angle or CN VIII; usually caused by unilateral tumors (i.e. acoustic neuromas) and are accompanied by tinnitus and dizziness/disequilibrium; results in a gradual hearing ;oss;
symptoms are often confused with Meniere’s disease; may be caused by von Recklinghausen disease (i.e. an inherited disease characterized by the presence of numerous small tumors that
grow slowly along the peripheral nerves)

4. ASSESSMENT OF HEARING IMPAIRMENT

Audiometry
Audiometer An electronic instrument that generates and amplifies pure tones, noise and other stimulus for a hearing test
Pure-Tone Audiometry
Pure Tone Hearing Carried out to determine the threshold of hearing for selected frequencies; audiologist tests both ears individually at 1000, 2000, 4000, 8000 and 250 Hz
Test
Threshold An intensity level at which a tone si faintly heard at least 50% of the time
Air Conduction Test The client wears earphones which deliver the sound stimulus directly to the ear; masking is used when hearing loss is markedly uneven between ears
Bone Conduction Test Assesses the sensitivity of the sensorineural portion of the auditory mechanism; bone vibrator is placed on the forehead or behind the test ear, when the sound strikes the bones, they vibrate
and stimulate the fluid in both ears; difficult to determine which ear heard the sound  audiologist masks one ear by sending noise to the ear not being tested
Speech Audiometry
Speech Audiometry Measures how well a person understands speech and discriminates between speech sounds
Speech Reception The lowest/softest level of hearing at which the person can understand 50% of the words presented from a spondee list (i.e. list of two-syllable equal stress words)
Threshold
Word Discrimination/ Establishes how well a person discriminates between words by having the client correctly repeat monosyllabic words; scored as percentage of presented words correctly repeated; helps
Recognition Test identify people who can hear but not understand speech which is more likely with people with sensorineural hearing loss
Acoustic Immitance
Acoustic Immitance A transfer of acoustic energy that takes place when a sound stimulus reaches the external ear canal and strikes the tympanic membrane
Impedance Resistance to the flow of sound energy; tympanic membrane and middle ear structure create impedance; very high and very low impedance suggests pathology within the auditory system (ex:
broken ossicular chain)
Admittance A measure of the amount of energy that flows through the system
Tympanometry A procedure in which acoustic immitance is measured with an electroacoustic instrument called an impedance bridge/meter; allows the audiologist to place a sound stimulus in the external ear
canal with airtight closure and measure the changes in acoustic energy as the sound stimulates the auditory system
Acoustic Reflex A simple reflex response of the muscles attached to the stapes bone; elicited in both ears by a relatively loud sound; involves a stiffening of the ossicular change (to protect the ear from
damage); valuable in detecting middle ear diseases; measured with an impedance meter
Other Methods
 Electrophysiological An objective measure of auditory mechanism functioning; in response to sound the cochlea, acoustic nerve and auditory centers of the brain generate measureable electrical impulses that are
Audiometry recorded as changes in the background electrical activity of the brain called auditory-evoked potentials; abnormal electrical activity indicates hearing loss; electrocochleography is the procedure
for measuring the electrical activity of the cochlea in response to sound; auditory brainstem response (ABR) is a technique used to record the electrical activity in the auditory nerve, brainstem
and cortical areas of the brain and is useful for detecting brainstem diseases and in testing hearing of newborns and infants
Medical Imaging Computerized axial tomography is an important tool in ontological diagnoses and helps to detect small tumors and brain legions causing hearing impairment; magnetic resonance imaging is
best for imaging the internal auditory canals, base of the skull and pituitary gland regions to evaluate possible pathologies affecting the auditory system and is helpful in detecting acoustic
neuromas or tumors
Hearing Screening
Hearing Screening A quick, preliminary way to determine whether a person has normal hearing or may have a hearing problem and needs further evaluation; within an SLPs scope of practice
Purpose
Hearing Screening Pure tones are presented at 20-25 dB at the frequencies of 500, 1000, 2000 and 4000 Hz; screening is p/f
Procedures
Assessment of Infants and Children
Newborn Screenings 1. Otoacoustic emissions (OAE)
2. Auditory brainstem response (ABR)
Localization Involves presenting a sound and seeing whether the infant will turn their head toward the sound; response is measured by presenting sounds from different directions and noting the infants
Audiometry response; often used with older infants
Operant Audiometry A child’s hearing is tested by conditioning voluntary responses to sound stimuli; works best with children who are challenging to test using traditional audiometric means
Interpretation of Hearing Test Results
Assessment Include:
Procedures 1. Case history and interview
2. Comprehensive speech and language assessment
3. Otological records
4. General medical reports relevant to patient’s hearing
5. Reports from regular and special education teachers for children
Judging Hearing Loss  Mild: 16-48 dB
 Moderate: 41-55 dB
 Moderately severe: 56-65 dB
 Severe: 66-89 dB
 Profound: 90+ dB
Unilateral Hearing Loss Hearing loss in one ear
Bilateral Hearing Loss Hearing loss in both ears
Audiograms Graphs displaying results of air and bone conduction tests in dB
Air-Bone Gap The difference between air conduction and bone conduction hearing thresholds for a given frequency in the same ear

5. MANAGEMENT OF HEARING IMPAIRMENT

Communication Disorders of People with Hearing Impairment
Factors Influencing Include:
Language 1. Age of onset: congenital hearing loss has greater impact than hearing loss acquired later in adult life; children with prelingual deafness (i.e. who become deaf before they acquire
Development speech and language) are at higher risk than children with postlingual deafness (hearing loss after the age of 5)
2. How early in life professional help are provided
3. The quality and scope of services the child receives
4. The extent to which the parents help their deaf child
5. The presence of other disabling conditions
Speech Disorders Children with hearing impairments have difficulty learning speech sounds because they cannot hear them; common speech problems include:
 Distortion of sounds (esp. fricatives and stops)
 Omission of initial and final consonants
 Consonant cluster reduction
 Voiced/voiceless, Nasal/oral substitutions
 Omission of /s/
 Increased duration and imprecise production of vowels
 Epenthesis (i.e. adding schwa to consonant blends)

Language Disorders Some individuals who are deaf use language well, however children who are prelingually deaf are likely to exhibit language difficulties including:
  Use of limited variety of sentence types
 Use of sentences with reduced length and complexity
 Difficulty comprehending and producing complex, compound and embedded sentences
 Occasional irrelevance of speech
 Limited oral communication
 Difficulty understanding proverbs, metaphors and other abstract utterances
 Slower acquisition of grammatical morphemes
 Poor reading comprehension and writing skills
Voice, Fluency and Problems in voice, fluency and resonance depend heavily on the degree of hearing loss and amount of intervention received; common difficulties include:
Resonance Disorders  Hypernasal resonance on non-nasal sounds
 Hyponasal resonance on nasal sounds
 Abnormal phrasing, flow and rhythm of speech
 Monotone and inappropriately intonated speech
 Improper stress patterns with excessive pitch inflections
 Restricted and inappropriately high pitch range
 Excessively slow/fast rate of speech
 Inappropriate pauses
 Inefficient breathing
 Deviations in voice quality (i.e. hoarseness and harshness)
Aural Rehabilitation
Aural Rehabilitation An educational and clinical program implemented by a team (i.e. audiologist, otologist, SLP, educator of the deaf, vocational counselor, etc.) to help people with hearing loss achieve their full
potential; usually focus on speech reading and auditory training; components include:
 Evaluation of hearing loss
 Assessment of communicative needs
 Determination of availability of resources
 Prescription and fitting of hearing aid
 Auditory training
 Use of amplification systems in communication and educational training sessions
 Focus on communication patterns in the environment
 Addressing the impact of social, vocational, psychological and educational factors of the hearing loss
 Counseling the student and their family
 Recommending additional services
 Periodic re-evaluation
Acoustic Highlighting Involves emphasis on key words, shorter sentences, increased repetition and redundancy, a slower speaking rate, nearness to listener, increased pitch and rhythm and emphasis on the ends of
sentences
Amplification
Hearing Aids Amplify sound and deliver it to the ear canal; traditionally small electronically devices worn inside the ear unilaterally or bilaterally; types of hearing aids include eyeglass variety, body aids,
behind-the-ear model, in-the-canal model, completely-in-the-canal model, and disposable hearing aids; an analog hearing aid creates patterns of electronic voltage that correspond to the
sound input and consist of a microphone, an amplifier, a receiver, a power source and volume control; digital hearing aids contain microcomputer technology and rapidly samples the input
signal and converts each sample into a binary system of zeros and ones that are then processed by a computer housed in a unit worn on the body – they are more flexible, amplify frequencies
associated with greater hearing loss, are more effective in reducing irritating noise and provide a better signal-to-noise ratio; hearing aids can be air conductors or bone conductors
Cochlear Implants Electronic devices implanted in the cochlea and other parts of the ear to deliver the sound in the form of electrical impulses directly to the acoustic nerve ending sin the cochlea; best suited for
individuals with profound hearing loss who cannot benefit from hearing aids, however if the cochlea and its hair cells are damaged a cochlear implant will not work; consist of a microphone, a
processor, an external transmitter and an implanted receiver; implants have multiple channels/electrodes that stimulate different areas of the cochlea and attempt to produce various tonal
perceptions; enhance a person’s speech-reading performance and give patients general sound awareness for speech and environmental sounds; prelingual children (as young as 6 months old)
who receive cochlear implants can make substantial progress ; cause of controversy within the Deaf community
Central Electroauditory An implant that directly stimulates the cochlear nucleus of the auditory nerve at the brainstem level; may become a viable option for individuals with cochlea and hair cell damage
Prosthesis
Tactile Aids A type of sensory substitution method used for individuals who are deaf that promote the comprehension of speech by means of touch by converting sound into vibrations for tactile
stimulation; tactile aids have vibrators that generate patterns of stimuli representing different speech sounds; involves a great deal of training and practice to master; the Tadoma Method
requires the person to place their hands on the speakers face to feel the vibrations of speech
Assistive Devices Can be used solely or in conjunction with other amplification devices; safety alerting devices help people with hearing impairments gain information through flashing lights/vibrations on
common devices; closed-captioning on television is an assistive device; telecommunication devices for the deaf allow people to use the telephone
Communication Training
 Auditory Training Designed to teach a person with hearing impairment to listen to amplified sounds, recognize their meanings and discriminate sounds from each other; sound may be amplified through a
hearing aid, a desktop auditory trainer, an fm auditory trainer, etc.; includes discrimination of environmental sounds (can be difficult because background noise and teacher voice is often at the
same level  negative signal-to-noise ratio), discrimination of speech sounds and word pairs, and discrimination of phrases and sentences using a multimodal approach
Speech Reading Involves deciphering speech by looking at the face of the speaker and using visual cues to understand what the speaker is saying; ideally should be supplemented with other means of
communication; only 30% of English sounds are visible on the face
Cued Speech Speech produced with manual cues that represent the sounds of speech; composed of eight signs or hand configurations for consonants and four signs for vowels

Oral Language Training Oral language training should begin early and language stimulation programs are best carried out in clinical, educational and home settings; best to initially select and teach functional words
and then teach phrase and sentence structures so they can interact with the environment and others more effectively; clinician should focus on grammatical morphemes, terms with dual
meanings, antonyms, proverbs and abstract terms
Speech, Rhythm and Important to provide visual cues (i.e. charts, pictures, etc.); clinicians should pay special attention to affricates, fricatives and stops as well as the voice-voiceless distinction; clinicians should
Voice training address any voice, resonance and prosody abnormalities
Approaches to Training 1. Aural/Oral Method: attempt to use amplification methods to tap children’s residual hearing; children undergo intensive auditory training and speech reading instruction with the
expectation of learning to speak and fitting into mainstream social, vocational and educational settings
2. Manual Approach: means of nonverbal communication involving signing and fingerspelling; the sign language system is viewed as a part of Deaf culture and is the standard form of
communication in the community
3. Total communication: involves teaching verbal and nonverbal means of communication; signs and speech are used simultaneously
4. Nonverbal communication – sign language:
 ASL: signs are used to express ideas and concepts through complex hand and finger movements with each sign expressing a different idea
 Seeing essential English: breaks down words into morphemes and use written English word order and uses markers to identify number and tense and uses specific signs
for some verbs and articles
 Fingerspelling: ideas are communicated through quick, precise movements made by fingers; can be used alone or in conjunction with other methods
 Rochester method: uses a combination of oral speech an dfinger spelling

Ch. 11 Assessment and Treatment: Principles of Evidence-Based Practice

1. EVIDENCE-BASED PRACTICE IN SPEECH-LANGUAGE PATHOLOGY
Evidence-Based Practice
EBP Ensures that clients receive services that are known to be based on reliable and valid research and sound clinical judgement; includes efficacy of treatment procedures; always client centered’
requires integration of the best research evidence for clinical methods with clinical expertise and sound judgment; is ethnoculturally sensitive
Standard Assessment Procedures
Screening A brief procedure that helps determine whether a client should undergo a further more detailed assessment clients are judged to be WNL or referred for more testing
Case History Yields detailed information to help the clinician understand the communication disorder and associated variables; should include health, family, educational, occupational, cultural and linguistic
history, etc. When collecting:
 A description of the communication disorder, clinician should ask what the problem is, when was it first noticed, what were early signs, has it progressed and how, how is this viewed
in your cultural community?
 Assessment and treatment history, clinician should ask about any specialist seen prior and what they said, whether the child received treatment and what the results were?
 Family history, clinician should ask about any family history of the disorder, who currently lives in the home, whether the child communicates with family members, what languages
are spoken at home, whether the child plays with other children and how?
 Prenatal, birth and developmental history, clinician should ask how the mother’s pregnancy and birth was, what were the child’s birth conditions and weight, were there any feeding
or nursing problems, have you noticed any signs of hearing loss, how would you describe speech and language development and has it ever concerned you?
 Medical history, clinician should ask about any childhood illnesses or traumas, any surgical or medical treatments, if the child is currently taking any medication?
 Educational history, clinician should ask what level of education has been completed, did communication pose any difficulties in school, has the child been advanced or retained at
all, has the child received any special education services and what kind?
 Occupational history, clinician should ask about current occupation and how communication impacts performance, how is your relationship with colleagues and supervisors, what is
your occupational goal?
Prognosis A professional judgment made about the future course of a disorder or disease; clinicians must take caution when providing a prognosis; according to ASHA it is unethical to provide a promised
outcome but it is acceptable to make a reasonable statement of possible outcomes under specified conditions; factors influencing a prognosis include:
 Severity of disorder
 Client’s general health
 Physiological course of an underlying disease
 Time, quality, intensity and consistency of intervention
 Family support
 Client motivation
 Hearing Screening A quick procedure to determine whether a client can be assumed to have normal hearing or needs to be more thoroughly evaluated by an audiologist; SLPs should screen all clients prior to
completing a speech-language evaluation and refer a client if they fail
 Child screening: 15 dB at 500, 1000, 2000, 4000 Hz
 Adult screening: 20-25 dB at 500, 1000, 2000, 4000 Hz
Orofacial Exam An evaluation of the oral and facial structures to identify or rule out obvious structural abnormalities that may affect speech production or may require medical attention
Interview Involves a face-to-face exchange with the client, family members or both to obtain additional information and clarify previously gathered information; purpose of interviewing is to obtain data,
inform the client and provide support; important for the clinician to establish good rapport with the client during the interview
Speech and Language The primary means of assessing a client’s speech and language production in a naturalistic way; goal is to obtain a representative sample of the client’s speech and language production in
Sample naturalistic contexts reflecting the client’s everyday communication; procedures for collecting a language sample include:
 Recording the speech sample in a quiet room and avoid noisy stimulus materials
 Obtaining a minimum of 100 utterances
 Select appropriate stimuli
 Use age-appropriate conversational topics
 Repeat unintelligible utterances for accurate transcription later
 Ask a variety of wh- and y/n questions without bombarding the client
Obtaining Related When working with children, clinicians should obtain information related to hearing, behavior, health/medications, education, psychological, etc.; when working with adults, clinicians should
Assessment Data obtain information related to health/medications, medical treatment plans, brain imaging/radiologic data, hearing, physical rehabilitations
Multidisciplinary Team members represent multiple disciplines, but each member conducts an individual evaluation, writes a separate report and has little interaction with other team members
Teams
Transdisciplinary Team Multiple specialists work together in the initial assessment, but only one or two provide services
Interdisciplinary Team Team members from multiple disciplines interact and use each other’s suggestions and information in interpreting data; the team collaboratively writes the evaluation report and intervention
plan

2. PRINCIPLES OF STANDARDIZED ASSESSMENT

Nature and Advantages of Standardized Assessment
Standardized Test Systematic; have explicit directions and strict controls about what the examiner must say and do, specific stimuli are used and explicit rules for scoring the test ton ensure there is no
experimenter bias and attempt to collect uniformed responses across examiners; provide quantitative data to compare to performance of peers sampled in the standardization process; a test
can be standardized without being normed
Normed-Reference Authors select a task believed to be valid in measuring certain behaviors and administer the tasks to subjects who are thought to be representative of the population, the performances are
Test analyzed and result in normative data for specific age groups; primary purpose is to compare individual clients score to the normative group
Limitations of Standardized Tests
Limitations 1. Clients being tested are often not represented in the normative sample – major problem with CLD patients
2. Interactive styles of children may not match the formal fixed visual stimulus-question-response format of the tests
3. Many standardized tests have small sample sizes (should be at least 100)
4. Sample skills may not be representative of client’s behavior in natural environments
5. Do not give clinician’s guidance for planning treatment or evaluating treatment progress
Prudent Use of Standardized Tests
General Guidelines Include:
 Select tests that have samples representative of the client
 Do not modify test items to suit a client
 Only use tests that have detailed manuals and instructions, offer current norms and report satisfactory reliability and validity
 Use incorrectly answered questions as a probe to create informal measurement to help create treatment goals
Types of Scores in Standardized Assessments
Raw Score The actual scores earned on a test; converted to be viewed on a distribution
Distributions Yield measures of the client’s performance compared to the performance of the normative sample; include the mean (i.e. the average of the scores of the normative sample) and the standard
deviation (i.e. the extent to which scores deviate from the mean in the same sample – reflects the variability of all the measures of the normative sample – the larger the SD, the more variable
the scores)
 Normal Distribution

Percentile Ranks Converted scores that show the percentage of subjects who scored at or below a specific raw score; used to express a client’s score relative to the normative sample; 50 th percentile is equal to
the mean
Age Equivalency Shows the chronological age for which a raw score is the mean in the standardization sample
Grade Equivalency Shows the grade placement for which the raw score is the mean in the standardization sample
Validity of Standardized Tests
Validity Refers to the degree to which a measuring instrument measures what it purports to measure
Concurrent Validity Refers to the degree to which a new test correlates with an established test of known validity; too high correlation  the new test may be as valid as the old but the tests are too similar
Construct Validity Refers to the degree to which test scores are consistent with theoretical constructs, concepts or expectations; includes any qualitative or quantitative information that supports the test makers
theory or model underlying the test; challenging to establish because it requires that measurements be based on a theory; the researcher must prove that the test conforms to the prediction of
the theory
Content Validity A measure of the validity of a test based on a thorough examination of all test items to determine whether the items are relevant to measuring what the test purports to measure and whether
the items adequately sample the full range of skill being measured
Predictive Validity i.e. criterion-related validity; refers to the accuracy with which a test predicts future performance on a related task
Reliability of Standardized Tests
Reliability The consistency or stability with which the same event is repeatedly measured; may be influenced by fluctuations in the examinee’s behavior, examiner error and instrumentation/equipment
errors
Correlation Coefficient A number or index that indicates the relationship between two or more independent measures; used to express level of reliability; expressed through Person Product Moment r; highest
positive value is 1 and the lowest negative value is -1; r=0 indicates no relationship
Interjudge Refers to how many similarly subject’s performance is independently rated or measured by two or more observers who independently score the same set of behaviors to find how their scoring
(Interobserver) relates; ideally r is at least .90
Reliability
Intrajudge The consistency with which the same observer measures the same phenomenon on repeated occasions
(Intraobserver)
Reliability
Alternate Form i.e. parallel form reliability; refers to the consistency of measures when two forms of the same test are administered to the same person sampling the same behavior
Reliability
Test-Retest Reliability Refers to consistency of measures when the same test is administered to the same person twice
Split-Half Reliability Refers to a measure of the internal consistency of a test; can show examinee first/second half or even/odd test questions; generally, overestimates reliability as it does not measure stability of
scores over time

3. RATING SCALES, QUESTIONNAIRES AND DEVELOPMENTAL INVENTORIES

Rating Scales
Rating Scale Describes a phenomenon, a property or characteristic and asks the responder to suggest the quantity or severity of what is described
Nominal Scale A category is present or absent; items or observations are classified into discrete groupings that do not have numerical relationships to one another
Ordinal Scale A numerical scale that can be arranged according to rank orders or levels
Questionnaires
Questionnaires Contain questions to which clients or family members respond; may be a useful tool with CLD clients; may be used in conjunction with an interview; yield quantitative data, qualitative data, or
both
Developmental Inventories
Developmental Help track children’s physical and behavioral changes over time; must utilize some standardization to assign observed skills or developmental levels to specific ages
Inventories
4. ALTERNATIVE ASSESSMENT APPROACHES
Functional Assessment
Functional Assessment Evaluates a client’s day-to-day communication skills in naturalistic, socially meaningful contexts; does not depend on standardized test scores; requires clinician to make targets, procedures and
settings of assessment as naturalistic and “real-life” as possible; clinicians should observe client with family/peers, obtain home speech and language samples, interview a relevant person,
create and structure assessment tasks meaningful to the client, etc.
Client-Specific i.e. individualized procedures; a preferred alternative to standardized tests where client-specific form a valid basis for developing client-specific treatments; important to establish a reliable
Assessment baseline (i.e. an extended measure of target behaviors in the absence of planned treatment)
Criterion-Referenced Assessment
Criterion-Referenced A form of assessment that minimizes the role of standardized test scores in assessing skills; performances is assessed through any means and compared to a standard of performance selected
Testing by the clinician (i.e. the criterion); may use standardized or informal assessments; helpful when norms of standardized tests don’t apply to the client
Authentic Assessment
Authentic Assessment Emphasis on naturalistic observation of skills through sampling speech and language skills in every day settings and avoids formal testing environments
Minimal Competency Taking age and specific context into account, the least amount of linguistic skill or knowledge that a typical speaker is expected to display
Core
Contrastive Analysis Requires a knowledge of the speaker’s dialect and a naturalistic language sample to determine whether the differences found are disorders or culturally appropriate communication patterns
Dynamic Assessment
Dynamic Assessment Seeks to evaluate the child’s ability to learn when provided with instruction using a test-teach-retest format; incorporates testing into the assessment process; determines the child’s ability to
learn, not just their knowledge at one time; ideal for CLD clients
Portfolio Assessment
Portfolio Assessment Involves collecting a number of samples of a child’s work or performance over a period of time and observing the growth that occurs when instruction is provided
Comprehensive and Integrated Assessment
Comprehensive and The clinician retains the necessary elements of the traditional approach, possibly using standardized assessments, and then choosing client-specific stimulus materials, sample communication in
Integrated Assessment natural settings and evaluate each skill in depth; targets of assessment are always functional and meaningful to communication across contexts; includes elements of the functional, client-
specific, criterion-referenced, authentic, dynamic and portfolio assessments along with the essential elements of the traditional approach

5. TREATMENT OF COMMUNICATION DISORDERS: BASIC CONCEPTS

Treatment Definition
Broad Definition of Teaching, training, any type of remedial or rehabilitative work and all attempts at helping people by changing their behaviors or teaching new skills; involves working with family members,
Treatment teachers, peers, etc. to support and sustain communicating and swallowing skills in natural and institutional settings
Strict Definition of A procedure in which contingent relations between antecedents, responses and consequences are managed by a clinician to effect desirable change
Treatment
A Treatment Paradigm for Communication Disorders
Ideal Treatment Should be objective, measurable, empirical and reliable
Basic Treatment Terms
Antecedents i.e. treatment stimuli; various objects, pictures, instructions, modeling prompts and other stimuli used to elicit target responses
Aversive Stimuli Events people tend to avoid or describe as unpleasant
Avoidance An action resulting in not coming in contact with an aversive event and hence is repeated when such contact seems imminent
Baselines Measured response rates in the absence of treatment; the natural rate of response when nothing special is done to affect its frequency; helps prove treatment was necessary by establishing
and monitoring progress; essential part of EBP
Booster Treatment Treatment given any time after the client has been dismissed from initial treatment; important maintenance strategy; may involve original or new form of treatment
Consequences (of Clinician reactions when the client gives a correct or incorrect response or fails to respond; includes positive reinforcement and corrective feedback
Target Responses)
Constituent Definitions Definitions of target behaviors; defining concepts with the help of other conceptual terms; not helpful in measuring what is being defined
Corrective Feedback Information given to the client on incorrect or unacceptable responses in an effort to decrease those responses
Criteria Guidelines for making such clinical decisions as when to judge whether a response has been learned, when to move on to another target and when to dismiss the client from treatment
Direct Methods of Reducing behaviors by immediately providing corrective feedback
Response Reduction
Discrete Trials Treatment methods in which each opportunity to produce a response is counted separately; more efficient in establishing target behaviors but less efficient than naturalistic methods in
promoting generalizability
Escape A behavior that reduces or terminates an aversive event after client comes in contact with that event; a behavior that increases in frequency because it helped to reduce or terminate an
aversive event
Evoked Response Spontaneous response given to natural stimuli
Evoked Trial Clinical procedure in which no modeling is given to the client and stimuli are used to provoke a response
Exemplar A specific target response that illustrates a broader target behavior; individual items trained in therapy sessions
Extinction Simply withholding such reinforces as attention to reduce a (negative) response
Fading A treatment procedure in which the controlling power of a stimulus is gradually reduced while the response is maintained
Follow-Up A posttreatment assessment procedure designed t find out whether clients have maintained their treatment gains
Functional Outcomes Effects of treatment that are generalized, broader and socially and personally meaningful to clients; qualitative effects
Generality of Evidence that a treatment found effective in one situation, by one clinician, with some clients, is effective in other situations, when used by other clinicians, with other clients; important in
Treatment recommending treatment approaches
Generalized Production of a clinically established behavior in natural settings with no particular or systematic reinforcement; may be temporary without enforcement
Production
IEPs i.e. individualized education programs; for children with disabilities or special needs; mandated in public schools
IFSPs i.e. individualized family service plan; legally mandated for infants and toddlers with disabilities or special needs and their family members
Imitation A process of learning in which the learner reproduces what is modeled by the clinician
Indirect Methods of Reducing undesirable behaviors by positively reinforcing and increasing desirable behaviors
Response Reduction
Informative Feedback Telling clients how well they are doing in treatment sessions; giving specific quantitative information on performance to motivate the client
Initial Response The first, simplified component of a target response the client can imitate while shaping a target response
Intermediate Response A response that helps move toward the final target in a shaping procedure; should not be stabilized by excessive reinforcement
Intermixed Probes Assessment of generalized production of trained responses by altering trained and untrained stimulus items
Maintenance Strategy Various methods used to help maintain treatment gains in natural settings including training family members and others in evoking and reinforcing target behaviors, and teaching self-
monitoring skills
Manual Guidance The use of physical guidance in a shaping process
Mode of Response Manner or method of response; includes imitation, oral reading, conversational speech, etc.
Modeled Trail A discrete opportunity to imitate a response when the clinician models it
Modeling The clinician’s production of the response the client is expected to learn; used to teach imitation; effective in establishing target behaviors
Operational Definitions that describe how what is defined is measured; helpful in quantitatively measuring changes in target behavior during treatment
Definitions
Peer Training A response maintenance strategy in which peers of clients are trained to identify, prompt, evoke, reinforce and record target behaviors in a naturalistic setting
Physical Setting Production of a clinically established response in such extraclinical environments as the home, school, office, etc.
Generalization
Physical-Stimulus Production of clinically established responses to stimuli that were not used in training but are similar to stimuli that were used in training
Generalization
Post-Reinforcement Absence of responses following the delivery of a reinforcer; more commonly observed under fixed-interval schedules of reinforcement
Pause
Posttests Procedures designed to measure target behaviors after treatment to document changes form the pretests
Pretests Procedures to measure target behaviors before starting treatment; necessary to justify the need for treatment and to document changes under treatment compared to the results of the
posttests
Probes Procedures to assess generalized production of responses without reinforcing them; involve a criterion to be met before training advances to a more complex level or to another target behavior
Procedures of i.e. methods of treatment; used to teach target behaviors; includes modeling, instructions, verbal praise, prompting, reinforcing, etc.
Treatment
Prompts Additional verbal or nonverbal stimuli to increase the probability of a target response; should eventually be faded out
Punishment Procedures of reducing undesirable behaviors by response-contingent presentation or withdrawal of stimuli; includes corrective feedback, time-out and response out
Pure Probes Procedures for assessing generalized production when only untrained stimulus items are presented
Response Cost A method of reducing responses by withdrawing reinforcers contingent on each response
Response Production of new (untrained) responses in a mode not involved in training
Generalization
Satiation An internal body state that renders primary reinforcers temporarily ineffective
Self-Control Deliberately maintaining, increasing or decreasing specific behaviors of oneself; useful in response-maintenance strategy and includes procedures such as self-monitoring and self-recording
Shaping A method of teaching nonexistent responses that are not even imitated; target response is broken down into initial, intermediate and terminal components and are taught in an ascending
sequence (i.e. successive approximation)
Stimulus Evocation of established responses by stimuli not involved in training
Generalization
Targets of Treatment Skills and behaviors a client is taught
Terminal Response The final target behavior in a shaping procedure
Time-Out A brief period of silence, inactivity, averted eye contact and lack of reinforcement imposed on a response to be reduced
Tokens Objects that are given for correct responses and later exchanged for one of several backup reinforcers; helps minimize the satiation effect
Trial A structured and discrete opportunity to produce a response
Reinforcement
Reinforcement A method of selecting and strengthening behaviors by arranging immediate consequences under specific stimulus conditions
Continuous A method of reinforcing all correct responses in treatment
Reinforcement
Intermittent Reinforcement of only some responses produced or those with some delay between reinforcers
Reinforcement
Differential Teaching a client to give different responses to different stimuli; involves reinforcing the correct response and ignoring the incorrect response
Reinforcement
Differential Reinforcing a specified, desirable alternative to an undesirable behavior; involves replacing undesirable behaviors with desirable ones that give the client access to the same consequences
Reinforcement of
Alternative Behaviors
Differential Decreasing undesirable behaviors gradually be reinforcing progressively lower frequencies of the behavior
Reinforcement of Low
Rates of Responding
Differential Reinforcing a desirable behavior that cannot coexist with the undesirable behavior to be reduced
Reinforcement of
Incompatible Behavior
Differential Specifying one behavior that will not be reinforced while reinforcing many unspecified desirable behaviors, any one of which is accepted and reinforced
Reinforcement of
Other Behaviors
Negative Strengthening of behaviors by the termination of an aversive event
Reinforcement
Reinforcement Prompt removal of reinforces to decrease a response; includes extinction, time-out, response cost, etc.
Withdrawal
Schedules of Reinforcement
Schedules of Different patterns of reinforcement that generate different patterns of responses
Reinforcers
Fixed-Interval A schedule of reinforcement in which an invariable time duration separates opportunities to earn reinforcers; a form of intermittent reinforcement based on time lapsed between two
Schedule reinforcements
Fixed-Ratio Schedule An intermittent schedule of reinforcement in which a certain number of responses are required to earn a reinforce; helps fade or reduce reinforcement density
Variable-Interval A reinforcement schedule in which the time between reinforcers is varied around an average; generates a high and consistent response rate
Schedule
Variable-Ratio A variable reinforcement schedule in which the number of responses needed to earn a reinforce is varied around an average; generates a high and consistent response rate
Schedule
Reinforcers
Reinforcers Events that follow behaviors and therefore increase the future probability of those behaviors; can be verbal or nonverbal
Automatic Reinforcer Sensory consequence of a behavior that reinforces that behavior
Backup Reinforcer Reinforcer given at the end of a treatment session in exchange for tokens the client earned in the treatment session
Conditioned Reinforcer whose effect does not depend on a particular motivational state of the client; effective in a wide range of situations and include tokens and money
Generalized Reinforcer
Conditioned/ Events such as praise, smile sand approval that strengthen a person’s response because of past learning
Secondary Reinforcer
Negative Reinforcer Events that are aversive terminates, avoids or postpones them
Positive Reinforcer Events that follow a response and thereby strengthen them; necessary in teaching any kind of skill to a client; may be verbal or nonverbal
Primary Reinforcer i.e. unconditional reinforcers; events whose reinforcing effects do not depend on past earning or conditioning; biologically determined because of their survival value; useful for establishing
target responses, not for promoting generalized production; useful in teaching infants and toddlers or those with severe intellectual disabilities; essential to reinforce verbal mands in any client
Secondary Reinforcer Social or conditioned reinforcers whose effects depend on past learning
6. AN OVERVIEW OF THE TREATMENT PROCESS
Selection of Treatment Targets
Normative Strategy Based on the notion that, especially for children, norms provide the best basis for selecting target behavior; most frequent strategy used in treating language and speech sound disorders; age-
based norms dictate target behaviors
Client-Specific Strategy Behaviors selected will improve the client’s communication and help meet the social, academic and other demands made on the client; may or may not be consistent with normative strategy;
suitable for selecting target behaviors for CLD clients due to emphasize on individualized treatment approaches
Functional The target behaviors selected are the most useful skills that enhance communication and helpmeet the social and other demands made on the client; grammatical accuracy and speech sound
Communication production accuracy are less important than effective communication; targets help to improve naturalistic communication based on the assumption that any mode of response is appropriate
Strategy
Integrated Approach Treatment targets are appropriate for the client’s age, ethnocultural background, individual uniqueness and communication requirements; targets should be functional and useful and should
to Target Behavior enhance natural communication in everyday situations; emphasis on client and effective communication and lessens the importance of age-appropriate targets
Selection
Factors of Treatment Sequence
Response Complexity Treatment generally starts at a simple level and proceeds to more complex levels; at each level a criterion must be met before advancing; typical levels of response complexity are syllables 
words  phrases  sentences
Degree of Structure The sequence of treatment is partially based on the degree of treatment structure where treatment is more structured in initial stages using highly discrete trials and as client becomes more
proficient training is moved to more spontaneous kinds of productions and treatment structure is loosened becoming more natural
Response Modes In most cases, treatment starts with imitation until client is proficient enough for modeling to be withdrawn and evoked trials are introduced (i.e. imitation  spontaneous productions)
Multiple Targets Most clients need to attain multiple targets in treatment
Training and Based on initial training and eventual maintenance of the target behaviors in natural settings and over time
Maintenance
Shifts in Treatment Treatment contingencies refer to the pattern of reinforcement and corrective feedback given for correct and incorrect responses; initially the client is reinforced for every response (i.e.
Contingencies continuous) and eventually reinforcement is decreased to intermittent
Maintenance Program
Promoting Clinician should:
Maintenance Skills  Select target behaviors most likely to be produced in a natural setting
 Use a variety of stimuli
 Give sufficient treatment
 Teach skills in a naturalistic setting
 Teach self-monitoring
 Fade initial continuous reinforcement to intermittent reinforcement
 Train family members
 Teach client to prime others for reinforcement
 Follow up with the client and give booster treatment when needed
Follow-Up
Follow-Up A clinical procedure designed to find out whether a client has maintained target communicative skills and whether additional treatment is necessary; first follow up is ~3 months post dismissal,
second follow up is ~ 6 months post dismissal, third follow up ~1 year dismissal, subsequent follow ups are completed as necessary
Booster Treatment
Booster Treatment Treatment offered any time after the initial dismissal from services; may be identical or modified version of original treatment, a different form of treatment, or much less extended than the
original treatment

7. A GENERAL OUTLINE OF A TREATMENT PROGRAM

Treatment Procedures 1. Assess client’s communication behavior
2. Select target behaviors for training
3. Establish baselines of target behaviors
4. Plan a comprehensive treatment program
5. Implement the treatment program
6. Implement a maintenance program
7. Follow up on clients progress
8. Arrange for booster treatment

Ch. 12 Research Design and Statistics: A Foundation for Clinical Science

1. ESSENTIALS OF THE SCIENTIFIC METHOD
The Philosophy of Science: Basic Precepts
Research The process of asking and answering questions
Empiricism The philosophical position that statements must be supported by experimental or observational evidence; assumes that sensory experience is the basis of knowledge and that the sensory
experience must be objectively verifiable through observation and measurement
Determinism Events do not happen randomly or haphazardly because they are caused by other events
Scientific Activity The search for cause to events with the goals of describing natural events/phenomena, understand and explain natural phenomena (i.e. cause and effect), predict occurrences of events and
control natural phenomena by understanding the causes of the events and predicting their occurrence
Inductive Method An experiment-first and explain-late approach; researcher starts by conducting a series of experiments and then proposes a theory based on the results
Deductive Method An explain-first and verify-later approach; researcher explains an event and then attempts to verify the explanation through experimentation
Theory A systematic body of information concerning a phenomenon, describing an event, explaining why the event occurs and specifying how the theory can be verified; specifies causal variables
Hypothesis A proposed and testable answer to a specific question
Null Hypothesis States that two variables are not related; researcher hopes to reject the null hypothesis
Alternative Hypothesis States that two variables are related and that one may be the cause of the other; researcher hopes to accept the alternative hypothesis
Data The result of systematic observation and experimentation
Qualitative Data Verbal descriptions of data
Quantitative Data Numerical descriptions of data
Validity of Measurements
Validity Refers to the degree to which a measuring instrument measures what it purports to measure
Concurrent Validity Refers to the degree to which a new test correlates with an established test of known validity; too high correlation  the new test may be as valid as the old but the tests are too similar
Construct Validity Refers to the degree to which test scores are consistent with theoretical constructs, concepts or expectations; includes any qualitative or quantitative information that supports the test makers
theory or model underlying the test; challenging to establish because it requires that measurements be based on a theory; the researcher must prove that the test conforms to the prediction of
the theory
Content Validity A measure of the validity of a test based on a thorough examination of all test items to determine whether the items are relevant to measuring what the test purports to measure and whether
the items adequately sample the full range of skill being measured
Predictive Validity i.e. criterion-related validity; refers to the accuracy with which a test predicts future performance on a related task
Reliability of Measurements
Reliability The consistency or stability with which the same event is repeatedly measured; may be influenced by fluctuations in the examinee’s behavior, examiner error and instrumentation/equipment
errors
Correlation Coefficient A number or index that indicates the relationship between two or more independent measures; used to express level of reliability; expressed through Person Product Moment r; highest
positive value is 1 and the lowest negative value is -1; r=0 indicates no relationship
Interjudge Refers to how many similarly subject’s performance is independently rated or measured by two or more observers who independently score the same set of behaviors to find how their scoring
(Interobserver) relates; ideally r is at least .90
Reliability
Intrajudge The consistency with which the same observer measures the same phenomenon on repeated occasions
(Intraobserver)
Reliability
Alternate Form i.e. parallel form reliability; refers to the consistency of measures when two forms of the same test are administered to the same person sampling the same behavior
Reliability
Test-Retest Reliability Refers to consistency of measures when the same test is administered to the same person twice
Split-Half Reliability Refers to a measure of the internal consistency of a test; can show examinee first/second half or even/odd test questions; generally, overestimates reliability as it does not measure stability of
scores over time

2. EXPERIMENTAL RESEARCH
Foundational Concepts
Experiment A means of establishing a cause-effect relationship
Independent Variable Directly manipulated by the researcher that causes change in the dependent variable
Dependent Variable i.e. effect; the variable that is affected by the manipulation of the independent variable
True Experimental Rules out the influence of extraneous/confounding variables to isolate the relationship between the IV and DV
Design
Group Designs
Experimental Group Contains participants who receive treatment and thus show changes in behaviors treated
Control Group Contains participants who do not receive treatment
 Randomization Design Experimenter randomly draws a sample of participants for the study from the population; experimenter may use random assignment (i.e. each selected participant has the same chance of
being assigned to one group or another) or random selection (i.e. each member of a population has an equal chance of being selected)
Population A large, defined group identified for a purpose of study
Pretest – Posttest There are two groups (i.e. experimental and control) and is designed to help evaluate the effects of a single treatment; based on the logic that to assess the effects of an IV , the only difference
Control Group Design between the groups must be that variable; groups should be as identical as possible
Multigroup Pretest – Used to evaluate the relative effects (i.e. which treatment is more effective) of two or more treatments; each additional treatment adds another group to the design
Posttest design
Pros and Cons of Pros:
Group Experimental  Well conducted group designs have strong internal validity
Designs  Yields helpful information for professionals
Cons:
 Not always possible to randomly draw participants from specific clinical populations
 May not allow extension of the study’s results to individual clients
 Information gathered may be limited in clinical use
Single-Subject Designs
Single Subject Designs Establish cause and effect relationships based on individual performances under the different conditions of an experiment; allow extended and intensive study of individual subjects and does
not involve comparisons based on group performances; measure the dependent variable continuously; because subjects aren’t randomly selected, statistical analysis may not be completed
AB Method Similar to a case study; routine clinical work in which baselines are established (A), treatment is offered (B), and progress is summarized in a case study; clinician can claim improvement but not
effectiveness for the procedure
Experimental Method Involves methods of demonstrating treatment effects by showing contrasts between conditions of no treatment, treatment, withdrawal of treatment and other control procedures and are
applied to all participants (there are no control subjects)
ABA Design The basic single-subject experimental design; useful in establishing efficacy; consists of A-baseline, B-treatment, A-treatment withdrawal
ABAB Design An extension of the basic design; useful in establishing efficacy; consists of A-baseline, B-treatment, A-treatment withdrawal, B-reinstatement of treatment; clients benefit from experiment and
final phase may be continued as long as necessary to stabilize newly established skills
Multiple-Baseline A single subject design that avoids the disadvantages of treatment withdrawal in which the effects of the treatment are demonstrated by showing that untreated skills did not change and only
Designs the treated skills did; three variations include:
1. Multiple baseline across subjects design: involves several participants who are taught one or more behaviors sequentially (in a staggered fashion) to show that only behaviors of
treated participants change; those untreated do not change and that the treatment was effective
2. Multiple baseline across settings design: involves a behavior being sequentially taught in different settings to demonstrate that the behavior changed only in a treated setting and
treatment was effective
3. Multiple baseline across behaviors design: involves several behaviors that are sequentially taught to show that only treated behaviors change, untreated behaviors show no change
and treatment was effective
Pros and Cons of Single Pros:
Subject Designs  Clinicians can integrate research and clinical service
 Clients who serve as participants receive treatment
 Help generalize from research studies to individual clients
 More easily replicated
Cons:
 Results of one or a few studies cannot be generalized to the population
 Not efficient in predicting the behavior profile of groups of individuals

3. VARIETIES OF DESCRIPTIVE RESEARCH

Foundational Concepts
Descriptive Research The researcher observes a phenomena of interest and records their observations; researcher does not want their presence to interfere with the natural phenomena being observed; cannot lead
to cause-effect relationship statements; useful when experimental method is unethical (ex: in completing research on women who drink alcohol during pregnancy); useful in understanding a
phenomenon
Classification Variable Analogous to the IV in experimental research
Criterion Variable Analogous to the DV in experimental research
Ex Post Facto i.e. after-the-fact research/causal-comparative studies; investigator begins with the effect of an IV that has occurred in the past and then makes a retrospective search for causes of events; may
(Retrospective) attempt to determine potential causes of disorders (CANNOT determine confirm causes without experimentation); help to study rare, individual cases of diseases and disorders in depth
Research
Survey Research Assess some characteristics of a group of people or a particular society and attempt to discover how variables such as attitudes, opinions or certain social practices are distributed in a
population; goal is to generate a detailed inspection of the prevalence of phenomena in an environment by asking people as opposed to direct observation; conducted through interviews and
questionnaires; can yield a wide range of data, however samples can often be biased (b/c people who return surveys tend to feel strongly about the issue); cannot be used to determine cause-
 effect relationships
Comparative Research i.e. standard group comparison; purpose is to measure the similarities and differences of groups of people with defined characteristics; take comparative research data with a grain fo salt
because similarities and differences may also be due to other variables
Developmental Purpose is to measure changes in subjects over time; type of research chosen when researchers believe that age may be the cause of changes seen in people; presumed IV is maturation; used
(Normative) Research extensively to create developmental norms; may be conducted with a longitudinal research design (i.e. the same participants are studied over time; making observations within subjects), using
a cross-sectional method (i.e. researchers select participants from various age levels and observe behaviors of the groups formed on the basis of age; making observations between subjects) or
a semi longitudinal procedure (i.e. the total age span to be studied is divided into several overlapping age spans; subjects are at the lower end of each age span and are followed until they reach
the upper end of their age span; making observations within and between subjects)
Correlational Research Researcher investigates relationships or associations between variables; correlation does not prove causation; suggests the direction (i.e. positive or negative) and the strength of the
relationship using Pearson r (i.e. -1.0 – +1.0 indicating strength and direction)
Ethnographic Research
Ethnographic Research Involves observation and qualitative description of naturally occurring phenomena; investigators conduct detailed observations but do not formulate hypothesis – observations lead to
conclusions; used with clients and cultural groups when experimentation is not ideal or possible
Meta-Analysis
Meta-Analysis A statistical method involving the integration of data across studies to form general conclusions; gives a summary of studies and findings

4. EVALUATION OF RESEARCH
Internal Validity
Internal Validity The degree to which data in a study reflects a true cause-effect relationship (i.e. strong internal validity indicates that the DV was only affected as a result of the IV and no
extraneous/confounding variables exist)
Threats to Internal Result in a failure to establish a cause-effect relationship; include:
Validity 1. Instrumentation refers to problems with such measuring devices as mechanical and electrical instruments, pen and paper instruments and human observers
2. History includes subjects’ life events that may be partially or totally responsible for changes recorded in the DV after the IV is introduced
3. Statistical regression refers to a behavior from an extreme high or low point to an average level
4. Maturation refers to biological and other kinds of changes within participants themselves that can have an effect on the DV
5. Attrition refers to the problem of losing participants as an experiment progresses
6. Testing refers to a change that occurs in a DV simply because it has been measured more than once
7. Subject selection biases are subjective factors that influence the selection of who participates in the study
8. The results of a study becoming confounded by a combination of threats to internal validity
External Validity
External Validity Refers to generalizability – to what settings, populations, treatment variables and measurement variables an effect can be generalized
Threats to External Limit the degree to which internally valid results can be generalized; include:
Validity 1. The Hawthorne Effect is the extent to which a study’s results are affected by participants’ knowledge that they are taking part in an experiment or being treated differently than usual
2. Multiple-Treatment Interference refers to the positive or negative effect on one treatment over another
3. Reactive or interactive effects of pretesting refers to the sensitization of the participant during a pretest of the DV impacting the effect of the treatment variable
Levels of Evidence for EBP
Classes Of Evidence From strongest  weakest
1. Class I evidence: based on a randomized group experimental design study, often referred to as a randomized clinical trial; the best evidence supporting a procedure; evidence must
come from at least one larger clinical trial with experimental and control groups
2. Class II evidence: based on well-designed studies that compare the performance of subjects that are not randomly selected or assigned to different groups; groups may or may not be
equal to begin with; no assurances noted on posttests due to treatment
3. Class III evidence: based on expert opinion and case studies; claim effectiveness but do not include control groups; weakest level of evidence
Hierarchy of Evidence From least  most desirable
Level 1: expert advocacy
Level 2: uncontrolled, replicated evidence
Level 3: uncontrolled, directly replicated evidence
Level 4: uncontrolled, systematically reduplicated evidence
Level 5: controlled, replicated evidence
Level 6: controlled, directly replicated evidence
Level 7: controlled, systematically replicated evidence

5. DATA ORGANIZATION AND ANALYSIS: PRINCIPLES OF STATISTICS

Foundational Concepts
Statistics Refers to the field of study involved with the art and science of data analysis and the specific pieves of data gathered
 Probability The chance of something occurring
Parameter A population value
Inference A conclusion one arrives at through reasoning
Statistical Techniques for Organizing Data
Variability The dispersion or spread in a set of data
Measures of Variability Include:
1. Range: the difference between the highest and lowest scores in a distribution or set of scores
2. Interquartile range: cuts off the highest and lowest 25% of the scores in a distribution
3. Semi-interquartile range: interquartile range divided by 2 (25:50)
4. Standard deviation: the extent to which scores deviate from the mean (the larger the sd the higher the variability)
Central Tendency A distribution or set of scores in an index indicating the average score for that distribution
Measures of Central Include:
Tendency 1. Mean: the average
2. Median: the middle number in the distribution of scores
3. Mode: the most frequently occurring score in the distribution
Types of Measurement Scales
Nominal Scale A category is present or absent; items/observations are classified into named groups which do not have a numerical relationship to each other
Ordinal Scale A numerical scale that can be arranged according to rank order or levels; use concepts greater than and less than; corresponding numbers do NOT have a mathematical meaning intervals
between numbers of categories are unknown and may not be even
Interval Scale A numerical scale that can be arranged according to rank orders or levels; numbers on scale must be designed in such a way that the intervals between them are equal in regard to the attribute
being scaled
Ratio Scale A numerical scale that can be arranged according to rank orders or levels; where numbers on scale have numerical value and must be designed in such a way that the intervals between them
are equal in regard to the attribute being scaled; zero indicates the absence of

Ch. 13 Special Topics in Speech Language Pathology

1. COUNSELING
Counseling Creating an interpersonal, helping relationship whose goal is to support clients and families who experience emotional distress related to a communication disorder
Qualities for Effective Include:
Counseling  Objectivity
 Competence and knowledge
 Honesty and openness
 Flexibility
 Empathy
 Trustworthiness
 Emotional stability
 Ability to motivate clients
 Nonjudgmental attitude
 Ability to listen
Special Include:
Issues/Influences in  Gender
Counseling  Age
 Culture
 Time
 Religion
Reactions and Include:
Emotions Related to  Shock and disbelief
Communication  Denial
Disorders  Anger
 Grief
 Guilt
 Anxiety
Defense Mechanisms Include:
 Rationalization
  Reaction formation
 Displacement
 Projection
 Repression
 Suppression
Approaches to Counseling
Psychodynamic Theory Views behavior as the product of conflictual interaction between three systems (i.e. the id, ego and superego) and anxiety is created when emotions arising from conflicts among these three
systems are repressed; purpose of treatment is to make clients aware of repressed problems and help them to resolve problems; counseling is best undertaken by trained mental health
professionals who understand and believe its efficacy
Client-Centered Assumes that clients need acceptance and positive unconditional regard in order to develop congruence between their self-concept and their behavior; centered around an empathic
Theory relationship between client and therapist; steps for counseling include:
1. Client is encouraged to freely express emotions and all emotions are accepted and explored in a warm, empathetic climate of listening
2. Clinician responds to both content and feelings of what the client expresses and listens without giving advice
3. Client becomes open to change and self-growth
4. Client assumes responsibility for determining goals and then to take action toward achieving goals
Behavior Theory Clinicians focus on what is observable with emphasis on environmental/external influences; focus on specific outcomes of counseling and interacting; focuses specifically on areas impacting the
clients communication; goals can be measured and observed to monitor progress; allows for documentation; based on the belief that:
 All behavior is a function of current environmental stimuli, past reinforcement and genetic/neurophysiological variables
 Behavior is shaped and maintained by immediate consequences
 Reinforcement must be given immediately
 Positive reinforcement increases the chance a behavior will occur
 Negative reinforcement can also cause a behavior to recur
 Behaviors that occur in the absence of reinforcement will be extinguished
Cognitive-Behavioral Assumes the client’s thoughts are key to their feelings and actions and the key variable is the meaning a person attributes to an event; clinician helps the client focus on the problem and replace
Theory old distorted thoughts with new more rational thoughts leading to behavior changes; the clinician would:
1. Help the client explore this thinking
2. Challenge the client to test the validity of their old belief through experimentation
3. Create a change in thinking through analyzing the data gathered through experimentation
4. Create a change in behavior based on the new, positive evidence
Eclectic Approach The combination of client-centered, behavioral and cognitive-behavioral approaches

2. MEDICAL SPEECH LANGUAGE PATHOLOGY

Practice and Responsibilities of SLPs
SLP Duties in a Medical Include:
Setting 1. Assessment and treatment in areas under the SLP scope of practice (i.e. cognition, neurogenic speech/language disorders, swallowing disorders, sensory awareness, voice disorders,
speech sound and resonance problems, communication problems)
2. Participation in multidisciplinary teams
3. Staff education
4. Counseling and education of patients and families
5. Documentation of assessment and treatment via SOAP notes
Infectious Diseases
AIDS Related Include:
Communication  Dementia
Problems  Aphasia
 Motor speech impairment
 Reduced verbal output
 Language of confusion
 Stuttering
 Voice disorders
 Etc.
Medical Imaging Techniques
Tomography A computerized radiographic method of taking pictures of different planes of body structures; used to scan brain structures and frequently used as a neurodiagnostic method for people with
communication disorders (ex: aphasia secondary to stroke)
 Computerized Axial Radiographic imaging procedure where x-ray beams circle through segments of the brain and pass through tissue and a camera takes pictures of sections of the structure being scanned, the
Tomogrophy (CAT) Scan scanner detects density differences and a computer analyzes the images and produces pictures of the scanned structures; can detect hemorrhages, lesions, tomors and other pathologies;
often sued with pathologies secondary to stroke
Electroencephalograph Neurodiagnostic method that records and measures electrical impulses of the brain through small surface electrodes attached to the scalp; can show different kinds of brain waves associated
y (EEG) with different kinds of activity; indicates cerebral pathology and is often used to detect seizures
Magnetic Resonance Neurodiagnostic imaging technique where fine details in the brain and spinal cord structure are shown; can provide images of soft tissues, large blood vessels and the heart; works based on
Imaging (MRI) alignment and realignment of nuclei of atoms in the cell when a structure is placed in a strong magnetic field; does not use x-rays and provides a higher resolution picture but is expensive and
patients may have difficult tolerating the procedure which takes place in a cylindrical container
Functional MRI (fMRI) Yields information that allows doctors and researchers to examine brain activity while the patient is engaged in a task
Positron Emission Neurodiagnositc procedure where emission-computer tomography allows imagining of metabolic activity through measurements of radioactivity in the section of the body being viewed;
Tomography (PET) patient is injected with radioactive substance that is detected by scans and suggests different rates of cerebral metabolism (low rates indicate neuropathology); effective for patients suspected
to have cerebral dysfunction secondary to a stroke
Single-Photon Emission- i.e. regional cerebral bloodflow-rCBF; evaluates the amount of blood flowing through a structure to help assess cerebral metabolism; patients inhale a radioactive gas and a scanner detects
Computed Tomography uptake in cerebral blood
(SPECT)
Videofluoroscopy A radiologic method of examining movement of internal structures and recording the movement patterns for assessment and diagnosis; useful for assessing velopharyngeal mechanism, vocal
folds, swallowing and respiratory movements; x-rays are transmitted through tissue under observation and the soft tissue is coated with barium with the help of a nasal spray; observer has
multiple views of the structures and their movements; often used to assess swallowing function

3. CRANIOFACIAL ABNORMALITIES AND GENETIC SYNDROMES

Craniofacial Abnormalities
Craniofacial Abnormalities of the face and head; congenital; largely genetic
Abnormalities
Cleft An opening in a normally closed structure
Cleft lip Opening in the lip; usually the upper lip, lower clefts usually associated with cleft palate; usually unilateral, more frequently on the left, bilabial frequently associated with cleft palate
Cleft Palate Various congenital malformations resulting in an opening in the hard palate, soft palate or both; malformations are due to disruption of the embryonic growth process resulting in a failure to
fuse structures that are normally fused; may be a part of genetic syndrome with other abnormalities
Etiology of Clefts Related to a variety of genetic, chromosomal, environmental, and mechanical factors, including:
 Genetic abnormalities:
o Autosomal dominant inheritance in some syndromes (i.e. Apert syndrome, Stickler syndrome, Van der Woude syndrome, Waardenburg syndrome, Treacher Collins syndrome)
o Recessive genetic inheritance in some syndromes (i.e. orofacial-digital syndrome)
o X-linked inheritance in some syndromes (i.e. oto-palatal-digital syndrome)
o Chromosomal abnormalities (i.e. Trisomy 13)
 Environmental teratogenic factors:
o Fetal alcohol syndrome
o Illegal drug use
o Side effects of prescription drugs
o Rubella
 Mechanical factors:
o Intrauterine crowding
o Twinning
o Uterine tumor
o Amniotic ruptures
Classification of Clefts Major types of clefts include cleft lip, cleft of alveolar process, cleft of prepalate, cleft of the palate, cleft of the prepalate and palate, facial clefts other than prepalate and palate
Microforms Minimal expressions of clefts; revealed only through laminographic examination; include submucous clefts (i.e. where surface tissues of the soft/hard palate fuse but underlying muscle or bone
tissues do not felt as a notch in the palate and characterized by hypernasal speech and frequent ear infections)
Congenital A related disorder of clefting referring to impaired velopharyngeal closing valve function; characterized by significant impairment of velopharyngeal functions; may be a result of a short palate,
Palatopharyngeal a submucous cleft, reduced muscular mass of the soft palate, deep or enlarged larynx, incorrect insertion of levator muscles, etc.; patients typically present with hypernasal speech
Incompetence
Communication Include:
Disorders Associated  Hearing loss (children with clefts are prone to middle ear infections and eaustachian tube dysfunction  hearing loss)
with Clefts  Speech sound disorders (more significant if cleft not repaired early or repair is inadequate; errors include difficulty with unvoiced sounds, pressure consonants, audible nasal air
emission, distortion of vowels, difficulty with sibilants, compensatory errors including substitutions and omissions and difficulty with affricates, fricatives and plosives)
  Language disorders (delayed language development, may be related to genetic syndrome)
 Laryngeal and phonatory disorders (vocal nodules, hypertrophy and edema of vocal folds, vocal hoarseness, reduced vocal intensity, hyper or hyponasality, denasality)
Assessment of Usually includes working with an multidisciplinary team comprised of surgeons, geneticist, pediodontists, etc.; assessment includes:
Children with Clefts 1. Assessment of velopharyngeal function include orofacial examination and judgments about hyper and hyponasality (indicating velopharyngeal dysfunction) and objective assessment
using endoscopic (nasopharyngeoscopy) or videofluoroscopic examination of velopharyngeal mechanism and motility; oral manometer may be helpful (ration <1 = velopharyngeal
incompetency-VPI); can complete cephalometric analysis (to measure relationship between depth of nasopharynx and length of soft palate)
2. Assessment of speech sound disorders: may use Iowa Pressure Articulation Test and obtain a speech sample
3. Assessment of language disorders
4. Assessment of phonatory disorders: make judgments about vocal quality deviations
5. Assessment of resonance disorders: assess hypernasality in speech and possibly hyponasality
Treatment of Children Includes:
with Clefts 1. Surgical management of cleft: may include primary and secondary surgeries for cleft, lip or palatal surgery, V-Y retroposition method of surgery, the von Langenbeck surgical method,
delayed hard palate closure, pharyngeal flop or pharyngoplasty
2. Treatment of speech sound disorders: training on /k, g/ may be inappropriate if velopharyngeal functioning is inadequate, includes typical speech sound treatment and teaching of
compensatory strategies; non-speech, oral-motor blowing exercises is helpful for children with cleft palates; electropalatography (i.e. an articicial palate with electrodes to visualize
palate movement and patterns) is effective in providing immediate visual feedback
3. Treatment of language disorders
4. Treatment of resonance disorders: hypernasality due to VPI should not be treated until surgical/prosthetic efficacy improves physiological functioning and the child is capable of
velopharyngeal closure; can use voice therapy techniques to reduce hypernasality (i.e. increase vocal loudness, discrimination training, lowered pitch and increased oral opening) as
well as utilizing instrumentation
Genetic Syndromes
Syndrome A constellation of signs and symptoms associated with a morbid process/genetic basis
Angelman Syndrome  Pregnancy and birth: usually involves a normal prenatal and birth history, normal head circumference and no obvious birth defects
 Etiology: chromosome 15 is duplicated from the father or deleted from the mother
 Diagnosis: between 3-7 years of age (although developmental delay may be apparent by 6-12 months)
 Symptoms: seizures, stiff and jerky gait, laughter and happy demeanor, easily excitable personality, hypermotoric behavior, hand-flapping, short attention span
 Speech characteristics: usually have few or no words and nonverbal communication and verbal receptive skills are higher than expressive
Apert Syndrome  Etiology: spontaneous autosomal dominant mutations (gene FGR2 at 10q25-26)
 Diagnosis:
 Physical characteristics: digital fusion (2nd, 3rd, 4th digits), craniosyntosis resulting in smaller skull diameter, flat frontal and occipital bones and high forehead, midfacial hypoplasia
(underdevelopment), arched and grooved hard palate, conductive hearing loss, class III malocclusion, irregular dentition, thickened alveolar process and soft palate, cleft of the hard
palate
 Speech characteristics: hyponasality, forward carriage of the tongue, articulation disorders (involving alveolar consonants and labiodental sounds; may have normal or impaired
intelligence
Cri du Chat Syndrome  Etiology: absence of the short arm of the fifth chromosome (i.e. 5p)
 Physical characteristics: low-set ears, narrow oral cavity, laryngeal hypoplasia, microcephaly, hypertelorism, micrognathaia and oral clefts
 Communication problems: articulation and language disorders typically associated with intellectual disability
Crouzon Syndrome  Etiology: autosomal dominant inheritance with varied expression in individuals
 Physical characteristics: small maxillary structure, sphenoethmoidal synchondroses, ocular hypertelorism (eyes too far apart), craniosytosis, hypoplasia of midface/maxilla, protrusion
of the eyeballs, a parrot like nose, facial asymmetry, tall forehead, class III malocclusion, highly arched palate, shallow oropharynx, long and thick soft palate and a short head
 Communication problems: conductive hearing loss, articulation disorders, hyponasality and language disorders
Down Syndrome  Etiology: an extra whole number chromosome 21, resulting in 47 chromosomes
 Physical characteristics: generalized hypotonia, cardiac malformations
 Communication problems: conductive/sensorineural hearing loss, possible language delay/disorder, deficient syntactic and morphological features accompanied by relatively better
vocabulary skills, hypernasality and nasal emission, breathy vocal quality, articulation disorders
Fragile X Syndrome  Etiology: expansion of nucleic acid cytosine-guanine-guanine (CGG), which repeats too often on the fragile x mental retardation gene (FMR1) located on the bottom of the x
chromosome
 Physical characteristics: large/long/poorly formed pinna, big jaw, enlarged testes, high forehead
 Communication problems: leading inherited cause of intellectual disability in males, jargon, perseveration, echolalia, inappropriate language or talking to oneself, lack of gestures/
nonverbal means of communication, males may experience social/pragmatic difficulties
Hurler’s Syndrome  Etiology: autosomal recessive deficiency of X-L iduronidase
 Prognosis: rare condition; most children die in their early teens or even before 10 years old
 Physical characteristics: dwarfism, hunchback, intellectual disability, short and thick bones, coarse facial features with a low nasal bridge, sensorineural deafness, noisy respiration
 Communication problems: compromised intelligibility (due to thick, everted lips, a large tongue and small, malformed teeth); hoarse vocal quality
Landau-Kleffner  Etiology: unknown
Syndrome  Characteristics: form of aphasia where formerly healthy children ages 3-7 lose their ability to comprehend language and then speak it (can occur gradually or suddenly); language loss
can be permanent or temporary (lasting months-years)
Marfan Syndrome  Etiology: autosomal, dominant inherited disorder caused by mutations in the FBN1 gene
 Physical characteristics: impacts the body’s connective tissue and may include bone overgrowth and loose joints; may have restricted lung disease due to overgrowth of ribs bending
the sternum in or pushing outward
 Communication problems: shortness of breath while speaking
Moebius Syndrome  Etiology: heterogeneous causation, including agnesis or aplasia of the motor nuclei of the cranial nerves
 Physical characteristics: involvement of facial and hypoglossal nerves and possibly trigeminal nerve, bilabial paresis and weak tongue control, unilateral/bilateral paralysis of
abductors of the eye, limited strength/range/speed of movements of articulators, feeding problems in infancy, mask-like face
 Communication problems: conductive hearing loss, delayed language, articulation disorders (mostly impacting bilabial, linguadental and lingua-alveola sounds)
Pierre-Robin  Etiology: occurs as an autosomal recessive inheritance or as a part of Stickler syndrome
Syndrome  Physical characteristics: mandibular hypoplasia, cleft of the soft palate, velopharyngeal incompetence, deformed pinna, low set ears, temporal bone and ossicular chain deformities,
glossoptosis (i.e. tongue is positioned posteriorly causing airway blockage), feeding difficulties
 Communication problems: conductive hearing loss (associated with otitis media and cleft palate), language delay or disorder, hypernasality and nasal emission, articulation disorders,
hypercompensaotry articulation
Prader-Willi Syndrome  Etiology: autosomal dominant inheritance and deletion in the region of the long arm of chromosomes 15
 Physical characteristics: low muscle tone, early feeding difficulties, failure to thrive initially, obesity after the first year, excessive eating, underdeveloped genitals
 Communication problems: imprecise articulation, oral-motor difficulties, hyper nasality, flat intonation, slow rate of speech, harsh/hoarse vocal quality abnormal pitch
 Clinical characteristics contributing to language problems: hypotonia, altered growth of the larynx, narrow/overjet/micrognathia and narrow palatal arch, tooth decay, cognitive
sequencing problems, intellectual disability and behavioral disturbances
Russel-Silver  Etiology: genetic factors; information regarding specific etiology is scarce
Syndrome  Baby characteristics: low birthweight, small for gestational age and have dwarfism
 Physical characteristics: asymmetry of the arms or legs, disproportionately large head, craniofacial disproportion, mandibular hypoplasia, high/narrow palate, microdontia
(abnormally small teeth)
 Communication problems: hypernasality, feeding problems in infancy, articulation disorders, expressive and receptive language disorders, abnormally high pitched voice
Tourette Syndrome  Etiology: inherited; no known specific cause
 Characteristics: uncontrollable vocal sounds (i.e. tics) and repeated involuntary movements usually manifesting before 18 years of age; tics begin with facial tics and may develop to
larger body tics or vocalizations
Treacher Collins  Etiology: autosomal dominant inheritance in most cases and spontaneous mutation in some
Syndrome  Physical characteristics: underdeveloped facial bones (i.e. mandibular and malar hypoplasia, dental maloclussion, downwardly slanted palpebral fissures), coloboma (i.e. lesion or
cleft) of the eyelids, stenosis/atresia of the external auditory canal, malformation of the pinna, middle and inner ear malformations, short/immobile soft palate, sucking and
swallowing problems in infancy
 Communication problems: congenital, bilateral conductive hearing loss, sensorineural hearing loss, language disorders, hypernasality and nasal emission and articulation disorders
Trisomy 13  Etiology: extra copy of chromosome 13, resulting in 47 chromosomes
 Physical characteristics: severe birth defects (i.e. congenital heart defects, severe brain anomalies, spina bifida, severe eye defects, cleft lip/palate and polydactyly-extra fingers/toes),
midline facial deformities and midline cleft lip indicating holoprosencephaly (i.e. the failure of the brain to divide into two hemispheres), profound intellectual disabilities and feeding
difficulties
 Prognosis: many babies with Trisomy 13 die before their first birthdays
Turner Syndrome  Etiology: occurs in females as a result of a missing or deformed X chromosome
 Physical characteristics: ovarian abnormality (causing infertility), congenital swelling of the feet/neck/hands, cardiac defects, webbing of the neck and low posterior hairline, broad
chest with widely spaced nipples, narrow maxilla and palate, micrognathia, auricle anomalies, high arched palate, cleft palate, right hemisphere dysfunction
 Communication problems: sensorineural hearing loss, middle ear infections, language and articulation disorders, visual/spatial/attentional issues
Usher Syndrome  Etiology: autosomal recessive inheritance in most cases and is X-linked in rare cases
 Physical characteristics: night blindness in early childhood, limited peripheral vision, eventual blindness, cochlear abnormalities
 Communication problems: sensorineural loss, language and articulation disorders, hypernasality and nasal emission
Velocardiofacial  Etiology: unknown; autosomal/genetic
Syndrome  Characteristics: cleft palate, middle ear infections, learning problems, speech and feeding problems, unique facial characteristics, velopharyngeal insufficiency, pharyngeal hypotonia,
oral apraxia, laryngeal and vascular anomalies, nasal regurgitation/omiting
 Craniofacial characteristics: wide nose, small ears, almond-shaped eyes, micrognathia, microcephaly and an elongated face
 Communication problems: significant language difficulties, articulation disorders, intellectual disability
Williams Syndrome  Etiology: abnormality on chromosome 7, including a gene that makes the protein elastin which provides elasticity and strength to blood vessel walls
 Physical characteristics: elf like resemblance, small boned and short, long upper lip, wide mouth, full lips, small chin, upturned noise and puffy eyes
 Intelligence: IQ within 50-70 and may have increased abilities in areas such as music, language and interpersonal skills
  Personality characteristics: charming, courteous, gregarious and loving, unafraid of strangers

4. MEDICALLY FRAGILE INFANTS

Neonatal Intensive Unit of a hospital specializing in high level of intensive care needed by premature or ill newborn infants; provide medically fragile infants with specialized feeding, temperature support, isolation
Care Unit (NICU) from infection and access to specialized resources and equipment
Feeding and Oral NICU babies are frequently fed through NG tubes to receive adequate nourishment; goal of feeding is to meet the child’s needs for healthy growth and development and to avoid endangering
Motor Development the child’s life; non-oral feedings can cause later refusal of food and inefficient digestion; when deciding method of feeding, must consider the severity of the medical condition, gestational age,
cardiovascular and respiratory stability, ability to complete oral feedings, coordination of sucking, swallowing and breathing; effective for babies to be stimulated to suckle during NG feedings
Hearing Conservation High and constant noise levels in NICUs can cause sensorineural hearing loss in infants and hearing should be assessed regularly throughout early childhood; if hearing loss is noted, aural
and Aural rehabilitation should take place
Rehabilitation
Infant Behavior, NICU team can evaluate infants for stabilization and homeostasis of behavior and physiological states which needs to be accomplished before the baby engages in communication and
Development and interaction; extended time in incubators results in limited bonding experiences which can lead to reduced communication, impacting cognitive and linguistic abilities; caregivers are taught
Communication effective responses to babies attempted communication and signs of disconnection

Ch. 14 Professional Issues

1. ASHA AND THE PROFESSIONS
SLP Scope of Practice
Scope of Practice Specifies what clinicians can and cannot due; an ethical guideline; some highlights include:
 Must have required qualifications, certifications, licensure and credentials when necessary
 Clinical decisions should be made based on best available evidence
 Domain of practice includes human communication behaviors and disorders, swallowing disorders and upper aerodigestive disorders
 SLPs practice involves offering prevention, screening, consultation, assessment, diagnosis, treatment, management, counseling and follow-up services for the disorders of speech
sound production (i.e. articulation, apraxia, dysarthria, ataxia, dyskinesia), resonance and voice, fluency, language, cognition, feeding and swallowing
 SLPs practice involves developing, implementing and prescribing AAC devices, screening hearing and offering auditory training, using appropriate instrumentation, selecting, fitting
and training for the use of prosthetic devices for communication and swallowing, collaborating in the assessment and treatment of central auditory disorders, educating and
counseling individuals, promoting community awareness, collaborating, serve CLD populations

2. ISSUES IN CERTIFACTION AND LICENSURE

Principles of Ethics
Principle of Ethics I States that clinicians should hold the welfare of persons they serve paramount by making sure they are well prepared to serve their clients, make appropriate referrals when necessary, do not
discriminate on bases of race/gender/ethnicity/national origin/disability/sexual orientation, do not guarantee the effects of treatment but make only reasonable statements of prognosis, do
not offer services solely by correspondence, obtain informed consent on all aspects of service delivery and research, offer treatments that are evidence based, maintain confidentiality
Principle of Ethics II States that clinicians shall maintain the highest level of professional competence by offering serves within the scope of practice and their own education/training/experience, obtaining
continuing education, not requiring or allowing persons working under their supervision perform activities which they are not qualified, and maintain all research/clinical assessment/treatment
instructions in proper working order
Principles of Ethics III States that clinician shall honor their responsibility to the public by not misrepresenting their qualifications, avoiding conflicts of interest, making referral solely on basis of clinical judgment,
avoiding any misrepresentation of clinical services or their effects, avoiding schemes to defraud in connection with billing, providing accurate information to the public about the profession’s
services and products, and adhering to the professional standards in advertising and promotion
Principles of Ethics IV States that clinicians shall honor their responsibilities to their profession, colleagues, students and members of related professionals by taking adequate supervisory responsibilities, giving
clinical or authorship credits to others when they are due, using professional judgment, maintaining professional demeanor and upholding the standards of the profession

3. LEGISLATIVE REGULATION OF THE PROFESSION

Federal Legislation Affecting School Settings
Public Law 94-142 i.e. the Education of the Handicapped Act (later IDEA); enacted in 1975; mandated free and appropriate education for disabled students from 3-21; includes the tenets that:
1. Disabled children and youth 3-21 were guaranteed free and appropriate public education in the least restrictive environment, including special education and related services
2. All students receiving special education services were to have Individualized Education Programs (IEPs), determined by parents and professionals that served as written records of
commitments to meet students’ goals
3. Students and parents were guaranteed protection of their rights through due legal process, including the right to an impartial due process hearing and the right to examine all
relevant records
4. The federal government was to provide funds for local and state agencies to carry out prescribed programs and to monitor and evaluate those programs
Public Law 99-457 Enacted in 1986; contained aendments to PL 94-142 that intended to provide early intervention to reduce number of children needing services in later years; increased federal monetary
 support of states to provide services of disabled children between 3-6 years old; created new program that provided funds for services for infants and toddlers (up to age 2) with disabilities;
required that all school service providers meet their state/s highest requirements for their disciplines; established mandated development of Individualized Family Service Plans (IFSPs) to follow
the child’s development, family needs, major goals and reviewal of plan every 6 months; children no longer had to classify preschool children to create service eligibility
Individuals with 1990: i.e. PL 101-476; enacted in 1990; reauthorized PL 94-142; replaced word handicap with disability; expanded number of categories of disabilities;
Disabilities Education 1997: amendments of 1997 increased meaningful parent involvement, improved educational results, increased participation of special educators in the general classroom setting, prevented
Act (IDEA) inappropriate identification/mislabeling, and improved use of alternative assessments
2004: i.e. PL 108-446; placed greater emphasis on using pre-referral services to prevent unnecessary referrals to special education and providing early intervention programs for children in
groups that are overrepresented in special education
Federal Legislation Affecting Employment Settings
Americans with i.e. PL 101-336; enacted 1990; provides civil rights protection relative to employment, state and local government services, telecommunications and public accommodations to all individuals
Disabilities Act (ADA) with disabilities; bars employment discrimination and requires employers to provide special equipment for workers with disabilities
Federal Legislation Affecting Health Care Settings
Social Security Act Passed in 1935; expanded the federal government’s grant-in-aid assistance to the states; provided the foundation for Medicaid and Medicare and established better benefits for the geriatric
population, public health, maternal and child welfare, people who are blind and children who are dependent or have a disability
Health Insurance Enacted in 2003; involves a set of rules followed by doctors, health plans, hospitals, and health care providers to uphold privacy standards and protect patient’s medical records and other
Portability and health information; key provisions include:
Accountability Act 1. Patients should have access to their medical records (within 30 days) and request corrections
(HIPAA) 2. Health care providers must provide a notice for how providers use personal information and patient rights
3. Limits are set on how covered entities may use personally identifiable health information
4. Patients may request covered entities take reasonable steps to ensure confidentiality
5. If covered entities misuse information, they may be civilly and criminally held responsible
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