Speech Therapy

There are a variety of tools and materials, which are designed for speech therapy in the market right now, thus giving the therapist much more options when it comes to choosing the equipments that could best maximize his services. One variety of materials are toys. And there are various reasons for the rise in its use.

The Toys and Their Functions

Before the therapy starts, an evaluation of the patient’s oral motor structures is usually done. This is where the therapist inspects the various structures that are inside and around the patient’s mouth that are used for speech. Some of these are the lips, tongue, teeth, jaw and cheeks.

For the structures to be seen more accurately, a penlight is usually used. The only problem with it is that the child may not find it very pleasant to have a flashlight in his mouth. This is now why there already is the colorful and jelly-like oral light system, which gives the same amount of light minus the metallic appearance.

The examination of these muscles also usually requires gloves and tongue depressors; in which kids do not appreciate both of whose smell and taste. This is now the reason why colorful and fruit flavored gloves and tongue depressors are already available.

After the said oral motor examination has been performed, the therapist may find a weakening in one or some of the structures. Some seemingly ordinary materials and toys may aid the strengthening of these muscles. One of them is the straw, which can come in all colors and designs. It serves two purposes.

The first purpose is for the rounding of the lips. This activity is important for the articulation of vowels and the semi-vowel /w/. Another function is the act of sipping. In this activity, the velum, the muscle right above the throat is exercised. This muscle is used when producing vowels and back consonants like /k/ and /g/.

Another commonly used material is a toy, which has to be blown. An example would be the whistle. The whistle is considered a difficult blow toy. It means that among the toys that work when blown, it is one of those, which requires more effort for it to perform its function.

The whistle, like the straw, aids in the exercise of the muscles of the lips. Another structure, which it strengthens, is the cheeks. It maximizes the capacity of the cheeks to hold in air and to gradually blow it out.

Other materials that are more commonly used are picture cards and interactive books. They usually contain pictures of words, which represent all the speech sounds. When these cards are used, all the therapist has to do is to show the picture and have the child produce the word together with the speech sound within the word.

Why Play?

If the patient sees the materials they have for therapy are colorful and fun toys, he will come to think that the reason he is in the clinic is to play and have fun. And having the child thinking this, will allow the child to cooperate with the therapist.

Play is a universal activity that blends social, cognitive, linguistic, emotional, and motor components. It is an integration of the many aspects of a child. Play serves as a representation of the thoughts and abilities of a child. Through play, the therapist will be able to know how to approach the concerns of his patient.

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The terminal goal of speech therapy is for the client to spontaneously use the appropriate speech sounds of his or her linguistic culture in connected speech. In this context, therapy becomes a continuum of short-term goals designed to meet the terminal goal. And therapy procedures may either use the motor or traditional approach or the cognitive-linguistic approach.

Motor or Traditional Approach

This approach is structure-based and uses drills more. Drills are activities that have rapid rates of stimulus presentation and which puts much stress on accuracy of the patient’s response to the stimulus and the said response reaching various set criteria.

Under this approach is auditory training. Its proponent is Charles Van Riper. This procedure uses pictures and games as motivational events or events that serve as a way of presenting stimuli. Activities are mainly about speech sound discrimination. It highlights the awareness and detection of sound.

Another procedure is the exercise of the oral motor structures. It is used when an oral motor assessment shows muscle weakness or spasticity. For children, it should be made fun and functional. It also uses mirrors for visual feedback.

One other procedure under this approach is phonetic placement. Van Riper was also the proponent of this procedure. It provides clients with verbal descriptions or instructions regarding articulatory position and movements for target sound. It is usually used together with visual, auditory, tactile and kinesthetic cues.

Weiner’s contribution to this field is his modified sensory motor approach. It is where a word in which the target sound is correct in the final position is paired with a word in which the same sound is in error in the initial position. The words are produced without a pause to facilitate assimilation of the incorrectly produced sound.

In this line also is syllabication. It uses the syllable-by-syllable production of words. It is used in addressing weak syllable deletion or the deletion of the syllable in a word which is the least stressed.

One procedure that is closely related to syllabication is chaining. The client is first asked to say the whole word. If he says a syllable incorrectly, the therapist instructs the patient to look at his lips while he produces the word syllable by syllable with the patient following him after every syllable until he produces the word the same way that the therapist did.

Cognitive-Linguistic Approach

The first procedure under this approach is auditory bombardment, also known as cycles approach. There are treatment cycles which have their designated phonemes, taught in a span of 2-4 weeks. Auditory bombardment requires that the patient be bombarded with the phonemes that he needs to learn without him being aware of it.

Another procedure is auditory bombarding with PACT (Parents and Children Together). Here, production should not be over-emphasized. It may use funny, perceptually salient make-up words like ker-plunk, boing, shilly-shally or kaboom. All that matters is that the words contain the phonemes that are being targeted.

Modified cycles approach is also under this group. It requires the clinician to make purposeful and obvious lexical errors in words that contain target phonemes to make the patient correct the clinician, thus producing the target sound. Parental involvement is important for explanations of goals, procedures, and assignments.

Minimal contrast therapy, on the other hand, contrasts presence and absence of phonemes, establishing also the difference between phonemes. This procedure can be utilized in addressing perceptual or production difficulties when it comes to final sounds of words, establishing the difference between words like fee and feet.

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Traumatic brain injury can cause about a lot of speech and language disorders that would entail the need of speech therapy. That’s why the role of speech therapy in the rehabilitation process of a traumatic brain injury patient is very vital.

What Speech And Language Problems TBI Brings About

A person may have loss of consciousness after a traumatic brain injury. This loss of consciousness can vary from seconds, minutes, hours, days, months or even years. The longer you are out of consciousness, the more severe your injury is. After a traumatic brain injury, you may suffer secondary consequences, which are considered to be more lethal and dangerous than the primary injury.

Some of these secondary consequences include damage to your brain’s meninges, traumatic hematoma, increased intracranial pressure, herniation, hyperventilation, ischemic brain damage, and cerebral vasospasm. When these brain damages occur, they tend to affect parts of your brain that are responsible for speech and language processing and production, thus you get speech and language problems.

Traumatic brain injuries can cause you permanent or temporary memory loss, orientation problems, lesser cognitive performance or slower processing of thought, attention problems, deterioration of skills in basic counting, spelling and writing. You can also have Aphasia, where you have a loss of words.

Traumatic brain injury can also cause you difficulty in reading simple and complex information. Your naming skills, of everyday seen objects, familiar others can also be affected. It can also bring about dysarthria, or problems with movement, that can cause you to have shaky movements leading to difficulty speaking and writing.

Speech Therapy For Traumatic Brain Injury Patients

Treatment for traumatic brain injury patients can be classified into three categories. There are different treatments for early, middle and late stages of a traumatic brain injury. There are also compensatory strategies taught for a TBI patient.

Early Stage Treatment

Treatment during the early stage of a traumatic brain injury would focus more on medical stabilization. A speech therapist would also deal more on establishing a reliable means of communication between the patient and the therapist. The patient is also taught how to indicate yes or no, when asked.

Another goal is for the patient to be able to make simple requests through gestures, nods, and eye blinks. The behavioral and mental condition of the patient is also treated. During the early stage, sensorimotor stimulation is also done. Where in the therapist would heighten and stimulate the patient’s sense of sight, smell, hearing and touch.

Middle Stage Treatment

The main goal during the middle stage treatment is for the patient to develop an increased control of the environment and independence. The adequacy of patient’s interaction to the environment is also increased. The therapist should also stimulate the patient to have organized and purposeful thinking. The uses of environmental prompts are to be diminished during this phase.

A lot of activities focusing on cognitive skills like perception, attention, memory, abstract thinking, organization and planning, and judgment, are also given.

Late Stage Treatment

During the late stage of treatment, the speech therapists’ goal is for the patient to be able to develop complete independence and functionality. Environment control is eliminated and the patient is taught compensatory strategies to cope with problems that have become permanent.

Some of these compensatory strategies are the use of visual imagery, writing down main ideas, rehearsal of spoken/written material, and asking for clarifications or repetitions when in the state of confusion.

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Teaching language to nonverbal, hearing-impaired children is in fact, a very controversial matter. The controversy stems from the idea that either of two goals is being targeted. One of which states that after language is learned, the child will be able to communicate orally; while the other states that the child will be able to communicate, not verbally, but manually.

Issues With This Approach

Although you may think that the best end goal would be a speaking child, some adult deaf groups would fiercely disagree. They believe that a hearing-impaired individual does not have to be verbal if only to be able to communicate with the rest of the population. For them, assimilation is not really a dream.

Although they aim to find some common grounds for communication, these groups do not really think it is necessary to learn spoken language just to take on the cultural traits of the verbal people.

And in respect to this claim, you have to understand that in some instances, language should be thought in completely nonverbal ways. The following are some of the means to facilitate language learning in nonverbal children.

British Sign Language (BSL)

This is a visual communication technique that incorporates the national or regional signs in Britain in a specified structure and is often taken as a language in its own. This kind of communication does not have a written form.

Manual English

This refers to all the communication systems that require signs, fingerspelling or gestures, which can appear separately or in combinations. This system keeps the word order and the correct syntactic form of the English language.

Signed English

This is the two-handed fingerspelling of the English language as based on British regional and national signs.

Fingerspelling

This is where the fingers of the hand assume 26 different positions. These 26 positions symbolize the 26 letters of the English alphabet. The combinations of these positions enable the formation of words or sentences.

Cued Speech

This is a one-handed supplement to lip-reading and is often used to clarify the nebulous phonemes that have been detected through lip-reading.

Paget Gorman Systematic Sign Language

This is a system devised by Sir Richard Paget and is used to give a grammatical representation of the spoken English language. It utilizes constructed signs and hand positions that differ form those used in the Britain Sign Language.

Signs Supporting English

This is composed of signs for keywords that would assist oral communication and used at appropriate times during utterances.

Auditory-Verbal Therapy

On the other hand, an even bigger number of people believe that language should be taught to nonverbal individuals so that they might actually be able to produce their own utterances. One of the most noteworthy methods in developing spoken language in nonverbal children is through the Auditory-Verbal Therapy.

The primary goal of the Auditory-Verbal Therapy is to maximize the child’s residual hearing so that audition might be fully integrated to his/her personality and that he/she may be able to participate in the hearing society. Another goal would be to make mainstreaming a reasonable option in the future. Thus, suggesting that the child is as capable as any hearing child in a normal educational environment.

The general premise of the Auditory-Verbal Therapy is to focus on the Auditory Approach where the hearing-impaired child would be given instructions to listen and not to lip-read or sign. This way, the child would be capitalizing on his residual hearing and it would be easy for him to learn auditory skills since he would not be relying on signed speech.

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Voice training is done to find an appropriate source of sound production that can be articulated for communication purposes. Criteria for selecting sound source include: degree of tissue loss, esophageal stenosis, physical limitations of the patient; noise level of the patient’s environment; motivation level; and patient’s preference of sound source.

Types Of Sound Source

There are mainly three types of sound source a patient can choose from. These are: external man-made prosthesis or artificial larynx; sphincter like junction of the pharynx and esophagus or esophageal speech; and lastly, surgically implanted device or transesophageal puncture and silicon prosthesis.

Artificial Larynx

The principle of artificial larynx is to have an external mechanical sound source that is substituted for the larynx. Anatomic structures for articulation and resonance are most of the time unaltered.

There are two general types of electrolarynges that are available: neck type and intra oral type. The neck type is placed flush to the skin on the side of the neck, under the chin, or on the cheek. Sound is conducted via the oropharynx and is articulated normally.

The intraoral type is used for patients that can’t conduct sound through skin adequately. A small tube is placed toward the posterior oral cavity, and the produced sound is then articulated. The tube has little effect on articulatory accuracy if the patient is taught properly and learns to use it well.

The advantage of artificial larynx is that voice is restored after surgery immediately and the maintenance of the hardware is minimal. The disadvantage however, is that the quality of sound may seem mechanical.

Esophageal Speech

The principle behind esophageal speech is that air is of greater pressure in one chamber (oral cavity) will flow to a chamber containing less pressure (esophagus), if these chambers are connected.

Goals of esophageal speech include: to be able to phonate upon demand, use a rapid method of air intake, short latency between air intake and phonation, produce four to nine syllables per air charge, achieve a speaking rate of 85-129 words per minute, and attain good speech intelligibility.

There are mainly three methods of esophageal speech. Injection is a method where air in the mouth/nose is compressed by lingual or labial movement and is injected into the esophagus. Swallowing method uses air that enters during oral opening when swallowing. The air is used to produce voice.

Inhalation method maintains a patent airway between the nose, lips and esophagus. The stoma is used for inhalation. Air enters the esophagus when the pharyngo-esophageal muscle is relaxed during inhalation.

The advantage of this kind of speech includes: no external devices, natural sounding speech, and the possibility of pitch and loudness control. Disadvantages on the other hand are: there is reduced length of utterance, is hard to learn and requires good articulation.

Transesophageal Speech

This is another approach to voice restoration. It requires a surgical/prosthesis procedure that makes use of a man-made device inserted into a surgically created midline transesophageal fistula.

Air is conducted from the trachea to the esophagus through the prosthesis to excite the pharyngo-esophageal segment for voice production.

Advantages include: rapid restoration, natural sound, normal utterance length, hands-free, minimal maintenance and intelligible tonal language. Disadvantages are: the need for surgery, puncture stenosis, candida growth, aspiration of foreign objects, and troubleshooting.

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There are two notable differences when teaching a hearing-impaired child compared to the traditional way of teaching language. First the choice of vocabulary taught is different. Second, the correctness of word order is different too.

Teaching at the Vocabulary or One Word Level

First, your choice of vocabulary is important. Customarily, words that are easy to say or lip read are usually taught first. Words like shoe, bow, tie, boot etc. are commonly taught with an emphasis on lip reading. On the other hand, children taught through auditory stimulation would likely say button first rather than bow. This is due to the inflectional pattern of button that is more stimulating to the child’s hearing.

Then there is the use for functional words. Auditory approach makes the early vocabulary of functional words possible. Words that a child uses to communicate everyday experiences but are very far off from the words said in the vocabulary lists devised for deaf children. Much of these words are not proper names or nouns.

Some of the first words are: Bye-bye, More, Oh, All gone, Off, Nice, Rough, Up, Uh-huh, Down, Hi, Ow, Hot, Cold, Light, No, Yummy, Yah, Pooie, Peeoo, Stop, Cut and Knock-knock.

While the first phrases include: open the door, I heard that, pick it up, bad girl, bye-bye in the car, daddy shop, I love you, come here, thank you, and peek-a-boo.

Developing First Nouns is the third critical point. When the child is already active in the communication process, it is recommended that the parents target a word that they perceive that the child would need. When the child is already able to recognize five to ten sounds associated to toys and a few functional words the development of symbolic language of the child should be accelerated.

The Circle Of Speech

The child’s vocabulary development could be illustrated in circles. The core skills comprise of basic listening experiences and pre-speech activities; and gestures. If the child possesses these skills, the therapist can proceed to the next level and teach him names like mommy, daddy, doggie, baby and a few verbs like listen and push, few adjectives like loud, hot and more and a few nouns like hat, cookie etc.

Fourth is the ability to developing language units. If the therapist would consider the child’s interests, it would be easy to plan language units. A few of these units are derived from the child’s everyday environment.

Body parts are one good example of language units. Words like eye, nose, and hair are words that a child can easily learn due to the association of his body. Family names are another example of language units. The child easily picks up words such as mama, Dada, and the names of his siblings since these are the people that he is exposed to most of the time.

Another language unit criteria can be food. Basic food related words like apple, candy and yummy can be taught. Verbs are also another kind of language unit. The therapist can teach words like cook, stir, drink, and jump. This can be done by doing the actions themselves so the child can easily pickup the concept.

School related words could also be a unit. Words like teacher, and his classmate’s names are a good start. Animal words, like dog, cat, kitty, can also be one separate unit, coupled with some sounds associated with animals.

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There are six main types of fluency disorders namely: normal developmental disfluency, stuttering, neurogenic disfluency, psychogenic disfluency, language based disfluency, and mixed fluency failures. Due to the uniqueness and difference of each case, all of them require a different kind of management approach in speech therapy.

Management For Normal Developmental Disfluency

Developmental disfluency occurs during the critical period of speech and language development. A child is considered to have this condition if 5% or less of his overall speech-sample are repetitions and 1% or less are prolongations.

Etiologies of this condition could be: excitement while speaking, demands of Language Acquisition, Speech-Motor control is lagging, environmental factors like stress in the family (e.g. separation of parents) and the situations they are in, and daily pressures of competition.

Concerned parents still make their children with this kind of disfluency undergo therapy even if this could still possibly decline. These children are taught how to: decrease the rate of their speech, relieve other pressures that the therapist and parents mutually agree to change, and simplify their language.

Management For Stuttering

The onset of stuttering may occur between ages 1 ½- 11 years old but it mostly occurs during early childhood stage, which ranges from 2-6 years old. A condition is diagnosed to be stuttering when the speech has 5% or greater repetitions and 1% or greater prolongations.

There are several approaches to therapeutic intervention for early stuttering namely: environmental manipulation, direct work with the child, psychological therapy, desensitization therapy, parent-child interaction therapy, fluency-shaping behavioral therapy, and parent and family counseling

Management For Neurogenic Disfluency

The onset of neurogenic disfluency is varied. It can occur at any age but it usually appears during adulthood or among the geriatric population. The neurological events that can trigger the onset of neurogenic disfluency are as follows: strokes, head trauma, extrapyramidal diseases, tumors, dementia, drug usage, anoxia, cryosurgery, viral meningitis, and vascular disease.

Self-monitoring program is one of the most suggested modes for the management of this kind of disfluency.

Management For Psychogenic Disfluency

The onset of psychogenic disfluency is also varied. A condition is said to be under this category when 90% of the patient’s utterances have become disfluent when the emotional stimuli is present. This condition originates in the mind. The etiology could be acute or chronic psychological disturbances. Stress is another factor that may also cause the disorder.

Psychologists, psychiatrist and counselors can only provide treatment of this kind of fluency disorder. Speech pathologists prioritize treatment only of the bad speech habits, which may still be present after resolving the emotional issues of the patient.

Management For Language Based Disfluency

This kind of fluency disorder may arise in a child as soon as any newly introduced language skill emerges, specifically during the toddler to preschool stage. The fluency failure may be due to linguistic or motor immaturity. It can also be a result of the child’s struggle to acquire newly introduced and more complex language rules.

The management of this kind of disfluency usually focuses on improving the child’s language skills to increase his/her linguistic and motor maturity.

Management For Mixed Fluency Failures

The onset of this condition cannot be exactly determined, since it is an overlap pf two or more causative factors. No specific age for identification since onset may be sudden. Therapists must prioritize the most debilitating and/or the most correctable aspect of the disfluency.

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